Case Study 2:

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.

Test results:

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?

SOLUTION – I have stomach pain Case Study

Exploring ROS Questions:

1. Location of Pain: Can you point to where you feel the pain? Is it in the upper abdomen, lower abdomen, or elsewhere?
2. Nature of Pain: How would you describe the pain? Is it sharp, dull, cramping, or burning?
3. Severity of Pain: On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate your current pain level?
4. Timing of Pain: When did the pain start? Has it been constant or intermittent? Does it occur after eating or at specific times of the day?
5. Associated Symptoms: Have you experienced any nausea, vomiting, bloating, or changes in bowel habits along with the pain?
6. Impact on Daily Activities: How has the pain affected your ability to eat, sleep, or perform daily activities?

Next Diagnostic Choices for Bowel Obstruction:

1. Abdominal CT Scan: This can provide detailed imaging of the abdomen, allowing visualization of any obstructions or abnormalities in the bowel.
2. Abdominal Ultrasound: Useful for assessing bowel motility and identifying any structural abnormalities or blockages.
3. Barium Swallow or Upper GI Series: Can help visualize the passage of barium through the digestive tract, highlighting any areas of narrowing or obstruction.

Differential Diagnoses for Abdominal Pain:

1. Bowel Obstruction: Partial or complete blockage of the intestines, leading to abdominal pain, distension, nausea, and vomiting.
2. Gastric Ulcer: A sore or lesion in the lining of the stomach, causing abdominal pain, especially in the epigastric region, along with nausea and vomiting.
3. Gallstones: Hardened deposits in the gallbladder or bile ducts, leading to sudden onset of severe abdominal pain, typically in the upper right quadrant, along with nausea and vomiting.

Next Step after CT Scan Confirms Small Bowel Obstruction:

1. Treatment Initiation: Start conservative management, including bowel rest, intravenous fluids, and nasogastric decompression to relieve distension and vomiting.
2. Surgical Consultation: Consideration for surgical intervention may be warranted, especially if the obstruction is not resolving with conservative measures or if there are signs of bowel ischemia or perforation.
3. Monitor for Complications: Continuously assess for signs of bowel compromise, such as worsening pain, fever, or abdominal distension, and intervene promptly if necessary.