Other and unspecified noninfectious gastroenteritis and colitis Pathologic fracture of vertebrae Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Esophageal reflux Other and unspecified hyperlipidemia Osteoarthrosis unspecified whether generalized or localized site unspecified Personal history of colonic polyps Other acquired absence of organ
 
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
bloody bowel movement
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
___ smoker w/ history of hyperlipidemia, BPH, GERD, DJD, 
osteoarthritis, and colon polyps presents today with one bloody 
BM, fever in AM and abdominal pain. Pt's last ___ was in ___ 
at which point he had some polyps that were benign.  
The patient woke up in the morning in his usual state of health. 
He went to work after eating a muffin and drinking a coffee. 
While at work, he experienced a band of pain along his abdomen, 
lasting for 45 minutes and was drenched in sweat. Had large 
blood BM at 11 AM (blood covered stool). Since then has had ___ 
belly pain in lower quadrants in a horizontal band.  
 
In the ED, initial vs at 14:22 were pain 6 t 98.6 64 133/78 16 
99%. He was ound to have elevated WBC (19.2). CT shows colitis, 
patient given 0.5 mg IV dilaudid, 400mg IV cipro. Transfer VS 
98.1po 59 16 126/81 100% RA ___.  
On arrival to the floor, patient reports continued abdominal 
pain, but is comfortable. He also reports continuing smoking and 
having a rash along his right axila. He denies any recent 
antibiotics, travel, changes in his diet, or sick contacts.  
 
REVIEW OF SYSTEMS:  
Recent headache over the weekend, twice, which is new for him..  

Denies fever, chills, night sweats, vision changes, rhinorrhea, 
congestion, sore throat, cough, shortness of breath, chest pain, 
constipation, melena, dysuria, hematuria.  
All other 10-system review negative in detail.  

 
Past Medical History:
1. Status post appendectomy.  
2. Status post sebaceous cyst excision.  
3. Status post arthroscopy, left knee.  
4. Status post arthroscopy, right knee. 
 
Social History:
___
Family History:
Positive for lung cancer, CAD, hypertension, and diabetes. No 
history of crohn disease or ulceraive colitis.
 
Physical Exam:
Admission:
VS 98.7, 146/89, 56, 18, 98%  
GEN Alert, oriented, no acute distress  
HEENT NCAT MMM EOMI sclera anicteric, OP clear  
NECK supple, no JVD, no LAD  
PULM Good aeration, CTAB no wheezes, rales, ronchi  
CV RRR normal S1/S2, no mrg  
ABD soft tender along left lower quadrant. ND normoactive bowel 
sounds, no hsm  
EXT WWP 2+ pulses palpable bilaterally, no c/c/e  
NEURO CNs2-12 intact, motor function grossly normal  
SKIN small erythematous papular rash under right axila. 

Discharge:
VS 98.4, 122/80, 65, 18, 96%RA
GEN Alert, oriented, no acute distress  
HEENT NCAT MMM EOMI sclera anicteric, OP clear  
NECK supple, no JVD, no LAD  
PULM Good aeration, CTAB no wheezes, rales, ronchi  
CV RRR normal S1/S2, no mrg  
ABD soft, mildly tender with soft and deep palpation in LLQ, no 
masses 
EXT WWP 2+ pulses palpable bilaterally, no c/c/e  
NEURO CNs2-12 intact, motor function grossly normal  
SKIN small erythematous papular rash under right axila.
 
Pertinent Results:
Admission:
___ 02:32PM   NEUTS-91.6* LYMPHS-5.7* MONOS-2.6 EOS-0 
BASOS-0.1
___ 02:32PM   WBC-19.2*# RBC-5.14 HGB-15.6 HCT-46.2 MCV-90 
MCH-30.4 MCHC-33.8 RDW-13.1
___ 02:32PM   LIPASE-51
___ 02:32PM   PLT COUNT-346
___ 02:32PM   ALT(SGPT)-30 AST(SGOT)-29 LD(LDH)-187 ALK 
PHOS-73 TOT BILI-0.5
___ 02:32PM   LIPASE-51
___ 02:32PM   GLUCOSE-120* UREA N-14 CREAT-0.7 SODIUM-137 
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12
___ 02:40PM   LACTATE-1.1
___ 07:52PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR 
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 
LEUK-NEG
___ 07:52PM URINE  COLOR-Yellow APPEAR-Clear SP 
___

Discharge:
___ 07:00AM BLOOD WBC-12.2* RBC-4.90 Hgb-14.3 Hct-43.5 
MCV-89 MCH-29.2 MCHC-32.9 RDW-12.6 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-138 
K-4.1 Cl-106 HCO3-25 AnGap-11
___ 07:00AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2

Micro:
___ 9:00 pm STOOL     CONSISTENCY: NOT APPLICABLE
      Source: Stool. 
                            **FINAL REPORT ___
   C. difficile DNA amplification assay (Final ___: 
      Negative for toxigenic C. difficile by the Illumigene DNA
      amplification assay. 
           (Reference Range-Negative). 
   FECAL CULTURE (Final ___:    NO SALMONELLA OR SHIGELLA 
FOUND. 
   CAMPYLOBACTER CULTURE (Final ___:    NO CAMPYLOBACTER 
FOUND. 
   FECAL CULTURE - R/O VIBRIO (Final ___:    NO VIBRIO 
FOUND. 
   FECAL CULTURE - R/O YERSINIA (Final ___:    NO YERSINIA 
FOUND. 
   FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: 
      NO E.COLI 0157:H7 FOUND. 

___ 2:52 pm BLOOD CULTURE
   Blood Culture, Routine (Pending): 

___BD & PELVIS WITH CO 
IMPRESSION: 
1.  Acute colitis involving the descending and sigmoid colon.  
Etiologies 
include infectious, inflammatory and less likely ischemic. 
2.  Enlarged prostate, correlate with PSA. 
3.  Bilateral small indeterminate adrenal nodules. 
4.  Mild compression of T11 and T12 vertebral bodies. 

Cardiovascular Report ECG Study Date of ___  3:26:28 ___   
Sinus rhythm. Normal tracing. No previous tracing available for 
comparison.  
  
 

 
Brief Hospital Course:
# Colitis: Patient presented with one bloody bowel movement 
associated with crampy abdominal pain.  CT showing acute colitis 
of descending colon. Differential diagnosis includes infectious 
(bacterial, viral, parasitic), ischemic, and inflammatory.  
Ischemic possible given high white count, acute nature and 
smoking history, however normal lactate.  EKG with normal sinus 
rhythm.  Infectious possible with high white count, however 
patient was afebrile and did not describe diarrhea or vomiting.  
Further, patient had no travel history, sick contacts or 
concerning food ingestion.  First presentation of inflammatory 
bowel disease is possible, however less likely given acute 
nature and disease of only descending colon.  Diverticuli seen 
on previous colonoscopy, however elevated white count and pain 
is not consistent with diverticular bleeding.  The patient was 
started on ciprofloxacin for possible infectious etiology and 
given IV fluids.  Gastroenterology was consulted due to concern 
for ischemic etiology.  Stool studes were sent and were negative 
for salmonella, shigella, campylobacter, vibrio and yersinia.  
C. difficile testing was not done as sample was unsuitable for 
testing (solid).  GI recommended discontinuing ciprofloxacin and 
outpatient follow up given resolving symptoms with stable 
hemodynamics and recent colonoscopy.  The patient was scheduled 
for outpatient follow up with gastroenterology.

Chronic Issues:
# T11/ T12 vetebral compression: Compression seen on CT scan.  
Patient has no current back pain with normal neurological exam.  

  
# Enlarged prostate: BPH, mildly symptomatic with stable PSA, 
and a relatively recent prostate biopsy, which was negative for 
malignancy.  Patient continued on finasteride and Flomax as 
prescribed.  

Transitional Issues:
-follow up with GI for possible endoscopy as outpatient
-follow up with PCP  
-___ cultures pending
 
Medications on Admission:
Preadmission medications listed are correct and complete.  
Information was obtained from PatientwebOMR.
1. Finasteride 5 mg PO DAILY 
2. Tamsulosin 0.4 mg PO HS 
Hold for SBP<100 

 
Discharge Medications:
1. Finasteride 5 mg PO DAILY 
2. Tamsulosin 0.4 mg PO HS 
Hold for SBP<100 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary: colitis

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

 
Discharge Instructions:
Mr. ___, 

It was a pleasure taking care of you at ___ 
___.  You were admitted with an episode bloody bowel 
movement.  CT scan showed colitis, which may have be infectious. 
You were seen by gastroenterology and will follow up with Dr. 
___ in clinic.

Medication changes: none
 
Followup Instructions:
___

{'bloody bowel movement': ['Other and unspecified noninfectious gastroenteritis and colitis'], 'fever in AM and abdominal pain': ['Other and unspecified noninfectious gastroenteritis and colitis'], 'band of pain along his abdomen': ['Other and unspecified noninfectious gastroenteritis and colitis'], 'elevated WBC': ['Other and unspecified noninfectious gastroenteritis and colitis'], 'CT shows colitis': ['Other and unspecified noninfectious gastroenteritis and colitis'], 'rash along his right axila': [], 'recent headache': [], 'history of hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'BPH': ['Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'], 'GERD': ['Esophageal reflux'], 'DJD': ['Osteoarthrosis', 'unspecified whether generalized or localized', 'site unspecified'], 'colon polyps': ['Personal history of colonic polyps']}