Case Study: Patient with Lower Abdominal Discomfort Nausea

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Herzing NU621 Unit 4 Discussion Advanced Pathophysiology: Case Study: Patient with lower abdominal discomfort nausea

Digestive Function

Read the following case study and answer the posed questions

Case #1:  A 64-year-old man presents to the emergency department (Links to an external site.) with abdominal pain and distention, as well as constipation of 8 days’ duration. He denies vomiting, fever, diarrhea, or dysuria. Except for hypertension, he is otherwise healthy with no prior surgeries. Case Study: Patient with lower abdominal discomfort nausea

His vital signs are normal except for a borderline pulse of 99 bpm. His physical examination is unremarkable except for his abdomen, which is large, rotund, and tympanitic. There is diffuse tenderness everywhere in the abdomen Case Study: Patient with lower abdominal discomfort nausea.

What history would you want to obtain?

What differential diagnoses would you consider?

List and describe the specific diagnostic tests you might order to determine cause of his concern?

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Case #2:

Kyle is a 58-year-old man who is experiencing lower abdominal discomfort nausea and diarrhea lasting 2 days. He thought he had eaten something that “disturbed his stomach” but since this has lasted so long, he is afraid it’s something serious.

As you obtain a history from this patient what differential diagnoses are you considering. Give rational for your choices.

Discuss the pathophysiologic relationship between nausea and vomiting?

Three days after Kyle’s initial visit his labs confirmed a diagnosis of cirrhosis.

Discuss the pathophysiologic relationship between cirrhosis and portal hypertension.

Cite current research findings, national guidelines, and expert opinions and controversies found in the medical and nursing literature to support your position and suggestions. Case Study: Patient with lower abdominal discomfort nausea

Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with citations and references in APA format.

Please review the rubric to ensure that your response meets the criteria.

Estimated time to complete: 2 hours

Discussion Peer/Participation Prompt [Due Sunday]

Please respond to at least 2 of your peer’s posts.  To ensure that your responses are substantive, use at least three of these prompts:

  • Do you agree with your peers’ diagnosis?
  • Take an alternate view and offer a potential alternate approach.
  • Share your thoughts on how you support their opinion and explain why.
  • Present new references that support your opinions.
  • Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.
  • Case Study: Patient with lower abdominal discomfort nausea

Intermittent Abdominal Pain Example

Today, an 18-year-old Caucasian female appears with intermittent stomach pain. She also has a low-grade fever, cramps, and diarrhea. She has also lost her appetite. She acknowledges smoking 1/2 PPD for two years. Denies using illegal drugs or alcohol and reports a Crohn’s disease history.

Differential Diagnosis

The top differentials I would consider include Crohn’s disease, ulcerative colitis, and appendicitis. The inflammatory bowel diseases  Crohn’s disease (CD) and ulcerative colitis (UC) have an immunological basis (Ranasinghe & Hsu, 2022). The trajectory of Crohn’s disease is one of remission and relapse. Typical symptoms of Crohn’s disease flare-ups include stomach discomfort, bloating, diarrhea, fever, weight loss, and anemia. Many of the manifestations can be seen in the patient. Ulcerative colitis is an inflammation of the colon that has no known cause. 

Bloody diarrhea, whether it contains mucus or not, is the predominant sign. Depending on how far the illness has spread and how bad it is, one may also have tenesmus, malaise, abdominal pain, weight loss, and fever (Lynch & Hsu, 2023). The condition usually worsens over time, and people with it often go through periods of remission followed by relapses. When the vermiform appendix gets inflamed, this is called appendicitis. According to research, anorexia and periumbilical pain are common symptoms of appendicitis, and they frequently precede right lower quadrant pain, nausea, vomiting, fever, and other symptoms (Echevarria et al., 2023). Crohn’s disease is, therefore, the presumptive diagnosis.

Focused Physical Examination

It would be useful for the patient with a suspected Crohn’s disease flare-up to have several targeted physical exam results. After visually inspecting the patient’s abdomen, all four quadrants should be auscultated to listen for any altered bowel sounds that might indicate obstruction. After that, the abdomen should be palpated to check for organomegaly, ascites, rebound pain, or distention (Ranasinghe & Hsu, 2022). All patients require a perineum exam. Skin tags, fistulas, scars, ulcers, and abscesses could all be seen during the examination.

Diagnostic testing to confirm the diagnosis

A thorough investigation is required for diagnosis confirmation. Infections can be ruled out by stool tests for culture, ovum and parasites, C. difficile toxins, leukocyte count, and calprotectin, which can identify active Crohn’s disease. It is possible to differentiate between Crohn’s disease and ulcerative colitis using blood tests such as the CBC, metabolic panel, ANCA, and ASCA. CRP or ESR indicates how severe the inflammation is (Kedia et al., 2019; Ranasinghe & Hsu, 2022). While plain X-rays can reveal intestinal obstruction, imaging techniques like CT scan/MRE of small bowel follow-through and VCE can see the afflicted areas.

Evidence-based treatment Approach

Crohn’s disease should be treated with a multidisciplinary approach based on the patient’s needs. Evidence-based treatment guidelines suggest that people with Crohn’s disease may need to take medicine and change their lifestyle. Anti-inflammatory drugs like aminosalicylates or corticosteroids can help reduce inflammation in the bowel (Ranasinghe & Hsu, 2022). 

Immune system suppressors like azathioprine or methotrexate stop the immune system from attacking the bowel. Anti-TNF drugs like infliximab, adalimumab, and golimumab block TNF to stop it from causing inflammation (Ranasinghe & Hsu, 2022). Nutritional support, such as a low-residue or elemental diet, is required to give the bowel time to recover. Smoking cessation and stress management are two lifestyle changes that can help to lessen flare-ups.

References

Echevarria†, S., Rauf†, F., Hussain†, N., Zaka, H., Farwa, U. -, Ahsan, N., Broomfield, A., Akbar, A., & Khawaja, U. A. (2023). Typical and atypical presentations of appendicitis and their implications for diagnosis and treatment: A literature review. Cureus. https://doi.org/10.7759/cureus.37024

Jones, M. W., Lopez, R. A., & Deppen, J. G. (2022). Appendicitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493193/#:~:text=Appendicitis%20is%20the%20inflammation%20of

Kedia, S., Das, P., Madhusudhan, K. S., Dattagupta, S., Sharma, R., Sahni, P., Makharia, G., & Ahuja, V. (2019). Differentiating Crohn’s disease from intestinal tuberculosis. World Journal of Gastroenterology, 25(4), 418–432. https://doi.org/10.3748/wjg.v25.i4.418

Lynch, W. D., & Hsu, R. (2023). Ulcerative colitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459282/#:~:text=Introduction-

Ranasinghe, I. R., & Hsu, R. (2022, May 15). Crohn disease. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK436021/

Abdominal Assessment Soap Note

The episodic SOAP note is of a 65-year-old African American male with epigastric pain.

Subjective Portion

The objective portion of the episodic SOAP note contained the chief complaint, history of presenting illness, past medical history, medication history, allergies, family history, and social history. These are essential components of the subjective portion of building a health history for any patient (Ball et al., 2022). Even though the review of the systems is also part of health history, the subjective portion of this episodic SOAP note is sufficient to construct a list of diagnoses and differential diagnoses. However, this portion would be more sufficient with extra elements to rule in or out some differential diagnoses. Important negatives are key aspects of building health history that directs the diagnostic approach and thinking of the doctor and the nurse in a patient evaluation.

The subjective portion mentioned the presence of intermittent epigastric pain. However, I would inquire more about the presence or absence of these symptoms in relation to food intake. Food intake influence is vital in evaluating dyspepsia and upper gastrointestinal symptoms because it can exacerbate or relieve some of the symptoms. Other exacerbations and relief of this pain, such as physical activity and abdominal distention, are also useful pieces of information in this patient’s history. The history of the use of nonsteroidal anti-inflammatory drugs (NSAIDs) is also important to exclude the role of these medications in this patient’s epigastric pain.

Objective Portion

The objective portion of this episodic SOAP note contained vital signs, heart examination, respiratory, skin, abdominal examination, and diagnostic results. The documentation is focused on signs and other objective features pertinent to the patient’s chief complaint. Most of the time, the objective aspects presented are determined by the examiners’ thought process of working up the patient. However, additional information on this patient’s initial investigations, such as a urease breath test, would be important to rule out the likelihood of peptic ulcer disease. Additional information on this patient’s general condition, such as respiratory distress, body build, and mental status, is also vital in figuring out the current general state of the patient. Additional tests such as abdominal ultrasound scans and esophagogastroduodenoscopy will save some time in the evaluation of this patient.

Diagnostic Tests

Serum electrolytes, urea, and creatinine are also baseline tests that would provide additional information on the biochemical function of the patient concerning renal and metabolism status. As aforementioned, esophagogastroduodenoscopy and abdominal ultrasound scan of the abdomen would also provide vital anatomical information on the etiology of this patient’s pain (Schill et al., 2022). A complete blood count would be essential in finding out whether there are infectious and inflammatory etiologies of this patient’s pain. Serum lipase levels will help in ruling out pancreatic disease.

Assessment

The provided differential diagnoses are relevant to the documented subjective and objective information. An abdominal aortic aneurysm is supported by the long-standing presence of symptoms and lack of response to proton pump inhibitors. This condition is life-threatening and would warrant his current emergency department admission (Shaw et al., 2023). The provided test would be essential in the evaluation of abdominal aortic aneurysms (Schill et al., 2022). 

The current deterioration could also indicate a complicated peptic ulcer disease in this patient. PUD can perforate, resulting in peritonitis that would present with pain (Kuna et al., 2019). However, this pain would be generalized and cause rebound tenderness or guarding. The third assessment, pancreatitis, is also a likely diagnosis in this patient. Even though the lack of response to PPIs would suggest an etiology outside the stomach and duodenum, the role of pancreatitis in this patient’s presentation is mainly supported by the location of the pain. The radiation of the pain to the back would also suggest the presence of pancreatitis.

Verdict on the Assessment

I accept the current assessments based on the available objective and subjective information. However, additional possible diagnoses would also apply to this patient based on the provided history and physical examination. Acute cholecystitis, small intestinal obstruction, and chronic gastritis are also likely diagnoses in this patient. Small bowel obstruction in this patient is suggested by the presence of abdominal pain. However, the absence of abdominal distention or vomiting makes intestinal obstruction less likely. 

The patient is a chronic tobacco user and has a positive history of alcohol intake which makes chronic gastritis more likely in this patient (Yawar et al., 2021). However, the recent acute clinical deterioration suggests an acute complication of this illness. Acute cholecystitis is also likely in this patient because this condition sometimes presents with epigastric pain, even in the absence of right upper quadrant tenderness. Therefore, this patient would benefit from an extensive workup.

Conclusion

In sum, the provided suggest that the patient has an intraabdominal illness. Perforated PUD, chronic gastritis, acute pancreatitis, acute cholecystitis, and abdominal aortic aneurysm are likely diagnoses. Therefore, additional information on the relationship between this patient’s epigastric pain to food intake and recent meditation use is essential. Additional investigations such as esophagogastroduodenoscopy, abdominal ultrasound, serum lipase level, full blood count, serum electrolytes, and urea levels should suffice further workup before definitive management.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2022). Seidel’s physical examination handbook: An interprofessional approach (10th ed.). Elsevier – Health Sciences Division.

Kuna, L., Jakab, J., Smolic, R., Raguz-Lucic, N., Vcev, A., & Smolic, M. (2019). Peptic ulcer disease: A brief review of conventional therapy and herbal treatment options. Journal of Clinical Medicine, 8(2), 179. https://doi.org/10.3390/jcm8020179

Schill, C. N., Tessier, S., Longo, S., Ido, F., & Nanda, S. (2022). Differential diagnosis of multiple systemic aneurysms. Cureus, 14(10), e30043. https://doi.org/10.7759/cureus.30043

Shaw, P. M., Loree, J., & Gibbons, R. C. (2023). Abdominal Aortic Aneurysm. In StatPearls. StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29262134/

Yawar, B., Marzouk, A. M., Ali, H., Ghorab, T. M., Asim, A., Bahli, Z., Abousamra, M., Diab, A., Abdulrahman, H., Asim, A. E., & Fleville, S. (2021). Seasonal variation of presentation of perforated peptic ulcer disease: An overview of patient demographics, management, and outcomes. Cureus, 13(11), e19618. https://doi.org/10.7759/cureus.19618