Assignment: Assessment of the Abdomen and Gastrointestinal System: 47 Year-Old White Male Patient JR

Assignment: Assessment of the Abdomen and Gastrointestinal System: 47 Year-Old White Male Patient JR

Assignment: Assessment of the Abdomen and Gastrointestinal System: 47 Year-Old White Male Patient JR

The Assignment

1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.

2. Analyze the objective portion of the note. List additional information that should be included in the documentation.

3. Is the assessment supported by subjective and objective information? Why or why not?

4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

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5. Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Case study:

Subjective:

• CC: “My stomach hurts, I have diarrhea and nothing seems to help.”

• HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.

• PMH: HTN, Diabetes, hx of GI bleed 4 years ago

• Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs

• Allergies: NKDA

• FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD

• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

• VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs

• Heart: RRR, no murmurs

• Lungs: CTA, chest wall symmetrical

• Skin: Intact without lesions, no urticaria

• Abd: soft, hyperactive bowel sounds, pos pain in the LLQ

• Diagnostics: None

Assessment:

• Left lower quadrant pain

• Gastroenteritis

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

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1. Subjective: Missing Information

• History of Present Illness (HPI): The patient is a 47 year-old Caucasian male presenting with abdominal pain and diarrhea. He denies previously having these symptoms that are characteristically intermittent. The pain is sharp and increased by walking. It somehow subsides when he is resting and oscillates between 5/10 and 9/10 in severity.
• Review of Systems (ROS)

1. Objective: Additional Information

General: He is alert and oriented in time, place, space, person, and event. He is well-dressed for the time of the day and the weather and speech is coherent and goal-directed (Ball et al., 2019).

HEENT: The head is normocephalic and shows no obvious signs of trauma. Extraoccular muscles are intact (EOMI) and both pupils are equal, round, and reacting to both light and accommodation (PERRLA). The eyes are not icteric and are not tearing. The conjunctivae are moist and movement of the eyeballs is symmetrical. There is no rhinorrhea and the nasal septum is medially placed. The nasal turbinates are moist and not inflamed. Nasal polyps are absent bilaterally. The external auditory canal is clear with no impacted cerumen. The reaction of the tympanic membranes to light bilaterally is good and the membranes are both intact with no overt perforation. There is no thrush, exudate, or erythema in the throat.

• Assessment: Support by the Subjective and Objective Documentation

There is enough support from the subjective and objective information gathered to warrant the diagnosis of gastroenteritis (GE). The presence of left lower quadrant (LLQ) pain and nausea after eating are both in sync with the presentation of the condition (GE). Cramping of the abdomen or LLQ pain, fever, nausea, and diarrhea are some of the symptoms that have been known to indicate the presence of GE. The GE can either be viral or bacterial in etiology (Bányai et al., 2018; Hammer & McPhee, 2018; Huether & McCance, 2017). Looking at the subjective and objective data presented, patient JR has a low-grade fever of 99.8°F, nausea, LLQ pain, and diarrhea. This is enough evidence that he could indeed be suffering from GE. To be precise, the ICD-10-CM code of A09 represents his exact diagnostic label of GE and colitis.

1. Pertinent Diagnostic Tests
2. Complete Blood Count (CBC)

A full blood count is a routine laboratory test that must be done in a patient that has fever and that is expected to be having an infectious process. Patient JR has a low-grade fever and diarrhea and so must have a CBC done. This will indicate whether there is leucocytosis suggestive of infection and inflammation requiring antibiotics. The hemoglobin level will also be known and anemia ruled out. If there will be eosinophilia, the rare eosinophilic gastroenteritis may be suspected.

1. Microscopy (stool)

A stool sample for microscopy, culture and sensitivity is a standard test that has to be done in a patent with diarrhea. This will enable the visualization of bacteria if it is infectious bacterial GE. Culture and sensitivity studies for the correct antibiotic to use are essential for antibiotic stewardship (Bashir & Gray, 2017). If no bacteria are found, the GE will then be managed as a viral GE with intravenous fluids and electrolytes (Hammer & McPhee, 2018; Huether & McCance, 2017).

1. Endoscopy

Endoscopy is a definitive test that will enable the confirmation of the diagnosis since there are many types of GE (eosinophilic GE, bacterial GE, and viral GE) that all have different morphological presentations in the gastrointestinal tract. By directly visualizing the intestinal and gastric mucosa, it is possible to arrive at a conclusive diagnosis of the type of GE patient JR is suffering from.  

1. C-Reactive Protein or CRP

The CRP test is an indicator of the process of inflammation caused by an infectious process. Doing it will give an indication if more needs to be done with a high CRP value. A normal CRP value is less than 3.0 mg/L (Hammer & McPhee, 2018; Huether & McCance, 2017).

1. Complete Metabolic Profile (CMP)

Patient JR has a number of chronic pre-existing conditions. These are diabetes and hypertension. There is also a family history of hyperlipidemia. These are sufficient grounds for performing a complete metabolic panel to ascertain the exact values of his blood sugar, cholesterol, and electrolytes. These will help in the planning of the management as these conditions affect and are also affected by the management of the GE.    

1. Diagnosis
2. Infectious Gastroenteritis and Colitis: It is known that GE frequently coexists with infectious colitis and so this is a very plausible primary diagnosis (Bányai et al., 2018; Hammer & McPhee, 2018; Huether & McCance, 2017).
3. Acute Sigmoid Diverticulitis: The other condition that also usually presents with LLQ pain and cramps is acute sigmoid diverticulitis. It s a possible differential diagnosis in the case of patient JR especially given his age (Hammer & McPhee, 2018; Huether & McCance, 2017).
4. Prostatitis

The last but not least possible differential diagnosis is prostatitis. In a male around the age of 50 years it is a very likely reality that he may be having an acute infection of the prostate and that is what may be presenting as LLQ abdominal pain (Hammer & McPhee, 2018; Huether & McCance, 2017).

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bányai, K., Estes, M.K., Martella, V., & Parashar, U.D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175–186. https://doi.org/10.1016/s0140-6736(18)31128-0

Bashir, A., & Gray, J. (2017). Fight antibiotic resistance – it’s in your hands to improve antibiotic stewardship. Journal of Hospital Infection, 95(4), 361–362. https://doi.org/10.1016/j.jhin.2017.02.018

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6^th ed. Elsevier, Inc.