clinical case-internal medicine practice 1

A 19-year-old male presents to the ER with the chief complaint of 6 hours
of abdominal pain and two episodes of vomiting. The pain awoke him from sleep,
and has been persistently increasing over time. He describes the pain as sharp
and crampy, and states that it comes in waves. Initially the paroxysms of pain
occurred every 10 minutes. But now they are occurring every 3 or 4 minutes, and
are increasing in length and intensity. The patient has had four episodes of emesis
over the last 3 hours. The vomit initially consisted of the contents of the previous
evening’s dinner, but subsequently became yellow and then greenish-brown,
though non-bloody. The patient states he had one “massive” explosive bowel
movement and now has the intense urge to have another, but has not been able
to even pass gas.

Pastmedical history
The patient’s history is significant for an urgent laparotomy last year after a gunshot
wound to his abdomen. He underwent resection of 18 inches of ileum, with an ileocecal
anastomosis.

Medications
The patient’s medications include clindamycin for a dental infection.

Allergies
The patient has no known drug allergies.

Physical exam and ancillary studies
Vital signs: the patient’s tympanic temperature is 37.8◦C, his heart rate is variable between
90 bpm and up to 130 bpm during a painful episode, his respiratory rate is 20, his blood
pressure is 142/100 mmHg, and his room air oxygen saturation is 98%.
General: the patient is awake, alert, and appropriate.He is resting in bed comfortably until
waves of pain cause him to double over and clutch his abdomen.
Head and neck: the patient’s mucous membranes are moist. His neck is supple without
jugular venous distension or bruit.The patient’s sclerae are non-icteric.
Cardiovascular: the patient’s heart is tachycardic without murmurs, rubs, or gallops. He
has 2+ distal pulses in all four extremities.
Lungs: the patient’s breath sounds are equal and lungs are clear bilaterally without
wheezes, rales, or rhonchi.
Abdomen: the patient’s abdomen demonstrates a midline surgical scar, well healed.The
right upper and lower abdominal quadrants are more distended than the left, with occasional observable peristaltic waves.The bowel sounds are initially normoactive, but
during auscultation a high-pitched sound with a “rush” is heard. There is slight tenderness
to palpation without rebound or guarding in the right lower quadrant.There are no
masses or organomegaly.
Extremities and skin: the patient’s skin is drywithout rashes.There is no peripheral edema.
The patient’s legs are of equal size, with no palpable cords.
Neurologic: the patient’s cranial nerves II–XII are grossly intact. He has 5/5 strength and
reflexes are 2+ in the upper and lower extremities.
Pertinent abnormal labs: the patient has a mildly elevated white count at 12 000, but without
left shift. His chemistry profile is significant for hypochloremia at 97 and a low bicarbonate
at 18.
Radiographs: the patient’s chest X-ray is unremarkable, with no free air below the
diaphragm. His flat and upright abdominal films show distended loops of small bowel,
no free air in the biliary tree, no air fluid levels, and no large bowel distension.

Questions for thought
What are the appropriate initial actions to take to stabilize this patient?
What are the differential diagnoses?
What are other ways to make the diagnosis?
What is the definitive treatment of this condition