Patient: Keyser Soze

Date of Birth: 8/18/1989

Date: 11/3/16
Time: 3:00 p.m.

Subjective:

Chief Complaint: Diarrhea, general abdominal discomfort

History of Present Illness: Mr. Soze presented to the Family Medicine Office with the chief
complaint of diarrhea and general abdominal discomfort for the past six weeks. His brother,
Matt, has accompanied him to the meeting.

Mr. Soze explained to me that his symptoms began after returning from a trip six weeks ago to
the Bahamas with his girlfriend. Prior to leaving for the trip, Mr. Soze had been on a
ketogenic, or paleo, diet. While on the trip, Mr. Soze gave up his diet and enjoyed eating
whatever he wanted and drinking copious amounts of margaritas. He started the diet originally
to lose some weight. He has noticed that he has since lost some weight over the past six
weeks. He recreationally drinks alcohol. Recently, he went to an Italian restaurant for a
spaghetti and meatball dinner with alcohol and afterwards felt sick. His symptoms are not
accompanied by vomiting. His diarrhea is floating and foul-smelling, without the presence of
blood. The diarrhea has not gotten worse since he came back from his trip, but some days he
maintains up to 4-5 diarrheal stools. Usually, he only passes 1-2 stools per day. He feels like he
is able to empty his bowels completely when going to the bathroom. After relieving himself, he
still feels some discomfort, but he is not bloated. Mr. Soze describes his abdominal pain as
crampy and uncomfortable with no focal area of pain. He has never had this combination of
diarrhea and abdominal pain before. He is currently taking 1-2 tums whenever he feels
abdominal pain but it doesnt help much. Mr. Sozes girlfriend is not currently experiencing any
of these symptoms, nor was she engaging in the paleo diet or taking any medication when
these symptoms began for him.

Allergies: Pollen congestion, rhinorrhea

Medications: Lisinopril 15 mg once per day oral

Tums 500 mg 1-2 tablets upon GI distress oral

Past Medical History: Hypertension currently taking medication, but not controlled. Broke
radius and ulna last year from a fall was set and casted in an outpatient clinic without the use
of anesthesia. Recent history of dental caries.

Past Surgical History: Tonsillectomy at age 8, no complications. Wisdom teeth removal at age
18, no complications.

Immunizations: Up to date on immunizations. Recent influenza vaccine.

Social History:
Tobacco - Does not and has never smoked tobacco.
Alcohol - Drinks recreationally up to four beers a week.
Diet - Has been on a paleo diet for the past two years, but gave up the diet before his
symptoms began. He eats whatever he wants to eat.
Illicit drugs No use of recreational drugs or steroids.
Exercise Not currently exercising.
Occupation Student
Marital Status Single girlfriend
Sexual History Sexually active with current girlfriend. Girlfriend is currently taking
contraceptives. He has had no homosexual contact and does not practice anal sex.

Family History: Mother is living, age 45, and has osteoporosis.

Father is living, age 42, and has diabetes and GERD.
Brother is living, age 24, and is healthy.

Review of Systems:

General: Patient confirms malaise, fatigue, and weight loss. Denies fever.

HEENT: Patient confirms dental carries, dysphagia, and heartburn. Denies vision changes and
mouth ulcers.

Cardiovascular: Patient denies chest pain, shortness of breath, palpitations, and swelling.

Pulmonary: Patient denies coughing or wheezing.

GI: Patient confirms gas and abdominal cramping. Patient denies nausea, vomiting, or
superficial, protruding veins.

Renal: Patient denies dysuria. Patient denies change in color of urine.

Dermatologic: Patient confirms pruritic rash on extensor surfaces of elbows and knees.

Objective:

Vitals:

Height: 61
Weight: 198 lbs.
Blood Pressure: 142/92 mm Hg
Heart Rate: 96 beats per minute
Respiratory Rate: 14 breathes per minute
O2 Sat: 99% on room air
Temperature: 99 degrees Fahrenheit

Physical Exam:

General: No acute distress. Normal body habitus. No presence of jaundice or pallor.

HEENT: Conjunctival pallor is present. Dental caries are seen on examination. Lids are
symmetric. PERLA and symmetrically round.

Cardiovascular: Regular rate and rhythm. Normal S1. Normal S2 with physiologic split. No S3
or S4. No murmurs, rubs, gallops, clicks or other adventitious sounds. No heaves or thrills.
Radial, carotid, brachial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are each
2+ and symmetric bilaterally. There is no pitting edema of the lower extremities or varicose
veins.

Pulmonary: Lung clear on auscultation and percussion bilaterally in all lung fields.

Neurologic: Oriented to person, place, time and situation. Cranial nerves I-XII intact.

Dermatologic: Papular and vesicular pruritic, crusting rash noted on extensor surfaces of elbows
and knees. Koilonychia present. Normal capillary refill. No scars, bruises, or other lesions
present.

Abdominal Exam: Abdomen is flat. Bowel sounds are hyperactive in all four quadrants. No
splenomegaly. No palpable masses. No rebound tenderness or guarding. Percussion is
tympanic in all four quadrants. There is no shifting dullness.

Structural Exam: Tissue texture change and asymmetry from T5-T9 palpable on exam.

Rectal Exam: Anal fissure on posterior midline present with occult blood on examination.

Assessment:

Problem list: Diffuse abdominal pain, diarrhea, popular/vesicular rash, dental caries, heartburn

Differential: Giardia, rotavirus, norovirus, E. coli, salmonella, shigella, C. difficile; Crohns

disease, ulcerative colitis, celiac disease, lactase deficiency, IBS, drug reaction

Labs: CBC with ESR, B12, folate, iron. Blood smear, CMP, IgA anti-TTG; anti-endomysial; anti-
deamidated gliadin, genetic testing for HLA-DQ2/HLA-DQ8, upper endoscopy with multiple
duodenal biopsies.

Pathology Duodenal biopsy indicated flat villi with deep crypts and lymphocytic infiltration.
Plan:

Moderate celiac disease Mr. Soze must go back on his paleo diet in order to eliminate
symptoms. I am confident that he will be able to do so, considering he managed to be on the
diet for two years previously. Maintaining a strict gluten-free diet should resolve his symptoms
in two weeks. If he remains on the diet, symptoms should not reappear.

Warren Lawless, OMS-II

Date: 11/6/16
Time: 9:00 p.m.