Brendan Bilodeau David Dilustro

IAL Intra-Abdominal Infection Case SOAP Note

S/O: The patient, JC, is a 67 y/o male, presenting to ED with a chief complaint of severe abdominal pain. Patient has a past medical history including cirrhosis with ascites, hepatic encephalopathy, GERD, hypertension, Hep C, and a colecytectomy. JC is currently taking amlodipine, spironolactone, and propranolol LA for HTN and famotidine and Maalox prn for the GERD. Patient is a severe alcoholic, averaging 10-12 beers/day for 25 years. JC presents with symptoms also showing evidence of the severe liver disease. Current temperature is 38.9C, and weight is 92 kg. Heartbeat is tachycardic, and RR is 32. Patient is positive for HSM. NH3 levels are 104 mcg/dL, SCr levels are 4.1 mg/dL, and WBC count is 12.25 x 103/mm3. JC has no know drug allergies.

A/P: CT scan for abcesses, spinal tap for meningitis, and sputum culture for pneumonia are all negative. Stool cultures for C. diff toxin come back positive. Patient diagnosed as suffering from an intra-abdominal CDI, resulting in hepatic encephalopathy. The CDI is the primary concern, and JC is started on Vancomycin 125 mg PO q6h x10 days. Trough levels and CrCl are to be monitored, along with continued blood samples to ensure that CDI does not enter the bloodstream and spread. Provide morphine drip for the pain, along with plenty of fluids to keep hydrated.