Bowel Obstruction SOAP Note Case Video Presentation

Bowel Obstruction SOAP Note Case Video Presentation. Includes at least 7 qualifiers, a brief past medical and surgical history, and your plan of care.

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Bowel Obstruction SOAP Note Case Video Presentation

Patient Initials: B.O, Gender: Female, Age: 67, Race/Ethnicity: Non-Hispanic White. Religion: Southern Baptist Convention

SUBJECTIVE

CC: “I am unable to defecate for the last three days.”

HPI: B.O is a 67-year-old Non-Hispanic White woman who presents to the E.D. complaining of abdominal pain. She also reports vomiting, constipation, and the absence of flatus. She further reports having a past medical history of intermittent abdominal pain accompanied by bloating over the past three months. The patient claimed the pain usually starts at the right upper quadrant and radiates throughout her abdomen. Abdominal distention was noted, characterized by rounded asymmetric contour, while bowel sounds were normal initially and fell silent later on. She is not on medications currently but admits to using herbal concoctions to alleviate the pain. Bowel Obstruction SOAP Note pulmonary embolism soap note gi soap note

The Pain Qualifiers

The PQRSTU mnemonic, where these initials stand for p- provocative or palliative, Q- quality, R- region or radiations- severity, T- timing, and U- understanding, is significant in assessing abdominal pain and other gastrointestinal (G.I.) symptoms like vomiting, nausea, and distention.

 The patient describes her pain as follows: palpitations soap note

Provocative/ Palliative: B.O. states the pain started  less than 72 hours ago is aggravated by extending the right lower extremity or coughing, and the pain gets better with gentle massage and rest; also, using a cold pack relieves the pain

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Quality: Crampy gas pain in the upper right-side abdomen abdominal pain soap note

 Region or radiation: Right upper quadrant that radiates throughout the abdomen

Severity: 8/10 Severe pain

Timing: Movement of the right leg or coughing (Bowel Obstruction SOAP Note)

 Understanding: The patient thinks the abdominal surgery she had a year ago could be responsible for the present symptoms.

Past Medical

B.O. recalls receiving immunization T.B. (BCG) and Polio (OPV); she had a smallpox infection at 15 years. Other health issues that did not necessitate hospital admission are coughs, colds, fever, sore throat, rashes, and diarrhea. She visits a doctor every two years for a medical–up and has a habit of using herbal medicating. She takes multivitamins.

Surgical History;

12 months ago, B.O. had an exploratory laparotomy and had an operation when the surgeon discovered a mass growth with the descending colon, had the tumor removed, and subjected the same for biopsy. However, the patient never went for the results’ colostomy was performed to help the patient eliminate waste products until the colon healed.

Review of Symptoms

Review of systems is noncontributory as most of it is negative except for G.I., where abdominal distention is noted, and the patient reports abdominal pain accompanied by other G.I. symptoms as captured in the HPI. The vital signs on arrival were all within normal limits.

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ASSESSMENT: Bowel Obstruction SOAP Note

Diagnostic Tests and Differential Diagnosis

1. Small Bowel Obstruction K56.60 – Confirmed-  According to Smith et al. (2017), Obstruction of the intestines is a serious mechanical impairment or complete stoppage of the passage of contents within the bowels. Generally, the most common cause of mechanical Obstruction are adhesions, hernias, and tumors. Additional causes include diverticulitis, foreign bodies, intussusceptions, and volvulus. An abdominal X-ray helped determine the cause of belly pain, while abdominal ultrasonography was instrumental in differential diagnosis that confirmed partial small bowel obstruction K56.60 of unspecified cause. The patient’s presenting symptoms, past medical history, and abdominal x-ray – showing the site of Obstruction helped confirm the diagnosis (TenBroek et al., 2018).
2. Appendicitis (K 35.80) was ruled out because its pain migrates from the navel to the right lower quadrant of the abdomen, but in B.O.’s case, the pain was centered in the middle of the abdomen nearer the stomach (Duc et al., 2020).
3. Likewise, Diverticulitis (K 57.92) was refuted because its characteristic pain is constant and usually concentrates within the left lower quadrant of the abdomen (Scarpignato et al., 2018).

PLAN – Bowel Obstruction SOAP Note

The plan involves the intravenous administration of fluids, bowel rest with nothing to eat (NPO), and then taking a Gastrografin challenge to predict whether the Obstruction will resolve by itself. After 48 hours of non-operative management. During this intervening period, the nurse has several responsibilities, monitoring urine output and conducting serial abdominal exams. Should the patient actively vomit, the physician should consult the OR surgical team for a recommendation like the placement of a nasogastric tube.

Medications include antiemetics like Emend 80mg P.O. twice daily and analgesics like Tylenol 4g P.O. four times daily. If no improvement is noted within 48 hours, consult the surgery team and discuss the surgery with additional imaging and eventually conduct the operation. Before surgery, intravenous therapy is to replace lost water, sodium chloride, and potassium (Amara et al., 2021). Nursing responsibilities include but are not limited to defining and explaining each test to be performed, stating its specific purpose, and discussing pretest preparation, procedure, and post-test care. Discharge planning with patient education on how nursing care will be continued, the role of diet, and other non-medication interventions.

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Referral to Oncologist will be considered if the patient’s symptoms do not resolve and continue to worsen despite the acute management.

Follow-up: The patient will return to the clinic after 14 days t assess and evaluate the patient’s physical status and progress towards recovery. Reinforcement of the previous teaching to happen.

References

Amara, Y., Leppaniemi, A., Catena, F., Ansaloni, L., Sugrue, M., Fraga, G. P., … & Richard, P. (2021). Diagnosis and management of small bowel obstruction in virgin abdomen: a WSES position paper. World journal of emergency surgery, 16(1), 1-9.

Duc, P. H., Xuan, N. M., Thuyet, N. H., & Huy, H. Q. (2020). Intestinal Obstruction due to acute appendicitis. Case Reports in Gastroenterology, 14(2), 346-353.

Scarpignato, C., Barbara, G., Lanas, A., & Strate, L. L. (2018). Management of colonic diverticular disease in the third millennium: Highlights from a symposium held during the United European Gastroenterology Week 2017. Therapeutic Advances in Gastroenterology, 11, 1756284818771305.

Smith, D. A., Kashyap, S., & Nehring, S. M. (2017). Bowel obstruction. Bowel Obstruction SOAP Note

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.

Vercruysse, G., Busch, R., Dimcheff, D., Al-Hawary, M., Saad, R., Seagull, F. J., … & Pumiglia, L. (2021). Evaluation and Management of Mechanical Small Bowel Obstruction in Adults.

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