I presented this H&P at my first site visit with Professor Lopez:
JC is a 64 y/o F with extensive PMHx including cocaine and alcohol abuse, asthma/COPD, Hepatitis C liver cirrhosis with portal hypertension s/p TIPS (2018), remote hx of ventral hernia repair x3 7 years ago with the last repair being mesh, presents to the ER with <12hr hx of sudden abdominal bulge on standing at the peri-umbilical area associated with 8/10, constant, non-radiating pain surrounding the swelling. She reports the bulge suddenly appeared at about 9 pm, last meal prior to that was 6 pm. Standing and coughing make the bulge more prominent, no alleviating factors pt denies taking anything for her pain. Patient’s last bowel movement was yesterday morning at 9 am, hasn’t passed flatus or gas since onset of symptoms. Patient denies fever, nausea or vomiting.
Past Medical History: Alcohol abuse, cocaine abuse, asthma, cirrhosis of liver, Hepatitis C.
Past Surgical History: Thoracentesis – 2021, TIPS procedure – 2018, Ventral Hernia Repair x3 – last one 2015. Allergies: No known food, drug or seasonal allergies. Family History: Mother – heart disease, Father – asthma, Sister – heart disease, Brother – HIV+. Medications: Diltiazem 30 mg – 1 tablet PO TID , Midodrine 10 mg – 1 tablet PO TID, Furosemide 40 mg – 1 tablet PO qd, Lactulose 10 g/15mL Soln – 30 mL (20 g total) PO TID, Fluticasone-salmeterol 500-50 mcg/dose – inhale 1 puff BID, Folic acid 1 mg – 1 tablet PO qd, Ipratropium-albuterol 0.5-2.5 mg/3mL – 3 mL by nebulization QID, Multivitamin – 1 tablet PO qd, Sennosides 8.6 mg – 8.6 mg PO BID, Spironolactone 25 mg – 1 tablet PO qd, Thiamine 100 mg – 1 tablet PO qd. Social History: patient is single, lives alone, no longer working. Admits to cocaine and alcohol use/abuse, denies tobacco or other illicit drug use. Has not been sexually active in 5 years, denies recent travel.
ROS: positive for recent weight loss, decreased flatulence, peri-umbilical abdominal pain, last bowel movement >36 hours ago.
Physical Exam: pt is A&O x3, interactive, not in acute distress or ill-appearing but looks visibly uncomfortable.
Vitals: BP: 205/63 (R arm, supine), RR: 20 breaths/min, unlabored, Pulse: 120 beats/min, regular rhythm, SpO2: 98% on room air, Height: 5’4”, Weight: 130 lb, BMI: 22.31 kg/m2
Cardiovascular: positive for tachycardia. Abdomen: has moderate distension. Is soft with a peri-umbilical mass (10 cm in diameter on either side of the midline). Abdominal tenderness and firmness noted around the para-median bulge and is hardly reducible. Transverse incisional scar on skin over the bugled area from previous ventral hernia repair(s). Bowel sounds are hyperactive/high-pitched, tympanic to percussion. No guarding or rebound noted, no hepatosplenomegaly, no CVA tenderness appreciated. All special tests negative.
Labs: WBC 6.97, Na 128, K 3.0, Cl 90, BUN 5, Cr 0.58, PT 31.4, INR 2.61, aPTT 38.8, albumin 2.3, total bilirubin 5.6, alk phos 160, ALT 26, AST 204. Lactate within range. Urine toxicology positive for cocaine.
Imaging: ECG sinus tachycardia. CT A/P There is an umbilical hernia defect measuring 4.8 cm in size. Moderate small bowel obstruction secondary to a R paraumbilical hernia with a defect measuring 1.6 cm in size. This finding is noted adjacent to the umbilical hernia. No intra-abdominal collections or masses are otherwise noted.
Assessment: JC is a 64 y/o F with an extensive PMHx of cocaine and alcohol abuse, asthma/COPD, Hepatitis C liver cirrhosis with portal hypertension s/p TIPS (2018), remote hx of ventral hernia repair x3 7 years ago with the last repair being mesh, presents with <12hr of sudden abdominal bulge at peri-umbilical area with associated pain.
On exam, pt is not ill-appearing but is in pain, abdomen is soft and distended with obvious, tender, hardly reducible-bulge in umbilical area.
CT A/P reviewed, suggestive of small bowel obstruction secondary to an incarcerated R peri-umbilical hernia with a defect measuring 1.6 cm in size. A patent portosystemic shunt is noted. Multiple cyst-like lesions are seen in the liver measuring 1 mm to the largest measures 2 cm in size.
Plan: Admit patient for emergency exploratory laparotomy, informed consent. Stat CXR, hepatic panel, PT/INR, PTT, T&S. IVF infusion, keep NPO.
Professor Lopez asked me questions regarding this case and my presentation, pushing me to think about all the contributing factors including the patient’s current state, her comorbidities and how those served as risk factors and contributed to her presentation. She also offered information which allowed me to have a fuller understanding of this case and the disease processes that were involved. She most definitely contributed to my learning and knowledge as a whole!
