SOAP Note – Small Bowel Obstruction
ID:
Client’s Initials: JRC. Gender: Female Age: 65 Race: African-American Marital Status: Married
The patient came to the clinic accompanied by her husband.
Subjective:
CC: “My stomach hurts so much, I feel so bloated, and I keep throwing up. I can’t
go to the bathroom either, it’s like everything is stuck.”
HPI: JRC is a 65-year-old female presenting to the clinic with complaints of abdominal pain, bloating, and vomiting. The pain started two days ago. It is located in the left lower side of the abdominal area. The pain has been present for the past two days. The pain is intermittent and whenever it occurs, it is prolonged and intense. The pain is improved by vomiting and rest and aggravated by food consumption. The patient noted that the pain is becoming worse as she is now experiencing longer episodes of pain. The pain also prevents her from performing her daily activities. The vomiting is also frequent. The vomitus is dark green. She has been unable to pass gas or have a bowel movement since the onset of the abdominal pain.
Past Medical History:
- Medical problem list
Hot flushes and night sweats.
- Preventative care:
A dental checkup in December last year revealed no dental abnormalities.
Routine breast and cervical cancer screening in February 2024 revealed no cervical or breast abnormalities or cancer.
The patient is up-to-date with all her vaccines and immunizations, including the annual flu vaccine and Covid-19 vaccine.
She has yet to do her annual full body check-up due to financial constraints.
- Surgeries:
The patient has a significant history of surgeries. She had a CS delivery for her last-born son when she was 39 years old. She had a gastric bypass surgery when she was 43 years old to resolve her weight issues. She also had a laparoscopic procedure two years ago after a series of unresolved GI complaints. JRC had a laparoscopic cholecystectomy a few months ago.
- Hospitalizations:
The patient was hospitalized due to Cesarian section delivery complications when she was 39 years old. She has also been hospitalized for GI-related complaints and when she had a gastric bypass. She has also been hospitalized for a few days following a kitchen accident.
Allergies: No known drug or food allergies.
Medications: The patient is currently on gabapentin, 300 mg administered orally every 8 hours for the management of hot flushes. She takes 1 g of calcium carbonate chewable tablets every 12 hours for osteoporosis prophylaxis. She has also been taking a vitamin B complex syrup for vitamin supplementation.
Family History: JRC has a significant history of GI-related issues. Her father died of colon cancer at the age of 63. Her mother is alive and 81 years of age. She has a history of irritable bowel syndrome. She is also a known hypertensive and has high cholesterol. One of her older brothers has Crohn’s disease. Her maternal grandfather died at the age of 70 from complications of diverticulitis, while her maternal grandmother died at age 68 due to surgeries from gallbladder surgery.
Social History:
Sexual history and contraception/protection: The patient is sexually active. She engages in sexual intercourse occasionally with her husband. She denies using any form of protection during sexual intercourse. She also denies having ever used any form of contraceptives in her lifespan.
Chemical history (tobacco/alcohol/drugs): The patient has a history of cigarette smoking but has now quit. She quit smoking seven years ago. She is a social drinker. She drinks occasionally, especially at social events. She has a preference for wine. She denies having ever taken any narcotics or illicit substances.
She consumes alcohol only at social events and has a preference for wine. She quit smoking upon being diagnosed with COPD. Before that, she used to smoke socially. She denies having ever used any illicit substances or narcotics.
Others: The patient is considerably keen on her diet. She limits fat and sugar intake per the recommendations of her nutritionist. She prefers a vegetarian diet but sometimes eats meat. She exercises mildly every day by either jogging or taking a walk in the park. JRC is a staunch Catholic. JRC works as a secretary in the Department of Health and Human Services. She has a college degree in Health records. She lives with her husband and two of their children in a five-bedroom house. They also live with three of their relatives. The neighborhood they live in is relatively safe, as there are no major incidents of crime or violence. She owns a gun that she keeps in locked cabinet.
ROS
Constitutional: There were no reports of recent weight loss. The patient has, however, lost weight progressively in the past few years, having lost around 16kg, something she attributes to following a diet-based weight loss program. There were no reports of chills or fever.
Cardiovascular: There were no reports of chest pain, discomfort, or palpitations. There were also no signs of swelling in her extremities.
Pulmonary: No reports of shortness of breath or labored breathing. There were also no reports of wheezing or excessive coughing.
Gastrointestinal: There were reports of extreme lower abdominal pain concentrated on the left lower quadrant. The patient also reported experiencing abdominal distension, abdominal cramping, and discomfort. The patient was also unable to pass gas, was constipated, and experienced bilious vomiting.
Musculoskeletal: There were no reports of muscle pain or stiffness. The patient also denied having had any recent muscular injuries or joint restrictions and limitations in any of her joints.
Integumentary & breast: The patient denied having had any skin color changes, tenderness, nodules, or scars on her skin. She also denies having any breast pain or tenderness.
Endocrine: There are no reports of cold intolerance or excessive sweating. She, however, had a recent cholecystectomy.
Objective
Vital Signs:
HR: 89 beats per minute, 88 bpm on repeat.
BP: 135/85mmHg, 133/84mmHg on repeat.
Temp: 99.0 degrees F
RR: 16 breaths per minute
SpO2: 97%
Height: 4’11
Weight 121.25 lbs
BMI: 24.5
Laboratory Findings
Complete Blood Count for JRC on 4/23/2024
| Hematology | Result | Normal range |
| Red cell count | 5.5 x 1012/L | 4.5–5.7 |
| White cell count | 13 x 109/L | 4.0–10.0 |
| Hemoglobin | 156 g/L | 133–167 |
| Hematocrit | 0.49 | 0.35–0.53 |
| MCV | 93 fL | 77–98 |
| MCH | 31.9 pg | 26–33 |
| MCHC | 351 g/L | 330–370 |
| RDW | 13.5% | 10.3–15.3 |
Physical Exam
General survey: The patient seems to be in distress and verbalizes pain. She gives her pain a score of 8 and notes that sometimes it goes to 10. There are, however, no signs of fever,or significant weight loss. There is also no sign of fatigue.
CVS: The patient’s heart rate is rhythmic but slightly elevated. There is, however, no sign of jugular venous distension. There is also no visible swelling in the extremities. Auscultation revealed no pericardial friction rub, murmurs, or gallop sounds. The S1 and S2 sounds were also of normal intensity.
Chest/Throrax: The chest is symmetrical on visual inspection. The respiratory rate was rhythmic, with no notable, labored breathing or use of accessory muscles for respiration. The cough reflex was intact, with no sign of excessive cough. The chest wall had a normal curvature with no sign of kyphosis or scoliosis on inspection of the anterior, posterior, and lateral chest walls. Wheezing sounds were not heard on auscultation.
Abdomen/GI: The abdomen is symmetrical. There are notable surgical scars on the abdominal area. There are also notable color inconsistencies in the abdomen, with the lower abdominal areas having a slightly pinkish coloration. The lower left abdominal area seems to be slightly distended. There are no signs of engorged veins or striae on the abdominal walls. There are also no signs of abdominal masses on the abdominal wall. There is a generalized rigidity of the abdominal wall, with no abdominal wall motion seen on observation.
High-pitched bowel sounds were heard on auscultation of the lower left quadrant. No ausclatation sounds were heard over the right lower quadrant on auscultations. Abdominal bruit sounds were heard in the area over the aorta, the iliac arteries, and the two renal arteries. Tympanic sounds were heard on percussion of the lower abdominal areas. There was no sign of a shifting dullness from the mid-line to the flank. Palpation of the abdominal wall revealed a crepitus of the lower abdominal quadrants. Two-hand palpations reveal no abdominal masses. Palpation of the liver revealed that the liver had smooth margins and was normative in size. The lower left quadrant was tender, with the patient verbalizing pain and discomfort on light palpation of the lower abdominal areas. There was a notable sign of abdominal rigidity on the left lower quadrant. There was also a notable guarding reflex in the abdominal area.
M/S: The joints were symmetrical. There was no sign of limitations in the joint movement. There was also no sign of muscle pain or stiffness.
Lymph: There were no signs of splenomegaly on palpation. .
Neurological: The patient is alert and responsive. She is aware of her environment and can verbalize what brought her to the hospital. She answers the questions asked in a goal-directed and coherent manner.
Assessment
Differentials
- Small bowel obstruction (ICD 10 K56. 609): Small bowel obstruction is a condition characterized by functional or mechanical blockage of the small intestines. It has a multifactorial etiology, with scar tissue, cancer, and a hernia, among others, being implicated in the development of a small bowel obstruction (Amara et al., 2021). The obstruction is usually preceded by an acute compromise in the blood supply to the bowel tissues distal to the point of blockage, resulting in tissue ischemia, perforation, and peritonitis. The obstruction causes GI components to back up into the stomach, causing nausea and vomiting. The vomit, in this case, is bilious. The bowel area just before the obstruction also becomes large and dilated and is then filled with air that would have otherwise moved forward. This causes abdominal distention or bloating. In case the bowel contents are unable to move past the obstruction, obstipation occurs. Small bowel obstruction usually precedes abdominal surgeries. They may occur weeks or even years after a surgical procedure on the abdomen. The likelihood of developing small bowel obstruction increases with increasing number of surgeries. Patients with small bowel obstruction will commonly present with complaints of abdominal distention, abdominal pain, bilious vomiting, and obstipation (Amara et al., 2021). In this case, the patients presented with complaints of abdominal distention and pain, vomiting, constipation, and obstipation. Additionally, she had a significant history of abdominal surgeries. These manifestations, along with the assessment findings, are definitive of and consistent with small bowel obstruction warranting the inclusion of this differential in the differentials list.
- Gastric Bypass Complication – K91.2: Gastric bypass complications are a spectrum of health conditions that follow gastric bypass surgery. These include band-related complications such as dysphagia, severe reflux-like symptoms, band erosion, bypass complications, such as anastomotic leak and stricture, and internal hernias, pulmonary embolisms, gall-stones, and GI bleeding, among others (Liakopoulos et al., 2019). Post-site hernias and bypass-related internal hernias are common severe complications of gastric bypass. Bypass-related Internal hernias can result in intestinal obstruction and subsequent ischemia, intermittent abdominal pain, and sometimes vomiting. Bowel obstruction, abdominal pain, and significant vomiting are the prominent features of post-site hernia (Liakopoulos et al., 2019). The patient in the case presented had abdominal pain, abdominal distention, and complaints of vomiting. This meets the criteria of gastric-bypass-related hernia and post-site hernia as complications of gastric bypass surgery and warrants their inclusion in the differential list.
- Chronic Constipation – K59.00: Chronic constipation is a condition characterized by sustained periods of difficulty or rare passage of stool. Chronic idiopathic constipation has no defined cause and often lasts for extended periods (Włodarczyk et al., 2021). Whenever it occurs, patients will present with difficulty in passing stool, stool stiffness, and pain during defecation. Concerning historical features that may also point towards this diagnosis include hemorrhoidal manifestations such as rectal bleeding that proceeds stool passage, abdominal pain, vomiting, loss of appetite, inability to pass flatus, and abdominal mass, among others (Włodarczyk et al., 2021). The patient in the case presented had abdominal pain, had difficulty in passing flatus, and reported complaints of vomiting. These manifestations are consistent with those of chronic constipation, warranting the inclusion of this condition in the differential list.
- Colon Cancer – Z80.0: Colorectal cancer is a common presentation among the elderly. The disease has a strong genetic predilection and environmental associations. Persons with a family history of colon cancer and Crohn’s disease are more likely to develop colorectal cancer (Alzahrani et al., 2021). Diagnosis of colon cancer can either be an incidental finding during the management of an emergent abdominal disorder, follow a routine screen for colorectal cancers, or follow a diagnostic colonoscopy for a sign of the disease. Abdominal pain, anemia, and peritonitis are common symptoms of the disease. The patient, in this case, had a family history of colon cancer and presented with abdominal pain. This warranted the inclusion of this differential.
Diagnosis: The Presumptive diagnosis in the case is Small bowel obstruction ICD 10 K56. 60. the presenting complaints were highly suggestive of a small bowel obstruction. The imaging results also revealed an obstruction in the small intestines. Imaging results were negative for intestinal hernia or anastomotic structures, ruling out gastric bypass complications. Colonic angiography was also negative for colorectal neoplasms, ruling out a colorectal neoplasm.
Plan
1.) Small bowel obstruction
Diagnostics:
Imaging: Abdominal X-rays are ordered to assess for intestinal obstruction. Computed tomography scans (CT Scans) can be used where X-rays are non-definitive. CT scans can help in the visualization of the small intestines and may reveal the presence of an intestinal obstruction. CT scans have a high sensitivity and are the gold standard in small bowel obstruction diagnosis (Amara et al., 2021).
Labwork: Routine lab work is ordered to help evaluate bowel ischemia, dehydration, and inflammation that often characterizes bowel obstruction. The presence of marked inflammatory and ischemic markers on laboratory workup may reveal the presence of peritonitis and ischemia (Amara et al., 2021). CBC may also help confirm the presence of an infection, as bacterial infections, especially Escherichia coli infections, are common in small bowel obstruction ischemia.
Treatment: The first line of management is to seek a general surgeon’s consult for potential surgical intervention. The patient will then be placed on a nil per os (NPO) to decrease the proximal intestinal content. Fluid replacement, through intravenous fluid, will also be initiated to maintain adequate hydration. In case of vomiting persists, a nasogastric tube will be placed for decompression. Injectable analgesics, such as IM ketorolac 15mg, may be used to attain fast analgesia (Klingbeil et al., 2023). Antibiotic therapy with broad-spectrum antibiotics may be warranted where bacterial infections are suspected.
Education: The patient should be educated on their condition. In this respect, they should be told that they are at risk of developing small bowel obstruction because of their surgical history. They should also be educated on the symptoms of small bowel syndrome to enhance their accountability in preventing potential complications such as ischemia whenever the condition recurs.
Follow-Up: The patient is expected to return for a follow-up two weeks after discharge to allow for monitoring.
2.) Gastric Bypass Complication – K91.2
Diagnostics:
The patient’s previous operative reports are evaluated to understand their surgical anatomy and any post-surgical concerns.
Imaging: Pelvic and abdominal CT scans with contrast will be ordered. These imaging techniques allow the visualization of gastric anatomy and may help reveal the presence of internal hernia and anastomotic structures. They can also help confirm the integrity of the gastric pouch.
Treatment: A general surgeon consult is sought due to the potential for bariatric surgery to correct internal hernias. The patient will be scheduled for laparoscopic surgery to correct the hernia. The patient may also be started on pain management using opioid analgesics to help address her abdominal pain. Administration of tramadol, 100mg every 8 hours, may be beneficial in pain relief.
Education: The patient should be educated on their condition, including the available therapeutic modalities. In the case of opioid use, they should be educated on the downsides of opioid use, such as the potential for tolerance and addiction if used inappropriately. They should also be told to stick to the prescribed doses to prevent side effects such as respiratory depression.
Follow-up: The patient is scheduled to return to the clinic for a follow-up one week after discharge for monitoring.
3.) Chronic Constipation – K59.00
Diagnostics:
Labwork: A complete blood count (CBC) is ordered to rule out anemia, as patients with chronic constipation and who are experiencing or have experienced rectal bleeding may develop anemia. Fecal occult blood testing is also ordered to rule out obstructive neoplasms of the colon. Thyroid function tests may also be ordered to rule out hypothyroidism as a causal factor for constipation.
Anorectal Manometry: Anorectal manometry can also be ordered to identify the potential cause of the constipation.
Imaging: Abdominal X-rays may be ordered to rule out mechanical obstruction.
Treatment: The patient will be started on mild laxatives or an enema, in the absence of a mechanical obstruction.
Education: The patient should be educated on their condition, including the available therapeutic modalities. They will also be advised to indulge in physical activity to promote bowel movement and lower their chances of developing another constipation.
Follow-Up: The patient is expected to return to the clinic for a follow-up one week after discharge.
4.) Colon Cancer – Z80.0
Diagnostics:
Imaging: Order a CT colonography to ascertain the presence of a colorectal neoplasm.
Colonoscopy: Colonoscopy is done upon confirming the presence of a colorectal neoplasm. It is required for tissue biopsy. It has a sensitivity of over 94% in diagnosing colorectal cancer.
Treatment: The patient will be placed on cancer treatment if diagnosed with cancer. For localized non-metastatic colorectal cancer, surgical resection of the neoplasm is the recommended therapeutic modality. Advanced disease can be managed using neoadjuvant therapy. Adjuvant therapy is applied for stage III colorectal cancers and stage II disease considered high-risk (Alzahrani et al., 2021).
Education: The patient should be educated on the disease, including the available therapeutic modalities. She will also be educated on the potential need for a colonoscopy in the wake of her recent manifestations with symptoms similar to those of colorectal cancer and her family history of the disease. She will also be educated on their risk status for the disease as she has a significant family history of the disease. She will also be educated on the significance of routine colorectal cancer screening in the early identification of the disease.
Follow-Up: The patient is expected to return to the clinic for a follow-up one week after discharge.
References
Alzahrani, S., Al Doghaither, H., & Al‑Ghafari, A. (2021). General insight into cancer: An overview of colorectal cancer (review). Molecular and Clinical Oncology, 15(6). https://doi.org/10.3892/mco.2021.2433
Amara, Y., Leppaniemi, A., Catena, F., Ansaloni, L., Sugrue, M., Fraga, G. P., Coccolini, F., Biffl, W. L., Peitzman, A. B., Kluger, Y., Sartelli, M., Moore, E. E., Di Saverio, S., Darwish, E., Endo, C., van Goor, H., & ten Broek, R. P. (2021). Diagnosis and management of small bowel obstruction in virgin abdomen: A WSES position paper. World Journal of Emergency Surgery, 16(1). https://doi.org/10.1186/s13017-021-00379-8
Klingbeil, K. D., Wu, J. X., Osuna-Garcia, A., & Livingston, E. H. (2023). Management of small bowel obstruction and systematic review of treatment without nasogastric tube decompression. Surgery Open Science, 12, 62–67. https://doi.org/10.1016/j.sopen.2022.10.002
Liakopoulos, V., Franzén, S., Svensson, A.-M., Miftaraj, M., Ottosson, J., Näslund, I., Gudbjörnsdottir, S., & Eliasson, B. (2019). Pros and cons of gastric bypass surgery in individuals with obesity and type 2 diabetes: Nationwide, matched, observational cohort study. BMJ Open, 9(1). https://doi.org/10.1136/bmjopen-2018-023882
Włodarczyk, J., Waśniewska, A., Fichna, J., Dziki, A., Dziki, Ł., & Włodarczyk, M. (2021). Current overview on clinical management of chronic constipation. Journal of Clinical Medicine, 10(8), 1738. https://doi.org/10.3390/
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Question 
Select a patient with a common condition(s) from your practicum experience this week. Submit a correctly formatted SOAP note on that patient in a Word document.
Please create a pretend patient and create a SOAP Note about Small Bowel Obstruction
SOAP Note – Small Bowel Obstruction
The patient is a 65-year-old
Initials: JRC
Gender: Female
Came with their husband in the clinic
Chief Complaint: “My stomach hurts so much, I feel so bloated, and I keep throwing up. I can’t go to the bathroom either, it’s like everything is stuck.”