Case:
CC: “My stomach has been hurting for the past two days.”
HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.
PMH: HTN
Medications: Metoprolol 50mg
Allergies: NKDA
FH: HTN, Gerd, Hyperlipidemia
Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female
Objective:
VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.
Diagnostics: US and CTA
Assessment:
Abdominal Aortic Aneurysm (AAA)
Perforated Ulcer
Pancreatitis
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
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.
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To gather more information about the patient’s condition, it would be appropriate to ask the patient about the timing and characteristics of the abdominal pain, any previous episodes of similar pain, any medications he is taking (including over-the-counter medications and supplements), and his diet and lifestyle. It would also be useful to ask about his family medical history, especially any history of gastrointestinal disorders or abdominal aortic aneurysm.
Physical exams that would be appropriate in this case include a thorough abdominal exam to assess for tenderness, guarding, mass, and rebound, as well as a cardiac and respiratory exam to assess for any related issues. Diagnostic tests that would be appropriate in this case include a complete blood count (CBC) to assess for anemia and inflammation, a chemistry panel to assess for pancreatitis and other issues, and imaging studies such as an ultrasound or computed tomography (CT) scan to assess for an AAA or perforated ulcer. The results of these tests would be used to make a diagnosis by identifying any abnormalities that may be contributing to the patient’s symptoms.
Possible conditions to consider in the differential diagnosis for this patient include pancreatitis, perforated ulcer, AAA, cholecystitis, and gastrointestinal bleeding.
The subjective portion of the note includes information about the patient’s history of abdominal pain and vomiting, as well as his past medical history and social history. Additional information that should be included in the documentation might include the patient’s diet and medication history, any previous episodes of similar pain, and any previous abdominal surgeries or procedures.
The objective portion of the note includes information about the patient’s vital signs and physical exam findings. Additional information that should be included in the documentation might include the results of the diagnostic tests mentioned above, as well as any additional findings from the physical exam (such as bowel sounds or the presence of abdominal masses).
The assessment of abdominal aortic aneurysm (AAA), perforated ulcer, and pancreatitis is supported by the subjective and objective information in the case study, as the patient’s abdominal pain and vomiting could potentially be caused by one of these conditions. However, it is important to note that the assessment is preliminary and will need to be confirmed or ruled out with further testing.
Diagnostic tests that would be appropriate for this case include a CBC, chemistry panel, and imaging studies such as an ultrasound or CT scan. The results of these tests would be used to confirm or rule out the conditions included in the differential diagnosis and to identify any other potential causes of the patient’s symptoms.
At this point, it would be inappropriate to reject or accept the current diagnosis without further testing. Further testing is needed to confirm or rule out the conditions included in the differential diagnosis and to identify any other potential causes of the patient’s symptoms.
Three possible conditions to consider as a differential diagnosis for this patient, based on current evidence-based literature, include cholecystitis, gastrointestinal bleeding, and appendicitis. Cholecystitis, or inflammation of the gallbladder, can cause abdominal pain and vomiting and is often accompanied by fever and jaundice (Palmer et al., 2018). Gastrointestinal bleeding can also cause abdominal pain and vomiting, and can be caused by a variety of conditions such as peptic ulcer disease or esophageal varices (
References:
Mayo Clinic. (2022). Gastroenteritis. Retrieved from https://www.mayoclinic.org/diseases-conditions/gastroenteritis/symptoms-causes/syc-20354659
Mayo Clinic. (2022). Cholecystitis. Retrieved from https://www.mayoclinic.org/diseases-conditions/cholecystitis/symptoms-causes/syc-20353441
National Institute of Diabetes and Digestive and Kidney Diseases. (2022). Diverticulitis. Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/diverticulitis
