Surgery H&P 3                                                      

Date: 07/20/2021
Location: Queens Hospital Center
Patient Name: MS
Informant: self, reliable

CC: abdominal pain x 1 day

HPI: 70 y/o male with PMH of hypertension and hyperlipidemia presented to ED with one day of abdominal pain. Patient reported left lower quadrant abdominal pain described as 6/10, dull, intermittent, not associated with eating or drinking, happening for about 12 hours since waking up this morning. Patient denies ever having these symptoms and admits to normal bowel movements and mild fever earlier in the day (100.3 F). Patient denied nausea, vomiting, diarrhea, constipation, dysuria, chills, chest pain, shortness of breath, blood in stool/urine, recent travel, sick contacts.

PMH
Current illnesses: hypertension, hyperlipidemia
Past Illness: denies
Surgeries: denies
Allergies: NKDA
Medications: unknown, patient unable to recall

Social History
Education: high school
Work/finances: retired
Family & relationships: lives with wife
Habits/risk factors: Denies tobacco, alcohol, illicit substance use.

Review of Systems

General: admits to fever. Denies chills, night sweats, fatigue, weakness, loss of appetite, recent weight loss/gain.

Pulmonary System: denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND.

Cardiovascular System: Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur.

Gastrointestinal System: admits abdominal pain. Denies nausea, vomiting, diarrhea, constipation, intolerance to specific foods, lack of appetite, dysphagia, pyrosis, unusual flatulence or eructation, jaundice, change in bowel habits, hemorrhoids, rectal bleeding, blood in stool, flank pain.

Endocrine System: denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism.

Physical Exam

VS:   BP: 111/66   HR: 96    RR: 18    O2 sat: 99%    Temp: 99 F

General: A&O to person, place, time. Well groomed, appropriately dressed, lying in stretcher, appears uncomfortable.

Skin: skin is warm, moist, good turgor, non-icteric.

Eyes: symmetrical OU. No strabismus, exophthalmos, or ptosis. EOM’s intact with no nystagmus. No icterus.

Nose: symmetrical, no masses, lesions, deformities, trauma, discharge.

Ears: symmetrical and normal size. No masses, lesions, trauma on external ears.

Neck: trachea midline. No masses, lesions, scars, pulsations.

Thorax and lungs: chest symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxic respirations, no use of accessory muscles. Lungs clear to auscultation and percussion bilaterally.

Cardiovascular: RRR. S1 and S2 distinct, no S3 or S4, no murmurs.

Abdomen: firm, mildly distended, with tenderness to palpation in LLQ and guarding noted. Bowel sounds normoactive. No palpable masses, surgical scars, pulsations, hepatosplenomegaly, CVA tenderness. Negative Murphy’s. McBurney’s, Psoas, Obturator, Rovsing signs.

Rectal: No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation, excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOBT negative.

Peripheral vascular: extremities normal in color, size, temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis, or edema noted bilaterally. Capillary refill < 2 seconds throughout.

Neurologic: CN II-XII intact. No atrophy, tics, tremors or fasciculations. Gait steady with no ataxia.

Musculoskeletal: 5/5 strength and FROM in all extremities. No atrophy, weakness, erythema, swelling.

 

Assessment:

70 y.o male with PMH of hypertension and hyperlipidemia presenting with one day of LLQ abdominal pain described as 6/10, dull, intermittent. LLQ tender to palpation with guarding and mild abdominal distention. Patient reports fever prior to ED visit, appears uncomfortable lying in stretcher.

Ddx:

• Diverticulitis
• Intestinal obstruction
• Intestinal ischemia
• Gastroenteritis/colitis

Plan:

• IV fluids – Lactated ringers 125 mL/hr
• Labs: CBC, CMP, lipase, Blood Gas, Covid Swab, Type and Screen, APTT, PT/INR, UA
• CT Abd/pelvis
• Surgery consult
• Monitor vital signs
• Repeat physical exam/reevaluate
• Diet: NPO

 

Results:

CBC	–       WBC 15.83 –       Hgb 13.8 –       Hct 44.2
CMP	Glucose 125
Lipase	17
APTT	31.8
PT/INR	15.5/1.3
UA	WNL
Covid Swab	Negative
Type and Screen	A positive
CT Abd/pelvis with contrast	–       Normal liver, spleen, gallbladder, appendix –       Stranding about sigmoid diverticula in left lower quadrant; large amount of air adjacent to site of inflammation; no adjacent fluid collection –       Small amount of free intraperitoneal air scattered throughout Impression: acute diverticulitis, complicated by rupture, with free air
Blood Gas	–       Lactate 3.0

 

Follow-up:

• Acute ruptured diverticulitis
  • Admit to surgery
  • Antibiotics – Zosyn 3.375 g in D5W 50 mL IVPB and Flagyl 500 mg IVPB
  • Start PPI – pantoprazole 40 mg
  • Diet – NPO
  • Nasogastric tube
  • Monitor ins and outs
  • IV fluids – normal saline (continuous infusion)
  • Analgesia – morphine 2 mg IV push
  • DVT prophylaxis with segmental compression devices