DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSIS: Abdominal pain.
DISCHARGE DIAGNOSES:
1. Constipation with encopresis.
2. Left hydronephrosis.
3. Small right pleural effusion.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American male with a history significant only for asthma and eczema who presented to the hospital emergency department for evaluation and treatment of acute onset of abdominal pain. The mother reports that the patient first developed fever and emesis four days prior to admission and after this was seen by the primary care physician who noted that the patient looked dehydrated.
Due to the above symptoms, the patient was referred to the emergency department where he was noted to still be slightly dehydrated with fevers, so he was given Tylenol, Motrin, was rehydrated, and sent home. Two days prior to admission, the patient began to develop right lower quadrant and right flank abdominal pain, and then on the day of admission, the pain worsened tremendously. Mother reports that the patient was quite hysteric and was unwilling to walk. T-max was 103.8 on the day of admission.
On presentation to the emergency department, the patient’s temperature was 103.8, pulse was 116, respirations 26, and blood pressure 100/60. The patient received normal saline bolus, was started on IV fluids, and then was treated with multiple doses of Zofran for nausea and Pepcid.
LABORATORY DATA: The patient’s CBC was as follows; WBC 7.2, hemoglobin 11.4, hematocrit 34.4, platelets 276,000, neutrophils 80.7%, lymphocytes 11.9%, monocytes 7.2%, eosinophils 0.1%, and basophils 0.1%. Chemistry; sodium 132, potassium 4.2, chloride 99, CO2 of 24, glucose 100, BUN 20, creatinine 0.6, calcium 8.6, total protein 6.8, albumin 3.2, total bilirubin 0.6, alkaline phosphatase 124, ALT 20, and AST 26. Urinalysis showed the clean catch was 1.036 specific gravity, albumin 3+, ketones 2+, and bacteria 2+. Otherwise, urinalysis was negative for leukocytes esterase, nitrites, and wbc’s. Urine culture was obtained in the emergency department and is currently negative today, and blood culture is also negative today.
RADIOGRAPHIC DATA: CT of the pelvis was obtained in the emergency department, which showed distended urinary bladder, still distended in the rectum and sigmoid colon, and a possible small amount of free fluid in the pelvis. CT of the abdomen showed abnormal appearance of the upper pole of the right kidney or possibly other portions on the right kidney. Findings could be secondary to pyelonephritis. We are unable to rule out neoplastic process. Small amount of fluid adjacent to the gallbladder.
HOSPITAL COURSE: The patient was admitted to the floor and immediately started on IV fluids and made n.p.o. Due to findings of the CT in the emergency department, the patient underwent a right lower quadrant ultrasound to rule out appendicitis and a renal ultrasound. The right lower quadrant ultrasound was inconclusive due to the fact that the appendix was not visualized, but the renal ultrasound did show mild left pyelocaliectasis, nonspecific. Could not rule out mild obstruction, even vesicoureteral reflux. Tiny amount of fluid in the Morison pouch, nonspecific, and there is still ill-defined hyperdense area in the upper pole of right kidney seen on CT scan but not delineated on the sonogram.
The patient also, on the day of admission, underwent an enema, which consisted of mineral oil, hydrogen peroxide, and soap that was successful. On the following day, the patient was seen by Nephrology, who felt that he should undergo a VCUG to rule out any vesicoureteral reflux. This was attempted on the third day of hospitalization, but due to retained contrast was unable to obtain. On the day of discharge, we attempted one more time to obtain a VCUG but were still with contrast in his colon and it was canceled. The patient did receive a second enema on the third day of the hospitalization, which was also successful. The plan was to also give her enema prior to discharge.
ASSESSMENT AND PLAN: A (XX)-year-old male with history of chronic constipation with encopresis admitted for fecal impaction with also abnormal findings on renal ultrasound. Plan is to discharge the patient home today after his last enema and also sent him home with MiraLax half a packet p.o. b.i.d. Due to the findings of a small pleural effusion on his chest x-ray and the fact that he did present with the fever, we will send the patient home on clindamycin p.o. for three more days to complete a 10-day course.
Due to the nature of the patient’s abnormal findings on his studies, the patient will need a VCUG as an outpatient, but prior to doing so, will have to get a KUB to rule out anymore contrast in his colon. Once his KUB is obtained and is found to be negative, primary care physician can refer the patient for the VCUG. Dr. John Doe would like to see the patient within three months but has recommended that if VCUG is positive that the patient is to undergo prophylactic treatment for UTI and due to the fact that the patient does seem to have significant constipation with encopresis and contrast slowly moving out of his intestines. The patient will need to see Dr. Jane Doe as an outpatient.
