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

Admission Notes and Diagnostic Approach for Intestinal Obstruction

The diagnosis of intestinal obstruction requires a structured approach including detailed history, physical examination, laboratory tests, and appropriate imaging, with CT scan being the most accurate diagnostic tool.

Key Components of Admission Notes

Patient Demographics

• Name, age, gender, hospital number
• Date and time of admission
• Admitting diagnosis: Intestinal Obstruction

Chief Complaint

• Document presenting symptoms: abdominal pain, distention, nausea, vomiting, constipation/obstipation

History of Present Illness

• Onset, duration, and progression of symptoms
• Character of pain (colicky vs. constant)
• Presence of nausea/vomiting and its characteristics (bilious, feculent)
• Last bowel movement and flatus passage
• Previous similar episodes

Past Medical History

• Previous abdominal surgeries (85% sensitivity, 78% specificity for adhesive small bowel obstruction) 1
• History of malignancy, inflammatory bowel disease, diverticulitis
• Radiation therapy to abdomen/pelvis
• Previous episodes of bowel obstruction

Medication History

• Current medications
• Special attention to opioids, anticholinergics, and other medications that affect motility 1

Physical Examination

• Vital signs (tachycardia may indicate dehydration or strangulation)
• General appearance and hydration status
• Abdominal examination:
  • Distention (highest predictive value for intestinal obstruction) 1, 2
  • Tenderness and its location
  • Presence of peritoneal signs (rebound tenderness, guarding, rigidity)
  • Bowel sounds (hyperactive, hypoactive, or absent)
  • Visible peristalsis
• Hernia orifice examination (umbilical, inguinal, femoral, incisional) 1
• Digital rectal examination to assess for masses, impaction, or blood 1

Diagnostic Approach

Laboratory Tests

• Complete blood count (WBC >10,000/mm³ may indicate strangulation) 1
• Comprehensive metabolic panel (electrolytes, BUN/creatinine)
• Lactate level (elevated in bowel ischemia)
• CRP (>75 may indicate peritonitis) 1

Imaging Studies

1. Plain Abdominal X-ray

   • First-line imaging but limited sensitivity (50-60%)
   • Look for: multiple air-fluid levels, distended small bowel loops, absence of colonic gas 1

2. CT Scan with IV Contrast

   • Gold standard with >90% diagnostic accuracy 2
   • No oral contrast needed for suspected high-grade obstruction 2
   • Helps identify:
     • Location and cause of obstruction
     • Presence of closed-loop obstruction
     • Signs of strangulation or ischemia
     • Alternative diagnoses

3. Water-soluble Contrast Studies

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

Etiology Assessment

Small Bowel Obstruction Causes

• Adhesions (55-75%)
• Hernias (15-25%)
• Malignancies (5-10%)
• Others: IBD, intussusception, gallstones, foreign bodies (15%) 1

Large Bowel Obstruction Causes

• Cancer (60%)
• Volvulus (15-20%)
• Diverticular disease (10%)
• Others (10%) 1

Initial Management Plan

Resuscitation

• NPO status
• IV fluid resuscitation with crystalloids
• Correction of electrolyte abnormalities
• Nasogastric tube insertion for decompression 2
• Foley catheter for strict input/output monitoring 1

Medical Management

• Antiemetics for symptom control
• Consider prokinetic agents for partial obstruction
• Broad-spectrum antibiotics if signs of infection/ischemia
• Pain management (avoid opioids if possible)

Surgical Consultation

• Early surgical consultation is recommended for all patients 2
• Document timing of consultation and recommendations

Indications for Urgent Surgery

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

Monitoring Plan

• Vital signs every 4 hours
• Serial abdominal examinations
• Daily laboratory tests
• Strict input/output monitoring
• Reassessment of response to conservative management

Common Pitfalls to Avoid

1. Delayed diagnosis - accounts for 70% of malpractice claims in ASBO 1
2. Misdiagnosis of partial obstruction as gastroenteritis due to presence of watery diarrhea
3. Overlooking strangulation - physical exam has only 48% sensitivity for detecting strangulation 1
4. Relying solely on plain X-rays - may miss early signs of peritonitis or strangulation
5. Excessive use of opioids for pain control - can worsen or mask symptoms
6. Failure to correct electrolyte abnormalities - particularly hypokalemia
7. Delayed surgical consultation - should be obtained early in the course

By following this structured approach to admission notes and diagnosis, you will ensure comprehensive assessment and appropriate management of patients with intestinal obstruction, ultimately improving patient outcomes.