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    Default Perferated Bowel: Emergency Surgery Case

    Figured I would share this case.

    This is my last call night at my independent practice (3 providers). Lead preceptor was having the anesthesia providers to her house for a farewell dinner (phenomenal group). After driving about 20 minutes and about 5 minutes away from her house, she gives me a call. I figured she was just asking where I was. Nope, she told me to turn around as we just got called for an emergency perforated bowel. Turned out to be real good case.

    Thursday 18:03: 91 year old female in the ER with abdominal pain. Free air identified in the abdomen.

    Turned out that she was in for a colonoscopy/EGD yesterday (Wednesday) looking for cause of anemia. There was a question at that time if bowel was perforated. She was sent home as she was not showing any symptoms and no definitive perforation.

    History:
    NIDDM
    HTN
    Elevated Cholesterol
    METS < 4
    0 alcohol / 0 tobacco
    Has felt weak for a couple of weeks

    Assessment:
    Weight: 60 kg
    Alert, but slightly lethargic. Responds appropriately to all questions.
    Looks pale and extremely dry mucous membranes. Poor skin turgor
    Heart RRR, S1-2 normal
    Lung sounds clear and equal.
    EKG: sinus tachycardia, otherwise normal
    Heart rate in 120’s. B/P’s 130/70. O2 sats in upper 90’s on room air.
    Airway: MP 2 / full ROM / Wide mouth opening / edentulous
    20 ga IV L wrist with LR.
    H/H 9.2/ 27.4 | Platelets: 224 | WBC: 14
    Na: 138 | K: 3.7 | BUN: 25 | Cr: 1.0 | Blood glucose:169

    NPO since Tuesday night at 20:00 (felt ill so she did not eat or drink anything since then)
    Bowel Prep also done on Tuesday night.

    ER Treatment prior to our arrival:
    IV 20 ga with LR at TKO.
    Metronidazole (flagyl) 500 mg IV x1
    Home meds:
    Amlodipine | a statin | Glucophage | MVI | HCTZ
    Proposed Surgery:
    Open colectomy with bowel repair / possible colostomy

    What would you do for this case:?
    What is the fluid deficit for this patient?
    Feel free to ask clarification questions?
    Last edited by Goose; 02-01-2013 at 02:36 PM.

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