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Administered by: Private Purchased by: Public
Life Threatening? Yes
Write-up: Rotateq given 5/23/06 and 8/4/06 developed intussusception Sept 5th requiring surgical reduction. 99/19/06-received office note for DOS 8/1-9/5/06- note for 9/5/06-vomiting/possible dehydration. vomiting times 2 days, constipated 2 days ago, blood in diaper today, small amount of stool. PE: awake alert responsive, unsmiling. Abdomen soft non-tender, transfer to hospital. Operative Report received from Southwest Texas Methodist Hospital: 9/7/06-Pre operative DX: Intussusception Postoperative DX and DC DX/: Ileo ileocolic intussusception. Procedure: open reduction of intussusception. Incidental appendectomy. Preoperative Note: admitted to hospital with bilious emesis approximately 36 hours ago. Upper GI normal, US failed to disclose a suspected intussusception. Underwent trial of feeds which were unsuccessful. Follow up CT scan disclosed intussusception in right lower quadrant which was masked by overlying small bowel. Open reduction recommended due to failure of hydrostatic reduction in radiology. HX of Present Illness: admitted 9/5/06 with emesis which progressed to bilious and fussiness and dry heaves. Seen in office after 2 hours of emesis and a normal BM. No diarrhea and no fever. PMH: Bronchitis. PE: Temp 99.5, HR 131, resp rate 32. Slightly lethargic, dry lips and mucous membranes. Mild tachycardia. Lungs clear. ABD: very supple without guarding, soft, nontender and nondistended. Normal bowel sounds. 2 trials of feeds failed with bilious emesis and started to have mucosy bloody stools. Attempted hydrostatic reduction was unsuccessful. Surgery 9/7/06 open reduction and intussusception and internal appendectomy. He did not require a bowel resection. Uncomplicated postoperative course with gradual resumption of p.o. feeds. Post op day #3 tolerating goal calorie and fluid diet. Afebrile, vital signs stable. DC to home follow up in 3-4 weeks.
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