CONSULTATION

PRESENT ILLNESS: She is admitted to the hospital because of vomiting and epigastric discomfort for
1 or 2 days prior to admission. At the time of admission, x-rays of the abdomen showed small bowel
air-fluid levels and 1 dilated loop of small bowel. A Gastrografin study was subsequently done,
which showed no obstruction, transit through the small bowel in 45 minutes, with contrast material
reaching the colon 45-minutes. No dilated loops were observed at the time of Gastrografin studies
were done. Today she is much better, has no pain or obstruction or distention in the abdomen. She
has had previous abdominal surgeries including cholecystectomy and uterine suspension. Other
details of the history will be documented by the attending physician.

EXAMINATION: A brief examination is done, shows that she has a pacemaker, and the heart is
regular at about 70 per minute. She does have a high-pitched systolic murmur at the apex of the
heart suggestive of mitral insufficiency. Breath sounds are good, lungs are clear. The abdomen is
slightly rounded. The abdomen is soft, no enlarged organs or masses are palpated, and there is no
tenderness. Careful listening to the abdomen fails to disclose any bruit. A brief neurological
examination shows that the pupils are equal and react light, and extraocular muscles are normal.

Grip strength is normal and equal. Finger-to-nose test and heel-to-shin test are normal.

Knee jerks are normal.

The question at this point is to try to determine a cause for her presenting symptoms. I should note
that she has had similar symptoms on several occasions in the past, and also has a history of having
had a stroke before as well as other medical conditions for which she is being treated.

DIFFERENTIAL DIAGNOSES: Differential of diagnoses must include

1. Ileus due to compression fracture of spine. She had a compression fracture involving T8 and T12.
At the present time she is not complaining of any back pain. However, compression fracture is a
good cause of ileus.

2. Ileus due to obstructive colon lesion. This is possible. It would have to be an intermittent
obstruction in her case. If there were a type of partial obstruction of the colon so that there was
intermittent backup into the small intestine, there is a possibility that such a picture could occur. A
barium enema would be helpful.

3. Ileus due to ischemia. She is in the right age group for mesenteric ischemia. I did question her
closely as to the possibility of pain after meals and particularly pain after large meals. She denies
having any pain. If this is a consideration, mesenteric angiography would be helpful, but abdominal
angina is not a common condition.

4. Ileus due to a stroke, TIA (transient ischemic attack), or other CNS (central nervous system) event.
I could not find a neurological deficit on my examination today. However, the fact that she has had a
stroke in the past makes this a possibility. A CT (computed tomography) head scan might be helpful.

5. Pseudo-obstruction due to diabetes, thyroid, or parathyroid lesion. She quite obviously does not
have familial Pseudo-obstruction, as she has not had these symptoms from the childhood. However,
she does have maturity-onset diabetes. The transit time through the small bowel was not slowed,
which lessons the likelihood that this is the explanation for these symptoms. However, it is worth a
consideration, and I believe that getting a thyroid panel would be helpful and to recheck the serum
ionized calcium. Her present calcium level at 8.9 is normal, but her albumin is quite low at 2.4,
which means that her ionized calcium might be high.

6. Pseudo-obstruction due to drugs. She is taking very few medications. Lomotil is on order for her,
but she and the nursing home personnel deny that she had any diarrhea or had any need for Lomtil
during the days prior to this event.

7. Pseudo-obstruction due to collagen disease, amyloidosis, or other such chronic disease. Other
signs of these diseases are not present. These are unlikely.

COMMENT: I am suggesting that this patient have a barium enema as soon as it is feasible for her to
do so. I am also getting an order for a thyroid panel and serum ionized calcium. Other tests as
suggested above will depend more upon how the clinical picture develops in the future.