Patient Name: David Moore
Patient ID: 246011
Consultant: Carl M. Martin, MD, Gastroenterology
Requesting Physician: Donald Burns, MD, Family Medicine
Date of Consult: 03/15/----
Reason for Consultation: Please evaluate GI distress.
I was asked to see this 23-year-old male in consultation because of unremitting nausea, diarrhea, vomiting, abdominal pain, dizziness, and low-grade fever. The patient has a poor appetite but reports no weight loss. He has noted some postprandial cramping, midepigastric pain, and unremitting diarrhea but no blood in the stool. He states he is “better” but he still has some dizziness.
Initial treatment consisted of IV fluids and control of electrolytes. Thereafter, the patient was progressed to clear fluids and soft diet. He has done well on this regimen; however, his dizziness has persisted. Fever has resolved.
On admission, the patient’s lab data revealed CBC with hematocrit of 42, hemoglobin 25, with differentials of neutrophils 52, bands 9%, lymphocytes 25%, monocytes 5%, basophils none. Serum electrolytes were normal. Potassium was low at 3.3, BUN-to-creatinine ratio was normal. Glucose was within normal range. Stool study was normal. Urinalysis within normal limit except for 8 to 10 WBCs. Specific gravity was 1.025
On examination, I find the patient to be lethargic and uncomfortable with mild nausea and dizziness. He prefers to keep his eyes closed. On examination of the eye, I find no nystagmus. There is pallor to the skin, and he seems cool to the touch. Upon standing by the bedside, the patient is unsteady. Although he resists to walking, when he attempts to walk, his gait is halting, and he tends to fall to the left side. Abdomen is flat and non-tender. Bowel sounds are WLN. Rectal deferred.
RECOMMENDATIONS: I think we should continue low-key treatment of this young gentleman. Because of the symptoms of dizziness on admission, we may want to consider a CT scan to rule out...
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