10-3. CASE STUDY History and Physical CC: C.diff HPl: The patient is a 44-year-o
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10-3. CASE STUDY History and Physical CC: C.diff HPl: The patient is a 44-year-old woman status post laparoscopic left salpingo- oophorectomy, lysis of adhesions, and cystoscopy about 10 days ago who presents with right-sided abdominal pain and Clostridium difficile colitis. The patient had been admitted to the hospital, where she underwent an operative laparoscopy with left salpingo-oophorectomy, lysis of adhesions, and cystoscopy. The surgery was performed for a newly diagnosed irregular cystic structure within the ovary. Final pathology from the left adnexal mass consisted of hydrosalpinges and tubal ovarian adhesions. The patient's blood loss during surgery was minimal. Pertinent operative findings included adhesions, normal-appearing bladder, and left ovarian fallopian tube adherent to the left pelvic side wall. The patient was extubated and transferred to the recovery room in stable condition following her procedure. However, she reported pain rated 8 to 9 out of 10 that was most notable at the right lower quadrant trocar site. She was re-admitted because of poor pain control at night. The patient was discharged the next day with the pain well controlled with Tylox. The patient says she began to experience right-sided abdominal pain shortly after she was discharged. She first presented to her local emergency department with right lower quadrant pain. A CT scan performed at that time showed postsurgical changes. The patient began to experience diarrhea, poor oral intake, and generalized weakness. She was admitted to another hospital and was subsequently given a Chapter 10 CerExplanation / Answer
Admit diagnosis : Clostridium difficile colitis.
Discharge disposition : home
Principal diagnosis : Clostridium difficile colitis
Secondary diagnosis : hypothyroidism
Seizure disorder. These two complaints patient have for years before date of admission and is under regular medication.
Hypokalemia - is due to the effect of colitis that is present right at the time of admission.
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