DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Left lower quadrant pain.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant, otherwise healthy gentleman who has left lower quadrant pain for about five days. The patient stated that he had a colonoscopy done five days ago. He states that he did have some cramping abdominal pain before the colonoscopy, but it has been gradually worsening over the past five days. It is cramping in nature. It is rated a 5/10 in severity.
The patient states that it does not radiate. It is not improved with anything. It is worse when he lifts up his left leg. He states he has been able to work for the last several days. He denies any fevers. He denies any vomiting and denies any diarrhea. The patient states he is having normal bowel movements with no blood, and he is tolerating p.o.
PAST MEDICAL HISTORY: Significant for anxiety and atrial fibrillation.
PAST SURGICAL HISTORY: None.
MEDICATIONS: Aspirin and metoprolol.
ALLERGIES: Penicillin.
SOCIAL HISTORY: The patient denies any tobacco, alcohol or drugs.
REVIEW OF SYSTEMS: Constitutional and GI as per HPI. Otherwise, 10-point review of systems was done and is negative.
PHYSICAL EXAMINATION:
GENERAL: The patient is well appearing, nontoxic, alert and oriented x4. GCS 15.
VITAL SIGNS: Blood pressure is 124/84, pulse is 86, respiratory rate is 16, temperature is 37.2, and saturation is 100% on room air, which is normal.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Oropharynx is benign with moist mucous membranes.
NECK: Supple. Full range of motion. No meningismus.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, mildly tender to palpation in the left lower quadrant. No rebound, no guarding. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: No rash, petechiae or purpura.
NEUROLOGIC: Cranial nerves II through XII are grossly intact. Strength is 5/5 x4 extremities. Sensation is intact to light touch distally.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. He was admitted to the emergency room for observation. The patient did not wish to have any pain medication in the emergency room. He stated that his pain was well controlled. He had a laboratory workup; the results were interpreted by us. CBC was within normal limits with a white blood cell count of 10.2; although, he did have a neutrophilia of 83%. Absolute neutrophil count was mildly elevated. His complete metabolic panel was normal. His coag studies were normal. Urinalysis was negative.
We discussed the case with Dr. John Doe of the GI service. He was able to review the patient’s colonoscopy. He stated that he did not have any polypectomy; however, he did have some sigmoid diverticular disease, and the physician that did the study felt that there was a little bit of edema.
He felt that it is possible that this is just pain resulting from dilation of the colon, but it is also possible this is the beginning of a mild diverticulitis, and he did recommend treating. The patient does not have any peritonitis to make us concerned that there is an abscess, and therefore, we do feel he is stable for outpatient treatment.
MEDICAL DECISION MAKING: The patient is very pleasant. He has left lower quadrant pain for five days. The differential diagnosis considered after he had the colonoscopy was a perforated viscus. The patient did not have any peritonitis. He had an x-ray that did not show any free air, and we are not concerned that he had a perforation of his colon at this time, as he is nontoxic and well appearing.
This could have been just pain from gas dilation of his colon, but given the history by Dr. John Doe, we do feel the patient needs to be treated for mild diverticulitis. There is no concern for an abscess at this time. The patient does not need inpatient treatment and can safely be discharged home.
DISPOSITION: Home.
CONDITION: Stable.
DIAGNOSES: Diverticulitis and left lower quadrant pain.
