ID:

Mr. J.F. NYP-Q

Informant: Self, Reliable

 

Chief Complaint:

Abdominal pain and inability to tolerate PO x4 days

 

HPI:

31 year old male with significant PMH of ulcerative colitis s/p proctocolectomy w/diverting ileostomy (11/8/19) presented to the emergency room on 2/8/20 with abdominal pain and inability to tolerate PO. Patient states that if he doesn’t eat he does not experience any pain. The pain is worsened by increased PO intake and the only relieving factor is to not eat, therefore he has not had PO intake due to pain since discharge. Denies any improvement of symptoms with the use of pain medications. Pain is located above and below site of prior ileostomy. Pain is throbbing in nature and sharp. Denies fever, nausea, vomiting or any difficulty with urination. Admits to non-bloody diarrhea 12 times in the past 24 hours and passing flatus. Patient was admitted to step-down unit on 2/9/20, was started on broad-spectrum antibiotics (Zosyn) and was transferred to floor on 2/10/20. RUE picc line placed (2/10) and TPN started at midnight on 2/11/20.

 

PMH:

Ulcerative colitis

 

PSH:

Ileostomy reversal (1/30/20), robotic assisted total proctocolectomy w/J pouch ileoanal anastomosis w/diverting loop ileostomy (11/8/19)

 

Medications:

Piperacillin Tazobactam Inj + R + 4500mg IV PiggyBack q8h

Pantroprazole inj + R + 40mg IV push daily (for GI)

Parenteral nutrition adult 2400ml IV cont infusion

 

Allergies:

Peanuts (swelling), Fish product derivatives (itching), Shellfish (swelling)

 

Social History:

Denies use of alcohol, cigarettes, and/or illicit drugs. Single, lives at home. Independent in ADLs.

 

Family History:

Non-contributory

 

Review of Systems:

General : Admits to weakness/ fatigue. Denies fever, chills, night sweats, loss of appetite, weight loss.

Skin, Hair, Nails : Denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, change in hair distribution

Head : Denies headache, trauma, unconsciousness, coma, fracture, vertigo

Eyes : Denies corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation

Ears : Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses : Denies discharge, epistaxis, obstruction, rhinorrhea

Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures

Neck : Denies lumps, swelling, stiffness, decreased range of motion

Breast : Denies lumps, nipple discharge, pain

Respiratory : Denies wheezing, cough, hemoptysis, cyanosis, dyspnea, shortness of breath, paroxysmal nocturnal dyspnea

Cardiovascular : Denies palpitations, chest pain, irregular heartbeat, edema, syncope, known heart murmur

Gastrointestinal : Admits to abdominal pain when eating, diarrhea. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, constipation, hemorrhoids, blood in stool

Genitourinary : Denies change in frequency, urgency, hesitancy, dribbling, nocturia, polyuria, oliguria, dysuria, change in urine color, incontinence, flank pain

Musculoskeletal : Denies muscle/joint pain, leg weakness, deformity, swelling, redness

Peripheral Vascular : Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change

Hematologic : Denies anemia, lymph node enlargement, history of DVT/PE, easy bruising/bleeding

Endocrine : Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism Neurologic :  Denies loss of strength, ataxia, seizures, loss of consciousness, sensory disturbances, paresthesia, dysesthesia, hyperesthesia, memory loss, asymmetric weakness

Psychiatric : Denies feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation, anxiety

 

Initial DDx:

Post-op leak

Partial small bowel obstruction

Gastritis

Post-op infection

GERD

Lactose intolerance

Achalasia

Somatoform disorder

 

Physical Exam (2/13/20):

Vital Signs :

T 36.4C

BP 102/64

P 85bpm

RR 16 breaths/min

SpO2 98% RA

BMI: 29.0

General Survey : 31year old male in no acute distress, well nourished and well developed

Skin : Warm and moist, non-icteric

Head : Normocephalic, atraumatic, non-tender to palpation throughout

Eyes : No conjunctival injection, pallor, or scleral icterus. PERRLA

Neck : Trachea midline. No masses, lesions, scars. Supple, nontender to palpation. Full range of motion. No palpable lymphadenopathy.

Chest : Normal expiration and no accessory muscle use. Respirations unlabored. Nontender to palpation.

Lungs : Lung fields are clear to auscultation bilaterally

Cardiovascular : S1 and S2 normal. Regular rate and rhythm. No S3, S4, splitting of heart sounds, murmurs, rubs.

Abdomen : Soft and non-distended abdomen. Left lower quadrant abdominal wound healing well. Mild tenderness to palpation above and below previous ostomy site. No guarding, rebound tenderness. BS present in all four quadrants. No bruits over aortic/renal/iliac/femoral arteries. 

Extremities/Peripheral Vascular :  Extremities are normal in size and temperature.  No clubbing/cyanosis/edema noted. Full ROM.

Neurologic : 

 

Mental Status:

Awake, alert and oriented to person, time, place, situation. Appears as stated age, well groomed, eye contact good. No dysarthria, dysphonia, aphasia noted.

 

Cranial Nerves:

II-XII grossly intact.

 

Labs/Imaging:

140 | 102 | 5.4

—————–< 97      Ca: 9.0  P: 3.2  Mg: 1.8  Anion Gap: 12

4.6 | 26 | 1.30

WBC: 6.24/Hb: 9.3 (MCV 101.1)/ Hct 28.3/ Plt: 646

 

2/9 CT a/p: IV/Oral contrast was administered, which is within the mid to distal small bowel at time of exam. Patient is status post total colectomy. Surgical changes from recent ileostomy reversal are noted. There is mild prominence of small bowel to 2.9cm without frank dilatation. There is non-specific small to moderate amount of pneumoperitoneum, possibly postsurgical in nature although viscus perforation cannot be entirely excluded. There is non-specific thickening of the distal small bowel in the region of the proximal and distal anastomoses, possibly post-surgical in nature although a non-specific enteritis in these locations cannot be excluded. There are post-surgical changes noted within the left anterior abdominal wall/subcutaneous soft tissue including small foci on subcutaneous air.

 

DDx:

Post-op leak

Partial small bowel obstruction

Gastritis

Post-op infection

 

Assessment:

J.F. is a 31 year old male with significant PMH of ulcerative colitis s/p proctocolectomy with diversion s/p recent ileostomy reversal who presented with partial SBO symptoms with possible leak. His abdominal pain has been improving since initial admission and he was started on parenteral nutrition.

 

Plan:

-Trial of full liquid diet tonight

-Continue TPN for now (order new bag for tonight)

-Continue antibiotics for now

-Make sure patient is ambulating

-Monitor diarrhea

-Trend labs (repeat in AM)

-If patient is tolerating full liquid diet, may consider not renewing TPN for tomorrow

-Possibly advance solids in AM