Case Study For Gastrointestinal Problem Assignment
Case Study For Gastrointestinal Problem Assignment
Patient Initials: H.A.
Age: 67 years
Gender: Male
Race: Caucasian
SUBJECTIVE
CC (Chief Complaint): Abdominal pain.
History of Present Illness (HPI): H.A. is a 67-year-old male who presents to the clinic with abdominal pain. He reports that he has been experiencing right and left lower quadrant pain for a duration that he can’t recall. He describes the pain as sharp, intermittent, and sudden. H.A. highlights that the pain worsens during quick movements such as twisting, does not radiate, and is relieved spontaneously. He rates the pain level as ten out of ten Case Study For Gastrointestinal Problem Assignment.
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Current Medications:
Lisinopril 5mg OD for essemtial hypertemsion.
Glipizide 5mg OD for diabetes.
Metoprolol tartarate 25mg BD for hypertension.
Atorvastatin 10mg O.D. Nocte for hyperlipidemia.
Allergies: No known drug allergy. No known food allergy.
Past Medical History (PMH): H.A. has a history of colon cancer (9/14/2021), hyperlipidemia (6/16/2022), lung cancer (9/14/2021), bilateral cataracts (9/14/2021), diabetes (9/28/2021), obesity (9/14/2021), deep venous thrombosis (9/14/2021), hypertension (9/14/2021), benign prostate hyperplasia (9/14/2021), gastro-esophageal reflux disease (9/14/2021) and liver cancer (9/14/2021). H.A.’s immunization status is up to date. He received the Moderna vaccine for covid 19 on 9/17/2021. Case Study For Gastrointestinal Problem Assignment
Social History: H.A. is divorced with two children. He is retired and lives with his son. He has been a former tobacco smoker for 25 years and has never taken alcohol. He uses caffeine once in a while but does not like it. He has a pet dog who lives with him. He is heterosexual but is currently sexually inactive. He cannot fully care for himself; therefore, his son employs a caretaker to help H.A. perform his daily activities. The caretaker ensures H.A. exercises daily by taking walks around the neighborhood. H.A. has a Medicare insurance cover which he finds to be efficient.
Family History: H.A.’s children are alive and healthy. H.A.’s father died of malignant neoplastic disease while his mother was alive and suffering from malignant neoplastic disease, type 2 diabetes mellitus, hypertension, and hypercholesterolemia. H.A. is the last born of two children. His brother has prostate cancer. Case Study For Gastrointestinal Problem Assignment
ROS:
General: Denies chills, fever, headache, day sweats, fatigue, daytime sleepiness, weight loss, or weight gain.
HEENT/Neck: Denies difficulty swallowing and rhinorrhea. Denies double vision, itchy eyes, painful eyes, blurred vision, and visual loss. Denies changes in hearing, ear fullness, ear noises, ear discharge, and ear infection. Denies dry mouth, difficulty swallowing, oral lesions, gum bleeding, or nasal congestion.
Skin: Denies rashes and itching.
Cardiovascular: Denies chest pain, chest discomfort, or chest pressure. Denies dyspnea, leg edema, palpitations, arrhythmias, or orthopnea.
Respiratory: Denies cough, wheezing, choking when swallowing, chest pains, shortness of breath, holding breath during sleep, difficulty breathing, or sputum production.
Gastrointestinal: Reports abdominal pain. Denies vomiting, diarrhea, heartburn, nausea, choking during sleep, indigestion, loss of appetite, acid reflux, constipation, or difficulty swallowing.
Genitourinary: Denies painful urination, vaginal discharge, urinary incontinence, dribbling, decreased stream, frequent urination, and blood in the urine.
Neurological: Denies memory loss, headache, changes in memory, loss of consciousness, seizures, confusion, difficulty balancing, numbness, tingling sensation, spells of blindness, or dizziness. Case Study For Gastrointestinal Problem Assignment
Musculoskeletal: Denies muscle pain, back pain, stiffness, or joint pain.
Hematologic: Denies easy bruising, exposure to HIV, swollen glands, anemia, and bleeding problems.
Lymphatic: Denies enlarged lymph nodes or splenectomy.
Psychiatric: Denies history of anxiety, depression, stress, loss of interest, or insomnia.
Endocrinology: Denies sweating, cold intolerance, polyuria, heat intolerance, or polydipsia.
Allergies: Denies hives, rhinitis, eczema, or asthma.
OBJECTIVE
Physical Exam:
Vital signs: BP 148/84 mmHg, HR-102 bpm, SPO2- 96% on room air, Temp 98.3, RR-18bpm, Height- 160.02cm, Weight- 93kgs, BMI 36.3.
General: The patient is comfortable, cooperative, hygienic, and well dressed. He is obese.
Psychiatric: He is aware of context and oriented to time and place. His recent and remote memory is normal. He is alert and in a normal mood.
HEENT: Clear oronasophaynx, PERRLA, normocephalic and atraumatic head, no visual acuity issues.
Neck: Neck has a full range of motion in all directions, normal symmetry, normal length, and no palpable lymph nodes.
Respiratory: On palpation, no tenderness or palpable mass. On auscultation, normal breath sounds without wheezing or audible breath sounds. No chest deformities.
Heart/Peripheral Vascular: On palpation, normal heart size and normal heart location. On auscultation, normal heart rate, normal rhythm, and no murmurs. Normal extremities.
Abdomen: Normal and present bowel sounds. Murphy’s assessment reveals the absence of pain in the right upper quadrant (Mealie et al., 2021). A Psoas test indicates a positive result for lower abdominal pain. On palpation, ventral hernia. Visible epigastric pulsation. Abdominal scarring left lower quadrant and right lower quadrant. On visual inspection, asymmetrical. Case Study For Gastrointestinal Problem Assignment
Musculoskeletal: Symmetric muscle development. Muscle power of 5/5 on extremities. No deformities or swelling on joints.
Neurological: All cranial nerves and deep tendon reflexes are intact.
Genital/Rectal: This exam was not conducted.
Lymphatic: No swollen lymph nodes.
Skin: His skin tone is appropriate to his ethnicity.
Diagnostic results:
C.T. scan: A CT scan is recommended to ascertain the diagnosis of ventral hernia and assess the exact position. The patient is obese; therefore, his physique might make it difficult to perform a conclusive physical examination.
Pulmonary function tests: This test is recommended because H.A. has a history of smoking tobacco for 25 years and a history of lung cancer.
Complete blood count: A CBC is recommended to check leukocytosis with the left shift.
Urinalysis: Urinalysis is recommended to rule out genitourinary factors leading to groin pain.
Ultrasonography: This imaging is recommended to detect ascetic fluid and free peritoneal blood. Results showed the absence of free peritoneal blood and ascetic fluid.
Lactate level test: This test is recommended to assess perfusion and strangulation. Elevated lactate levels signify hypoperfusion.
Endoscopy: This test is recommended to rule out ulceration in the intestinal walls or blockade. Case Study For Gastrointestinal Problem Assignment
ASSESSMENT
Differential Diagnoses
Abdominal ventral hernia: Patients diagnosed with a ventral hernia usually complain of abdominal pain, fullness, or swelling (Smith & Parmely, 2022). H.A. complained of abdominal pain. A strangulated or incarcerated hernia can cause asymmetry, as seen in H.A.’s abdominal visual assessment, which reveals asymmetry. Obesity is a primary risk factor for abdominal hernia. H.A. has a BMI of 36.3, which signifies that he is obese. H.A. also has a history of hernia, which tend to relapse in some patients.
Abdominal aortic aneurysm: Patients diagnosed with abdominal aortic aneurysm usually complain of severe abdominal pain and the presence of a palpable mass. Men above 65 years old, hypertensives, and smokers are at a high risk of suffering from abdominal aortic aneurysms (Shaw et al., 2022). This is a differential diagnosis since H.A. is male, 67 years old, has a history of smoking, and is a known hypertensive.
Ascites: This condition is described by fluid accumulation in the abdominal cavity. Liver disease is a primary underlying factor of ascites (Chiejina et al., 2022)Case Study For Gastrointestinal Problem Assignment. H.A. has a history of liver cancer which makes ascites a differential diagnosis. Patients diagnosed with ascites usually have a palpable mass and sometimes experience severe pain.
PLAN
Additional tests: I would have performed a stain of nodal tissue. Although the patient is not coughing, he has smoked for 25 years and is highly susceptible to T.B. or COPD.
Therapeutic interventions: The primary diagnosis is a ventral abdominal hernia. The patient is scheduled for a laparoscopic ventral hernia repair. Intravenous ceftriaxone and general anesthesia were administered before the procedure. The patient was discharged on amoxicillin. H.A. was prescribed oral tramadol for pain management.
PRIME HOSPITAL
2020 MAIN STREET
Name: H.A. Sex: Male
Age: 67 Date: 29/7/2022
Amoxicillin 500mg TDS × 7/7
Tramadol 50mg B.D. × 1/12 (Dispense 60 tablets of 50mg tramadol tablets for pain management postoperative care)
Doctor’s signature: DR. T.T
Dispensed by:
Referral: A surgeon is consulted to determine if the hernia can be reduced, if there are comorbid risks for sedation, and assess of strangulated or incarcerated hernia. Looking at the patient’s history, there was a need to refer to an oncologist and gastroenterologist for further evaluation. The oncologist should rule out the presence of a malignancy. The patient is directed to a nutritionist to advise on the benefits and ways of losing weight through a healthy diet.
Follow-up: The follow-up is scheduled for three weeks after repair to observe the patient’s progress. The patient is advised to report to the hospital in case of severe pain, signs of wound infection, or any other concern. Case Study For Gastrointestinal Problem Assignment
Reflection: I learned that preoperative planning is crucial to determining the need for general anesthesia. The patient’s rights were respected, and he was informed o the benefits and risks of the surgical procedure. The patient was allowed to consent to his surgery. I agree with the patient’s management except for the duration of the prescribed tramadol. I would have prescribed the tramadol for three weeks since the patient is scheduled for a review in three weeks.
Health promotion and disease prevention: H.A. and his caretaker are advised to do strenuous activities that can increase intraabdominal pressure. They are advised against the patient lifting anything above 4.5kg in the first week after repair. The patient and his caregiver are trained on wound care, hygiene, and how to prevent wound contamination. They are advised to ensure the patient is compliant with his other medications.
References
Chiejina M, Kudaravalli P, Samant H. Ascites. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470482/
Mealie CA, Ali R, Manthey DE. Abdominal Exam. [Updated 2021 Oct 15]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459220/
Shaw PM, Loree J, Gibbons RC. Abdominal Aortic Aneurysm. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470237/
Smith J, Parmely JD. Ventral Hernia. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499927/ Case Study For Gastrointestinal Problem Assignment
PLEASE READ INSTRUCTION CAREFULLY
I UPLOAD THE TEMPLATE, PT INFORMATION AND THE RUBRIC
PT INITIAL H.A, 67 Y/O
pt with gastrointestinal problem. You will need to perform TWO specific PROVIDER GI tests (not the standard RN tests of auscultation, percussion, palpation …). Examples of GI exam techniques are Psoas sign, Rosving, Obturator…there are others.
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must have AT LIST 3 credible references (no textbook (Buttaro), no WebMd, no UpToDate, no Cleveland Clinic, no John’s Hopkins…..) Your sites may not be general patient information sites. You must use peer reviewed professional references. Most of the professional organization websites (American Academy of Family Physicians, American Academy of Orthopedic Surgeons, American College of Cardiology , American Journal of Managed Care…) are considered credible and have professional guidelines Case Study For Gastrointestinal Problem Assignment