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Hello Doctor, I Am A Student And Need Some Direction
Question: Hello Doctor,
I am a student and need some direction with this case study assigned- abdominal pain. I listed some of the differential diagnoses I thought of, but would like to ask about the clinical assessment process to collect the data and your reasoning, to help me come to an understanding of the problem. There is a lot of additional history I need to collect and I am allowed “to fill in the blanks” in whatever direction I choose to support, but what blood work, imaging studies are needed? If need be I can divide this into a few questions. Thank you. Respectfully, XXXXXXX (PLAN: not required)
SUBJECTIVE:
CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago due to NSAIDs
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys), no recent travel
OBJECTIVE:
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248 lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, obese, hyperactive bowel sounds, positive pain in the LLQ
Diagnostics: none
ASSESSMENT:
Left lower quadrant pain
Gastroenteritis
Differential Diagnoses:
1. GI causes: constipation; obstruction; inflammatory bowel disease, diverticulosis complicated by acute sigmoid diverticulitis; abscess or fistula formation; peritonitis; perforation; ischemic bowel; omental infarction
2. GU causes: UTI; prostatitis; seminal vesiculitis; ureterolithiasis
I am a student and need some direction with this case study assigned- abdominal pain. I listed some of the differential diagnoses I thought of, but would like to ask about the clinical assessment process to collect the data and your reasoning, to help me come to an understanding of the problem. There is a lot of additional history I need to collect and I am allowed “to fill in the blanks” in whatever direction I choose to support, but what blood work, imaging studies are needed? If need be I can divide this into a few questions. Thank you. Respectfully, XXXXXXX (PLAN: not required)
SUBJECTIVE:
CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago due to NSAIDs
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys), no recent travel
OBJECTIVE:
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248 lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, obese, hyperactive bowel sounds, positive pain in the LLQ
Diagnostics: none
ASSESSMENT:
Left lower quadrant pain
Gastroenteritis
Differential Diagnoses:
1. GI causes: constipation; obstruction; inflammatory bowel disease, diverticulosis complicated by acute sigmoid diverticulitis; abscess or fistula formation; peritonitis; perforation; ischemic bowel; omental infarction
2. GU causes: UTI; prostatitis; seminal vesiculitis; ureterolithiasis
Brief Answer:
intestine infection most likely.
Detailed Answer:
Hello and welcome to Ask A Doctor service.
I have read your query and here is my advise.
* As per my surgical experience, the symptoms and presentation of your patient sound
more likely to be in relation with intestine infection, probably diverticulitis or else.
In absence of urinary complaints, your 2nd possibility sounds less likely.
My guidelines for the particular approach
- Patient requires basic work up with the lab tests including fasting blood sugar, total
white cell counts, ESR, lipid profile, serum amylase, lipase levels, liver function tests
with stool microscopy report.
- Primary radiology evaluation with ultrasound of the abdomen and pelvis proves as
great helpful tool.
- Depending upon the lab results and ultrasound findings decision regarding abdomen CT
scan or colonoscopy should be made by the clinician.
Hope this information will help in management of your case.
Do feel free to discuss further regarding the same.
Wish you great day ahead.
Regards.
Dr Bhagyesh ( MS consultant surgeon )
intestine infection most likely.
Detailed Answer:
Hello and welcome to Ask A Doctor service.
I have read your query and here is my advise.
* As per my surgical experience, the symptoms and presentation of your patient sound
more likely to be in relation with intestine infection, probably diverticulitis or else.
In absence of urinary complaints, your 2nd possibility sounds less likely.
My guidelines for the particular approach
- Patient requires basic work up with the lab tests including fasting blood sugar, total
white cell counts, ESR, lipid profile, serum amylase, lipase levels, liver function tests
with stool microscopy report.
- Primary radiology evaluation with ultrasound of the abdomen and pelvis proves as
great helpful tool.
- Depending upon the lab results and ultrasound findings decision regarding abdomen CT
scan or colonoscopy should be made by the clinician.
Hope this information will help in management of your case.
Do feel free to discuss further regarding the same.
Wish you great day ahead.
Regards.
Dr Bhagyesh ( MS consultant surgeon )
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Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Answered by
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