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I human Case Study-Dorothy Jones, 54 years old Female, CC: Abdominal Pain

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I human Case Study-Dorothy Jones, 54 years old Female, CC: Abdominal Pain I human Case Study-Dorothy Jones, 54 years old Female, CC: Abdominal Pain Dx: SBO • Feedback: the patients presentation w/ acute mid-abdominal pain, distention, nausea/vomiting, constipation and inability to pass g...

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Geupload op 1 november 2023
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Type Case uitwerking
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I human Case Study-Dorothy Jones, 54 years old

Female, CC: Abdominal Pain

Dx: SBO

• Feedback: the patients presentation w/ acute mid-abdominal pain,

distention, nausea/vomiting, constipation and inability to pass gas is

consistent with SBO. An abdominal series confirms the present of multiple

dilated loops of small bowel. Her history of 2 prior abdominal surgeries

significantly increases the likelihood of her bowel

obstruction being secondary to postsurgical adhesions. Approximately 93%

of all patients who have had prior abdominal surgery have adhesions; of

whom 14% will require intervention for adhesion-related sequelae within 10

years of their surgery.

Problem statement:

Dorothy Jones is a 54 year old female that presents with acute, progressive

abdominal pain for 3 days. She complains of absence flatus, emesis and abdominal

, distention. Past medical history includes hysterectomy removal 2 years ago,

cholecystectomy 15 years ago, hyperlipidemia and constipation. Upon assessment,

patient noted to be tachycardic, obese, absent bowel sounds, periumbilical

discomfort to palpation, distended abdomen and tympany noted on percussion.

Ms. Jones is awake, alert and oriented x4. No acute distress. Patient is age

appropriate and looks uncomfortable. Her vital signs are as follows: blood pressure

128/72, pulse 100 beats per minute, 37 degrees Celsius (98.6 degrees Fahrenheit),

respiration rate is 18 and oxygen level is 98%. Upon assessment, her

HEENT/Neck is normal. PMI is in the 5th intercostal space at the midclavicular

line. Normal jugular venous pressure but is noted to have tachycardia. Her chest is

symmetrical and no use of accessory muscles are noted while breathing. All

superficial thoracic lymph nodes are non-palpable, of normal size and consistent

throughout. Anterior lung fields are resonant. The left anterior chest and right

lower chest are dull. The rest of lung fields are resonant. Lung sounds bilaterally

are normal. The abdomen is atraumatic, mildly obese, symmetrical, slightly taut

and distended. Surgical scars noted. No visible peristalsis, mass or organomegaly.

Mild discomfort throughout abdominal palpation and occasional palpable

peristalsis. No involuntary guarding or rebound tenderness noted. Upon percussion,

moderately tympanitic noted. Normal girth. Absent bowel sounds. Patient has no

problem with her genitourinary or rectum. She has noted however that her urine is

darker than normal. She has normal and equal ROM bilaterally. Her gait is steady.

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