Adrienne Arbour, MD

Internal Medicine HO II

November 15,2011

Transferred from an outside facility for

worsening diarrhea, abdominal pain and

distension

54 year old man with PMHx of pulmonary TB (treated in 1985 x 9 months), hypertension and alcohol abuse presented to an outside facility with a 4 day history of copious amounts of diarrhea, and diffuse, colicky abdominal pain associated with nausea but not vomiting. He also started to develop progressive abdominal distension.

Patient had 10-12 episodes per day of dark,nonbloody, non-foul smelling stools

No hematemesis or melena

The patient was transferred to UH for evaluaionby the Gastroenterology service

PMH: See HPI

PSxH: Right knee and foot surgery after MVA

All: NKDA

Home Meds: Unknown BP medication

Social history : Smokes ½ ppd x 40 years;

3-7 beers daily; chronic benzodiazepine abuse unknown quantity and duration

Family Hx: Noncontributory

Health Maintenance: No flu, Tetanus uptodate; no colonoscopy

Primary care provider -none

Imepenem-Cilastatin -500 mg IV q 6 hrs

Metronidazole 500 mg IV Q 8 hrs

Ceftriaxone 1gm IV daily

Amlodipine 10 mg daily

Pantoprezole 40 mg daily

Admits to –

SOB increasing

over several days

Denies-

fever

chills

weight loss

night sweats

Triage:

Temp 99.2° F

BP 140/100

HR 129 bpm

ORTHOSTATICS -Positive by symptoms

RR 19

Oxygen 95% on NRB

Pain index-6/10

WT190pounds

HT-5’10’’

BMI-27.3

Gen: AAOx3, mild respiratory distress

HEENT: PERRL, EOMI, NCAT, dry mucus menebranes, poor dentition, OP clear

Neck: No cervical LAD,supple

CVS: JVP around 6cms; S1S2 normal,tachycardic, no murmurs

Lungs: Rhonchi bilaterally, poor inspiratory effort

Abd: Distended; decreased bowel sounds; tympanic to percussion throughout, moderately tender to palpation diffusely, no rebound, no guarding,No flank dullness,shifting dullnes or fluid thrill appreciated

Rectal exam-Normal tone,no mass, brown stool in the vault

Extremeties-No C/C/E

WBC- 16

Hgb/Hct- 15.3/44.6

Plt- 174

MCV- 95

RDW- 14.5

Segs- 87

Bands- 3

Lymphocytes- 4

Monocytes- 6

INR- 1.2, PT-13.5, PTT-22.8

Hep Panel- NR

Ammonia- 22

Na- 130

K-5.5

Cl- 102

HC03- 23

BUN- 13

Cr- 0.67

TP- 5.9

Alb-2.3

TB- 0.9

AST-164, ALT-69

Alk Phos- 55

p-Amylase- 189

WBC- 28.1

Hgb/Hct- 14.5/43.3

Plt- 227

MCV- 100.4

RDW-16.1

Segs-82

Bands-9

Lymphocytes- 2

Monocytes-6

Metamyelocyte- 1

INR- 1.2, PT-14.1, PTT-26.2

Lactic Acid-1.3

Mg-2.4

Na-136

K-4

Cl-103

HCO3- 23

BUN- 19

Cr- 0.82

TP- 6.2

Alb- 2.3

TB- 1.4

AST- 133, ALT- 74

Alk Phos- 79

Phos-2.4

Amylase- 201

Blood Cultures- Negative after 2 days

Stool Cultures – Negative

No ova or parasites

Shiga toxin- Negative

Clostridium difficile toxin A & B- negative

(EIA)

Given the right upper lobe haziness and

history of tuberculosis –

3 smears negative for AFB before transfer

Pulmonary felt radiographic abnormality was

likely an old scar and not an active process

The patient was admitted to the floor on

telemetry and prescribed oral vancomycin

and IV metronidazole

Evaluated by the internal medicine, general

surgery and GI teams

Patient remained afebrile and

hemodynamically stable on the floor.

The following day he underwent a

colonoscopy which revealed:

Significant dilatation of the sigmoid, descending,

transverse and ascending colon, as well multiple

pseudomembranes => consistent with Clostridium

difficile colitis

NG tube placed over a guidewire into the cecum

(no rectal tubes available)

Large amount of liquid stool seen throughout the

colon

Normal anus and rectum

Once rectal tube positioning confirmed by x-ray,

vancomycin retention enemas begun in addition to

intravenous metronidazole

Patients hospital course was complicated by alcohol

withdrawal

Remained in the ICU for 3 days

Patient pulled out rectal tube after 2 days which

was not reinserted secondary to improvement;

regimen converted to oral vancomycin and

intravenous metronidazole

Patient continued to improve and was

stepped down to general medicine floor

PSEUDOMEMBRANOUS COLITIS

Once the patient improved symptomatically

he was transferred back to outside facility to

complete 2 additional weeks of oral

vancomycin and intravenous metronidazole