allergies: iodine; iodine containing attending: chief complaint: vomiting major surgical or invasive procedure: small bowel resection small bowel-large bowel bypass history of present illness: mr. is a 73 year old man with aids (cd4 126 on ), type ii diabetes mellitus, and an invasive squamous cell carcinoma of the anorectal canal (s/p chemo-radiation therapy and extensive surgery ) with chief complaint of vomiting over the last month. he says that, for about the last month, he has been vomiting now daily. he denies any blood or coffee grounds in his vomtius. he vomits food or gastric contents. he has stopped eating solid foods due to fear of vomiting. he vomits up any food that he has eaten, even up to 6 hours prior, but has been able to keep liquids and his medications down. his colostomy is working well, although he has noted an increase in bowel movements despite cutting back on his diet. he has no blood in the stools, and no black stools. stools are liquidy brown and "cocoa -colored." he has had intermittent right lower quadrant "crampy" pain, but is not sure of the association of this with the vomiting or bowel movements. he has had no fevers, and denies night sweats. he says he has been taking all of his medications on time and as directed, and has not been eating outside of his home or had any unusual or poorly cooked meals. his partner notes that he is becoming weaker, and has to rest after walking only a few feet because he's "tired." he denies any shortness of breath. at the time of his prior office visit in , he was going for daily walks w/o problems. his partner also thinks that mr. also seems to be confused: forgetting things/elements of conversations, and not following conversations. past medical history: 1. aids: he was found to be hiv positive in ; his (only) risk factor is (homo-)sexual exposure(s). he has a multi-resistant virus, due to serial monotherapy in the early 's and some adherence problems thereafter. is currently on a regimen of atazanavir 300 mg/day boosted by ritonavir 100 mg/day, emtrictabine 200 mg/day, tenofovir 300 mg/day, and zidovudine 300 mg po bid. his last cd4 count in was 126, with a corresponding viral load that was undetectable. . 2. invasive squamous cell carcinoma of the anorectal canal: in early had brbpr. colonscopy showed 8 mm sessile polyp in the sigmoid colon,and a fugating 3.5 cm mass just above the anal verge. the biopsies of both lesions revealed focally invasive squamous cell carcinoma. he had a complicated course since the tumor was necrotic, infected, and obstructing the rectal canal. he needed a diverting colonoscopy to be placed, and had two admissions for fevers due to infection of the tumor. in , he started radiation therapy with chemotherapy for augmentation (5- fluorouracil and cisplatin).in early , he had an antrior/posterior resection of the primary tumor. pathology of the tissue removed revealed foci of active tumor. . 3. dm2: diagnosed in . this was initially treated with dietary intervention. he had been on a regimen of actos and glyburide, but has had medications withdrawn since marked weight loss during the chemo-radiation therapy. his last glycated hemoglobin in was 4.5%. . 4. remote etoh abuse:he has a history of ethanol abuse, but this has been inremission for over 10 years. . 5. lung nodule: he has a calcified pulmonary nodule on a chest x ray in 11/93.his sister had tuberculosis, but he had minimal exposure to her. . 6. syphilis: he has a history of syphilis in the late 's and does not recall what therapy he received. . 7. cystic parotiditis . 8. normal ett mibi: in , he had a ct scan of his heart (as part of a study)that revealed extensive calcifications of his coronary arteries.he, therefore, had an exercise thallium study that revealed an ef of 62% and no perfusion defects at a 111% predicted heart rate. . 9. hyperlipidemia:was on statins before losing weight. . 10. copd: "copd" by ct scan in . initial ct scan showed ground glass opacities. seen by pulmonolgy at and repeat ct scan was normal. . past surgical history: 1. he had some cosmetic surgery at the age of 18 to correct a scar on his head sustained in some childhood head trauma. 2. he had an appendectomy at the age of 45. social history: social history: he was in the air force, and then got a college education.after that, he moved to and worked as an interior designer for several decades, and retired to , mass. he has traveled to europe, the middle east, the sw usa, and . he lives with his partner. has several dogs at home. tobacoo: none x 12 years, but previous 40 pack year history; etoh: prior alcoholism, but none for 12 years; illicit drugs: none. family history: family history: mother who died at the age of 94. his father died at the age of 101. he has 1 sister who had tuberculosis, and 2 sisters died of breast cancer. he has one brother who has had a melanoma, and one brother has arthritis. no other disorders that he is aware of run in his family. physical exam: t 97.7 bp 106/60 hr 83 20 97%ra gen: chronically ill appearing male in no respiratory distress heent: moderate facial wasting. anictertic sclera. conjunctivae not pale.mucous membranes moist. poor dentition. o/p clear. neck: supple, no lymphadenopathy. thyroid smooth and not enlarged. jvp at 1cm above angle. lungs: clear to auscultation bilateally, no wheezes, rhonchi or rales cor: regular rate, nl s1 and s2, ii/vi systolic murmur at the lsb. abd: soft, non-tender (although exam in clinic notable for rlq tenderness)hypoactive bs. no masses. ostomy site without redness. liquid brown stool in colostomy. ext: there is no clubbing or edema. rectal: 2cm opening with white fluid at prximal edge of flap, no tenderness, no surrounding erythema. no drainage. no fluctuance. otherwise well-healed flap. neuro:orientated x 3 to time, place, person. the cranial nerves iii to xii are normal. the toes are down-going, and reflexes are equal and intact bilaterally. strength is and symmetric in upper and lower extremities. brief hospital course: a/p 73 yo male with aids, dm2, invasive carcinoma of the anorectal canal s/p resection and diverting colostomy presented with vomiting and and intermittent rlq pain. he was diagnosed with a partial small bowel obstruction until , when his symptoms failed to resolve and a ct scan showed a transition point. he was taken to the operating room and underwent extensive lysis of adhesions and a biopsy of a small bowel mass. the operation was made much more challenging by the existence of radiation changes in his pelvis after treatment for anal cancer. his recovery was arduous, and bowel function was slow to recover. he was started on tpn. on , he developed gross hematuria, and a urology consult recommended a cystoscopy. as a follow-up surgery was planned for , the cystoscopy was done at this time. his surgery on consisted of an ex lap and construction of an ileocolic bypass. cystopscopy revealed only small clot and expected inflammatory changes. unsurprisingly, his bowel function was again slow to return. he continued tpn, and continued to have high ngt outputs. although his ostomy output continued to be negligible, the tissue itself was viable, and there was no indication of frank obstruction. a repeat small-bowel follow through on was negative for obstruction, and in fact the contrast could be seen freely passing from the ostomy site. on , his urine again darkened and became quite cloudy. he was fluid resuscitated and his urine color and output improved. initially the cloudiness was concerning for a colovesical fistula, but a sterile urinalysis and subsequent clearing of the urine argue definitively against this. by there was some return of bowel function, with evidence and gas and liquid contents in the ostomy bag, and his ngt was discontinued. the pt experienced no nausea subsequently. he resumed a diet on and continued to tolerate this well. although he was clearly improved, it was felt he would be unable to support himself nutritionally, and a dobhoff feeding tube was placed on and he was placed on ultracal 1/2strength without fiber at 30cc/h. unfortunately he vomited this out on . however, he was able to increase his oral caloric intake. it is our belief that he can successfully wean off the tpn and onto regular food. at all times he should try to support himself with food intake, unless his abdominal symptoms return. medications on admission: 1. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 2. sucralfate 1 g tablet sig: one (1) tablet po four times a day. 3. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 4. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 5. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). 6. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection (2 times a day). 7. zidovudine 100 mg capsule sig: three (3) capsule po bid (2 times a day). 8. ritonavir 100 mg capsule sig: one (1) capsule po daily (daily). disp:*60 9. atazanavir sulfate 100 mg capsule sig: three (3) capsule po daily (daily). 10. acyclovir 200 mg capsule sig: two (2) capsule po q12h (every 12 hours). 11. pioglitazone hcl 30 mg tablet sig: one (1) tablet po daily (daily). 12. emtricitabine 200 mg capsule sig: one (1) capsule po q24h (every 24 hours). 13. tamsulosin hcl 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po daily (daily 14. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 15. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 16. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. discharge medications: 1. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). disp:*qs 1* refills:*2* 2. sucralfate 1 g tablet sig: one (1) tablet po four times a day. disp:*120 tablet(s)* refills:*2* 3. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). disp:*qs 1* refills:*2* 4. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. disp:*qs 1* refills:*0* 5. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 6. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection (2 times a day). disp:*qs 1* refills:*2* 7. zidovudine 100 mg capsule sig: three (3) capsule po bid (2 times a day). disp:*180 capsule(s)* refills:*2* 8. ritonavir 100 mg capsule sig: one (1) capsule po daily (daily). disp:*60 capsule(s)* refills:*2* 9. atazanavir sulfate 100 mg capsule sig: three (3) capsule po daily (daily). disp:*60 capsule(s)* refills:*2* 10. acyclovir 200 mg capsule sig: two (2) capsule po q12h (every 12 hours). disp:*120 capsule(s)* refills:*2* 11. pioglitazone hcl 30 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. emtricitabine 200 mg capsule sig: one (1) capsule po q24h (every 24 hours). disp:*30 capsule(s)* refills:*2* 13. tamsulosin hcl 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po daily (daily). disp:*30 capsule, sust. release 24hr(s)* refills:*2* 14. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 15. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 16. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. disp:*qs 1* refills:*0* discharge disposition: extended care facility: & rehab center - discharge diagnosis: small bowel obstruction anal cancer diabetes mellitus type ii hypertension discharge condition: stable discharge instructions: routine ostomy care. physical therapy. nutritional medical management of hiv followup instructions: please call dr office to schedule your follow up appointment. md Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Insertion of other (naso-)gastric tube Other lysis of peritoneal adhesions Other small-to-large intestinal anastomosis Transfusion of packed cells Suture of laceration of small intestine, except duodenum Open biopsy of small intestine Transurethral clearance of bladder Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Chronic airway obstruction, not elsewhere classified Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Accidental puncture or laceration during a procedure, not elsewhere classified Human immunodeficiency virus [HIV] disease Cachexia Paralytic ileus Pressure ulcer, lower back Personal history of irradiation, presenting hazards to health Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection) Attention to colostomy Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus