Identifying Data:

Age: 64 y/o

Sex: Male

Date of encounter: February 17, 2022 (day 2 of admission)

Location: Internal Medicine. North Shore University Hospital. Manhasset NY

Race: White

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Chief Complaint: Abdominal pain x several hours

History of Present Illness:

Pt is a 64 y/o male with PMH of GERD, HTN, HLD, aortic stenosis s/p AVR, asthma, anxiety, depression, BPH, who presented to the ED yesterday for abdominal pain. The pain began at 11AM yesterday, located right lower quadrant without radiation, intermittent, with episodes lasting 30-60 min, of “crampy” quality, worse with movement, no alleviating factors, moderate severity, with associated mild nausea. Pt reports having an episode of similar pain about 2 years ago that resolved after taking Dulcolax and having a BM. He did not take a laxative or any other medications this time. Last BM before pain started was the night before (2/15) and it was of normal consistency (soft) and color. He states he normally has BM twice a day.

Pt denies fever, weight change, constipation, diarrhea, blood in stool, vomiting, change in appetite, dysuria, shortness of breath, chest pain. No recent changes in diet. Of note, pt’s last colonoscopy in April 2021 was reportedly normal and pt’s daughter has Crohn’s disease.

Past Medical History:

Hypertension

Hyperlipidemia

Aortic stenosis

Asthma

Anxiety

Depression

GERD

BPH

Immunizations – up to date, including COVID (Pfizer x3)

Colonoscopy – April 2021, normal per patient.

Denies recent hospitalizations.

Past Surgical History:
Tonsillectomy – 2011

Denies past blood transfusions. Denies history of stroke or DVT.

Medications (home + hospital): 

Aripiprazole 1 mg – 1 tablet PO daily

Aspirin (enteric coated) 81 mg – 1 tablet PO daily

Atorvastatin 10 mg – 1 tablet PO daily

Budesonide/formoterol 160 mcg/4.5 mcg inhaler – 2 puffs inhalation BID

Ceftriaxone 1000 mg – IVPB every 24 hours

Divalproex ER 500 mg – 1 tablet PO daily

Enalapril 10 mg – 1 tablet PO daily

Enoxaparin 40 mg – injected subcutaneous every 24 hours

Metronidazole 500mg – 1 tablet PO every 8 hours

Montelukast 10 mg – 1 tablet PO daily

Pantoprazole 49mg – 1 tablet PO daily before breakfast

Tamsulosin 0.4 mg – 1 tablet PO at bedtime

Allergies:

Nuts – anaphylaxis

Sesame seeds – anaphylaxis

Family History:

Daughter with history of Crohn’s disease. Another daughter with psoriatic arthritis.

Social History:

JG lives with his wife. He is able to complete ADLs independently.

Habits – Denies smoking history. Denies alcohol use. Denies history of illicit substance use.

Travel – No recent travel.

Review of Systems:

General – Denies recent fever, chills, unintentional weight loss/gain, fatigue, night sweats, or change in appetite.

Skin/nails – Denies rash, change in pigmentation, or wounds.

Head – Denies headache, dizziness, lightheadedness, recent head trauma.

Eyes – Denies visual disturbances.

Ears – Denies change in hearing, otalgia. No hearing aid use.

Nose – Denies congestion, discharge, epistaxis.

Mouth/throat – Denies sore throat, dysphagia, bleeding gums.

Neck – Denies pain, stiffness, limited ROM, injury/trauma.

Pulmonary – Denies SOB, DOE, cough, wheezing, orthopnea, PND, hemoptysis. Sleeps with 1 pillow for comfort.

Cardiovascular – Denies chest pain, palpitations, lower extremity swelling, syncope.

GI – (+)abdominal pain. (+)nausea. Denies vomiting, diarrhea, constipation, rectal bleeding. No recent changes in BM.

Genitourinary – (+)frequency – BPH, unchanged from baseline. Denies dark urine, incontinence, urgency, dysuria, hematuria.  

Nervous – Denies tingling, seizures, confusion, weakness, numbness, gait change.

Musculoskeletal – Denies body aches, back pain.

Hematologic – Denies history of DVT/PE, blood transfusions, bruising.

Psychiatric – (+)depression and anxiety, unchanged from baseline. Denies suicidal thoughts.

Physical Exam:

Vital signs:      BP: Seated      L-arm: 112/71             R-arm: omitted due to IV in R antecubital

RR:      18 breaths/min, unlabored                 Pulse: 79 bpm, regular                      

T:        97.8 degrees F (oral) O2 Sat: 96% on room air

Height: 67 inches        Weight: 170 lbs.       BMI: 26.6

General: Pt alert, oriented. No acute distress. Well nourished. Looks stated age.

Skin: Skin is warm & moist. No ecchymosis. Nonicteric. No rashes appreciated.

Hair:  (+)male pattern baldness.

Nails:  no clubbing, capillary refill <2 seconds in upper extremities.

Head:   normocephalic, atraumatic, nontender to palpation throughout

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears. No mastoid tenderness b/l. (+)Moderate amount of cerumen in auditory canals bilaterally. No discharge or foreign bodies in auditory canals.  TMs pearly and intact with cone of light in good position bilaterally.

Nose –Symmetrical. No masses, lesions, deformities, trauma, discharge.

Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy.

Septum midline without lesions, deformities, injection, perforation.  No foreign bodies.

Mouth/Oropharynx – Lips appear pink and moist, with no masses, cyanosis, or ulcers. Mucosa pink and moist. No lesions or masses. No leukoplakia. Palate pink, moist, intact with no lesions, masses, or scars.

No gingival hyperplasia or recession.

Tongue is midline. No discharge, masses or lesions.

Uvula is midline and rises symmetrically with phonation. No edema or lesions.

Oropharynx is pink and moist. No tonsils visualized. No swelling, erythema, exudates, masses/lesions, foreign bodies.

Neck – Full ROM. Supple. Non-tender to palpation. No JVD. Trachea is midline. No masses or lesions. No scars. Lymph nodes non-palpable bilaterally. No stridor. 2+ carotid pulses bilaterally. Thyroid is non-tender with no palpable masses. No thyromegaly.

Eyes – (+)reading glasses. Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink bilaterally. PERRL.
EOMs intact with no significant nystagmus.
Fundoscopy – Red reflex intact OU.

Chest/Pulmonary: Chest is symmetrical, without deformities or trauma. Lat to PA diameter is 2:1. Respirations unlabored. No use of accessory muscles noted. CTA bilaterally. No wheezes, rhonchi, rales, or other adventitious sounds.

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated. Carotid pulses are 2+ bilaterally without bruits.

Abdomen: Abdomen nontender to palpation throughout. No guarding or rebound. Tympanic throughout. No hepatosplenomegaly. Abdomen flat, soft, symmetric. No scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants. No CVA tenderness noted.

Mental Status Exam: Appearance and behavior – patient alert, no abnormal movements, grooming/hygiene appropriate, appropriate facial expression and manner.

Speech and language – follows 2 stage commands. Speech is of appropriate quantity, rate, volume, flow, and articulation.

Conversation progresses logically towards a goal.

Oriented to name, date, time, location.

Neurologic:

Cranial Nerves –See “Eyes” for CN II assessment. Conjugate gaze without nystagmus. Convergence of eyes. No ptosis. Symmetric and fluid facial movements. No difficulty with BMP or LTND speech sounds.

Soft palate rises and uvula is midline. No hoarseness or nasal quality in voice. No facial droop.

Peripheral Neuro –

Motor/Cerebellar

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout, including grip strength. Gait steady with no ataxia.

Meningeal Signs

No nuchal rigidity noted.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.

Interval history:

2/16 –

CBC: WBC 19.11, Hgb 15.2, Hct 45.8, Plt 457

CMP: within normal limits

Lipase: 11 U/L

UA notable for: small amt ketones, protein 30 mg/dL, nitrites negative, large amt leukocyte esterase, RBC: 1/hpf, WBC: 108/hpf, bacteria negative.

CT abdomen pelvis with contrast: “Long segment circumferential bowel wall thickening with adjacent inflammatory change/fluid and mesenteric edema involving the distal ileum predominantly located in the right lower quadrant compatible with an ileitis. No bowel obstruction. Small volume abdominal and pelvic ascites. No pneumoperitoneum.”

Given 1 dose of zosyn IV in the ED. Blood cultures obtained. Patient admitted. GI and ID consulted. Seen by GI who recommends starting cipro/flagyl

Seen by ID who recommends switching cipro to ceftriaxone, trending WBC.

2/17 – Patient reports having a bowel movement this morning. Soft yet formed, no blood. Mild, 1/10 RLQ abdominal pain, significantly improved from yesterday. Nausea has resolved.

CBC: WBC 8.36, Hgb 11.9, Hct 35.6, Plts 318

CMP: within normal limits

Blood cultures x2 (collected yesterday) – no growth to date

Urine culture (collected yesterday) – results pending

Pt seen by GI and ID who both state pt can be discharged as symptoms have significantly improved and leukocytosis resolved. Can switch abx to PO cefpodoxime 200mg BID and flagyl 500mg every 8 hrs until 2/25. Recommend outpatient ileocolonoscopy.

Differential Diagnoses:

• Ileitis – inflammatory etiology (Crohn’s disease)
• Ileitis – infectious
• Cystitis
• Ileitis – ischemia (less likely due to patent vessels on CT)
• Drug-related ileitis – rare

Assessment:  64 y/o male with PMHx of GERD, HTN, HLD, aortic stenosis s/p AVR, asthma, anxiety, depression, BPH, c/o RLQ abdominal pain. Found to have ileitis on CT. Leukocytosis resolved (19.18.3). Symptoms significantly improved. Cleared for discharge by GI and ID. Patient agrees.

Plan:

Abdominal pain/ileitis:

Obtain GI PCR from stool sample to rule out/in infectious etiology

Pt stable for discharge with close outpatient GI follow up for ileocolonoscopy.

Given strict return precautions for worsening pain or any other concerns.

Chronic conditions (HTN, HLD, GERD, BPH, asthma, anxiety, depression):

Continue outpatient meds. Follow up with PCP within 1-2 weeks.

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JOURNAL ARTICLE RELATED TO THE CASE: “Fecal microbiota transplantation in inflammatory bowel disease patients: A systematic review and meta-analysis” 2020

This systematic review aimed to assess the efficacy and safety of fecal microbiota transplantation in patients with inflammatory bowel disease (IBD) by analyzing the clinical remission, clinical response, and prevalence of adverse events. It included 60 studies, consisting of quasiexperimental trials, RCTs, cohort studies, case series, and case reports. Six RCTs were included in a meta-analysis comparing fecal transplant versus placebo. Fecal transplant showed significantly greater rates of clinical response and remission over placebo. This review also suggested that frozen fecal material may be more effective for remission than fresh fecal material, and fecal material from universal donors may be more effective than that of relatives/acquaintances. Although most of the studies included were outside of the United States, it does propose some guidance in terms of IBD treatment and which sources and methods to think of using when considering fecal microbiota transplantation.

Caldeira, L. F., Borba, H. H., Tonin, F. S., Wiens, A., Fernandez-Llimos, F., & Pontarolo, R. (2020). Fecal microbiota transplantation in inflammatory bowel disease patients: A systematic review and meta-analysis. PloS one, 15(9), e0238910. https://doi.org/10.1371/journal.pone.0238910