FCM Sample Write-Up #5
Term 2, Spring Quarter
Sample A

ID/CC: Ms. S is a 47 year old woman with a history of stage three rectal cancer who presents one month status post lower anterior resection with ileostomy placement who presents with 6 days of low grade fever, lethargy and progressive diffuse lower abdominal pain.

HPI: Ms. S was a previously healthy woman who, 7 months prior to admission, noted that her stool was streaked with blood. This continued for a few weeks but presented with no other symptoms and Ms. S attributed it to hemorrhoids. Two weeks after the onset of blood-streaked stool she had a bowel movement of a large amount bright red blood. She then underwent a colonoscopy and was diagnosed with stage three rectal cancer. Over the next several months she received chemotherapy to treat her cancer. One month ago, she underwent lower anterior resection with placement of a temporary ileostomy. After surgery she had numbness that progressed to pain throughout her saddle region that persists today. Otherwise she had a relatively normal recovery.

She was due to restart her chemo this week but 6 days prior to admission, she noticed that she had a slight fever (100.8 F), fatigue, and abdominal “aching”. She went to her PCP who performed a series of lab tests which revealed elevated liver enzymes.

Ms. S reports that nothing alleviates or aggravates her abdominal pain. Her stools have been looser than normal, but she denies constipation, nausea, vomiting, or blood in the stool. She reports a mild back ache, but denies dysuria, a change in urinary frequency, cough, or dyspnea.

Hospital course: Following her PCP’s advice, Ms. S came to the ED. Since being in the hospital, she has been placed on IV antibiotics but she notes this hasn’t improved her fever. She also complains of new onset nausea that occurs a few hours after she eats. She notes that resting helps improve the nausea. She also has consistent, diffuse and non-radiating aching bilaterally in the suprapubic area. Ms. S has also notes a new onset of bilateral pain in the CVA and decrease in urine output, but without sharp and colicky pain. Ms. S has been told that her liver enzymes have returned to normal since being in the hospital while her creatinine levels have risen. A CT reportedly revealed numerous small fluid sacs around the perineum and suprapubic areas suggestive of abscesses but was not conclusive.

Past Medical History
Rectal cancer, stage 3, s/p chemotherapy and resection
Post-operative neuropathy
Endometriosis
Allergic rhinitis
Genital herpes

Past Surgical History
Low anterior resection with ileostomy placement—1 month ago
Metacarpal surgery – “a few years ago”
Surgery for Endometriosis -1999 (unknown procedure)

Family History
Father – Cerebral vascular accident, age 67
Grandmother – Stomach cancer at an advanced age
Daughter – Developmental delay

Medications (doses unknown)
NSAIDs for incisional pain
Gabapentin for neuropathy
Fluticasone nasal spray; 2 sprays per nostril QD
Valacyclovir PRN for genital herpes, dosage unknown

Allergies
Contrast dye—causes anaphylaxis
Sulfa antibiotics—causes rash

Health Related Behaviors
EtOH/Tobacco/Drugs: Ms. S drinks one or two drinks a couple times a month and denies smoking and any other drug use.
Sexual History: Not presently sexually active due to her surgery
Diet/Exercise: Healthy diet with balanced home-cooked meals and minimal sugary drinks Relatively active prior to starting cancer treatment

Social History

Ms. S is a school nurse and is married to her husband of 19 years with whom she has a supportive relationship. Her gender identity is female. She is also the mother of a 13 year old   boy and 15 year old daughter with developmental delay. She notes that she has some increased stress from caring for her daughter. They live in Spokane and she reports having a relatively active life, including hiking, camping, and gardening. Her hobbies also include going out to dinner, the movies, and reading. Her family occasionally goes to church.

Review of Symptoms
Constitutional – See HPI
HEENT:  No visual changes, discharge, pain. No ear pain, change in auditory acuity, sore throat, or nasal discharge.
Pulmonary – See HPI
Cardio – Denies chest pain, orthopnea, PND, racing heart.
GI – see HPI
GU/GYN – No vaginal discharge or bleeding.
Endocrine – No polydipsia or weight changes
MS – Mild bilateral knee pain, but otherwise no joint or muscular pain.
Heme – Notes easy bruising, but no bleeding.
Immune – Chronic nasal allergies, and ‘prone to catching colds’
Neuro – Numbness/tingling post surgery
Skin – No skin rashes or new skin lesions
Psych – Periodic low mood since cancer dx.

Physical Exam

Ms. S is alert and engaged, laying in a hospital bed in no apparent distress but who moves slowly and deliberately.

Vitals-
Pulse – 84
RR – 16
BP – 130/85

Skin – Warm and without lesions. Nails without clubbing or cyanosis

HEENT

• Head – Normocephalic without trauma or lesions. No parotid or submandibular gland swelling or tenderness.
• Eyes – No scleral icterus or conjunctival erythema. Bilateral pupil response to light. EOM’s intact. Red reflex present bilaterally.
• Ears – No tenderness or diminished hearing. Tympanic membranes pearly gray with intact light reflex.
• Nose – External nose without lesions or asymmetry.
• Mouth/Throat – Mucosa pink and without lesions. Uvula midline. No exudates or erythema. No TMJ tenderness.

Neck – No palpable cervical or supraclavicular lymph nodes. No thyromegaly or thyroid nodules.

Chest/Lungs – Right central line noted. Breathing symmetrical without use of accessory muscles. No CVA tenderness. Lung fields resonant to percussion. Lungs clear to auscultation bilaterally, without wheezes or rales.

Cardiovascular—No precordial heaves. PMI not palpable. Regular rate and rhythm without murmur, rubs, or gallops. JVP 7 cm. Carotid, radial, and dorsalis pedis pulses 2+ bilaterally. No carotid bruits.

Abdomen – Flat and tender around the suprapubic incision sites and in the RLQ and LLQ. Normal active bowel sounds. Liver 9 cm on percussion. Spleen not palpable. No masses. Ileostomy present in the RLQ with liquid brown stool.

Musculoskeletal – Full active ROM in arms, limited ROM in legs due to recent surgery and post-surgical pain. No lower extremity edema

Neurologic

• Mental status – Alert, oriented x3. Speech fluent, articulate, and appropriate
• Cranial Nerves:
  • CN II, III—PERRLA, visual acuity 20/30 OS, 20/20 OD, 20/20 OU
  • CN III,IV,VI—EOM’s intact without nystagmus
  • CN V—Facial sensation intact bilaterally; muscles of mastication symmetric.
  • CN VII—Muscles of facial expression intact and symmetrical
  • CN VIII—Hearing intact to finger rub bilaterally
  • CN IX, X—Palatal rise symmetrical. Gag reflex intact.
  • CN XI—SCM and trapezius strength intact and symmetrical
  • CN XII—Tongue is midline and symmetrical without fasciculations.
  • Sensation: Intact to light touch in the upper and lower extremities. Romberg test negative.
• Motor: Upper extremities: shoulder abduction, elbow flexion, elbow extension, wrist flexion, wrist extension, finger abduction, grip strength 5/5 bilaterally. Lower extremities: Hip abduction, adduction, and flexion limited due to pain. Knee flexion, knee extension, foot dorsiflexion, foot plantar flexion 5/5 bilaterally. No pronator drift.
• Reflexes: Biceps, triceps, patellar reflexes 2+ bilaterally; Brachioradialis and ankle reflexes 1+ bilaterally.
• Cerebellum – Finger-nose-finger test smooth bilaterally. Heel-shin test smooth bilaterally. Rapid hand movements intact bilaterally.

Summary – Ms. S is a 47 year old woman with a recent diagnosis of stage 3 rectal cancer who presents one month post-surgical resection with low grade fever and fatigue, diffuse suprapubic aching and a physical exam remarkable for LLQ and RLQ tenderness and a CT suggestive of numerous small abscesses throughout the surgical site.

Diagnosis	History of present illness	Predisposing conditions & risk factors	Physical exam
Postoperative intraabdominal abscess	Abdominal pain Fever Fatigue	Recent surgery	Abdominal tenderness May have peritoneal signs
Diverticulitis	Abdominal pain, typically in LLQ Diarrhea or constipation Fever	Age > 60	LLQ tenderness May have peritoneal signs
Recurrent rectal cancer	Abdominal pain Weight loss	History of rectal cancer	Abdominal tenderness Other signs of metastases

Assessment –

The most likely cause of Ms. S’s fever and abdominal aching is post-surgical infection. Less likely causes are diverticulitis, peptic ulcer disease, mesenteric ischemia, and a recurrence of her neoplasm.

A diagnosis of infection is supported by Ms. S’s low grade fever and her post-surgical status. The diffuse bilateral aching in the suprapubic region correlates with the location of the fluid collections seen on CT. That her fever has not resolved with the IV antibiotic is less typical but could be due to the infection being walled off or caused by an organism that is not sensitive to the antibiotic. Her new onset of nausea and AKI can be explained as being secondary to her vancomycin, complicated by dehydration. Common causes of post-surgical infection include skin flora—specifically staph and strep. As she is status- post bowel surgery, enteric bacterial and anaerobes must be considered.

Ms. S’s fever and gradual onset and location of the pain is also suggestive of diverticulitis. However this is less likely due to her age and lack of rectal bleeding and loss of appetite and because she has pain bilaterally. One would also expect to see evidence of diverticulitis on the CT scan, if this were the cause of her pain and fevers.

Given her recent surgery, diffuse pain, and symptoms that increase a few hours after eating, Ms. S could also be suffering from mesenteric ischemia. However, this is less likely as she does not have vomiting, diarrhea, or hematochezia. Furthermore, patients with mesenteric ischemia frequently have a history of vascular disease. This patient has no such history.

Finally, one must consider that her pain is due to a recurrence of her neoplasm. However, this is less likely due to her fever suggesting an infectious process and because her resection was only one month ago.

Plan:

• Consult general surgery for evaluation of fluid collections visualized on CT
• Consider aspiration/drainage of fluid collections (pending Gen Surg consult) for diagnosis (i.e. identification of specific organisms and susceptibilities) and definitive treatment
• Consider additional bolus of isotonic fluid if patient becomes hemodynamically stable. For now, she is normotensive with a normal HR, so no need for IV fluids at this time
• Consider acetaminophen for pain, fever, would avoid NSAIDs given that dyspepsia is a common S/E and opioids given concerns for opioid-induced ileus.
• Patient will be ready for discharge once she remains persistently (>24 hours) afebrile and hemodynamically stable, as well as able to manage her pain with po pain medication and tolerate po intake without emesis.