CASE OF THE MONTH OCTOBER-NOVEMBER 2015
HISTORY OF PRESENT ILLNESS:
The patient is a 19-year-old man with a history of ulcerative colitis who presented after a friend alerted him that his eyes were yellow. He denies prior known jaundice. He denies any recent viral or febrile episodes though he did have some nausea a couple days prior to the visit. He has no medication or over-the-counter supplements except as noted below—none new since his colectomy last year. He has never been transfused.
Past Medical & Surgical History:
1. Ulcerative colitis with loose bloody stools diagnosed at age 15 years
2. s/p colectomy for ulcerative colostomy 2014 J-pouch May 2015 with multiple loose stools daily after
3. Dental extractions without problems
Allergies as charted in the allergies profile as of 07/22/15 15:34:22.
NKA
MEDICATIONS:
-loperamide (loperamide 2 mg oral capsule)(Rx): 2 mg, PO, every 6 hours, as needed
-liquid iron
-Chewable multi vitamin
Social History: No cigarette use though smokes a hookah. Moderate alcohol use. No recreational drug use. Sophomore in college. One brother.
Family History: (obtained from the father)
unknown to patient
REVIEW OF SYSTEMS:
Constitutional: No fevers, chills or sweats. No change in weight. Preserved appetite.
Head: No headaches.
Eyes: No visual acuity change, blurred vision, diplopia or ocular pain. Jaundice improved
ENT: No reduced hearing, tinnitus, or ear drainage. No nasal congestion or discharge. No epistaxis. Mouth/throat: No oral lesions, odynophagia, dysphagia.
Heme/Lymph: No adenopathy. No bruising or bleeding. See HPI.
Cardiovascular: No chest pain. No palpitations. No orthopnea or paroxysmal nocturnal dyspnea. No lower extremity swelling.
Respiratory: No shortness of breath, cough, sputum productivity.
Gastrointestinal: No abdominal pain, fullness or early satiety. No constipation. Loose stools every 60 minutes without noted blood. No hematemesis, hematochezia, or melena.
Genitourinary: No dysuria, urgency or frequency. No hematuria. No coca-cola colered urine
Musculoskeletal: No focal back or bone pains noted
Neuro: No focal motor or sensory deficits. No seizures. No stroke.
Skin: No reported rash
PHYSICAL EXAMINATION:
VS: T 36.2 C BP 109/62 HR 70 RR 18 Sp02 98% Ht 178.0 cm(70") Wt 83.9 kg
BMI 26.5 BSA 2.04 (07/22 15:28)
Constitutional: Generally healthy-appearing male in no acute respiratory distress.
HEENT: Head: Normocephalic, atraumatic. Eyes: PERRL. EOMi. Very mildly icteric sclerae. Pink conjunctivae. Ears: Normal external ear structures. Nose: Normal nares. Mouth: Oral mucosa is moist and pink without lesions, erythema, or exudates. No angular cheilitis. Normal-appearing tongue. No tongue ulcerations or lesions.
Neck: No thyromegaly or masses.
Lymphatics: No adenopathy—all areas.
Respiratory: Lungs CTA bilaterally. Normal chest excursion
Cardiovascular: Regular S1, S2 without murmurs, rubs or gallops.
Abdomen: BS+. Soft, NTND. No hepatomegaly or masses. Spleen palpable below the costal margin by about 3 cm.
Extremities: No CCE. No joint deformities or deviation.
Skin: No pathological rashes, bruises or petechiae.
Neuro: Awake and alert. Normal speech with full content. Ambulatory without ataxia and without assistance. No focal motor deficits
CURRENT LABORATORY & RADIOLOGY STUDIES:
CBC Hgb 11.6 HCT 33.0 MCV 80.6 WBC 9.3 PLT 370
Retic 455.7 (11.6%)
DAT negative
Na 142 K 3.8 Cl 108 CO2 28 BUN 7 Cr 0.72 Glu 86 CA 9.7
ALB 4.4 AlPh 98 ALT 253 AST 88 TBil 6.9 TPrt 6.7 CBil 2.2 Glb 2.4
COAG PTT 33
Old labs through 2009 reviewed with consistently elevated bilirubin though mildly so generally (<3 typically) with reticulocytosis and hyperbilirubinemia noted in 2009. Most labs drawn when in the hospital for UC flares or related surgeries with moderate Hgb variability
SLIDE AVAILABLE ON MMEC-11 FOR YOUR REVIEW