DATE: JANUAR 30, 2024 . SECTION: 3F .

Group Members: Abigail T. Pahang (leader); Angel Marie Cris G. Ornos (scribe); Cayla D. Matias ; Jasmine Jane S.
Nadiahan; Rhea Faye C. Nitollama; Chijoke Okafor ; Parisutham Pasupathi .
CHIEF COMPLAINT: Abdominal pain and vomiting
HISTORY AND PHYSICAL EXAMINATION
History and PE: (pertinent information) Additional Information you would like to ask? Why?
Positives: - Which came first, vomiting or abdominal pain?
- Colicky abdominal pain o Pain before vomiting is due to mechanical small bowel
- Abdominal distention, and reduced bowel function obstruction
- Vomited four times o Vomiting before pain is secondary t underlying
- Surgical history: laparotomy for a perforated appendix 5 medical conditions
years ago - Onset of abdominal pain and vomiting
- Dry, coated tongue with loss of skin turgor - What are the factors that precipitate the pain and trigger
- Orthostatic hypotension: tachycardia (115 bpm) on lying vomiting
position, while 135 bpm and systolic bp drops to 95 mmHg o Food intake
on sitting position o Physical activity
- Obesity Class I: BMI 30kg/m2 - What are the factors that relieve the pain and vomiting
o Are there any medications used?
Negatives: o Did the patient seek to consult with another
- Apyrexia physician?
- Absence of flatus - Severity of pain and character of vomiting (color and
- No signs of abdominal hernia volume)
- Timing of pain and vomiting
- Family history of bowel diseases
- Personal History:
o Smoking
o Patient diet

DIFFERENTIAL DIAGNOSES
Initial Clinical Diagnosis: Small Bowel Obstruction secondary to Differential Diagnoses followed by basis:
post-operative adhesions - Small Bowel Obstruction
Basis: - Ileus
- Surgical laparotomy for perforated appendix 5 years ago o Basis: pain, distention, vomiting, electrolyte
- Colicky abdominal pain imbalance, dry coated tongue, reduced bowel
- Vomiting movement
- Absence of flatus o Ruled out: High-pitched bowel sounds
- Frequent and high-pitch bowel sounds - Volvulus
o Basis: distended abdomen, pain, dry coated tongue,
reduced bowel movement
o Ruled out: High-pitched bowel sounds, absence of
coffee-bean sign in the radiograph, and vomiting

DIAGNOSTIC WORK-UP
Pertinent Diagnostic Work-up available (interpret) Additional Diagnostic Work-up to be requested and why?
- Serum Electrolytes - Arterial Blood Gas (ABG)
o Hypernatremia, hyperchloremia, hypokalemia o Dehydrated patients are at risk for metabolic acidosis
 Extracellular fluid shift - Complete Blood Count (CBC)
- Abdominal X-ray o Hematocrit must be monitored to check the extent of
o Positive: centrally dilated loops, air-fluid levels, coiled hydration
spring sign - Whole Abdominal CT Scan
o The bowel wall between loops is thickened and o Differentiate mechanical ileus from small bowel
edematous obstruction
- Electrocardiogram (ECG)
o Cardiac status dues to electrolyte imbalance

FINAL DIAGNOSIS
Final Diagnosis: Basis for your diagnosis
“Moderate dehydration due to small bowel obstruction - Moderate dehydration:
secondary to post-operative adhesions” o Vomiting
o Dry, coated tongue
o Loss of skin turgor
o Thirsty
o Tachycardia
- Small bowel obstruction:
o Colicky abdominal pain
o Vomiting
o Abdominal distention and reduced bowel function
- Post-operative adhesions:
o Surgical history of laparotomy because of ruptured
appendix 5 years ago

MANAGEMENT
Main Management of the Disease: Supportive Management:
- Initial Management: - Laboratory test:
o Nothing per orem (NPO) o CBC
o Aggressive fluid resuscitation: isotonic saline or o Serum Electrolytes
lactated ringer solution - Abdominal radiographs
o Nasogastric tube (NGT) decompression- for suctioning - Hemodynamic monitoring
of GI contents and to prevent aspiration
o Analgesics, antiemetics, and antibiotic prophylaxis
o Urinary catheter for initial management of fluid
balance
- Surgical management
o According to the etiology of the obstruction
o Adhesiolysis
 SURGERY PRECEPTORSHIP 2022-2023
ATTENDANCE AND GRADING SHEET

TOPIC: FLUIDS AND ELECTROLYTES DATE: January 30, 2024

NAME SECTION GRADE COMMENTS

LEADER: ABIGAIL T. PAHANG F

SCRIBE: ANGEL MARIE CRIS G. ORNOS F

MEMBERS: CAYLA D. MATIAS F

JASMINE JANE S. NADIAHAN F

RHEA FAYE NITOLLAMA F

CHIJOKE OKAFOR

PARISUTHAM PASUPATHI

PRECEPTOR/SURGEON: DRA. ANA PATRICIA VILLANUEVA- DE GRANO

QUESTIONS FOR ANSWER:
1. Which of the above tests will help in your management
 High hemoglobin levels reflect dehydration. This would be correlated with elevated hematocrit
o High hemoglobin and hematocrit reflects hemoconcentration
 Serum electrolytes levels also shows dehydration
o Elevated sodium ((149mmol/L), chloride (112mmol/L)
o Decreased level of potassium (3.4mmol/L)

2. Will this radiograph help you in the management of the patient

 YES, distended small bowel loops in the center of the abdomen with prominent “Valvulae
conniventes”
 Helps the clinician localize the origin of chief complaint.
LARGE BOWEL SMALL BOWEL
Peripheral Central
Haustral marking Valvulae conniventes

 Narrow down the possible diagnosis and for us to provide effective treatment regimen.

3. Most likely, what is the most immediate problem of the patient

- Dehydration due to GI losses
a. What are the fluid and electrolyte losses of this patient?
Parameters Actual value of Reference Range Interpretation
the patient
Potassium 3.4 mmol/L 3.8- 5.2 mmol/L Hypokalemia
Sodium 149 mmol/L 135-145 mmol/L Hypernatremia
Chloride 112 mmol/L 99-110 mmol/L Hyperchloremia

b. How will you prepare this patient pre-operatively (in terms of fluids and electrolytes)?
o Address the electrolyte imbalance, and dehydration by administering NSS or plain lactated
ringer solution
o Fluid resuscitation shall be administered following the Holliday-Segar formula
 Patient weight: 90kg
 For >20kg patient:
 Hourly: 60mL + 1mL/kg for every kg >20kg
 Daily: 1500mL + 20mL/kg/day for every kg >20kg
 Hourly: 60mL + (1 x 70kg) = 130mL/ hr
 Daily: 1500mL + (20 x 70kg) =2900/ daily

c. How will you monitor fluid and electrolyte status

o Request for the following laboratory parameters to monitor how the patient
responds to the therapy
 Serum electrolytes- monitor for relative changes in concentrations
caused by water loss.
 Urine output- also reflects hydration status
  CBC- monitor hemoconcentration
 ABG- monitor metabolic acidosis
o Since our patient is tachycardic, monitor the vital signs of the patient
 Blood pressure- dehydration leads to high BP by constricting the blood
vessels. Hypotension is also a reflection of shock
 Heart rate- dehydration causes the amount of blood circulating in the
body to decrease, which causes the heart to compensate this by beating
faster, thus increasing the heart rate
 Oxygen saturation
o Monitor central venous pressure (reference range: 2-8 mmHg)
 Low: hypovolemia
 High: overhydration