Prac 6531 week 6 assignment 2 episodic visit gastrointestinal focused note
Prac 6531 week 6 assignment 2 episodic visit gastrointestinal focused note
Prac 6531 week 6 assignment 2 episodic visit gastrointestinal focused note
Episodic/Focus Note Template
Patient Information:
Initials: D.S, Age: 53 years, Sex: Female, Race: White
S.
CC (chief complaint) “I have lower abdominal pain.”
HPI: D.S is a fifty-three-year-old white female patient who came to the facility complaining of lower abdominal pain. The patient reports that the symptoms of lower abdominal pain started five days ago and have been continuous. The patient denies any pain, radiation, fever, or chills. She also denies any diarrhea, vomiting, or nausea. The patient has not taken any over-the-counter medication for the experienced pain. She reports the pain to be 7 on a scale of 1 to 10 as its worst. The initial pain starts at about 5/10 and progressively gets worse. The patient also reports urinary frequency and urgency. However, she denies any burning upon urination.
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Current Medications: The patient is currently using various medications as home medicines, including Hydroxyzine (25 mg PO QD), Olanzapine (10 mg PO QD), and Olanzapine (5 mg PO QD)
Allergies: The patient has no known allergies
PMHx: The patient has a history of ulcers, depression, and anxiety. She also has a history of hysterectomy. She also has a complete Covid-19 vaccination (Covid #1 (02/10/20210), Covid #2 (03/10/2021) Covid booster (01/07/2022). No abnormal pap; last pap conducted on 9/2022, and mammogram in 2022.
Soc Hx: The patient denies smoking tobacco. However, she occasionally consumes alcohol, which she started using at the age of fifteen. She currently takes 1-2 drinks per week. She likes doing physical exercises as she engages in physical exercise five to seven times a week. The patient always practices safe sex and uses condoms. She is currently single and heterosexual. She has had three pregnancies and three live births. She is currently employed at a sewing machine factory where she operates a sewing machine making uniforms. The patient currently lives with her children, and she also has four siblings.
Fam Hx: The patient has no known significant family history.
ROS:
GENERAL: No fatigue, weakness, chills, fever, or weight loss.
HEENT: Eyes: No double vision or yellow sclera, no blurred vision, no visual loss. Ears, Nose, Throat: No ear pain or loss of hearing, no sneezing, congestion, sore through, or runny nose.
SKIN: No itching, rash, or change in color.
CARDIOVASCULAR: No edema or palpitations. No chest discomfort, chest pressure, or chest pain.
RESPIRATORY: No breath shortness, sputum, or cough.
GASTROINTESTINAL: The patient reports lower abdominal pain. No diarrhea, vomiting, nausea, or anorexia.
GENITOURINARY: Reports urinary frequency and urgency. However, she denies any burning upon urination.
NEUROLOGICAL: No change in bladder or bowel control, no tingling or numbness in the extremities, no ataxia, paralysis, syncope, dizziness, or headache.
MUSCULOSKELETAL: No muscle stiffness, no joint pain, back pain, or muscle pain.
HEMATOLOGIC: No bruising, bleeding, or anemia.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: The patient has a history of anxiety and depression.
ENDOCRINOLOGIC: No polydipsia, no polyuria. No reports of heat or cold intolerance and no reports of sweating.
ALLERGIES: The patient has no known allergies.
O.
Vital signs: BP 120/85, P 77, RR 18, Temp 97.9, O2 Sat 97% R/A.
Weight: 155.6 lbs Height: 5ft 2 inches BMI: 28.5
Physical exam:
General: The patient looks healthy, well-developed, and nourished. She seems bothered by the abdominal pain. She has no signs of acute distress.
HEENT: Head: Normocephalic/atraumatic. Symmetrical. Normal hair distribution and pattern. Eyes: PERRLA. EOMI. Conjunctiva pink. Sclera white. No redness or drainage was observed. Ears: External auditory canals clear, no drainage. Tympanic membrane pearly gray and intact with a good cone of light reflex bilaterally, no bulging, retractions, redness, or fluid. Nose: No congestion or blockage. No discharge was observed. Throat: Oral mucosa pink and moist, no lesions.
NECK: Supple. No pain or neck stiffness.
Cardiovascular: No Tachycardia or murmurs were noted. Normal S1 and S2 auscultated.
Pulmonary: The lungs are bilaterally resonant and clear. No cough was observed, chest expansion was symmetrical, and no labored breathing was observed.
Gastrointestinal: A slight distention observed, no observable scars, no skin lesions. The abdomen is non-tender. No enlargement of the spleen or liver. The bowel sounds are hyperactive in all the quadrants. No abnormal sounds were heard.
EXTREMITIES: No joint pain and tenderness, no edema. Motion range in extremities is normal, no deformities, normal gait.
NEUROLOGICAL: Alert and oriented, normal speech, normal muscle strength, and tone. No focal, motor, or sensory deficits.
Diagnostic results:
Urinalysis should be performed to explore the problem causing reports of urinary frequency and urgency. Another necessary test is lower gastrointestinal tract radiography for further assessment of abdominal pain. A colonoscopy should also be performed to assess intestinal injuries or tumors. Endoscopy can also help assess if there are any stomach ulcers.
A.
Differential Diagnoses
- Irritable bowel syndrome (ICD 10 code: K58): This is a GI condition known to affect the intestines and stomach. Some of the common symptoms include constipation, diarrhea, gas, bloating and abdominal pain. Recent research has also connected this condition with frequent urination and abdominal pain. The patient reported urinary frequency and urgency and abdominal pain, making this a primary diagnosis (Camilleri, 2021)
- Interstitial cystitis (ICD 10 code: N30.10): This is a condition that causes bladder inflammation and irritation, especially in females. It makes the bladder lining stiff, which may lead to pain. Some of the symptoms include the need to urinate frequently, lower abdominal pain when the bladder is filling up, a sudden strong urge to urinate, and intense pelvic pain (Clemens et al., 2022). The patient showed some of these symptoms making it a potential diagnosis.
- Urinary tract infections (ICD 10 code: N39.0): This is a condition that impacts the urinary system, and in most cases, it impacts the lower tract, which includes the urethra and the bladder. The symptoms include pelvic pain, strong-smelling urine, cloudy urine, increased urination frequency, a burning feeling when urinating, and a strong urge to urinate that doesn’t go away (Klein & Haltgren, 2020). Even though the patient reports urinary frequency and urgency, several other symptoms are missing making this diagnosis less likely
- Endometrial cancer (ICD 10 code: C54.1): This is a condition in women that leads to pain in the abdomen and while urinating (Passarello et al., 2019). The patient also had a lower abdominal pain. Hence, this can also be a differential diagnosis.
As part of the plan, various diagnostic studies should be accomplished. Urinalysis should be performed to explore the problem causing reports of urinary frequency and urgency. Another necessary test is lower gastrointestinal tract radiography for further assessment of abdominal pain. A colonoscopy should also be performed to assess intestinal injuries or tumors. Endoscopy can also help assess if there are any stomach ulcers. The listed diagnoses can also be managed using various approaches.
The Irritable bowel syndrome should be treated with rifaximin (550 mg PO TID for 14 d). Non pharmacological approaches for this condition include stress management, psychological and behavioral therapies and relaxation training.
Alternative treatments: Include prebiotics and probiotics. For the urinary tract infection, the patient needs to use nitrofurantoin (100 mg) taken twice a day (Klein & Haltgren, 2020). In the case of Interstitial cystitis, the patient should use Amitriptyline (25 mg) taken before sleep. The patient can also avoid certain foods, such as those with too much acid. For endometrial cancer, the patient should use Jemperli 500 mg every three weeks.
Follow-up: The patient should use the prescribed medications and come for a follow-up after two weeks.
Reflection: I agree with the preceptor’s treatment of the patient since the patient’s history and current symptoms majorly point to a GI complication. One of the things I have learned from this case study is that there is a need to carry out comprehensive assessments and various laboratory tests in the case of lower abdominal pain, as there are so many conditions that may lead to lower abdominal pain (Newton et al., 2019). One of the things I would do differently is to take a CBC to help reveal any other infections that could have led to the pain and increased frequency, and the need to urinate. As part of the health promotion, the patient should be educated to adhere to the treatment plan and report immediately if any adverse reactions occur. The patient should also watch out for what she eats and the quantities she consumes, as these can all lead to abdominal complications.
References
Camilleri, M. (2021). Diagnosis and treatment of irritable bowel syndrome: A review. Jama, 325(9), 865-877. Doi: 10.1001/jama.2020.22532
Clemens, J. Q., Erickson, D. R., Varela, N. P., & Lai, H. H. (2022). Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. The Journal of Urology, 208(1), 34-42. Doi: 10.1097/JU.0000000000002756
Klein, R. D., & Hultgren, S. J. (2020). Urinary tract infections: microbial pathogenesis, host–pathogen interactions and new treatment strategies. Nature Reviews Microbiology, 18(4), 211-226. https://doi.org/10.1038/s41579-020-0324-0
Newton, E., Schosheim, A., Patel, S., Chitkara, D. K., & van Tilburg, M. A. (2019). The role of psychological factors in pediatric functional abdominal pain disorders. Neurogastroenterology & Motility, 31(6), e13538. https://doi.org/10.1111/nmo.13538
Passarello, K., Kurian, S., & Villanueva, V. (2019, April). Endometrial cancer: An overview of pathophysiology, management, and care. In Seminars in oncology nursing (Vol. 35, No. 2, pp. 157-165). WB Saunders.https://doi.org/10.1016/j.soncn.2019.02.002
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EPISODIC VISIT: GASTROINTESTINAL-FOCUSED NOTE
Case Study:
53-year-old female c/o “lower abdominal pain.” Reports symptoms started five days ago and have been continuous. Denies any pain radiation. Denies any fever or chills. Denies any nausea, vomiting, or diarrhea. Denies taking any over-the-counter medication for the pain. Reports pain at a 7/10 @ its worst, with initial pain starting @ 5/10 and progressively getting worse. Reports urinary urgency and frequency but denies any burning upon urination. Reports no symptoms before five days ago.
Vital signs: BP 120/85, P 77, RR 18, Temp 97.9, O2 Sat 97% R/A.
Weight: 155.6 lbs
Height: 5ft 2 inches
BMI: 28.5
Allergies: NKDA
Home Medication: Hydroxyzine 25mg PO QD
Olanzapine 10mg PO QD
Olanzapine 5mg PO QD
PMH: Anxiety, Depression, Ulcers
PSH: Hysterectomy
Family HX: unknown
Vaccinations: Covid #1 (02/10/20210) Covid #2 (03/10/2021) Covid booster (01/07/2022)
No HPV vaccine
GYN: No abnormal pap, hysterectomy, last pap 9/2022, sexually active, No history of STIs. Always practice safe sex with the use of condoms. Heterosexual. Single. Mammogram 2022.
OB History: Gravida 3, Para 3.
Non-smoker, no illicit drugs, Occasional consumption of alcohol, started drinking at age 15. Currently have 1-2 drinks per week. Moderate exercise level @ 5-7 times per week. The highest level of school is the 11th grade. She is currently employed @ a sewing machine factory where she operates sewing machines while making uniforms. No difficulties with ADLs. She now lives with her children.
Number of siblings (4)
Please include A Total of Four Differential Diagnosis with the ICD 10 codes
Please include diagnostic tests that would be required to determine that diagnosis.
Please inlcude Referrals, Treatment, Follow-up & Reflections.
