A Patient With Perforated Appendice

A 69 y.o. Male

Situation

• 69-year-old male with extensive PMHx, admitted for perforated appendicitis complicated by bacteremia, intra-abdominal abscess, fulminant C. diff, DVT, GI bleeding, and SBO.

• Abscess improving on repeat imaging, drain still in place (clamped). Plan: remove in days if stable.

• Ongoing diarrhea, positive rhinovirus, history of recurrent C. diff.

• Vascular Surgery to revise nonfunctioning AV fistula before discharge.

• Code status: Full Code.

Background

• PMHx: ESRD on HD (MWF), obesity (BMI 41) s/p sleeve gastrectomy, LGIB, IBS, GERD, anemia, gout, OSA, anxiety, HTN, HLD, COPD, CVA, DMII, PAD (s/p popliteal stent), history of Pseudomonas pneumonia.

• Hospital course:

  • Drain placed 8/15, upsized 9/5; minimal residual fluid with bowel fistula on; capped.

  • Treated for bacteremia (E. coli, Enterococcus, now resolved).

  • Complications: fulminant C. diff (completed oral vanc), malnutrition requiring TPN (now improved), DVT (on apixaban), recurrent GI bleed (last, resolved), recurrent SBO (not clinically obstructed).

• Comorbidities at admission: ESRD, anemia of chronic disease/blood loss, electrolyte disturbances (hyper/hypokalemia, hypo/hypernatremia, hypocalcemia).

• Diet: Regular + Nepro TID.

• Prophylaxis: On DOAC.

Assessment

1. Intraperitoneal abscess (resolving) — RLQ pigtail drain in place; capped 9/20; likely removal in 7–10 days. CRP improving.

2. Perforated appendicitis (resolving).

3. Bacteremia (resolved) — Prior resistant organisms; TTE negative for IE.

4. Fulminant/recurrent C. diff — Completed treatment; monitor for recurrence.

5. SBO (resolved clinically) — Still appears on imaging but no symptoms.

6. Malnutrition (improving) — Tolerating PO, nutrition supplements.

7. LUE swelling, nonfunctioning AV fistula — Vascular Surgery to revise before discharge.

8. DVT, multiple sites — On apixaban 5mg BID; stable.

9. GI bleed history — Last 8/8, resolved. Continue PPI daily, transfuse PRN Hb <7.

10. ESRD on HD--Continue MWF dialysis, darbepoetin weekly, iron per nephrology.

11. HTN — On coreg, losartan, amlodipine (added 9/18).

12. CVA / PAD — Continue aspirin, clopidogrel stopped per Vascular due to Eliquis.

13. COPD — Continue Symbicort, montelukast, albuterol PRN.

14. Psych (anxiety/depression) — On Lexapro, amitriptyline, hydroxyzine.

15. Recent chest pain/SOB episode 9/17 (resolved) — Noncardiac, improved with albuterol.

16. Rhinovirus LRTI — Symptomatic treatment with Robitussin DM.

Recommendation / Plan

• Abscess: Continue IV tigecycline until drain removed, then stop per ID. Repeat CT A/P in 2 weeks).

• Nutrition: Continue Nepro TID, monitor intake.

• Vascular: Schedule AVF revision prior to discharge.

• DVT: Continue apixaban; monitor Hb; transfuse PRN.

• GI: Continue PPI daily. Monitor stools.

• Renal: Continue HD MWF; darbepoetin weekly.

• Cardiopulmonary: Continue current COPD, HTN, PAD, CVA management.

• Psych: Continue current psychiatric meds.

• Other: Continue regular diet, supplements; maintain DOAC prophylaxis.

• Code: Full code