Ch. 5 – Complete hospital discharge summary

CONSULTING PHYSICIAN: Non-dictated.

DISCHARGING RESIDENT: XXXXXXX, M.D.

DISCHARGING SERVICE: Trauma surgery.

DISPOSITION: Discharged to home self.

FINAL DIAGNOSES:

1. History of aortic disease, splenic infarct.

2. Diabetes status post laparoscopic cholecystectomy in 1995.

3. Acute thrombosis of superior mesenteric artery.

4. Short gut syndrome, prolonged nausea and vomiting.

 

PROCEDURES:

1. On 8/17, exploratory laparotomy, no resection (dusky small bowel seen, combined case with vascular surgery who performed a superior mesenteric thrombectomy and vacuum closure of the abdomen) .

2. On 8/18, small bowel resection around 10 cm from the ligament of Treitz up to and including a right hemicolectomy.

3. On 8/19, washout of open abdomen, wound VAC change.

4. On 8/22, reanastomosis of small bowel to colon, jejunal colonic reanastomosis, closure of abdomen.

5. On 8/21, transthoracic echocardiogram showing segmental left ventricle dysfunction, normal ejection fraction.

6. On 8/24, transesophageal echocardiogram showing normal left ventricular contractile performance, negative bubble study. No thrombus seen.

7. On 9/25, small bowel follow through showing rapid transit, no strictures, no dilatation.

8. On 10/2, upper 81 endoscopy showing gastric mucous atrophy, nonbleeding gastropathy, normal duodenum and around 15-20 em of the jejunum, hiatus hernia.

9. On 12/26, Dopplers bilateral lower extremities with no DVT seen.

HOSPITAL COURSE: This is a 37-year-old female with an acute history of aortic disease and splenic infarct who presented to  the hospital in August with acute abdominal pain and was found to  have superior mesenteric artery occlusion on CT scan. Her operative course and postoperative workup are described above and  postoperatively, she was worked up for an altered mental status  and clinical stroke. A CT scan showed no damage to internal  organ or previous function. She was treated with levofloxacin  and cefazolin for a central line infection with proteus

mirabilis. She was started on TPN for short gut syndrome and was  treated with TPN throughout her hospital course. She was worked  up for nausea and vomiting with regular food and was scoped by 81  and found gastritis and recommended a proton pump inhibitor for  which she was treated. Her disposition was confounded by lack of

payment structures in order to pay for home TPN treatment.  However, she was cycled with her TPN for overnight TPN  administration but funding could never be found for her TPN at  home and her albumin remained steady throughout her hospital  course at 3.4. It was noticed that her TPR was normal and  therefore we decreased the amount of calories that were provided  in her TPN and suprisingly with her diet (short gut syndrome  diet) and even though decreasing the TPN total calories, her TPR continued to rise and during the last 3 weeks of hospitalization,

we decreased her TPN in to 800 total calories per day and her TPR  rose, last variation was 17 to 21. We discontinued her TPN to  see how she would do with her regular diet and her chemistry  panels remained within normal limits. She did have some  hypomagnesemia for which she was treated with high magnesium diet

and her magnesium remained steady at 1.5 and in fact on the day  of discharge, her magnesium was 1.6. The rest of the chemistries  were within normal limits. She, on the day of discharge, also  reported having 6 bowel movements a day. Her glucose was well controlled, she would require an average 0 to 4 units of glucose per day although she was initially diagnosed with diabetes and  required much more glucose at the beginning of her  hospitalization. Her weight, off TPN, was initially 145 and the  next day dropped to 139 and we thought this might be an error in the scale, within normal range, and her vitals remained within  normal limits throughout the days that she was off TPN.

She had further workups while inpatient which included:

1. Hematology-oncology consult to evaluate for hypercoagulable state given spontaneous superior mesenteric artery thrombosis. This entire workup was negative with no findings to explain her any hypercoagulable state. She was also worked up for iron deficiency anemia and followup appointments should be made to see Dr. Moll in clinic which were not arranged at the time of discharge. She was treated as an inpatient with 3 months of anticoagulation treatment dose of Lovenox.

2. Cardiology consult: A transthoracic echocardiogram to evaluate the mural thrombus which was difficult study, showed elements of left ventricular dyskinesia which were not found on more sensitive and more specific transesophageal echocardiogram as described above. In addition, there was a negative bubble study and no thrombus seen.

3. OB-Gyn: Ob-Gyn was initially consulted for vaginal bleeding while on Lovenox and the patient had a previous history of dysfunctional uterine bleeding. There was also a low-density lesion seen in the lower uterine segments on the CT scan. She had a history of abnormal Pap smear HG SIL in 7/2006 and on 12/20 she was taken by Ob-Gyn service for a colposcopy with biopsy taken and endocervical curretage. This biopsy showed high-grade SIL, CIN III with the cervix pathology reading CIN I and endocervix pathology CIN III. There was also noted to be evidence of yeast infection and the patient was treated with Diflucan as well as Monistat cream. The patient should follow up with her Ob-Gyn to discuss the results of this test.

 

DISCHARGE INSTRUCTIONS:

1. High magnesium short gut syndrome diet as discussed multiple times with nutrition as an inpatient.

2. Activities as tolerated.

3. No wound care necessary. The patient’s abdominal wounds have healed by the time of discharge.

4. Call if fever greater than 101.5 degrees Fahrenheit, any increase in nausea and vomiting, any constipation, any dehydration, low urine output, not going to bathroom for 8 hours even after drinking water.

5. The patient was discharged with a PICC that was initially placed on 8/29 and she was given a prescription for heparin 200 mL per 2 mL flush and she was instructed on how to flush her PICC. This is the floor protocol for PICC checks. She should also have dressing changes every 7 days for her PICC dressing, this was not arranged when she was discharged on the day before Christmas.

 

DISCHARGE MEDICATIONS:

1. Potassium powder 20 mEq by mouth twice daily.

2. Liquid multivitamins 5 mL by mouth twice daily.

3. Nystatin cream applied to affected areas as needed for yeast infection.

4. Prochlorperazine (Compazine) 5 mg p.o. every 8 hours as needed for nausea.

5. Lansoprazole Solutabs 60 mg by mouth twice daily.

6. Turns 500 mg by mouth 3 times daily.

7. Promethazine 12.5 mg by mouth every 4 hours as needed for nausea.

8. Aspirin 81 mg by mouth daily (over-the-counter).

FOLLOWUP APPOINTMENTS:

1. Please see Trauma Surgery Clinic on Tuesday 12/26 when we will discuss long term PICC plans, arrange for home health as needed and check Accu-Chek.

2. Gynecology followup on an elective basis for irregular menses and to follow up on the pathology results as discussed above. The patient should call to arrange the appointment.

3. The patient may follow up with Hematology-Oncology for iron deficiency anemia as needed once diet is stabilized.

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