question help

Initials: E.P.

Age: 78

Gender: female

Height

Weight

BP

HR

RR

Temp

SPO2

5’2 ft

120 lbs

110/70

92

16

37.0 C

98.00%

History of Present Illness (HPI)

Chief Complaint (CC)

Abdominal pain and constipation for 5 days, worsened 2 days ago

O nset

5 days ago when attempting to move bowels, she normally has daily BM

L ocation

abdomen unspecified

D uration

constant

C haracteristics

general discomfort, cramping, bloating, increased flatulence. Rates pain at level 6/10. Reports onset of diarrhea 2 days ago for 1 day consisting of loose and watery BM

A ggravating Factors

Ambulation/food intake

R elieving Factors

Some relief with rest, but ineffective. Hasn’t tried pain medications or laxatives

T reatment

drinks small sips of warm water for pain relief-ineffective.

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

10mg PO

once daily in the morning

long lasting

HTN

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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.

Allergies: Latex:contact dermatitis

Immunizations: current except influenza

Hx of HTN diagnosed at age 54

Denies neurologic, respiratory,cardiovascular, GI,GU, skin disorders.

Surgeries: C-section at age40, Cholecystectomy at age 42

3 pregnancies: 1 stillbirth, 2 live children. No abortions or miscarriages

Hospitalizations: None other than above surgical and deliveries.

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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.

Lives with daughter-good support system. Reports keeping house clean daily.

Enjoys fitness class, daily walking, gardening.

Diet: Reports last meal was toast at breakfast, Typically eats 3 meals, does not eat snacks, breakfast is a piece of fruit, lunch is soup, sometimes skips lunch, dinner is chicken or fish with vegetables and rice. Reports getting fiber from 1 daily vegetable

Reports 6 glasses of water daily, decreased thirst lately. Eating or drinking elicits abdominal pain.Denies coffee or soda

Sexually active with 1 sexual partner “her gentleman friend” practices oral sex, denies intercourse, denies use of condoms. Reports being satisfied with sex life. Denies Hx of STI, pain, lumps yellow, green or malodorous drainage to vaginal area. Last pap smear 10 years ago.

Reports yearly PCP check ups at ShadowHealth clinic, last 3 months ago.

Last colonoscopy: 10 years ago, denies abnormal findings.

Enjoys fitness class, daily walking, gardening.

Denies alcohol or illicit drug use.

Reports 1 alcoholic beverage per week, on Sundays

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: Deceased at 88. Hx of HTN and DM type II

Father: Deceased at 82. Hx of HTN and Hypercholesterolemia

Maternal Grandparents:CAD and DM Type II

Paternal Grandparents:Obesity, CVA, HTN

Brother: Hx of HTN and Hypercholesterolemia and Prostate cancer

Son: healthy, 48

Daughter: healthy, 46

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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

Skin

HEENT

X Fatigue

☐Weakness: denies to r/o malignancy, anorexia .

☐Fever/Chills:denies to r/o infection

☐Weight Gain .

☐Weight Loss: denies to r/o malignancy, anorexia .

☐Trouble Sleeping .

☐Night Sweats .

☐Other:

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☐Itching .

☐Rashes .

☐Nail Changes .

☐Skin Color Changes .

☐Other:

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☐Diplopia .

☐Eye Pain .

☐Eye redness .

☐Vision changes .

☐Photophobia .

☐Eye discharge .

☐Earache .

☐Tinnitus .

☐Epistaxis .

☐Vertigo .

☐Hearing Changes .

☐Hoarseness .

☐Oral Ulcers .

☐Sore Throat .

☐Congestion .

☐Rhinorrhea .

☐Other:

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Respiratory

Neuro

Cardiovascular

☐Cough .

☐Hemoptysis .

☐Dyspnea:Denies

☐Wheezing .

☐Pain on Inspiration .

☐Sputum Production

Choose an item.

Choose an item.

Choose an item.

☐Other: .

☐Syncope or Lightheadedness .

☐Headache .

☐Numbness .

☐Tingling .

☐Sensation Changes

Choose an item.

☐Speech Deficits .

☐Other: .

☐Chest pain:Denies to r/o cardiac cause

☐SOB: Denies to r/o cardiac cause

X Exercise Intolerance

☐Orthopnea .

☐Edema .

☐Murmurs .

MSK

GI

GU

PSYCH

☐Pain .

☐Stiffness .

☐Crepitus .

☐Swelling .

☐Limited ROM Choose an item.

☐Redness .

☐Misalignment .

☐Other: .

☐Nausea/Vomiting Denies to r/o obstruction/GERD

☐Dysphasia: Denies

X Diarrhea .

X Appetite Change:decreased

☐Heartburn: Denies to r/o other GI causes

X Blood in Stool: reports darker stool

X Abdominal Pain .

XExcessive Flatus .

☐Food Intolerance .

☐Rectal Bleeding:Denies to r/o IBS, UC, colorectal cancer

X Other:CONSTIPATION

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☐Urgency:Denies

☐Dysuria .Denies to r/o out UTI

☐Burning: Denies to r/o out UTI

☐Hematuria:Denies to r/o out UTI

☐Polyuria .

☐Nocturia .

☐Incontinence: Denies to r/o other GU causes

☐Other:

X Darker urine and less frequent.

☐Stress .

☐Anxiety .

☐Depression .

☐Suicidal/Homicidal Ideation .

☐Memory Deficits .

☐Mood Changes .

☐Trouble Concentrating .

☐Other: .

GYN

☐Rash .

☐Discharge .

☐Itching .

☐Irregular Menses .

☐Dysmenorrhea .

☐Foul Odor .

X menopausal

X Other:Denies intercourse for many years: to r/o STD

☐Amenorrhea .

☐LMP: AGE 54

☐Contraception .

☐Other:denies use of condoms.

Body System

Positive Findings

Negative Findings

General

Choose an item.

Pleasant 78 year old woman, no acute distress, good eye contact, well articulated, steady gait.

Skin

Choose an item.

flushed appearance

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No tenting

HEENT

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Mouth and Nasal mucosa moist and pink

Respiratory

Choose an item.

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Breath sounds clear in all areas.

Neuro

Choose an item.

Skull and face symmetrical

Cardiovascular

Choose an item.

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No edema to BLE. S1 and S2 audible, no extra sounds.

Aorta, bilateral femoral, inguinal, iliac and renal arteries :No bruit. Aortic width: less than 3cm. Liver palpable. Spleen not palpable.

Musculoskeletal

Choose an item.

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Gastrointestinal

Choose an item.

Surgical scar to LUQ. Tenderness and distention to LLQ. Palpable 2x 4cm mass palpated to LLQ. Fecal mass in rectal vault.

Abdomen flat and symmetric. Normoactive bowel sounds to all quadrants. Liver and spleen: no friction rub. Abdomen: Some areas dull, some tympanic. Spleen: tympanic. Liver: between 6-12cm.

Genitourinary

Choose an item.

Urinalysis: clear,acidic, dark yellow

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No CVA tenderness noted. Bladder and kidneys: not palpable.

Psychiatric

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Gynecological

Choose an item.

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Pelvic exam: no abnormal findings.

Problem List

1 constipation

6 diet low in fiber

2 abdominal pain

7 dehydration

3 functional decline

8 activity intolerance

4 fatigue

9 . need for disease process education

5 loss of appetite

10 .

Diagnosis

ICD-10 Code

Pertinent Findings

Fecal Impaction

K56.41

Constipation with alternating loose watery stool. Poor appetite, abdominal pain after meals, malaise. Diet low in fiber. Fecal mass in rectal vault

Constipation

K59.00

denies bowel movement for 5 days, her usual frequency is daily. Abdominal pain and cramps. Diet low in fiber. Fecal mass in rectal vault

Diverticulitis

K57.92

Abdominal pain and guarding to LLQ, pain worsens when eating. Constipation. Last colonoscopy 10 years ago

Diagnostics: List tests you will order this visit

Test

Rationale/Citation

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Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent.

Drug

Dosage

Length of Treatment

polyethylene glycol oral

Fleet Enema

1 to 3 liters of polyethylene glycol over a period of hours

If the fecal impaction is located distally, then the use of enemas and suppositories can be helpful. For proximal fecal impaction, the ideal laxative is polyethylene glycol and enema. One may have to administer from 1 to 3 liters of polyethylene glycol over a period of hours before a response is seen. If abdominal cramps and nausea occur, then no more polyethylene glycol should be ingested (Waheed et. al, 2019)

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Referral/Consults:

See follow up note below

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Education:

Eat a diet rich in fiber which includes 5 servings of darker green vegetables and fruits, more vegetables than fruit. Examples of fiber rich foods are prunes, spinach, broccoli. Resume your water intake to 6 glasses a day.

Fecal impaction is a significant but preventable problem in the elderly population. The best way to treat it is to prevent it from developing in the first place. The cause of constipation should be identified early and managed appropriately. The patient should be educated about lifestyle measures and dietary habits to prevent fecal impaction. Unfortunately, recurrent fecal impaction is very common in elderly and institutionalized patients. Often these patients present to the emergency department because the presenting symptoms can mimic other sinister intestinal pathology (Waheed et. al, 2019)

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Rationale/Citation

Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.

If impaction is not relieved by use of Polyethylene glycol and enema, call the office. (If not relieved, depending on her symptoms, I would have to either refer the patient to a gastroenterologist who can see her soon to perform disimpaction procedure or have her go to the ER for further evaluation.)

Rationale/Citation

The enema is best delivered with a Foley catheter past the hardened stool. The best method is to use ample water and combine it with docusate or sorbitol. It is important to administer small amounts of enema so as not to create discomfort in the patient. Once the enema is administered, one can help the process of evacuation by gently massaging the lower abdomen. This process may have to be repeated several times until only clear liquid passes (Waheed et. al, 2019). This is treatment should be performed by a medical professional

References

Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting.

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Waheed, A., Mathew, G., & Cagir, B. (2019). Fecal Impaction. https://www.ncbi.nlm.nih.gov/books/NBK448094/

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