Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Omental patching, Osteonecrosis, Parenteral nutrition, Peritoneal fluid analysis abnormal, Peritonitis
Clinical narrative: Admit date: 12/11/2023  Discharge date: 01/04/2024  Admitting Physician: MD   Attending Physician at the Time of Discharge: DO  Primary Care Physician: DO Reason for Admission: Abdominal pain  Brief Summary of Hospital Stay: As per H&P Patient is a 72 YO female with PMHx of afib  cirrhosis, autoimmune hepatitis, iron deficiency anemia, osteoarthritis  presented to the hospital due to severe abdominal pain.  Patient stated she started to have abdominal pain this morning which was progressively getting worse through the day.  Patient states she has had abdominal pain and left flank and left hip pain on a off and has been taking Norco and other "pain medications" with mild relief. She was not able to tolerate the pain and decided to come to the emergency department. Associated with nauseas no vomiting, and poor appetite, shortness of breath with exertion. Patient denies fever and chills. Patient seem to have history of PUD . And had several hospital visits due to abdominal and flank pain.    On the emergency department, patient presented with, hypotension, HR 151, abdominal tenderness and abdominal pain, blood work significant for elevate lactate(13.1), elevated to Cr. 2. EKG, showed afi with RVR. CT angio abdomen pelvis showed a perforated gastric ulcer. Patient to the OR per General surgery/  She was started on levophed and admitted to the ICU for close monitoring.  Hospital Course: Admitted on 12/11 in septic shock and AKI secondary to perforated viscus.  Exploratory laparotomy revealed 4.5 L of bile-stained succus and ascites and a 2 cm indurated duodenal perforation.    Now POD 23 s/p laparotomy with Graham patch.   All drains removed.  Drainage appliance on RUQ prior drain site.  Moderate Protein Calorie Malnutrition:             Oral intake improved.  Tolerating diet well.  Off TPN.  Medical Conditions:  - Covid + this admission, out of isolation - Afib with RVR (resolved) - Cirrhosis: likely secondary to autoimmune hepatitis with              Portal hypertension, Ascites, Esophageal Varies and Coagulopathy              **Large volume ascites from drain site. Received albumin x3 since admission. - Hyperglycemia: On SSS and accu-checks   Issues Requiring Follow Up o Perforated duodenal ulcer, S/P omental patch repair o Peritonitis with peritoneal fluid cultures positive for Actinomyces odontolyticus and Rothia mucilaginosa, without overt preexisting actinomycosis o Probable duodenal ulcer repair site leak, S/P percutaneous drainage of two fluid collections after the patient declined repeat laparotomy; right upper quadrant drain in place with collection bag.  Fluoroscopy upper GI single contrast with small bowel imaging on 12/22/2023 showed a probable walled off perforation near the duodenum.  The patient has been on IV antibiotic therapy since her original repair of perforated duodenal ulcer. o Small upper midline abdominal incision opening at site of small I&D for hematoma, without fascial dehiscence o Anorexia, on mirtazapine o Moderate protein calorie malnutrition.  Total parenteral nutrition was discontinued yesterday o Chronic ascites o Hepatic cirrhosis o Autoimmune hepatitis o Atrial fibrillation, on digoxin and metoprolol; not on anticoagulant therapy o Hypotension, improving.  Midodrine weaned to 2.5 mg TID o History of essential hypertension o Hyponatremia, multifactorial (cirrhosis, postoperative changes, recent TPN, poor PO intake) o Osteonecrosis of left hip, previously scheduled for surgery by orthopedic surgeon o COVID-19, acute on admission vs. prior to admission o VTE risk in hospital, on heparin for VTE prophylaxis  PLAN o Continue ceftriaxone, flagyl, and fluconazole through 1/13/24 o Continue abdominal fluid drainage through right upper quadrant drain with collection bag o Continue PT/OT Discharged to SNF