FACE SHEET
Date of Admission: 5/16/2021
Reason for Admission: Perforated Sigmoid
Colon
Patient Name: Alfonso Campos
Address: 1755 County Rd 789A
Date of Birth: 2/2/1958 Gender: Male
Uvalde, TX 78801
Home Phone: (830) 789-1234
Cell Phone: (830) 567-8910
Email:
Emergency Contact: Laura Campos
Address: 1755 County Rd 789A
Uvalde, TX 78801
Relationship to Patient: Spouse
Home Phone: (830) 789-1234
Cell Phone: (830) 567-8910
Primary Insurance: self funded
Secondary Insurance: n/a
Member ID:
Member ID:
Group Number:
Group Number:
Name of Policy Holder:
Name of Policy Holder:
Date of Birth:
Date of Birth:
Religious Affiliation: Catholic
Advanced Directive on File?: Yes__
Church Membership: Our Lady of Guadalupe
Catholic Church
No_X_
Hospitalist History and Physical
05/16/2021
Admission History & Physical
Patient Name: Alfonso Campos
DOB: 2/2/1958
History of present illness: The patient is a 63 yom who presented to the emergency department
with left lower quadrant abdominal pain. He was drowsy, confused, and peripherally cold and cyanotic.
His systemic arterial blood pressure was 75/50 mm Hg, and his heart rate was 125 beats per minute He was
found to have a perforated sigmoid colon and underwent emergency surgery for resection and stabilization. He
is now in the SICU, sedated from surgical anesthesia and requiring ventilator support.
Allergies: none
Current Medications:
Levophed, Coumadin, Vancomyocin, Lorazepam
Past Medical History: hypertension, hypercholesterolemia
Past Surgical History: none
Social History: formerly heavy alcohol intake, non-smoker, lives with wife in Uvalde, works as
an independent landscaping contractor
Family History: Significant for his father who has a history of hypertension.
Physical Examination: hypercholesterolemia
Vital Signs: BP 88/52 mmHg, HR 120 bpm
General: he is sedated on ventilator support
HEENT: pupils are equal, round and reactive to light, extraocular muscles are intact. Sclera are
clear, TM’s clear, oropharynx clear.
Neck: Supple with full range of motion.
Cardiovascular: Normal sinus rhythm
Lungs: Ventilated via ET tube, ventilator settings are eight hundred, SIMV of twelve, fifty
percent, and plus five
Abdomen: colostomy and abdominal incision intact, JP drains x2
Extremities: No cyanosis, clubbing or edema
Neurologic: sedated due to surgical anesthesia
Impression:
Mr. Campos is stable status post surgical repair of sigmoid colon rupture with resection and
colostomy. We will work on weaning him from the ventilator over the next 24 hours,
monitoring pulmonary function.
Plan:
1. Begin reducing sedation and wean from ventilator
2. Physical therapy for early mobilization tomorrow
3. Monitor pulmonary function
4. Monitor blood pressure
5. Continue IV fluid support and NPO
6. Enterostomal therapy nurse consult for stoma care
Electronically signed by Dr. Haus Pitalist 5/16/2021 21:34
General Surgery Operative Report
05/16/2021
DATE OF SURGERY: 05/16/2021
PREOPERATIVE DIAGNOSIS: Perforated sigmoid colon
POSTOPERATIVE DIAGNOSIS: Perforated sigmoid colon
OPERATION PERFORMED: Abdominoperineal resection with prominent left lower
quadrant colostomy.
SURGEON: John Smith, MD
ASSISTANT: Jane Smith, MD
ANESTHESIA: Spinal.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
POSTOPERATIVE CONDITION: Stable.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, placed on
the operating room table in supine position. General endotracheal anesthesia was
performed. The patient's legs were placed up in Allen stirrups. A Foley catheter was
inserted using the aseptic technique. A rectal washout was then performed by inserting a
22-French Foley catheter inserted in the patient's rectum. The balloon was then
inflated. The rectum was then irrigated out with sterile water and Betadine solution until
clear. The balloon was then deflated and the Foley was removed out of the rectum. The
patient's abdomen was then shaved, prepped, and draped. Using the aseptic technique, a
central line was subsequently placed by Anesthesia, as well as insertion of NG tube. The
patient's perineal area was prepped as well.
Attention was then turned to the patient's lower abdomen. Incision was made
from symphysis pubis to umbilicus, midline. The incision was carried down through the
dermis, subcutaneous fat, and linea alba using electrocautery. Preperitoneal fat was incised
using electrocautery. Peritoneum was grasped with pickups. Small incision was made in
the peritoneal cavity. The preperitoneal fat and peritoneum were then incised along the
length of the incision. The abdominal cavity was then explored, beginning with the stomach
and duodenum. NG tube was felt to be in adequate position. The left lobe and right lobe of
the liver were palpated and felt to be normal. The right colon, transverse colon, and
descending colon were palpated and felt to be grossly normal as well. Sigmoid colon was
markedly redundant. A Bookwalter retractor was then placed on the operating room table
and used for retraction throughout the procedure.
Attention was then turned to the sigmoid colon. The lateral attachments were freed up
using electrocautery. Left ureter was identified in the left retroperitoneal space. A site was
chosen in approximately the proximal sigmoid colon for proximal wide resection. This was
determined by placing the rectum, sigmoid on stretch. A hemostat was then introduced
between the mesentery and the bowel wall. The ligature was then used to ligate
the mesentery up to the vascular pedicle. Pericolic fat and mesentery immediately around
the bowel wall was freed up using electrocautery. The pursestring device was then brought
into field, placed across the colon at that point. Kocher clamp was placed
distally. Noncrushing bowel clamp was placed proximally, then severed between the
two. The pursestring device was then removed leaving the pursestring in place. The bowel
limb was then opened with Babcock clamps, with Betadine soaked 4 x 4. A 29 EEA stapler
was brought into the field. The limb was then inserted into the proximal colon
and pursestring was tied. This was then tacked off in left upper quadrant.
Attention was then turned back to the sigmoid colon. The mesentery was high ligated,
doubly clamped, with 2-0 silk double ligatures proximally, one distally. The sigmoid colon
was then reflected inferomedially. The perineum on either side of the sigmoid colon and
rectum was incised and then anteriorly on the cul-de-sac of Douglas. The sigmoid colon
was then reflected inferiorly, medially. Dissection was carried out over the presacral space
and avascular space down to Waldeyer fascia. Waldeyer fascia was incised
using electrocautery. The lateral ligaments were taken down
using electrocautery. The presacral nerves were visualized and appeared intact throughout
the procedure.
Anteriorly, dissection was carried down through
the Denonvilliers fascia. Posterior Waldeyer fascia was incised. Levators were visualized on
either side of the rectum. Dissection was carried down until the rectum was visualized and
meeting out to the levator muscles circumferentially. The tumor was palpable within the
rectum and extended all the way down to the levator muscles. It appeared that a distal
margin would not be obtainable. At this point, I elected to proceed
with abdominoperineal resection.
Attention was then turned to the patient's perineum. A 0 Prolene suture was used
for pursestring around the anus. An elliptical incision encompassing the anus was then
performed using a scalpel. Hemostasis controlled using electrocautery. The Lone Star
retractor was brought into the field and used for retraction. The stays were placed
circumferentially in the skin. Dissection was carried out posteriorly through
the anococcygeal ligament. Access was gained into the perineal cavity, above the
sacrum. The levator muscles on either side were incised using the ligature. Anteriorly, the
dissection was carried out through the transverse perineal muscle. The proximal sigmoid
colon was then delivered posterior to the anus. The main portion of the rectum and anus
was excised using electrocautery from the remaining levator sling complex. Specimen was
then placed on the back table, opened, and appeared to be adequate resected margin,
including radial, without evidence of involvement grossly of the rectal wall or surrounding
tissue. Hemostasis controlled using electrocautery. The pelvis, perineal portion was then
irrigated out with sterile water. Good hemostasis noted.
Closure of the peritoneal wound was then begun approximating the levator muscles from
posterior to anterior with 2-0 Vicryl interrupted sutures. Subcutaneous tissue was
approximated using 2-0 Vicryl interrupted sutures. The skin was approximated using 3-0
nylon vertical mattress sutures. The wound was then cleansed and dried, and sterile
dressing was applied.
Attention was then turned back to the abdominal cavity and perineum. A site was chosen in
the left lower quadrant for the ostomy site, which had been previously marked
by Enterostomy Therapy. The skin was grasped with Kocher clamp. An oval incision was
made using the scalpel. The subcutaneous fat was incised in conical fashion down to the
anterior rectus sheath. The anterior rectus sheath was incised in
a cruciate fashion. The rectus muscle was separated. The posterior perineum was incised
using electrocautery. The transected sigmoid colon, with the anvil in place, was then
delivered out of the ostomy site. The mesentery above the skin area was incised
using electrocautery down to the colonic wall. A 10 Blake drain was then inserted through a
stab wound in the right lower quadrant, placed in the pelvis. The perineum was
approximated to the midline over the pelvis with 3-0 Vicryl running continuous suture. The
Blake drain was sutured to the skin using 2-0 silk. All packs and retractors were then
removed. Seprafilm was placed in the pelvis over the approximated perineum, over
the omentum anteriorly.
Closure was then begun by approximating linea alba from the umbilicus down and from
the symphysis pubis up with one looped PDS running continuous
suture. Hemostasis controlled using electrocautery. Wound was irrigated out with sterile
saline. Good hemostasis noted. Skin edges were approximated using skin staples.
Attention was then turned to the ostomy site. The redundant sigmoid colon was excised
using electrocautery. The ostomy was matured with absorbable suture. The wound was
then cleansed, dried around the ostomy site. Benzoin followed by ostomy appliance bag
was applied with clip. Sterile dressing and tape were applied to the midline incision. The
patient was then taken out of Allen stirrups, transferred to ICU bed and transported to SICU
in stable condition.
Electronically signed by: John Smith, MD 05/16/2021 20:49
05/16/2021 Nursing note
05/16/2021 22:58
Pt admitted to SICU from OR s/p colon resection with colostomy. Pt is sedated and ventilated
via ET tube. Dr. Smith and Dr. Pitalist have been here to assess pt post-operatively. Pt's wife
updated on pt's status and oriented to SICU, waiting area and visiting hours. Established
password for phone updates with family members.
05/17/2021 Nursing note
05/17/2021 07:31
Received report from night shift, assessment completed. Pt is asleep, vented via ET tube,
orders to wean vent today.
05/17/2021 -2 Nursing note
05/17/2021 08:57
Pt cont to have low but stable BP, called pt's wife to give update.
05/17/2021 labs
05/17/2021 24:11
ABG
Result
Flag
pH
7.32
X
--
PaCO2 28
X
mmHg
35 - 45
mmHg
80-100
PaO2
85
HCO3
19
BLa
3.0
X
Units
7.35 - 7.45
mmol/L
X
Reference Interval
22 -26
mmol/L
0.5 - 1.6
05/17/2021- case manager note
Spoke with the patient's wife, Mrs. Laura Campos. She states Mr. Campos works as an
independent landscape contractor, and they live in a mobile home in Uvalde with 3 steps to
enter. They do not own any DME. Mrs. Campos works as a care provider for an elderly
woman, and she feels comfortable with helping Mr. Campos with bathing, meals, showers,
medications, and dressing changes at home, but she does not feel that she will be able to lift
him.
At this time, Mr. Campos does not have funding, and he is not eligible for CareLink because
they do not live in Bexar County. Mrs. Campos was provided with the contact information for
Project Mend in the event he does need DME, and she said she will reach out to their family
and church friends to see what local support is available for them at home.
Electronically signed by Rose Shaffer, RN Case Manager 05/17/2021 09:14