GASTRO INTESTINAL

Review this week’s Learning Resources, and consider the insights they provide about the case study.
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.

ANSWER

Additional information on the note’s subjective portion includes the patient’s information from her perspective to the healthcare provider. It contains concerns, opinions, perceptions, and emotion and is collected through a one on one between doctor and patient. In this case, the patient generalized abdominal pain while evidence that the abdomen is vast in regions where the patient could narrow down. Similarly, the patient mentions a pain level of 9/10 when the problems started but 5/10 when she sees the doctor. With this information, the patient should also include the pain’s quality to point out whether the pain is localized of migratory. Whether the pain increases and decreases in levels depending on activity or situation.

The pain begins and where it radiates to and whether it is a gradual pain or occurs suddenly. Equally important, the patient must explain the activity situation when the pain started, for instance, lifting something heavy or something similar. With abdominal pain, often, some of the physical activity, such as lying down, could be relieving while eating could be aggravating; these are points that must be put on record (Oberstein et al. 2013). This information is fundamental in establishing a most probable diagnosis.

Additionally, the doctor needs to obtain more information on urinary and bowel habits on the diarrhea symptom. Such information could include the frequency of bowel movement, including the number of diarrhea instances in a day with a clear indication of whether local methods such as saltwater seemed to relieve it. Urinary habits are also very much at play, where frequency should be noted, incontinence, urgency, and dysuria (Vincent et al., 2011). Odor, color, and levels of discomfort during and after relieving wold also be instrumental in a later analysis of symptoms. The hypothesis to eliminate in an examination of urinary and bowel habits is potential pancreatic cancer, which causes the lightening of the stool and darkening of the urine (Vincent et al., 2011).

Lastly, on the ‘hx of GI bleed four years ago,’ which could mean a completely different diagnosis must be examined further. For instance, blood in stool must be noted, and if vomiting occurs, blood must also be noted, including odor and color. And the medication the patient is taking for diabetes and hypertension, the skipping of doses within the last three days should be noted. To eliminate physical injury, it is essential to note the patient’s occupation, including daily routines and activities.

The objective portion of the analysis comprises a comprehensive abdominal and physical examination. The first additional note to cover is the patient’s physical appearance that could be sick-looking, pain, lethargic, gait, and nutritional status. An observation of the patient’s mental state could be recorded. Should an alternative diagnosis be cancer, then the observation of physical status to eliminate malnourishment and cachectic factors could provide more insight. Skin appearance beyond lesions and urticarial to pigmentation, jaundice, and pallor should be added. Further additional information to be collected is data from inspection, auscultation, palpation, and percussion of the abdomen (Ryan et al., 2014).

The absence or presence of scars on various parts of the body is paramount to eliminating previous surgeries’ possible effects. Data on the presence or absence of veins, distended, and visible must be recorded. In addition to palpation data, the abdomen’s state, whether rigid or soft, tender or not, fluid-filled or nor should be included. If rigid, the examination could provide insight into the digestive fluid in the abdomen, bowel, or blood in the stomach cavities. Lumps could indicate a form of stomach cancer like pancreatic cancer, aneurysm, tumors, or an obstructed bowel (Oberstein et al., 2013). Analysis of specific areas regarding sensibilities such as tenderness is crucial to narrow down the cause to guide the diagnosis.

The assessment provided for this patient is left lower quadrant pain and gastroenteritis. The assessment concurs with both subjective and objective data. For instance, in the patient’s subjective data, diarrhea symptoms without vomiting are a significant indication of a gastrointestinal infection (Oberstein et al., 2013). However, beyond gastroenteritis, in a case where the ailment proves to be pancreatic cancer supported by the diagnosis so far, diarrhea could be from the inability to produce the pancreatic juices that aid in the digestive processes. The resultant effect would be the inadequate production of pancreatic juices and then malabsorption and, therefore, diarrhea (Oberstein et al., 2013). On the other assessment that pointed to pain in the left lower quadrant of the abdomen, the organs in question would be the rectum, ileum, parts of the colon, and ureter. A possible diagnosis would still be gastroenteritis.

The most appropriate diagnostic test would be a liver function test, a complete blood count, and a tumor marker test from the information obtained. Blood count would provide information on anemia and thrombocytosis, which could point to cancer of the pancreas (Hallet et al., 2015). The liver test could reveal bilirubin levels, serum amylase, lipase, and alkaline phosphatase, mostly related to jaundice (Hallet et al., 2015). The tumor test, most specifically a carbohydrate antigen where elevation would be noted and depending on the elevation level, indicates pancreatic cancer (Ryan et al., 2014). Rather than MRI, a CT scan would be most appropriate to reveal the pelvis and abdomen in entirety where the appearance of low-density lesions would point to pancreatic cancer.

The diagnosis is pancreatic cancer, as confirmed in a CT scan. From previously documented diagnosis, patients with pancreatic cancer report abdominal pain, which often points to a gastrointestinal infection. The pain usually is gradual and radiates from the upper abdomen to the back. Diarrhea is very prominent, causing loss of appetite, loss of weight, and a sickly appearance. Weight loss also occurs due to impaired food absorption mechanisms because the body cannot digest food properly with the inhibited production of pancreatic juices. The malabsorption, thereby, causes consisted of diarrhea. The presence of a tumor also suggests that the patient could have had an aggravated pain level after feeding and a lot of discomfitures. In terms of the jaundice diagnosis, a blocked bile duct can be revealed by the CT scan with other objective observations such as a yellow coloration of the skin, darkened urine, and lightened stool.

The pancreas is found at the upper quadrant of the abdomen; therefore, pain radiating from the upper abdomen to the lower abdomen due to the pressure on nerves supports the diagnosis (Halbrook et al., 2017). Therefore, the diagnosis would be acceptable to me. Other potential ailments from the diagnosis that would make more testing necessary include an abdominal aortic aneurysm, pancreatic lymphoma, intestinal ischemia, and gastric lymphoma.

An abdominal aortic aneurysm is a condition that causes an enlarged aorta, the blood vessel responsible for blood supply in the abdomen. The condition is life-threatening and could cause death by bursting if left unchecked. Some of the initial diagnosis symptoms are abdominal pain close to the navel (Sakalihasan 2005). The pain radiates to the back from the front and could be aggravated by physical activity. On the other hand, pancreatic lymphoma consists of symptoms that identical to pancreatic cancer, in particular, should the lymphoma be malignant. Lower back pain darkened urine, and lighter stool could be observed. Pancreatic lymphoma though very rare, fits the symptoms of the patient. Differentiating between pancreatic cancer and pancreatic lymphoma is very important because pancreatic lymphoma is highly treatable when it is not malignant. A CT scan would create this difference by observing an enlargement of one or more lymph nodes that could protrude towards the skin in the upper abdomen (Merkle 2000). The bump would be painless. Lastly, intestinal ischemia results from low blood supply to the digestive tract, particularly the intestines. Its cause is a blocked blood vessel or atherosclerosis. Due to poor food absoption in the digestive tract, the patient would experience diarrhea and severe abdominal pains. Additional symptoms would be vomiting and nausea with more aggravated pain after eating. A CT scan or an MRI would reveal any issue present in the abdomen’s blood vessels (Brandt 2000).

References

Brandt, L. J., & Boley, S. J. (2000). AGA technical review on intestinal ischemia. Gastroenterology, 118(5), 954-968.

Halbrook, C. J., & Lyssiotis, C. A. (2017). Employing metabolism to improve the diagnosis and treatment of pancreatic cancer. Cancer Cell, 31(1), 5-19.

Hallet, J., Law, C. H. L., Cukier, M., Saskin, R., Liu, N., & Singh, S. (2015). Exploring the rising incidence of neuroendocrine tumors: a population‐based analysis of epidemiology, metastatic presentation, and outcomes. Cancer, 121(4), 589-597.

Merkle, E. M., Bender, G. N., & Brambs, H. J. (2000). Imaging findings in pancreatic lymphoma: differential aspects. American Journal of Roentgenology, 174(3), 671-675.

Oberstein E P., & Olive O. P. K., (2013). Pancreatic cancer: why is it so hard to treat? Therapeutic Advances in Gastroenterology 6(4):321-327.

Ryan, D. P., Hong, T. S., & Bardeesy, N. (2014). Pancreatic adenocarcinoma. New England Journal of Medicine, 371(11), 1039-1049. Cancer and Women’s and Men’s Health

Sakalihasan, N., Limet, R., & Defawe, O. D. (2005). Abdominal aortic aneurysm. The Lancet, 365(9470), 1577-1589.

Vincent, A., Herman, J., & Goggins, M. (2011). Pancreatic cancer. Lancet. 378(9791):607-620