HISTORY
Patient is a 68-year-old female who last night said at about
6 o'clock, she felt like she had to go to bathroom and she just passed bright
red blood, really was not a lot of stool
at all, just blood, but she did another 16 times throughout the night; her husband
counted. She said it was always red and
was just blood. They called the office
in the morning because they worried about Feldene she was placed on for
arthritis, that might be causing this, but with that many times of blood, we
recommended to come to the ER. She
denies any fever, but when she is passing the blood, she is having lower
abdominal pain and/or cramps. She states
it is kind of the same. She has never
had anything like this before. She
states she has not had a colonoscopy before.
PAST MEDICAL HISTORY
She is allergic to the STATIN drugs. She had a myositis from that, and that is one
reason she is on the Feldene.
CURRENT MEDICATIONS
Include:
1. Zetia 10
milligrams a day.
2. Feldene
20 milligrams a day.
3. Amoxil
500 t.i.d., which was started 5 days ago for a sinus infection.
4. She is
also on Evista 60 milligrams a day.
Dr. Hunt is her GYN.
She has really been healthy most of her life except for hyperlipidemia
that she developed. She has allergy
problems and takes Flonase and Claritin on a p.r.n. basis.
FAMILY HISTORY
Her mother died in her 80s in her sleep in Vietnam. Her dad died of diarrhea at a young age in
Vietnam of complication with diarrhea, but she said they did not have much
medicine back then.
SOCIAL HISTORY
She does not smoke.
She does not drink. She has been
married for 30 years.
OBJECTIVE
GENERAL: When I see
the patient, she is in bed, getting blood drawn, said she feels a lot better.
ENT EXAM: Her sclerae
really are pink. They do not really look
that pale. Her oropharynx is a little
bit dry. Her TMs are clear. Nasal passage revealed no blood.
NECK: Supple. There is no lymphadenopathy.
CHEST: She has
bilateral breath sounds, which are clear.
CARDIAC EXAM:
Revealed a regular rate and rhythm without ectopy.
ABDOMEN: Soft. She is a little tender to push on her lower
abdomen, but there is really no point tenderness.
RECTAL EXAM: Did not
do a rectal since it was done in the ER, and she was guaiac positive.
EXTREMITIES: No
edema.
NEUROLOGIC EXAM: She
is alert and oriented x4. She can move
all 4 extremities and said she had no problem walking over here.
LABORATORY DATA
Obtained in the ER includes a CBC with a white count of
22.5, hemoglobin of 14.1, hematocrit of 42.1.
This was repeated further in the day and her white count was then 18.3,
H and H 13.5 and 40, but she still has a left shift with 91 segs, 3 bands. Stool was positive for blood, and they said
it was bloody stool. PT and PTT are
normal, plus her nonfasting sugar is 169.
Her potassium is 3.7, chloride was 98.
She has never had a problem with diabetes and it has been checked
recently because her husband is diabetic.
Ultrasound of her abdomen was evidently normal per ER report and her CT
scan showed some inflammation or thickening of the colon that was described per
ER physician and radiology. I do not
have official report back at this time, but they did not see any masses. Dr. Meichner has been consulted.
ADMISSION DIAGNOSES
1. Lower
gastrointestinal bleed, etiology could include ischemic colitis,
diverticulitis. I am going to get stool
for Clostridium difficile as she took Amoxil 5 days, albeit low dose, but still
she took it.
2. Leukocytosis. Dr. Meichner shortly put her on IV Levaquin
and Flagyl.
3. Lower
abdominal pain because of lower gastrointestinal bleed.
4. Hyperlipidemia. We will hold her Zetia.
5. Hormonal
insufficiency. Hold her Evista at this
time.
6. Allergies,
not a problem at this time.
PLAN
We will get a C. diff.
Tylenol as needed. Dr. Meichner
has already scheduled for colonoscopy in the morning, which is probably going
to be our proof. We will get the stool
for C. diff. Continue the IV
antibiotics. Fluids, are going to
hydrate, because she is going to have to do the GoLYTELY. Follow electrolytes closely.
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