PRAC 6541 Episodic Visit: Gastrointestinal or Genitourinary Condition Focused Note

Episodic Visit: Gastrointestinal Or Genitourinary Condition Focused Note

Patient Information

Patient Name: K. A.
Sex: M
Encounter Date: 07/01/2024
Encounter Type: Office Visit

SUBJECTIVE

Chief Complaint: “Stomach pain for 2 weeks.”

History of Present Illness (HPI):

Onset: 2 weeks ago.

Location: Epigastric and right lower quadrant.

Duration: Persistent for 2 weeks.

Characteristics: Burning pain, cramping lower abdominal discomfort.

Associated symptoms: Diarrhea for 2 weeks, some nausea, occasional vomiting, no fever, no hematemesis.

Relieving factors: None reported.

Treatment: Pepto-Bismol started 2 days ago with no improvement.

Severity: Described as moderate discomfort.

Medications: Pepto-Bismol 262 MG/15ML Oral Suspension

Allergies: None reported.

Past Medical History (PMH): No significant past illnesses or hospitalizations.

Past Surgical History (PSH): No surgeries reported.

OB/GYN History: Not applicable.

Personal/Social History:

• School status: Attending school regularly.
• Parental smoking history: Not mentioned.
• Birth history: Not mentioned.

Immunizations:

Family History: Family history of gastritis.

Review of Systems (ROS):

• General: Sick looking, not fevers.
• Skin: No rashes or lesions. No skin color change
• Eyes: No visual changes, no eye pain or redness. No tearing
• Ears, Nose, Throat: No hearing loss, no sore throat, no nasal congestion.
• Cardiovascular: No chest pain, no palpitations, No dyspnea.
• Respiratory: No cough, no shortness of breath, no difficulty in breathing
• Gastrointestinal: Epigastric and right lower quadrant pain, diarrhea, nausea, occasional vomiting, no blood in stool.
• Genitourinary: Normal urine output, no dysuria, no hematuria.
• Musculoskeletal: No joint pain, no swelling, no muscle pain.
• Neurological: No headaches, no dizziness, no seizures.
• Psychiatric: No anxiety, no depression, no behavioral changes.

OBJECTIVE

Vital Signs:

• Height: 50.25 in
• Weight: 74.00 lbs
• BMI: 20.60
• Blood Pressure: 106/74 mmHg
• Temperature: 97.00°F

Physical Exam:

• General: Appears acutely ill, afebrile, normotensive.
• Skin: No rashes, lesions, or jaundice.
• Head: Normocephalic, atraumatic.
• Eyes: PERRLA, EOMI, no scleral icterus.
• Ears: Tympanic membranes clear, no discharge.
• Nose: Nasal passages clear, no discharge.
• Throat: Oropharynx clear, no tonsillar enlargement.
• Neck: Supple, no lymphadenopathy.
• Chest: Lungs clear to auscultation bilaterally; no rales, wheezes, or rhonchi.
• Heart: Regular rate and rhythm, no murmurs, rubs, or gallops.
• Abdomen: Soft, diffusely tender with maximal tenderness in the epigastric region; no masses or organomegaly.
• Genitourinary: Normal external genitalia, no inguinal hernia.
• Musculoskeletal: Full range of motion in all extremities, no deformities, no swelling.
• Neurological: Alert and oriented, cranial nerves II-XII intact, motor and sensory functions normal.
• Psychiatric: Appears anxious, appropriate mood and affect.

ASSESSMENT

Primary Diagnosis

1. Acute Gastroenteritis (ICD-10: A09)

Acute gastroenteritis is characterized by the sudden onset of inflammation of the stomach and intestines, leading to symptoms such as diarrhea, vomiting, and abdominal pain. In the case of Kash Acosta, a 7-year-old male, the primary diagnosis of acute gastroenteritis is supported by his presentation of persistent epigastric and right lower quadrant abdominal pain lasting for two weeks, accompanied by diarrhea and occasional vomiting. The absence of fever and hematemesis further aligns with the clinical presentation of gastroenteritis. Acute gastroenteritis in children is commonly caused by viral, bacterial, or parasitic infections, with viral etiologies being the most prevalent. The management primarily focuses on supportive care, including hydration and symptom relief, as there are typically no specific antiviral or antibacterial treatments required unless a specific pathogen is identified (García-Santos et al., 2023).

Differential Diagnoses

1. Appendicitis

Appendicitis is a very important differential in the diagnosis especially in children who present with abdominal pain. It is an acute inflammation of the appendix, commonly manifesting with right lower quadrant pain that may be accompanied by fever, nausea, vomiting, and anorexia. For example, after Kash came to the operating room with abdominal pain, appendicitis was suspected for his condition because of the localization of pain in the area. However, there are several features that rule out this diagnosis. Firstly, the nature of the pain Kash felt in the abdomen was burning and cramping rather than the sharp localized pain that is characteristic of appendicitis. Moreover, he does not present with fever, which is expected in acute appendicitis (Hijaz & Friesen, 2017). His abdomen is mildly tender in all quadrants but does not exhibit focal tenderness or rebound tenderness in the right lower quadrant, which are cardinal signs. Moreover, there is no evidence of oliguria in Kash, which decreases the possibility of an appendiceal pathology that would have severe systemic manifestations. Although appendicitis cannot be excluded without imaging or further clinical assessment, the current clinical scenario is less likely to be appendicitis.

2. Gastritis

Another major differential diagnosis is Gastritis, which is the inflammation of the stomach lining. Gastritis is another condition with symptoms that may mimic those of gastroenteritis and they include epigastric pain, nausea and vomiting (El-Zimaity et al., 2018). This consideration is also supported by Kash’s family history of gastritis. Gastritis is a condition that can result from infections, for example, Helicobacter pylori, use of NSAIDs, and stress factors. Kash’s pain is burning and has been continuous for over two weeks, which aligns with gastritis according to El-Zimaity et al., (2018). However, without endoscopic confirmation or testing for H. pylori, this is only one of the differential diagnoses. Further investigations like a urea breath test or a stool antigen test for H. pylori would be useful in the diagnosis of this case.

3. Food Intolerance

As Hon & Gupta stated (2021), Food intolerance can also be a possible reason for Kash’s gastrointestinal complaints. Food intolerances, unlike food allergies, do not involve the immune system and often result in digestive issues such as abdominal pain, bloating, and diarrhea after consuming certain foods. Lactose intolerance, for example, can lead to symptoms similar to those presented by Kash. However, in this case, there are no specific triggers related to food consumption reported, and the onset of symptoms does not appear to be linked to any dietary changes. The chronic nature of his symptoms and lack of specific food-related exacerbations makes this diagnosis less likely but still worth considering. If other differentials are ruled out, a detailed dietary history and possibly an elimination diet could be used to identify potential food intolerances.

PLAN

Treatment Plan:

Immediate Action: Given the potential severity of appendicitis, Kash should be sent to the emergency department immediately for further evaluation and imaging to definitively rule out this condition. Prompt attention is crucial to avoid complications from a possible appendiceal rupture.

Fluids: Promote oral rehydration using Pedialyte so as to help in the replenishment of the lost electrolytes. Also, recommend the consumption of the BRAT diet, which includes bananas, rice, applesauce, and toast since these foods are easy on the stomach and aid in controlling diarrhea.

Medication: Go on using Pepto-Bismol as and when required to alleviate the symptoms. If it has not been helpful up to this point, question its need and look for other remedies if the signs do not disappear.

Follow-up: If symptoms do not subside or become worse in the following days, arrange for a follow-up appointment. Check for any new signs that may develop which will require a more detailed assessment.

Education: Educate Kash’s family about his illness, acute gastroenteritis, with increased fluid intake and possible medication. Educate other concerning symptoms that warrant immediate medical attention, such as if the pain is extreme, if vomiting occurs persistently, or if dehydration is evident.

Health Promotion: Make sure Kash is receiving age-appropriate preventive care according to the Bright Futures guidelines such as immunizations, and well check-ups.

Disease Prevention: Teach the family signs of early detection of dehydration and other gastrointestinal diseases. Promote such measures as hand washing and proper food preparation to avoid getting infected.

REFLECTION

Learning Points

The case of Kash Acosta illustrates very well why differential approach is necessary when one tries to label a diagnosis on a child who brings a gastrointestinal complaint to the attention of the doctor. In simple terms, a differential diagnosis should include, along with more serious possibilities such as appendicitis, relatively mundane possibilities like gastroenteritis. It is effective for covering all possibilities of aetiology and removes any chance of missing a cause, hence, safe. Furthermore, the case reveals the importance of liaising with parents and the clarity and effectiveness of communication. They should also be educated on the probable severity of a child’s illness and measures that should be taken in the first place. It enables them to be informed on time on when to seek further medical attention which is important in avoiding complications.

Changes for Future Practice

Other areas of practice that need to change in the future include increased likelihood of direct referral to emergency services if symptoms point to possible appendicitis. Since it is a potential serious condition and because of the risk of deterioration, it is much safer to be referred to further evaluation through the emergency department. This will reduce the waiting time of the patient and when the patient needs to be taken for surgery, it will be done within a minute. Thus, with the help of this change, the risk of adversity is reduced, and it becomes safe for patients. This case highlights the importance of monitoring ambient signs and symptoms of illness and the need to be aggressive in managing paediatric patients.

References

El-Zimaity, H., Choi, W. T., Lauwers, G. Y., & Riddell, R. (2018). The differential diagnosis of Helicobacter pylori negative gastritis. Virchows Archiv, 473(5), 533-550.

García-Santos, J. A., Nieto-Ruiz, A., García-Ricobaraza, M., Cerdó, T., & Campoy, C. (2023). Impact of probiotics on the prevention and treatment of gastrointestinal diseases in the pediatric population. International Journal of Molecular Sciences, 24(11), 9427.

Hijaz, N. M., & Friesen, C. A. (2017). Managing acute abdominal pain in pediatric patients: current perspectives. Pediatric health, medicine and therapeutics, 83-91.

Hon, E., & Gupta, S. K. (2021). Gastrointestinal food allergies and intolerances. Gastroenterology Clinics, 50(1), 41-57.