DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation of small bowel obstruction.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old Hispanic female, highly debilitated, admitted with possible small bowel obstruction. The patient apparently had some vomiting prior to admission, the etiology of which is uncertain. Shortly after being brought through the emergency department, the patient had a CT scan of the abdomen and pelvis, which revealed a ventral hernia containing both small bowel and colon. This was not definitely described as the cause of her bowel obstruction nor was it diagnostic. The patient was described as having a cough, and her vomiting may have been caused by intense coughing. The patient is a poor historian. There has been no vomiting since being admitted to the hospital. The NG tube is actually being clamped, and we therefore do not have any measurable NG tube outputs. An abdomen series performed yesterday revealed a nonspecific bowel gas pattern.
PHYSICAL EXAMINATION:
GENERAL: The patient is in bed and arousable. She is not wide awake and does not give a history.
HEENT/NECK: Head and neck examination is mostly unremarkable. There was no gross motor deficit. Oral mucosa is dry.
LUNGS: Breath sounds are equal bilaterally. We cannot assess the lung bases, however.
HEART: Regular rate and rhythm.
ABDOMEN: Completely soft. Essentially nontender. There is a palpable hernia above the umbilicus, but for the most part, this looks reducible and we do not believe that she has an obstruction at this level. No other evidence of abdominal wall hernia.
EXTREMITIES: Unremarkable.
SKIN: Warm and dry.
LABORATORY DATA: On admission revealed a white blood cell count elevated at 23,600, hemoglobin 18.2, hematocrit 55, and 88% neutrophils. Electrolytes were mostly normal. BUN of 62 and creatinine 2.1. Liver function enzymes are normal. White blood cell count today down to 13.2, hemoglobin 16.8, and hematocrit 50. Band neutrophils now appeared at 44% and the absolute band count is elevated. BUN and creatinine are elevated today with BUN of 88 and creatinine of 3.
ASSESSMENT:
1. Leukocytosis of uncertain etiology. The patient may have pneumonia and we do not see a CT of the chest. This is most likely something that will need to be done in order to better evaluate her history of cough and her elevated white count.
2. Bowel obstruction is unlikely based on a relatively benign-appearing abdominal flat plate and an equivocal CT scan mentioning the presence of some dilated small bowel, but there is no strong suggestion of bowel obstruction.
PLAN: CT scan of the chest will be ordered. Tomorrow, we will obtain a small bowel series. We will follow the patient along with you. We will place her nasogastric tube to suction and evaluate her further. The patient is currently receiving intravenous antibiotics and the antibiotics are being managed by Infectious Disease.
