Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Reason for Visit:
Document the reason for this visit. This may be:
Initial evaluation of a newly diagnosed enterocutaneous (EC) fistula.
Follow-up visit for a patient with an established EC fistula.
Visit to address a specific concern related to the fistula (e.g., increased drainage, change in output).
History of Present Illness:
For newly diagnosed fistulas:
Onset and characteristics of the drainage from the fistula (e.g., amount, frequency, consistency).
Associated symptoms (e.g., abdominal pain, nausea, vomiting, diarrhea).
Prior abdominal surgeries or procedures (risk factors for fistula formation).
For established fistulas:
Changes in the character or amount of drainage.
New or worsening symptoms.
Management strategies employed at home (e.g., dressing changes, dietary modifications).
Past Medical History:
Briefly document any relevant past medical conditions, surgeries, or allergies, especially those involving the abdominal cavity or GI tract (prior surgeries, inflammatory bowel disease, malignancy).
Social History:
Dietary habits that may contribute to fistula drainage (e.g., high-fiber diet).
Medications:
List all current medications, including:
Antidiarrheal medications
Antibiotics (if on therapy for fistula management)
Nutritional supplements
Allergies:
Document any known allergies, especially allergies to medications used for fistula management or wound dressings.
Physical Exam:
Vital Signs: Include temperature, blood pressure.
Abdominal Exam:
Assess for abdominal distention, tenderness, or masses.
Locate the fistula site and describe its appearance (size, location, surrounding skin condition).
Assess for signs of infection (erythema, induration, purulence).
Laboratory:
Document any laboratory tests performed, such as:
Electrolytes: May be deranged due to ongoing fluid and electrolyte losses from the fistula drainage.
Nutritional labs: Albumin, pre-albumin may be low indicating malnutrition.
Inflammatory markers (CRP, ESR): May be elevated if there is an infectious component to the fistula.
Fistula output analysis (if indicated):
May be sent for culture and sensitivity to identify any bacterial growth.
Imaging:
Imaging studies may be helpful in some cases to delineate the fistula tract and identify the underlying cause.
Studies used may include:
Abdominal X-ray: Limited utility but may identify air or fluid in the fistula tract.
CT scan with contrast: More detailed visualization of the fistula tract and surrounding structures.
Fistulagram: Contrast injected directly into the fistula to delineate the tract anatomy.
Assessment:
Enterocutaneous fistula: Confirmed based on clinical presentation and diagnostic tests.
Identify the location of the fistula according to the intestinal segment involved (e.g., jejunal fistula, ileal fistula).
Acute vs. chronic fistula: Classify the fistula based on its duration and cause (if known).
Consider the underlying cause of the fistula formation (e.g., Crohn’s disease, surgical complication, malignancy).
Evaluate nutritional status due to potential fluid and electrolyte losses.
Plan:
The overall goal of treatment is to achieve fistula closure and improve nutritional status.
The specific treatment plan will depend on several factors, including:
Cause of the fistula
Location and size of the fistula
Overall health of the patient
Treatment options may involve:
Conservative management:
Nutritional support (肠内营养 chíng cháng yíng yǎng enteral nutrition or total parenteral nutrition (TPN) if fistula output is high).
Fluid and electrolyte replacement.
Wound care and management of fistula drainage.
Medications (antidiarrheals, antibiotics if indicated).
Interventional radiology procedures:
Fistula closure with stents or plugs (applicable in select cases).
Surgery:
Fistula repair surgery may be necessary, particularly for definitive management or if conservative measures fail.