Hospitalist Inpatient Admission

Chief Complaint: The patient presents with a two-day history of worsening left lower quadrant abdominal pain and subjective fevers.

History of Presenting Illness: Mr Arthur Pendelton, a 64-year-old male, presented to the emergency department at 14:30 on 14/05/2024 with acute-onset, constant, dull left lower quadrant pain that began 48 hours ago. The pain is rated 7/10, non-radiating, and exacerbated by movement and oral intake. Associated symptoms include subjective chills, nausea without emesis, anorexia, and two episodes of loose, non-bloody stools yesterday. He has a known history of colonic diverticulosis noted on a screening colonoscopy three years ago, though this is his first episode of suspected acute inflammation.

Detailed history of investigations and findings performed in the emergency department or transferring facility: Upon arrival to the emergency department, the patient was found to be febrile and mildly tachycardic. Blood tests were drawn, revealing leukocytosis and an elevated C-reactive protein, while a venous blood gas showed a normal lactate level. Computed tomography of the abdomen and pelvis with intravenous contrast demonstrated acute uncomplicated sigmoid diverticulitis. He was administered sodium chloride 0.9% 1,000 mL IV stat, paracetamol (Panadol®) 1,000 mg IV stat, ondansetron (Zofran®) 4 mg IV stat, ceftriaxone 2 g IV stat, and metronidazole 500 mg IV stat prior to inpatient referral.

Past Medical History: Hypertension, hyperlipidaemia, colonic diverticulosis, gastro-oesophageal reflux disease, osteoarthritis of the right knee.

Home Medications: perindopril 5 mg PO daily, atorvastatin (Lipitor®) 40 mg PO nocte, esomeprazole (Nexium®) 20 mg PO daily, paracetamol (Panadol®) 1,000 mg PO QID PRN.

Allergies: The patient has a documented allergy to penicillin, which causes a generalised maculopapular rash.

Social History: He is a retired accountant who lives at home with his wife, is an ex-smoker with a 15-pack-year history having quit 10 years ago, and consumes 2 standard alcoholic drinks per week.

Family History: His father died of a myocardial infarction at age 72, and his mother had a history of type 2 diabetes mellitus and hypertension.

Review of Systems

Constitutional symptoms: The patient reports subjective fevers, chills, anorexia, and mild fatigue over the past two days.

Eyes: He denies any visual changes, blurred vision, or scleral icterus.

Ears, Nose, Mouth, Throat: He reports dry mucous membranes but denies sore throat, epistaxis, or tinnitus.

Cardiovascular: He denies chest pain, palpitations, orthopnoea, or peripheral oedema.

Respiratory: He denies shortness of breath, cough, wheezing, or haemoptysis.

Gastrointestinal: He reports left lower quadrant abdominal pain, nausea, and loose stools, while denying vomiting, haematochezia, or melaena.

Genitourinary: He denies dysuria, haematuria, urinary frequency, or flank pain.

Musculoskeletal: He reports chronic baseline right knee ache but denies acute joint swelling or myalgias.

Integumentary (Skin): He denies any new rashes, pruritus, or skin lesions.

Neurological: He denies headache, dizziness, syncope, or focal weakness.

Psychiatric: He denies anxiety, depression, or confusion.

Endocrine: He denies polyuria, polydipsia, or heat intolerance.

Hematologic/Lymphatic: He denies easy bruising, prolonged bleeding, or lymphadenopathy.

Allergic/Immunologic: He denies acute urticaria, angioedema, or seasonal rhinorrhoea.

Physical Exam

Vitals: BP 138/84 mmHg, HR 96 bpm, Temp 38.2 °C, RR 18 breaths/min, SpO2 98 % on room air.

Abdominal examination: The abdomen is soft and non-distended with normoactive bowel sounds, marked tenderness to palpation in the left lower quadrant, voluntary guarding, and no rebound tenderness or palpable masses.

Lab Results

Pathology demonstrates a white blood cell count of 14,800 /mm³, neutrophils of 11,900 /mm³, C-reactive protein of 115 mg/L, haemoglobin of 142 g/L, platelets of 265,000 /mm³, creatinine of 88 µmol/L, eGFR of 78 mL/min/1.73m², lipase of 32 U/L, and lactate of 1.4 mmol/L.

Imaging Results

CT abdomen and pelvis with IV contrast shows segmental wall thickening of the sigmoid colon with pericolonic fat stranding and multiple diverticula, consistent with acute uncomplicated diverticulitis without abscess, perforation, or free air.

Assessment/Plan

1. Acute uncomplicated sigmoid diverticulitis.

• Impression: This is a 64-year-old male presenting with his first episode of Hinchey stage Ia acute sigmoid diverticulitis, complicated by systemic inflammatory response and inability to tolerate oral intake reliably.
• Differential diagnosis: Acute infectious colitis, ischaemic colitis, inflammatory bowel disease, colorectal malignancy, epiploic appendagitis.
• Investigations planned: Daily full blood count, urea and electrolytes, C-reactive protein, blood cultures if temp exceeds 38.5 °C, outpatient colonoscopy in 6 to 8 weeks.
• Treatment planned: Nil by mouth except sips of clear fluids, Hartmann's solution 83 mL/hr IV continuous, ciprofloxacin 400 mg IV BID (given penicillin allergy), metronidazole 500 mg IV TID, paracetamol 1,000 mg PO/IV QID, oxycodone (Endone®) 5 mg PO Q4H PRN for severe pain, enoxaparin (Clexane®) 40 mg SC daily.
• Relevant referrals: An inpatient consultation has been placed to the Colorectal Surgery team for co-management and follow-up planning.

Two Midnight Documentation

The patient is expected to require hospitalization spanning at least two midnights due to persistent systemic infection, need for intravenous broad-spectrum antibiotics, parenteral hydration, and serial abdominal examinations to monitor for perforation or abscess formation.

Total time spent: A total of 55 minutes was spent admitting the patient, reviewing emergency department records, performing the bedside examination, and coordinating care with the surgical team.