1. MORNING REPORT
08/02/18

2. CC
82 y.o. male w/ nausea and abdominal pain x 4 days

3. HPI
82 y.o. male c/o constant, dull abdominal pain x4 days which he describes as a “pressure”-like sensation located diffusely. Reports decreased appetite due to nausea. Denies vomiting. Has had approx. 7 watery diarrhea per day. Discharged from hospital 5 days ago following R total hip replacement, had post-op constipation and was given mag citrate and enema. Since then, has noticed loose stools. Also concerned that he’s been unable to pass gas over the past several days. Complains of progressing abdominal distension.

4. ROS General: No subjective fevers, chills, night sweats, or headaches
CV: No chest pain or palpitations
Respiratory: No SOB, cough, sputum production, or wheeze
GI: +Nausea, no vomiting, +diarrhea, no constipation, +diffuse dull abd pain
GU: No dysuria
Ext: No swelling
Neuro: No weakness, lightheadedness, dizziness, syncope or near syncope

5. Thoracic aortic aneurysm Gout BPH Past surgical history:
Medications:
Allopurinol 200mg PO daily
Amlodipine 5mg PO daily
Metoprolol tartrate 25mg PO BID
Omeprazole 20mg PO BID
Tamsulosin 0.4mg PO daily
ASA 81mg PO daily
Allergies:
NKDA
Family history:
Non-contributory
Social history:
Tobacco- quit in 1972, smoked 1.5 PPD x 20 yrs
Alcohol- quit in 2009, drank 2-4 beers/day for 6-7 yrs
Drugs- denies use
Past medical history:
DJD
HTN
HLD
GERD
Thoracic aortic aneurysm
Gout
BPH
Past surgical history:
B/l total hip replacements
Bilateral inguinal hernia repairs

6. Vitals: T 98 F, HR 85, RR 20, BP 122/77, O2 sat 98% on RA
Physical exam:
General: Alert and oriented, appears stated age, lying in bed in NAD
HEENT: NC/AT, EOMI, MMM
Cardiovascular: RRR, S1/S2 normal, no M/G/R
Lungs/Respiratory: No respiratory distress, speaking full sentences, CTAB, no wheezes/rales/rhonchi
Abd/GI: Firm, distended abd, high-pitched bowel sounds, mild tenderness in all quadrants to deep palpation, no guarding, no rebound tenderness
GU: Reducible L inguinal hernia
Extremities: No peripheral edema, clubbing, or cyanosis, radial and DP pulses +2/4 bilaterally
Skin: Warm, dry, no rashes
Neuro: Awake, alert, oriented x4 (person, place, time, situation), speech spontaneous, moves all extremities against gravity

7. Differential diagnoses:

8. Labs/ Imaging WBC 13.2, Hgb 9.0, Hct 26.7, Plt 255 Na 129, K 3.4,
CL 95,
CO2 25,
BUN 39,
Cr 1.70
Lipase 27
CXR- no acute CP process, but with gaseous distension of visualized colon
Tprotein 5.6
Tbili 0.8
D.bili 0.3
AST 49
ALT 19
Alk phos 54
Albumin 3.5
Magnesium 1.87

9. KUB

11. Presentation of LBO Symptoms: Exam:
Abrupt onset of abd distension & crampy abd pain
Obstipation
± Nausea/ vomiting
With partial obstruction, overflow diarrhea may be present
Exam:
Abd distended, may be tender
Tympany on percussion
Hyper-/ hypoactive bowel sounds
Incarcerated hernias – frequently missed cause of bowel obstruction
L-sided inguinal hernia – colonic obstruction can be caused by sigmoid colon incarcerated in hernia

12. Diagnosis of mechanical LBO
Plain radiography (84% SN, 72% SP)
2 views (supine & upright) to evaluate for free air
Dilatation of colon to point of obstruction, absence of gas in rectum
Cecum diameter >12 cm = danger of cecal rupture
CT (96% SN, 93% SP)
Better distinguish betw. true colonic obstruction & pseudo-obstruction
Transition point w/ proximal dilation & distal collapse
Intraluminal colon or rectal mass, or volvulus
Gastrografin enema (96% SN, 98% SP)
Water-soluble contrast
Colum of contrast ending in “bird’s beak” – suggests colonic volvulus

13. Treatment
Initial volume resuscitation, electrolyte repletion, timely surgical consult
Bowel rest
NG tube for colonic distension & vomiting
Removing source of obstruction
Sigmoid volvulus – flexible sigmoidoscopy or colonoscopy w/ volvulus reduction
Mechanical obstruction – partial colectomy
Self-expanding metallic colorectal stents for distal colorectal tumors

14. Thinking Styles Pitfalls
Egocentric thinking
Thinker believes his understanding of things is the absolute truth
Not listen to argument or other viewpoints
Individuals tend to be unaware of this characteristic within them
Can lead to close-mindedness, which impedes critical and logical thinking
Ex. A surgeon performed splenectomy in a patient with lymphoma. Patient developed post-op fever. The surgeon insisted that the cause of the fever is lymphoma and not subphrenic abscess.

15. Cognitive Dispositions to Respond
What is the appropriate action?
Run, System 1 Thinking
Fight, Dual System Thinking
Hide, Ostrich Effect Bias
Investigate, System 2 Thinking
Call for help, Collaborative Thinking

16. References
Large Bowel Obstruction. Medscape. medscape.com/article/ overviewpa= XD3jX%2BU A1VHbeE%2B01bQ4Z0T17lvdA4zsnaUcn4Jakr8aMyf5PXog3Vc76FHA7wxKcFrqow%2Bf2%2F37XuRaZT6JAA%3D%3D
Malignant Large Bowel Obstruction. In Dynamed Plus.
Overview of mechanical colorectal obstruction. UpToDate.