Age: 37.0
Sex: M
Vaccine: COVID19
Symptoms: Large intestine polyp, Leukocytosis, Muscle spasms, Oesophagogastroduodenoscopy abnormal, Presyncope
Clinical narrative: Date of Admission: 3/9/2022   Chief Complaint:  Low hemoglobin    Source of Information:  Patient and Available medical record   History of Present Illness:  This is a 38y.o. male who presented to Emergency Department after he was seen by his primary care doctor who noted that the patient was anemic. Patient also had a reported syncopal event last Saturday which is why he saw his PCP.   Patient is known to the Gen. surgery team. Patient did undergo an EGD and colonoscopy on 10/19/2021 for anemia with general surgery and the patient was found to have H. pylori gastritis as well as a adenomatous cecal polyp. The gastroenterology team did evaluate the patient after this for possible endoscopic mucosal resection of the polyp and the patient underwent a repeat colonoscopy on 12/14/2021. GI team did note a large polyp Floyd neoplasm in the proximal ascending colon greater than 3 cm as well as a 1.5 cm pedunculated polyp in the midascending colon as well as internal hemorrhoids. Patient was not a candidate for endoscopic mucosal resection, and was referred back to surgery for resection. On 2/22/2022 patient underwent a laparoscopic right hemicolectomy which was uneventful. His postoperative course is uncomplicated with return of bowel function and he was subsequently discharged on 2/24/2022. Patient did undergo follow-up in office on 2/28 which patient was noted to be healing appropriately with return of regular bowel movements and tolerating a diet. He shouldn't did come to the general surgery office yesterday for staple removal. He was noted to be continuing to pass gas and have bowel movements.   Patient was seen and examined at the bedside in the emergency department. On presentation patient is hemodynamically stable and afebrile. A states that he was initially doing well postoperatively. Prior to his first postop appointment he states that he had an episode of multiple loose stools and had gotten lightheaded and had a near syncopal event however it resolved after food hydration and continued to do well subsequently following that. He does state that last Monday however he was having some tight right sided abdominal pain and significant bloating and which she had multiple episodes of emesis and felt significantly better. He reports that since then he is still have a tall crampy right-sided pain. He has been passing gas and having regular bowel movements. He denies any further episodes of emesis. He denies any blood in his stool. Currently denying any fevers or chills.   Patient is noted to have a mild leukocytosis of 12.1 as well as a hemoglobin of 7.0. His hemoglobin was last noted to be 9.4 on 2/23 prior to discharge from the hospital. Patients labs are otherwise unremarkable. Patient did undergo an acute abdominal series in which there was mildly dilated loops of small bowel with air-fluid levels. CT scan of the abdomen and pelvis was ordered revealing post-surgical changes near the right hemicolectomy anastomosis line with a air-fluid 4.3 cm fluid collection concerning for abscess with dilated loops of bowel favoring an ileus.