intermittent epigastric abdominal pain Case Study

QUESTION

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

1. 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

then do the following:

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

ANSWER

Subjective

Additional information that should be included in the documentation:
Duration and frequency of the abdominal pain
Characterization of the pain (e.g., sharp, dull, burning)
Any alleviating or exacerbating factors
Any associated symptoms such as nausea, vomiting, bloating, or changes in bowel habits
History of previous episodes of similar abdominal pain
Medication history related to pain relief attempts
Patient’s concerns or fears regarding the abdominal pain
Any recent changes in diet or lifestyle

Objective

Additional information that should be included in the documentation:
Results of the abdominal examination, including any specific findings such as palpable masses or organ enlargement
Assessment of bowel sounds
Assessment of other vital signs such as temperature, respiratory rate, and oxygen saturation
Any abnormal findings on skin examination
Detailed findings from diagnostic tests such as ultrasound and CT angiography

The assessment is supported by the subjective and objective information. The patient’s symptoms of intermittent epigastric abdominal pain that radiates to the back, along with tenderness in the epigastric area, guarding, and vomiting, are consistent with the possible diagnoses of abdominal aortic aneurysm (AAA), perforated ulcer, or pancreatitis.

Appropriate diagnostic tests for this case would include

Abdominal ultrasound to evaluate the abdominal aorta and assess for the presence of an AAA
CT angiography to further evaluate the abdominal structures and confirm the presence of an AAA or assess for other potential causes such as perforated ulcer or pancreatitis
Laboratory tests such as complete blood count, liver function tests, amylase, and lipase to assess for any abnormalities suggestive of pancreatitis

Based on the available information, it is difficult to accept or reject a specific diagnosis without further diagnostic tests and evaluation. Three possible differential diagnoses to consider in this case could be:
1. Gastritis: Inflammation of the stomach lining that can cause epigastric pain, often associated with factors such as alcohol use and previous history of GERD.
2. Gallbladder disease: Conditions such as cholecystitis or gallstones can cause abdominal pain that may radiate to the back, and can be associated with vomiting and fatty food intolerance.
3. Gastroenteritis: Infections or inflammation of the gastrointestinal tract can present with abdominal pain, vomiting, and diarrhea, which may explain the patient’s symptoms.

References

1. Rosenblatt M, Abulebda K, Crain J, et al. Pediatric Abdominal Pain: Update on Diagnosis and Management in the Emergency Department. Pediatr Emerg Med Pract. 2019;16(Suppl 11-2):1-23.
2. Peery AF, Crockett SD, Murphy CC, et al. Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2018. Gastroenterology. 2019;156(1):254-272.e11.
3. Ng FH, Wong SY, Lam KF, et al. Gastrointestinal and psychological factors in uninvestigated dyspepsia patients: a comparison of gastroesophageal reflux disease and functional dyspepsia. J Gastroenterol Hepatol. 2008;23(2):243-247.