CPC Case for JUNE 6, 2003
Discussant: Mark Feldman, MD
Case presented by Jennifer Stalkup, MD
| CC | Abdominal pain, nausea, and vomiting x 2 days |
| HPI | The patient is a 53 yo WM with a known history of diabetes type 2 who was in his usual state of health until one week prior to admission when he reports that he began to feel slightly nauseated. At that time, he had no further complaints. On the day prior to admission, he reports that he suddenly developed severe nausea, vomiting, and crampy lower abdominal pain with bloating. He reports that he vomited approximately 8 to 9 times that morning and several times during the afternoon. He did not notice any blood in his vomitus. He describes the abdominal pain as crampy, intermittent, and located in his hypogastric area without radiation. He further describes anorexia and bloating. He denies hematemesis, hematochezia, or melena. He claims to have regular bowel movements that are well-formed and of normal caliber. His last BM was 2 days ago. He denies fever, chills, weight loss, fatigue, CP, heart palpitations, SOB, DOE, cough, diarrhea, dysuria, or LE swelling. He has not traveled outside the U.S. or been around any sick contacts. He reports that he has had diabetes for 25 years, which is now insulin-dependent. He does not check his blood sugars regularly because he does not like needles. He has not seen a PCP in over 4 years and has never had a colonoscopy. |
| NKDA | |
| MEDICATIONS | Insulin 70/30 40 units SQ in AM and 30 units SQ in PM |
| PMH | Diabetes type II - diagnosed 25 years ago |
| PSH | Tonsillectomy |
SH |
Smoked a pipe for a few years, no cigarettes, no alcohol use, no IVDA, works as a CPA, lives alone, has a girlfriend, does not have a PCP as his died 3 years ago |
| FH | Mother: died age 83 of diverticulitis; Father: died age 85 of kidney failure; Sister: has diabetes |
| ROS | As per HPI |
| PHYSICAL EXAM: | Vitals: T 98.5 P 103 BP 157/82 R 24 Pain 2/10 GENERAL: Alert, NAD, ruddy complexion HEENT: NC AT, PERRL, anicteric sclera, OP slightly dry. NECK: no JVD, supple, no bruits. CVS: tachycardic, no m/r/g CHEST: CTAB ABDOMEN: soft, slightly distended, quiet BS, mildly tender in lower abdomen, stool guiaic negative EXTREMITIES: no CCE SKIN: diaphoretic, warm and moist, blotchy and red especially over upper back and chest |
LABS: |
D-stick: 431 CHEM-14: NA 132 K 5.6 CL 96 CO2 22 BUN 31 Cr 1.3 G 439 UA: glc > 1000, ketones > 80+ CBC: WBC 15.9 Hgb 15.4 Hct 45.8 Plt 229 MCV 87.3 Neut 94.2 Cardiac enzymes negative - 1st set LDH 494 Lactic acid 1.83 Amylase 36 |
| STUDIES: | EKG: rate 110, LAD, NSR, good R wave progression, no acute ST/T changes Abdominal series at admission: multiple dilated small and large bowel loops with questionable ileus or partial bowel obstruction; left mid-lung atelectasis CT scan with contrast of abdomen/pelvis: dilated large and small bowel in a somewhat segmental distribution with probable small filling defect in the superior mesenteric vein; no abdominal or pelvic abcesses Superior mesenteric
arteriogram, celiac arteriogram, splenic arteriogram, inferior mesenteric
arteriogram, supraselective superior division of IMA
arteriogram: negative |
| HOSPITAL COURSE (Short) | Over the next 5 days, the patient's diabetes was appropriately controlled, but his ileus/bowel obstruction persisted with minimal flatus, increasing abdominal distension, and obstipation despite NGT decompression. A diagnostic procedure was done. |