Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
• With regard to the Episodic note case study provided:
o Review this week’s Learning Resources, and consider the insights they provide about the case study.
o Consider what history would be necessary to collect from the patient in the case study.
o 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?
o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
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 the 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?
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.
ABDOMINAL ASSESSMENT
Subjective:
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:
1. Abdominal Aortic Aneurysm (AAA)
2. Perforated Ulcer
3. Pancreatitis
_________________________
Additional information that should be included in the documentation for the subjective portion of the note:
Duration and frequency of the epigastric abdominal pain.
Any exacerbating or relieving factors.
Detailed description of the pain (e.g., sharp, dull, burning).
Any associated symptoms, such as nausea, vomiting, or changes in bowel movements.
Any recent dietary or lifestyle changes.
Any previous episodes of similar pain.
Family history of gastrointestinal conditions.
Additional information that should be included in the documentation for the objective portion of the note:
Detailed abdominal examination findings, including palpation of other quadrants.
Bowel sounds assessment.
Assessment of peripheral pulses.
Assessment of the patient’s general appearance and signs of distress.
Results of laboratory tests (if available) such as complete blood count (CBC), comprehensive metabolic panel (CMP), and lipase levels.
Results of imaging studies, including specific details from the ultrasound (US) and computed tomography angiography (CTA).
The assessment is partially supported by the subjective and objective information. The patient’s symptoms of intermittent epigastric abdominal pain, radiating to the back, vomiting, and tenderness in the epigastric area suggest a possible gastrointestinal issue. However, further evaluation and diagnostic tests are required to confirm the diagnosis and rule out other conditions.
Diagnostic tests that would be appropriate for this case include:
Laboratory tests: CBC, CMP, amylase, and lipase levels to assess for inflammation and pancreatic enzymes.
Imaging studies: US and CTA to evaluate the abdominal aorta, identify any aneurysm or perforated ulcer, and assess the pancreas for signs of pancreatitis.
The results of these diagnostic tests would be used to make a diagnosis by identifying any abnormalities or confirming suspected conditions. Abdominal aortic aneurysm, perforated ulcer, and pancreatitis are among the potential diagnoses considered in the assessment.
Regarding the current diagnosis, it is difficult to fully accept or reject it without further evaluation and confirmatory tests. Three possible conditions to consider in the differential diagnosis, based on the provided information, are:
Gallbladder disease: Although the patient’s symptoms are not specific to gallbladder disease, it can cause epigastric pain that radiates to the back. Further evaluation with imaging studies, such as an abdominal ultrasound, may be necessary.
Gastroesophageal reflux disease (GERD): The patient’s history of GERD in the family, along with the epigastric pain and lack of relief with PPIs, suggests the need for further investigation. Esophageal pH monitoring or upper endoscopy could be considered.
Peptic ulcer disease: The patient’s symptoms of epigastric pain, vomiting, and lack of relief with PPIs raise suspicion for peptic ulcer disease. Confirmation can be done via an upper gastrointestinal endoscopy.
