Urgent Care, a few days before Colonoscopy September 27, 2008

Urgent Care Saturday September 27, 2008, 5 days before being diagnosed with Ulcerative Colitis

Dr. V, from the Palo Alto Medical Clinic.
Progress Notes:

“Adam is an 29 year old male who presents with symnptoms of abdominal pain and bloody stools.  Had szs for several months, gradually worsening since that time.  No history of gastrointestinal disease.  No known risk factor for parasitic or bacterial infection.  Per patient, he was livingin Eastern europe for 1 year and at that time was asymptomatic, recently returned to US to start a new business and had for the last 10 days noticed bloody bowel movements.  Stools sometimes appear like strawberry jelly.  His paternal uncle has Crohn’s disease.\

No family h/o of CA colon
Denies using ASA/NSAIDS
Drinks 1-2 beers daily
No recreational drugs.
No regular use of any meds or abx.
Has increased appettitte w/o wt gain
No past medical history on file.
No past surgical history on file.
No hospital prescriptions on file as of 9/27/2008.

Review of patient’s allergies indicated no known allergies.

Tobacco Use: not on file
Alcohol Use:  not on file

Review of Systems:
Skin: negative
Ears/Nose/Throat: negative
Respiratory: negative
Genitourinary: negative
MSS- HAS LOWER BACK PAIN for 1.5 years, noticed since the onset of bowel disease.

OBJECTIVE:
BP 134/84 |  Pulse  69   |   Temp (Src) 97 degrees |   Resp 20
General appearance:  healthy, alert, no distress
Hydration: well hydrated
Ears: R TM- normal, L TM-normal
Nose: normal
Oropharynx: normal
Neck: supple and no adenopathy
Lungs: clear to auscultation
Heart: regular rate and ryhthm and no murmurs, clicks, rubs, or gallops
Abdomen: flat, normal bowel sounds
Tenderness: present, mild LLQ
Masses: none
Organomegaly: none
Rectal: stool guaiac positive

ASSESSMENT:

History is strongly suggestive of inflammatory bowel disease

PLAN:
1) CBC, chem, urogram and stool cx
2) Dietary advice given, GI referral
3) Recheck prn persistence, worsening, appearance of new symptoms

Associated Diagnoses:
569.3 Rectal & Anal Hemorrhage

Urogram (Dipstick) Results:
Urine Color:  yellow
Urine appearance: clear
Urine glucose:  negative
Urine Bilirubin  1+
Urine Ketones: negative
Urine Specific Gravity: >=1.030
Urine Blood:  negative
Urine pH:  5.0
Urine Protein: trace
Urine Urobilinogen: 0.2
Urine Nitrite: negative
Urine Leukocytes: negative

White Blood Cell Count:  7.3
Red Blood Cell Count:     4.79
Hemoglobin:                  14.5
Lymphocytes:                23
Monocytes:                   13
Glucose:                        104
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