LOCATION: Hospital Emergency Department PATIENT: Simon Sharp PHYSICIAN: Paul Sutton, M

LOCATION: Hospital Emergency Department PATIENT: Simon Sharp PHYSICIAN: Paul Sutton, M.D. SUBJECTIVE: The patient is a 51-year-old who presents to the emergency room with complaints of diarrhea. He has had a long history of diarrhea. He is a quadriplegic with some movement of his upper extremities but otherwise wheelchair bound. He was hospitalized for pneumonia and paroxysmal atrial fibrillation. He had diarrhea in the hospital and had it when he was discharged. During his outpatient workup for that, they found out he was C-difficile positive. He is on Cipro, Flagyl and vancomycin. The vancomycin was just started recently. He continues to have the diarrhea. He normally has a couple of healthcare workers that come over and help get him ready. When a friend and aide was over today, he noted that he sort of was sitting in some stool today. They cleaned him up and then he had another small bout of diarrhea. There has not been any blood. No black or tarry stools. He occasionally has some abdominal distention or cramping throughout these past weeks. It is not any worse today. It is actually a little bit better today than it was earlier. He has not had any fevers or chills. Appetite has maybe been a little bit down but he is trying to keep hydrated and drinking fluids and Gatorade. He has been trying to watch what he eats but he did have some chili in the last day. They did contact Dr. Naraquist, who recommended coming here and having his electrolytes checked. PAST MEDICAL HISTORY: 1. C-diff positive as noted above. 2. Quadriplegia from previous C5 fracture during an MVC. 3. He has a urostomy. 4. Left gluteal ulcer that he had for quite a long time which is now healed. 5. Tracheal stenosis. 6. Chronic renal insufficiency. 7. Tracheostomy. MEDICATIONS: Please see nurses’ notes for meds and allergies. SOCIAL HISTORY: He is not smoking or drinking. FAMILY HISTORY: Noncontributory. OBJECTIVE: GENERAL: Exam showed a 51-year-old, alert and oriented, in no acute distress. VITAL SIGNS: Blood pressure 85/59, pulse 64, temperature 36.1 degrees. HEENT: Eyes are clear. Nose/oropharynx is negative. Mucous membranes seem moist. NECK: Supple. HEART: Regular S1, S2. ABDOMEN: Soft. It seems a little bit distended. Active bowel sounds throughout. No real tenderness to palpation. ER COURSE: I did get a basic metabolic panel which showed sodium 131. Potassium was normal at 4. BUN and creatinine were normal at 21 and 0.7, respectively. Glucose 107, CO2 20.4. White count normal, hemoglobin and hematocrit 12.6 and 38.4, respectively. ASSESSMENT: 1. Recurrent C-difficile infectious diarrhea. 2. Hyponatremia. PLAN: The case was discussed with the patient, caregiver and als Cpt and icd-10 codes