allergies: shellfish derived attending: chief complaint: leukocytosis and free air in abdomen on ct scan at osh-found to have pneumatosis major surgical or invasive procedure: right colectomy, end ileostomy, hartmann's pouch for perforated colon and obstructed small bowel at ileoileostomy site history of present illness: this is a 51 year-old male with a history of stage iv rectal cancer s/p chemo/xrt s/p lap-assisted protectomy with coloanal anastomosis and diverting loop ileostomy s/p ileostomy takedown on who is admitted to the from the or after resection of ischemic right colon, end-ileostomy, and long hartmann's pouch (left colon is blindly attached, from -anal anastomosis to transverse colon). pt intermittently required phenylephrine during procedure, despite resuscitation with 4l lr, 3l ns, 600cc albumin (total 50g); intra-op ebl as 150cc and hct 30, so has not received blood. . the patient originally presented to the ed at hospital with abd pain. he was transferred to our ed after he was found to have pneumatosis and was taken directly to the or to have a partial coletomy and diverting ileostomy, as above. past medical history: medical hx: 1) rectal cancer stage iv 2) skin cancer on shoulder surgical hx: none all: nkda social history: he currently smokes one pack of cigarettes a day and used to drink three to four alcoholic beverages a day, but now drinks one a day. he works as a printer and has maintained work schedule pretty well throughout his treatment. family history: his past family history includes a mother with colorectal cancer and a maternal grandmother who may have had colon cancer. physical exam: at admission: vitals: t: bp: hr: rr: o2sat: gen: well-appearing, well-nourished, no acute distress heent: eomi, perrl, sclera anicteric, no epistaxis or rhinorrhea, mmm, op clear neck: no jvd, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline cor: rrr, no m/g/r, normal s1 s2, radial pulses +2 pulm: lungs ctab, no w/r/r abd: soft, nt, nd, +bs, no hsm, no masses ext: no c/c/e, no palpable cords neuro: alert, oriented to person, place, and time. cn ii ?????? xii grossly intact. moves all 4 extremities. strength 5/5 in upper and lower extremities. patellar dtr +1. plantar reflex downgoing. no gait disturbance. no cerebellar dysfunction. skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses. . at discharge: vitals: 98.7, 109, 133/83, 20, 96%ra gen: nad, a/ox3 cv: rrr resp: ctab incision: midline, abdominal with white/black sponge with vacuum dressing at 125mmhg. pink-red granulation tissue mid to distal portion of wound. minimal fibrinous tissue. the upper portion of the wound tracks up to 9 cm at 1 - 2 o'clock and as little as 3 cm at 12 - 12 o'clock. ostomy: beefy red viable with thick brown effluence. +gas. extrem: no c/c/e pertinent results: 07:05am blood wbc-25.4*# rbc-3.19*# hgb-10.0* hct-30.1* mcv-94 mch-31.5 mchc-33.4 rdw-17.4* plt ct-1470*# 01:22am blood wbc-18.4*# rbc-3.80*# hgb-12.0*# hct-34.9*# mcv-92 mch-31.5 mchc-34.3 rdw-17.5* 04:50am blood wbc-37.3* rbc-2.97* hgb-9.2* hct-28.4* mcv-96 mch-31.0 mchc-32.4 rdw-17.4* plt ct-909* 05:38am blood wbc-12.5* rbc-2.55* hgb-7.8* hct-23.3* mcv-92 mch-30.6 mchc-33.4 rdw-17.0* plt ct-640* 05:06am blood wbc-12.2* rbc-2.85* hgb-8.9* hct-26.6* mcv-93 mch-31.3 mchc-33.5 rdw-17.0* plt ct-852* 04:32am blood wbc-10.5 rbc-2.68* hgb-8.0* hct-25.0* mcv-93 mch-29.8 mchc-32.0 rdw-17.1* plt ct-989* 06:51am blood wbc-12.6* rbc-2.30* hgb-6.9* hct-21.4* mcv-93 mch-30.0 mchc-32.2 rdw-17.6* plt ct-1222* 05:59am blood wbc-14.2* rbc-3.09*# hgb-9.0*# hct-27.7*# mcv-90 mch-29.2 mchc-32.5 rdw-18.2* plt ct-1154* 04:51am blood wbc-9.1 rbc-2.73* hgb-7.9* hct-25.1* mcv-92 mch-29.1 mchc-31.7 rdw-17.6* plt ct-1215* 05:27am blood wbc-10.3 rbc-2.44* hgb-7.3* hct-21.8* mcv-89 mch-29.7 mchc-33.3 rdw-17.2* plt ct-1149* 05:06am blood pt-15.3* ptt-31.1 inr(pt)-1.4* 04:51am blood glucose-105 urean-14 creat-0.5 na-136 k-4.5 cl-101 hco3-28 angap-12 10:33am blood glucose-107* urean-14 creat-0.5 na-135 k-4.6 cl-101 hco3-28 angap-11 06:10am blood glucose-105 urean-17 creat-0.5 na-137 k-4.3 cl-104 hco3-25 angap-12 05:59am blood glucose-102 urean-15 creat-0.5 na-137 k-4.4 cl-108 hco3-25 angap-8 09:15pm blood glucose-107* urean-20 creat-1.1 na-136 k-3.8 cl-106 hco3-19* angap-15 05:59pm blood glucose-104 urean-20 creat-1.1 na-136 k-3.9 cl-107 hco3-20* angap-13 07:05am blood glucose-98 urean-17 creat-0.8 na-135 k-3.7 cl-97 hco3-25 angap-17 03:18am blood alt-15 ast-26 alkphos-112 totbili-0.4 09:15pm blood alt-7 ast-14 alkphos-97 amylase-10 totbili-0.7 07:05am blood alt-15 ast-15 alkphos-310* totbili-0.5 04:51am blood calcium-7.9* phos-3.9 mg-1.9 10:33am blood calcium-7.6* phos-3.4 mg-1.9 06:10am blood albumin-2.4* calcium-7.9* phos-4.1 mg-1.9 iron-10* 06:51am blood calcium-7.5* phos-3.3 mg-2.0 03:22am blood albumin-2.0* calcium-6.8* phos-3.5 mg-1.9 iron-8* 03:18am blood albumin-1.9* calcium-7.4* phos-4.1 mg-1.9 05:59pm blood albumin-2.4* calcium-7.8* phos-5.2* mg-1.6 07:05am blood albumin-2.9* calcium-8.4 06:10am blood caltibc-126* ferritn-249 trf-97* 05:42am blood vitb12-1257* folate-6.6 04:32am blood caltibc-112* ferritn-275 trf-86* 03:22am blood caltibc-107* ferritn-262 trf-82* 06:10am blood triglyc-159* 04:32am blood triglyc-76 03:22am blood triglyc-89 05:42am blood tsh-5.1* 06:17am blood t4-7.5 t3-75* . 06:10am prealbumin test result reference range/units prealbumin 10 l 21-43 mg/dl . rpr - non reactive am cxr- bilateral pleural effusions; pm cxr - improved effusions ct a/p: 1. diffuse peritonitis ,concerning for leak possibly involving the proximal or distal colonic sutures. 2. large subcapsular splenic hematoma, possibly due to retraction injury. kub - continued sbo; no change in position of drain in pelvis ct: 1. interval decrease amt of intra-abdominal fluid and air. intra-abdominal fluid, air directly contiguous with the midline anterior abdominal wall soft tissue defect. persistent thickening, enhancement of the peritoneum. multiple loops of dilated small bowel measuring up to 5 cm with a relative decrease in small bowel caliber from the region of sb anastamosis to rlq stoma. . brief hospital course: mr. was transferred to from hospital after ct scan revealed free air in abdomen with wbc above 20. he was urgently taken to or per dr. upon arrival to hospital. his operative course was prolonged. patient required iv pressor support and hydration to maintain blood pressure due to shock symptoms from ischemic bowel. post-op he was transferred to medical icu for close monitoring: ventilation support, hydration, and blood pressure support with pressors. he continued on antibiotics, and labwork was trended during icu stay. his condition gradually improved-weaned from vent, and able to maintain blood pressure. he then became fluid overloaded and required aggressive pulmonary toilet and diuresis. he remained on nasal cannula, and demonstrated s/s of respiratory decompensation with minimal activity. he was aggressively diuresed. respiratory status improved, and he was transferred to stone 5 for post-op care. . on stone 5, patient continue to diurese. his mental status remained slightly compromised, but he remained a/ox3. physical was consulted due to lower extremity edema, and compromised respiratory status. tpn started for supplemental nutrition support and to promote wound healing due to low albumin levels, and decreased appetite. advanced to regular diet once ostomy began to function. calorie counts initiated. labwork, including nutrition labs trended closely. . incision noted to have erythema and draining purulent fluid. opened at bedside and packed with moist gauze. drainage was copiuous, and required suction. vacuum dressing applied to midline abdominal incision to promote granulation tissue. continued with iv meropenem, and flagyl switched to oral once tolerating regular food. pain well controlled with oral oxycodone, tylenol, and fentanyl patch. foley removed once patient hemodynamically stable. able to urinate without difficultly. ostomy rn continued teaching patient re: ostomy care. . his ostomy output increased to 3 liters once he was eating a regular diet. imodium was started, and titrated up to 4 times per day with adequate effects. metamucil wafer was also started, but discontinued once osotmy output decreased to about 600cc in 24hrs. he was advised to titrate his imodium at home based on discharge instruction parameters. he is aware to call dr. office with concerns. . mr. physical, surgical, & medical status improved dramatically. his diet improved, tolerated adequate amounts of po intake to meet daily nutritional needs. tpn stopped prior to discharge. he was independent with adl's and activity. antibiotics discontinued on , remained afebrile with normal wbc for 48hrs. he was discharge home with vna for management of vacuum dressing to abdominal wound, ostomy care, and fluid/electrolyte management. vacuum dressing changed on and switched to portable (home) vacuum pump prior to discharge. he will follow-up with dr. in weeks. discharge information discussed with patient in detail. medications on admission: oxycodone, colace discharge medications: 1. outpatient lab work weekly cbc & chem-10 please fax results to dr. (. 2. loperamide 2 mg capsule sig: two (2) capsule po qid (4 times a day) as needed for excessive ostomy output: do not exceed 16mg in 24hrs. disp:*240 capsule(s)* refills:*2* 3. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. ibuprofen 400 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain for 10 days: take with food. disp:*45 tablet(s)* refills:*0* 5. percocet 7.5-325 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain for 2 weeks: do not exceed 4000mg of acetaminophen in 24hrs. disp:*60 tablet(s)* refills:*0* 6. fentanyl 100 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours) for 1 months. disp:*10 patch 72 hr(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: primary: ischemia of colon perforation of the right colon post-op septic shock post-op hypotension post-op wound infection post-op malnutrition post-op fluid overload post-op delirium . secondary: rectal ca stage iv s/p chemo and xrt discharge condition: stable tolerating a regular diet adequate pain control with oral medication. discharge instructions: please call your doctor or return to the er for any of the following: * if you are vomiting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomiting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * your pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *avoid lifting objects > 5lbs until your follow-up appointment with the surgeon *avoid driving or operating heavy machinery while taking pain medications. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. * continue to ambulate several times per day. . vacuum dressing/incision care: - visiting rn will continue to manage your vacuum dressing at home. changing dressing every 3 days. -keep vacuum pressure at 125mmhg at all times to promote healing. -please call vna or dr. if vacuum machine not functioning properly or leaking. -you may shower, and wash surgical incisions. coordinate with vna dressing changes. -avoid swimming and baths until your follow-up appointment. -please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . monitoring ostomy output/prevention of dehydration: -keep well hydrated. -replace fluid loss from ostomy daily. -avoid only drinking plain water. include gatorade and/or other vitamin drinks to replace fluid. -try to maintain ostomy output between 1000ml to 1500ml per day. -if ostomy output >1.5 liter, please call dr. . continue to take your imodium as advised. do not exceed 16mg/24 hours. -if osotomy output decreases under 500cc in 24hrs, please inform dr. . . swelling of feet: -continue to walk at least 3-4 times per day to help with circulation of fluid in legs. -while resting, keep your legs elevated. try to elevate above level of your heart when sleeping. followup instructions: 1. please follow-up with dr. in weeks. 2. follow-up with ostomy rn as advised. call to make appointments (. 3. follow-up with dr. (liver surgeon) ( as needed. summary neither dictated nor read by me Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Temporary ileostomy Open and other right hemicolectomy Open and other resection of transverse colon Diagnoses: Malignant neoplasm of liver, secondary Other postoperative infection Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Unspecified transient mental disorder in conditions classified elsewhere Accidental puncture or laceration during a procedure, not elsewhere classified Septic shock Peritoneal abscess Accidental cut, puncture, perforation or hemorrhage during surgical operation Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus