Francesca383
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Hello,
We have a patient that had surgery and 3 wks later was admitted to the hospital. The surgeon did an H&P and wants to know if he can be paid for it or if it is part of the global package from the surgery. Help
ADMISSION DIAGNOSIS: Probable Clostridium difficile colitis.
HISTORY OF PRESENT ILLNESS: PT is now about 3 weeks out from recent ileostomy reversal after a very distal low anterior resection and debridement with ileostomy for a large locally advanced mid to distal rectal cancer after neoadjuvant chemoradiation roughly 9 months ago. She did very well with that surgery without any major issues or problems. She underwent debridement with ileostomy given the prior neoadjuvant chemoradiation and the very distal nature of the low anterior resection. She then underwent subsequent additional adjuvant chemo which she did well with. She has not had any evidence of recurrence. She was then evaluated heavily for ileostomy reversal at roughly the 9-month mark. This included both the colonoscopy with contrast done as well as a repeat abdominal and pelvic CT scan. She had some an area of narrowing in what would be the equivalent of the mid sigmoid colon but it did not appear to be any sort of an intraluminal abnormality and it was felt to likely be extrinsic compression. CT failed to reveal any evidence of a mass, but the presumption was that this was likely related to external adhesive disease, but both contrast and the scope were able to be navigated through this area and, again, there was no intraluminal abnormality or masses in the area extensively. Therefore it is felt that she would be able to tolerate ileostomy reversal.
She underwent an uneventful ileostomy reversal roughly 3 weeks ago. Did well initially but then began to develop copious amounts of diarrhea and had a positive C. diff stool culture. She was placed on oral vancomycin for a 2-week course. She improved quite a bit to the point that she was discharged roughly a week after ileostomy reversal and went home and completed another 10 days of oral vancomycin, which she discontinued/completed roughly a week ago.
We were notified by both her and her home health assistant that she was having increasing abdominal discomfort with distention, diarrhea, and just poor oral intake. I spoke to her by phone yesterday, and I immediately then became aware of this and asked her to present to the emergency room for evaluation.
She came to the emergency room at Sacred Heart yesterday and underwent a full evaluation in the ER which included both abdominal films as well as a CT scan, all of which I felt radiographically presented was most consistent with a picture of early toxic megacoln, and C. difficile stool cultures subsequently appear consistently positive.
She did not appear to be otherwise toxic. She had a normal white count. She had tests, but otherwise her laboratory parameters and vital signs were good, and there were no acute surgical indications.
Based on that, we asked for her to be admitted. We started her on Flagyl and oral vancomycin. An NG tube was placed. She was made nothing by mouth and is now in her second hospital day.
PAST MEDICAL HISTORY:
1. Rectal cancer.
PAST SURGICAL HISTORY:
1. Low anterior resection with loop ileostomy.
2. Ileostomy reversal.
REVIEW OF SYSTEMS: A full 10-point review of systems is conducted and the pertinent positives and negatives as mentioned in above HPI, otherwise unremarkable.
FAMILY AND SOCIAL HISTORY: Reviewed and otherwise noncontributory.
EXAMINATION:
VITAL SIGNS: On admission, temperature of 37.2, blood pressure 107/68, heart rate 76, respirations 20, SpO2 of 95.
GENERAL: Alert and oriented times 3, in no acute distress. HEAD: Normocephalic.
NECK: Soft, supple. No adenopathy.
CHEST: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm.
ABDOMEN: Soft, moderately distended but nontender. There are no peritoneal findings. Her belly is soft. She has the vacuum placed over the ileostomy site in the right mid abdomen. No other issues to report.
EXTREMITIES: Well-perfused, well-formed.
REVIEW OF RADIOGRAPHIC STUDIES: Both abdominal and plain films and CT scan present a picture that appears to be one of predominate colonic distention. There is really no small bowel distention and there is no evidence of free fluid. Intraperitoneally, there is no evidence of free air. The colon and right colon are predominately distended, but she appears to have a pattern consistent with colonic ileus and/or early toxic megacolon, but of course, distal colonic obstruction could not be completely ruled out based on this evaluation.
LABORATORY STUDIES: White blood cell count 5.3, platelet 349, hemoglobin 14.1. She does have a mild left shift on her WBC with about 80 percent neutrophils. There was no substantial bandemia.
Basic metabolic profile: Sodium 138, potassium 2.6, chloride 98, CO2 28, BUN 11, creatinine 0.77.
IMPRESSION AND PLAN:
1. Colonic distention with probable chronic ileus secondary to persistent and recurrent Clostridium difficile colitis and potentially early toxic colon.
2. Could not entirely rule out distal colonic obstruction at this point.
3. Stool for Clostridium difficile is pending at the time of her admission but should be treated presumptively with oral vancomycin and IV Flagyl, nasogastric tube for bowel decompression. We will also place a peripherally inserted central catheter line to initiate total parenteral nutrition and IV fluid resuscitation.
4. At this point, she appears clinically quite benign. I do not see any indications for surgical intervention. There is some possibility, as mentioned, that she could have a distal colonic issue either at the anastomosis or higher than that could be posing some sort of obstruction. This may ultimately need to be scoped to assure no obstruction at or prior to the anastomosis, which is very distal.
5. Both an Infectious Disease and GI Consult will also be necessary.
6. I had a lengthy discussion with her about the potential serious nature and possible severity of Clostridium difficile colitis, and she is aware that this is something that will need to be treated to full resolution here in the hospital prior to discharge.
We have a patient that had surgery and 3 wks later was admitted to the hospital. The surgeon did an H&P and wants to know if he can be paid for it or if it is part of the global package from the surgery. Help
ADMISSION DIAGNOSIS: Probable Clostridium difficile colitis.
HISTORY OF PRESENT ILLNESS: PT is now about 3 weeks out from recent ileostomy reversal after a very distal low anterior resection and debridement with ileostomy for a large locally advanced mid to distal rectal cancer after neoadjuvant chemoradiation roughly 9 months ago. She did very well with that surgery without any major issues or problems. She underwent debridement with ileostomy given the prior neoadjuvant chemoradiation and the very distal nature of the low anterior resection. She then underwent subsequent additional adjuvant chemo which she did well with. She has not had any evidence of recurrence. She was then evaluated heavily for ileostomy reversal at roughly the 9-month mark. This included both the colonoscopy with contrast done as well as a repeat abdominal and pelvic CT scan. She had some an area of narrowing in what would be the equivalent of the mid sigmoid colon but it did not appear to be any sort of an intraluminal abnormality and it was felt to likely be extrinsic compression. CT failed to reveal any evidence of a mass, but the presumption was that this was likely related to external adhesive disease, but both contrast and the scope were able to be navigated through this area and, again, there was no intraluminal abnormality or masses in the area extensively. Therefore it is felt that she would be able to tolerate ileostomy reversal.
She underwent an uneventful ileostomy reversal roughly 3 weeks ago. Did well initially but then began to develop copious amounts of diarrhea and had a positive C. diff stool culture. She was placed on oral vancomycin for a 2-week course. She improved quite a bit to the point that she was discharged roughly a week after ileostomy reversal and went home and completed another 10 days of oral vancomycin, which she discontinued/completed roughly a week ago.
We were notified by both her and her home health assistant that she was having increasing abdominal discomfort with distention, diarrhea, and just poor oral intake. I spoke to her by phone yesterday, and I immediately then became aware of this and asked her to present to the emergency room for evaluation.
She came to the emergency room at Sacred Heart yesterday and underwent a full evaluation in the ER which included both abdominal films as well as a CT scan, all of which I felt radiographically presented was most consistent with a picture of early toxic megacoln, and C. difficile stool cultures subsequently appear consistently positive.
She did not appear to be otherwise toxic. She had a normal white count. She had tests, but otherwise her laboratory parameters and vital signs were good, and there were no acute surgical indications.
Based on that, we asked for her to be admitted. We started her on Flagyl and oral vancomycin. An NG tube was placed. She was made nothing by mouth and is now in her second hospital day.
PAST MEDICAL HISTORY:
1. Rectal cancer.
PAST SURGICAL HISTORY:
1. Low anterior resection with loop ileostomy.
2. Ileostomy reversal.
REVIEW OF SYSTEMS: A full 10-point review of systems is conducted and the pertinent positives and negatives as mentioned in above HPI, otherwise unremarkable.
FAMILY AND SOCIAL HISTORY: Reviewed and otherwise noncontributory.
EXAMINATION:
VITAL SIGNS: On admission, temperature of 37.2, blood pressure 107/68, heart rate 76, respirations 20, SpO2 of 95.
GENERAL: Alert and oriented times 3, in no acute distress. HEAD: Normocephalic.
NECK: Soft, supple. No adenopathy.
CHEST: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm.
ABDOMEN: Soft, moderately distended but nontender. There are no peritoneal findings. Her belly is soft. She has the vacuum placed over the ileostomy site in the right mid abdomen. No other issues to report.
EXTREMITIES: Well-perfused, well-formed.
REVIEW OF RADIOGRAPHIC STUDIES: Both abdominal and plain films and CT scan present a picture that appears to be one of predominate colonic distention. There is really no small bowel distention and there is no evidence of free fluid. Intraperitoneally, there is no evidence of free air. The colon and right colon are predominately distended, but she appears to have a pattern consistent with colonic ileus and/or early toxic megacolon, but of course, distal colonic obstruction could not be completely ruled out based on this evaluation.
LABORATORY STUDIES: White blood cell count 5.3, platelet 349, hemoglobin 14.1. She does have a mild left shift on her WBC with about 80 percent neutrophils. There was no substantial bandemia.
Basic metabolic profile: Sodium 138, potassium 2.6, chloride 98, CO2 28, BUN 11, creatinine 0.77.
IMPRESSION AND PLAN:
1. Colonic distention with probable chronic ileus secondary to persistent and recurrent Clostridium difficile colitis and potentially early toxic colon.
2. Could not entirely rule out distal colonic obstruction at this point.
3. Stool for Clostridium difficile is pending at the time of her admission but should be treated presumptively with oral vancomycin and IV Flagyl, nasogastric tube for bowel decompression. We will also place a peripherally inserted central catheter line to initiate total parenteral nutrition and IV fluid resuscitation.
4. At this point, she appears clinically quite benign. I do not see any indications for surgical intervention. There is some possibility, as mentioned, that she could have a distal colonic issue either at the anastomosis or higher than that could be posing some sort of obstruction. This may ultimately need to be scoped to assure no obstruction at or prior to the anastomosis, which is very distal.
5. Both an Infectious Disease and GI Consult will also be necessary.
6. I had a lengthy discussion with her about the potential serious nature and possible severity of Clostridium difficile colitis, and she is aware that this is something that will need to be treated to full resolution here in the hospital prior to discharge.