Surgery Soap: # 2

Date: 6/28/2023

Full Name: GW

Address:  NY, NY

Date of Birth: 12/5/1986

Location: Woodhull Hospital

Source of Information: 

Reliability: Reliable

Source of Referral: Self

S

HPI: GW is a 50-year-old female with PMHx of obesity who presented to the ED on 6/25/2023 for abdominal pain located to the umbilical area, and episodes of vomiting, and shortness of breath that started the day before. Abdominal pain is described as sharp, 7/10, and is worse with movement. The abdominal pain has gradually gotten worse, which prompted her to visit the ED. Patient had a tummy-tuck on 6/23/2023 and symptoms began the day after and hasn’t had a bowel movement since. The patient is passing flatus. The patient denies diarrhea, fever, and chest pain.

PMHx: Obesity

PSHx: Dermatolipectomy on 6/23/2023

Medication: None

Allergies: NKDA

FHx: None

Social History: Socially drink 3-4x a month usually. Does not smoke cigarettes or partake any recreational drugs

ROS: Denies diarrhea, fever, chest pain, and chills.

O:

Vitals:

Vitals: T: 98.6°F (37.8° C) oral | P: 85 BPM, regular | RR: 18 breaths/min, unlabored | BP: 127/78 mm Hg | SpO2: 99% room air | Wt: 220 lb (99.8 kg) |

Physical Exam:

General: Obese female. Alert, awake, and oriented x 3. In no

acute distress.

HENT: Normocephalic and atraumatic, PERRLA and extraocular movements intact. Moist and pink oropharynx.

CV: RRR. S1 and S2 normal. No murmurs.

Pulmonology: No respiratory distress, breathing comfortably on room air, no accessory muscle use

Abdomen: Multiple sutures below the umbilical area that are clean, intact, and healing

with no signs of drainage or swelling.  Generalized abdominal tenderness. Bowel sounds are present.

Imagining:

Chest X-Ray:

Impression: Cardiac silhouette is normal in size, and position. There is no consolidation, effusion or pneumothorax. No active pulmonary disease.

CT Abdomen & Pelvis without contrast:

Impression: Partial small bowel obstruction possible due incarcerated umbilical hernia.

A:  50-year-old obese female with SBO s/p dermatolipectomy. The patient is minimally tender on physical exam and is passing flatus. Iatrogenic SBO. Conservative management of SBO.

P:

  • NPO diet
  • Analgesia for pain
  • Early ambulation
  • Lovenox for DVT prophylaxis
  • Continue with abdominal exams