Abdominal Pain - Consult
Abdominal Pain - Consult
Description: The patient presented to the
emergency room last evening with approximately 7- to 8-day history
of abdominal pain which has been persistent.
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss.
PAST MEDICAL HISTORY: Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.
PAST SURGICAL HISTORY: Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.
ALLERGIES: SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.
SOCIAL HISTORY: She does not drink or smoke.
REVIEW OF SYSTEMS: Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.
PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly thin white female, very
pleasant, in no acute distress.
VITAL SIGNS: Her temperature is 98.8 and vital signs are all
stable, within normal limits.
HEENT: Head is grossly atraumatic and normocephalic. Sclerae are
anicteric. The conjunctivae are non-injected.
NECK: Supple.
CHEST: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Generally nondistended and soft. She is focally tender in
the left lower quadrant to deep palpation with a palpable fullness
or mass and focally tender, but no rebound tenderness. There is no
CVA or flank tenderness, although some very minimal left flank
tenderness.
PELVIC: Currently deferred, but has history of grade 4 urinary
bladder prolapse.
EXTREMITIES: Grossly and neurovascularly intact.
LABORATORY VALUES: White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7.
DIAGNOSTIC STUDIES: EKG shows normal sinus rhythm.
IMPRESSION AND PLAN: A 71-year-old female with
greater than one-week history of abdominal pain now more localized
to the left lower quadrant. Currently is a nonacute abdomen. The
working diagnosis would be sigmoid diverticulitis. She does have a
history in the distant past of sigmoid diverticulitis. I would
recommend a repeat stat CT scan of the abdomen and pelvis and keep
the patient nothing by mouth. The patient was seen 5 years ago by
Dr. Y in Colorectal Surgery. We will consult her also for
evaluation. The patient will need repeat colonoscopy in the near
future and be kept nothing by mouth now empirically. The case was
discussed with the patient's primary care physician, Dr. X. Again,
currently there is no indication for acute surgical intervention on
today's date, although the patient will need close observation and
further diagnostic workup.
Relate the diagnosis to the appropriate information in
the medical record, including physical findings and laboratory and
diagnostic tests. Provide at least three examples linked to topics
covered in the textbook material.
Discuss the prognosis for the selected
disease.
The three examples which can be linked to the disease are
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