Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for admission, typically abdominal pain, distension, nausea, and vomiting.
History of Present Illness:
Onset and duration of symptoms
Character of pain (colicky, constant)
Associated symptoms (constipation, diarrhea, bloating, nausea, vomiting)
Any aggravating or relieving factors (e.g., meals)
Past medical history (comorbidities, previous surgeries, potential risk factors for ACPO)
Medications (including opioids)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
General examination (appearance of illness)
Abdominal examination (distention, tenderness, bowel sounds)
Rectal examination (rule out fecal impaction)
Laboratory Findings:
Complete blood count (CBC) – may show elevated white blood cell count (WBC)
Basic metabolic panel (BMP) – may show electrolyte imbalances
Inflammatory markers (CRP, ESR) – may be elevated
Imaging Studies:
Abdominal X-ray – may show signs of colonic distension
CT scan of the abdomen and pelvis (with contrast preferred) – typically used to rule out mechanical obstruction, perforation, or ischemia. May show dilated colon without transition point.
Assessment:
Summarize the findings and consider the diagnosis of ACPO based on clinical presentation and imaging.
Discuss potential underlying causes of ACPO (e.g., postoperative, medication-induced, neurological).
Plan:
Conservative Management (initial approach):
Intravenous fluids
Nasogastric (NG) tube decompression
Electrolyte correction
Prokinetics (medications to stimulate colonic motility) – use with caution
Pain management
Consider bowel rest or clear liquid diet initially, then progress as tolerated
Surgical Management (considered in severe cases or lack of response to conservative measures):
Exploratory laparotomy or laparoscopy to rule out other causes and potentially perform colectomy (removal of part of the colon)
Progress Notes:
Document daily assessments including vital signs, abdominal exam findings, NG tube output, bowel sounds, and toleration of diet.
Note any laboratory or imaging results obtained during the hospitalization.
Update the plan as needed based on the patient’s progress.
Discharge:
Summarize the patient’s hospital course and current condition.
Address the underlying cause of ACPO if identified and recommend further management.
Discharge instructions including medication regimen (pain medication, dietary recommendations), follow-up appointments, and signs and symptoms to watch for.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment.