Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Abdominal pain / Nausea / Vomiting / Constipation / Distention / Difficulty passing gas
History of Present Illness:
Onset, duration, severity, and character of abdominal pain (colicky, constant, dull ache).
Frequency and volume of vomiting (projectile, bilious).
Constipation (frequency, duration, time of last bowel movement).
Distention and difficulty passing gas.
Any recent changes in appetite or weight loss.
Previous history of abdominal surgeries or bowel resections (if applicable).
Known history of malignancy (mention primary site if known).
Past Medical History:
Underlying malignancies that can cause bowel obstruction (e.g., colorectal cancer, ovarian cancer).
Previous surgeries (exploratory laparotomy, bowel resections) that may have increased risk of adhesions.
Inflammatory bowel disease (IBD) that can contribute to strictures.
Diverticular disease (another cause of obstruction).
Medications:
List all current medications, including opioids (can worsen constipation).
Allergies:
Mention any allergies to medications, particularly antibiotics or contrast agents used for imaging.
Social History:
Tobacco use (can increase risk of colorectal cancer).
Family History:
Inquire about a family history of colorectal cancer or other relevant malignancies.
Physical Exam:
Vital signs: Assess for fever (may indicate perforation), tachycardia (rapid heart rate), tachypnea (rapid breathing).
Abdominal examination:
Distention
Tenderness
Hyperactive bowel sounds (early obstruction) or hypoactive/absent sounds (advanced obstruction)
Palpable mass (may be present)
Rectal exam: Assess for stool impaction and rectal tone.
Laboratory Tests:
Basic metabolic panel (BMP): May reveal electrolyte imbalances due to dehydration from vomiting.
Complete blood count (CBC): May show elevated white blood cells if there is perforation or inflammation.
Coagulation studies (PT/PTT): May be checked before surgery.
Imaging Studies:
Abdominal X-ray: May show signs of obstruction like air-fluid levels and dilated bowel loops. Not definitive for malignancy but helpful in initial evaluation.
CT scan of the abdomen and pelvis with contrast: The most definitive imaging study to identify the location and cause of the obstruction, assess for metastases, and plan for surgery.
Assessment:
Malignant bowel obstruction: Confirm the diagnosis of malignant bowel obstruction based on clinical presentation, imaging studies, and the patient’s history of malignancy (if known).
Location of obstruction: State the suspected location of the obstruction based on imaging findings.
Severity of obstruction: Describe the severity of the obstruction based on clinical presentation and imaging studies (complete vs. partial obstruction).
Plan:
Urgent surgical consultation: Malignant bowel obstruction is a surgical emergency. Early surgical intervention is crucial to relieve the obstruction and prevent complications (perforation, sepsis).
Preoperative management:
Nasogastric (NG) tube placement to decompress the stomach and relieve vomiting.
Intravenous (IV) fluids for hydration and electrolyte replacement.
Broad-spectrum antibiotics to prevent infection, particularly if perforation is suspected.
Bowel rest with bowel cleansers may be considered in some cases.
Postoperative management: Depends on the surgical procedure performed (resection with anastomosis, diverting stoma creation).
Pain management
Monitoring for signs of surgical site infection and anastomotic leak.
Gradual return to oral diet as tolerated.
Oncology consultation (if not already established): Discuss the need for further oncological management (adjuvant chemotherapy, radiation therapy) based on the specific cancer type and stage.
Palliative care consultation (if indicated): For patients with advanced disease or those unlikely to undergo curative surgery, discuss goals of care and incorporation of palliative measures to manage symptoms and improve quality of life.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Malignant bowel obstruction is a complex condition requiring prompt surgical intervention and a multidisciplinary approach to care. It is recommended to consult with relevant medical resources and surgical guidelines for management of malignant bowel obstruction.