++
++
History of Present Illness
++
AH is a 52-year-old Caucasian male with a recent history of hospitalization for cellulitis. He presents to the emergency department with watery diarrhea. He reports approximately 5 unformed stools per day over the last 3 days. He also complains of fever, chills, abdominal cramping, and general fatigue. He states that he was admitted to the hospital 10 days prior for cellulitis of the right knee and was treated with clindamycin. He was discharged, after a 2-day admission, on 5 additional days of clindamycin therapy.
++
T2DM, diabetic neuropathy, HTN, HLD, chronic venous stasis, obesity, GERD, cellulitis (resolved)
++
Father with T2DM, obesity, and deceased at age 71 secondary to a myocardial infarction. Mother with HTN (living). Sibling with T2DM, HTN (living)
++
Tobacco 1/4 ppd × 45 years (quit 8 years prior); 1 (12 oz) beer per day. No illicit drug use
++
Penicillin (swelling of the face)
++
++
Glipizide XL 10 mg PO daily
++
++
Lisinopril/HCTZ 20 mg/12.5 mg, 2 tablets PO daily
++
Amlodipine/atorvastatin 10 mg/80 mg PO daily
++
++
Omeprazole 20 mg PO daily
++
Clindamycin 450 mg PO QID (recently completed a 7-day course of therapy)
++
Temp 102.7°F, P 88, RR 18 breaths per minute, BP 158/88 mm Hg, pO2 94%, Ht 5′10″, Wt 141 kg
++
++
Normocephalic, atraumatic, PERRLA, EOMI, pink/moist mucous membranes and conjunctiva, no headache, no neck stiffness/pain, no photophobia
++
++
++
Soft, non-distended, mildly tender to palpation, positive guarding, bowel sounds hyperactive
++
Normal male genitalia, no complaints of dysuria or hematuria
++
A&O ×3, cranial nerves intact
++
Normal range of motion, no edema, changes consistent with venous stasis
++
Emergency Department Labs
++