Diverticulitis of large intestine with perforation and abscess without bleeding Essential (primary) hypertension
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
abdominal pain
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
___ years old woman with past medical history of hypertension
comes to the ED complaining of abdominal pain. Patient refers 
she
was in her usual state of health until 9 days ago when she
started having intermittent severe crampy abdominal pain. She
refers that sometimes the pain was so severe that it was
associated with nausea but no emesis. She also refers some 
chills
and subjective fevers but no recorded fevers and loose bowel
movements. 

Yesterday her pain worsened so she called her PCP who ordered ___
CBC and UA, both of which were normal so she was sent home. This
morning her pain was again worse so she went back to her PCP and
had done a CT scan of abdomen and pelvis that showed acute
diverticulitis with small abscess so she was referred to the ED
for surgical evaluation.

 
Past Medical History:
HTN  
 Diverticulosis  

 
Social History:
___
Family History:
non-contributory
 
Physical Exam:
PHYSICAL EXAM: upon admission:  ___
 VITAL SIGNS: 98.4, 81, 138/79, 18, 100% RA 

 GENERAL: AAOx3 NAD
 HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD
 CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G
 PULMONARY: CTA ___, No crackles or rhonchi
 GASTROINTESTINAL: soft, non-distended, mildly tender diffusely
in lower abdomen. No guarding, rebound, or peritoneal signs.
+BSx4
 EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion.
 NEUROLOGICAL: Reflexes, strength, and sensation grossly intact
 CNII-XII: WNL

Physical examination upon discharge:  ___:

GENERAL:  NAD

CV:  ns1, s2, no murmurs
LUNGS:  clear
ABDOMEN: hypoactive BS, soft, non-tender
EXT:  no calf tenderness bil., no pedal edema bil
NEURO:  alert and oriented x 3, speech clear

 
Pertinent Results:
___ 04:15AM BLOOD WBC-6.2 RBC-3.96 Hgb-12.7 Hct-36.8 MCV-93 
MCH-32.1* MCHC-34.5 RDW-11.1 RDWSD-37.8 Plt ___
___ 04:49AM BLOOD WBC-6.1 RBC-3.74* Hgb-12.1 Hct-34.7 
MCV-93 MCH-32.4* MCHC-34.9 RDW-11.1 RDWSD-38.0 Plt ___
___ 01:44PM BLOOD WBC-8.6 RBC-3.86* Hgb-12.5 Hct-37.0 
MCV-96 MCH-32.4* MCHC-33.8 RDW-11.4 RDWSD-40.0 Plt ___
___ 04:15AM BLOOD Plt ___
___ 04:15AM BLOOD Glucose-83 UreaN-5* Creat-0.6 Na-142 
K-4.3 Cl-105 HCO3-24 AnGap-13
___ 08:30PM BLOOD Glucose-70 UreaN-12 Creat-0.5 Na-136 
K-4.2 Cl-95* HCO3-23 AnGap-18
___ 04:15AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.3
___ 08:38PM BLOOD Lactate-1.0

___:  CT scan abdomen and pelvis:

Sigmoid diverticulitis with 1.2 cm intramural abscess.  No 
evidence of 
macro-perforation. 
-3 mm hypodensity within the pancreatic body likely represents a 
benign 
intra-ductal papillary mucinous neoplasm.  Nonurgent MRCP is 
recommended for further evaluation. 
  
RECOMMENDATION(S):  Non-urgent MRCP 
  
NOTIFICATION:  The findings were discussed with ___, M.D. 
by ___ 
___, M.D. on the telephone on ___ at 4:00 pm, 5 minutes 
after discovery of the findings. 

 
Brief Hospital Course:
___ year old female admitted to the hospital with abdominal pain. 
 Upon admission, the patient was made NPO, given intravenous 
fluids, and underwent imaging. She was reported to have sigmoid 
diverticulitis with 1.2 cm intramural abscess. The patient was 
started on a course of intravenous ciprofloxacin and flagyl and 
placed on bowel rest. Her white blood cell count was monitored. 
After the patient's abdominal pain decreased, she was started on 
clears and advanced to a regular diet.  

The patient was discharged home on HD #5.  Her vital signs were 
stable and she was afebrile.  She was tolerating a regular diet 
and voiding without difficultly.  She was ambulatory and return 
of bowel function.  Discharge instructions were reviewed and 
questions answered.  The patient was given a prescription for 
completion of a course of ciprofloxacin and flagyl.  The patient 
was instructed to follow up with her primary care provider.

+++++++++++++++++++++++++++++++++++++++++++++++

Of note:  incidental finding on cat scan imaging showed a 3 mm 
hypo-density within the pancreatic body likely represents a 
benign intra-ductal papillary mucinous neoplasm.  Non-urgent 
MRCP is recommended for further evaluation. The patient was 
informed of this finding and given a copy of her report.  
     
 
Medications on Admission:
ESTRADIOL [ESTRACE] - Estrace 0.01% (0.1 mg/gram) vaginal cream. 
 
 1 gram Use as directed PRN - (Prescribed by Other Provider)  
 LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth Q Day  
 NIACIN - niacin ER 500 mg tablet,extended release 24 hr. 1  
 tablet(s) by mouth once a day  
 RALOXIFENE - raloxifene 60 mg tablet. 1 tablet(s) by mouth 
daily  
 RHIZINATE X3 - Dosage uncertain - (Prescribed by Other 
Provider)  
 
 Medications - OTC  
 ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by  

 mouth Daily - (Prescribed by Other Provider)  
 CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 4,000 
unit  
 capsule. 1 capsule(s) by mouth Daily - (Prescribed by Other  
 Provider)  
 MULTIVIT-MIN-LYCOP-LUT-HERB___ [PHYTOMULTI] - PhytoMulti 3 mg-3 
 
 mg-200 mg tablet. 2 tablet(s) by mouth Daily - (Prescribed by  
 Other Provider)  
 VIT A AND D3 IN COD LIVER OIL [COD LIVER OIL] - cod liver oil  
 4,000 unit-400 unit/5 mL oral liquid. 1 Tbsp by mouth Daily -  
 (Prescribed by Other Provider)  
 --------------- --------------- --------------- --------------- 
 

 
Discharge Medications:
1.  Acetaminophen 650 mg PO Q6H:PRN Pain - Mild  
2.  Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days 
___ 
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every 
twelve (12) hours Disp #*14 Tablet Refills:*0 
3.  MetroNIDAZOLE 500 mg PO Q8H Duration: 7 Days 
last dose ___ 
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 
eight (8) hours Disp #*21 Tablet Refills:*0 
4.  Aspirin 81 mg PO DAILY  
5.  Losartan Potassium 25 mg PO DAILY  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
diverticulitis

 
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 with abdominal pain. You 
underwent imaging which showed sigmoid diverticulitis with a 
intra-mural abscess.  You were placed on bowel rest and given a 
course of antibiotics.  Your abdominal pain has decreased and 
you have resumed a diet.  You are being discharged home with the 
following recommendations:   

 Please call your doctor or nurse practitioner or return to the 
Emergency Department for any of the following:

*You experience new chest pain, pressure, squeezing or 
tightness.

*New or worsening cough, shortness of breath, or wheeze.

*If you are vomiting and cannot keep down fluids or your 
medications.

*You are getting dehydrated due to continued vomiting, diarrhea, 
or other reasons. Signs of dehydration include dry mouth, rapid 
heartbeat, or feeling dizzy or faint when standing.

*You see blood or dark/black material when you vomit or have a 
bowel movement.

*You experience burning when you urinate, have blood in your 
urine, or experience a discharge.

*You have shaking chills, or fever greater than 101.5 degrees 
Fahrenheit or 38 degrees Celsius.

*Any change in your symptoms, or any new symptoms that concern 
you.

 
Followup Instructions:
___

{'abdominal pain': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'chills': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'nausea': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'subjective fevers': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'loose bowel movements': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'tender diffusely in lower abdomen': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'hypoactive BS': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'soft, non-distended, mildly tender diffusely in lower abdomen': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'no guarding, rebound, or peritoneal signs': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], '+BSx4': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'alert and oriented x 3, speech clear': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'no calf tenderness bil., no pedal edema bil': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'neuro: alert and oriented x 3, speech clear': ['Diverticulitis of large intestine with perforation and abscess without bleeding']}