Charnita R. Anderson RN,MSN,FNP-C - Home/Welcome



Differential Diagnosis Paper________________________________________Presented toDr. Cheryl Juneau, DrPh, RN, FNP-CTHE UNIVERSITY OF TEXASSCHOOL OF NURSING AT GALVESTON________________________________________In Partial FulfillmentOf the Requirements for the CourseGNRS 5669 – FNP Adult/Women’s Health________________________________________By:Charnita Anderson RN, BSN&Natalie Bernard RN, BSNFebruary 18, 2013Case StudyA 33year old, Caucasian, male came into the family practice clinic with the complaint of lower right sided & epigastric abdominal pain. The pain is a dull, achy pain that radiates to the scapular area of the right shoulder. He suffers from alternating episodes of constipation & diarrhea with mucous in his stools. He has been experiencing a lot of bloating, flatulence & belching. These symptoms have been present for over three months. Differential Diagnoses1. Irritable Bowel Syndrome (IBS) - It produces a crampy, hypogastric pain that is variable, infrequent duration. The pain is associated with bowel function, gas, bloating, and distention. Relief is often obtained with the passage of flatus or feces (Dains, 2012). 2. Appendicitis- The patient reports sudden onset of colicky pain that progresses to a constant pain. The pain can begin in the epigastric or periumbilicus and later localize to the right lower quadrant. The pain worsens with movement or coughing. On physical examination, the patient will be lying still and will demonstrate involuntary guarding (Dains, 2012). 3. Acute cholecystitis- Most patients complain of indigestion, nausea, vomiting, especially after eating a meal high in fat. Usually begins with acute, colicky- type pain. However the pain may persist and as the inflammation progresses the pain localizes over the RUQ. Patients may complain of referred pain that radiates to the middle of the back, or to the right shoulder (Dunphy, 2011). 4. Crohn’s disease- Crohn’s disease is an inflammatory bowel disease that presents with abdominal cramping, rectal bleeding, and bloody diarrhea. Weight loss is common because of malabsorption. The disease can affect any part of the tract from the mouth to the anus. Disease affecting the small bowel affects nutritional status and weight loss (Dains, 2012).5. Chronic Pancreatitis- is defined as a slowly progressive inflammatory process that results in irreversible fibrosis of the pancreas with destruction and atrophy of the exocrine and endocrine glandular tissue. The most frequent presenting symptoms can be mild as dyspepsia, nausea, and vomiting. Abdominal pain is usually epigastric or in the Left Upper Quadrant (LUQ), may radiate to the back or the left lumbar region described as dull and constant (Dunphy, 2011).Three Selected DifferentialsThe three differentials that we have chosen are the ones that we feel best fit our patient’s symptoms. These are Irritable Bowel Syndrome (IBS), appendicitis, and acute cholecystitis. Each of these is a disorder of the gastrointestinal system but present in different ways as mentioned in the above documentation & referenced literature. Throughout the history & physical exam it will be explained what pertinent symptoms the patient is experiencing and how it lead us to these chosen differential diagnoses.History & Physical ExamPresent history: This patient came into the clinic with a chief complaint of lower right sided and epigastric pain that radiates to his right shoulder area. He describes the pain a dull, achy pain and has been experiencing this pain for three months. Cholecystitis can cause a colicky pain with progression to constant pain. Pain in the Right Upper Quadrant (RUQ) can radiate to the right scapular area (Dains, 2012). On a pain scale of 0 to 10 he rates the pain as a 4. The pain is constant for two to three days in a row then leaves. A couple weeks later the pain returns. He exercises four days a week, and the pain does not prevent him from exercising or performing any activities of daily living (ADL’s). He has lost 10lbs in the last two months with diet & exercise. The patient notices that when he eats red meat his pain is exacerbated. He also admits to experiencing alternating bouts of constipation & diarrhea with increased flatulence, bloating, and mucus in his stool. Irritable Bowel Syndrome (IBS) causes hypogastric pain, crampy, variable infrequent duration; associated with bowel function, gas, bloating distention and relief with passage of flatus & feces (Dains, 2012). He does not have any allergies and only takes Fish Oil tablets & a multi-vitamin every day. He does not take any prescribed medication, but is up-to date on immunizations. He drinks alcohol 1-2 times per week and he also had a habit of smoking in high school, but quit over 10 years ago. He denies use of any recreational drugs. The patient’s last physical exam was less than a year ago, 5/2012, and he performs self-testicular exams once a month. He admits to eating fast food for lunch 3-4 days per week, but his wife cooks a healthy dinner for him each night. Past medical history: Patient admits to having multiple kidney infections & Urinary Tract Infections (UTI’s) when he was in his younger 20’s. He also had a reconstructive right knee surgery in 2010 due to a serious injury to his ACL and meniscus in high school. He suffered from chicken pox and measles as a child, but no other illnesses that he could think of.Social History: Patient lives with his wife and two dogs in a house in Webster, Texas. They moved here three months ago from central Texas. He works in a bank in downtown Houston as a financial consultant. His wife is a school teacher at Clearlake High School. They are both part of the Protestant religion and have no reservations regarding medical care.Family History: Both of the patient’s parents suffer from hypertension.Explanatory model: Patient believes that his diet is causing his discomfort.Review of Systems: General: The patient admits that he is becoming irritated with this pain in his abdomen. Diet: He tries his best to avoid caffeine & alcohol because it does cause him to have kidney infections and UTI’s. HEENT: He does not have any skin lesions or history of dermatological issues, nor does he have any headaches, dizziness or tenderness of lymph nodes. He denies any burning, discharge, or pain, from the eyes, ears or nose. The patient denies symptoms of a sore throat, canker sores, bleeding gums, phlegm, or hoarseness. Cardiovascular: He denies chest pain or palpitations, but he does admit to having high blood pressure reading at his last physical exam in 5/2012. The doctor did not place him on any hypertensive medication at that time. Chest & Lungs: He denies any shortness of breath, wheezing, or history of asthma. GU: Again, he admits to having a history of numerous UTI’s & kidney infections in the past, but avoids excessive use caffeine & alcohol for this reason. He denies kidney stones, incontinence, or hesitancy. Gastrointestinal: Patient admits to a dull, achy pain in his lower right side of the abdomen, and in the upper middle area of his abdomen. His pain radiates to his right shoulder area. He admits to increased flatulence, bloating and alternating bouts of constipation & diarrhea with mucus in his stool. The presenting complaint can be either diarrhea or constipation. Alternating episodes of each is characteristic of IBS. Mucus in stools are common (Dains, 2012).Psychiatric: Patient admits to being under an increased amount of stress in the last three months since he & his wife moved to a new home, new job, and dealing with this abdominal pain. He denies any anxiety, nervousness or depression. Physical Exam (objective) General Description: Patient is appears to be well- nourished and in good health. H: 72.75 in. W: 205lb, BMI: 27.2 .Vital Signs: T: 99.3 (oral), B/P 136/85(sitting/left arm), HR: 72, RR: 12. Skin: No lesions or rashes present. Head, Eyes, Ears, Nose, & Throat (HEENT): Head: Shape, size, and appearance of head are normal. Hair is soft to touch. No pain or sensitivity when sinuses are palpated. Eyes: No discharge, no redness, vision is normal. Patient wears prescriptive glasses. Ears: No redness of the internal or external ear, no discharge from ears. Tympanic membrane is light pink in color. No pain when ears are palpated. Hearing acuity is within normal range. No hearing devices being used. Nose: No redness in nares, no discharge present. Throat: No redness, or drainage from throat. Lymph: Lymph nodes are soft, mobile, and non-tender. No swelling present. Cardiovascular: Heart tones are clear & crisp. No bruits or murmurs present upon auscultation. Apical pulse is strong and bounding. No jugular vein distention present. No thrills upon palpation. Chest/Lungs: Chest is symmetric. Lungs sounds are clear bilaterally and resonant. No adventitious sounds present upon auscultation. Male Genital/ GU: No genital exam performed. Urinalysis performed and the results were unremarkable. Gastrointestinal: Bowel Sounds present & hyperactive in all four quadrants, no bruits auscultated. Abdomen is soft, but tender in the Lower Right Quadrant (LRQ) and epigastric area of the abdomen. No masses palpated. Guarding and rebounding are present upon deep palpation to the lower right quadrant of abdomen. Liver’s edge is unable to be palpated and there is a negative Murphy’s sign. Acute Cholecystitis will elicit a positive Murphy’s sign when the right subcostal region is so tender that there is a painful splinting with deep inspiration or when palpation over the RUQ area causes transient inspiratory arrest (Dunphy, 2011). No sign of enlarged liver. Kidneys are not palpable and there is no costovertebral tenderness. Rovsing’s & Psoas sign are also both negative. These test are used in a physical exam to determine if the patient has appendicitis (Dunphy, 2011). Being that both of the tests gave negative responses appendicitis was ruled out. DiagnosticsThe following tests are being ordered to help diagnose this patient: complete blood count with differential (CBC-D) to establish patient’s baseline and evaluate for infection and anemia, blood culture to rule out systemic infection, liver panel since cholecystitis can affect liver enzymes, abdominal x-ray to check for gastric abnormalities, sigmoidoscopy and/or colonoscopy to evaluate the lining of the colon and check for changes, antitissue transglutaminase antibodies (tTGA) or anti-endomysium antibodies (EMA) to rule out any possibility of celiac disease which can sometimes present as IBS, sed rate and c-reactive protein to rule out the possibility of Crohn’s disease, a fecal occult blood sample to ensure that no blood is in the stool which is a symptom of Chrohn’s disease, stool antigen test to check for gastrointestinal infection or inflammation, and stool cultures to rule out/evaluate for gastrointestinal infections. Post abdominal x-ray, a Computerized Tomography scan of the abdomen may need to be done to rule out cholecystitis and pancreatitis (Dains, 2012). Differentials TableDx 1: Irritable Bowel SyndromeDx 2: AppendicitisDx 3: Acute Cholecystitis Subjective DataPain in lower right side of stomach (4/10) for the past 3 monthsThe pain is dull and achy and radiates to the epigastric areaThe pain is constant 2-3 days in a row, leaves and a couple of weeks later returns The pain worse with red meatThe pain worse during the day Diarrhea at least once/day (depending on what he eats), The pain does not affect exercising or ADLSLost 10 lbs in the last month intentionallyAlternating bouts of constipation and diarrhea with increased flatulence, bloating, and mucous in stoolIncreased stress in the last 3 monthsPain in lower right side of stomach (4/10) for the past 3 monthsThe pain is dull and achy and radiates to the epigastric areaThe pain is constant 2-3 days in a row, leaves and a couple of weeks later returns The pain worse with red meatThe pain worse during the day Diarrhea at least once/day (depending on what he eats), The pain does not affect exercising or ADLSLost 10 lbs in the last month intentionallyAlternating bouts of constipation and diarrhea with increased flatulence, bloating, and mucous in stoolIncreased stress in the last 3 monthsPain in lower right side of stomach (4/10) for the past 3 monthsThe pain is dull and achy and radiates to the right shoulder areaThe pain is constant 2-3 days in a row, leaves and a couple of weeks later returns The pain worse with red meatThe pain worse during the day Diarrhea at least once/day (depending on what he eats), The pain does not affect exercising or ADLSLost 10 lbs in the last month intentionallyAlternating bouts of constipation and diarrhea with increased flatulence, bloating, and mucous in stoolIncreased stress in the last 3 monthsObjective DataT: 99.3 (oral), B/P 136/85(sitting/left arm), HR: 72, RR: 12 Ht: 72.75 in, Wt: 205lbs, BMI: 27.2Bowel Sounds present & hyperactive in all four quadrants, no bruits auscultated.Lymph nodes are soft, mobile, and non-tender, with no swelling Abdomen is soft but tender in Right lower quadrant (RLQ) and epigastric area. Guarding and rebounding present upon deep palpation to RLQ No masses palpated. No guarding or rebounding present upon palpation in the lower right quadrant of abdomen. Liver’s edge is unable to be palpated. No sign of enlarged liver. Negative Murphy’s sign Kidneys are not palpable and there is no costovertebral tenderness. T: 99.3 (oral), B/P 136/85(sitting/left arm), HR: 72, RR: 12 Ht: 72.75 in, Wt: 205lbs, BMI: 27.2Bowel Sounds present & hyperactive in all four quadrants, no bruits auscultated.Lymph nodes are soft, mobile, and non-tender, with no swelling Abdomen is soft but tender in Right lower quadrant (RLQ) and epigastric area. Guarding and rebounding present upon deep palpation to RLQ No masses palpated. No guarding or rebounding present upon palpation in the lower right quadrant of abdomen. Liver’s edge is unable to be palpated. No sign of enlarged liver. Negative Murphy’s sign Kidneys are not palpable and there is no costovertebral tenderness. T: 99.3 (oral), B/P 136/85(sitting/left arm), HR: 72, RR: 12 Ht: 72.75 in, Wt: 205lbs, BMI: 27.2Bowel Sounds present & hyperactive in all four quadrants, no bruits auscultated.Lymph nodes are soft, mobile, and non-tender, with no swelling Abdomen is soft but tender in Right lower quadrant (RLQ) and epigastric area. Guarding and rebounding present upon deep palpation to RLQ No masses palpated. No guarding or rebounding present upon palpation in the lower right quadrant of abdomen. Liver’s edge is unable to be palpated. No sign of enlarged liver. Negative Murphy’s sign Kidneys are not palpable and there is no costovertebral tenderness. Lab/Diagnostic Datan/a at this time, patient needs these labs and diagnostics:Complete Blood Count with Differential (CBC-D), abdominal x-ray, sigmoidoscopy and/or colonoscopy, proctoscopy, antitissue transglutaminase antibodies (tTGA) or anti-endomysium antibodies (EMA) to rule out celiac disease, sed rate and c-reactive protein to rule out Crohn’s disease, Fecal Occult Blood Sample, stool antigen test, stool cultures & C-urea Breath TestUrinalysis is negative (rule out kidney stones), patient needs these labs and diagnostics:Complete Blood Count with Differential (CBC-D), Blood Culture, liver enzymes, abdominal x-ray, Fecal Occult Blood Sample, stool antigen test, stool cultures & C-urea Breath Test, computerized tomography (CT) scann/a at this time, patient needs these labs and diagnostics: Complete Blood Count with Differential (CBC-D), Blood Culture, liver enzymes, abdominal x-ray, Fecal Occult Blood Sample, stool antigen test, stool cultures & C-urea Breath Test, computerized tomography (CT) scanRuling Out the DifferentialsIrritable Bowel Syndrome (IBS) produces a crampy, hypogastric pain that is variable, infrequent duration. The pain is associated with bowel function, gas, bloating, and distention. Relief is often obtained with the passage of flatus or feces (Dains, 2012). We are ruling this as our medical diagnosis because this patient had an exam that was positive for pain, rebounding, and guarding. He also mentioned that his pain is intermittent and does not prevent him from his daily activities. He also experiences diarrhea with mucous at least once a day that alternates with constipation and finds that his diet triggers his symptoms. Appendicitis has been ruled out. The patient reports sudden onset of colicky pain that progresses to a constant pain. The pain can begin in the epigastric or periumbilicus and later localize to the right lower quadrant. The pain of appendicitis worsens with movement or coughing. On physical examination, the patient will be lying still and will demonstrate involuntary guarding (Dains, 2012). We are ruling this diagnosis out because the patient has some guarding or pain on light or deep palpation, but the pain does not affect his activities of daily living. Rovsing’s & Psoas’s signs are both negative.In acute cholecystitis, most patients complain of indigestion, nausea, and vomiting, especially after eating a meal high in fat. It will usually present with an acute, colicky- type pain. However the pain may persist and as the inflammation progresses, but the pain is usually localized over the RUQ. Patients may complain of referred pain that radiates to the middle of the back or to the right shoulder (Dunphy, 2011). We are ruling this out as a diagnosis because this patient is experiencing lower right quadrant pain, and not right upper quadrant pain. He has no radiating pain to the back or shoulders. He also is denying any nausea or vomiting.TherapeuticsIt is important to inform the patient to start taking a probiotic such as Lactobacillus. It is hypothesized that alterations in the gut’s flora may reduce symptoms through suppression of inflammation or reduction of bacterial gas production. This results in reduced distention, flatus, and visceral sensitivity. Fatty foods & caffeine are not tolerated well with IBS (McPhee, 2013).PharmacotherapeuticsWe would prescribe him an antispasmodic/ anticholinergic drug such as Dicyclomine 20mg tablet by mouth four times a day, dispensing 120 tabs, with no refills. The only effective dose is 160mg/day by mouth, divided into four equal doses. However we will begin with 80mg/day divided into four equal doses, and increase to 160mg/day unless side effects limit the dosage (Karch, 2012). In addition, we would also prescribe him Loperamide 2mg tab by mouth as needed for diarrhea, dispensing 60 tabs with no refills. The initial dose will be 4mg by mouth followed by 2 mg after each unformed stool. He is not to exceed 16mg/day (Karch, 2012).Diagnostic TestsA urinalysis has already been done, which came back negative. The following tests are being ordered to help diagnose this patient: complete blood count with differential (CBC-D), blood culture, liver enzymes, abdominal x-ray, sigmoidoscopy and/or colonoscopy, antitissue transglutaminase antibodies (tTGA), or anti-endomysium antibodies (EMA) to rule out celiac disease, sedimentation rate and c-reactive protein to rule out the possibility of Crohn’s disease, a fecal occult blood sample, stool antigen test, and stool cultures. Post abdominal x-ray, a Computerized Tomography scan of the abdomen may need to be done as well (Dains, 2012). Patient Education & CounselingEducation needs to be provided to him regarding the effects that Dicyclomine can have. Anticholinergic side effects are common, including urinary retention, constipation, tachycardia, and dry mouth. We would also inform him that caffeine & fatty foods can trigger his symptoms, so he needs to try and avoid them (McPhee, 2013). Educational information regarding diet and nutrition will be given. He also has an elevated blood pressure with a family history of hypertension; therefore, we would inform him that his change in diet will also help lower his blood pressure. This patient will also be educated on the importance of being compliant with all referrals and lab work in order to confirm diagnosis and better manage his symptoms.Referral and Follow UpPatient will need to be referred to a Gastroenterologist in order to have the colonoscopy and/or sigmoidscopy completed per the gastroenterologist’s recommendation. Pending the results of the selected endoscopy procedure, the patient is to follow up here at the clinic after seeing the gastroenterologist and completing with lab work. He will be called with the results of the test ordered at the clinic. We would recommend that he continues to see the gastroenterologist for management of the disease process after confirmation of this disorder.ReferencesDains, J.E., Baumann, L.C., & Scheibel, P., (2012). Advanced health assessment and clinical diagnosis in primary care. (4th ed.). St. Louis: Elsevier Science.Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, d. J. (Eds.). (2011). Primary care the art and science of advanced practice nursing (3rd ed.). Philadelphia: F.A. Davis.Karch, A. (2012). Lippincott’s Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins.McPhee, S., Papadakis, M., Rabow, M. (2013). Current medical diagnosis & treatment. (52nd ed.) McGraw- Hill Companies: USA ................
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