DISCHARGE SUMMARY

DISCHARGE DATE: 12/10/20XX

ADMITTING DIAGNOSIS:

1. Distal high-grade small bowel obstruction.
2. Diabetes
3. Hypertension
4. Hyperlipidemia

DISCHARGE DIAGNOSIS:

1. Distal high-grade small bowel obstruction due to adhesions.
2. DM TYPE II, diet controlled
3. HTN, continue lisinopril
4. Hyperlipidemia, continue Crestor

PROCEDURE: On 12/08/20XX, diagnostic laparoscopy and release of small bowel obstruction.

HOSPITAL COURSE: The patient is a 50-year-old female with no history of prior abdominal surgery, who presented to the emergency room on 12/08/20XX with signs and symptoms of small bowel obstruction.

A computerized tomography scan was performed, which demonstrated evidence for high-grade distal small bowel obstruction with the point of obstruction in the pelvis. She was taken to the operating room that day and underwent a diagnostic laparoscopy with release of small-bowel obstruction without difficulty.

For further details of operative finding, please see separately dictated operative report. Her postoperative course was uncomplicated. She was permitted to take liquids and light snacks following surgery.

On postoperative day 1, she was still feeling rather bloated and uncomfortable. She was requiring intravenous fluids and intravenous pain medications. She began passing more and more gas from that point forward. She was advanced to a light, soft diet.

By postoperative day 2, she was having minimal residual discomfort. Her pain was well-controlled with oral pain medications, tolerating a soft bland diet. She was discharged home that day and will be followed up as an outpatient.

Her chronic conditions of hypertension, hyperlipidemia, and DM type II were stable throughout admission.

HISTORY AND PHYSICAL EXAMINATION

HISTORY OF PRESENT ILLNESS:

The patient is a 50-year-old female who presents to the emergency room today because of abdominal pain. She had a normal dinner last night. She has been having normal bowel movements lately and her last one was yesterday, as is typical for her. She was feeling normal and in her usual state of health when she went to bed last night, but then awoke about 2:30 in the morning with upper abdominal pain. She thought maybe she had some indigestion and took some Pepcid but it did not alleviate her symptoms any. She got progressively worse through the night. By this morning, she was nauseated and vomited about 3 times today. The pain and symptoms persisted, prompting her to present to the emergency room today. She has not been sick or ill in any other way. Her bowel movements have been formed and there has been no diarrhea. She has not had any urinary complaints. She has not had any fever or other systemic symptoms.

PAST MEDICAL HISTORY:

1. Hypertension, on lisinopril.
2. Hyperlipidemia, on Crestor
3. DM TYPE II, diet controlled.
4. Had a hysteroscopy and D and C in 20XX by Dr. Andrews, normal screening colonoscopy in 20XX by Dr. Thomas, remote left knee surgery.

ALLERGIES: Penicillin.

PHYSICAL EXAM: Vital Signs:

Temp 96.6, BP systolic of 100, heart rate 86, respiratory rate 28, O2 saturation 100% on room air. General: Pleasant, well-developed, well-nourished 56-year-old female in no acute distress. HEENT: Unremarkable. Neck: Supple.

Chest: Lungs clear to auscultation. Heart: Regular rate and rhythm. Abdomen: Moderately distended and feels firm and tender to palpation throughout without any real localization. Extremities: unremarkable. Neuro: Non-focal.

LABORATORY DATA: Chem-13 normal. Urinalysis negative. WBC 8.8, hematocrit 45, CRP 0.6, Lipase 104.

IMAGING: CT scan abdomen and pelvis with IV and oral contrast shows most of the contrast is retained within a distended stomach. There are multiple dilated loops of small bowel with air-fluid levels throughout the majority of the abdomen. There appears to be a discrete transition point in the pelvis but no twisting or mass is seen at the transition point. Per Radiology “the ileal loop beyond the point of obstruction is decompressed; demonstrates wall enhancement, possibly ileitis.” The terminal ileum and appendix are normal.

IMPRESSION: Moderate, possible high-grade distal small-bowel obstruction with transition point in the pelvis in the patient with history of no prior abdominal surgery.

I have discussed these finding at length with the patient and her husband. This appears to be a mechanical and not a functional obstruction. Given that it is a mechanical obstruction and the distal moderate to high-grade nature, I feel it is less likely to resolve without operative management. We have discussed the relative merits and risks of observation, namely that with observation she may potentially have progressive bowel distention, bowel compromise, prolonged bowel atony with further distention, and possibly prolonged recovery.

After discussion between the patient and her husband, have decided to proceed with surgery. The technical details as well as possible risks and complications have been discussed; operative consent has been signed.

PLAN: To operating room for laparoscopy, possible laparotomy.

OPERATIVE REPORT

PROCEDURE DATE: 12/08/20XX

PREOPERATIVE DIAGNOSIS: Small-bowel obstruction.

POSTOPERATIVE DIAGNOSIS: Small-bowel obstruction secondary to small bowel entrapped in the pelvis by intestinal adhesions.

PROCEDURE: Laparoscopy with release of small bowel obstruction by lysing adhesions.

INDICATIONS: This is a 50-year-old female who has had no prior abdominal surgery presented to the emergency room this afternoon with a high-grade partial distal small-bowel obstruction on CT scan with a transition point in the pelvis.

DESCRIPTION OF TECHNIQUE IN DETAIL: The abdomen was prepped and draped in the usual manner. A small infraumbilical longitudinal skin incision was made. Dissection was carried out down to the anterior fascia at the base of the umbilicus. The base of the umbilicus was grasped in order to elevate the fascia. The fascia was incised in the midline sharply with a scalpel blade. The underlying peritoneum was grasped and elevated and opened. There was free access to the peritoneal cavity. A 5-mm trocar port was easily inserted in this opening. Pneumoperitoneum was easily achieved.

Brief cursory examination of the abdominal revealed grossly dilated loops of small bowel all throughout the abdomen. The visualized portions of the colon appeared grossly normal. The appendix was not visualized at this point. A very prominent round ligament was seen entering the right internal inguinal orifice with an indentation representing a defect at the level of the internal inguinal orifice, but further examination of the scope could not definitively identify a true hernia. Representative intra-operative photographs were taken for future reference and documentation. Examination of the left side revealed that the left internal inguinal orifice was completely peritonealized. There was no evidence for hernia.

A left lower quadrant 5-mm port was inserted in the usual manner under direct visualization. The left adnexa was elevated up into view. Representative photographs of the right internal inguinal orifice and round ligament, the left internal inguinal orifice, the round ligament coursing back to the uterus, and the right adnexa were taken.

There were numerous flimsy adhesions between the ovary, the fallopian tube, and the uterus on the right side and representative photographs were taken.

Attention was then turned towards the left side. The left round ligament was seen coursing form the uterus up into the level of the left internal inguinal orifice. The left adnexa was grasped and elevated. There were a few small adnexal cysts but was otherwise overall unremarkable.

Attention was then turned back towards the right side. The uterus and the adnexa were elevated further and there was bowel that was entrapped in the pelvis underneath these aforementioned flimsy adhesions of the adnexa. Decompressed collapsed bowel was identified in the pelvis, grasped and elevated up into view. Representative photograph was taken, this bowel was then followed in a retrograde stepwise fashion until the dilated obstruction proximal bowel was identified. There was a clear point of obstruction, which was kinked and entrapped under the aforementioned adhesions, which was released without any difficulty. The bowel was followed more proximally for a short distance and remained dilated and distended, but there was no further point of obstruction.

Further pictures of the right adnexa and down into the pelvis were taken. The small bowel was returned to normal anatomic position. The right side off the uterus and the right adnexa were then covered with interceded adhesion barrier.

All the ports were then removed, and Pneumoperitoneum was released. The periumbilical fascia incision was closed with figure-of-eight 0 PDS suture. The remaining skin incisions were then closed with 4-0 Monocryl subcuticular suture and Dermabond.

PROGRESS NOTE 12/9/20XX

The patient is doing well with no complications following surgery. She was able to take liquids and light snacks after surgery yesterday without problems, no reported nausea or vomiting. Today she states that she is still feeling rather bloated and uncomfortable.

Temp 98.6, BP 114/78, heart rate 76, respiratory rate 20, O2 saturation 100% on room air. General: Pleasant, well-developed, well-nourished 56-year-old female in no acute distress. HEENT: Unremarkable. Neck: Supple. Chest: Lungs clear to auscultation. Heart: Regular rate and rhythm. Abdomen: soft, not tender to palpation, +bs. Extremities: unremarkable. Neuro: Non-focal.

A/P: 56 y/o female s/p diagnostic laparoscopy with release of small bowel obstruction; post-op day 1. She is still requiring intravenous fluids and IV pain medications, continue and transition to oral intake and PO pain medication as tolerated. Advance to soft bland diet as tolerated. Plan to dc tomorrow if she does well with advancing diet and pain under control with oral medication.

PROGRESS NOTE 12/10/20XX

The patient is doing well with no complications following surgery. More flatus; reports only minimal abdominal discomfort at this time. She has tolerated advancing diet to bland soft foods. No nausea, emesis, or diarrhea. Pain controlled with oral meds.

Temp 98.4, BP 112/76, heart rate 68, respiratory rate 18, O2 saturation 100% on room air. Chest: Lungs clear to auscultation. Heart: Regular rate and rhythm. Abdomen: soft, not tender to palpation, +bs. Extremities: unremarkable. Neuro: Non-focal.

A/P: 50 y/o female s/p diagnostic laparoscopy with release of small bowel obstruction; post-op day 2. She is tolerating soft bland diet and pain is controlled with PO pain medications. Plan to dc today if remains stable and will follow up as outpatient.