Vijay Rao HPI Bad belly pain iHuman case study, Exams of Nursing

Download Vijay Rao HPI Bad belly pain iHuman case study and more Exams Nursing in PDF only on Docsity! Vijay Rao HPI Bad belly pain iHuman case study RATED Have you had the pain in your Just intermittently for this past ' months | guess. |never had Characteristics abdomen before? problems with my stomach before ‘though. i area patiors to your abil | Yo, uml Fappne abo an Crenceretee |pah? hour oF so after eating charcadeiee yourancomen wort arpng, a buring psn most, ‘buming, stabbing, aching, tingling, Oecaspnaly itis stabbing squeezing) {ques fal ulr sooner, but | anohst cower oa al Doyoutet ta pire you tn | MBPaL Sm wert ica - ating anormal szomea?””” Etim. and ao el ad ponies Does fs poh your abdomen characteris | ove he pn Yes, ow di you know? Iveboen ying ara, toy wed ‘chp mathe pan ete at Aogrvaing ows ring mate he aainin—ayeren yarn won, -_ raven't noticed anything in parkour at nae wore Feng Wa eames have you had for Tring Toamons, What tosiments hav ust tara ip ties ada and ow it TingTicamerts, om fon does his abdominal pain. Ne cay gos aay comput Toy tis 2 6:710. Moet thr day ae betvoona S/O severity How ser (110 sal) is your taght tut Sarod eatng ore nnnne regular it would get better, but it Son wr PMH, FH, SH as Needed (© Asked X Not asked Graded Approach Question Response Information Obtained Clinic Notes Yes. Tums. Also, my knees have been bothering me more italy. | pm _Af@you taking any over-the-counter guess its because 'm doing more ‘or herbal medications? since my retirement. Anyhow, Ive been taking more ibuprofen fr that lately. 4 to 6 tablots a day. It helps. pm Af youtaking any prescription Yes, I take something fr my blood ‘medications? pressure. Review of Systems (ROS) ‘Select the major body systems that have not been touched on during the interview process forthe HPI. © Asked X Not asked Graded Question Response Do you have problems with heat or cold intolerance, increased thst, increased Problems with Information Obtained Clinic Notes temperature? No. What ‘sweating, frequent urination, or change else did you ask? ? in appetite’ Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or = UP tremor? Do you experience shortness of breath, wheezing, afclly catching Your Nope, breath, chronic cough, or sputum production? Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or bloating? | dont have any nausea or vorniting, but | have noticed dart tarry stool. Really smelly sometimes. Name: Age: Sex: Height: Weight: BMI: Cognitive status: Temp: Pulse: BP: Orthostatic BP: Respiration: SpO,: Vijay Rao 60 y/o M 74" 204 Ib 26.1 AandOx4 36.8 °C (98.2 °F) (oral) 110 bpm, rhythm: regular, strength: normal left: 120/68, right: 120/68, assessment: normotensive, pulse pressure: normal 104/62 mmHg upon standing 18 bpm, rhythm: regular, effort: unlabored 96% Physical Exam Feedback © Performed Correctly ‘+ auscultate abdomen © You performed the simulation correctly. ‘+ auscultate heart © You performed the simulation correaly ©. You interpreted assessment correctly. ‘+ auscuitate lungs © You performed the simulation correctly. © You interpreted lft lung and right lung correctly ++ blood pressure ‘= examine pupils, © You performed the simulation correctly. © You interpreted left pupil and right pupil correctly. inspect eyes Eye inspection provides a window into the adequacy ofthe circulatory and hematologic systems. “+ inspect mouthipharynx. In cases where patients present with diffuse symptoms such as fatigue, itis always important to rule-out chronic infections as etiologic. + orthostatic blood pressure (BP) ‘+ palpate abdomen, ‘Acareful abdominal exam is essential in any patient presenting with the complaint of belly pain. During the exam make x you evaluate: 1) vasculature, je. abdominal aorta for diameter and pulsations, 2) liver and spleen size, 3) masses all of which could provide additional clues into the etiology of his complaint. + palpate neck In cases where patients present with diffuse symptoms such as fatigue, itis always important to rule-out chronic infections as etiologic. + pulse © You performed the simulation correctly © You interpreted rate, rhythm, and strength correctly. = rectal exam Rectal exam provides information on the neurologic innervation i.e. sphincter tone, prostate palpation looking for signs of prostate malignancy and finally the stool color and whether blood is found inthe stool (gualac evaluation). reflexes - deep tendon © You performed the simulation correctly. + temperature ‘+ visual inspection abdomen ‘Abdominal inspection isthe fist step in the evaluation of the abdomen. One is looking for masses, abnormal contour and venous vascul indication of possible liver abnormalities. @ Not Required, Not Inappropriate + cognitive status + eight ‘+ respiration + $90, + weight X Missed ‘+ perform ocular motor test © You did not cover all the areas. Result: basic metabolic panel (BMP), blood Name Sodium (Na+) Potassium (K+) Chloride (CI-) Carbon dioxide, total (CO2) Glucose (BG/Glu) Urea nitrogen (BUN) Creatinine (Cr) Calcium (Ca2+) “Anion Gap Interpretation Normal Value Units 144 mmol/L 51 mmol/L 101. mmol/L a7 mmol/L 78 mg/dL 13 mg/dL 0.9 mg/dL 10.4 mg/dL 13 mEq/L Reference Range 135-148 4.0-6.0 95-102(1mo-adult), 91-118(1d-1mo) 22-29(15y-adult), 20-28(ty-15y) 70-110(fasting), 70-130(non-fasting) 8-21(15y-adult), 5-18(1mo-15y) 0.6-1.3(4), 0.5-1.1(2) 8.7-10.7(1 moa-adult), 8.7-11.9 10-20 [(Na+) - (Cl-) - (CO2)] Result: comprehensive metabolic panel (CMP), blood Name Sodium (Na+) Potassium (K+) Calcium (Ca2+) Chloride (Cl-) Carbon dioxide, total (CO2) Glucose (BG/Glu) Urea nitrogen (BUN) Creatinine Albumin Bilirubin, total Protein, total Alkaline phosphatase (ALP) Aspartate transaminase (AST) Alanine transaminase (ALT) Interpretation Normal Value Units 141. mmol/L 5.1 mmol/L 10.4 mg/dL. 101 mmol/L. 27 mmol/L 78 mg/dL 13 mg/dl 0.9 mg/dL 46 g/dL 1.0 mg/dL 7.8 g/dl 118 units/L 40 units/L. 30 units/L, Reference Range 135-145 3.5-5.1 (imo-adult) 8.7-10.7, 8.7-11.9 (mo = adult) 95-102, (1d - 1mo) 91- (15y - adult) 22-29, (ty - 15y) 20-28 (fasting) 70-110, (non-fasting) 70-130 (15y - adult) 8-21, (1mo - 15y) 5-18 (3) 0.6-1.3, (9) 0.5-1.4 (adult) 3.5-5.0, (0 - 3y) 2.9-5.5 (Amo - adult) 0.2-1.3, (1d - 1mo) 0.6- W1 (8y - adult) 6.0-8.2, (1mo - 8y) 5.6-8.5 (adult) 30-125, (1d - 15y) 80-250 3-44 0-40 Result: complete blood count (CBC), blood Name White blood cells (WBCs) Red Blood Cell Count (RBC) Hemoglobin (Hgb) Hematocrit (Hct) Mean corpuscular volume (MCV) Mean corpuscular hemoglobin (MCH) Mean corpuscular hemoglobin concentration (MCHC) Platelets (thrombocytes) Red cell distribution width (RDW) Neutrophils Lymphocytes Monocytes. Eosinophils Basophils Segmented neutrophils Band Cells Interpretation Value Units 4725 mm3 million/ 5.7 yl 10 gid 30 % 74 fl 2 um3 32 % 350 k/dL 12.7 % 58 % 35 % 4 % 2 % 1 % 52 % 6 % Reference Range 4,000-10,000 4.5-5.9(3), 4.0-5.2(2), adults 14-18(2), 12-16(2), adults 42-54(3), 37-47(2), adults 82-103, adults 26-34, adults 30-37, adults 150-399, adults 11.5-14.5, adults 46-78, adult 18-52, adult 3-10, adult 0-6, adult 0-3, adult 36-72, adult 0-6, adult Microcytic anemia probably due to iron deficiency from chronic Gl bleeding Result: lipase, blood Name Value Units Reference Range Lipase 49 Interpretation Normal units/L 10-52 diau |. | Result: liver function tests (LFTs): ALT, albumin, ALP, AST, GGT, bilirubin (direct and indirect) Name Albumin Alanine transaminase (ALT/SGPT) Aspartate transaminase (AST/SGOT) Alkaline phosphatase (ALP/ALK Phos) Bilirubin, total Bilirubin, conjugated Gammaz-glutamyl transpeptidase (GGT) Interpretation Normal Value Units 3.8 = pg/dL 30 units/L, 40 units/L, 118 units/L 1.0 mg/d 0.2 mg/dL 85 units/L, Reference Range 3.5-5.0 (adult); 2.9-5.5 (0-3y) 0-40 3-44 30-125(adult), 80-250(1d-15y) 0.-1.3 (1 mo-adult); 0.6-11.1 (1d- 11mo) 0-0.3 18-85(3), 18-61(2) Plan Feedback Management Plan H. pylon PUD 4. Observation vs Horne therapy: Patient stated last tarry black stool was more than 3 days ago and has been intermittent, thus home management with frequent clinic follow-up was chosen. 2. Triple therapy was chosen due to the severity of presentation - treatment length is 14 days with H. Pylori breath test at the end of therapy. * proton pump inhibitor (double normal dose) BID * clarithromycin 500 mg po BID + Amoxicillin 1 gm po BID 8. Stop all NSAIDs, alcohol and tobacea (nicotine patch provided) 4, Follow-up endoscopy in 6 weeks to ensure ulcer is healed I 5. Continue proton pump inhibitor for total of 6 weeks and pm after that Iron Deficiency Anemia/GI bleed 1. start multivitamin with iron for 1 month and repeat CBC 2. Schedule for colonoscopy - patient is 9.5 years since last one. Although PUD is the most likely cause of his tarry stool and anemia, the ulcer was not bleeding at the time of endoscopy, thus, the true source of the bleed has not been visualized and therefore, an occult malignancy has not been complstely excluded. Since he is only 6 months from his need of a screening colonoscopy, it seems prudent to accelerate the date and get this done ASAP to ensure an occult cancer is not being missed. 1of1 Index of Exercises Feedback @Correct XMissed € Incorrect Choice Yours Graded Det: Stress reduction oO etal EGD with Biopsy and H. pylori testing Tell her the ulcer is likely due to her oe @Correct prednisone ° + EGD with Biopsy and H. pylori testing ° ° Alcohol cessation EGD is indicated in this patient with melena and weight loss to evaluate for an activaly bleeding ulcer, stricture or a malignancy. A gastric ulcer can actually be an ulcerated gastric carcinoma and should be biopsied. Helicobacter Pylori is the major cause of paptic ulcer disease. H. pylori testing can be done by biopsy and observation of the tissue under the microscope or by doing a test for urease. Empiric treatment with omeprazole  Case Summary Learning Objectives 41, Can identify risk factars for peptic ulcer disease. 2. Can discuss various clinical presentations of peptic ulcer disease. 8. Can outline appropriate testing for patients with suspected peptic ulcer disease. 4. Can develop a treatment plan for @ patient with peptic ulcer disease. Risk factors for peptic ulcer disease. Peptic ulcer disease is often multifactorial, but the most common! important risk factors are Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs or aspirin. Other risk factors include gastrinoma, carcinoid, alcohol and tobacco use. pyloriis the major cause and is found in more than 70% of patients with duadenal ulcers and gastric ulcers in the US. Itis a Gram negative flagellated spirochete that is transmitted by fecal-oral spread or from mother to child. 50 % of the world's population is infected with H. pylori, and 10 to 20% of pationts infected with H. pylori develop gastritis or peptic ulcer disease. Eradication markedly reduces peptic ulcer recurrence. The risk of peptic ulcer disease with conventional NSAIDs is 4%. Fisk factors for NSAID induced ulcers include H. pyloriinfection, advanced age, history of ulcer, concomitant therapy with corticosteroids, anticoagulants or selective serotonin reuptake inhibitors, high doses of NSAIDs and serious systemic disorders. Presentations of pet Patients generally have epigastric burning or a dull gnawing pain that is relieved by antacids. Duodenal ulcer pain is improved with food and recurs 2 to 3 hours after a meal. Gastric ulcer pain may be worsened by food. Pain awakening a patient fram sleep is very specific for peptic ulcer disease. It occurs in two thirds of duodenal ulcer patients and one third of gastric ulcer patients. The pain radiates to the back with perforation. Nausea and substantial vomiting suggest gastric outlet obstruction due to scarring from chronic inflammation or gastric carcinoma. Weight loss may be caused by fear of food intake in patients with gastric ulcers or be due to vomiting. Upper Gl bleeding can occur, resulting in hematemesis, coffee graund emesis and melena. Anemia can occur acutely from rapid blood loss or dus ta iron deficiency from chronic: blood loss. Associated sympioms may include fatigue, lightheadedness or dyspnea ic ulcer disease. Patients may have epigastric tendemess. Tachycardia, hypotension or pallor may be seen with anemia, A board-like abdomen and rebound tenderness may be noted if the ulcer is perforated, ‘Testing for patients with suspected peptic ulcer disease, ‘The diagnosis is generally clinical based on typical symptoms and signs and improvement with empiric treatment. CBC and stoal Guaiac may be done if bleeding is suspected, EGD or Upper GI (X-ray atter giving radiopaque contrast) should be considered in all patients 50 years or alder, persistent symptoms despite treatment, anorexia and weight loss and voriting and with acute Gl bleeding to evaluate for stricture/ obstruction and gastric cancer. H. pyloritests include H. pylori IgG (blood test), which indicates history of infection but not necessatily active infection, a urea breath test (Capsule or liquid containing C-13 or C-14 labeled urea -H. pylori metabolizes urea resulting in radioactively labeled CO2 being released), Stool for H. pylori antigen or biopsy with urease test, histology or culture (only done if sensitivity testing needed). ‘Treatment plan for a patient with peptic uleer disease. + Eradicate Helicobacter pylori: Therapy with proton pump inhibitor and 2-3 antibiotics for 10 to 14 days + Stop NSAIDS, alcohol and tobacco. = H2 antagonists, Proton pump inhibitors, Cytotec and or antacids if H. pylori negative; Continue Proton pump inhibitor or H2 blocker as needed after therapy for Helicobacter pylori is completed. + Surgical treatment (endoscopic or open) for perforation / severe bleeding + Surgical treatment is also available for acid suppression ¢e.g., vagotomy or resection) but has been rarely needed since the advent of proton pump inhibitors Basic science "Pearls" Pathophysiology of peptic ulcer diseas: + Increased acid: H. pylori (Decreased somatostatin results in increased gastrin, Gastrinoma (increased gastrin), Carcinoid (increased histamine), Intracranial surgery stimulates vague nucl + Defect in mucosal barrier (especially important in gastric ulcers): NSAIDs! aspirin & steroids inhibit prostaglandin production, EtOH, Tobacco, H. pylori releases urease and mucolytic enaymes, Stress/ shock results in decreased blood flow, which results in the accumulation of acid, bums, radiation, Grohn’s disease + Exogenous aggressive factors’ inflammation: H. pylori incites B-cell and T-cell response, Grahn's disease, Systemic mastocytosis| Differentiate between gastritis/ duodenitis and gastric ulcer/ duodenal ulcer * Gastritis involves mucosal damage. + Peptic ulcer involves submucosal damage and can be defined as mucosal lesions that penetrate the muscularis, mucasae layer and form a cavity surrounded by acute and chronic inflammation, + Gastric ulcers are located in the stomach, often along the lesser curvature in the transition zone from corpus to antrum mucosae. + Duodenal ulcers are located in the duodenal bulb. Patient Disposition ‘The pationt received triple therapy for H. pylori with rapid resolution of symptoms. Follow up EGD in 6 waoks shows that the uleer had healed,