Age: 59.0
Sex: F
Vaccine: FLU4
Symptoms: Abdominal distension, Abdominal pain lower, Abdominal tenderness, Acute kidney injury, Alanine aminotransferase normal
Clinical narrative: Document Type: History and Physical  Document Subject: History & Physical Note  Performed By: MD on November 12, 2023 15:19  Verified By: MD on November 12, 2023 15:19  Encounter Info: Hospital, Inpatient, 11/12/23 -   * Final Report *          History of Present Illness/Subjective    Patient is a 59-year-old female past history significant for hyperlipidemia, prediabetes, and anxiety with depression present emergency room with a 3-week history of watery diarrhea. Patient states she was in her normal state of health up until 3 weeks ago. She notes that time she had evidence of diarrhea. Initially was intermittent but loose. Over time the diarrhea became more watery and more regular with multiple voluminous diarrhea spells throughout the day. Over the last 2 weeks has become increasingly more weak. She has lost over 15 pounds as a result. She had some intermittent lower abdominal cramping. No symptoms of melena, bright blood per rectum or dark tarry stools. She denies any chest pain or shortness of breath. She has had several episodes of nausea as of late. In the last week has become increasingly more orthostatic with arising with positional changes. She been feeling progressively weakened. As result she presented to the walk-in clinic on the 10th where she was advised to hydrate and stool studies are pending. Over the last 48 hours her symptoms have worsened to the point that she had to come in for further evaluation due to weakness. Overall her symptoms have lasted approximately 3 weeks. She denies a fever or chills. No melena or bright red blood per rectum or tarry stools. She took Pepto-Bismol with only transient relief. She has not been on any antibiotics recently. She has not been around anybody who has been ill. Her daughter who had some loose stools for 3 days but this is since resolved. She does not work in healthcare.  In the emergency room her blood pressure was 83/63, heart rate was as high as 151 bpm, respiratory rate as high as 34, temperature 36.8 with O2 sat 95% on room air.  Serology: White count 23,200 with left shift hemoglobin 15.4 hematocrit 45.6 and a platelet count of 232,000. Sodium 132 potassium 3.9 chloride 97 bicarb 20 BUN 15 creatinine 1.71 and a blood sugar of 193. Calcium 8.5 alkaline phosphatase 52 ALT 12 AST 16 total bilirubin 0.9 total protein 6.2 albumin 3.4 lipase of 5 serum lactate 3.7. Stool sample positive for C. difficile. CT scan of the abdomen pelvis without contrast showed significant abnormal wall thickening and mucosal edema of the entire colon suggestive of pancolitis. A previously administered oral contrast media seen with no bowel obstruction and the small bowel segments were found to be unremarkable. COVID PCR pending  Past medical history: Prediabetes, hyperlipidemia, autoimmune pulm cytopenia, anxiety and depression  Review of Systems    All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI.  Physical Exam/Objective Vitals & Measurements most recent past 24 hours T: 36.8 °C (Oral) BP: 94/70 HR: 121 (Monitored) HR: 121 (Peripheral) RR: 28 SpO2: 93% Oxygen Therapy: Nasal Cannula Oxygen Flow Rate: 2 (L/min) WT: 64.80 kg (WFC)   Hemodynamics  Neurologic Glasgow Coma Score: 15  Patient Weight Current Daily Weight: 64.8 kg 11/12/23  Patient Height Current Height: 157.2 cm 11/12/23       General: Alert and oriented, No acute distress. Eye: Extraocular movements are intact, Vision unchanged HEENT: Normocephalic, Normal hearing Neck: Supple, Non-tender Respiratory: Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness. Cardiovascular: Regular rate, Normal rhythm, No murmur, No gallop, Normal peripheral perfusion, Good pulses equal in all extremities, No edema. Gastrointestinal: Soft, diffuse bilateral abdominal tenderness, mildly distended, normal bowel sounds, no evidence of hepatosplenomegaly. Lymphatics: No lymphadenopathy neck Musculoskeletal: Normal range of motion, Normal strength Integumentary: Warm, Dry, No rash. Feet: Normal by visual exam, Normal pulses, Sensation intact. Neurologic: Alert, Oriented, Normal motor function Psychiatric: Cooperative, Appropriate mood & affect, Normal judgment.    Assessment/Plan      1. Colitis due to Clostridium difficile A04.72 Patient presents with acute C. difficile pancolitis with secondary severe sepsis, orthostatic hypotension, dehydration, weight loss and precipitated SVT. Uncertain trigger this appears to be community-acquired C. difficile. She was started on oral vancomycin and IV Flagyl therapy. We will also start probiotic therapy. Given the volume of diarrhea soon we will start low-dose of Colestid to see if this helps improve her symptoms to help improve her dehydration. We will continue close monitoring of leukocytosis and volume status. Consider GI consultation if symptoms persist.   2. Diarrhea R19.7 As above. Work-up including culture pending at this time.   3. Severe sepsis R65.20 Patient feels criteria for severe sepsis with C. difficile being the source with pancolitis.IV fluid rehydration has been started. Sepsis bundle has been initiated. Culture data pending. IV fluid rehydration will be started with lactated Ringer's. She was placed on appropriate antibiotic therapy for C. difficile.   4. SVT (supraventricular tachycardia) I47.10 Patient 1 point presented with SVT. She came in tachycardic which increased. She has had intermittent tachycardia since she became dehydrated and over the last week or so. She was given a dose of adenosine. This is since resolved. She is currently has sinus tachycardia we will monitor this while hydrating.   5. Hypotension I95.9 Patient's profound hypotension with dehydration and orthostasis. She placed intensive care setting. We will be starting her on IV fluid rehydration and consider Levophed if symptoms persist or decline. She has evidence of hemoconcentration of her hemoglobin as well.   6. Renal insufficiency N28.9 Presenting now with acute kidney injury secondary to prerenal azotemia and dehydration likely associated from her C. difficile confounded by severe sepsis. We will continue IV fluid rehydration and monitor closely. If there is further decline we will ask nephrology to see her in consultation.   7. Prediabetes R73.03 Noted. A1c pending. We will not be initiating CDA protocol. We will continue to follow with daily testing. Carb controlled diet.   8. Anxiety and depression F41.9 Noted. Stable at this time. We will titrate in patient's home medication.   9. Autoimmune thrombocytopenia D69.3 Noted. Patient follows up with hematology. Currently under surveillance.   Home medications were reviewed and appropriate medications ordered at this time. GI and DVT prophylaxis have been addressed.  Total critical care time: Approximately 45 minutes?severe sepsis/C. difficile colitis/acute kidney injury/SVT Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient's response to treatment; frequent reassessment; and, discussions with other providers. This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time.  Code Status  None Recorded  Chronic Problem List   Anxiety and depression  Autoimmune thrombocytopenia  Colitis due to Clostridium difficile  Diarrhea  History of abnormal cervical Papanicolaou smear  History of endometriosis  History of neutropenia  Hyperlipidemia  Left hand pain  Low hemoglobin  Normal routine physical examination  Osteoarthritis of carpometacarpal joint of left thumb  Osteoarthritis of carpometacarpal joints of thumbs, bilateral  Prediabetes  Right carpal tunnel syndrome  Right hand pain  Routine health maintenance  Severe sepsis  Procedure/Surgical History ?LT Thumb CMCA w/FCR TT (09/06/2023) ?Carpal tunnel syndrome of right wrist (09/01/2019) ?colonoscopy (11/30/2017) ?Mammogram (12/15/2015) ?FOB - Fecal occult blood screening (11/19/2015) ?Ablation (11/04/2014) ?HPV typing (09/22/2014) ?Pap smear for cervical cancer screening.... (09/22/2014) ?Endometrial biopsy (09/23/2013) ?Screening for Chlamydia trachomatis (09/20/2013) ?Surgery (2000) ?Cesarean delivery (1987) ?TL - Tubal ligation (1987) ?Cesarean delivery (1986)   Surgical History Internal 11/30/2017 Colonscpy Diagnostic/Screen MD  Medications  Home Medications (7) Active busPIRone 5 mg oral tablet 5 mg = 1 Tablet, Orally, TID Crestor 20 mg oral tablet 20 mg = 1 Tablet, Orally, QHS Estrace Vaginal Cream 0.1 mg/gm 1 GM, Vaginally, 2x/WK multivitamin 1 Tablet, Orally, Daily Unknown Med , Vitamin B12 Vitamin D3 (cholecalciferol) , Orally Zoloft 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications None Reported  One-Time Medications Given 11/11/23 00:00:00 TO 11/12/23 15:19:32 adenosine, Injection, 6 mg, IV Push, ONCE, (1 DOSE 11/12/23 12:27:00) Cipro, Infusion, 400 mg, IVPB, ONCE, (1 DOSE 11/12/23 11:39:00) fentaNYL, Injection, 50 mCg, IV Push, ONCE, (1 DOSE 11/12/23 10:13:00) Flagyl, Infusion, 500 mg, IVPB, ONCE, (1 DOSE 11/12/23 11:41:00) ondansetron, Injection, 4 mg, IV Push, ONCE, prn, Nausea/Vomiting IV - Use First, (1 DOSE 11/12/23 10:13:00) Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 500 mL, IVPB, ONCE, (1 DOSE 11/12/23 10:36:00) Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 11/12/23 10:36:00) Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 500 mL, IVPB, ONCE, (1 DOSE 11/12/23 12:15:00) vancomycin (vancomycin 125 mg oral capsule), Capsule, 125 mg, Orally, ONCE, (1 DOSE 11/12/23 12:38:00)  PRN Medications (0600 - 0559) from 11/11 - 11/12 fentaNYL, 50 mCg, IV Push, Q10min, 0 Dose(s)  Allergies  Robitussin (diff breathing, hives)  codeine (mood swings)  Social History   Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Employed, Work/School description:   Exercise   Exercise type: Walking.   Home/Environment   Moved in with boyfriend recently (He had a stroke), Lives with Significant other. Feels unsafe at home: No.   Nutrition/Health   Diet: Regular. Caffeine intake amount: Tea, soda.   Sexual   Sexually active: Yes.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History  Breast cancer: Grandmother (M) (Dx at 50).  Cancer of lung...: Grandfather (M).  Cervical dysplasia: Sister.  Diabetes mellitus type 2: Father and Sister.  Endometriosis: Mother.  Heart disease..: Father.  Hyperlipidemia..: Father and Sister.  Hypertension..: Mother.  Myocardial infarction...: Father.  Stroke: Sister.  Lab Results   All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 23.2 k/cumm High (11/12/23 10:07:00) RBC: 5.12 million/cumm (11/12/23 10:07:00) Hgb: 15.4 GM/dL High (11/12/23 10:07:00) Hct: 45.6 % (11/12/23 10:07:00) MCV: 89 fL (11/12/23 10:07:00) MCH: 30 pg (11/12/23 10:07:00) MCHC: 33.7 GM/dL (11/12/23 10:07:00) RDW: 13.8 % (11/12/23 10:07:00) Platelet: 232 k/cumm (11/12/23 10:07:00) MPV: 8.7 fL (11/12/23 10:07:00) Band: 13 % (11/12/23 10:07:00) Neutrophil: 67 % (11/12/23 10:07:00) Lymphocyte: 10 % (11/12/23 10:07:00) Monocyte: 10 % (11/12/23 10:07:00) Absolute Band: 3 k/cumm High (11/12/23 10:07:00) Absolute Neutrophil: 15.4 k/cumm High (11/12/23 10:07:00) Abs Lymphocyte: 2.3 k/cumm (11/12/23 10:07:00) Absolute Monocyte: 2.3 k/cumm High (11/12/23 10:07:00) RBC Morphology: See description UC (11/12/23 10:07:00) Polychromasia: Slight. (11/12/23 10:07:00) Schistocyte: Few (1+). (11/12/23 10:07:00) Platelet Estimate: Adequate. (11/12/23 10:07:00) Platelet Morphology: See Comment. (11/12/23 10:07:00) Chemistry: Sodium SerPl QN: 132 mmol/L Low (11/12/23 10:07:00) Potassium SerPl QN: 3.9 mmol/L (11/12/23 10:07:00) Chloride SerPl QN: 97 mmol/L Low (11/12/23 10:07:00) Carbon Dioxide SerPl QN: 20 mmol/L Low (11/12/23 10:07:00) Anion Gap: 15 mmol/L High (11/12/23 10:07:00) BUN SerPl QN: 18 mg/dL (11/12/23 10:07:00) Creatinine SerPl QN: 1.71 mg/dL High (11/12/23 10:07:00) Estimated GFR (CKD-EPI, no race): 34 mL/min/1.73m2 Low (11/12/23 10:07:00) Estimated CRCL (CG): 31 mL/min Low (11/12/23 10:07:00) Glucose SerPl QN: 193 mg/dL High (11/12/23 10:07:00) Calcium Total SerPl QN: 8.5 mg/dL (11/12/23 10:07:00) Alkaline Phos SerPl QN: 52 Units/L (11/12/23 10:07:00) ALT SerPl QN: 12 Units/L (11/12/23 10:07:00) AST SerPl QN: 16 Units/L (11/12/23 10:07:00) Bilirubin Total SerPl QN: 0.9 mg/dL (11/12/23 10:07:00) Total Protein SerPl QN: 6.2 GM/dL Low (11/12/23 10:07:00) Albumin SerPl QN: 3.4 GM/dL Low (11/12/23 10:07:00) Lipase SerPl QN: 5 Units/L Low (11/12/23 10:07:00) Lactate Venous Pl QN: 3.7 mmol/L High (11/12/23 10:07:00) Anion Gap, POC: 20 mmol/L (11/12/23 10:14:00) CO2, POC: 19 mmol/L Low (11/12/23 10:14:00) BUN, POC: 16 mg/dL (11/12/23 10:14:00) Chloride, POC: 97 mmol/L Low (11/12/23 10:14:00) Creatinine, POC: 1.7 mg/dL High (11/12/23 10:14:00) Glucose, POC: 199 mg/dL High (11/12/23 10:14:00) Potassium, POC: 3.7 mmol/L (11/12/23 10:14:00) Sodium, POC: 131 mmol/L Low (11/12/23 10:14:00) Estimated CRCL (CG), POC: 31 mL/min Low (11/12/23 10:14:00) Estimated GFR (CKD-EPI, no race), POC: 34 mL/min/1.73m2 Low (11/12/23 10:14:00) All Other Labs: Stool Sample Consistency: Unformed Stool (11/12/23 11:30:00) C diff Algorithm Interp: See Comment (11/12/23 11:30:00) C diff Assay EIA Interp: Positive Abnormal (11/12/23 11:30:00)    Diagnostics Radiology Results - Last 24 hours Across Visits 11/12/2023 13:24 - CT Abd/Pelvis W/O IV Contrast IMPRESSION:Significant abnormal wall thickening and mucosal edema of the entirecolon suggestive of pancolitis. A previously administered oralcontrast media seen. No bowel obstruction. Small bowel segments areunremarkable.Thank you for consulting our team of subspecialty radiologists. Please contact us at with any questions.                 Signature Line Electronically Signed on 11/12/23 15:19 ________________________________________________________ MD