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

Admission Notes and Diagnostic Approach for Intestinal Obstruction

The most effective admission note for intestinal obstruction should include a structured assessment of symptoms, physical examination findings, laboratory tests, and imaging studies, with CT scan being the gold standard diagnostic tool with over 90% accuracy.

Key Components of Admission Note

History Taking

• Document duration and progression of symptoms:

  • Colicky abdominal pain (location, severity, pattern)
  • Abdominal distension (sudden onset for volvulus, progressive for cancer)
  • Nausea and vomiting (earlier and more prominent in small bowel obstruction)
  • Absence of flatus and bowel movements (timing of last passage)
  • Previous episodes of similar symptoms 1

• Risk factors and etiology assessment:

  • Previous abdominal surgeries (adhesions account for 55-75% of small bowel obstructions) 1
  • History of hernias (15-25% of small bowel obstructions) 1
  • History of malignancy (accounts for 5-10% of small bowel and 60% of large bowel obstructions) 1
  • Previous episodes of diverticulitis (potential cause of large bowel obstruction) 1
  • Radiation therapy history 1
  • Current medications (especially opioids, anticholinergics) 1

Physical Examination

• Vital signs (tachycardia, fever, hypotension may indicate complications)

• Abdominal examination:

  • Distension (highest predictive value for obstruction with positive likelihood ratio of 16.8) 1
  • Tenderness (location and severity)
  • Peritoneal signs (rebound tenderness, guarding - suggest strangulation/ischemia)
  • Bowel sounds (hyperactive early, absent late)
  • Visible peristalsis 1

• Complete examination of all hernia orifices (umbilical, inguinal, femoral) 1

• Digital rectal examination (to detect masses or blood) 1

• Nutritional assessment (BMI, percentage weight loss) 1

Laboratory Tests

• Complete blood count (leukocytosis >10,000/mm³ suggests inflammation or ischemia) 1
• Comprehensive metabolic panel (electrolyte disturbances, especially hypokalemia) 1
• Lactate levels (elevated in bowel ischemia) 1
• C-reactive protein (CRP >75 suggests peritonitis) 1
• BUN/creatinine (assess hydration status) 1
• Coagulation profile (if surgery anticipated) 1

Diagnostic Approach

Initial Imaging

1. CT scan with IV contrast (diagnostic accuracy >90%) 2

   • Most effective for confirming obstruction, identifying transition point, determining cause, and detecting complications
   • No oral contrast needed for high-grade obstruction (may increase risk of vomiting) 2
   • Look for:
     • Transition point between dilated and collapsed bowel
     • Closed loop obstruction
     • Signs of ischemia (pneumatosis intestinalis, portal venous gas)
     • Cause of obstruction 3

2. Plain abdominal X-ray (if CT unavailable)

   • Sensitivity 50-60%, specificity 70-80% 1
   • Look for:
     • Dilated bowel loops
     • Air-fluid levels
     • Absence of gas in colon 1

3. Abdominal ultrasound (if CT unavailable)

   • Higher sensitivity than X-ray (88% vs 74-84%) 1
   • Can detect free fluid and bowel wall thickening 1

4. Water-soluble contrast studies

   • Useful when CT is not required
   • Has both diagnostic and potential therapeutic value
   • Appearance of contrast in colon within 4-24 hours predicts successful conservative management (sensitivity 96%, specificity 98%) 1

Management Plan in Admission Note

Initial Stabilization

1. NPO status
2. IV fluid resuscitation (isotonic crystalloids) 1
3. Nasogastric tube insertion for decompression 1
4. Foley catheter for strict input/output monitoring 1
5. Electrolyte replacement (especially potassium) 1
6. Anti-emetics for symptom control 2

Surgical Consultation Criteria

Document indications for urgent surgical intervention:

• Peritonitis or signs of perforation
• Evidence of bowel ischemia or strangulation
• Complete obstruction failing to improve with conservative management
• Hemodynamic instability 2, 3

Monitoring Parameters

• Vital signs every 4 hours
• Abdominal examination every 6 hours
• Daily electrolytes and renal function
• Input/output monitoring
• Nasogastric tube output documentation

Common Pitfalls to Avoid

1. Failing to recognize strangulation (clinical signs have low sensitivity - only 48%) 1
2. Misdiagnosing partial small bowel obstruction as gastroenteritis (watery diarrhea may be present) 1
3. Delaying surgical consultation (should be obtained early) 2
4. Overreliance on plain radiographs (can be normal in 10-20% of obstructions) 1
5. Missing adhesive small bowel obstruction in patients without prior surgery (can still occur in 26-75% of cases) 1
6. Failing to consider malignancy in elderly patients (most common cause of obstruction in patients without prior surgery) 4

By following this structured approach, you will create comprehensive admission notes that facilitate prompt diagnosis and appropriate management of patients with intestinal obstruction, potentially reducing morbidity and mortality.