CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia.  She has developed worsening confusion, fever, and intractable diarrhea.  She was brought to the emergency department for evaluation.  Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6.  She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness.,PAST MEDICAL HISTORY: , Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism.,MEDICATIONS:  ,Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone.,SOCIAL HISTORY: , The patient has been residing at South Valley Care Center.,REVIEW OF SYSTEMS: , The patient is unable answer review of systems.,PHYSICAL EXAMINATION:,GENERAL:  This is a very elderly, cachectic woman lying in bed in no acute distress.,HEENT:  Examination is normocephalic and atraumatic.  The pupils are equal, round and reactive to light and accommodation.  The extraocular movements are full.,NECK:  Supple with full range of motion and no masses.,LUNGS:  There are decreased breath sounds at the bases bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm with normal S1 and S2, and no S3 or S4.,ABDOMEN:  Soft and nontender with no hepatosplenomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient moves all extremities but does not communicate.,DIAGNOSTIC STUDIES: , The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000.  The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3.,IMPRESSION/PLAN:,1.  Elevated white count.  This patient is admitted to the hospital for treatment of a febrile illness.  There is concern that she has a progression of pneumonia.  She may have aspirated.  She has been treated with ceftriaxone and clindamycin.  I will follow her oxygen saturation and chest x-ray closely.  She is allergic to penicillin.  Therefore, clindamycin is the appropriate antibiotic for possible aspiration.,2.  Intractable diarrhea.  The patient has been experiencing intractable diarrhea.  I am concerned about Clostridium difficile infection with possible pseudomembranous colitis.  I will send her stool for Clostridium difficile toxin assay.  I will consider treating with metronidazole.,3.  Hypokalemia.  The patient's profound hypokalemia is likely secondary to her diarrhea.  I will treat her with supplemental potassium.,4.  DNR status:  I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy.  , 