Infectious colitis enteritis and gastroenteritis Bipolar I disorder most recent episode (or current) depressed unspecified Anxiety state unspecified Vaccination not carried out for other reason Other symptoms referable to back
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
tramadol
 
Attending: ___
 
Chief Complaint:
Abdominal pain, diarrhea  

 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ with h/o bipolar, anxiety, substance abuse, and suicide 
attempt by overdose transferred from ___ on ___ with 
abdominal pain, nausea, diarrhea, and BRBPR. The patient was 
seen in the ___ on ___ for these complaints. Had normal CBC, 
chem, and LFTs, rectal was notable for ___ guiac postive 
stool, CT abd/pelvis prelim read was no acute pathology and the 
patient was discharged back to ___. The final read of the CT 
commented on mild stranding and thicken of the ascendign colon 
concerning for colitis. He was contacted by the ___ QI RN and 
returned for reevaluation.  

The patient has has been having these symptoms since ___. 
He initally presnted to ___ for evaluation of his abominal 
pain, nausea, and rectal bleeding and was diagnosed with 
pancreatitis. His symptoms contineud and he went back to ___ 
on ___ and diagnosed with hemorrhoids. Given persistance of 
symptoms he presented for eval to ___ as above. 
 
In the ___ intial vitals were: 8 98.5 86 136/78 16 100% RA  
- Labs including CBC, chem, and UA were unremarkable  
-Imaging: CT with abd/pelvis showed Mucosal hyperenhancement in 
the ascending colon with mild wall thickening and minimal 
stranding which may represent mild colitis.  
- Patient was given 2L NS, paroxetine 40mg, prazosin 1mg, 
percocet, zofran 4mg IV, flagyl 500mg, cipro 500mg, trazadone, 
and seroquel.  
He was supposed to be discharged back to ___ however the 
facility was not comfortable taking patient back given decreased 
PO intake.  
Vitals prior to transfer were: 98.4 74 110/70 16 100% RA  

On the floor is very sleepy after getting most of his ___ meds in 
the ___. He does report having about 20 BM daily, some small 
volume and some normal with BRBPR and clots. He also endorse 
tenesumus and acutally soiled himself on arrival to the floor. 
He continues to endorse abdominal pain ___, no nausea or 
vomitting. Also reports decreased PO intake for the past few 
day. No fevers, sweats or chills, or weight loss.  

 
Past Medical History:
-Bipolar disorder with previous suicide attempt by OD req: ICU 
admission at ___  
-Anxiety  
-Polysubstance abuse  
-Depression  

 
Social History:
___
Family History:
No family history of IBD, Crohn's, UC, bowel disorders 
 
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T97.6 128/59 72 18 97% RA  
GENERAL: NAD, sleepy but arousable  
HEENT: AT/NC, EOMI, MM  
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs  
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably 
without use of accessory muscles  
ABDOMEN: mild TTP bilateral upper quandrants, voluntary guarding 
no rebound, normoactive BS  
RECTAL: No hemmorrhoids. Brown stool guaiac negative. Normal 
rectal tone. Pain with rectal penetrance.
EXTREMITIES: moving all extremities well, no cyanosis, clubbing 
or edema  
PULSES: 2+ DP pulses bilaterally  
NEURO: CN II-XII intact  
SKIN: multiple tattoos  

DISCHARGE PHYSICAL EXAM:

 
Pertinent Results:
ADMISSION LABS:
___ 09:12PM BLOOD WBC-10.0 RBC-4.70 Hgb-14.1 Hct-41.5 
MCV-88 MCH-30.0 MCHC-34.0 RDW-12.9 Plt ___
___ 09:12PM BLOOD Neuts-71.8* Lymphs-17.8* Monos-8.0 
Eos-2.1 Baso-0.3
___ 09:12PM BLOOD ___ PTT-29.3 ___
___ 09:12PM BLOOD Glucose-103* UreaN-12 Creat-0.9 Na-138 
K-3.9 Cl-102 HCO3-24 AnGap-16
___ 09:12PM BLOOD ALT-12 AST-14 AlkPhos-81 TotBili-0.3
___ 09:12PM BLOOD Albumin-4.3
___ 08:45AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.6
___ 09:12PM BLOOD CRP-12.8*
___ 09:12PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG 
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:33PM BLOOD Lactate-1.5

___ ECG:
Sinus rhythm. Normal ECG. No previous tracing available for 
comparison. 
  Intervals Axes 
Rate PR QRS QT/QTc P QRS T 
88 160 70 350/399 53 52 54 

___ CT ABD AND PELVIS WITH ORAL AND IV CONTRAST
INDICATION:  ___ man with bloody stools, evaluate for 
colitis or 
source of acute bleed. 
COMPARISON:  None. 
TECHNIQUE:  Contiguous axial MDCT images through the abdomen and 
pelvis with oral (Volumen)and intravenous contrast, with 
multiplanar reformats. 
FINDINGS: 
Lung bases are clear.  There is no pleural effusion.  Liver 
enhances 
homogenously without focal lesions.  Gallbladder, spleen, 
pancreas, and 
adrenal glands are within normal limits.  Kidneys enhance 
symmetrically 
without focal lesion or hydronephrosis. 
Stomach is distended with oral contrast but does not show wall 
thickening.  The duodenal sweep is unremarkable.  Proximal loops 
of small bowel are distended with oral contrast but do not show 
wall thickening or signs of obstruction.  Distal small bowel 
loops are less distended.  Prominent enhancement of the colon, 
ascending colon in particular, may relate to the phase of 
contrast; however, there is also mild thickening of the colonic 
wall and minimal fat stranding which could reflect colitis. The 
appendix is normal. 
There is no mesenteric or retroperitoneal lymphadenopathy.  
There is no 
intra-abdominal free fluid or free air. 
Bladder, seminal vesicles, and prostate are unremarkable.  There 
is no pelvic free fluid.  There is no inguinal or pelvic 
lymphadenopathy. 
Osseous structures are unremarkable. 
IMPRESSION:   
Mucosal hyperenhancement in the ascending colon with mild wall 
thickening and minimal stranding may represent mild colitis.  

DISCHARGE LABS
___ 11:15AM BLOOD WBC-7.0 RBC-4.46* Hgb-13.8* Hct-39.7* 
MCV-89 MCH-30.9 MCHC-34.7 RDW-13.0 Plt ___
___ 07:15AM BLOOD Glucose-99 UreaN-9 Creat-0.8 Na-138 K-4.2 
Cl-101 HCO3-29 AnGap-12
___ 07:15AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.___ with extensive psychiatric history (bipolar, depression, 
suicide attempt by OD, substance abuse, on ___, 
presenting with one week of abdominal pain, bloody stools, 
diarrhea, and tenemsus, with mild ascending colitis on CT scan.

# Acute colitis. Initially, he presented with bloody diarrhea 
for one week. He ad no family history of IBD, no prior GI 
history, no recent travel, no recent antibiotic use, and no 
sexual risk factors. He denied any anal intercourse. He was 
initially guaiac positive in the ___ on his first presentation, 
but was then negative the next day in the ___ and on admission to 
the floor. He was treated with IV fluids and IV ciprofloxacin 
pending stool studies. However, all stool studies were negative 
including C.diff, stool culture, Campylobacter, Salmonella, 
Shigella, and EHEC. He continued to have about 5 bouts of 
diarrhea a day, some watery brown and some with blood streaks. 
He was treated with oxycodone and Zofran for abdominal pain and 
nausea. Given his ongoing symptoms, GI was consulted. Reviewing 
the CT, he had some distention in the proximal small bowel and 
colitis only in the ascending colon, narrowing the differential 
to Yersinia vs Crohn's. Stool cultures have remained negative 
but Yersinia was pending at time of discharge. Patient was 
started on ciprofloxacin to complete total of 14 days (day 
___, last dose ___. By day of discharge, patient was 
tolerating a low residue, lactose free diet with decreased 
sugars without vomiting. He is to f/u with GI outpatient for 
further evaluation re: colonoscopy. He complains of abdominal 
pain but this is likely component of colitis in addition to 
somatization of pain. Pain has been treated with oxycodone q4 
PRN.

## CHRONIC ISSUES ##
# Depression/bipolar. ___ with 1:1 sitter. Continue home 
seroquel, prazosin, trazadone and paroxetine  
# Back spasms. Stable. Continue home diazepam prn and 
Methocarbamol prn  

### TRANSITIONAL ISSUES ###
**PATIENT IS MEDICALLY STABLE. HE IS TOLERATING FULL MEALS AND 
HE HAS NO ASSOCIATED VOMITING. ABDOMINAL PAIN THAT HE COMPLAINS 
OF IS LIKELY A COMPONENT OF SOMATIZATION. HE CONTINUES TO HAVE 
INTERMITTENT BLOOD IN HIS STOOLS WHICH IS EXPECTED WITH COLITIS 
AND SHOULD RESOLVE WITH TIME.**
TRANSITIONAL ISSUES
- f/u Yersinia studies
- Patient to f/u with GI
- last dose ciprofloxacin ___
- QTC not prolonged during this hospitalization (Qtc___ on 
___ though he is on multiple qtc prolonging medications. 
Should obtain repeat EKG qdaily X 5 days and stop daily EKGs if 
QTc is not prolonging. If Qtc is prolonged, consider d/c qtc 
prolonging medication
- Patient was started on dicyclomine on discharge to help with 
abdominal cramping - 20mg QID should be continued for 7 days. 
After 1 week, may increase to 40 mg 4 times daily. Please stop 
medication after this period (total of 2 weeks).
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prazosin 1 mg PO QHS 
2. QUEtiapine Fumarate 200 mg PO QHS 
3. TraZODone 200 mg PO HS 
4. Paroxetine 40 mg PO DAILY 
5. Methocarbamol 500 mg PO TID PRN back pain/spasm 
6. DiphenhydrAMINE 50 mg PO QHS PRN  insomnia 
7. Diazepam 2.5 mg PO BID PRN  back spasm 
8. Mylanta 30 mL oral q4H PRN gastritis 
9. Nicotine Polacrilex 2 mg PO Q1H:PRN cravings 

 
Discharge Medications:
1. Diazepam 2.5 mg PO BID PRN  back spasm 
2. DiphenhydrAMINE 50 mg PO QHS PRN  insomnia 
3. Methocarbamol 500 mg PO TID PRN back pain/spasm 
4. Paroxetine 40 mg PO DAILY 
5. Prazosin 1 mg PO QHS 
6. QUEtiapine Fumarate 200 mg PO QHS 
7. TraZODone 200 mg PO HS 
8. Mylanta 30 mL oral q4H PRN gastritis 
9. Nicotine Polacrilex 2 mg PO Q1H:PRN cravings 
10. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days 
Last dose ___ 
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every 12 
hours Disp #*20 Tablet Refills:*0
11. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN breakthrough 
abd pain 
RX *oxycodone 5 mg 1 capsule(s) by mouth every 4 hours Disp #*18 
Tablet Refills:*0
12. DiCYCLOmine 20 mg PO QID Duration: 7 Days 

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY:
-Acute bloody diarrhea

SECONDARY:
-Depression
-Anxiety
-History of substance abuse

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Dear Mr. ___,

It was a pleasure to take care of you at ___ 
___. You were admitted to the hospital because of 
bloody diarrhea and were found to have inflammation of your 
colon. You were treated with IV fluids, antibiotics, and pain 
medications. You were evaluated by the Gastroenterology team. It 
is unclear what was causing inflammation of your colon but your 
symptoms improved. We have arranged for you to have a follow-up 
appt with Gastroenterology for further evaluation. 

We wish you a speedy recovery, 

Your ___ team
 
Followup Instructions:
___

{'Abdominal pain': ['Infectious colitis', 'enteritis', 'and gastroenteritis'], 'Diarrhea': ['Infectious colitis', 'enteritis', 'and gastroenteritis'], 'Nausea': ['Infectious colitis', 'enteritis', 'and gastroenteritis'], 'Rectal bleeding': ['Infectious colitis', 'enteritis', 'and gastroenteritis'], 'Tenemsus': ['Infectious colitis', 'enteritis', 'and gastroenteritis'], 'Depression': ['Bipolar I disorder', 'most recent episode (or current) depressed', 'unspecified'], 'Anxiety': ['Anxiety state', 'unspecified']}