CHIEF COMPLAINT: failure of a creation of an artificial opening into the colon
HISTORY OF PRESENT ILLNESS: This patient had a creation of an artificial opening into the colon called a stoma, placed 9 days ago after resection of the large intestine (colon) due to a tumor that could become progressively worse if it wasn’t treated. Earlier today, he felt as he was going to vomit and stated that his artificial opening into the colon stopped filling. He also had a sensation of “indigestion.” He denies vomiting but has been feeling as if he is going to vomit. He denies frequent discharge of liquid stool. He denies passage of bloody stool, vomiting of blood, or black tarry stool that contains digested blood. He denies frank stomach pain or frequent changes in body temperatures.
PAST MEDICAL HISTORY: As above. Also, blood pressure that is above normal, usually greater than 140/90.
ALLERGIES: Introduction of fluid in the rectum to promote evacuation of feces or as a means of administering nutrients, medicine or opaque material for radio logic examination. MEDICATIONS: Accupril and vitamins
REVIEW OF SYSTEMS: SYSTEMIC: The patient denies body temperature over 100 degrees F or feeling cold with shivering.
HEAD EARS EYES THROAT: The patient denies blurred vision, headache, or change in hearing. NECK: The patient denies difficulty swallowing, difficulty speaking, or neck pain. RESPIRATORY: The patient denies shortness of breath, cough, or blood stained matter ejected from the lungs, bronchi and trachea through the mouth. CARDIAC: The patient denies history of any disturbance or abnormality in hearts normal rhythmic pattern, swelling of the extremities, unpleasant sensation of irregular and/or forceful beating of the heart, or chest pain. GASTROINTESTINAL:
See above. MUSCULOSKELETAL: The patient denies inflammation of any joints, pain in the joints, or joint swelling. NEUROLOGIC: The patient denies difficulty with balance, numbness, or the loss of ability to move part or most of the body.
GENITOURINARY: The patient denies painful or difficulty urination, pain, or the presence of blood in his urine.
VITAL SIGNS: The pressure of blood within the arteries is 183/108, the rhythmical throbbing of the blood within the arties is 76, breathing is 16, and temperature of the body is 98.7 degrees F.
HEAD EARS EYES THROAT: Nerves in the skull are grossly intact. There is no yellowish pigment of the skin.
NECK: No stretching beyond normal dimension for the large pulmonary vein on the side of the neck.
CHEST: Clear to listening for sounds within the body through a stethoscope on both sides. CARDIAC: Regular rate and rhythm. No short-duration humming sound of cardiac or vascular origin.
ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline incision into the abdominal cavity, scar, with staples still in place. There is no evidence of wound infection. Examination of the artificial opening into the colon port reveals no obvious accumulation of hardened feces in the rectum or lower colon that he cannot move or site of blockage. There is no evidence of infection. The mucous appears normal. There is a small amount of nonbloody stool in the bag that is worn over the stoma to catch fecal discharge. There are no masses or or abnormal sounds noted.
EXTREMETIES: There is no blueish color to the skin from lack of oxygen, ends of the fingers and toes are enlarged and the nails are shiny with an abnormal curve, puffy swelling of tissues from the accumulation of fluid. The throbbing of the arteries as the blood passes through is 2+ and equal on both sides.
NEUROLOGIC: The patient is alert and awake with no sudden attack of disease or a decreased ability to perceive various sensations noted.
MEDICAL DECISION MAKING: Failure of the stoma to function may repre- sent a process of being impacted especially in the…