Assessment and Differential Diagnosis of Abdominal Pain in a 65-Year-Old Male

QUESTION

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

Question:

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 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.
6. References not more than 4 years. Please use appropriate citations

ANSWER

Assessment and Differential Diagnosis of Abdominal Pain in a 65-Year-Old Male

Introduction

Abdominal pain is a common complaint that can be challenging to diagnose accurately. This essay aims to analyze the subjective and objective portions of a patient’s note and evaluate the assessment provided. We will also discuss appropriate diagnostic tests and consider alternative differential diagnoses based on current evidence-based literature.

Analysis of the Subjective Portion

The subjective portion of the note provides relevant information regarding the patient’s presenting complaint and medical history. However, additional information that should be included in the documentation includes:

Onset and duration of the pain: Clarifying the exact time when the abdominal pain started and whether it has been continuous or intermittent can provide valuable insights into the condition’s severity and progression.
Characterization of pain: Determining the type of pain (e.g., sharp, dull, cramping) and any factors that exacerbate or alleviate it can help identify potential causes.
Associated symptoms: Inquiring about other symptoms such as nausea, vomiting, changes in bowel movements, or presence of blood in stool can aid in differential diagnosis and narrowing down the possible etiologies.
 Aggravating or relieving factors: Exploring any activities or positions that worsen or alleviate the pain may assist in identifying potential triggers or underlying conditions.

Analysis of the Objective Portion

The objective portion of the note provides crucial information about the patient’s vital signs, physical examination findings, and initial diagnostic tests. Additional information that could enhance the documentation includes:

Abdominal examination: Detailed documentation of the specific findings during palpation, including the location, tenderness, presence of guarding or rebound tenderness, and any palpable masses, is important for differential diagnosis.
Assessment of bowel sounds: Documenting the presence, absence, or abnormal bowel sounds can contribute to the overall evaluation of the gastrointestinal system.
Comprehensive review of systems: Expanding the assessment to include other relevant body systems, such as respiratory or cardiovascular, can provide a more comprehensive picture of the patient’s overall health status.

Assessment and its Supportive Information

The assessment provided in the note includes three potential diagnoses: abdominal aortic aneurysm (AAA), perforated ulcer, and pancreatitis. The subjective information supports the possibility of these diagnoses as the patient reports severe abdominal pain with radiation to the back, vomiting, and increasing pain severity. The objective findings of tenderness in the epigastric area without rebound or mass further support these potential diagnoses.

Appropriate Diagnostic Tests and Their Role

Abdominal ultrasound (US): An abdominal ultrasound is a valuable tool for evaluating the abdominal aorta, assessing for an AAA, and ruling out other causes of abdominal pain.
Computed tomography angiography (CTA): A CTA provides detailed imaging of the abdominal region, allowing for accurate assessment of the abdominal aorta and identification of potential aneurysms or other vascular abnormalities.

The results of these diagnostic tests would assist in confirming or ruling out the presence of an AAA, perforated ulcer, or pancreatitis, providing valuable information for making an accurate diagnosis.

Acceptance of the Current Diagnosis and Differential Diagnoses

Based on the available information, accepting the current assessment is reasonable. However, it is essential to consider alternative differential diagnoses to ensure a comprehensive evaluation. Three possible conditions to be considered are:

Gastroesophageal reflux disease (GERD): GERD can cause epigastric pain, and the patient’s history of GERD in the family may increase the likelihood of this diagnosis.
Gastritis: Inflammation of the stomach lining can present with similar symptoms, and the patient’s history of NSAID use for rheumatoid arthritis may contribute to the development of gastritis.
Gallbladder disease: Gallstones or inflammation of the gallbladder can cause epigastric pain and may need to be explored further.

Conclusion

Thorough documentation of subjective and objective information is crucial in the evaluation of abdominal pain. The provided assessment aligns with the subjective and objective findings, indicating potential diagnoses of AAA, perforated ulcer, or pancreatitis. Appropriate diagnostic tests such as abdominal ultrasound and CTA can aid in confirming or ruling out these conditions. Considering alternative differential diagnoses ensures a comprehensive evaluation, and in this case, GERD, gastritis, and gallbladder disease should also be considered.