You are doing an open jejunostomy feeding tube placement.

You go to assess the patient:

tb2.jpg

43 y.o. 5'8" man with a severe case of tuberculosis with extensive involvement of his lungs and abdomen. Admission weight a week prior was 38kg, he is now down to about 36kg.

He was in his village for a year being worked on by witch doctors before being brought in.

Vitals: 90/60, HR 105 SR, Temp 37.5 RR 29 SaO2 90% on RA.

MP1, poor dentition.

Lungs have rhonchi in all fields, he has a very frequent productive cough - thick purulent green/yellow sputum.

NG in place, kidney basin next to him filled with about 100ml of a mix of bile, ng feed, blood, and sputum. NG is clamped.

Abdomen is tight, you see venous distension. Rare active bowel sounds. He complains of 10/10 abd pain, pt is nauseous.

Nurse tells you that his residuals have been <100ml, although on Friday when the NG was placed about 400ml of thick mucousy fluid was aspirated.

Ultrasound of his abdomen shows narrow intestinal lumen surrounded extremely thick bowel wall, where the TB lesions have grown:

IMG_20140623_101839.jpg

No edema on the extremities, just severe muscle wasting. Ambulates (barely) with a lot of assistance. Essentially bedridden.

labs:

hgb: 9.7
Hct: 29.9
wbc 10.8
glucose 83
BUN/cr 29/0.9
Cl 88
K+ 2.9

PT 28
PTT 67
Platelets 262

Meds include:
Cefotaxime, metronidazole, rifampin, omprepazole, paracetamol, iron


What's your plan? You're an independent provider, so in addition to the perioperative plan there needs to be orders for after discharge from PACU.