Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Constipation, Dyspnoea, Enema administration, Faecal disimpaction, Hypoxia
Clinical narrative: HOSPITAL COURSE: This is a 67 y.o., female, with PMH of chronic pain disorder, chronic opiate use, bipolar, chronic constipation, COPD, bipolar disorder, who was admitted on 1/28/2022, with acute abdominal pain and found to have findings consistent with stercoral colitis, COVID-19. For more detail, please see admission H&P. Hospital course dictated by problem: Stercoral colitis with severe constipation, Opiate-induced constipation (acute on chronic), Patient reports lifelong severe constipation with opiate use. With PTA use of Dulcolax and Senna not being sufficient. Has had multiple admits with drug-induced constipation 3/16/21, 7/16/2021. Med overuse. She had a recent change in her opiates from fentanyl low-dose to Butrans. During this admittance, patient required manual disimpaction and enema in the ED. This resulted in a few small bowel movements but not significant improvement/resolution in constipation. Constipation also likely contributing to urinary retention (see below). She achieved regular bowel movements with the following: s/p 1x dose relistor IM 1/29, incremental Senna to 2 tabs BID, MiraLAX BID, addition of lactulose BID on 1/30 and reduction in opioid dosing. Per previous HM provider she had strongly been encouraged to reduce opioid dose d/t ongoing issues with constipation. Her PTA oxycodone was reduced from 10mg to 5mg TID.  At DC will continue: MiraLAX daily, Senna 1-2 tabs BID. She also has MiraLAX available prn if no BM in 1 day and for further constipation lactulose BID prn. Outpatient Pain provider to Relistor, evaluate other constipating meds. Urinary retention - resolved. Likely related to severe constipation in setting of several pain medications. This resolved with improvements in constipation and reduction in opioid dosing. Did require straight catheter prn here but by discharge had been urinating with no straight catheter need for > 24 hours. Sinus tachycardia, increased O2 needs - resolved In setting of COVID-19. No longer tachycardiac and O2 sats stable on PTA O2 needs of 2L. Acute on chronic respiratory failure with hypoxia. COVID-19 (1/28/2022). Positive on admit. Fully vaccinated but 3/2021 and did not get a booster. She has had mild increased shortness of breath for the last week PTA. PTA on home O2 at 2L and remained on her home O2 needs here. CT and lung bases w/o infiltrate. CXR does not show infiltrate. Chronic COPD w chronic respiratory failure on home o2. HX COPD, former smoker, started home O2 5/2021, currently at 2 L. At present, doubt active COPD exacerbation. No wheezing. PTA ALB MDI, Home O2 at 2 L, ok to increase to 4l Prn discomfort (per patient request). New order placed at discharge deferred to allow it to be higher. Follow-up with PCP, consider outpatient PFTs /pulmonology. Persistent pulmonary infiltrates-last 11/2021 repeat CT chest w Previously identified subtle mosaic attenuation is less conspicuous on the current study. No focal infiltrate. PCP follow-up with Chest CT. History of chronic pain, whole body, peripheral neuropathy. Chronic opiate use. CHRONIC PAIN WITH OPIOID DEPENDENCE. Struggled with severe constipation prior to opiates but worse since. Now with stercoral colitis. Follows with the pain clinic, Dr. gives 2-week refills. Had a HX of multiple admits last yr w 2 fentanyl patches on/patient w limited comprehension re risk. Recently she has been transitioned from the fentanyl 12.5 over to Butrans 5. She is been transition from gabapentin over to Lyrica. Trying to de-escalate opiates here to help with her constipation issues. 1/31 - now reports increase pain w decrease in opiates. Adjusted discharge recommendations to allow slightly increased at bedtime dose. PTA oxycodone 10 mg TID-- > decrease to 5mg TID here, PTA Butrans 5 mcg patch QD (recent change), PTA Lyrica 25mg TID (recent change), PTA Cymbalta 60 daily, PTA tizanidine 2 mg TID prn spasm, PTA baclofen 10 mg twice daily, PTA trazodone 100 at bedtime prn insomnia continued, close Follow up with the pain clinic, Dr.-consider opiate dose and other meds. Bipolar disorder-per past reports as a case worker as well as ILS worker (however could not recall either the names). She defers that her mood is fine. PTA Cymbalta, PTA Zyprexa 10 mg Qd, PTA trazodone 100mg HS (caution given constipation). Follow-up with outpatient provider, CM. ILS, PCP. Cognitive impairment-in past admits, 6/2021 admit slums was 18 out of 13. She lives alone. Powered wheelchair. Denies she has cognitive declines. Speech pattern slow. Has a brother and 2 daughters. Cautious allowing us to call daughter who report patient relatively stable lately. H/o CAD, vasospasm: -continue home atorvastatin, ASA, metoprolol. Hypothyroidism-PTA Synthroid 75 daily continued, HLD -PTA atorvastatin 40, Tricor 160 daily continue, Vitamin D deficiency - PTA vitamin D 1000 units daily.