Unspecified intestinal obstruction Regional enteritis of unspecified site Unspecified essential hypertension Obstructive sleep apnea (adult)(pediatric) Gout unspecified Other and unspecified hyperlipidemia Acquired absence of intestine (large) (small)
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
Abdominal pain, small bowel obstruction
 
Major Surgical or Invasive Procedure:
NONE

 
History of Present Illness:
Mr. ___ is a ___ year old male with history of Crohn's 
disease s/p ileocectomy w/ ileostomy and subsequent reversal who 
has had multiple episodes (>10) of small bowel obstruction who 
presents with 1 day of crampy abdominal pain consistent w/ 
previous episodes of SBO. He states he was at a ___ game 
when he first began to feel the crampy abdominal pain, which 
worsened by early morning so he came to the ED. He reports he 
was dehydrated and eating peanuts at the time, but otherwise, 
leafy green vegetables can sometimes bring out an episode of 
SBO. They have all been managed conservatively in the past, and 
an NG tube was used only once. He currently reports improved 
pain, no fever, chills, chest pain, shortness of breath, 
headache, dizziness, blood per rectum or dysuria. He last passed 
gas and had a small BM yesterday evening, but reports none 
since.

 
Past Medical History:
Past Medical History:
- Crohn's disease
- Hypertension
- Obstructive sleep apnea
- Gout
- Hyperlipidemia
________________________________________________________________
Past Surgical History:
- Appendiceal abscess s/p ileocectomy, ileostomy placement
(___)
- Ileostomy reversal (___)
- Repair of abdominal wall diastasis/weakness (___)
________________________________________________________________

 
Social History:
___
Family History:
No family history of inflammatory bowel disease or colon cancer.

 
Physical Exam:
ON ADMISSION
Vitals: Afebrile, vital signs stable
GEN: Alert and oriented, no acute distress, conversant and
interactive.
HEENT: Sclerae anicteric, mucous membranes moist, oropharynx is
clear. 
NECK: Trachea is midline, thyroid unremarkable, no palpable
cervical lymphadenopathy, no visible JVD.
CV: Regular rate and rhythm, no audible murmurs.
PULM/CHEST: Clear to auscultation bilaterally, respirations are
unlabored on room air.
ABD: Soft, non distended, mildly tender to palpation diffusely 
in
lower quadrants. No guarding or rebound tenderness.
Ext: No lower extremity edema, distal extremities feel warm and
appear well-perfused.

ON DISCHARGE:
VS: T 97.7, HR 58, BP 138/72, RR 18, SaO2 98% RA
GEN: No acute distress, alert and cooperative
CV: RRR
PULM: Easy work of breathing
ABD: Soft, nontender, nondistended
EXT: Warm, well perfused.
 
Pertinent Results:
___ 03:00AM BLOOD WBC-8.6 RBC-5.00 Hgb-15.4 Hct-45.1 MCV-90 
MCH-30.8 MCHC-34.1 RDW-12.3 RDWSD-40.5 Plt ___
___ 03:00AM BLOOD Neuts-80.2* Lymphs-11.9* Monos-7.3 
Eos-0.1* Baso-0.3 Im ___ AbsNeut-6.92* AbsLymp-1.03* 
AbsMono-0.63 AbsEos-0.01* AbsBaso-0.03
___ 05:30AM BLOOD Glucose-117* UreaN-8 Creat-0.9 Na-136 
K-3.8 Cl-103 HCO3-25 AnGap-12
___ 03:00AM BLOOD Glucose-126* UreaN-15 Creat-1.0 Na-135 
K-4.0 Cl-98 HCO3-25 AnGap-16
___ 05:30AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.8

___ KUB:
IMPRESSION: 
Nonspecific bowel gas pattern with paucity of small bowel gas,
though no specific plain radiographic evidence for obstruction. 
If SBO remains of clinical concern, followup imaging should be
considered.

___ CT A/P:
IMPRESSION:  
Mild distention of mid jejunum up to 3 cm with slight 
surrounding
free fluid and two proximal and distal transition points.  This
could be seen in setting of partial or early small bowel
obstruction or possibly enteritis, and is not suggestive of a
high-grade obstruction.

 
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with long history of 
previous small bowel obstructions after ileocectomy, ileostomy, 
and then reversal. He presented with 1 day of abdominal pain 
associated with nausea and minimal bowel function. CT findings 
on arrival to ___ were consistent with small bowel 
obstruction. He was admitted to ___ 
___ monitoring and IV fluids. Overnight, he reports he 
began to pass flatus and had several bowel movements. His diet 
was advanced, and he reports his abdominal pain had resolved. He 
was deemed ready for discharge. He expressed understanding of 
the plan. We recommended that he follow-up with his 
gastroenterologist or surgeon if his symptoms are becoming more 
frequent as this may indicate need for intervention.
 
Medications on Admission:
- Sulfasalazine
- Atorvastatin
- Benicar
- Allopurinol
- Vitamin B12
- Folic acid
- Probiotic
- Imodium
 
Discharge Medications:
Please resume your medications at home at their usual doses. 
There are no changes or additions to your medications at home.
 
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:
Dear Mr. ___,

You were admitted to ___ after 
experiencing small bowel obstruction associated with abdominal 
pain and some nausea for 1 day. Overnight, you began passing 
flatus and having bowel movements, suggesting that your 
obstruction is not relieved. You have now also tolerated a diet 
without abdominal pain and are ready to be discharged. Please 
continue to stay hydrated and monitor your diet. Return to the 
ED if you have fever, chills, worsening abdominal pain, or are 
not having bowel movements or passing flatus for several days. 

Given your history of previous small bowel obstructions, you 
should continue to follow-up closely with your 
gastroenterologist as well as surgeon. You may need a surgical 
repair of the anastomosis where there appears to be a stricture 
if your small bowel obstructions are becoming more frequent.

Thank you for allowing us to participate in your care
 
Followup Instructions:
___

{'Abdominal pain': ['Regional enteritis of unspecified site'], 'Crampy abdominal pain': ['Regional enteritis of unspecified site'], 'Nausea': ['Regional enteritis of unspecified site'], 'Dehydration': ['Regional enteritis of unspecified site'], 'Small bowel obstruction': ['Regional enteritis of unspecified site']}