Case #3:

RH is a 20 YO female with history of Crohn's disease, which presented to a medicine clinic with a two-week history of night sweats, right lower quadrant crampy pain, and frequent bowel movements. These symptoms had been getting worse over the preceding two days. She appeared pale and acutely ill. Her weight was 110 Lbs, height is 5'6", and she had lost 20 lbs over last 3 months because of inadequate oral intake secondary to abdominal pain. Vital signs were: BP: 100/70 which dropped to 80/P when standing; T: 39.0; P: 110; and RR: 31. Breath sounds were clear; she was tachycardic but cardiac examination was otherwise normal. The abdomen was scaphoid but there appeared to be a fullness in the right lower quadrant. This ill defined mass was tender to the touch. An obturator and psoas sign were present. CT scan demonstrated a perforation in the area of the ileum and enteral-enteral fistula with a suspicion of gas in the portal vein.

She was then taken to surgery where the abscess was drained, and a right hemicolectomy, a take down of fistula and ileal resection were performed. A diverting colostomy was placed. The estimated remaining small bowel is nine feet. The patient did well for the first week postoperatively with return of bowel sounds by day five, and introduction of clear liquids by day seven. Unfortunately on day eight the patient became hypotensive and febrile. A repeat CT scan showed a fluid collection at the area of the ileostomy site. Ins/Outs: 4000/5400:1500 (urine), 3900 (ostomy output). As IV access, currently she has double lumen peripherally inserted central catheter (PICC). Her current IV hydration consists of normal saline solution infused at 150ml/hr.

Laboratory data: