Focus I: Primary Care & Prevention Gastrointestinal Case Study

A 35-year-old Indian female presents with recurrent, cramping abdominal pain that has been occurring over the past several years. This pain has become increasingly severe and debilitating over the past few months. It is usually relieved by a bowel movement. She has a pattern of intermittent constipation and loose stools. She denies blood in the stool. The pain tends to be diffuse in nature and seems unrelated to diet, exercise, and/or stress. She is new to your practice, having moved to this geographic area only recently (over the past few months) related to her husband’s job. She has stayed with the same firm, although is in a new location. She does not smoke, drinks only socially, has a good job, denies excessive stress, and is married without children—no recent weight loss. CC: “I want to find out what is wrong. I am tired of always worrying about where a bathroom is!” Physical exam: Vital signs are WNL. Essentially normal abdominal exam and an overall negative general exam. Lab results: Stool is negative for blood and mucus. Students are to respond to all of the following questions: What additional subjective data (list 5) would you collect? (15 points) What additional objective data (excluding laboratory or diagnostic studies, list 5) would you collect? (15 points) List and prioritize differential diagnoses (list 4) you would consider. For each differential diagnosis proposed, list specific information from the case study or from your suggested data that supports the diagnosis. (20 points: 3 points for each appropriate diagnosis, 2 points for each RATIONALE of diagnosis) What laboratory or diagnostic studies should be considered to assist with or confirm the diagnosis, and what would be the EXPECTED FINDINGS of these studies? (15 points) Outline your treatment plan: • Recommended prescription therapy: (10 points) - 5 points for appropriate prescriptive therapy (including dosing) - 5 points for RATIONALE of therapy • Recommended non-prescription (OTC, complementary) therapy (list 3): (10 points)

Sample Solution

Additional Subjective Data (5 points each)

Character of the abdominal pain: Inquire about the intensity, location, duration, and radiation of the abdominal pain. This information can help differentiate between different types of abdominal pain and guide further evaluation.
Association of pain with food intake: Ask if the pain is related to meals, specifically if it worsens after eating or improves with bowel movements. This information can help rule out mechanical obstruction or food intolerance.

Full Answer Section

Urinary and gynecological symptoms: Inquire about urinary urgency, frequency, or hematuria. For women, ask about menstrual regularity, dysmenorrhea, or vaginal discharge. These symptoms can indicate pelvic inflammatory disease or endometriosis.
Family history: Ask about a family history of irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), celiac disease, or other digestive disorders. Familial predisposition can increase the likelihood of certain conditions.
Psychological factors: Assess the patient's stress levels, anxiety, and coping mechanisms. Psychological factors can exacerbate gastrointestinal symptoms and influence treatment decisions.

Additional Objective Data (5 points each)

Abdominal palpation: Palpate the abdomen to assess for tenderness, masses, or organomegaly. This can help identify potential areas of inflammation or obstruction.
Rectal exam: Perform a rectal exam to check for stool consistency, blood, or hemorrhoids. This can provide clues about underlying gastrointestinal conditions.
Perineal exam: Examine the perineum for signs of inflammation, fissures, or fistulas. These findings can suggest anorectal disorders or Crohn's disease.
Pelvic exam: For women, perform a pelvic exam to rule out gynecological causes of abdominal pain, such as pelvic inflammatory disease or endometriosis.
Anthropometric measurements: Measure the patient's height, weight, and body mass index (BMI) to assess for malnutrition or signs of inflammatory bowel disease.

Differential Diagnoses (3 points each) and Supporting Information (2 points each)

Irritable Bowel Syndrome (IBS):
- Supporting information:
  - Recurrent abdominal pain relieved by bowel movement
  - Intermittent constipation and loose stools
  - No blood in the stool
  - Non-specific abdominal exam
  - Normal lab results
Inflammatory Bowel Disease (IBD):
- Supporting information:
  - Recurrent abdominal pain
  - Intermittent constipation and diarrhea
  - Possible blood in the stool
  - Family history of IBD
  - Non-specific abdominal exam
  - Normal or inconclusive lab results
Celiac Disease:
- Supporting information:
  - Recurrent abdominal pain
  - Intermittent constipation and diarrhea
  - Unexplained weight loss
  - Family history of celiac disease
  - Normal abdominal exam
  - Elevated anti-endomysial antibodies (IgA EMA)
Functional Dyspepsia:
- Supporting information:
  - Recurrent abdominal pain in the upper abdomen
  - Early satiety
  - Bloating
  - Normal abdominal exam
  - Normal lab results

Laboratory or Diagnostic Studies (15 points)

Stool occult blood test: This test can detect microscopic amounts of blood in the stool, which could indicate an ulcer or other bleeding source.
- Expected findings:
  - Negative for blood: This would decrease the likelihood of an ulcer or bleeding source.
  - Positive for blood: This would warrant further investigation, such as colonoscopy.
Stool culture: This test can identify bacterial, parasitic, or viral infections that could be causing the patient's symptoms.
- Expected findings:
  - Negative for pathogens: This would rule out infectious causes of abdominal pain.
  - Positive for pathogens: This would guide appropriate antibiotic or antiparasitic treatment.
Abdominal ultrasound: This imaging study can visualize the abdominal organs, including the liver, gallbladder, pancreas, and intestines, to detect abnormalities or masses.
- Expected findings:
  - Normal anatomy: This would rule out structural abnormalities.
  - Abnormalities: This could indicate gallstones, pancreatitis, or other conditions.
Colonoscopy: This endoscopic procedure allows direct visualization of the colon and rectum to identify inflammation, ulcers, polyps, or other abnormalities.
- Expected findings:
  - Normal mucosa: This would rule out IBD or other inflammatory conditions.
  - Abnormalities: This could indicate IBD, polyps, or cancer.

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