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ypothyroidism, Anxiety, Alzheimer's dementia, knee osteoarthritis and Rheumatoid arthritis, Chronic Systolic HFrEF (LVEF: 10-15% on Echo 4/24/24) admitted for coffee ground emesis, fatigue and dehydration associated with upper abdominal pain, that began 5 days prior to presentation to ED. General surgery consulted concerning SBO on serial abdominal imaging two days after admission. At time of surgery evaluation the patient’s son report the mother was having persistent vomiting and not able tolerate any oral intake and the vomitus was initially NBNB but after several episode of vomiting it become dark colored. Also experience general body weakness. Last BM was about 5 days ago per the son

1. Perforated Small bowel Secondary to Strangulated Femoral Hernia M ohammad Gilani, MD Khuram Khan, MD 08/15/24 Surgical Conference

2. HPI 90 yo F with PMH of HTN, Hypothyroidism, Anxiety, Alzheimer's dementia, knee osteoarthritis and Rheumatoid arthritis, Chronic Systolic HFrEF (LVEF: 10-15% on Echo 4/24/24) admitted for coffee ground emesis, fatigue and dehydration associated with upper abdominal pain, that began 5 days prior to presentation to ED. General surgery consulted concerning SBO on serial abdominal imaging two days after admission. At time of surgery evaluation the patient’s son report the mother was having persistent vomiting and not able tolerate any oral intake and the vomitus was initially NBNB but after several episode of vomiting it become dark colored. Also experience general body weakness. Last BM was about 5 days ago per the son. However nurses report 2 BM overnight. Denies any other acute complaints.

3. HPI PMH: HTN, Hypothyroidism, Anxiety, Alzheimer's dementia, knee osteoarthritis and Rheumatoid arthritis, Chronic Systolic HFrEF (LVEF: 10-15% on Echo 4/24/24) PSH: Hip replacement Allergy: PCN Meds: sertraline 50mg, clonazepam, Levothyroxine, Lisinopril/HCTZ SH: Denies toxic habits

4. PE V/s: BP 153/69 HR 80 RR 18 Sao2:97% on RA T 99 Weight 55 kg Gen: Well-developed, no apparent distress, Respiratory: normal respiratory effort Abdomen: soft, distended, non-tender to palpation, R groin mass, firm, non-reducible, nontender to palpation MSK: normal gait and sensation Neuro: awake, alert and oriented to self and place

5. Labs

6. Imaging CT scan: There is moderate generalized fluid-filled small bowel dilatation involving the diffusely involving the jejunum. Multiple nondistended ileum in the right lower quadrant.. Transitional small bowel findings suspect for bowel obstruction (partial versus possible evolving high-grade. The transitional zone appears to be associated with small fluid-filled small bowel herniation in the right inguinal region. (Possibly femoral medial to the femoral right femoral vein) report . Finding of Evolving small bowel obstructive pattern as described. Transitional zone appears associated with right groin hernia.

7. Operative Course 8/7/24 Preop: Incarcerated Right groin hernia Post op : Strangulated Right femoral hernia with small bowel perforation Procedure : Open right femoral hernia w/o mesh, small bowel resection(15cm) with primary anastomosis Findings: femoral hernia with perforation of small bowel possible jejenum, resection and primary side to side anastomosis, stool expressed from perforation site. Primary Tissue repair, McVay EBL 50, received 600 crystalloids, NGT 400, UOP350

8. Images

9. Post Op Course: POD#0 : SICU, NPO, IV fluids, IV abx, monitor bowel fxn, ID consulted and switched to Meropenem POD #1 : afebrile, Tachycardia 100's. Received 500cc bolus. Pt removed NGT during morning rounds, wbc 18, Foley in situ: 800cc, no bowel fxn, stated on sips/chips for comfort, Foley and A-line removed in PM POD #2 : afebrile, Pt had BM overnight, started on CLD, seen by PT, SAR vs Home w/PT, wbc 15.3 from 14.5, DG to IMCU POD #3 : afebrile, WBC 20.6 from 15, CXR neg, UA+, Tol CLD, working with PT, seen by Speech&Swallow: started chopped thin liquids with aspiration precautions,

10. Post Op Course: POD #4 : adv to reg soft diet, abx switched to Rocephin/Flagyl, wbc 20.2 from 20.6 POD #5 : Tol soft diet, wbc 15 from 20, CXR atlectaits, DG to floor POD #6: Tol diet and having bowel fxn, wbc 11.2, POD #7: Tol diet and having bowel fxn, DC home with home services

11. Timeline of Events Pt came to ED 8/5 00:21 8/5 11:56 CT scan: Evolving small bowel obstructive pattern as described. Transitional zone appears associated with right groin hernia (possibly femoral). General surgery consulted: After eval, pt was taken emergently to OR as RED CARD 8/7 8am Admitted to Medicine for Hematemesis 8/5 0253 8/7-814 Pt was managed in SICU and Floor and Discharged on POD 7

12. Discussion……..

13. Discussion- Femoral Hernias