DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CHIEF COMPLAINT: Guaiac positive stool and anemia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American female with multiple medical problems, including a recent non-ST elevation MI. She was requested to be seen for evaluation of anemia with guaiac positive stool. The patient was admitted for altered mental status and has been treated for CDT colitis. While being on anticoagulation, the patient was noted to have anemia with guaiac positive stool. GI service was consulted to assist in further evaluation and management. The patient complains of nausea, however denies any vomiting. Abdominal pain is described as diffuse, especially along the left side. The patient has resolving diarrhea and had five brown soft bowel movements since morning. Denies any fevers. Appetite is decreased.
PAST MEDICAL HISTORY: Significant for recent acute MI, diabetes mellitus, hypertension, multiple falls with right upper extremity fracture, history of anemia with hemoglobin 8.8 on admission.
PAST SURGICAL HISTORY: Significant for open reduction and internal fixation of femoral fracture.
MEDICATIONS IN HOSPITAL: Include Remeron, Lanoxin, metoprolol, Niferex, multivitamins, vancomycin, Alinia, insulin, and Coumadin on hold.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies any smoking, alcohol or drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: A 14-point review of systems is essentially unremarkable, except as per HPI.
PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly female lying in bed without any obvious distress.
VITAL SIGNS: Blood pressure 146/74, pulse 68, respiratory rate 18, and afebrile.
HEENT: Examination shows no pallor, no icterus, dry and pink oral mucosa.
NECK: Supple, no JVD, no adenopathy.
CHEST: Clear to auscultation.
HEART: Heart sounds regular rate and rhythm, S1 and S2, with systolic ejection murmur.
ABDOMEN: Soft. Diffuse tenderness, especially along the left side of the colon. No organomegaly. Bowel sounds are positive. No rebound or guarding is felt.
RECTAL: Exam was deferred.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: Examination was nonfocal.
LABORATORY DATA: WBC 7.6, hemoglobin 11.6, hematocrit 33.8. Hemoglobin on admission was 8.8. Basic metabolic profile was within normal range. PT was 25.4 with INR of 2.26. UA was unremarkable. Fecal occult blood test was positive.
IMPRESSION:
1. Guaiac positive stool.
2. Anemia.
3. Coagulopathy.
4. Clostridium difficile toxin colitis, being treated with vancomycin and Alinia.
5. Status post recent myocardial infarction recently.
PLAN: We will recommend supportive care. Follow H&H and transfuse as needed. Protonix 40 mg p.o. daily. The patient is to continue treatment for CDT as advised by ID service with the intention to treat with vancomycin for six weeks tapering dose. Guaiac positive stool is likely secondary to CDT colitis, which is improving, and it may be acceptable to keep the patient on low dose anticoagulation due to her recent MI with close followup of H&H. The patient will need elective outpatient colonoscopy versus air contrast barium enema in two to three months.
Thank you very much for allowing us to participate in taking care of this patient.
