Johns Hopkins Medicine                                                                Phone: 410-616-7361

Remote Second Opinion Program                                                   Fax: 410-616-7351

2360 W. Joppa Road                                                                

Joppa Concourse, Suite 205

Lutherville, M.D. 21093

 

 

John Physician, M.D.

123 Smith Lane

Anytown, MS 12345

 

Re: Remote Second Opinion; Patient – Joe Smith

 

Dear Dr. Physician,

 

Thank you for referring Mr. Smith to me for an assessment and recommendation regarding his gastrointestinal condition.  As a reminder, this request was submitted through our Remote Second Opinion Program.  Since I have not seen this patient in person, limitations exist that may affect the assessment and recommendations outlined below; your patient has acknowledged his/her understanding of these limitations.

 

Review of Available Data

Patient Name: Joe Smith
Physician's name: John Physician, M.D.
Date of Birth: 08/28/1917

Mr. Smith is an 89-year-old man who experienced alternate diarrhea and constipation for approximately two months.  The patient has received antibiotics on at least one occasion (date unknown) for a urinary tract infection.  It seems that he has had multiple medical problems in the past including Nephrotic syndrome, CVA, history of colon polyps as well as a family history of colon cancer.  There is also some evidence in the available records that the patient has lost some weight.  In Jan. 2006 his weight was 193 but in May 2006 his weight dropped to 178. 

 

I reviewed his laboratory testing and it seems that he has a mild anemia, mild hyperglycemia, and marked hypoalbuminemia.  The patient has also had an evaluation with stool exams for ova and parasites, leukocytes, and a c-diff, which have all been negative.  He has also had a CT scan of the abdomen done in Dec. 2005 which showed non-obstructing renal calculi bilaterally.  The chest CT scan showed evidence of bilateral pleural effusion as well as some bibasilar infiltrates.  The patient had acute obstructive films of the abdomen done on 12/27/05 which showed evidence of adynamic ileus.  I do not see any repeat films since then. 

 

Johns Hopkins Remote Second Opinion Assessment/Recommendations:

 

This is an 89-year-old gentleman with multiple medical problems which include Nephrotic Syndrome, CVA, recent urinary tract infection, and has a suprapubic catheter.  He also has a history of colon polyps (type and date removed unavailable) as well as a family history of colon cancer.  He has had diarrhea for two months and also some weight loss and anemia.  The weight loss may be explained on the basis of fluid retention and diuresis, but is of some concern. 

 

My differential diagnosis included the possibility of an antibiotic associated diarrhea, possibly C-Diff. Although the negative stool test speaks against it they do not completely exclude it.  Other possibilities such as ischemic colitis or mucosal edema with a malabsorption state should also be considered in view of his age and the presence of Nephrotic Syndrome.  Additionally, the possibility of a colonic tumor and stool impaction with seepage of liquid stools is other possibilities.

 

In view of his medical condition invasive procedures should be kept to a minimum; however I recommend the following:

 

·         Abdominal films should be obtained to rule out the possibility of fecal impaction as well as colonic ischemia. 

·         If the abdominal films are negative I would be inclined to provide a therapeutic trial with Flagyl 250 mg q.i.d combined with Questran 1 scoop b.i.d for a period of 10 days.

·         In the event that he does not respond to the above management, it would be beneficial to obtain a colonoscopy to exclude the possibility of tumors or inflammatory bowel disease or ischemic colitis.

 

Thank you again for requesting a remote second opinion.  I hope this service has complemented the excellent care that you are providing to your patient.  I look forward to working with you again in the future should another need arise for your patient.  Should you have any questions regarding this assessment, please feel free to call me at 410-616-7361.

 

 

With Sincere Regards,

 

Salah M. Nasrallah, MD, FACG

Johns Hopkins Medicine

Division of Gastroenterology & Hepatology

 

*Disclaimer: By engaging our services, you acknowledged and agreed to assume the risk of these limitations.  You further understood that no warranty or guarantee has been made to you concerning any particular result or cure of your condition.