S:

35 y/o F s/p laparoscopic cholecystectomy due to cholelithiasis POD 5 with no complications and hypothyroidism, who was admitted to the hospital yesterday for worsening epigastric pain x 2 days. Patient was seen in the ED with burning pain with associated nausea and non-bloody diarrhea. ED ordered a CT abdomen/pelvis with IV contrast, which showed a massive pneumoperitoneum with no free fluid. Surgery was consulted and the patient was admitted under surgery. CT also showed distended bladder and patient had a Foley placed in the ED, as well as a urology consult. The patient reports no overnight events this morning. She reports current, mild epigastric pain but denies fever, chills, chest pain, SOB, nausea, vomiting, change in BM, surgical site erythema or other symptoms at this time. Patient was tolerating her diet after her surgery and reports to normal urination and ambulation at home.

PMHx: hypothyroidism x 4 months 

PSHx: laparoscopic cholecystectomy 2/17/21 no complications at WMC, colonoscopy 12/11/2020, esophagogastroduodenoscopy 10/22/2020

Medications: Acetaminophen 500mg 2 tablets PO q8h for 7 days, Bisacodyl 5mg PO daily as needed for constipation, Norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-25mcg PO daily, Omeprazole 20mg PO q12 hours for 14 days, Levothyroxine 25 mcg PO daily 

Allergies: Penicillin – pruritus and rash

Social History: Denies tobacco, alcohol or drug use

O:

VS: T 98.1, Pulse 79 bpm, RR 17 breaths/minute, BP 107/70, O2 98% on room air, Ht 5’0”, Wt 120lb, BMI 23.44 kg/m²

Physical Exam:

Gen: alert and oriented x3, in no acute distress

Skin: surgical incision sites on abdomen healing well with no surrounding erythema or signs of infection

HEENT: no gross abnormalities

CV: Regular rate and rhythm

Pulm: Clear to auscultation bilaterally

Abd: soft, nondistended, nontender

Labs

4.87 | 11.6 | 220                              140 | 104| 9      85

             35.0                                        4.1  |26   |0.54

Magnesium: 2.0

Phosphorus: 4.5

APTT: 42.5

PT: 12.7

INR: 1.08 

Alk Phos: 124

ALT: 188

AST: 33

Albumin: 4.8

Total bilirubin: 0.4

Direct bilirubin: < 0.2

CT abdomen/pelvis with IV contrast: large pneumoperitoneum with large extraluminal air seen anterior upper abdomen extending to the mid and lower abdomen as well as some of the free air is seen extending to the anterior lower pelvis anterior to urinary bladder. Lung bases visualized with no consolidation or effusion. Liver is normal in size without focal abnormality. No evidence of intrahepatic or extra hepatic ductal dilatation. SMA celiac axis renal arteries and portal vein are patent. There is moderate thickness of the gastric antrum. Status post cholecystectomy. Spleen, pancreas and adrenals are within normal limits. Physiologic changes in the pelvis. No abnormal dilatation of bowel. No evidence of obstruction. No abscesses or collections. Kidneys are normal in size and position. Kidneys display a prompt symmetric nephrogram effect. No evidence of hydronephrosis or hydroureter. Bladder is distended and smooth in contour. 

CXR: No focal infiltrates. Massive pneumoperitoneum with free air underneath the hemidiaphragms bilaterally concordant with findings on CT.  

A: 

35 y/o F s/p laparoscopic cholecystectomy due to cholelithiasis POD 5 with no complications, who was admitted to the hospital yesterday for worsening epigastric pain x 2 days. Patient had no overnight events. 

P:

Discontinue IV fluids

Have patient ambulate 

Give patient solid food 

Continue with laxatives 

Consult urology in regard to foley and if the patient should follow up in clinic

Trial of voiding later this morning

Possible discharge later today