a 78-year-old male admitted with RLQ (right lower quadrant) pain. While grimacing, he complains of pain in his right lower abdomen
You are assigned to Mr. Robert Rosario, a 78-year-old male admitted with RLQ (right lower quadrant) pain. While grimacing, he complains of pain in his right lower abdomen. You ask him his pain scale and he reports it is a 9/10. His vital signs are T: 98.80 F, BP: 130/88, HR: 80, RR: 22, O2: 98%. Please perform a focused assessment using your "Critical Thinking" skills on this patient using the SOAP Method:
The best approach to this exercise to imagine the patient in front of you.
This patient does not have any pain medication orders. Using the SBAR Method of communication, write out what you would say when you call the Physician who is Dr. Dickson.
Expert solution paper
S= Subjective :
Mr. Robert Rosario who is a 78-year-old male admitted with RLQ (right lower quadrant) pain.
O = objective:
All vitals and pain scale (9/10).
T: 98.80 F,
Assessment for condition like appendicitis, gastroenteritis, irritable bowel syndrome, intussuseption ( caecum into colon) , colon carcinoma.
Colonoscopy = to check abnormalities in colon.
Ultrasound = for Abscess, mass and Appendicitis.
Xray = to check size of colon, Appendicitis.
Blood culture: for bleeding assessment.
Stool culture= gastroenteritis ( bacteria in stool)
Urineanalysis= for RBCs and WBCs.
Narrate history to Dr. Dickson about patient lower abdominal pain .
B = background.
Provide information on vital and pain scale of 9/10 to Dr. Dickson.
Tell to Dr. Dickson on examination patient pain is increasing after admission .
R = recommendation: