allergies: codeine / iodine attending: chief complaint: abdominal pain major surgical or invasive procedure: laparotomy, lysis of adhesions, sigmoid colectomy and transverse loop colostomy. endotracheal intubation, cardio-pulmonary resuscitation history of present illness: the patient is a 68 y/o male who presented to an outside hospital on for lower abdominal pain. the abdominal pain started the day prior to presentation and has worsened in severity. he denies fever, chills, nausea/vomiting, or a change in bowel habits. he was evaluated at the outside hospital where a ct scan showed sigmoid diverticulitis, adjacent stranding, and a small amount of free air. he is referred to for management of his comorbidities. past medical history: 1. cad - mi, ptca in , deccreased ef 2. cva - left monocular blindness 3. copd on home o2 4. chronic renal insufficiency 5. renal cell carcinoma s/p nephrectomy 6. sleep apnea 7. diverticulitis 8. iliac stent social history: patient smokes a pack per day of cigarettes. family history: non-contributory physical exam: t 98.0 p 88 bp 132/85 r 26 sao2 95% 5l nc gen - mild discomfort, non-toxic appearing lungs - decreased in bases bilaterally heart - regular rate and rhythm, no murmurs rubs or gallops abd - very distended, tender to palpation in lower quadrants, no rebound or guarding ext - no lower extremity edema pertinent results: 08:42pm blood wbc-23.4* rbc-4.13* hgb-12.4* hct-37.3* mcv-90 mch-30.2 mchc-33.4 rdw-15.3 plt ct-337 08:42pm blood neuts-90* bands-4 lymphs-3* monos-2 eos-0 baso-0 atyps-0 metas-0 myelos-1* 08:42pm blood glucose-224* urean-72* creat-2.4* na-140 k-4.2 cl-99 hco3-28 angap-17 08:42pm blood alt-15 ast-11 ck(cpk)-26* alkphos-58 amylase-53 totbili-0.5 08:42pm blood lipase-30 08:42pm blood albumin-3.2* calcium-8.3* phos-5.6* mg-2.1 8:57 pm swab site: abdomen **final report ** gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram negative rod(s). smear reviewed; results confirmed. wound culture (final ): this is a corrected report . probable enterococcus. moderate growth. probable enterococcus. sparse growth. 2nd morphology. staph aureus coag +. sparse growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. pseudomonas aeruginosa. sparse growth. albicans, presumptive identification. sparse growth. previously reported as mold (). reported by phone to r.n cc6 1pm. bacillus species; not anthracis. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | pseudomonas aeruginosa | | cefepime-------------- <=1 s ceftazidime----------- 2 s ciprofloxacin--------- <=0.25 s clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s <=1 s imipenem-------------- =>16 r levofloxacin---------- =>8 r meropenem------------- 2 s oxacillin------------- =>4 r penicillin------------ =>0.5 r piperacillin---------- <=4 s piperacillin/tazo----- <=4 s rifampin-------------- <=0.5 s tetracycline---------- <=1 s tobramycin------------ <=1 s vancomycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. 3:21 pm stool consistency: not applicable source: stool. **final report ** clostridium difficile toxin assay (final ): reported by phone to m. mal @8:07 am. clostridium difficile. feces positive for c. difficile toxin by eia. reference range: negative. a positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). operative report : perforated sigmoid diverticulitis with intraabdominal contamination. procedure performed: laparotomy, lysis of adhesions, sigmoid colectomy and transverse loop colostomy. ct scan : impression: 1. no evidence of pulmonary embolism. please note that evaluation of small branches in lower lobes are somewhat limited due to quantum mottle and atelectasis. 2. severe centrilobular emphysema with peribronchial opacities, pulmonary edema, and bilateral small effusion and atelectasis. enlarged main pulmonary artery. 3. probable tracheobronchomalacia. 4. mediastinal lymphadenopathy, which can be reactive. 5. multiple small hypodense lesions in the liver, too small to characterize. 6. gallstones. 7. 1-cm right renal lesion, of indeterminate appearance on this one-phase ct. further characterization by dedicated mri or ct scan is recommended on non- urgent basis. 8. changed appearance of the bowel in this patient with recent sigmoidectomy. head ct scan : conclusion: no evidence of hemorrhage. no mass effect. opacified ethmoid sinus. chest x-ray : findings: since the prior study, the patient has been extubated and there is a right cvl with the tip in the svc and no ptx. there is no focal consolidation; the left cp angle is cutoff from view. there is continued demonstration of right pleural thickening, unchanged from the previous study. pulmonary vascular markings are within normal limits. previously seen area of increased density in left upper lung zone is not seen on the current film. impression: no radiographic explanation for the patient's dyspnea ekg : baseline artifact sinus rhythm probable left atrial abnormality right bundle branch block consider prior inferolateral myocardial infarct since previous tracing of , no significant change intervals axes rate pr qrs qt/qtc p qrs t 62 172 136 464/468.71 -1 47 11 right upper extremity ultrasound : mpression: negative right upper extremity dvt study. discharge labs: complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:14am 8.9 3.15* 9.6* 27.6* 88 30.6 34.9 15.4 282 basic coagulation (pt, ptt, plt, inr) pt ptt plt smr plt ct inr(pt) 06:14am 282 chemistry renal & glucose glucose urean creat na k cl hco3 angap 04:45am 138* 20 1.5* 137 4.1 100 32 9 chemistry totprot albumin globuln calcium phos mg uricacd iron 04:45am 8.0* 2.5* 1.9 brief hospital course: the patient was deemed a poor surgical candidate given his co morbidities and the initial plan was to admit him to the sicu for monitoring and to treat his diverticulitis with iv antibiotics of ampicillin, ciprofloxacin, and flagyl, and bowel rest. -rectal surgery was consulted to provide recommendations on management and concurred with the decision to manage the patient non-operatively. serial exams were performed on the patient and he continued not to display any peritoneal signs. on hospital day #2, conservative management was continued. however, the patient's abdomen became firmly distended and became larger throughout the course of the day. a ct scan was obtained which showed enlarging air and fluid collection in the central abdomen abutting a region of sigmoid colon with multiple diverticula. this finding was significantly larger compared to the ct scan at the outside hospital. in the context of significantly increasing pneumoperitoneum, the patient likely had a perforated sigmoid diverticulitis with associated phlegmon or abscess. given the new findings, it was decided to take the patient to the or for a laparotomy, lysis of adhesions, sigmoid colectomy and transverse loop colostomy. the fascia was closed with interrupted sutures and the umbilicus was loosely approximated with staples and the abdominal wound was packed. after the surgery, the patient was transferred back to the sicu intubated and in stable condition. the patient was able to be weaned off the vent and was extubated on post-op day 1. given the patient's history of copd, aggressive pulmonary toilet was initiated to help improved the patient's respiratory status. the patient received iv hydrocortisone for his copd and this was eventually tapered and switched to prednisone when the patient was tolerating pos. the patient was doing well post-operatively and was able to be transferred to the floor on post-op day 3. however overnight, the patient became agitated and went into rapid atrial fibrillation and was transferred back into the sicu where he was started on an amiodarone drip for a his rapid afib. the patient was able to revert back to sinus rhythm on his own and amiodarone was switched over to the po form. the patient's iv antibiotics were switched to vancomycin and zosyn given the sensitivities on his wound culture. flagyl was also started for clostridium difficile colitis. the patient continued to do well and was transferred back to the floor on post-op day 6. the patient was tolerating a regular diet and was able to ambulate in the hallways with physical therapy. on , the patient was set to go to rehab. however, patient stated that in the morning he felt funny for seconds with an "electric" feeling throughout his body and felt a little lightheaded. he pushed the call button for help and pitched forward and the nursing aide helped lower him to the floor and a code was called. code team promptly arrived and the patient was ventilated well via a bag-valve mask. the patient was found to be in pea and acls protocol was initiated. cpr was started and the patient was given atropine and epinephrine as well as bicarbonate and calcium. the patient was intubated without difficulty with good chest rise and bilateral breath sounds. the patient eventually regained a pulse and maintained a sbp in the 120s. the patient was transferred to the icu. the patient had a ct angiogram which showed no pulmonary embolus. a head ct scan showed no evidence of hemorrhage or mass effect. in the icu, he was noted to have one episode of non-sustained junctional rhythm, though review of the telemetry strip prior to code was negative for any arrhythmias. cardiac enzymes were cycled which were negative. he was transfused 2 units of packed rbcs for a hct of 22.4. the patient was able to be weaned from the vent and extubated the following day. cardiology was consulted and they suggested that a vaso-vagal response could have been the cause of the patient's code. prior to the patient coding, the cap on his central line had fallen off and the current working diagnosis is that this gave the patient an air embolus. the patient remained stable and was transferred to the floor on . on the floor the patient remained on telemetry for monitoring and remained normotensive and good rate control with oral metoprolol and amiodarone. the patient was edematous from the iv fluids he received during his resuscitation and received iv lasix. due to the patient's edema, the fascia from the abdominal wound pulled apart with bowel exposed. xeroform was placed over the exposed bowel and a vac dressing was placed on the patient's abdominal wound with continuous suction. he remained afebrile with no leukocytosis and was to complete his course of flagyl on , and low dose prednisone on . the patient was discharged to rehab on , in stable condition tolerating a regular diet, his colostomy was functioning well, and with his pain well controlled on oral dilaudid. he was to receive continued physical therapy as recommended to increase his gait and functional mobility. medications on admission: plavix norvasc asa tricor toprol lipitor amitriptyline prednisone discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 3. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 5. nicotine 7 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). 6. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 2 days: last dose pm . 7. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 10. prednisone 5 mg tablet sig: one (1) tablet po daily (daily) for 24 doses: last dose . 11. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day): hold for hr < 69 hold for sbp < 120. 13. hydromorphone 2 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain: be sure to give 1 hour prior to vac dressing changes. 14. miconazole nitrate 2 % powder sig: one (1) appl topical prn (as needed): to groin area. 15. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 16. insulin sliding scale sig: regular insulin sliding scale qachs: insulin sc sliding scale q6h regular insulin 0-60 mg/dl amp d50 61-120 mg/dl 0 units 121-140 mg/dl 3 units 141-160 mg/dl 5 units 161-180 mg/dl 7 units 181-200 mg/dl 9 units 201-220 mg/dl 11 units 221-240 mg/dl 13 units 241-260 mg/dl 15 units 261-280 mg/dl 17 units 281-300 mg/dl 19 units 301-320 mg/dl 21 units 321-340 mg/dl 23 units 341-360 mg/dl 25 units > 360 mg/dl notify m.d. . 17. glargine insulin sig: ten (10) units at bedtime: give in addition to regular insulin sliding scale. discharge disposition: extended care facility: - discharge diagnosis: perforated diverticulitis requiring pouch and transverse colostomy abdominal wound with incisional hernia atrial fibrillation air embolus clostridium difficile cad htn chronic renal failure chf copd requiring steroids steroid induced dm discharge condition: stable discharge instructions: notify md or return to the emergency department if you experience: *increased or persistent pain not relieved by pain medication *fever > 101.5 *nausea, vomiting, or increased abdominal distention *increased or decreased ostomy outputs over 24 hours *change in color or appearance of stoma *shortness of breath or chest pain *changes in appearance of abdominal wound or drainage from vac followup instructions: follow-up with dr. in weeks, call for an appointment follow-up with your pcp, . upon discharge from the hospital, call for an appointment Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Insertion of other (naso-)gastric tube Other lysis of peritoneal adhesions Open and other sigmoidectomy Transfusion of packed cells Exteriorization of large intestine Cardiopulmonary resuscitation, not otherwise specified Other immobilization, pressure, and attention to wound Application or administration of an adhesion barrier substance Infusion of vasopressor agent Diagnoses: Tobacco use disorder Congestive heart failure, unspecified Long-term (current) use of steroids Other specified disorders of pancreatic internal secretion Adrenal cortical steroids causing adverse effects in therapeutic use Chronic airway obstruction, not elsewhere classified Atrial fibrillation Disruption of internal operation (surgical) wound Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Paroxysmal ventricular tachycardia Cardiac arrest Peritoneal adhesions (postoperative) (postinfection) Incisional hernia without mention of obstruction or gangrene Intestinal infection due to Clostridium difficile Other complications due to other vascular device, implant, and graft Morbid obesity Personal history of malignant neoplasm of kidney Acquired absence of kidney Peritonitis (acute) generalized Diverticulitis of colon (without mention of hemorrhage) Late effects of cerebrovascular disease, disturbances of vision Abscess of intestine Profound impairment, one eye, impairment level not further specified