Date: 1/17/20

Patient Name: NC

CC: “I’ve been having diarrhea” x5 days

HPI: NC is a 37 year old middle-eastern man with no significant PMH presenting to the ER for 5 days of diarrhea. He reports crampy, 3/10 severity, non-radiating abdominal pain on the right side radiating to the back. He reports tea helps and he has taken Imodium which gave some relief. He denies aggravating factors. Pt reports being able to eat and drink normally and reports that he has been feeling slightly better today. He also reports his stool is lighter in color. Denies lightheadedness, n/v/c, fever, new foods, recent travel, SOB, chest pain. Pt reports 5-6 drinks 4-5 times a week while he works as a DJ.

 

PMH

Current illnesses: NA

Past Illness: NA

Surgeries: Septoplasty

Allergies: NA

Medications: NA

Hospitalizations: NA

Trauma/Injuries: None known

 

Social History

Education: High school completed

Military: None

Work/finances: Works as a DJ in Manhattan.

Family & relationships: Lives with wife in Staten Island.

Habits/risk factors: Reports 16 pack years (1 pack a day for 16 years). Reports 5-6 drinks 4-5 times a week. Reports using cocaine twice in the past year.

Reproductive History: Sexually active with 1 partner, his wife. Denies history of STDs.

Family History

Mother: 60, HTN, DM, asthma.

Father: 64, BPH, COPD.

 

Review of Systems

General: Denies fever, weight loss,  loss of appetite, weakness.

Head: Denies headaches, syncope.

Eyes: Denies any changes

Respiratory: Denise shortness of breath

Cardiac: Denies palpitations, murmurs, chest pain.

GI: Reports abdominal pain, diarrhea, and pale stools.

GU: Denies problems with urination.

Musculoskeletal: Denies muscle weakness.

Neurologic: Denies change in mental status,  unusual sensations, dizziness.

Psychiatric: Denies changes in mood.

 

 

 

Physical Exam

VS: BP: 100/82 Pulse: 68 Respirations: 16 Temperature: 98.9 degrees F O2 Sat: 98%

General: Pt is a slender male and looks stated age of 37. He is sitting up on exam bed and appears in no apparent distress. AOx3.

HEENT

Head: Sensation to light touch is equal bilaterally on forehead, cheeks, jaw and around her mouth. Cranial nerves 2 – 12 intact. Facial movements are equal and symmetrical.

Eyes: PERRLA, EOM intact, visual fields normal.

Mouth: Tongue and uvula midline. No changes in sensation

Musculoskeletal: Upper and lower extremity muscle tone and strength is 5/5 bilaterally, sensation to light touch is equal bilaterally. Brachial, radial, popliteal reflexes 2+. No pronator drift, finger to nose test is normal.

Cardiovascular: RRR, normal S1S2, no murmurs/gallups/rubs.

Pulmonary: CTA from bases to apices, no rhonchi/wheezes/rates.

Abdomen-  flat and symmetrical, no scars/masses/lesions, BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Diffuse tenderness to light and deep palpation.  No evidence of organomegaly/ guarding/ rebound tenderness.   No CVAT noted bilaterally. Negative Murphy’s, Rovsing, Psoas, Obturator sign.

GU (Not performed but should have)- Circumcised male. No penile discharge/ lesions. No scrotal swelling/ discoloration. Testes descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Rectal: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and nontender with palpable median sulcus. No melena in rectal vault.

Neurological: Mental status articulate; normal cerebellar function (finger to nose, gait, Romberg’s), DTR’s 2+ and symmetric upper and lower extremities, cranial nerves I – XII intact; sensation intact to touch bilaterally.

Skin: Normal

 

Assessment: 37 year old male with history of heavy drinking presents for 5 days of diarrhea and abdominal pain.

 

Problem List:

1. Diarrhea/ abdominal pain
2. Heavy drinking
3. Pale stool

 

 

Plan:

1. Order CBC, CMP, lipase,
2. Order non-contrast CT abdomen pelvis to rule out acute pancreatitis
3. Have patient continue taking Imodium.
4. Counsel patient on dangers of heavy drinking.

 

Differentials-

1. Acute pancreatitis- He has lighter colored stools, is a heavy drinker, and has abdominal pain radiating to the back.
2. Viral gastroenteritis- He presents with 5 days of diarrhea and has general non-localized abdominal pain. He does not present with fever.
3. Food poisoning- He works as a DJ in a club and may have possibly eaten something bad while at work.
4. Alcoholic hepatitis- He does have lighter colored stools but he is slightly out of the typical age range of 40-50 years old. Also, he doesn’t present with jaundice or fever.
5. Cholelithiasis- Patient is presenting with right sided pain but negative Murphy’s and no history of gallstones.
6. Ulcerative colitis- Unlikely because of the acute nature of the diarrhea and no GI complaints prior.