CONSULTATION FILES SET_B

CON_1B

The patient is an 86-year-old woman who was admitted for further workup and management of gradually worsening thoracic back pain for the past month or so, not responsive to a trial of higher dose prednisone.  The patient has required narcotic analgesia for the back pain and the pain has markedly compromised her quality of life.  The patient does have a questionable history of polymyalgia rheumatica and had been maintained on a very low dose of prednisone indefinitely, but she was trialed with a higher dose of prednisone within the past few weeks, but there was no improvement in her back symptoms.  The patient has had anorexia and some weight loss, but is not cachectic and has not had any fevers, chills, or sweats.  MRI of the thoracic spine done on a few days ago reveals severe compression deformity of T5 and kyphotic deformity at this vertebral level with some retropulsion, which contacts and displaces the cord.  There was also some signal alteration seen along the right pedicle that was concerning for a possible fracture and there was also noted to be edema in the T6 vertebral body and along the inferior end plate of T4 without compression deformity.  The patient’s sed rate has also been elevated for several months now.  Most recently it was 114 on April 2, 2008, it was 112 on December 31, 2007.  The patient tells of no recent falls nor andy direct trauma to the back within the past several months.  She reports no cough or pleuritic chest pain.  She has no dysuria, no diarrhea, no history of TB or TB exposure as far as she knows.

The patient has no known drug allergies.

The past medical history includes coronary artery disease, hypertension, and hyperlipidemia, as well as osteoarthritis, and degenerative joint disease.  The patient also has mild asthma, and also had history of the left-sided breast cancer, and some anxiety as well.

The medication regimen presently in the hospital includes, Colace, Senokot, subcu heparin, Lasix, p.r.n morphine, p.r.n. Lortab.

The patient had been on prednisone recently as I mentioned.  No recent antibiotics.

The past surgical history includes a left mastectomy, right hip placement, and CABG.

SOCIAL HISTORY:  The patient has no smoking history.  She does not use excessive alcohol.  She lives with her sister-in-law.  The patient was born in vicinity, and as I mentioned, has no history of TB or TB exposure as far as she knows.

The family history is not an issue at this patient’s age.

On review of systems, please see HPI.  The patient also history of some chronic lymphedema of the left arm after her mastectomy.

On physical exam, the temperature on admission today is 96.5.  This is somewhat cantankerous, but otherwise fully alert and responsive, nontoxic appearing elderly white female who is uncomfortable secondary to her back and shoulder discomfort and recently placed thoracic brace, but she is not in any acute medical distress.  Presently, the patient is not cachetic and is a bit obese.  The sclera are anicteric.  The oropharynx is clear.  Neck is supple.  No adenopathy.  Lungs are clear.  Heart exam, S1 and S2 are present.  The abdomen is moderately obese.  Bowel sounds are present.  The abdomen is soft and nontender.  No CVA tenderness.  On extremity exam, there is 1+ bilateral lower extremity edema.

LABORATORY EXAM:  Please see HPI.  White count today 7.9, hemoglobin 10.6, platelets of 347,000, sed rate from August 2, was 114.  Today’s sed rate is 105.  The creatinine 1.4, alk phos is a bit elevated at 125, transaminases are normal, total bilirubin 0.6.  The recent chest x-ray showed no evidence of any acute disease or any old evidence of TB.

ASSESSMENT AND PLAN:  The patient may very well have a thoracic vertebral disc space infection, but it is far from a certainty at this point in time, but again it is a very possibility and needs further workup.  Blood cultures have been sent as well as UA, C and S.  The patient will have a plain x-ray of the thoracic spine and also a CAT scan.  I have also ordered a gallium scan.  PPD will be planted and a blood test for TB.  The TB DNA PCR test will be done as well.  No empiric antibiotics will be given at this time, but if suspicion for infection arises over the next few days, as further workup is obtained then perhaps Rocephin will be a good empiric choice.  However, Dr. feels that because of the patient’s severe compression deformity and kyphosis that a surgical intervention may be needed for a structural reason alone, and if that needs to be done within the next few days or so, then we may benefit from starting antibiotics after that surgery when intraoperative cultures can be obtained.

I discussed my impression and plan with the patient and the patient’s daughter as well as with Dr. and Dr. .  I will follow along with you.

Thank you for the courtesy of this referral.

CON_2B 

 I  was  asked  to   see   this  75−year−old   woman   for   rectal   bleeding   and   diarrhea.

 The  patient   had   been   well  until   yesterday   morning   when   she   started   to   have   abdominal  cramping  followed   by   loose   stool.

Subsequently,  she  has  had  more  than  10  bowel   movements   yesterday   with   stool,   fresh  blood,  and  clots.   She   had   more   blood  per  rectum   this   morning   and   the   patient   was   instructed   to   come  to   the   emergency   room   for   evaluation.   Prior   to    leaving,   she   had   another  semi−formed  stool  without   any   blood   present.   She   denies  fevers  or   vomiting.   She   has   had   nausea   and  decreased  p.o.   intake.   She   was   on   Avelox   for   sinus   infection   about  2−3   weeks   ago.   She   denies   any   recent  travel   or   history   of   colitis.  She  had  a  routine  colonoscopy   done   by   Dr.  BLANK  in  May  2004,   which   showed   mild   diverticulosis.  The  patient  has   not   had   any   prior   rectal   bleeding.   She   had   an   upper   endoscopy   in  ebruary  2008,  which  showed  severe  gastritis,  status  post  Nissen  fundoplication,  which  was  intact.  The  patient  has  been  noting  sharp,  total   abdominal   pain   over   the   past   24   hours.   The   pain   is   slightly   better   now   after  a  dose  of  fentanyl  in   the   emergency   room.   She  has  had   no   recent   aspirin   or   nonsteroidal   medications.

PAST   MEDICAL   HISTORY:
1.  Hypertension.
2.  Nissen  fundoplication.
3.  GERD.
4.  Asthma.
5.  Remote  history  of   breast   cancer,   status   post   left   mastectomy.
6.  Sinus   infection.
7.  Kidney   stone   remote.
8.  Bunionectomy.
9.  Appendectomy.
10. Right   shoulder   replacement   in   August   2007.

MEDICATIONS:  Cardizem,  Advil  p.r.n.,  Advair,  Lexapro,  hydrochlorothiazide,  Klonopin,  Colace.

ALLERGY:  To  Augmentin,  sulfa,  and  clindamycin.

REVIEW  OF   SYSTEMS:   Negative   for   coronary   artery   disease  or  claudication.

PHYSICAL  EXAMINATION:   GENERAL:   The   patient   is   slightly   uncomfortable,  although  nontoxic  appearing.  His  blood  pressure  144/68  with  a   heart   rate   of  70  lying  down  and  a  blood  pressure  of  149/76  with  a  heart  rate  of  80  standing  up,  temperature  98.7,  100%  on  room  air.  Chest  is  clear  to  auscultation  bilaterally.  CARDIOVASCULAR:  Regular  rhythm.  Normal  S1,  S2  without  murmur.   Abdomen   is   obese,   soft,  diffusely  tender,  but   no   rebound   or   guarding.   There   are   hypoactive   bowel  sounds.  RECTAL  EXAM:  Notable  for  scant  blood   and   no   stool.

LABORATORY   DATA:   White   count  11.1  at  baseline,  70%  polys,  19%  lymphocytes,  hemoglobin  14.1  above  baseline,  platelet  count  236,000.   INR   1.0,   BUN   16,   creatinine   0.8.  LFTs  are  normal  with   albumin   of   3.0.

IMPRESSION   AND   RECOMMENDATIONS:   The  patient  is a  75−year−old   woman   with   a   history   of  diverticulosis,   presenting   with   diarrhea   and   rectal   bleeding  without   abdominal   pain   and   cramping.   She   has  been  on  antibiotics  recently.  Her  symptoms  are  suggestive   for   an   infectious  colitis,  possibly  C.  difficile.  Without  clear  cardiac  risk  factors,  this  less  likely  should  be  ischemic   colitis.   With   the   abdominal   discomfort,   diverticular   bleeding   is   also  ess  likely.
 

We  will  admit  the  patient  and  start  IV  hydration.  We  will  send  her  stools  for  C.  diff  culture,  O  and  P,  and  Giardia.  I  plan  to  start  empiric  p.o.  Flagyl.   I   will   hold   off   colonoscopy   and  I   have   planned   to   follow   her   clinical   course.   I   will   continue   to   follow   her   hemoglobin   and   hematocrit.