Unspecified intestinal obstruction Ulcerative colitis unspecified Anxiety state unspecified Alcohol abuse in remission
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
decreased ostomy output
 
Major Surgical or Invasive Procedure:
none
 
History of Present Illness:
___ s/p subtotal colectomy w/ end ileostomy for ulcerative
colitis in ___. Followed closely by gastroenterology for
inflammatory bowel disease. Post-operatively, dealing with
constant lower abdominal pain described as muscle spasms which
wraps around the lower edge of his stoma. There episodes occur
t/o day and he is treated with oxycodone. 

Now reports one day history of decreased ostomy output. Has not
changed his ostomy yet from normal ___. Fairly nauseous o/n
with several episodes of non-bloody, non-bilious emesis. Still
nauseous but no vomiting since this AM. Currently symptoms
resolved with medication (morphine, ativan, zofran) in the ED. 
 
Past Medical History:
PMH: UC, pain control issues

PSH: abd colectomy, end ileostomy
 
Social History:
___
Family History:
non-contributory
 
Physical Exam:
Vitals: 97.0 88 146/62 18 100 
Gen: NADS, AAOx3
Lungs: CTA
Cardio: RRR
Abd: soft, midline incision, tenderness (baseline) to lower
abdomen, hypoact BS, end ileostomy stoma patent, digitized and
normal feeling
Ext: no c/c/e

 
Pertinent Results:
___ 11:00AM   WBC-5.9 RBC-3.94* HGB-6.0* HCT-24.6* MCV-63* 
MCH-15.3* MCHC-24.5* RDW-18.4*
___ 11:00AM   NEUTS-83.7* LYMPHS-12.1* MONOS-3.8 EOS-0 
BASOS-0.4
___ 11:00AM   GLUCOSE-121* UREA N-11 CREAT-0.8 SODIUM-138 
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
___ 11:00AM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 11:00AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 
LEUK-NEG

CT AP: 1. Dilated small bowel in the right lower quadrant 
proximal to the ileostomy with two apparent points of transition 
with a closed loop obstruction. Internal hernia in this patient 
with prior subtotal colectomy. Lack of enteric contrast does 
limit the evaluation. 
2. Hypodensities in the liver and kidney may represent cysts but 
several are too small to accurately characterize. 
3. Enlarged Prostate. Correlate with PSA. 

 
Brief Hospital Course:
Mr. ___ presented with decreased ostomy output and nausea and 
CT consistent with small bowel obstruction. He was treated 
nonoperatively with a nasogastric tube and IV fluids with 
ultimate resolution of his small bowel obstruction. As he began 
to have ostomy output and decreased NG output, the NG tube was 
removed and his diet was advanced. He is being discharged 
afebrile, with stable vital signs, tolerating an oral diet and 
with pain controlled on oral medications. His home pain 
medications of oxycodone and oxazepam were stopped and he was 
given intermittent ativan for anxiety and help sleeping. He was 
discharged on this with follow up to his primary care physician 
and to the ___.
 
Medications on Admission:
___: oxycodone and oxazepam for sleep
 
Discharge Medications:
1. Oxycodone  Oral
2. Oxazepam  Oral
3. Ativan 0.5 mg Tablet Sig: ___ Tablets PO at bedtime as needed 
for insomnia for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
4. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO 
once a day.
Disp:*30 Tablet(s)* Refills:*2*

 
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:
Please call your doctor or return to the emergency room if you 
have any of the following:
* You experience new chest pain, pressure, squeezing or 
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in 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 have shaking chills, or a fever greater than 101.5 (F) 
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that 
concern you. 
* Please resume all regular home medications and take any new 
meds as ordered.
 
Followup Instructions:
___

{'lower abdominal pain': ['Ulcerative colitis'], 'nausea': ['Ulcerative colitis', 'small bowel obstruction'], 'vomiting': ['Ulcerative colitis', 'small bowel obstruction'], 'decreased ostomy output': ['small bowel obstruction'], 'muscle spasms': ['Ulcerative colitis']}