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Larry Orlander 50 Y/O

IHUMAN.CC: Abdominal Pain,

Nausea and Vomiting.

(NR667 IHuman latest update 2023)

History and Physical Examination

Patient Demographics Name: Larry Orlander Age/Race/Sex: 50 y/o African American Male CC : Abdominal pain, Nausea and Vomiting.

History

Mr. Orlander is a 50 y/o African American male that presents to the clinic with a 3- day history of intermittent abdominal pain, nausea and vomiting that has been progressively getting worse. PMH: diverticulitis. Currently on no medications. Denies any hematemesis, fever, chills, or night sweats.

Physical Examination

Physical exam reveals hyperactive bowel sounds, tenderness to palpation on abdomen and “drum” like sounds heard on percussion. History of diverticulitis Abdominal pain Absence of gas Periumbilical pain No blood in stool History of abdominal surgery Nausea Vomiting

Weakness Tachycardia Inability to urinate

12 Does the pain in your abdomen radiate someplace else?

13 Is the pain in your abdomen affected by what, when, or how much you eat? 14 Any change in the frequency of your bowel movements? 15 Any previous medical, surgical, or dental procedures?

16 Are you unable to pass gas? 17 Can you tell me about any current or past medical problems you’ve had? 18 Do you have a history of bowel obstruction? 19 Have you or any family member had a history of inflammatory bowel disease? 20 Have you had the pain in your abdomen before? 21 Do you have heart disease and/or have you ever had a heart attack? 22 Have you lost weight? 23 Have you been vomiting anything that looks like blood or coffee grounds?

24 Do you have any black tar or foul-smelling stools? 25 Have you ever been hospitalized? 26 Do you have diarrhea? 27 Do you have a history of volvulus? 28 Do you avoid eating because you are worried about the pain? 29 How long does the pain in your abdomen last? 30 Is there any blood in your stools or with your bowel movements? 31 How often does this abdominal pain occur? 32 Have you been diagnosed with chronic mesenteric ischemia? 33 Do you now, or have you ever had cancer?

FYI – The electronic health record is not listed on the rubric as

being graded, check with your professor before spending the time

completing the EHR. Some professors still wanted to see that it was

completed, some did not require it – the EHR information is here

for you just in case.

ELECTRONIC HEALTH RECORD- HISTORY

Reason for encounter Abdominal pain HPI Patient presents with a progressive 3-day history of severe cramping, abdominal pain 5/10 with associated nausea, vomiting on undigested food General Patient denies fever/chills, unexpected weight loss, fatigue, night sweats, and inability to pass gas or have a BM. Denies any hematochezia or melena in stool, diarrhea, fever, chills or night sweats. Last BM:2 days ago HEENT/NECK Head: Patient denies headaches, no vertigo, no injury Eye: Normal vision, no tearing, no scotomata, no pain

Nose: Patient denies any epistaxis, no coryza, no obstruction, no discharge Ears: Patient denies any change in hearing, no tinnitus, no bleeding, no vertigo Neck: Patient denies any stiffness, no pain, no tenderness, no noted masses Cardiovascular Patient denies chest pains, palpitations, edema, syncope, decrease in exercise tolerance Respiratory Patient denies expectoration, dyspnea with rest or exertion, orthopnea, PND GI Patient endorses abdominal pain, nausea, vomiting, constipation, decreased appetite and inability to pass gas, last BM : 2 days ago. Denies dyspepsia GU Patient denies dysuria frequency, urgency hematuria nocturia, incontinence MS Patient denies dribbling, new weakness hesistancy, arthralgias, retention, myalgias, flank pain, swelling, stiffness, wheezing, belching, melena or bloody stools, cramps or weakness

GU/Rectal Hepatomegaly. Tympanic “drum-like” sounds heard upon percussion. Abdomen/femoral arteries intact Rectal inspection: No visible fissures, induration, or lesions Rectal exam: Normal. No mases or stools on the rectal exam.Heme-occult negative. No palpable masses. MS 100% for differential diagnosis ranking and MNM. Adequately aligned spine.ROM intact spine and extremities. No joint pain. Large bowel obstruction development

Skin abdominal x

Aortic x

Aneurysm x

Several dark parches on the dorsal aspect of both hands otherwise x

Skin of normal colour, texture,and turgor, no lesions or eruptions x

Mesenteric ischemia x

Lymph x

No pathological lymph nodes in the cervical, supraclavicular, axillary or retroperitoneal x

Hemorrage clavicular chains x

Small bowel obstruction x

Psych x

Sigmoid Volvulus

XX

Small bowel neoplasm

X

Inflammatory bowel disease

X

Acute pancreatitis

X

Pancreatitis, acute alcoholic

X

Irritable bowel syndrome

X

Pancreatitis, chronic

X

Diverticulitis

X

Gastric outlet obstruction

X

X

Lactose intolerance

Acute megacolon

X

Constipation

X

Peritonitis

X

Peritonitis, spontaneous

X

Peptic ulcer disease

X

Small intestinal overgrowth

X

Colitis, infectious

X

Crohn’s disease

X

Liver abscess

X

Pancreatic abscess

X

Pancreatic cancer

X

Abdomen XR BMP Dilated loops of bowel, multiple air fluid levels. Colonoscopy Bowel obstruction due to mass in transverse colon Diagnostics – 100 %

CBC

Refer to emergency departments for management

of LBO and hypokalemia. IV fluid for rehydration.

CT Abdomen Bowel obstruction due to mass in transverse colon

Zofran Q6 PRN for N/V NG tube

for bowel rest and colonic

decompression NPO for bowel

rest and possible surgery

Lactic Acid

Upper GI barium Series Normal

Diagnosis – 100 %

Large bowel obstruction

Exercise Answers – 100 %

1 Pancreatitis

2 Calcification of the pancreas

Management Plan

Surgical consult

Referral to gastroenterology

Possible referral to oncology based on findings.

Resources:

Hsu, J., & Sevak, S. (2019). Management of malignant large-bowel

obstruction. Diseases of the Colon & Rectum, 62(9), 1028–1030.

https://doi.org/10.1097/dcr.0000000000001441

Johnson, W. R., & Hawkins, A. T. (2021). Large bowel obstruction.

Clinics in Colon and Rectal Surgery, 34(04), 233–241.

https://doi.org/10.1055/s- 0041 - 1729927

Alavi, K., Poylin, V., Davids, J. S., Patel, S. V., Felder, S., Valente, M. A.,

Paquette, I. M., & Feingold, D. L. (2021). The american society of colon

and rectal surgeons clinical practice guidelines for the management of

colonic volvulus and acute colonic pseudo-obstruction. Diseases of the

Colon & Rectum, 64(9), 1046–1057.

https://doi.org/10.1097/dcr.0000000000002 159

Irani, J. L., , Hedrick, T. L., Miller, T. E., Steinhagen, E., Goldberg, J. E., &

Paquette, I. M. (2023). Management of Colonic Volvulus and Acute

Colonic Pseudo-Obstruction [PDF]. American Society of Colon and

Rectal