Medical Text: Admission Date:  [**2145-3-31**]              Discharge Date:   [**2145-4-7**]

Date of Birth:  [**2071-6-4**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins / Dilantin

Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Severe abdominal and back pain
Unable to take oral intake.
No flatus or bowel movement.
Abdominal distention.


Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Lysis of adhesions
Small Bowel Resection
Jejunosotomy


History of Present Illness:
Ms [**Known lastname **] is a 73 year old female with a history of multiple
abdominal surgeries, pancreatitis and previous SBO. She
presented to the Emergency Department on [**2145-3-30**] with complaints
of [**11-10**] abdominal pain, radiating to her back that began in the
morning. She complains of distention, inability to have a bowel
movement, inability to take oral intake, no fever, chills or
diarrhea.

Past Medical History:
Chronic Pancreatitis
Migraines

Surgical history:
Pancreatic diversion, cholecystectomy, appendectomy,
small bowel obstruction.


Social History:
Married, lives with husband who is a retired pediatric
infectious disease doctor.


Family History:
Father: deceased, leukemia
Brother: colon cancer


Physical Exam:
T: 97.9 HR: 79 BP: 153/60  RR: 22 Spo2 100% on RA

Constitutional: in pain
Head/Eyes: mucous membranes dry
ENT/Neck: neck supple
Chest/Respiratory: Clear to auscultation Bilaterally
GI/Abdominal: Tender to light palpation. Multiple well healed
scars + guarding, hypoactive bowel sounds
GU: no costovertebral angle tenderness
Musculoskeletal: WNL
Skin: Dry
Neuro: alert & oriented


Pertinent Results:
[**2145-3-30**] 09:15PM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2145-3-31**] 10:26AM BLOOD WBC-12.3*# RBC-4.01* Hgb-12.3 Hct-37.1
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.2 Plt Ct-259
[**2145-3-30**] 09:15PM BLOOD ALT-12 AST-22 AlkPhos-89 Amylase-169*
TotBili-0.3
[**2145-4-2**] 06:15AM BLOOD Amylase-107*
[**2145-3-31**] 10:26AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.6
[**2145-3-31**] 12:44AM BLOOD Lactate-3.1*
[**2145-4-2**] 02:10PM BLOOD Lactate-1.9
[**2145-3-30**] 11:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
.
ABDOMEN (SUPINE & ERECT)
IMPRESSION: Nonspecific bowel gas pattern without evidence of
obstruction.
.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
IMPRESSION:
1. High grade small-bowel obstruction. Unusual configuration of
a loop of small bowel in the mid abdomen is concerning for
closed loop obstruction. There is a moderate amount of free
fluid within the abdomen.
2. Ill-defined opacity in the right middle lobe representing
infection or BAC and should be further evaluated with PET CT.
3. Thickening of the first portion of the duodenum, of uncertain
clinical significance.
.
CHEST (PORTABLE AP)  [**2145-4-2**] 1:51 PM
IMPRESSION: Right lower lobe airspace opacity, which could
represent pneumonia in the appropriate clinical setting. Small
bilateral pleural effusions. Followup to assure resolution is
recommended.
.
CT Chest [**2145-4-2**]
IMPRESSION:
1. New right lower lobe pneumonia. Small bilateral pleural
effusion and left basilar atelectasis.
2. Ill-defined opacity in the right middle lobe representing
either infection or BAC and should be further evaluated once
acute issues resolve.
3. No evidence of pulmonary embolus or aortic dissection.
4. Small mediastinal and axillary lymph nodes, which do not meet
CT criteria for pathologically enlargement.

CXR [**2145-4-6**]
IMPRESSION:
1. Improving airspace consolidation in the right lower lung
field consistent with resolving pneumonia.
2. Small bilateral pleural effusions.


Brief Hospital Course:
Ms [**Known lastname **] was admitted through the emergency room on [**2145-3-31**] and
taken to the operating room. She underwent an uncomplicated
exploratory laparatomy for small bowel resection, jejunosotomy
and lysis of adhesions, see op report for details. She was
stabilized in the PACU, and transferred to SICU on POD#1. She
was extubated, her pain was well controlled with morphine PCA,
she remained NPO with NGT and foley catheter. She was initiated
on Cefazolin/Flagyl x 24 hours.

POD#2 she developed confusion and decreased oxygen saturation,
requiring 3L nasal cannula. Narcotics were stopped, CXR and CT
of chest were obtained and revealed right lower lobe pneumonia,
see pertinent results for details. Vanc/Levo/Flagyl were
initiated as well as an ID and medicine consult. She was
transferred to SICU. POD#[**4-4**] she remained in SICU, her mental
status and respiratory status improved. POD#4 her NGT was
removed and she was transferred to [**Hospital Ward Name 121**] 9, she was weaned to
room air. Her pain was well controlled with tylenol and small
doses of oxycodone. POD#5 she reported flatus followed by
multiple loose stools. Stool for C diff was negative. She was
started on sips, and tolerated it easily. POD#6 she tolerated
clear liquids but no longer wanted to take antibiotics due to
frequent stools. CXR was repeated which showed resolving
pneumonia. She tolerated a regular diet in the evening without
difficulty. Infectious disease team recommended completion of 7
days of Levofloxacin. Clips were removed on POD#7, she was
discharged home in stable condition with antibiotics, pain
medication and all appropriate follow up appointments.

Medications on Admission:
Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).

Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime)
as needed.
Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6
hours).
6. Trileptal
Resume your home dose of trileptal


Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1 Tablet PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. 7. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*7 Tablet(s)* Refills:*0*
Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6
hours).
6. Trileptal
Resume your home dose of trileptal


Discharge Disposition:
Home

Discharge Diagnosis:
Small bowel obstruction
Internal hernia with necrotic jejunum
Pneumonia


Discharge Condition:
good


Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.

No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.

Activity: No heavy lifting of items [**11-15**] pounds until the
follow up
appointment with your doctor.

Medications: Resume your home medications. If you have a problem
with constipation, you should take a stool softener, Colace 100
mg twice daily as needed. You will be given pain medication
which may make you drowsy. No driving while taking pain
medicine.


Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2145-4-20**] 2:00

You have an appointment to see Dr. [**Last Name (STitle) **] on Friday, [**2145-4-23**] at
3:30. Phone #: [**Telephone/Fax (1) 2723**].

Please see your primary care physician regarding follow up from
your CT scan within 1 month. Your CT results and Discharge
summary will be faxed to her.



Completed by:[**2145-4-7**]
ICD9 Codes: 486, 4019