Case Scenario Abdomen- Valerie Hoffman, small bowel obstruction (SBO)

History of Present Illness: V. Hoffman is a 48-year-old who presented to the ED with intractable
vomiting and nausea that started about 4 days ago. The patient stated they were unable to keep
down any food or liquids, so decided to come in and be seen. V. Hoffman stated they have never
had anything like this before. Additionally, the patient reports a bloated stomach and no BM in
over a week. The patient does not recall the last time they passed gas. V. Hoffman does have a
history of chronic constipation since childhood. The patient reports cramping in all areas of the
abdomen that comes and goes. And has had a history of GERD for 6 years that it is managed
with Tums.

PMH: Constipation (since childhood), GERD (6 years)

PSH: Exploratory lap (2011)
Medications: Immunizations are current. Tums (unsure of dose) 1 tablet PRN indigestion
Allergies: IV Contract, Shellfish, Sulfa
Family History: Mother and father alive. Father has DM 2, HTN, CAD, and hyperlipidemia. Mother
has HTN. 3 siblings alive and well. 2 children alive and well.

Social History: V. Hoffman lives with a spouse and two children ages 15 and 11. Parents live
out of town but come to visit often to see the grandchildren. V. Hoffman is active in church and
sings in the choir during services. The patient is employed full time as Software Product
Manager. Denies tobacco, alcohol or illicit drug use. Main support system is faith, family, and
church members.
Lab

Test Collected Today 0630 Collected 2 Days ago Reference Range

Chemistry
Sodium 138 146 135-145 mEq/L
Potassium 3.2 3.0 3.5-5 mEq/L
Chloride 103 109 100-108 mEq/L
CO2 31 35 24-30 mEq/L
BUN 17 18 8-20 mg/dL
Creatinine 1.0 1.2 0.6-1.2 mg/dL
Glucose 82 85 70-110 mg/dL
Hematology
WBC 5,600 6,000 4,500-11,000/mm3
Hemoglobi 14.5 18.5 13.0-18.0 g/mL
n
Hematocrit 40% 49% 37-49%
Platelets 224 250 140-400 x 103mm3
Radiology
CT Results: Multiple dilated fluid-filled loops of proximal small intestine with
Abdomen decompressed distal small intestine.
Impression: Small bowel obstruction secondary to adhesions.
Physician Orders

Patient Name: Hoffman, V. Diagnosis: SBO

DOB: 12/01/**** MRN: 363278101 Physician: Carl Jones, MD
Age: 48 Height: 64 inches Allergies: Sulfa, IV Contrast,
Weight: 64 kg Shellfish
Code Status: FULL
Date Time Physician Order
Admission 1200 Admit to medical unit
Standard Precautions
Condition: Stable
Code Status: Full Code
Vital signs every 4 hours
Activity: OOB as tolerated
 Encourage ambulation in the halls TID
Place nasogastric tube for decompression to low intermittent wall suction
Strict intake and output every shift
Daily weights every morning
Diet: NPO
Medications:
 Heparin 5000 units SQ Q8H
 Phenergan 12.5mg IM Q4H PRN nausea
Labs: daily CBC, BMP
STAT CT abdomen and pelvis without oral or IV contrast
Call if:
 Temp >101.5 F
 HR <60 or >100
 RR <12 or >30
 SBP <90 or >160; DBP <60 or >100
 SPO2 <92% on oxygen
Today 1500 Clamp NG tube as tolerated. Place back on low intermittent wall suction for
nausea/vomiting.
Daily abdominal x-ray
In AM 0600 Remove NG tube if tolerating PO

Physician/Provider Signature Carl Jones, MD

Medication Administration Record

Patient Name: Hoffman, Diagnosis: SBO

Valerie MRN: 363278101 Physician: Carl Jones, MD
DOB: 12/01/19xx Height: 64 inches Allergies: Sulfa, IV Contrast,
Age: 48 Weight: 64 kg Shellfish
Code Status: FULL
Administration Period
0701 – 1900 1901 – 0700

Heparin 5000 units SQ Q8H 0800

0000
Co-Sign Required 1600

Odanasteron 4mg IVP

Q4H PRN nausea

Ventral Glut Vas Lateralis Upper Arm Abdominal

Right= RG Right= RVG Right= RUA Right UQ= RUQ Initials Signature
Left= LG Left= LVG Left= LUA Left UQ= LUQ
Right LQ= RLQ
Omitted Doses Reason Codes Left LQ= LLQ
(Circle hour if drug not administered and indicate reason)
A = NPO Diagnostic E = Hold Dose
B = NPO Surgery F = Absent from Department
C = Patient Refused G = Drug Not Available
D = Nausea H = Other (See Nurse’s Notes)
 Additional Assessment Findings
Vital Signs Heart Rate: 80
Respirations: 16
BP: 138/74
Temp: 99.0
SpO2: 94% on 2 l/m nasal cannula
General Survey Appears stated age. Weight appears within normal range
for age & genetic heritage. Speech clear and articulate.
Well groomed, clean hair and nails.
Mental Status Alert & oriented to person, place and time. Pleasant affect,
interacts with examiner, cooperative.
HEENT/Neuro Facial features symmetric. Visual acuity-patient able to
read the newspaper and dietary menu. PERRLA. Airway
patent, mucous membranes pink, moist and intact. No
other neurologic tests indicated or performed.
Lungs Diminished lungs sounds bilateral in the bases
Heart Regular rhythm with S1, S2 and no S3 present
Vascular Radial pulses 2+/3+ bilat
Dorsalis Pedis and Posterior Tibial pulses 2+/3+ bilat
Capillary refill <2 seconds X 10 fingers
< 2 seconds X 10 toes
Musculoskeletal Full ROM with strength 5/5 bilat upper and lower
extremities.
Skin Pink/Tan, equally warm bilat.
Abdomen/GU Voiding clear, yellow colored urine