week 6 paper
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Focused Exam: Abdominal Pain Results | Turned In
Physical Assessment – June 2020, NUR 3010
Return to Assignment (/assignments/351028/)
Objective Data Collection: 21 of 21 (100%)
Your Results Reopen (/assignment_attempts/7049123/reopen
Lab Pass (/assignment_attempts/7049123/lab_pass.p
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Care Plan
Correct
Partially correct
Incorrect
Missed
Inspected head and face 1 of 1 point
Skull Symmetry (1/3 point)
Symmetric
Asymmetric
Facial Feature Symmetry (1/3 point)
Symmetric
Asymmetric
Appearance (1/3 point)
No visible abnormal findings
Flushed appearance
Rash or lesion
Skin growths (freckles, moles, or birth mark)
Excessive hair growth
Evidence of skin trauma (scar, laceration, or bruising)
Inspected nasal mucosa 1 of 1 point
Appearance (1/1 point)
Moist and pink
Dry appearance
Redness
Inspected mouth 1 of 1 point
Oral Mucosa (1/1 point)
Moist and pink
Dry appearance
Redness
Inspected abdomen 1 of 1 point
Symmetry (1/3 point)
Symmetric
Asymmetric
Contour (1/3 point)
Flat
Rounded
Protuberant
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Hollowed
Appearance (1/3 point)
No visible abnormal findings
Rash
Striae
Bulging around umbilicus
Distension
Visible masses (warts, cysts, or tumors)
Freckles, birthmark, or discoloration
Excessive hair growth
Scarring
Laceration, lesion, or wound
Bruising
Redness
Jaundice
Prominent veins
Inspected for edema in lower extremities 1 of 1 point
Right: Edema (1/4 point)
No edema
Pitting
Non-pitting
Right: Severity Of Edema (1/4 point)
No edema
1+ Slight pitting
2+ Deeper pit, disappears in 10 to 15 seconds
3+ Noticeably deep pit that lasts more than a minute
4+ Very deep pit that lasts 2 to 5 minutes
Left: Edema (1/4 point)
No edema
Pitting
Non-pitting
Left: Severity Of Edema (1/4 point)
No edema
1+ Slight pitting
2+ Deeper pit, disappears in 10 to 15 seconds
3+ Noticeably deep pit that lasts more than a minute
4+ Very deep pit that lasts 2 to 5 minutes
Auscultated heart sounds 1 of 1 point
Heart Sounds (1/2 point)
S1 and S2 audible
S1, S2, and S3 audible
S1, S2, and S4 audible
S1, S2, S3, and S4 audible
Extra Heart Sounds (1/2 point)
No extra sounds
Gallops
Murmur
Friction rub
Valve clicks
Auscultated breath sounds 1 of 1 point
Breath Sounds (1/3 point)
Present in all areas
Diminished in some areas
Absent in some areas
Adventitious Sounds (1/3 point)
No adventitious sounds
Wheezing
Fine crackles
Stridor
Rhonchi
Rales
Location (1/3 point)
All areas clear
Adventitious sounds in anterior right upper lobe
Adventitious sounds in anterior right middle lobe
Adventitious sounds in anterior right lower lobe
Adventitious sounds in anterior left upper lobe
Adventitious sounds in anterior left lower lobe
Adventitious sounds in posterior right upper lobe
Adventitious sounds in posterior right lower lobehttps://www.coursehero.com/file/63204063/Esther-Parks-Focused-Exam-Abdominal-Pain-Objectivepdf/
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Adventitious sounds in posterior left upper lobe
Adventitious sounds in posterior left lower lobe
Auscultated abdominal aorta 1 of 1 point
Sound (1/1 point)
No bruit
Bruit
Auscultated bowel sounds 1 of 1 point
Bowel Sounds (1/2 point)
Absent
Hypoactive
Normoactive
Hyperactive
Location Of Non Normoactive Bowel Sounds (1/2 point)
All quadrants normoactive
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Auscultated abdominal arteries 1 of 1 point
Right: Renal (1/6 point)
No bruit
Bruit
Right: Iliac (1/6 point)
No bruit
Bruit
Right: Femoral (1/6 point)
No bruit
Bruit
Left: Renal (1/6 point)
No bruit
Bruit
Left: Iliac (1/6 point)
No bruit
Bruit
Left: Femoral (1/6 point)
No bruit
Bruit
Percussed abdomen 1 of 1 point
Observations (1/1 point)
All areas generally tympanic
Some areas dull, some tympanic
Some areas resonant
Percussed CVA tenderness 1 of 1 point
Patient Reaction (1/1 point)
Did not react
Pain reaction
Percussed spleen 1 of 1 point
Spleen (1/1 point)
Tympany
Dullness
Percussed liver 1 of 1 point
Liver Span (1/1 point)
Smaller than 6 cm
Between 6 and 12 cm
Greater than 12 cmhttps://www.coursehero.com/file/63204063/Esther-Parks-Focused-Exam-Abdominal-Pain-Objectivepdf/
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Palpated abdomen – light 1 of 1 point
Tenderness (1/3 point)
None reported
Tenderness reported
Location Of Tenderness (1/3 point)
No quadrants tender
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Observations (1/3 point)
No additional observations
Masses
Guarding
Distension
Palpated abdomen – deep 1 of 1 point
Presence Of Unexpected Mass (1/2 point)
No palpable mass
Palpable mass
Location Of Mass (1/2 point)
No palpable mass
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Around umbilicus
Palpated liver 1 of 1 point
Detection (1/1 point)
Not palpable
Palpable
Palpated spleen 1 of 1 point
Detection (1/1 point)
Not palpable
Palpable
Palpated bladder 1 of 1 point
Detection (1/1 point)
Not palpable
Palpable
Palpated kidneys 1 of 1 point
Right (1/2 point)
Palpable
Not palpable
Left (1/2 point)
Palpable
Not palpable
Tested skin turgor 1 of 1 point
Observations (1/1 point)
No tenting
Tenting
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http://www.tcpdf.org Document: Provider Notes
Student Documentation
Model Documentation
Subjective
Ms. Parks reports some abdominal discomfort and pain over the last week with increase in the pain over the last 2-3 days. She rates her abdominal pain at 6/1, describing it as “dull and crampy” in left lower abdomen. She states she had a diarrhea 3 days ago and since than she had no bowel movement. She denies any abdominal pain radiation. She denies any rectal pain or bleeding, fever, nasuea, vaginal discharge or discomfort, burning sensation or any other urinary symptoms. She denies any past medical or family history of GI problems. She states haveing c-section and cholecystomy in early 40s. She has had a decrease in appetite over the last few days; states she drinks small amount of water and fluids. She denies taking any medications for abdominal pain or constipation. She states passing gass. The normal BM is regular, soft and brown in color, every 1-2 days with no other problems. Ms. Parks lives with daughter. Daughter does the shopping and Ms.Parks cooks herself
Ms. Park reports that she is having pain in her belly. She experienced mild diarrhea three days ago and has not had a bowel movement since. She reports that she has been feeling some abdominal discomfort for close to a week, but the pain has increased in the past 2-3 days. She now rates her pain at 6 out of 10, and describes it as dull and crampy. She reports her pain level at the onset at 3 out of 10. She is also experiencing bloating. She did not feel her symptoms warranted a trip to the clinic but her daughter insisted she come. She describes her symptoms primarily as generalized discomfort in the abdomen, and states that her lower abdomen is the location of the pain. She denies nausea and vomiting, blood or mucus in stool, rectal pain or bleeding, or recent fever. She denies vaginal bleeding or discharge. Reports no history of inflammatory bowel disease or GERD. Denies family history of GI disorders. Her appetite has decreased over the last few days and she is taking small amounts of water and fluids. Previously she reports regular brown soft stools every day to every other day.
Objective
Elderly womes sitting up in the exam with grimace at the time of discomfort. Appears a liitle bit distressed but stable, able to answer all inquiries and is goog historian. HEENT: nose and mouth with moist pink mucouse membranes, normal skin turgor with no tenting. Cardio: S1, S2, no gallops, rubs, or murmurs noted. No edema to lower extremities. Respiratory: respiration unlabored and quiet, abel to speak full sentences with no SOB. Lung breath sounds CTA in all lobes. Abdominal: 10 cm scar at midline in suprapubic region and 6 cm scar in RUQ, Exam reveals no discoloration, bowel sounds WNL in all quadrants; no friction sounds over spleen or liver, no bruits in any areas; tympany presides; Liver span at 7 cm; Guarding to light touch at LLQ; 2×4 mass in LLQ with deep palpation; strong sphincter tone, fecal mass detected in rectal vault. GU: bilateral kindey nontender; urine clear and dark yellow, normal odor, no nitrites, WBCs, RBCs, or keatones, pH 6.5, SG 1.017.
General Survey: Uncomfortable and flushed appearing elderly woman seated on exam table grimacing at times. Appears stable but mildly distressed. HEENT: Mucus membranes are moist. Normal skin turgor; no tenting. Cardiovascular: S1, S2, no murmurs, gallops or rubs; no S3, S4 rubs. No lower extremity edema. Respiratory: Respirations quiet and unlabored, able to speak in full sentences. Breath sounds clear to auscultation. Abdominal: 6 cm scar in RUQ and 10 cm scar at midline in suprapubic region. An abdominal exam reveals no discoloration; normoactive bowel sounds in all quadrants; no bruits; no friction sounds over spleen or liver; tympany presides with scattered dullness over LLQ; abdomen soft in all quadrants; an oblong mass is noted in the LLQ with mild guarding, distension; no organomegaly; no CVA tenderness; liver span 7 cm @ MCL; no hernias. Rectal: No hemorrhoids, no fissures or ulceration; strong sphincter tone, fecal mass in rectal vault. Pelvic: No inflammation or irritation of vulva, abnormal discharge, or bleeding; no masses, growths, or tenderness upon palpation. Urinalysis: Urine clear, dark yellow, normal odor. No nitrites, WBCs, RBCs, or ketones detected; pH 6.5, SG 1.017.
Assessment
Primary: Constipation Secondary: Small Bowel Obstruction
Mrs. Parks bowel sounds are normoactive in all quadrants, with no bruits or friction sounds. Scattered dullness in LLQ during percussion is suggestive of feces in the colon; otherwise, her abdomen is tympanic. Her abdomen is soft to palpation; mild guarding and oblong mass suggesting feces were discovered in LLQ. No CVA tenderness; liver span 7 cm @ MCL; no splenic dullness. Digital rectal exam revealed a fecal mass in the rectal vault. No abnormalities were noted during the pelvic exam, so pelvic inflammatory disease is not suspected. Ms. Parks urinalysis was normal, which rules out a urinary tract infection. No signs of dehydration or cardiovascular abnormalities. Mrs. Parks symptoms and health history suggest she has constipation. Differential diagnoses are constipation, diverticulitis, and intestinal obstruction.
Plan
Encourage to drink more fluids at tleast 8-10 glasses water a day Encourage to drink prune juice Prescription for stool softener Docuset 100 mg BID PO Abdominal x-ray Abdominal CAT scan Blood draw CBC, BMP, Hep/Lip panel
Mrs. Park should receive diagnostic tests to rule out differentials: CBC to assess for elevated WBCs associated with diverticulitis, electrolyte profile to evaluate electrolyte and fluid status, and a CT scan to assess for obstruction. If Mrs. Park has diverticulitis I recommend IV fluids and bowel rest. If she has bowel obstruction, I recommend NPO, IV fluids, and general surgical consult. If she has constipation, I recommend that she increase fluids, increase fiber, and increase activity as tolerated. SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: E.P.
Age: 78 years old
Gender: Female
Height
Weight
BP
HR
RR
Temp
SPO2
Pain Rating
Allergies (and reaction)
Latex ( skin rash)
5 2 feet 120 lbs 110/70 92 16 37.0 99 %
6/10
Medication: NKA
Food: NKA
Environment: latex (dermatitis)
History of Present Illness (HPI)
Chief Complaint (CC)
Abdominal Pain
CC is a BRIEF statement identifying why the patient is here – in the patients own words – for instance “headache”, NOT “bad headache for 3 days. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom
O
nset
Since 5 days ago
L
ocation
Lower abdomen quadrants
D
uration
5 days ago
C
haracteristics
Cramp, dull, discomfort
Aggravating factors
Activity and eating
R
elieving Factors
Rest and not to move too much
T
reatment
Click or tap here to enter text.
Current Medications:
Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic)
Dosage
Frequency
Length of Time Used
Reason for Use
Accupril PO 10 mg daily continue HTN
Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.
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Past Medical History (PMHx)
Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Hypertension diagnosed at age 54
Immunizations up to the date
No flu vaccination this year (pending for next appointment)
3 pregnancies
Surgical history of a C-section at 40 and a cholecystectomy at 42
No recent hospitalizations.
Social History (Soc Hx) –
Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Patient denied tobacco, cigar and marihuana
Patient denied any use of any illicit drugs
Pt drink one glass of dry wine sometimes
Family History (Fam Hx) –
Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Mother: history of hypertension and DM type II.
Father: Died in his sleep, history of hypertension and hypercholesterolemia.
Maternal grandparents: family history of coronary artery disease and DM type II.
Paternal grandparents family history of obesity, CVA and hypertension.
Siblings: HTN, hypercholesterolemia, prostate cancer (one of the brother).
Son and daughter with no medical history.
Review of Systems (ROS):
Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.
Constitutional
If patient denies all symptoms for this system, check here:
Skin
If patient denies all symptoms for this system, check here:
HEENT
If patient denies all symptoms for this system, check here:
Fatigue Click or tap here to enter text.
Weakness Click or tap here to enter text.
Fever/Chills Click or tap here to enter text.
Weight Gain Click or tap here to enter text.
Weight Loss Click or tap here to enter text.
Trouble Sleeping Click or tap here to enter text.
Night Sweats Click or tap here to enter text.
Other:
Click or tap here to enter text.
Itching Click or tap here to enter text.
Rashes Click or tap here to enter text.
Nail Changes Click or tap here to enter text.
Skin Color Changes flushed
Other:
Click or tap here to enter text.
Diplopia Click or tap here to enter text.
Eye Pain Click or tap here to enter text.
Eye redness Click or tap here to enter text.
Vision changes Click or tap here to enter text.
Photophobia Click or tap here to enter text.
Eye discharge Click or tap here to enter text.
Earache Click or tap here to enter text.
Tinnitus Click or tap here to enter text.
Epistaxis Click or tap here to enter text.
Vertigo Click or tap here to enter text.
Hearing Changes Click or tap here to enter text.
Hoarseness Click or tap here to enter text.
Oral Ulcers Click or tap here to enter text.
Sore Throat Click or tap here to enter text.
Congestion Click or tap here to enter text.
Rhinorrhea Click or tap here to enter text.
Other:
Click or tap here to enter text.
Respiratory
If patient denies all symptoms for this system, check here:
Neuro
If patient denies all symptoms for this system, check here:
Cardiac and Peripheral Vascular
If patient denies all symptoms for this system, check here:
Cough Click or tap here to enter text.
Hemoptysis Click or tap here to enter text.
Dyspnea Click or tap here to enter text.
Wheezing Click or tap here to enter text.
Pain on Inspiration Click or tap here to enter text.
Sputum Production
Choose an item.
Choose an item.
Choose an item.
Other: Click or tap here to enter text.
Syncope or Lightheadedness Click or tap here to enter text.
Headache Click or tap here to enter text.
Numbness Click or tap here to enter text.
Tingling Click or tap here to enter text.
Sensation Changes
Choose an item.
Speech Deficits Click or tap here to enter text.
Other: Click or tap here to enter text.
Chest pain Click or tap here to enter text.
SOB Click or tap here to enter text.
Exercise Intolerance Click or tap here to enter text.
Orthopnea Click or tap here to enter text.
Edema Click or tap here to enter text.
Murmurs Click or tap here to enter text.
Palpitations Click or tap here to enter text.
Faintness Click or tap here to enter text.
Claudications Click or tap here to enter text.
PND Click or tap here to enter text.
Other: Click or tap here to enter text.
MSK
If patient denies all symptoms for this system, check here:
GI
If patient denies all symptoms for this system, check here:
GU
If patient denies all symptoms for this system, check here:
PSYCH
If patient denies all symptoms for this system, check here:
Pain Click or tap here to enter text.
Stiffness Click or tap here to enter text.
Crepitus Click or tap here to enter text.
Swelling Click or tap here to enter text.
Limited ROM Choose an item.
Redness Click or tap here to enter text.
Misalignment Click or tap here to enter text.
Other: Click or tap here to enter text.
Nausea/Vomiting Click or tap here to enter text.
Dysphasia Click or tap here to enter text.
Diarrhea Click or tap here to enter text.
Appetite Change Click or tap here to enter text.
Heartburn Click or tap here to enter text.
Blood in Stool Click or tap here to enter text.
Abdominal Pain Click or tap here to enter text.
Excessive Flatus Click or tap here to enter text.
Food Intolerance Click or tap here to enter text.
Rectal Bleeding Click or tap here to enter text.
Other: loose and watery stools 5 days ago, bloating, passing gases, distention and tenderness.
Urgency Click or tap here to enter text.
Dysuria Click or tap here to enter text.
Burning Click or tap here to enter text.
Hematuria Click or tap here to enter text.
Polyuria Click or tap here to enter text.
Nocturia Click or tap here to enter text.
Incontinence Click or tap here to enter text.
Other: Click or tap here to enter text.
Stress Click or tap here to enter text.
Anxiety Click or tap here to enter text.
Depression Click or tap here to enter text.
Suicidal/Homicidal Ideation Click or tap here to enter text.
Memory Deficits Click or tap here to enter text.
Mood Changes Click or tap here to enter text.
Trouble Concentrating Click or tap here to enter text.
Other: Click or tap here to enter text.
GYN
If patient denies all symptoms for this system, check here:
Hematology/Lymphatics
If patient denies all symptoms for this system, check here:
Endocrine
If patient denies all symptoms for this system, check here:
Rash Click or tap here to enter text.
Discharge Click or tap here to enter text.
Itching Click or tap here to enter text.
Irregular Menses Click or tap here to enter text.
Dysmenorrhea Click or tap here to enter text.
Foul Odor Click or tap here to enter text.
Amenorrhea Click or tap here to enter text.
LMP: Click or tap here to enter text.
Contraception Click or tap here to enter text.
Other:Click or tap here to enter text.
Anemia Click or tap here to enter text.
Easy bruising/bleeding Click or tap here to enter text.
Past Transfusions Click or tap here to enter text.
Enlarged/Tender lymph node(s) Click or tap here to enter text.
Blood or lymph disorder Click or tap here to enter text.
Other Click or tap here to enter text.
Abnormal growth Click or tap here to enter text.
Increased appetite Click or tap here to enter text.
Increased thirst Click or tap here to enter text.
Thyroid disorder Click or tap here to enter text.
Heat/cold intolerance Click or tap here to enter text.
Excessive sweating Click or tap here to enter text.
Diabetes Click or tap here to enter text.
Other Click or tap here to enter text.
O: Objective
Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write Unable to assess. Document pertinent positive and negative assessment findings. Pertinent positive are the abnormal findings and pertinent negative are the expected normal findings. Separate the assessment findings accordingly and be detailed.
Body System
Positive Findings
Negative Findings
General
Click or tap here to enter text.
Skin
Flushed of the skin noted during inspection
Skin is warm, dry, clean and intact, no open wounds, no ulcerations, and no tenting, nasal mucosa and mouth are pink and moist
HEENT
Click or tap here to enter text.
No visible findings to the head, skull and facial symmetry,
Nose and oral mucosa moist and pink.
Respiratory
Click or tap here to enter text.
Breath sounds present and clear in all the quadrants anteriorly and posteriorly, no adventitious sounds present
Neuro
Click or tap here to enter text.
Patient is alert and oriented x 4, follow commands, answer questions properly.
Cardiovascular
Click or tap here to enter text.
Heart sounds S1 and S2 audible in auscultation
No additional heart sounds found
Musculoskeletal
Click or tap here to enter text.
Normal range of motion in all extremities, no stiffness noted
Gastrointestinal
Distention, pain, tenderness and mass in left lower quadrant
Genitourinary
Click or tap here to enter text.
Psychiatric
Click or tap here to enter text.
Pt denied any suicidal thoughts and denied any depression and anxiety.
Gynecological
Click or tap here to enter text.
No abnormal findings, no inflammation, no irritation, no discharges, no bleedings, no tenderness. Digital rectal exam: negative for hemorrhoids, no fissure or ulcerations, strong sphincter tome, no fecal mass detected
Problem List
Constipation
6. Click or tap here to enter text.
11. Click or tap here to enter text.
2. Diverticulitis
7. Click or tap here to enter text.
12. Click or tap here to enter text.
3. Fecal or intestinal obstruction
8. Click or tap here to enter text.
13. Click or tap here to enter text.
4. Dehydration
9. Click or tap here to enter text.
14. Click or tap here to enter text.
5. Electrolyte Imbalance
10. Click or tap here to enter text.
15. Click or tap here to enter text.
A: Assessment
Medical Diagnoses. Provide 3 differential diagnoses (DDx) which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.
Diagnosis
ICD-10 Code
Pertinent Findings
Diverticulitis
K57.92 Constant pain that last several days. Skin is flushed which can indicated that pt may start having a low grade fever, no BM in the last 5 days, last BM was watery with loose stools.
Intestinal Obstruction or Fecal Impaction
Intra- abdominal Mass
K56. 41
R19.00
Abdominal pain with cramps and colicky, vital signs may be normal in early bowel obstruction but with signs of dehydration ( acidic of the urine), abdominal distention and tenderness
Mass and lump, swelling and bloating.
Dehydration
E 86.0 Low fluid intake ( 2 glasses of water per day), skin is dry, and 6.5 urine acidity
P: Plan
Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write None at this time but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.
Diagnostics:
List tests you will order this visit
Test
Rationale/Citation
Ct scan of the abdomen Is used to diagnose diseases of the small bowel, colon and other intestinal organs. It is painless and noninvasive and accurate to help to diagnose diverticulitis because it can show infected or inflamed pouches
X ray of the abdomen or KUB It can help to diagnose fecal impaction because it can shows abdominal distention, bowel obstruction, or nonconstructive ileus and evaluation of palpable mass.
Chemistry 7 lab test To check electrolytes imbalance and base line and kidney function
Click or tap here to enter text. Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text.
Medications:
List medications/treatments including OTC drugs you will order and continue meds if pertinent.
Drug
Dosage
Length of Treatment
Rationale/Citation
Accupril PO 10 mg daily Click or tap here to enter text. HTN
Metronidazole 500 by mouth BID 14 days Possible diverticulitis
Tylenol PO 500 mg Q6 PRN For pain management
Senna PO 8.6mg BID daily For constipation
Miralax 1 package 1 package daily
daily
For constipation
Referral/Consults:
Gastroenterologist
Depending on CT or Xray diagnostic test results, a consult with specialist in GI is necessary to establish goals of care, management and continuity of care.
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Education:
Diet modification, increase in fluid intake, OTC fiber and continuity of active physical activity, pain management.
Increase in fiber intake in diet is essential in case of fecal impaction and constipation. In addition, increase of fluid intake to 8 glasses of water per day is essential to prevent dehydration and constipation. Decreased the use of teas or herbal products because are diuretics (at least for now). Use of analgesic to control pain and symptoms. Use of stool softener to increase peristalsis.
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Follow Up:
Indicate when patient should return to clinic and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere.
Primary Care doctor follow up in 3 days
Follow up with GI doctor
To monitor improvement of symptoms , bowel sounds, bowel movement and monitor if medical treatment was effective
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References
Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting.
Shin, A. (2020). Patient considerations in the management of chronic constipation: focus on prucalopride. Patient Preference and Adherence, 1373+. Retrieved from https://link.gale.com/apps/doc/A622160320/AONE?u=fjp_jvpl&sid=AONE&xid=6f22d865
Nigar, S., Sunkara, T., Culliford, A., & Gaduputi, V. (2017). Giant Fecalith Causing Near Intestinal Obstruction and Rectal Ischemia. Case Reports in Gastroenterology, 11(1), 59+. Retrieved from https://link.gale.com/apps/doc/A596061162/AONE?u=fjp_jvpl&sid=AONE&xid=31bb71f1
Pfutzer, R. H., & Kruis, W. (2015). Management of diverticular disease. Nature Reviews Gastroenterology & Hepatology, 12(11), 629+. Retrieved from https://link.gale.com/apps/doc/A434224977/AONE?u=fjp_jvpl&sid=AONE&xid=ddd5c3ff
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