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Life Threatening? No
Write-up: Intusssception in 2 places. One of which required air enema, the other needed surgical reduction. 2/15/07 Received medical records from PCP which included vax records. Patient seen on 12/28 w/nasal congestion & right nasolacrimal duct obstruction. Next visit on 1/2/07 for vomiting, listless, diarrhea. Other family members ill w/stomach flu. Exam revealed afebrile, good hydration. Dx w/gastroenteritis. Next seen 1/25/07 for vomiting, crankiness, decreased appetite, nasal congestion. Dx/vomiting secondary to unspecified acute illness, posible gastroenteritis. Seen for vax on 2/7. Then next seen on 2/10 for emesis, dry heaves, no diarrhea, normal stools. With other episodes, had some loose stools that were mucousy & little bit of blood at time. 2/11/07 phone call revealed patient continued to have vomiting. UA revealed UTI & was sent to hospital for admission for UTI, vomiting & dehydration. At hospital was found to have IS. 3/13/07 Medical records reviewed which reveal patient admitted 2/11/07 s/p vomiting for 1-2 days, 1 bloody mucous stool & having a UTI. Exam revealed VSS, abdomen soft & diffusely tender w/o masses palpable. ALso noted erythematous rash on back & arms. Lungs were clear w/mild subcostal retractions. Ped surgery consulted. Taken to OR after BE failed to reduce. Procedure was attempted laparoscopic reduction of IS; open resection of ileoileal IS, including Meckel''s diverticulectomy; & appendectomy. No D/C summary available. T/C to hospital to request d/c date which was 2/15/07. Final Dx: Ileoileal intussusception w/Meckels diverticulum as the lead point.
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