Gastroenterology study

EMERGENCY ROOM REPORT

HISTORY

A healthy 70-year-old male who complains of a 4-day history of increasing abdominal pain, accompanied over the last several hours by watery diarrhea.  He got some relief for a brief period by inducing vomiting during the night, last night.  There was no hematemesis, and there has been no rectal bleeding.  He has had chills but no sweats or identified fever.  He had something a little bit like this last week, but previous to that had never had any problems.  There has been no pain in the back.  He has a history of appendectomy many years ago.  Currently, his medicines are aspirin and niacin.  He has no known allergies.

PHYSICAL EXAMINATION

The patient is an alert, well-oriented male with mild distress from pain.  His head, eyes, ears, nose, and throat are unremarkable, and the lungs are clear.  The heart shows a regular sinus rhythm without murmur, rub, or gallop.  The abdomen is round and tympanitic in various areas.  Bowel sounds are quiet but present.  The stool is light brownish-yellow and guaiac negative.  The rectum is nontender.  There is no peripheral edema or jugular venous distention.

LABORATORY FINDINGS

The patient had an unremarkable abdominal series and had a white count of 12,500 with 68 segs, 1 band, 13 lymphs, 17 monos,
1 eosinophil.  The hematocrit was 45.  The urinalysis showed
1+ bacteria and 8 to 12 hyaline casts per high-power field.  There is bilirubin in the urine as well.  The ECG is unremarkable.

COURSE IN THE EMERGENCY DEPARTMENT

The patient was admitted to the ER (emergency room) and seen, then labs ordered.  His pain persisted throughout his stay.  There was no vomiting or diarrhea during the ER (emergency room) visit.  Decision was made to admit the patient to further evaluate what appears to be a significant event in light of his deterioration after 4 days, instead of improvement.  An ultrasound will be ordered to evaluate the gallbladder, and a culture has been started to further evaluate the urinary tract.

DIAGNOSES

1. Cholelithiasis.

2. Pyelonephritis.

3. Gastroenteritis.

FOOTNOTE

Line 33 (Page 1).  Alternative:  8-12.  The physician made a correction:  hyaline cell (not a legitimate term) was changed to hyaline casts.  High-powered field was changed to high-power field.

Line 41 (Page 1).  Was made was inserted to improve grammar.