Case Study For Patient Complaining Of Abdominal Pains

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Case Study For Patient Complaining Of Abdominal Pains

Subjective

Reason for Encounter: Abdominal pains

HPI (History of Present Illness): The patient, Evita Alonso is a 48 year old Hispanic Female who presented with the chief complaint of abdominal pains that have made her unable to go to work. The abdominal pains started spontaneously two weeks ago with insidious onset and much less intensity but then got progressively more frequent and more painful. The patient was able to continue to go to work amidst the abdominal pain but the last two days the pain has been “dreadful.” She graded the pain as starting as a 2 or 3 and gets up to a 5 or 7 but at the time of the interview, the pain was at about 3 to 4. The abdominal pains are felt more on the right upper side of the abdomen under the ribs and tend to radiate to the right shoulder (on and off). The pain is described as being crampy, gnawing ache in character, and present all the time. The pain is worse on deep breath and on eating anything especially fast foods. It has no known relieving factors. It is associated with feeling of fullness and vomiting that is post-prandial and the patient states that she is “unable to keep anything down.” There is also history of fever on and off in the last two days, and changes in stool color (passing pale stool) and dark urine, but no changes in frequency and amount. There is no night sweats or general body malaise. The pain does not seem to change with her period.  The patient reports having had similar abdominal pains a few times over the past year, however, the pain always went away on its own after a day or so. It has never been this bad. She had used antacids and ibuprofen to help with the pain but neither was helpful. The patient has history of tubal ligation with her last pregnancy and a positive family history of gall stones in the mother who had her gallbladder removed. The dad has a heart disease and the patient takes a glass of wine at every night with dinner Case Study For Patient Complaining Of Abdominal Pains.

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Current medications: None

Allergies: She denies any allergies (No known environmental, food, or drug allergies).

Pertinent PMHx: None remarkable

OBS/GYN: Her menarche was when she was 12 years old. She has a regular every 26 to 28 days cycle. Her LMP was three weeks ago. She reports no premenstrual symptoms like abdominal pains or nausea or vomiting. She has had three deliveries all normal and tubal ligation with her last pregnancy.

Social Hx: She lives with her three children in the same house. She works as an army, Lieutenant colonel. She takes a glass of wine with dinner every night and reports no problems with alcohol use. She reports that she has never smoked or chewed tobacco or used any recreational drugs.

Fam Hx: She has been married for 18 years with three children all alive and well. She reports that her dad has heart disease and her mother has breast cancer that is under control for a long time. Also, that her mother had her gallbladder removed due to stones Case Study For Patient Complaining Of Abdominal Pains

History questions asked:

  1. How can I help you today?
  2. When did your abdominal pain start?
  3. Where more precisely is your abdominal pain?
  4. What does the pain/discomfort in your abdomen feel like? (cramping, burning, stabbing, aching, tingling, squeezing).
  5. Have you had the pain in your abdomen before?
  6. What are the events surrounding the start of your abdominal pain?
  7. Does anything make the pain in your abdomen better or worse?
  8. Do your symptoms if you stop eating?
  9. Does the pain get worse with breathing?
  10. Does the pain change with your period?
  11. How severe (1-10 scale) is your abdominal pain?
  12. What treatments have you had for your abdominal pain?
  13. Have you had any trauma to your abdomen?
  14. Is there any changes in the shape of your stools?
  15. Do you have black tar-like or foul smelling stools?
  16. Has there been a change in your urination frequency?
  17. Does the pain in your abdomen radiate someplace else? Where?
  18. Have you ever been hospitalized for symptoms like the ones you have now?
  19. Have you recently been hospitalized?
  20. Any previous medical, surgical or dental procedures?
  21. Have you had any recent blood or lab tests? What were the results?
  22. Are you taking any prescription medications?
  23. Do you have any allergies?
  24. At what age did your periods begin?
  25. How regular are your periods?
  26. When did your last period begin?
  27. What other symptoms do you have with your periods? (abdominal pain, headache, bloating, etc.)
  28. Are there any diseases that run in your family?
  29. Where and with whom are you living?
  30. Tell me about your work.
  31. Have you had more pressure at work?
  32. Do you drink alcohol? If so, what do you drink and how many drinks per day?
  33. Has drinking alcohol ever caused you problems?
  34. Do you now or have you ever smoked or chewed tobacco?
  35. Do you use any recreational drugs? If so, what?
  36. Any diet changes since your last appointment?
  37. How is your appetite? Any recent change?
  38. How many diets have you been on in the last year? Case Study For Patient Complaining Of Abdominal Pains

Review of Systems

General: Presence of fever on and off in the past two days. No night sweats, general body malaise or fatigue.

HEENT/Neck: No headache, hearing problems, ear pain, double or blurring vision, sinus problems, chronic sore throats, or difficulty swallowing. No running nose or nose problems.

CVS: No history of dizziness with exertion or when angry, chest pain/pressure/discomfort, palpitation, syncope, difficulty breathing, or decreased exercise tolerance.

Respiratory: No history of shortness of breath, wheezing, cough or chest pain or difficulty breathing.

Gastrointestinal: Present abdominal pains on the right upper abdomen with radiations to the right shoulder. The pain is graded 3 to 4 on pain scale, and associated with vomiting that is post-prandial, and fever. No changes in bowel movement; normal stool in color, amount, and consistency.

Genitourinary: No changes in micturition habits. Has regular period with no associated changes in the abdominal pains with periods.

Musculoskeletal/Osteopathic Structural: No muscle cramps.

Neurological: No dizziness or fainting, headache, seizures, weakness, numbness, tremors, or tingling sensations.

Integumentary/Breast: No changes in skin color changes or changes in consistency. She reports no problems with itchy scalp, moles, thinning hair, or brittle nails. There are no breast masses/lumps, scaly nipples, pain, redness or discharge.

Psychiatry: No psychiatric symptoms.

Endocrine: No history of cold or heat intolerance, weight loss/gain, increased thirst, increased sweating, frequent urination, or change in appetite.

Hematologic /Lymphatic: No history of bruising, bleeding gums, nose bleeds, or other sites of increased bleeding.

Preventive health: She is part of a weight loss program for the past 4 months.

Objective

General: Patient is A and O x4

VS: Temp. 38.0 C, PR: 101 bpm, regular rhythm, and normal strength.  BP: 136/76, normotensive, normal pulse pressure. RR: 16bpm, regular and unlabored. 98% SpO2 on Room Air. Height 66” Weight 170 lb, BMI 27.4.

General Appearance: Fair general condition; not sick looking and well-groomed.

Skin/Integumentary: Good turgor, no pallor, no jaundice, no rash, or any lesion. Capillary refill <3 secs.

Lymphatics: No lymphadenopathy.

Abdominal: On inspection, it is atraumatic, mildly obese, non-distended, no visible organomegaly or herniation. Present bowel sounds three in a minutes and no bruits. On palpation, there is tenderness to RUQ palpation, voluntary guarding present, no rebound tenderness. Non-tender throughout the remainder of the exam. No hepatosplenomegaly, masses, herniation, or abnormal pulsations. Positive murphy’s sign. On percussion, tympanic to percussion throughout.

Genital: Normal and present genitalia. No masses, and normal pelvic exam.

Respiratory: Normal symmetry and antero-posterior diameter. The excursion with respiration is symmetrical and there are no abnormal retractions or use of accessory muscles. No distension, scars, masses, or rashes. No tenderness, lumps, or masses. Normal tactile fremitus. All superficial thoracic lymph nodes (axillary, infraclavicular, supraclavicular) are non-palpable or of normal size and consistency. The lung fields are resonant. The left anterior chest (heart) and right lower chest (liver) are dull to percussion. The rest of the lung fields are resonant and are not hyper-resonant Case Study For Patient Complaining Of Abdominal Pains

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CVS: Apex beat 5th intercostal midclavicular line. Heart sounds S1S2 heard no murmurs.

Neurologic: Normal mini mental status exam.

Assessment

  • Complete blood count (CBC)
  • Liver Function Tests (LFTs)
  • Urinalysis
  • Amylase, Serum
  • Lipase
  • Coagulation profile – PT/INR, aPTT
  • Abdominal ultrasound

Primary Diagnosis and ICD-10-Codes

  1. Ascending Cholangitis (K83.0): Ascending cholangitis is a serious infectious and inflammatory condition of the biliary tree that is characterized by biliary obstruction and overgrowth of bacteria within bile (Vagholkar, 2020). The disease could to sepsis and death and therefore, early diagnosis and assessment of severity of the disease is essential (Vagholkar, 2020). The disease is common among obese individuals with a 2 to 3 times higher incidence rates among females (Vagholkar, 2020). Clinical features of the disease include right upper quadrant abdominal pain, high-grade fever for more than 24 hours, and jaundice, the so called Charcot’s triad (Vagholkar, 2020). The management of the disease include initial stabilization through aggressive fluid resuscitation, systemic empirical antibiotics as one awaits culture and sensitivity results, and early biliary decompression through bile extraction (Vagholkar, 2020)Case Study For Patient Complaining Of Abdominal Pains.

Differential Diagnosis and ICD 10 Codes

  1. Cholecystitis (K81.0): Cholecystitis refers to the inflammation of the gallbladder. The cause of the disease is often gallstones obstructing the outflow of the gallbladder. The patient tends to present with severe pain in the upper-right quadrant of the abdomen with bloating. The pain if often radiated to the shoulder on the right and can be associated with generalized body malaise, fever, shills, sweating, biliary colic or jaundice.
  2. Choledocholithiasis (K80.3): Choledocholithiasis refers to the present of common bile duct stones leading to obstruction to the flow of bile. The disease often presents with RUQ abdominal ain, fever, jaundice, anorexia, nausea and vomiting, and stool color changes (clay-colored stool – white/pale) reflecting lack of bilirubin in the gut.
  3. Acute pancreatitis (K85.9): Pancreatitis refers to the inflammation of the pancreas which often occurs following the release of the pancreatic enzymes leading to auto cleavage or lysis of the pancreas. The disease cause death in 10% of the cases and patients tend to present with upper abdominal pain that often radiates to the back, tender abdomen on palpation, fever, tachycardia, and nausea and vomiting.
  4. Peptic ulcer disease (K27.1): Peptic ulcer disease refers to the erosion of the epithelial barrier of the stomach due to imbalances in protective and noxious agents to the gastric epithelium. The disease is often caused by a bacterium Helicobacter pylori. The symptoms of the disease include epigastric pain, increasing pain with eating (gastric ulcer) or pain relieved by eating (duodenal ulcer), hematemesis, melena stool, or hematochezia. The disease is often treated using triple regimen of proton pump inhibitors such as omeprazole and two types of antibiotics such as metronidazole and amoxicillin.

Plan

Additional laboratory and diagnostic tests:

  • Blood and bile cultures upon bile extraction.

Consults:

  • Consult with a nutritionist for further dietary evaluation and management.
  • Consult with a surgeon and gastroenterologist for the possible bile extraction/decompression/drainage.

Therapeutic Modalities: Pharmacological and Nonpharmacological Management

  • Admit the patient to the ward.
  • Give aggressive fluid resuscitation to correct the dehydration (Ahmed, 2018; Vagholkar, 2020). Fix urine catheter and monitor urine output.
  • Systemic empiric antibiotics should be started as you await culture results. Start on piperacillin-tazobactam, ceftriaxone and metronidazole, or ampicillin-sulbactam as initial choice (Ahmed, 2018). Consider ciprofloxacin, carbapenem, or gentamicin with metronidazole in penicillin allergies (Vagholkar, 2020). Adjust the antibiotics based on the results of culture and sensitivity testing.
  • Consider biliary drainage using therapeutic ERCP to reduce biliary pressures and allow adequate biliary antibiotic secretion (Ahmed, 2018; Miura et al, 2018; Vagholkar, 2020). Biliary drainage is highly indicted for a patient not responding to initial treatment (Miura et al, 2018).
  • Consider fresh frozen plasma or vitamin K to prevent coagulopathy (Vagholkar, 2020; Miura et al, 2018)Case Study For Patient Complaining Of Abdominal Pains.

Social Determinants of Health (SDoH)

  • Evaluate for healthy nutrition literacy and review with the nutritionist the weight loss program.
  • Encourage weight loss and reduction in the consumption of fatty foods.
  • Closely monitor the patient’s vital signs and urine and hepatic functions through serial renal and hepatic function tests.

Health Promotion

  • Discuss about maintaining an healthy weight and BMI and the benefits of a healthy diet.
  • Discuss with the patient the cause of the disease and its prognosis into the future.
  • Discuss with the patient how to avoid repeat occurrences such as through diet modification and weight loss.
  • Encourage early ambulation to prevent DVT after surgery if drainage is done.

Patient education: Explanations and advice given to patient and family members.

  • Encourage healthy nutrition with a diet low in fat or fried foods.
  • Encourage increased water intake.
  • Encourage the patient to reduce their weight.
  • Encourage the patient to increase physical activity.
  • Educate the caregiver on administration of medication and the need for healthy balanced diet.
  • Educate on any danger signs such as severe abdominal pain with vomiting and anorexia and the need to seek immediate care Case Study For Patient Complaining Of Abdominal Pains

Disposition/follow-up instructions:

  • To follow up with the patient in two weeks to evaluate for improvement and response to treatment.

References

Ahmed, M. (2018). Acute Cholangitis – an update. World Journal of Gastrointestinal Pathophysiology, 9(1), 1-7. https://doi.org/10.4291%2Fwjgp.v9.i1.1

Miura, F., Okamoto, K., Takada, T., Strasberg, S., Asbun, H., Pitt, H., Gomi, H., Solomkin, J., Schlossberg, D., Han, H., Kim, M., Tsann-Long, H., et al. (2018). Tokyo Guidelines 2018: Initial management of acute biliary infection and flowchart for acute cholangitis. Journal of Hepato-Biliary-Pancreatic Sciences, 25(1), 31-40. https://doi.org/10.1002/jhbp.509

Vagholkar, K. (2020). Acute Cholangitis: Diagnosis and Management. International Journal of Surgery Sciences, 4(2), 601-604. http://dx.doi.org/10.33545/surgery.2020.v4.i2g.447

The following information is to be included in your i-Human cases:

HPI: You will type this in the EMR section of the case (NOT the problem statement)

This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. This is for subjective findings. Use LOCATES or OLDCARTS Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. Include any pertinent history information that might impact the differential diagnosis formulation. If the CC was “headache,” the LOCATES for the HPI would include the following information: Case Study For Patient Complaining Of Abdominal Pains

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

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Management Plan – must include these headings

  • Therapeutic/Non therapeutic modalities, including additional laboratory and diagnostic tests (5 points)
  • Social Determinants of health (5 points)
  • Health Promotion: Address risk factors as appropriate. students should have 5 bullet points) (5 points)
  • Patient Education: MUST have 5 (5 points)
  • Consults: 5 points (can put N/A if none)
  • Disposition: 5 points
  • Must use 3 scholarly references Case Study For Patient Complaining Of Abdominal Pains