Progress Report Overview

Student: FSN 430-5 F18

Activity: ​Shawn Callahan Scene 2

Start Time: 10/16/2018 16:57:04

End Time: 10/23/2018 14:47:24

Total Time: 09:06:14

Actions

Note at 10/16/2018 17:16:32 Note at 10/23/2018 14:47:21

​Shawn Callahan Scene 2
Documentation
Student: FSN 430-5 F18
Activity Start: 10/16/2018 16:57:04
Activity Completion: 10/23/2018 14:47:24
Activity Completion: 09:06:14

Patient Data

Patient: Shawn Callahan DOB: 10/18/1972

Age/Sex: 46 yo M MR#: MR-0635
Location: General Hospital Admit Date: 10/16/2018

Notes

Note at 10/16/2018 12:32:01

Preoperative H&P Details

Basic Information

Date: 10/16/2018 12:32:01

Author: Manuel Bachman, MD

Location: General Hospital

Title: Preoperative H&P

Note: Admitting complaint: Recent exacerbation from non-resolving colitis

resulting in dehydration and severe pain.

Past medical history: Shawn was diagnosed with Crohn�s disease at

age 19 following a year of non-specific symptoms including joint pain
and swelling of his hands and feet, stomach pains and fatigue.
Crohn�s was diagnosed through an upper G.I and follow through
which showed strictures and narrowing in the small intestine indicative
of the disease. Since diagnosis, he has had a number of flare-ups with
4 small bowel resections and a few minor procedures for various
complications related to Crohn's. He has been admitted today via his
gastroenterologist with joint pain and swelling, dehydration and severe
pain secondary to exacerbated and persistent colitis. He denies history
of recent international travel, consumption of undercooked or raw
foods, or recent antibiotics use for an unrelated illness.

Review of systems is positive for fatigue, persistent diarrhea with up to

12 incidences per day, nausea, anorexia, an urgent need to move
bowels, abdominal cramps and pain, and sensation of incomplete
evacuation. Crampy or steady right lower quadrant or periumbilical
pain and frequently develops 30-60 minutes following meals; the pain
precedes and is partially relieved by defecation. Stool often contains
bright red rectal bleeding and mucous. Also present and chronic are
arthralgias of the hands and feet. Denies constipation, dizziness, loss
of consciousness, chest pain, acute weakness, vomiting, or fever.

Surgeries: Four small bowel resections and a number of minor

procedures for various complications related to Crohn's over the last
26 years.

Injuries: Non-contributory

Family History: Father and Paternal grandmother were known to have

�nervous stomachs.� Both died of other causes in early middle age.
Grandmother died of brain cancer and father in a MVA. No other
autoimmune disorders known in family members. Patient does have
two young children who do not have symptoms of Crohn�s.

Current medications:
Metrol dose pack taper (methylprednisolone) - He has maxed out the
recommended duration of steroid treatment
Metronidozole 1 gm per day
Loperamide (2-4 mg) prn for diarrhea, up to 4 times daily

Allergies: Reglan & morphine

Exam: 99.8, 78, 18, 132/76; weight: 165, height: 5'8", BMI: 25.1
This is a pleasant, well-developed man who appears slightly younger
than stated age, who complains of abdominal cramping and hurting,
rates pain 7/10.
Head - normocephalic, non-traumatic, no masses /lesions
Eyes - visual fields intact, PERRLA, conjunctiva clear, sclera white,
anicteric
Ears - TM's non-injected (or TMs erythematous, bulging), good light
reflex
Nose - nares patent, no deformity, septal deviation or perforation
Throat - pharynx non-injected, palate rises symmetrically, gag present,
tonsils present
Mouth - buccal mucosa moist with stomatitis evident and multiple
canker sores present. Dentition intact, no caries visible, tongue
midline
Neck & axilla � Supple without lymphadenopathy, masses, or
thyromegaly. Carotid pulses 2+ bilaterally, no bruits, full ROM, trachea
midline, breasts symmetric, no retraction, lesions, masses or
tenderness
Back, thorax & lungs - chest expansion symmetric, CTA (clear to
auscultation), eupnea, no adventitious sounds (rales, crackles,
wheezes)
CV - RRR no systolic ejection murmur, rubs, gallops, s1-s2, no s3
Abdomen � soft, non-tender w/o masses. Mild diffuse tenderness.
Tympany to percussion in all 4 quads, BS present and hyperactive; no
hepatosplenomegaly, no bruits
Extremities - extremity size symmetric w/o swelling/atrophy, temp
warm and equal bilaterally. All pulses present, 2+ and equal bilat.
Skin - pink-tan in color, good turgor w/o lesions, redness, cyanosis, or
edema; no piercings, tattoos, or major scars. No wounds, rashes or
lesions. Nails without clubbing or deformities with good cap refill
Musculoskeletal - gait normal, able to tandem walk, no rhomberg's
sign; joints and muscles symmetric, no swelling, masses, deformity or
tenderness to palpation; no heat or swelling of joints; full ROM; muscle
strength 5/5- able to maintain flexion against resistance with
complaints of mild tenderness in hands and feet
Genitalia/rectum - no lesions, inflammation or discharge from penis,
rectum: no fissure, hemorrhoids, fistula or lesions in perianal area;
sphincter tone good; prostate not enlarged, no masses, nodules or
tenderness.
Nervous system - (LOC, DTR's, MMS) - CN II-XII grossly intact, alert
oriented, cooperative.

Diagnostics: Endoscopy, as shown here, which was done as an

outpatient yesterday shows severe inflammation along the ilius.

Lab results are normal except for presentation of mild dehydration

 and non-specific inflammation. Abdominal CT scan shows widely
distributed damage and inflammation consistent with advanced
Crohn's exacerbation and severe colitis. CBC shows mild anemia, and
an elevated WBC and PLT count, with low albumin.

Assessment: Persistent exacerbation of Crohn�s disease of a

stenosing or stricturing type with ileal involvement.

Plan: Admit for a temporary loop ileostomy for fecal diversion to

enable healing of the intestine most impacted by the Crohn's disease.
I have explained to the patient that in a loop ileostomy we will pull a
loop of small intestine out through an incision in the abdomen,
stitching the intestine to the abdomen and opening it up to form a
stoma on the right-hand side of his abdomen. The remaining diseased
ileum will be re-evaluated at regular intervals following the surgery to
determine whether the inflammation has abated and the stoma can be
resected or if the stoma needs to be made permanent. The patient has
been advised that the current alternative to this plan of treatment is a
permanent ileostomy done at this time. He understands the risks and
potential complications of the loop ileostomy and would like to
proceed with surgery as discussed. The indications for the loop
ileostomy procedure are advanced Crohn�s inflammation and
strictures of the ileus leaving the patient at high risk of bowel
obstruction or perforation, unresponsive to agressive steroid
treatment. This procedure is of an emergent nature due to the rapidly
deteriorating status of the patient and ileus. Patient is currently NPO.
Will need to be prepped for surgery.

Note at 10/23/2018 06:30:40

ADIME Note

Basic Information

Date:

10/23/2018 06:30:40

Author:
FSN 430-5 F18

Location:
General Hospital
Patient name:

Shawn Callahan

Date:

October 23, 2018

Assessment

Diagnosis:

Crohn's Disease

Age:

45 years old

Gender:

Male

Race:

White

Client History

Medical history:

Diagnosed with Crohn's at the age of 19

Pt has had a number of flare ups and has had 4 small bowel resections
Experiences joint pain and swelling
Stomach pains and fatigue
No hx of traveling, consumption of raw or undercooked foods, or antibiotic use
Recent exacerbation from non-resolving colitis resulting in dehydration and severe pain
Allergic to Reglan and Morphine

Medical diagnoses:
 Persistent exacerbation of Crohn's disease of a stenosing or stricturing type with ileal
involvement

Family history:

Father and Paternal grandmother were known to have nervous stomachs. Both died of
other causes in early middle age. Grandmother died of brain cancer and father in a MVA.
No other autoimmune disorders known in family members. Patient does have two young
children who do not have symptoms of Crohn's.

Current medications:

Is taking Metronidozole--may cause stomach upset, nausea, vomiting, loss of appetite,

diarrhea, constipation, or metallic taste in mouth, Metrol dose pack taper--may cause
nausea, vomiting, heartburn, appetite changes, higher blood sugar, and Loperamide--may
cause constipation

Nutrition-related medications:

Remicade--may cause stomach pain, nausea, difficulty breathing, low or high BP and
Sodium Chloride--may cause trouble breathing and swelling of hands and feet

Current supplements:

N/A

Anthropometric history

Height:

5'8"

Weight at admission:

165 lbs.

Current Weight:
 165 lbs.

BMI:

25.1 kg/m^2 (normal)

IBW:

154 lbs.

% IBW:

107%

Weight assessment:

Pt has a normal BMI

Biochemical history, medical tests, labs, and procedures:

Hemoglobin=12.4g/dL (low), Hematocrit=37% (low), RBC’s=6.2ml (high), segmented

neutrophils=63% (high), lymphocytes=23% (low), all other WNL
Recently had loop ileostomy

Nutrition Focused Physical Exam

Skin Assessment

Intact

Edema
None

Feeding Ability

Independent

Oral Motor

Intact

Muscle and fat store assessment:

 N/A

Food and Nutrition History

Current diet order:

Clear liquid diet postoperatively to provide at least 50% of his energy needs. REE: 2,092 kcal,
104g protein, 313g CHO, 46 g fat, and 2,092 ml fluid divided over 6 small meals/day. Based
off tolerance slowly progress to low fiber, lactose-free nutrition therapy.

Assessment of usual intake:

N/A

Assessment of current intake:

N/A

Supplements/herbals:

N/A

Food allergies and intolerances:

N/A

Intake and digestive problems:

Loop ileostomy decreases absorption of vitamin C, folate, B12, vitamin D, Vitamin K,

Magnesium, bile salts and acids. Pt has experienced persistent diarrhea with up to 12
incidences per day, nausea, anorexia, an urgent need to move bowels, abdominal cramps
and pain, and sensation of incomplete evacuation. Crampy or steady right lower quadrant
or periumbilical pain and frequently develops 30-60 minutes following meals; the pain
 precedes and is partially relieved by defecation. Stool often contains bright red rectal
bleeding and mucous.

Assessment of Nutritional Status/Nutrition Risk

No malnutrition noted

Malnutrition criteria met per current malnutrition guidelines:

N/A

Nutrition Recommendations

kcal/day based on:

Energy: 2,092 kcals/day (MSJ and an AF of 1.4 because of his recent surgery)

g protein/day based on:

Protein: 104g/day (higher protein needs during exacerbation of the disease)

mL fluid/day based on:

Fluid: 2,092 ml/day (1ml per kcal)

Nutrition assessment summary:

N/A
Diagnosis

PES Statement:

Altered GI function related to decreased functional length of intestinal tract, as

evidenced by loop ileostomy/ trauma

Nutrition Intervention

Nutrition prescription:

Overarching goal: Optimize nutritional intake, decrease risk of obstruction, maintain

normal fluid and electrolyte imbalance, reduce excessive fecal output, minimize gas
and flatulence with return to normal dietary intake as soon as possible
Clear liquid diet postoperatively to provide at least 50% of his energy needs. REE 2,092
kcal (27.9 kcal/kg), 104g protein (21%, 1.4g/kg), 313g CHO (60%), 46 g fat (19%), and
2,092 ml fluid divided over 6 small meals/day. Based off tolerance slowly progress to
low fiber, low-lactose nutrition therapy.

Food and nutrition delivery:

Clear liquid diet will include fruit juice, broths, gelatins, and popsicles
Glutamine supplement given
Multivitamin given
Based off tolerance for clear liquid diet PT will slowly transition to a low fiber, lactose-
free regular diet
Oral diet will consist of 6 small frequent meals/day
 Nutrition education:

Educational materials given about low fiber nutrition therapy

Education about getting adequate fluids, chewing food thoroughly, and eating meals
and snacks at the same time each day
Education given on what nutrients are absorbed in the ileum (vitamin C, folate, B12,
vitamin D, Vitamin K, Magnesium, bile salts and acids) and need to increase
consumption of these micronutrients with intravenous B12 supplementation
Educational materials given on list of foods to avoid in order to decrease gas and
diarrhea.

Monitoring and Evaluation

Food and nutrient intake:

PT will log his meals. Success if first day post operation meets 50% of energy needs on liquid
diet. REE 2,092 kcal, 104g protein, 313g CHO, 46 g fat, and 2,092 ml fluid divided over 6 small
meals. Success if electrolytes stay in normal range. Check understanding of low fiber nutrition
therapy, about getting adequate fluids, chewing food thoroughly, eating meals and snacks at the
same time each day, nutrients that are absorbed in the ileum (vitamin C, folate, B12, vitamin D,
Vitamin K, Magnesium, bile salts and acids) need to increase consumption of these
micronutrients with intravenous B12 supplementation, and foods to avoid in order to decrease
gas and diarrhea. Monitor energy intake, amount of food consumed, oral fluid intake, and
micronutrient supplementation. Monitor output. Success if output is within average range of
1,200 ml/day initially

Anthropometric measurements

Monitoring BMI. Success if no weight loss occurs

Biochemical data:

Monitor electrolytes, Hemoglobin, Hematocrit, RBC’s, segmented neutrophils, and lymphocytes.

Success if all return to normal levels
Signature/credential/date:

8120/ student/ October 23, 2018