DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Febrile syndrome of undetermined etiology.
2. Ileus of undetermined etiology.
3. Do not resuscitate.
DISCHARGE MEDICATIONS:
1. Dilaudid 2 mg subcutaneously q. 4 h. p.r.n. pain.
2. Prevacid SoluTab 30 mg p.o. daily.
3. Xanax 0.5 mg q. 12 h. p.r.n. agitation.
CONSULTATIONS:
1. GI service.
2. Urology service.
3. General surgery service.
4. Infectious diseases service.
DIAGNOSTIC STUDIES:
1. CAT scan of the abdomen and pelvis performed revealed no evidence of intra-abdominal pathology.
2. Repeat CAT scan of the abdomen and pelvis performed revealed no evidence of free air or obstruction.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: The patient is a (XX)-year-old Hispanic male who was transferred from the nursing home to the emergency room here with chills, fever, and headache. In the emergency room, the patient had an albumin of 4.3, total protein of 7.9, alkaline phosphatase of 82, SGPT of 13, BUN of 18, total bilirubin of 0.9, calcium of 9.2, pO2 of 28, and chloride of 100. His creatinine was 1.5, potassium of 5, SGOT of 27, sodium of 142, and glucose of 108. Also, at the time of presentation, he had a urinalysis that was normal. T4 of 8.3, T3 circulating of 100, and a TSH of 0.87. The INR was 1.3. The PTT was 38. The white blood cell count was 9600, hemoglobin 13, and hematocrit 42. Platelets were 268,000.
The patient appeared clinically dehydrated and was started on IV fluids and brought to the medical floor. Blood cultures were obtained, and he was started on empiric antibiotic therapy. Within 24-48 hours, he showed significant signs of abdominal distension and discomfort and was not passing any stools. He was seen initially by the urology service, who performed a rectal examination. They found no evidence of any excessive stool in the rectal vault.
He had an obstructive series performed, which revealed possible pneumoperitoneum. This was followed up by a CAT scan, which revealed no evidence of free air or intestinal obstruction. The patient continued to show extensive bowel distension and discomfort. The rectal tube was placed by Dr. John Doe, which provided the patient very little relief. He continued to suffer tremendously with the abdomen.
He was seen in consultation by Dr. Jane Doe, who offered performing a transverse colostomy to relieve the discomfort. The family adamantly refused any interventional procedures, and the patient was made DNR. He was given palliative parenteral hyperalimentation and was also given narcotic analgesia.
At the time of his discharge, his albumin was 2.9, total protein 5.6, alkaline phosphatase 125, SGPT was 72, BUN 15, creatinine was 0.8, SGOT was 59, and sodium was 135. He was transported from the hospital to (XX) under hospice guidance, where he will be given palliative comfort care.
