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.
Student Documentation Student Documentation Model Documentation Model Documentation Assessment Primary: K56.41 Fecal impaction r/t constipation and fecal mass in rectal vault. Possible: K57.92 Diverticulitis of the intestine, part unspecified without performation or abscess, without bleeding r/t constipation and LLQ pain K56.609 Unspecified intestinal obstruction, unspecified as to partial verses complete obstruction r/t constipation, episode of diarrhea and fecal mass in rectal vault LLQ abdominal mass. Differential diagnoses include constipation, diverticulitis, and intestinal obstruction. Plan Diagnostics: CBC to assess WBC count to rule out diverticulitis BMP to evaluate electrolyte and fluid status r/t patient not eating or drinking as much CT scan to assess for obstruction Medications: If able to, manually remove the fecal mass, and follow up with an enema to clear anything remaining. Education: For constipation I recommend increasing fiber intake and drinking more water. Referral/consults: If patient is found to have diverticulitis or obstruction, then surgical consult or Gi consult is recommended. Follow up: 5-7 days for evaluation When to seek immediate medical attention: If patient develops a fever, nausea, vomiting or worsening of abdominal pain. Diagnostics • Abdominal x-rays or CT scan to assess for obstruction • CBC to assess for elevated WBCs associated with diverticulitis and electrolyte profile to evaluate electrolyte and fluid status Medication • None at this time Education • Educate to increase/maintain fluid intake • Diet is important in maintaining colon health. Pending diagnostic test results, educate Ms. Park to eat a diet rich in fiber such as whole wheat, pears, and many other fruits, vegetables and oats Referral/Consultation • Pending diagnostic test results, may need GI or surgical referral Follow-up Planning • Instruct the patient that is she develops a fever, nausea, vomiting, and worsening abdominal pain, she should seek immediate medical attention • Revisit clinic in 5-7 days for follow up and evaluation Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health 2018 ®
- Fall '15