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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.
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?
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescriiption and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.