Received Mar 10, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 6 | 8080473 | IM / RA |
Name: Medical Record #: Age: 71 y.o. DOB: 4/X/19XX Admit date: 3/2/2025 Discharge date: 3-5-25 Admitting Physician: MD Attending Physician at the Time of Discharge: MD Primary Care Physician: MD Reason for Admission: Small bowel obstruction Brief Summary of Hospital Stay: 71 year old female admitted with abdominal pain, nausea, and vomiting. Abdominal surgical history includes cholecystectomy, sleeve gastrectomy (2014) with a recent medical history of positive Covid (2-27-25). CT abd/pel were concerning for possible small bowel obstruction and possible pneumatosis intestinalis of jejunal loops. Laboratory studies were significant for lactic acid of 2.7. Patient was admitted and a gastrografin challenge was completed - no evidence of fecal impaction with oral contrast within the colon and distal ileum. A clear liquid diet was started and tolerated. Zosyn 4.5 g IV was ordered due to the concern of pneumatosis intestinalis. That was discontinued on hospital day #2. Patient was in isolation due to her recent Covid status but ambulated in room, completed her own self care without difficulty. Abdominal pain, nausea, and vomiting subsided. As patient is a bariatric patient, diet and behaviors were discussed. Patient has not been to the bariatric clinic for several years. Patient agreed to return to get her dietary choices back on track. By hospital day #2, patient tolerated full liquids with diet advancement. There was no return of abdominal pain, nausea, or vomiting. It was determined that patient was stable for discharge home.