Patient: [Patient Name]
Date: [Date of Encounter]
I. History of Present Illness:
Onset and duration of symptoms:
Abdominal pain (sudden onset, severe, cramping)
Distention
Nausea and vomiting
Constipation (absolute or obstipation)
Inability to pass gas
Past episodes of colonic volvulus (yes/no)
Risk factors for colonic volvulus (select all that apply):
Diverticulosis
Chronic constipation
Adhesions from previous abdominal surgery
Hirschsprung’s disease (congenital)
Chagas disease
Neurologic conditions (impaired gut motility)
II. Past Medical History:
Underlying medical conditions (diverticulosis, constipation, neurologic disorders)
Previous abdominal surgeries: (yes/no) – If yes, specify details (type of surgery)
III. Social History:
Medications: List all current medications (including laxatives)
IV. Physical Exam:
Vital signs: (may be normal or show signs of dehydration/shock)
Abdominal exam:
Distention
Tympany (drum-like sound on percussion)
Visible peristalsis (visible waves of contractions)
Tenderness to palpation (may be localized or diffuse)
Rectal exam: (feces may not be present, possible rectal blood)
V. Assessment:
Suspected colonic volvulus (sigmoid or cecum)
Severity of presentation (acute or chronic obstruction)
Differential diagnoses (intestinal obstruction from other causes)
Risk of bowel ischemia and perforation
VI. Diagnostic Studies:
Laboratory tests:
Complete blood count (CBC) with differential (elevated white blood cells may indicate inflammation/infection)
Electrolytes
Renal function tests (BUN, creatinine)
Imaging studies (urgent evaluation needed):
Abdominal X-ray: (air-fluid levels, dilated colon)
CT scan with contrast: (confirmation of volvulus, assess for ischemia/necrosis)
VII. Plan:
Treatment plan depends on severity and viability of bowel:
Urgent bowel decompression (nasogastric tube, rectal tube)
Intravenous fluids for hydration and electrolyte balance
Broad-spectrum antibiotics (prophylactic or therapeutic based on ischemia)
Surgical intervention (laparoscopic or open) for detorsion and possible bowel resection
Supportive care: (pain management)
Follow-up plan: (clinical monitoring, repeat imaging if indicated)
VIII. Notes:
Include any additional relevant information, such as surgical findings, presence of bowel gangrene, and potential for colostomy creation.
Mention the importance of prompt diagnosis and intervention to prevent bowel infarction and perforation.
IX. Resources:
Consider providing patient education materials on colonic volvulus from reputable sources (e.g., National Institute of Diabetes and Digestive and Kidney Diseases).