PATIENT NAME – Dorothy Jones i human 2022
PATIENT NAME – Dorothy Jones
AGE - 54 YEARS
SEX - Female
HEIGHT – 5’6” (168
... [Show More] cm)
WEIGHT - 165.0 lb (75 Kg)
CHIEF COMPLAINT – Abdominal Pain
• Feedback: the patients presentation w/ acute mid-abdominal pain, distention,
nausea/vomiting, constipation and inability to pass gas is consistent with SBO. An
abdominal series confirms the present of multiple dilated loops of small bowel. Her
history of 2 prior abdominal surgeries significantly increases the likelihood of her bowel
obstruction being secondary to postsurgical adhesions. Approximately 93% of all
patients who have had prior abdominal surgery have adhesions; of whom 14% will
require intervention for adhesion-related sequelae within 10 years of their surgery.
Problem statement:
Dorothy Jones is a 54 year old female that presents with acute, progressive abdominal pain for 3
days. She complains of absence flatus, emesis and abdominal distention. Past medical history
includes hysterectomy removal 2 years ago, cholecystectomy 15 years ago, hyperlipidemia and
constipation. Upon assessment, patient noted to be tachycardic, obese, absent bowel sounds,
periumbilical discomfort to palpation, distended abdomen and tympany noted on percussion.
Ms. Jones is awake, alert and oriented x4. No acute distress. Patient is age appropriate and
looks uncomfortable. Her vital signs are as follows: blood pressure 128/72, pulse 100 beats per
minute, 37 degrees Celsius (98.6 degrees Fahrenheit), respiration rate is 18 and oxygen level is
98%. Upon assessment, her HEENT/Neck is normal. PMI is in the 5th intercostal space at the
midclavicular line. Normal jugular venous pressure but is noted to have tachycardia. Her chest is
symmetrical and no use of accessory muscles are noted while breathing. All superficial thoracic
lymph nodes are non-palpable, of normal size and consistent throughout. Anterior lung fields
are resonant. The left anterior chest and right lower chest are dull. The rest of lung fields are
resonant. Lung sounds bilaterally are normal. The abdomen is atraumatic, mildly obese,
symmetrical, slightly taut and distended. Surgical scars noted. No visible peristalsis, mass or
organomegaly. Mild discomfort throughout abdominal palpation and occasional palpable
peristalsis. No involuntary guarding or rebound tenderness noted. Upon percussion, moderately
tympanitic noted. Normal girth. Absent bowel sounds. Patient has no problem with her
genitourinary or rectum. She has noted however that her urine is darker than normal. She has
normal and equal ROM bilaterally. Her gait is steady. All reflexes are intact. Skin is warm and dry.
Diagnosis: Small Bowel Obstruction
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