Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
___ Complaint:
Nausea, emesis and abdominal pain

 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ year-old male with past medical history of ulcerative colitis 
s/p laparoscopic proctocolectomy, ileal pouch anal anastomosis 
with diverting loop ileostomy (___) with subsequent takedown 
(___) by Dr ___, presenting to the ED on ___ with a 
24-hour history of persistent nausea and emesis. Patient states 
that he has not had a bowel movement or passed any gas since ___ 
hours ago (normally multiple bowel movements per day). He 
endorses persistent nausea and bilious emesis since waking up 
this morning, as well as moderate, pressure-like, abdominal 
pain, that he has been having intermittently for the past few 
months. He denies fever, chills, or bright red blood per rectum. 
Of note, patient stated that in the recent past, he has 
developed symptoms of "partial obstruction" where he feels 
constipated, distended, and nauseated. These episodes occur 
approximately once a month and last for about ___ hours before 
spontaneously resolving. Also, for the past few months, he had 
been experiencing occasional rectal and lower abdominal pain, 
especially when going to the bathroom at night, with some 
feeling
of tightness in the rectum. On his last visit to his 
gastroenterologist two weeks ago (Dr ___, a 
possible explanation given to his symptoms was that of 
pouchitis, for which purpose a ___ had been arranged.
 
Past Medical History:
PMH: Ulcerative colitis

PSH: ___- Laparoscopic proctocolectomy and mobilization of
splenic flexure, ileal pouch anal anastomosis with diverting
loop ileostomy.

 
Social History:
___
Family History:
He has 2 maternal cousins with underlying inflammatory bowel 
disease. He has one twin brother and one sister who are in good 
health. Maternal GF pancreatic cancer 56. Maternal GM breast 
post menopausal age ___. Paternal GF ? lung ca.

 
Physical Exam:
Vitals: VSS on discharge
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding, 
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused

 
Pertinent Results:
___ 09:40PM   WBC-11.4* RBC-4.99 HGB-14.5 HCT-43.6 MCV-87 
MCH-28.9 MCHC-33.1 RDW-14.7
___ 09:40PM   NEUTS-84.1* LYMPHS-5.6* MONOS-9.9 EOS-0.2 
BASOS-0.2
___ 09:40PM   PLT COUNT-208
___ 01:59PM   LACTATE-1.6
___ 01:49PM   LACTATE-1.6
___ 01:09PM   ___ PTT-24.3* ___
___ 12:50PM   GLUCOSE-102* UREA N-14 CREAT-0.9 SODIUM-141 
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-16
___ 12:50PM   estGFR-Using this
___ 12:50PM   ALT(SGPT)-22 AST(SGOT)-20 ALK PHOS-86 TOT 
BILI-0.7
___ 12:50PM   LIPASE-18
___ 12:50PM   ALBUMIN-5.3*
___ 12:50PM   WBC-16.4*# RBC-5.68# HGB-16.5# HCT-49.6# 
MCV-87 MCH-29.0 MCHC-33.2 RDW-14.6
___ 12:50PM   NEUTS-89.3* LYMPHS-3.9* MONOS-6.3 EOS-0.3 
BASOS-0.3
___ 12:50PM   PLT COUNT-230
 
Brief Hospital Course:
Mr ___ presented to the ED on ___ with nausea, emesis 
and abdominal pain. Given his history of ulcerative colitis s/p 
laparoscopic proctocolectomy, ileal pouch anal anastomosis with 
diverting loop ileostomy (___) with subsequent takedown 
(___) by Dr ___ was admitted to the floor for 
conservative management of SBO. CT scan confirmed SBO with 
transition point at proximal pelvic anastomosis. In the ED he 
was made NPO, had an NGT placed and was maintained on IV fluids. 
After a brief and uneventful stay in the ED, the patient was 
transferred to the floor for further management.

Neuro: The patient received IV pain control with good effect. 
Narcotic medications were avoided.

CV: The patient remained stable from a cardiovascular 
standpoint; vital signs were routinely monitored. 

Pulmonary: The patient remained stable from a pulmonary 
standpoint; vital signs were routinely monitored.

GI: The patient was made NPO, had an NGT placed and received IV  
fluids. On HD#2 the patient passed gas and had BMs. The NGT was 
subsequently clamped with 0 residual output. GI was consulted; 
as per their recommendations the patient would be discharged on 
a low-residue diet and would follow up with his 
gastroenterologist Dr. ___ to determine the 
underlying cause of his condition (stricture versus 
inflammation). Diet was advanced which was initially well 
tolerated. For the rest of his stay, patient's intake and output 
were closely monitored, and IV fluid was adjusted when 
necessary. Electrolytes were routinely followed, and repleted 
when necessary. 

GU:The patient voided without difficulty throughout his hospital 
stay.

ID: The patient's white blood count and fever curves were 
closely watched for signs of infection. On admission his WBC was 
16.4 which when repeated went down to 11.4. 
 
On ___, the patient was discharged to home. At discharge, 
he was tolerating a regular diet, passing flatus, stooling, 
voiding, and ambulating independently. He will follow-up in 
clinic. This information was communicated to the patient 
directly prior to discharge with verbalized understanding and 
agreement.

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LOPERamide 2 mg PO BID 
2. Psyllium Wafer 1 WAF PO BID 
3. Tamsulosin 0.4 mg PO HS 
4. Ferrous Sulfate 325 mg PO BID 

 
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain 
do not take more than 3000mg of tylenol in 24 hours 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
small bowel obstruction

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
You were admitted to the hospital for a small bowel obstruction. 
You were given bowel rest and intravenous fluids and a 
nasogastric tube was placed in your stomach to decompress your 
bowels. Your obstruction has subsequently resolved after 
conservative management. You have tolerated a regular diet, are 
passing gas and your pain is controlled with pain medications by 
mouth. You may return home to finish your recovery. You should 
keep your appointment with Dr. ___ your ___ 
tomorrow. Please follow the instructions given to you by his 
office for the bowel prep. After this procedure, Dr. ___ 
also study the pouch. 
 
Please monitor your bowel function closely. If you notice that 
you are passing bright red blood with bowel movements or having 
loose stool without improvement please call the office or go to 
the emergency room if the symptoms are severe. If you have any 
of the following symptoms please call the office for advice or 
go to the emergency room if severe: increasing abdominal 
distension, increasing abdominal pain, nausea, vomiting, 
inability to tolerate food or liquids, prolonged loose stool, or 
extended constipation.
 
Thank you for allowing us to participate in your care! Our hope 
is that you will have a quick return to your life and usual 
activities. Good luck!

 
Followup Instructions:
___

{'Nausea': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'Emesis': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'Abdominal pain': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)']}