Surgical Notes:

HISTORY/COMPLAINTS:  A 52 year old white female referred by physician for evaluation for resection of Meckel’s diverticulum.  She has had 2 massive GI bleeds requiring admission and transfusion.  The earliest was 4 years ago – most recently 6 weeks ago.  At both of these hospitalizations, she underwent full work-up including bleeding scan, angiogram, and endoscopy.  None of these revealed a source of bleeding.  On an elective upper GI small bowel follow-through, she was noted to have a Meckel’s diverticulum.  She has not re-bled since 6 weeks ago and she had not had a Meckel’s scan at the time of either of these admissions.  The Meckel’s is carefully described on the small bowel follow-through 15cm proximal to ileocecal valve and approximately 8cm in length.  She is referred for evaluation for laparoscopic dissection of this, assuming it is the most likely source of bleeding. 

Past Medical History:

1)   Mild heartburn.

2)   Chronic osteoarthritis in the lower back.

3)   Two motor vehicle accidents resulting in pelvic fractures. 

 

Past Surgical History:

1)   Several benign breast biopsies.

2)   Colonoscopy with polypectomy of benign polyps x2.

3)   EGD.

Medications:     Nasacort.

Allergies:          Environmental only.  No known drug allergies. 

Family History: Heart disease is in her father’s side. 

Social History:  She drinks 2-3 drinks daily and does not smoke cigarettes. 

Review of Systems:       No history of asthma or wheezing.  No history of heart disease.  No chest pain.  No murmurs.  No arrhythmias.  Denies frequent nausea or vomiting or abdominal problems.  No history of liver or kidney disease.  No history of neurological or psychiatric problems.  She has history of blood in her stool at the 2 above mentioned times.  Otherwise, has bowel history that is significant for constipation.  She denies any transfusion reaction.  She has no history of diabetes, cancer, reaction to anesthesia, but does admit to a recent 5lb-weight loss. 

PHYSICAL EXAM: This is a very thin white female in no acute distress. 

ASSESSMENT & PLAN:

1)         Patient is a 52 year old with 2 severe lower GI bleeds with completely normal work-ups including angio and nuclear medicine scans.  The only positive finding was that of a Meckel's diverticulum found on a small bowel follow-through. 

I had a very lengthy discussion with the patient and her husband explaining the operation in careful detail.  We discussed laparoscopic versus open surgery.  We also discussed the risks of bleeding after diverticulectomy.  I’ve explained that this is the most likely cause of her bleeding, although it cannot be guaranteed 100%.  We talked about what would happen should she develop further bleeding.  She understands and wishes to think about this further.  She will call us when she is ready to schedule a surgery date.