Case 47 – History

 

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Case 47

MIddle-aged woman status post remote hysterectomy


Preview:

Brief History of Present Illness

 
The patient was a middle-aged African American woman with history of morbid obesity, hypertension, and status post remote hysterectomy for fibroid uterus, who presented with abdominal pain and constipation. She was seen as an outpatient and prescribed laxatives. The symptoms did not resolve, and, after a few days, the patient reportedly began vomiting stool.

 

Hospital Course

She was admitted to the hospital and diagnosed with a complete bowel obstruction. An abdominal mass was identified radiographically.

 

First Operation

The patient underwent a left hemicolectomy with ostomy placement. The mass was biopsied intraoperatively and found to be benign. The post-surgical course was complicated by necrosis of the skin at the ostomy site with dehiscence.

 

Second Operation

The ostomy site was repaired during a second operation in which the necrotic skin was removed, and the ostomy site revised. The main abdominal incision was left open (instead of surgically closed) and packed.

 

Remaining Hospital Course

The post-operative course was next marked by ongoing heart failure. This was managed medically, including with extensive fluid support. (The family notes “fluid coming out of the open surgical wound.”) The patient remained critically ill for the next five days and then died.

 

Next: External exam

Discussion Questions


1. How do you interpret the history?
 
2. What is the likely reason the patient developed a bowel obstruction?
 
3. What is the likely etiology of the “mass” in the abdomen?
 
4. How common is this scenario?