CONSULTATION FILES SET_A

 CON_1A

Bright red blood per rectum.

HISTORY:  A 78-year-old female was brought to the Hospital by ambulance this morning because of an acute gastrointestinal illness marked by nausea, diarrhea, and blood in stool.  The patient denied any chest pain, lightheadedness, or any emesis.  The patient did state that she noted some clots with her bowel movements.  The patient denies any prior history of gastrointestinal disease with the exception of some efflux, for which she takes Prevacid.  The patient recalls approximately 10 or 2 more years ago being told she had a hiatal hernia.  The patient denies any family history of colon cancer or imflammatory bowel disease.

There was a family history of diverticular disease.

ALLERGIES:  Sulfa, levaquin.

MEDICATIONS:  Prevacid, Norvasc, Avapro, Synthroid.

PAST MEDICAL HISTORY:  Non-insulin-dependent diabetes, hypertension, arthritis, hiatal hernia, GERD, shingles in 2004, Bell palsy, and glaucoma.

MEEEDICATIONS ON ADMISSION:  Pervacid, Norvasc, Avapro, Synthroid, Voltaren eye drops.

PAST SURGICAL HISTORY:  Lipoma, left buttock; arthroscopy; lumbar laminectomy; cataract; hysterectomy; appendectomy; and tonsillectomy.

PHYSICAL EXAMINATION:  Pleasant elderly female.  SKIN:  No significant lesions.  HEENT:  Oropharynx benign.  NECK:  Full range of motion.  CHEST:  Clear anteriorly.  CARDIAC EXAM:  Regular rate and rhythm.  ABDOMINAL EXAM:  Soft, positive bowel sounds.  EXTREMITIES:  No edema.

LABORATORY DATA:  Hemoglobin 10.0, hematocrit 32, MCV 65.3 (stable hemogram, thalassemia), iron 101, TIBC 342, PT 12.2, INR 1.1.  Serum electrolytes, serum chemistries are normal.

IMPRESSION:  A 78-year-old female who presents with acute gastrointestinal illness marked by diarrhea, blood per rectum, nausea.

PLAN:  In order to out neoplasm, diverticular disease, AVM, colitis, a colonoscopy is indicated.  In addition, given her long history of GERD and the fact that she has had nausea, an endoscopy would be prudent to proceed with as well.  Therefore, a thorough review of the risks, benefits, and alternatives with respect to the stool, interventions were undertaken with the patient who appears to understand the issues at hand.  The patient consents to proceeding on 4/2/08, and certainly further management and recall protocol will be based upon findings.

I do wish to thank you very much for the courtesy of this referral.

CON_2A

 A pleasant  77−year−old  smoker   with   a   history   of  peripheral  vascular  disease.

  She  has  undergone  endograft  stenting  of  abdominal  aortic  aneurysm  and  iliac  aneurysm  in  2005.  She  has  a  history  of  hypertension  as  well  as  apparently  untreated  dyslipidemia.

  The  patient  reported  that  she  had  some  teeth  pulled  early  part  of  March.  She  received  antibiotics   for   a   couple   of days,  she  began   developing   significant   diarrhea.  <>  this      This  had  blood  in  it.  This  was   associated   with   most   minimal   abdominal cramping.  She  eventually  was  presented  to  hospital.  She  was  found  to  have  C.  diff  infectious  colitis,  diarrhea  was  actually  improving.  The  patient  was  noted   to   have   minimally   elevated  troponin.  All  initial  CK  was  normal.  An   MRI   is   pending  today.  Nuclear  study  shows  a  poorly  functioning  gallbladder.  Ultrasound  also  suggested  cystic  mass  in  the  liver,  which  is  to  be  evaluated  by  MRI.  The  patient  has  no   prior   cardiac   history.   She   underwent stress  testing  prior  to  her  endograft  repair  and  showed  normal  gated  ejection  fraction   without   evidence   of   ischemia.

An  echocardiogram  was  performed  on  admission,  which  shows  normal  hypodynamic  left  ventricular  systolic  function  without  significant  valvular  disease.

  The  patient  denies   any   particular   chest   pain   or  breathlessness.   She   has   had   some   abdominal cramping  and  somewhat  poor  appetite.

  Past  surgical  history  is  also  significant  for  hysterectomy.

  The   patient   has   no relevant  family  history  or  coronary  disease  in  her  early  age.  She  has  a  history  of  hypertension.

  The  patient  is  upwards  of  2−pack  a  day  smoker.  There  is  no  history  of  alcohol  or  other  drug  use.

  There  are  no  known  drug  allergies.

  MEDICATIONS  AT  HOME:  Toprol−XL  300  mg  daily,  aspirin  81  mg  daily,  Tarka  2/240  daily,  potassium  10  mEq  daily,  iron  325  mg  daily,  and  multivitamin.

  REVIEW  OF  SYSTEMS:  Otherwise   negative.   She   has had  no  particular  fevers  or  chills.  She  had  no  skin  breakdowns.  She  has  had  no  joint  complaints.

  She  has  had  no  urinary  complaints.

  She  has  been  breathing  comfortably.  No   psychiatric   or   neurologic   problems  or  complaints.

  PHYSICAL  EXAMINATION:  Shows  an  elderly  woman  in   no   distress.   Blood pressures  seem  to  have  been  running  in  the 170-180  range.  HEENT  is  unremarkable.  She  is  normocephalic,  atraumatic.  Conjunctivae  are  noninjected.  Dentition  is  fair.  There  are  no  gross  ENT  lesions,  less  than  6  cm  of  jugular  venous  distention.  There  is  no  bruit.  Carotid  upstrokes  are  brisk  with  shotty  anterior  and  posterior  cervical  adenopathy.  No  fixed  adenopathy.  Her  lungs  are  clear  to  auscultation  and  percussion.  Her  heart  is  regular.  There  is  an  S4.  There  is  a  short  ejection  murmur  at  the  base.  There  is  no  holosystolic  murmur.  Breasts  and  pelvic  exam  are  deferred.  Abdomen  is  soft.  There  is  no  tenderness,  masses,  bruits,  guarding,  or  rebound.  There  are  active  bowel  sounds.  Soft  bilateral  femoral  bruits.  Peripheral  pulses  are  palpable.  There  is  no  edema.  Sensation  and  muscle  strength  are  grossly  intact.

  LABORATORY  DATA:  Troponin  is  0.06,  0.25,  0.16.

  EKG  shows  first-degree  AV  block.  Nonspecific  ST  changes.

  IMPRESSION:
  1.  Abnormal  troponin.  The  patient  likely  has  coronary  artery  disease;  however,  I  suspect  that  this  does  not  represent  acute  coronary  syndrome.  She  has  absolutely  no  cardiac  symptoms,  benign  ECG.  This  may  just  be  due  to  subendocardial  ischemia  with  LVH  and  hypodynamic  left  ventricle.  We  would  add  clonidine  to  her  current  medical  regimen.  I  would  favor  stress  testing  to  assess  myocardial  perfusion.
  2.  Infectious  colitis  with  workup  ongoing.
  3.  Liver  mass,  MRI  is  pending.
  4.  Electrolyte  abnormalities  are  noted  and  are  being  corrected.
  5.  Peripheral  vascular  disease.  The  patient  has  history  of  endograft  stenting.  Her  colonoscopy,  however,  is  not  consistent  with  ischemia.

  Thank  you  very  much  for  allowing  me  to  see  this  patient.

CON_3A

The patient is a 35-year-old man who is an active nasal cocaine user who was admitted yesterday for further workup and management of several months of varying degrees of cough, odynophagia, cold, “postnasal drip” and a change in vocal quality.  The patient has had a rather extensive outpatient workup including ENT evaluation to date and is status post several courses of quinolone antibiotics with the most recent course ending just a few days ago.  The patient has also had oral methylprednisolone, but only minimal therapies administered thus far.

Yesterday the patient developed recurrence of severe odynophagia yesterday after eating some lemon.

The patient had a CT of the neck performed and this showed extensive adenopathy in the neck.  The patient has had some sweating at night, but no fevers or weight loss.  His chest x-ray is clear and rapid strep and throat culture negative thus far.

The above-mentioned symptoms have been waxing and waning for a few months now.

The patient has no known drug allergies.

The past medical history includes a viral meningitis several years ago and occasional sinusitis.

The patient’s medication reegimen prior to admission includes some over-the-counter Claritin as well as some analgesics.  He was on Levaquin through Monday, March 31.

The past surgical history includes cervical disc surgery and some surgery on the left arm for a fracture.

SOCIAL HISTORY:  The patient has been an active cigarette smoker.  He admits using marijuana occasionally ,and after his wife had exited the room, acknowledged rather a long and active history of intranasal cocaine use, he denies intravenous drug use, he denies heroin use of any kind, and denies any history of sex with other women or with men.  He has worked for many years running an auto body shop including auto painting.  He is married and has 2 children living at home with him, both of whom had been well.  He traveled to Florida recently, but no more exotic destinations.  No history of tuberculosis.  He was born in the vicinity.  He was never incarcerated.  I do not believe the patient has any pets.

Family history is positive for diabetes and high blood pressure.

REVIEW OF SYSTEMS:  Please see HPI.  The patient reports no chest pain, no skin rashes, no abdominal pain, nausea, vomiting, diarrhea or dysuria.

On physical exam, the blood pressure is 137/77, heart rate 85, breathing at 20, and temperature 97.9.  This is an ill-appearing, but completely nontoxic, moderately obese white male who is no acute distress, but the general exam is notable for a very weak hoarse vocal quality.  The sclera are anicteric.  There is minimal anterior cervical adenopathy.  Neck is supple.  The oropharyngeal examination is negative for any ulcerations.  There is mild palatine tonsillar enlargement with a hint of exudates, but certainly not very prominent in my opinion.  Lung exam reveals coarse bilateral breath sounds.  There was no stridor.  HEART exam, S1, and S2 are present.  The abdomen is moderately obese.  Bowel sounds are present.  The abdomen is soft and nontender, no hepatosplenomegaly.  On extremity exam, there is no clubbing, cyanosis or edema.

LABORATORY EXAM:  Please see HPI.  White count 14.6 with no left shift.  The patient is presently on some corticosteroids.  This should be noted.  Urinalysis negative, RPR negative, HIV negative, ASO titer 153, CMV IgG negative.  Rapid strep negative.  Throat culture negative so far.

Chest x-ray negative.  CT of the neck reveals rather extensive neck adenopathy diffusely.  Liver function tests normal.  On the visualized portions of the sinuses on the CT of the neck, I do not see very active sinusitis.  There has been definitive note of extensive abnormality of his nasal septum from the cocaine as it appears.

The assessment and plan, this patient may or may not have an infectious disease problem here, but my suspicion is relatively low at this time.  He may be, however, periodically aspirating.  Esophagitis is a possibility either from candida and/or viral etiology such as HSV or CMV although the patient had no oral ulcers and had no thrush on exam.  Lymphoma was also in the differential diagnoses.  TB is very unlikely as I see it, but I suppose not impossible.  Viral etiology is also in the differential.

The plan for now will be for GI to perform EGD tomorrow.  Please limit the steroids unless absolutely necessary.  A TB blood PCR test has been ordered and is pending.  No antibiotics will be administered at this time.  The patient at some point may need a lymph node biopsy.  I have also requested a bedside swallow evaluation.

I discussed my impression and plan with Dr. and with the patient.  I will follow along with you.

Thank you for the courtesy of this referral.

CON_4A

An 80-year-old female presented to the emergency room, at the request of Dr., today because of anemia.  The patient had some blood work drawnn in preparation for her annual physical exam.  She was noted to have significant low MCV anemia, see below, and then was advised to present to the emergency room.  The patient states she has been somewhat fatigued and mildly short of breath of recent days and weeks.  The patient denies any melena, hematemesis, abdominal pain, unintentional weight loss, jaundice, fevers or chills.  The patient does take one aspirin daily, however, she denies any other nonsteroidal anti-inflammatory medications aside from the very rare Advil.

The patient states that she has had colonoscopies in the past on 4/30/03.  Dr. removed an adenomatous and hyperplastic polyp, her most recent colonoscopy occurred on February 24, 2004, no recurrent polyps noted, however, diverticulosis had been noted.  The patient states her appetite has been good lately, and there has really been no other acute medical issue.

ALLERGIES:  None.

MEDICATIONS:  Aspirin 325 mg p.o. daily, Lipitor 20 mg p.o. daily.

PAST MEDICAL HISTORY:  Hyperlipidemia, left ankle surgery, and degenerative joint disease.

PHYSICAL EXAMINATION:  Chatty, pleasant animated white female in no apparent distress.  Weight 206 pounds, temperature 97.5, blood pressure 143/61,heart rate 83 and regular, and respiratory 20.  SKIN:  Pale.  HEENT:  Oropharynx benign.  NECK:  Full range of motion.  CHEST:  Clear anteriorly.  Cardiac exam regular rate and rhythm.  Abdominal exam, soft, positive normal bowel sounds.  EXTREMITIES:  Notable for osteoarthritic changes.

LABORATORY DATA:  White blood count 8400, hemoglobin 7.6, hematocrit 25.6, MCV 65.1, platelet count 215,000, 48 segmented neutrophils, 45.3 lymphocytes, 0 bands (hemoglobin 13.6, hematocrit 41.4, MCV 89.6 all on April 4, 2007, one year ago).  Coagulation performs normal.  Chemistry is normal sanctum, hyperglycemia with glucose of 179.

IMPRESSION:  An 80-year-old female present because of a low MCV anemia, symptomatic (colon polyps are noted).

PLAN:  In order to a gastrointestinal focus for the patient’s blood work, a colonoscopy, and endoscopy are indicated.  The patient would undergo <_____> this evening, colonoscopy and endoscopy schedule for 4:05 awaits and certainly further management we did for the findings.

I do wish to thank you very much for the courtesy of this referral.

CON_5A

CHIEF COMPLAINT:  Dizziness, low blood pressure.

HISTORY:  The patient is an 82-year-old male with known history of atrial fibrillation, COPD, and dementia, who recently was admitted to Hospital on April 3, 2008, with a complaint of weakness and dizziness.  At that time, he was noted to have and elevated heart rate of 150.  The patient had recently had a discontinuation of his Cardizem reportedly.  The patient was seen in the emergency room by medical doctors at Hospital, and with IV diltiazem, the patient had reduction in heart rate.  The patient at that time was admitted to Telemetry for further monitoring.  At that time, chest x-ray showed possible left lower lobe infiltrate though patient had normal saturations.  The patient had good rate control with p.o. Cardizem in house, subsequently was discharged on April 4, to for assisted living facility.

The patient on review with nursing staff had been stable there.  Subsequently this morning, the patient was given 240 mg of p.o. diltiazem.  The patient had eaten a full breakfast subsequently though shortly after taking his dilitiazem, he began to feel dizzy, lightheaded, clammy, complaining he was feeling weak.  Nurses at that time checked his blood pressure, which was approximately 90/60.  Heart rate was controlled below 100.

The nursing staff paged me.  I reviewed with them the patient had no chest pains, palpitation or shortness of breath.  On sitting down, the patient was more comfortable.  Nursing staff was instructed to lay the patient down, check blood sugar, reassess BP shortly, and we reviewed with the nursed.  Subsequently the patient was noted to have a sugar of 127 after eating.  Pulse rates continued to remain below 100.

We reviewed though the nurses noted that the blood pressure was even lower, approximately 60/40, patient though seemed to be mentating well though still reported feeling somewhat weak.  No other symptoms were noted.

Nurses were instructed to recheck the blood pressure one more time, and if pressure remain low, to send the patient to hospital emergency room for further evaluation.  The patient had no other acute findings.

On review of systems with the nurses, no unusual nausea, vomiting, fevers, chills, sweats, shortness of breath, chest pain, falls, change in mental status, melena, hematochezia, or other conditions that were notable.

The patient on presentation to the emergency room was noted initially to have a temperature of 97.8, BP 94/49, pulse 76, and respiratory rate 24.  The patient though was mentating and alert, patient’s past medical history, but given low BP and recent admission and recent addition of diltiazem, it was felt that he would be best observed for further observation and re-review of blood pressure and medication management.

The patient’s past medical history, as stated is significant for chronic obstructive pulmonary disease, pneumonia, atrial fibrillation, glaucoma, cataract surgery, and dementia.  He recently had admissions for pneumonia.  He has had progressive deterioration in dementia over the last several months now prompting transition to the assisted living facility.

The patient’s surgeries include cataracts and glaucoma surgeries.

He reportedly has no known drug allergies.

SOCIAL HISTORY:  The patient is married.  Wife also has dementia and recently has been transferred to a nursing home also.  The patient is a former smoker over 40 years, but quit more than 25 years ago, drinks alcohol approximately 1 drink per day.  Mother apparently passed away at 88 and father passed away at 88 of heart disease.

CON_6A

years old woman who is a long-term nursing home resident who has prominent dementia, who is admitted very early this morning with increased lethargy and some fever.  The patient had been on Bactrim initially and then Cipro at the nursing home for treatment of a UTI with a recent urinalysis showing pyuria and urine culture with mixed gram-negative and gram-positive flora.  The patient unfortunately is quite demented and is unable to provide any direct input into her history presently.  The patient was given the dosage of Zosyn and vancomycin after cultures were sent and the patient was also placed on stress dose steroids given her chronic alveit low-dode prednisone for polymyalgia rheumatica.

The patient has no known drug allergies.

The past medical history includes hypertension, dementia, polymyalgia rheumatica, osteoporosis, osteoarthritis, and spinal stenosis.

The medication regimen at the nursing home included hydrochlorothiazide, Zoloft, Advair, eyedrops, calcium, Seroquel, some p.r.n. medications, Bactrim for 4 days followed by Cipro for a week, Actonel, prednisone 5 mg every other day, Diovan.

The past surgical history includes left carpal tunnel surgery and right carpal tunnel surgery.

SOCIAL HISTORY:  The patient is a long-time nursing home resident.

FAMILY HISTORY:  Not an issue at this patient’s age.

On review of systems, please see HPI.  There is no definitive report of diarrhea, but I will need to investigate this further.  No definite vomiting.  The patient, I believe, does have some incontinence.

On physical exam, blood pressure is 138/71, heart rate 89, breathing at 24, temperature 97.1 with a T max thus far 101.5.  This is an ill-appearing, confused, and demented elderly white female who is nonetheless in no acute distress apparently.  She is awake, but is only able to moan periodically and can barely if at all follow very simple commands reliably.  The patient is anicteric.  The neck is without nuchal rigidity.  The lung exam reveal a few bibasilar crackles, left greater than right.  Heart exam S1 and S2 are present.  The abdomen is slightly distended.  Bowel sounds are present.  The abdomen is soft.  There is minimal right upper quadrant, and perhaps trace diffuse tenderness of the abdomen.  No CVA tenderness.  Foley catheter is in place.  On extremity exam, there is minimal bilateral lower extremity edema.

LABORATORY EXAM:  Urinalysis is negative for pyuria.  White count 11.5, hemoglobin 12.2, and platelets are 359,000,  Creatinine 2.8.Flu wash negative.  Urine and blood cultures negative thus far at this early time point.  ALT 93, AST 71, and total bilirubin 0.5.

Chest x-ray one view shows no definite pneumonia in my opinion.

ASSESSMENT/PLAN:  This elderly nursing home resident with dementia presents with fever and mild leukocytosis and has minimal abdominal tenderness.  C. diffile colitis is certainly possible, I suppose cholecystitis is also possible, but much less likely.  The patient may also very well be aspirating periodically as well.

For now, al antibiotics will be discontinued and we will follow the patient off of antibiotics closely especially since C. difficile is a very real possibility here.  Stool will be sent to C. diff.  Urine and blood cultures will be followed up closely.  I agree with the plan for CT of the abdomen and pelvis and this will also allow us to examine the lung bases as well.  If possible, I would try to decrease if not discontinue the stress dose steroids.

I discussed my impression and plan with Dr.  I will follow along with you.

Thank you for the courtesy of this referral.

 CON_7A

This patient is an 85-year-old gentleman who I am asked to see in neurology consultation for advice and opinion regarding bradykinesia, stiffness, shuffling gait, and soft voice.  The patient has been admitted for gait ataxia and a recent fall.  He does have quite a bit of stiffness and has difficulty with using his knife and fork and buttoning buttons.  His handwriting is getting smaller.  He shuffles when he walks.  He has stopped posture.  He has decreased facial expressions and decreased eye blinks.  I am asked to see him regarding the possibility of Parkinson’s disease, which I think is very probable.

His past medical history is significant for aortic valve disorder, dorsal kyphosis, carotid artery disease, bilateral inguinal hernia, bilateral deafness, history of DVT, tricuspid regurgitation, aortic regurgitation, bilateral cataracts, benign prostatic hypertrophy, diastolic dysfunction, and congestive heart failure.

He denies any chest pain, shortness of breath, abdominal pain, hematochezia, hematuria, headaches, nosebleed, or rash.

Family history is noncontributory.

PERSONAL AND SOCIAL HISTORY:  He is divorced.  Does not use alcohol or tobacco.

MEDICATIONS:  Include aspirin, Colace, Lasix, Tkheragran, and Klor-Con.  He has no known drug allergies.

On physical examination, his temperature us 36.0 degrees Celsius, pulse 68, respirations 18, and blood pressure 133/71.  CHEST:  Clear.  HEART:  S1, S2.  He is oriented to person, place, and to time.  His speech is fluent and spontaneous, although is voice is very weak.  His skull is normocephalic and atraumatic.  His spine is unremarkable.  Cranial nerves show masked facies.  He has a positive Stellwag’s sign.  On motor examination, he has stiffness and cogwheeling of his right upper extremity.  He has generalized weakness.  His sensory examination is intact.  On coordination testing, he has a stooped posture and shuffling gait and uses a walker.  Deep tendon reflexes are 1+ and symmetric.

The patient is an 85-year-old gentleman with a history and physical examination consistent with Parkinson’s disease.  I will get a CT scan of the brain, EEG, and some labs looking for other explanations for his Parkinson’s picture, although Parkinson’s disease seems to be less likely.  I will start him on some Mirapex and follow with you.

Please see orders for details of these plans.  He will follow with you.

Thank you for the consultation.

CON_8A

     Reason  for  consult  is   abdominal   pain   and  suspected  colitis.

 HISTORY:  The  patient  is  44  years  old.  She  is  admitted  through   the   emergency   room.   She   is   complaining  of  diffuse   rather   severe   abdominal   pain   and   tenderness.   Pain  has  been  present  for   almost   2   weeks   and   this  may   be   worse   in   the  lower  abdomen,  but  does  not  localize.  She  has  had   some   nausea,   but does  not  vomit.  She  has   eaten   very   little   in   2   weeks   and   has  had  a  little  stool,  what  stool  she  has,  has  been  loose  in   nature   and   not bloody.  In  the  emergency  room,  she  was  febrile  with  a  temperature  of  38.4.  Her  white  count  was  elevated  at  17,800.  Abdominal x−rays  were  unremarkable  without  free  air,  but  a   CT  x−ray   shows   edema   or   thickening   of   her   colon.

The  patient   was   hospitalized   in   May  of  2008   also   with   abdominal   pain   and   diarrhea. At  that  time,  evaluation  found  gallstones.  On  a  HIDA  scan,  there  was  nonvisualization  of  her  gallbladder.  The  CT  also  showed  thickening  of  her  colon  and  she  was  found  to  have  acute  colitis.  She  was  again  treated  with  antibiotics.  On  5/28,  her  flexible  sigmoidoscopy  was  normal.  She  had  followed  up  with  Dr.  in  our  office.  He  obtained  inflammatory  bowel  disease  markers,  which  were  completely  normal.  In  August  of  2008,  the  patient  underwent  a  laparoscopic  cholecystectomy  by  Dr.  .  An  operative  cholangiogram  was  normal.  She  recovered  from  her  gallbladder  surgery  and  generally  felt  well.  She  was  well  until  about  2  weeks  prior  to  admission  when  her  pain  and  diarrhea  recurred.

  Her  past  history  is  notable  for  the  question  of  colitis  in  May  of  08  and  prior  laparoscopic  cholecystectomy.

  Prior  to  admission,  her  only  medication  was  Allegra.

  She  is  allergic  to  aspirin.

  Family  history  is  unremarkable  for  inflammatory  bowel  disease.  There  is  a  family  history  of  heart  disease,  hypertension,  and  diabetes.

  The  patient  does  not  smoke.  She  denies  any  significant  alcohol  use.

  Review  of  system  is  significant  for  generalized  pain,  tenderness  in  her  abdomen,  fever,  weakness,  and  malaise.  She  has  had  some  nausea,  but  no  vomiting.  She  denies  chest  pain,  breathing  difficulty,  or  joint  pain.

  Physical  exam  reveals  a  young  female,  in  no  distress.  She  is  febrile  with  a  temperature  of  38.4,  pulse  is  104,  and  blood  pressure  is  116/78.  Her  chest  is  clear.  Cardiac  exam  reveals  a  regular,  rapid  rhythm.  Abdomen  is  diffusely  tender.  Bowel  sounds  are  active.  There  is  some  voluntary  guarding,  but  no  rebound  tenderness  is  noted.

  In  summary,  the  patient  is  44  years  old.  She  is  admitted  with  abdominal  pain,  fever,  some  loose  stools,  and  a  CT  that  shows  thickened  colon  raising  concern  of  colitis.  We  have  never  documented  true  ulcerative  colitis  and  her  sigmoidoscopy  in  May  2008  was  normal  and  IBD  markers  have  been  negative.

  PLAN:  At  this  time,  she  has  been  started  on  Flagyl  and  Cipro.  She  is  receiving  Dilaudid  for  pain.  I  will  prescribe  Zofran  for  nausea.  I  will  attempt  a  bowel  preparation  today  and  schedule  colonoscopy  for  03/13.

CON_9A

Reason for consult is vomiting.

  HISTORY:  The patient is 86 years old.  He is admitted with persistent vomiting that has been present for almost 2 weeks.   He cannot tolerate even solids or liquids.

   He does complain of some mid abdominal pain, but it is not localized or severe. He has been moving his bowels regularly.  He has never vomited blood.  He has not had bloody stools, but he cannot tolerate food or liquids.

  The patient was hospitalized in January of 2009 with concern of coffee−ground emesis. An upper endoscopy at that time   demonstrated a very large hiatal hernia with antral gastritis   and erosions. Biopsies of the antrum are negative for Helicobacter.  At discharge, he was tolerating a cardiac diet.   His hemoglobin was 10.3. He was on Prilosec.

 Past   history   is  notable   for   hypertension,   coronary  artery  disease  with  prior  bypass  surgery.  He  has  had  hyperlipidemia,   prostate   cancer,   prior   stroke,   and   tonsillectomy.

He  does  report  allergy  to  penicillin.

 Family   history   is   unremarkable   for  GI  problems.

  He  is  a  pipe  smoker.  Apparently,   he   does   drink occasionally  and  had  100%  vodka,  which  seemed  to  cause  some  GI  upset,  but  he  does   not   drink   on   a   regular   basis.

Physical  exam  reveals  an  elderly  frail  male,   in   no   acute   distress.  He  is  afebrile.  Pulse  is  64  and  blood  pressure  is   136/64.   Chest   is airly   clear.   Cardiac   exam   is   normal.  The  abdomen  is  soft.  Bowel  sounds  are  active.  He  has  mild  tenderness,  but  no  guarding  or  rebound.

  LABORATORY  STUDIES:  His  white   count   is   6.8,   hemoglobin   is   10.8, and  platelet   count   is   236,000.   Serum   electrolytes   are   normal.   BUN   is   36,   creatinine   is   1.2.

IMPRESSION:  The  patient  is  86  years  old.  He  presents  with  vomiting.  He   is   known   to   have   a   very   large   hiatal   hernia.   An upper GI   was   just   completed   and shows  nearly  50%  of  the  stomach  or  even   more   herniated   into   the chest.  There has been no stricture  and  no  obstruction.  The barium does pass into   the   small   bowel.  I suspect his   vomiting   relates   to   the   large   hernia   with   spontaneous reflux.

PLAN:  I will treat with IV Protonix and Reglan.  We will allow a   liquid   diet.  We check his liver tests, amylase.  Dr.  will be  seeing  this  patient  to   consider   surgical   repair   of   his  large  hiatal   hernia.

CON_10A

 is  a  73−year−old  female  I  saw  in  the  office  last  week.  She  has  a  known  history  of  paroxysmal  atrial  fibrillation.
  She  states  that  Saturday,  she  developed  rapid  heart  rate,  felt  somewhat  lightheaded.  No  frank  syncope.  She  rechecked  it  later  in  the  day.  It  was   the   same   and  her  symptoms  did  not  improve,  and  her  palpitations  continued.  She  presents  to  the  emergency  room  and  was  found  to  be  in  rapid  AFib  and  admitted  in  that  regard.

  Past  medical  history  is  positive  for:
  1.  Mitral  valve  prolapse,  status  post  mitral  valve  repair.
  2.  Paroxysmal  atrial  fibrillation.
  3.  Hypertension.
  4.  Pacemaker.
  5.  Long-term  anticoagulation.

  Medications  at  home  include  aspirin,  Zocor,  metoprolol,  lisinopril,  and  Coumadin.

  Allergies  to  sulfa.

  SOCIAL  HISTORY:  No  smoking  or  heavy  alcohol.

  FAMILY  HISTORY:  Noncontributory.

  REVIEW  OF  SYSTEMS:  As  stated  above,  otherwise  unremarkable.

  EXAM:  A  pleasant  female,  in  no  acute  distress,  now  in  sinus  rhythm.  Blood  pressure  130/70,  heart  rate  70,  and  respirations  18.  HEENT  is  unremarkable.  Neck  is  supple.  No  JVP.  No  carotid  bruits.  Lungs  are  clear.  Heart  is  regular,  soft  aortic  flow  murmur.  Abdomen  is  soft  and  nontender.  EXTREMITIES:  No  edema.  NEUROLOGIC:  Nonfocal.  INTEGUMENT:  No  lesion.

  Workup  is  as  per  chart.

  IMPRESSION:
  1.  Afib,  rapid  rate,  now  converted  to  sinus.
  2.  History  of  PAF.
  3.  Mitral  valve  replacement.
  4.  Hypertension.
  5.  Pacemaker.

  PLAN:  Discharged  home.  Same  medications,  but  add  amiodarone  400  mg  a  day  for  a  week  and  then  200  mg  a  day,  to  see  if  we  can  maintain  sinus  rhythm.  Follow  up  in  the  office  in  2  weeks  to  readjust.

 CON_11A

 REASON  FOR  CONSULTATION:  Acute  renal  failure,  low  urine  output.

  REASON  FOR  HOSPITALIZATION:  Possible   UTI   with   sepsis.  The  patient  is  currently  intubated,   cannot   give   history.   Chart  was  reviewed.

  Data  reviewed.

  HISTORY:   This   is   an  85−year−old   patient    who  was  admitted  through  the  ER.   He   is   a   nursing   home   resident.  Apparently,   he   was   admitted with  a  diagnosis  of  "sepsis",  elevated  troponins,  pressure  ulcers,  and  right  lower  infiltrate.  The  patient   was   noted   to   be   hypotensive   in   ER  and   is   known   to   be   diabetic.

   His   admission   BUN  was  27,   creatinine   1.72,   calcium   8.8,  total  protein  5.8,  albumin  3.0,  and  alkaline  phosphatase  is   140.   His   PT   was   59,  and  INR  was  1.3.  Apparently,   the   patient   did   present   with   fever   up   to   104.   The  patient  was  also  noted  to  be  somewhat  tremulous.

   His   past   medical   history   is   remarkable   for  dementia,   dysphagia,   history   of aphasia,   history   of   previous  pneumonitis,   and   pneumonia,   history   of  gastroesophageal   reflux   disease,   history   of   previous feeding  tube  placement  on  9/06,  history  of  type  2  diabetes,  and  history  of  peripheral   neuropathy.

   Home   medications   prior   to   admission  include  Neurontin  100  mg  twice  a  day,  Allegra  180  mg  per  day,  Aricept  10  mg  per  day,  glyburide  5  mg  daily,  Desyrel  25  mg  at  bedtime,  Flonase  1

  spray  right  nostril  twice   a   day,   and DuoNeb  unit  inhalation  as  needed.

  Review  of  systems  is  as  per  HPI  and  chart  currently  is  unavailable  because  the  patient  is  intubated.

   Additional   medications   at   the   present   time   have   included Invanz   and   Levaquin.

   Most   recent   lab   data  from  this  morning,  ABG  showing  a  pH  of  7.35,  PCO2  of  34,  PO2  of  328,  100%  saturation   and   this   was   on   100%    FiO2.  His  troponin  is  slightly  elevated  at  2.5.  Serum  myoglobin  is  1829.

  His   chest  x−ray   did   not   show   any   pneumonia   or   known  pneumothorax  actually.  His  blood   cultures   are   so   far  are  showing  some  possible  gram-negative  rods  apparently.  His  urinalysis  showed  a  large  amount  of  leukocyte  esterase,  5-10  wbcs,  2+  bacteria,  10-15  rbcs  per high-power  field,  moderate  blood,  30  mg/dL  protein.  His  BNP  was  701.  His  baseline  creatinine  was  1.72;  alkaline  phosphatase  140,  glucose  was  118,  potassium  of  4.0.  Chest  x-ray  from  3/19,showed  possible  mild  CHF.

  PHYSICAL  EXAMINATION:  The  patient  is  on  the  ventilator.  His  paracentral  line  in  place,  right  IJ.  His  lungs  show  some  basilar  rales  right  more  than  left.  His  extremity  shows  no  edema.  His  abdomen  is  soft,  nontender.  Bowel  sounds  are  active.  Extremity  shows  no  edema.  A  Foley  catheter  in  place.

  His  most  recent  lab  data  from  this  morning  showed  a  BUN  of  38,  creatinine  1.9,  calcium  7.1,  hemoglobin  12.5,  hematocrit  36.8,  white  count  is  37,000,  polys  35,  bands  32,  lymphs  1.

  IMPRESSION:  This  patient  probably  has  acute  renal  failure  likely  sepsis  underlying  diabetes.  The  patient  was  hypotensive  and  febrile.  He  does  have  apparently  some  gram-negatives  in  the  blood.  According  to  ID  note,  the  patient  did  have  septic  shock  requiring  pressors.

  PLAN:  Continue  IV  fluids.  Check  his  CVP.  Continue  IV  antibiotics.  Check  an  ultrasound  of  the  kidney.  Monitor  renal  function.  There  is  no  emergent  need  for  dialysis  at  the  present  time.  I  will  make  further  recommendation  after  the  above  database  is  complete.