Diverticulitis of colon (without mention of hemorrhage) Abdominal aortic ectasia Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Esophageal reflux Osteoarthrosis unspecified whether generalized or localized site unspecified Personal history of colonic polyps Personal history of tobacco use Need for prophylactic vaccination and inoculation against influenza
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
abdominal pain
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
 Mr. ___ is a ___ year old gentleman with ahistory of 
diverticulosis seen on prior colonoscopies whopresents with 3 
weeks of low abdominal pain and profusenon-bloody diarrhea. He 
saw his PCP who dismissed his symptoms. 

He and his wife were en route to ___ and had a layover in 
___ when his diarrhea and abdominal pain became worse. They 
ended up staying the night in a hotel in ___ where he spent 
the entire night in the bathroom having severe abdominal pain, 
profuse diarrhea, and diaphoresis. The next morning, he caught
the first flight back to ___ and came directly to the ___
ED. 

His most recent colonoscopy was in ___. He was told
he had diverticuli and some polyps were biopsied. 

 
Past Medical History:
diverticulitis, BPH, OA, GERD, colonic adenomas, HPL 
 
Social History:
___
Family History:
NC
 
Physical Exam:
EXAM: upon admission:  ___

VS - 97.7 73 143/92 18 99% RA 
GEN - NAD, awake/alert, cooperative & pleasant
HEENT - NCAT, EOMI, dry mucous membranes, no scleral icterus
___ - RRR
PULM - CTAB
ABD - soft, nondistended, mild suprapubic tenderness to 
palpation
without evidence of rebound or guarding
EXTREM - warm, well-perfused; no peripheral edema

Physical examination upon discharge:  ___:

vital signs:  t=97.7, hr=59, bp=116/61, rr=18, 98% room air

CV:  ns1, s2, -s3, -s4
LUNGS:  diminished bases bil
ABDOMEN:  soft, hypoactive BS, mild tenderness left lower 
quadrant, no rebound
EXT:  no calf tenderness bil., no pedal edema bil
NEURO:  alert and oriented x 3, speech clear

 
Pertinent Results:
___ 06:06PM BLOOD WBC-5.8 RBC-4.36* Hgb-14.0 Hct-41.5 
MCV-95 MCH-32.1* MCHC-33.7 RDW-15.5 Plt ___
___ 12:41PM BLOOD WBC-6.5 RBC-4.35* Hgb-13.9* Hct-40.6 
MCV-93 MCH-32.1* MCHC-34.3 RDW-15.3 Plt ___
___ 12:41PM BLOOD Neuts-56.5 ___ Monos-5.7 Eos-5.0* 
Baso-0.6
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD Glucose-85 UreaN-13 Creat-1.4* Na-140 
K-4.1 Cl-104 HCO3-26 AnGap-14
___ 06:06PM BLOOD Glucose-81 UreaN-12 Creat-1.4* Na-139 
K-3.9 Cl-101 HCO3-26 AnGap-16
___ 12:41PM BLOOD Glucose-96 UreaN-16 Creat-1.4* Na-137 
K-4.3 Cl-100 HCO3-27 AnGap-14
___ 12:41PM BLOOD ALT-33 AST-35 AlkPhos-54 TotBili-0.7
___ 09:00AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.2

___:  cat scan of abdomen and pelvis:

Small amount of ascites in the lower pelvis which is abnormal 
but not 
specific. Given clinical concern for diverticulitis the 
possibility could be considered when it is noted that the fluid 
resides near as diverticula at the rectosigmoid junction. 
2.  Fatty infiltration of the liver. 
3.  Findings consistent with mesenteric panniculitis. 
4.  Moderate atherosclerotic change, including mild aortic 
ectasia. Follow-up ultrasound is suggested to reassess in one 
year. 
  

/___ 9:12 am 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). 

 
Brief Hospital Course:
The patient was admitted to the hospital with a 3 week course of 
abdominal pain. Upon admission, he was made NPO, given 
intravenous fluids, and underwent imaging.  Cat scan imaging 
showed moderate to severe sigmoid diverticulosis.  The patient 
was placed on bowel rest and placed on intravenous ciprofloxacin 
and flagyl.  

He resumed a clear liquid diet on HD #3, but reported increased 
burning sensation in his abdomen.  He was again placed on bowel 
rest with resolution of his abdominal pain.  He resumed clear 
liquids on HD #4, and advanced to a regular diet.  His white 
blood cell count remained normal, along with a negative c.diff.  
The patient was ambulating without difficulty.  

On HD #6, the patient was discharged home in stable condition.  
He was instructed to complete a 10 day course of ciprofloxacin 
and flagyl.  His vital signs upon discharge were stable and he 
was afebrile.  He was voiding without difficulty and moving his 
bowels. Follow-up appointments were made with the acute care 
service and with his primary care provider.  

Moderate atherosclerotic change, including mild aortic ectasia 
were reported on the abdominal cat scan. Follow-up ultrasound 
was suggested to reassess in one year. Both the patient and his 
wife were informed of these findings and a copy of the cat scan 
report was provided.  
  
  
 
Medications on Admission:
doxazosin (unknown dose), gemfibrozil 600', omeprazole 20', 
flonase 50 prn 
 
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H 
last dose ___ 
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every 
twelve (12) hours Disp #*12 Tablet Refills:*0
2. Doxazosin 2 mg PO HS 
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 
last dose ___ 
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) 
hours Disp #*18 Tablet Refills:*0
4. Omeprazole 20 mg PO DAILY 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
sigmoid diverticulosis

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

 
Discharge Instructions:
You were admitted to the hospital with abdominal pain and 
diarrhea.  You underwent a cat scan of the abdomen which showed 
diverticulosis.  You were placed on bowel rest.  Your abdominal 
pain has resolved and you are preparing for discharge home with 
the following instructions: 

 Please call your doctor or return to the emergency room if you 
have any of the following:
 

 * You experience new chest pain, pressure, squeezing or 
 tightness.
 
* New or worsening cough or wheezing.
 
* If you are vomiting and cannot keep in fluids or your 
 medications.
 
* You are getting dehydrated due to continued vomiting, 
 diarrhea or other reasons. Signs of dehydration include dry 
 mouth, rapid heartbeat or feeling dizzy or faint when standing.
 
* You see blood or dark/black material when you vomit or have a 
 bowel movement.
 

* You have shaking chills, or a fever greater than 101.5 (F) 
 degrees or 38(C) degrees.
 
* Any serious change in your symptoms, or any new symptoms that 
 concern you. 
 

 
Followup Instructions:
___

{'abdominal pain': ['Diverticulitis of colon (without mention of hemorrhage)'], 'diarrhea': ['Diverticulitis of colon (without mention of hemorrhage)'], 'suprapubic tenderness': ['Diverticulitis of colon (without mention of hemorrhage)'], 'diminished bases bil': ['Abdominal aortic ectasia'], 'mild tenderness left lower quadrant': ['Diverticulitis of colon (without mention of hemorrhage)'], 'hypoactive BS': ['Diverticulitis of colon (without mention of hemorrhage)']}