tokens: Admission Date : 2014-02-21 Discharge Date : 2014-03-25 Date of Birth : 1928-07-25 Sex : F Service : SURGERY Allergies : Sulfa ( Sulfonamides ) Attending : Mattie R. A. Hamilton , M.D. Chief Complaint : Nausea , vomiting , Abdominal pain , distention . Major Surgical or Invasive Procedure : 1. Subtotal colectomy , end ileostomy , Hartmann's pouch , G-tube 2. Completion sigmoid colectomy , repair of colovesicular fistula , small bowel repair History of Present Illness : Ms Crossman is an 84 year old female with complaints of abdominal pain , diarrhea , nausea and vomiting x 1 week , who presented to an outside hospital . She was transferred to Arbour Hospital on 2015-02-21 for bowel obstruction , ischemia and worsening abdominal distention and pain . Past Medical History : CAD s/p MI , HTN , DMII Social History : Lives independently , but in the same building with daughter . Amy 3 children , 2 daughters and 1 son . Daughter Lurline is Durable Power of Attorney . The other daughter was recently in a car accident and underwent surgery at Saint Vincent Hospital . Family History : NC Physical Exam : At time of discharge : Afebrile , VSS A&O X 3 , NAD RRR CTAB , mildly decreased breath sounds b/l Abd soft , NT/ND , + bs , no masses , ostomy in RLQ pink , with stool G-tube in place LE trace edema Pertinent Results : 2014-02-21 12:20 PM BLOOD WBC - 10.2 RBC - 5.32 Hgb - 14.9 Hct - 43.4 MCV - 82 MCH - 28.0 MCHC - 34.4 RDW - 16.0 * Plt Ct - 204 2014-02-21 12:20 PM BLOOD PT - 12.9 PTT - 32.5 INR(PT) - 1.1 2014-02-21 12:20 PM BLOOD Glucose - 345 * UreaN - 34 * Creat - 1.0 Na - 137 K - 4.3 Cl - 99 HCO3 - 24 AnGap - 18 2014-02-21 12:20 PM BLOOD ALT - 17 AST - 27 AlkPhos - 119 * Amylase - 27 TotBili - 0.9 2014-02-21 12:20 PM BLOOD Lipase - 11 2014-02-21 12:20 PM BLOOD CK-MB - 7 cTropnT -< 0.01 2014-03-09 02:59 AM BLOOD cTropnT - 0.21 * 2014-03-09 11:29 AM BLOOD CK-MB - 35 * MB Indx - 25.5 * cTropnT - 0.45 * 2014-03-09 07:52 PM BLOOD CK-MB - NotDone cTropnT - 0.55 * 2014-03-10 05:25 PM BLOOD cTropnT - 0.42 * 2014-03-11 02:00 AM BLOOD cTropnT - 0.45 * 2014-03-19 07:13 AM BLOOD CK-MB - 3 cTropnT - 0.19 * 2014-03-19 01:33 PM BLOOD CK-MB - NotDone cTropnT - 0.17 * 2014-03-21 09:58 AM BLOOD CK-MB - NotDone cTropnT - 0.06 * 03-07 wound swab : VRE CT Abd 02-21 : 1. Markedly dilated colon throughout ascending , transverse , and descending colon with air-fluid levels , overall unchanged since prior study performed on the same day with pneumatosis in the ascending colon . Sigmoid diverticulosis with focal narrowing of the sigmoid colon just distal to the dilatation with wall thickening , due to diverticulitis . This area can be a leading point of obstruction . An underlying mass lesion or cancer cannot be excluded in this area , and further clinical investigation is recommended . 2. Limited evaluation for known sigmoid-vesicle fistula . 3. Small amount of ascites , somewhat increased anterior to the liver . 4. Bilateral renal cysts . 5. Heavy calcification of the aorta and SMA and its branches . Due to atherosclerosis , assessment of the intraluminal process of these branches is limited . CTA/CT abd 03-07 : 1. No evidence of pulmonary embolism . Small bilateral pleural effusions with compressive atelectasis . 2. Left lower quadrant thick-walled peripherally enhancing fluid collection , which appears to communicate with the sutured end of the proximal sigmoid colon via a small collection of extraluminal gas . In the correct clincial setting , this could be consistent with an abscess . 3. Moderate intraabdominal ascites . 4. Status post ileostomy without evidence of small-bowel obstruction . 5. Distended gallbladder . 6. Diverticulosis within the right remnant sigmoid colon . 03-21 VCUG - no leak Brief Hospital Course : Ms Crossman was admitted on 2015-02-21 from an outside hospital to the ICU . Neuro : Developed confusion during her first 5 days in the ICU . Post-operatively mental status improved . Intermitent delirium throughout admission . Required restraints to prevent DC of pertinent therapies while in the ICU . Currently AAOx3 . Cardiovascular : Complained of chest pain during first few days of admission , a cardiology consult was obtained . She recieved serial enzymes and EKGs . Troponins remained mildly elevated as high as 0.6 throughout her admission , and most recent result now 0.1 . She was treated in IUC for unstable angina with nitroglycerin . It was recommended to maximize her medical treatment with Beta blockers , aspirin , a statin and an ACE Inhibitor . Required diuresis of > 9 L while in the ICU , after 2nd surgery . Continues to have trace lower extremity edema , and recieves lasix po . Respiratory : She was intubated briefly post-op subtotal colectomy and again for several days after second surgery . Recieved nebulizer treatments post-op in the ICU , after successfully extubated . Gastrointestinal : Her initial CT scan showed dilated Turner colon , wall thickening and pneumatosis see pertinent results . She was initially treated nonoperatively with IV fluids , antibiotics , serial exams and NGT decompression . On HD#5 flexible sigmoidoscopy was performed for colonic decompression . On HD#6 , colonscopy was performed for decompression , and revealed pseudomembrane and friable colonic tissue . Her abdomen remained tender and distended despite attempted decompression . She was taken to the OR for Subtotal Colectomy , G tube and ileostomy due to unresponsiveness to non-operative treatment . Ileostomy remains pink and intact , draining green-brown soft stool . Her post-operative course continued uneventfully in the ICU , and she was transferred to the floor POD#6 . She developed additional abdominal tenderness and distention . Her HCT dropped and she recieved 1 unit PRBCs . Geriatric consult was obtained to assist with management . On POD#8 a CT scan was obtained which revealed an abcess with a colovesicular fistula . She was taken to the OR for exploration and drainage . She recieved further resection of remaining colon , repair of a leak from Relaford pouch and repair of colovesicular fistula . After her 2nd surgery she returned to the ICU and improved steadily . Abdomen remained soft and nontender . She remained on IV antibiotics x 14 days and required pressors for the first few days post-op . Her incision has remained clean , dry , intact , with staples removed on POD# 27/18 . Genitourinary : She had a foley catheter from the time of admission . POD# 23/14 she recieved a cystoscopy which revealed no leak . Her foley was subsequently dc 'd . Musculoskeletal : Has suffered significant deconditioning since admission , but has consisitently recieved PT . See PT note for further assessment and discussion . Nutrition : She was held NPO at admission , and initiated on TPN by HD#3 . Post-operatively she began on TF s, and the TPN was weaned down . By POD# 05-29 she was having high residuals on TF s, so TPN was reinitiated . Tf 's were dc 'ed prior to second surgery . POD# 15/6 , she resumed TF 's and TPN was tapered again . TF goals were achieved and TPN dc 'ed. A diet by mouth was initiated . At time of discharge she is tolerating a regular diet with TF 's at goal . Patient is an insulin dependent diabetic . She was followed by Cape Cod Hospital Clinic for treatment of persistent hyperglycemia . Pain : Her pain was controlled with IV pain medicines while in ICU . She has been adequately controlled with Tylenol , Motrin & Oxycodone by mouth , per recommendations by Geriatrics . POD# 22/15 Ms Crossman was transferred to 3 North where she continued to progress well with PT , increasing PO intake , tolerating TF s, and weaning from nasal cannula oxygen . She has remained stable with no acute events . She is discharged to rehab on POD# 27/18 . Medications on Admission : Norvasc Atenolol Isosorbide Lasix Insulin Discharge Medications : 1. Heparin ( Porcine ) 5,000 unit / mL Solution Sig : One ( 1 ) mL Injection TID ( 3 times a day ). 2. Acetaminophen 325 mg Tablet Sig : 1-2 Tablets PO Q4-6H ( every 4 to 6 hours ) as needed . 3. Polyvinyl Alcohol - Povidone 1.4-0.6 % Dropperette Sig : 02-25 Drops Ophthalmic PRN ( as needed ). 4. Metoprolol Tartrate 25 mg Tablet Sig : One ( 1 ) Tablet PO TID ( 3 times a day ). 5. Aspirin 81 mg Tablet , Chewable Sig : One ( 1 ) Tablet , Chewable PO DAILY ( Daily ). 6. Atorvastatin 10 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). 7. Lisinopril 5 mg Tablet Sig : 0.5 Tablet PO DAILY ( Daily ). 8. Furosemide 40 mg Tablet Sig : 1.5 Tablets PO BID ( 2 times a day ). 9. Ipratropium Bromide 17 mcg / Actuation Aerosol Sig : Two ( 2 ) Puff Inhalation Q4-6H ( every 4 to 6 hours ) as needed . 10. Albuterol 90 mcg / Actuation Aerosol Sig : 1-2 Puffs Inhalation Q6H ( every 6 hours ) as needed . 11. Oxycodone 5 mg Tablet Sig : One ( 1 ) Tablet PO Q4-6H ( every 4 to 6 hours ) as needed for pain . 12. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ). 13. Potassium Chloride 20 mEq Tab Sust . Rel . Particle / Crystal Sig : One ( 1 ) Tab Sust . Rel . Particle / Crystal PO once a day . 14. Glargine Sig : Twenty Two ( 22 ) units at bedtime . 15. Miconazole Nitrate 2 % Powder Sig : One ( 1 ) Appl Topical BID ( 2 times a day ) as needed . 16. Miconazole Nitrate 2 % Cream Sig : One ( 1 ) Appl Topical BID ( 2 times a day ). 17. Ibuprofen 100 mg/5 mL Suspension Sig : Twenty ( 20 ) mL PO Q8H ( every 8 hours ) as needed . 18. Debrox 6.5 % Drops Sig : Five ( 5 ) Drop Otic BID ( 2 times a day ) for 5 days : both ears . 19. Trazodone 50 mg Tablet Sig : 1 / 2-1 Tablet PO HS ( at bedtime ). Discharge Disposition : Extended Care Discharge Diagnosis : Hurtado Colon Diverticulitis S/P Subtotal Colectomy , Ileostomy , Gastrostomy tube S/P Exploratory laparotomy , resection of small intestine with primary anastomosis , Sigmoid colectomy , repair of colovesicular fistula Unstable Angina Discharge Condition : stable Discharge Instructions : Please call the surgeon or return to the Emergency Department 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 12-08 pounds until the follow up appointment with your doctor . Medications : Resume your home medications . You should take a stool softener , Colace 100 mg twice daily as needed for constipation . You will be given pain medication which may make you drowsy . Followup Instructions : Provider : Joe Kari , MD Phone :( 625 ) 747-8259 Date / Time : 2014-04-11 1:15 Joe Kari MD 09-697 Completed by : Carol Robert NP 80-CIY 2014-03-25 @ 0837 Signed electronically by : DR. Marion SCHNEIDER on : Sandra 2014-03-25 12:56 PM ( End of Report )