What are the key components of admission notes and diagnostic approach for a patient presenting with intestinal obstruction?

Comprehensive Admission Notes and Diagnostic Approach for Intestinal Obstruction

The most effective approach to a patient with intestinal obstruction requires prompt diagnosis through specific clinical findings, appropriate imaging, and laboratory tests, followed by timely intervention based on obstruction severity and etiology.

Key Components of Admission Notes

History

• Previous surgeries: Particularly important as adhesions account for 55-75% of small bowel obstructions 1
• Onset and progression of symptoms: Document colicky abdominal pain, distention, nausea, vomiting, and absence of stool/flatus
• Previous episodes: History of radiological obstructive episodes 1
• Medication history: Special attention to opioids, anticholinergics, and other medications that affect motility 1
• Weight changes: Document usual weight in health and weight changes over last 2 weeks, 3 and 6 months 1

Physical Examination

• Vital signs: Tachycardia, hypotension, and fever may indicate strangulation or perforation 1, 2
• Abdominal examination:
  • Distention (most reliable physical finding with highest predictive value for intestinal obstruction) 2
  • Tenderness and location (localized vs. generalized)
  • Presence of peritoneal signs (rebound tenderness, guarding, rigidity) suggesting strangulation 1
  • Bowel sounds (high-pitched, tinkling sounds in early obstruction; absent in late stages)
• Hernia orifices: Examine all potential hernia sites (inguinal, femoral, umbilical, incisional) 1
• Digital rectal examination: To detect masses, blood, or impacted stool 1

Nutritional Assessment

• Calculate BMI and percentage weight loss 1
• Document other anthropometric measurements

Diagnostic Approach

Initial Laboratory Tests

• Complete blood count: WBC >10,000/mm³ may suggest inflammation or strangulation 1
• Comprehensive metabolic panel: Assess electrolytes (particularly potassium), renal function (BUN/creatinine) 1
• Lactate levels: Elevated in bowel ischemia 1
• CRP: Values >75 may indicate peritonitis 1

Imaging Studies

1. Plain Abdominal X-rays:

   • Look for multiple air-fluid levels, distended small bowel loops, and absence of gas in colon 1
   • Limited sensitivity (approximately 70%) 1
   • Useful as initial screening but insufficient for definitive diagnosis 1

2. CT Scan with IV Contrast (preferred imaging modality):

   • Diagnostic accuracy >90% 2
   • No oral contrast needed for suspected high-grade obstruction 2
   • Can identify:
     • Location and cause of obstruction
     • Presence of closed-loop obstruction
     • Signs of strangulation (pneumatosis intestinalis, portal venous gas)
     • Alternative diagnoses 1

3. Water-soluble Contrast Studies:

   • Useful for both diagnostic and therapeutic purposes
   • Can predict need for surgery if contrast fails to reach colon 1

Management Plan

Initial Resuscitation

1. IV fluid resuscitation: Correct dehydration and electrolyte imbalances 2
2. Nasogastric tube placement: For decompression and symptom relief 1, 2
3. NPO status: No oral intake until clinical improvement 2
4. Urinary catheter: To monitor urine output 1
5. Antibiotics: Broad-spectrum if signs of infection or suspected strangulation 2

Determine Need for Surgical Intervention

Urgent surgical exploration indicated for:

• Signs of peritonitis or perforation
• Evidence of bowel ischemia or strangulation
• Complete obstruction failing to improve with conservative management
• Hemodynamic instability 2

Conservative management appropriate for:

• Partial obstruction without signs of complications
• Stable patients with adhesive small bowel obstruction and no signs of strangulation 1

Documentation Format for Admission Notes

Admission Note Template

1. Patient Demographics: Age, gender, date and time of admission
2. Chief Complaint: In patient's own words
3. History of Present Illness: Detailed chronology of symptoms
4. Past Medical/Surgical History: Focus on abdominal surgeries
5. Medications and Allergies
6. Social History: Relevant to current condition
7. Review of Systems: Focused on GI and constitutional symptoms
8. Physical Examination: As detailed above
9. Laboratory and Imaging Results
10. Assessment: Including differential diagnosis
11. Plan: Detailed management strategy

Common Pitfalls to Avoid

1. Delayed diagnosis: Failure to diagnose or delayed diagnosis represents 70% of malpractice claims in adhesive small bowel obstruction 1
2. Misdiagnosis: Watery diarrhea in partial obstruction can be mistaken for gastroenteritis 1
3. Missing strangulation: Physical examination alone has only 48% sensitivity for detecting strangulation 1
4. Overreliance on plain radiographs: CT scan is more sensitive and specific 2
5. Delayed surgical consultation: Early surgical consultation is recommended for all patients with intestinal obstruction 2

By following this structured approach to admission notes and diagnosis, surgical residents can ensure comprehensive evaluation and appropriate management of patients with intestinal obstruction, ultimately improving patient outcomes and reducing morbidity and mortality.