Max is an 80-year-old male with a history of gastroesophageal reflux disease (GERD), hypertension (HTN)
CC: “I have stomach pain.”
HPI: Max is an 80-year-old male with a history of gastroesophageal reflux disease (GERD), hypertension (HTN), and a pacemaker placed 10 years ago for third-degree heart block. He presents today with a complaint of abdominal pain.
You suspect a bowel obstruction in Max, an 80-year-old patient with complaints of cramping abdominal pain, nausea, and vomiting for 4 days.
Describe six (6) ROS questions you would explore further with him to determine the location, severity, and timing of his pain.
PE: On exam, the abdomen appears distended, Max has generalized tenderness over the epigastric region on palpation. He is guarding so the exam is limited. Bowel sounds are decreased.
His vital signs are normal. He describes his abdominal pain as 7/10.
As the APRN, you order an abdominal x-ray.
Test results:
The abdominal x-ray is indeterminate. What are your next diagnostic choices to determine a bowel obstruction in this patient?
List at least three differential diagnoses for abdominal pain.
The CT scan shows that Max has a small bowel obstruction. What is your next step?
Expert Answer and Explanation
Focused SOAP Note Small Intestine Obstruction
Patient Information:
Max, 80 years, male, African American
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CC: “I have stomach pain.”
HPI: Max is an 80-year-old male of African American origin who came to the health clinic complaining of abdominal pain. The pain is located in the abdominal area. It started four days ago. The character of pain is cramping and intermittent. Associated signs include nausea and vomiting. The patient notes that the severity of the pain is 7/10.
Current Medications: No medications.
Allergies: No food, dug, or environmental allergies.
PMHx: Past major illnesses include hypertension (HTN), gastroesophageal reflux disease (GERD), and a pacemaker placed 10 years ago for third-degree heart block. He does not remember when he took tetanus or pneumonia shots.
Soc and Substance Hx: He took alcohol in his thirties and quit over 45 years ago. He comes from a working family. No history of illicit drug or tobacco use. He says that he has smoke detectors in his house and wears seat belts while driving. His support system is his son and two daughters.
Fam Hx: His father died from colon cancer. His mother died from type II diabetes. His older son died in an accident at the age of 28. His second child has type two diabetes. His grandchildren are healthy.
Surgical Hx: He reports a knee operation at 33 years old.
Mental Hx: No mental health disorder diagnosis and treatment. No history of self-harm.
Violence Hx: No history of violence.
Reproductive Hx: He is sexually inactive and has no reproductive health.
ROS
- GENERAL: He reports fatigue and weakness. No fever or chills.
- HEENT: Eyes: No visual loss. Ears, Nose, Throat: No congestion, sneezing, hearing loss, sore throat, or runny nose.
- SKIN: No rash or itching.
- CARDIOVASCULAR: No chest discomfort, pressure, pain, or edema.
- RESPIRATORY: No shortness of breath.
- GASTROINTESTINAL: No diarrhea or anorexia.
- GENITOURINARY: No burning on urination.
- NEUROLOGICAL: No dizziness, headache, paralysis, or syncope.
- MUSCULOSKELETAL: No joint or muscle pain.
- HEMATOLOGIC: No anemia.
- LYMPHATICS: No enlarged nodes.
O
Physical exam:
- Vitals: BP 139/92, Temp 35, P 78, Ht. 5’9, Wt. 87kgs.
- Cardiovascular: No cracks in the chest. No edema.
- Respiratory: No breathing distress. No wheezes or crackles. No fluids in the lungs.
- Genitourinary: No urinary retention. No renal angle tenderness. No tender bowel loops. No abdominal masses.
- Gastrointestinal: Bowel sounds absent on inspection. Distension of the abdomen on auscultation.
Diagnostic results:
The abdominal x-ray is indeterminate. Since an x-ray is indeterminate, a CT scan should be ordered.
A CT scan combined with X-ray images. Dou et al. (2022) noted that a CT scan combined with multiple X-ray images will show intestinal obstructions.
Blood test: A blood test will be used to identify whether the patient has intestinal infections.
A
Differential diagnoses:
- Small intestine obstruction: The primary diagnosis for this case is small intestine obstructions. According to Jackson and Cruz (2018), the symptoms of small intestine obstructions include vomiting, crampy abdominal pain and comes and goes, constipation, loss of appetite, swelling of the abdomen, and inability to pass gas or have a bowel movement.
Small intestine obstruction is the main diagnosis because the patient complains of crampy abdominal pain, nausea, and vomiting which are major symptoms of the disease (Jackson & Cruz, 2018). Physical exam results (bowel sounds absent on inspection, distension of the abdomen on auscultation) also show that the patient has a small intestine obstruction.
- Appendicitis: The second diagnosis is appendicitis. The symptoms of appendicitis include flatulence, loss of appetite, vomiting and nausea, sudden pain that starts in the lower abdomen, pain that worsens when one coughs, diarrhea and constipation, low-grade fever and might increase if the illness progresses, and abdominal bloating (Talan & Di Saverio, 2021).
The disease has been included because the patient reports abdominal pain, nausea, and vomiting which are part of the clinical manifestations of appendicitis. However, it is a secondary diagnosis because the patient does not have a low-grade fever, diarrhea, or pain in the lower abdomen.
- Intestinal Infection: The last diagnosis is an intestinal infection. The symptoms of intestinal infection include headache, vomiting, nausea, diarrhea, crampy abdominal pain, and fever (Guo et al., 2021). The disease has been ruled out because the patient does not have a headache or fever.
P
The patient will be recommended to undergo a CT scan combined with a series of X-ray images of the small intestine. The patient will also undergo blood tests. These tests will help identify the actual disease affecting the patient. Since it is suspected that the patient has small intestine obstructions, he should be hospitalized (Ten Broek et al., 2018)).
The pain should be stabilized by placing an intravenous (IV) line into the patient’s arm so that he can be given fluids. Abdominal swelling should be relieved by putting a nasogastric tube inside the patient’s nose into his stomach to suck out fluids and air. A catheter should be put into his bladder to drain urine. Pain medications should be given to the patient through IV to help relieve pain (Ten Broek et al., 2018). If the patient has partial small bowel obstruction, further treatment is needed after the patient has been stabilized.
A low-fibre diet should be recommended to make it easy for the partially blocked intestine to process. The patient should be referred to a gastroenterologist for surgery if the patient has complete obstruction (Ten Broek et al., 2018)). If the patient has appendicitis, he can also be referred to a gastroenterologist for laparoscopic appendectomy to remove the appendix (Talan & Di Saverio, 2021). The patient can be disposed of two days after surgery. The patient can be educated on how to cope after surgery.
If the patient has intestinal infections, antibiotics should be recommended to help fight the infections. The patient should be educated to eat a low-fiber diet to make it easy for the stomach to digest. The patient should be educated to take small amounts of food frequently instead of having huge meals at once. For instance, he should have five to six meals throughout the day. The patient should be educated to chew food well about 20 times.
Reflection
I have learned a lot from this case. One of the things I have learned from the case is that abdominal pain is caused by various health problems. Healthcare professionals need to conduct a thorough assessment to determine the exact cause of the pain. Another thing I have learned is that patients should be provided proper education after hospitalization to prevent any readmissions.
The following are the review of systems questions that the patient should be asked to determine the severity, location, and timing of this pain. The first question is what are other associated symptoms? The second question is where do you feel the pain? The patient’s answer will help me identify the exact location of the pain. The third question is apart from cramping, what are other characteristics of the pain? This question will help me understand if the pain comes and goes.
The fourth question is can you do your daily chores with the pain? This question will help me rate the severity of the pain. The fifth question is, can you explain your bowel movements? The last question is what aggravates the pain?
References
Dou, C., Li, K., & Wang, L. (2022). Computed tomography image segmentation of the proximal colon by u-net for the clinical study of somatostatin combined with intestinal obstruction catheter. Computational and Mathematical Methods in Medicine, 2022. https://doi.org/10.1155/2022/6868483
Guo, M., Tao, W., Flavell, R. A., & Zhu, S. (2021). Potential intestinal infection and faecal–oral transmission of SARS-CoV-2. Nature reviews Gastroenterology & hepatology, 18(4), 269-283. https://doi.org/10.1038/s41575-021-00416-6
Jackson, P., & Cruz, M. V. (2018). Intestinal obstruction: evaluation and management. American Family Physician, 98(6), 362-367. http://dispatcher1.ds.aafp.org/content/brand/aafp/pubs/afp/issues/2018/0915/p362/
Talan, D. A., & Di Saverio, S. (2021). Treatment of acute uncomplicated appendicitis. New England Journal of Medicine, 385(12), 1116-1123. https://www.nejm.org/doi/full/10.1056/NEJMcp2107675
Ten Broek, R. P., Krielen, P., Di Saverio, S., Coccolini, F., Biffl, W. L., Ansaloni, L., & van Goor, H. (2018). Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of Emergency Surgery, 13(1), 1-13. https://link.springer.com/article/10.1186/s13017-018-0185-2
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