bradtPA Posted February 3, 2011 Share Posted February 3, 2011 A straightforward case, but it does contain several teaching points that I think are important... 52 y/o AAF presents with c/c of nausea, vomiting, heartburn, and RUQ pain x 3 months. discuss... Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted February 3, 2011 Share Posted February 3, 2011 A straightforward case, but it does contain several teaching points that I think are important... 52 y/o AAF presents with c/c of nausea, vomiting, heartburn, and RUQ pain x 3 months. discuss... I can't believe I'm the first on the case! Here goes... Pain for 3 months...has it been intermittent or constant over this period of time? What was the patient doing when the pain/N/V/heartburn first presented. If the pain is intermittent has she noticed any triggers? Does the heartburn occur at any particular time and in any particular position? Is the pain only localized to the RUQ, or does she experience pain anywhere else? Next I'd like some more information about the pain. Quality (colicky, stabbing, cramping), can she rate the pain on a scale from 0-10? Does the pain radiate to any other part of the body. Is the nausea always followed by vomiting? How many times has she vomited and what does it look like? Again, does the N/V occur after any specific time (eating, exercising, etc.) What makes the sx worse and what makes it better? Any blood noticed in the vomitus? Any change in bowel habits? Any recent changes in diet? Any distension or feeling of bloating? Any chance of pregnancy? Any chest pain/pressure other than the heartburn? How has this been impacting her normal daily routine. What has changed in her sx that prompted her to come in now? Have the sx gotten worse over time? Has she taken anything for the sx and have they helped? Does she have any idea what might be going on? Current medications including herbals and OTC's. Any medical/food allergies? I'll stop there and let someone else chime in! Thanks Brad! These cases are awesome and much appreciated. Link to comment Share on other sites More sharing options...
Just Steve Posted February 3, 2011 Share Posted February 3, 2011 fever? fertile? fatty food exacerbation? VS? Recent bowel patterns? obvious distress or tolerating well? Surgical hx? trauma? ETOH consumption? I like to pick the low hanging fruit early so I'm looking at gall bladder function and liver issues ranging from a gall stone to fatty liver to hepatitis. Surgically hot abdomen or something that can stand the time to run some labs such as a cbs/diff, metabolic panels with liver functions? I'd expand the circle of primary exam to include a cardiac work up as well, if she is pregnant get a HCG. 1. pain is a little high for an appy, and the time line has been fairly lengthy..if it was a hot appy, it would have resolved or ruptured by now (this is what I'm thinking, may not be correct). 2. Consider intestinal issues to include impaction, small perf from diverticulitis, ischemic bowel 3. Tumor 4. Ectopic but again, a bit high 5. Cardiac/MI...not likely but can't ignore it With what little you gave, my gut is saying gall bladder or liver issues. Most of the other differential dx would worsen or resolve by now Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 3, 2011 Administrator Share Posted February 3, 2011 Vital signs? Social Hx, including ETOH/tobacco use? The differentials above look pretty reasonable so far. Gall bladder is #1, but there are a lot of others... Link to comment Share on other sites More sharing options...
bradtPA Posted February 3, 2011 Author Share Posted February 3, 2011 I will start with filling in the history that was asked for. develop your diff dx and plan from there:). Meds: lisinopril 20 mg PO daily, omeprazole 20 mg PO daily, clonazepam 0.5 mg PO BID PRN PMhx: anxiety, HTN, GERD. Allergies: PCN, TCN, Erythromycin Surg HX: c-section 1985, 1987 Social Hx: employed as a mental health worker. Divorced. 2 children. No ETOH use. No smoking. Drinks 2-3 cups of coffee daily. nausea/vomiting/heartburn is several times a day, worsened with food. Omeprazole helps only a little. Definitely pos for bloating. RUQ pain is 6 out of 10, intermittent, several times weekly, no apparent relationship to food. No blood in the vomitus. No change in stool habits. No chance of pregnancy, she is in menopause. Vital signs: T98.0, BP 141/97, P86, R 16 BMI 37.45 ht 66' wt 232 Link to comment Share on other sites More sharing options...
marilynpac Posted February 3, 2011 Share Posted February 3, 2011 My first guess...what a nice chole, thank goodness she read the book. Female, fat(?), flatus, forty/fifty, fertile...then one has to remember how many women have fallen victim to MI b/c of this tunnel vision. Link to comment Share on other sites More sharing options...
bradtPA Posted February 3, 2011 Author Share Posted February 3, 2011 gallbladder disease is definitely high on the list. Anything else you want to do, like an exam? Link to comment Share on other sites More sharing options...
marilynpac Posted February 3, 2011 Share Posted February 3, 2011 Ok Brad, I'll do a complete exam on her paying specific attention to heart/abd sds but that probably won't tell me too much. Why did she wait 3mons? Most people would have waited 3hrs..not more than 3 days?? Link to comment Share on other sites More sharing options...
bradtPA Posted February 3, 2011 Author Share Posted February 3, 2011 She did see someone at an urgent care one month ago, but they gave her omeprazole which didn't do much and sent her out the door. Some people are stoic, others just hate seeing the doctor:).... Cardiac exam: RRR, no murmurs, rubs, or gallops. No pedal edema. Carotids without bruit. Lungs: CTAB, regular Abd exam: mild epigastric tenderness without rebound or guarding. Mild RUQ tenderness, but no Murphy's sign. Gallbladder non-palpable. Stool guac neg. Any labs you want? Any tests? Link to comment Share on other sites More sharing options...
Just Steve Posted February 3, 2011 Share Posted February 3, 2011 usual disclaimer: have only been accepted to PA school, won't start until this summer. Thanks a bunch though for the opportunity to engage the brain That caffeine habit isn't doing her GERD any favors, nor is the weight helping her HTN which is marginally being controlled by the ACE inhibitor. However, with the Hx of anxiety, and a decent probability of White Coat Syndrome I would not be surprised if she's little hypertensive just on the visit. I would ask her to follow her BP for a week though, x2 QD if she's willing to do that. Any diabetes? That aside, back to her chief complaint...Still pointing a finger at the gall bladder. Any liver engorgement appreciated on palpation? Tenderness? Murphy's sign findings? Jaundiced? There has been "no change" in bowel movements, but what are they typically? Are they normally well formed or is she under the impression that watery stools are ok? How often does she move her bowels? Was the stool checked for occult blood? Does she belch often or is it upward movement from digestive tract just emesis? Is the emesis well digested mix of chum that is about to enter the small intestine but takes a 180 degree turn or is it freshly chewed where the stomach just doesn't have room for what she is swallowing? How soon after eating does she hurl? (ok, vomit for you medical term people :-) ) I ask about the belching because of the bloating...where is that gas going may help point a finger where it is building at...if it's beyond the stomach then the increase in the intestinal pressure may be causing the stomach to reject it's contents and contribute to the pain she's feeling (again, theory, no data to support). Being afebrile, skin is warm, dry, normal color, normal mentation and with a 3 month hx, I want to believe this is not an acute infection. Diff Dx: 1. Cholecystitis with or without stone/blockage of common bile duct 2. Pyloric valve/duodenum stricture/blockage 3. gastic ulcer exacerbation 4. gastroesophogeal junction issues ie: hiatal hernia 5. hepatic insufficiency but if there is a lack of jaundiced and LFT's come back benign, I'd turn my attention elsewhere 6. Still pending a cardiac work up 7. Drug seeking 8. Tumor Love to see some blood work but I like to look at these cases as if the lab is not a viable option, such as a clinic in Haiti or the bush. In the mean time I'd look at perhaps adding some Ranitidine and PO Ondansetron Simethicone prn for bloating. Highly encourage a low fat diet to not only lessen the strain on the biliary system but also may drop a few lb's that would benefit her HTN and impending renal stress and decrease the rate that diabetes will catch her, if it hasn't already. Encourage decreasing the caffeine intake, perhaps switching to half decalf to reduce the irritant/stimulant of caffeine. Going to avoid pain meds right now to help encourage diet changes. If she takes pain meds and things get better, she won't be motivated to change her diet. If she changes her diet and feels better without narcotics, it's a win/win all around. Plus I'm not sold that she isn't drug seeking. Follow up next week following the dietary restrictions and new meds. Return sooner if sx worsen or develop a persistent fever of unknown cause (ie: not due to URI sx) edited to add: I see some further posts have been added while I was typing this...things seem to be moving away from my #1 choice for culprit but I'll keep it in the list for now. LFT's? WBC? Is it worth an ultrasound/radiological studies at this point such as at the very least a flat plate of the abdomen looking for free air/obstruction/stricture? I would highly doubt there are surgical adhesion issues from that very old C section scar causing a referred pain but I'll add it to my list below tumor Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 3, 2011 Administrator Share Posted February 3, 2011 residual PE: Any jaundice? Check CVA tenderness for pyelo. Not too likely, but simple to do and terrible to miss. Labs: Amylase/Lipase for Pancreatitis Check urine for pregnancy (yes, always check...), UTI Would consider H. pylori test, depending on how much defensive medicine we're practicing. Symptoms are not optimally consistent with an ulcer, though. Link to comment Share on other sites More sharing options...
bradtPA Posted February 3, 2011 Author Share Posted February 3, 2011 Amylase 42 (nl) Lipase 16 (nl) h pylori antibody positive. Alt 15 (nl) CBC was normal Urine HCG was not done. No jaundice. No CVA tenderness. RUQ US negative for stones Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted February 3, 2011 Share Posted February 3, 2011 I'd like to go back to the history if you don't mind, Brad. In regards to her surgical history, did she have any complications with any of the c-sections? Any transfusions? Is there any particular body position that alleviates the pain? Can we probe a bit deeper into her drug/ETOH hx? PE: any scleral icterus? organomegaly? any masses felt in the abdomen? Fluid wave? Labs: What about prothrombin time, ALP and AST, GGPT, EKG to be sure the heart is ok. Hepatitis panel. Ddx: Cholecystitis Hepatitis (she's not febrile but can't be ruled out yet) Neoplasm IBS That's all I got for now. Link to comment Share on other sites More sharing options...
bradtPA Posted February 3, 2011 Author Share Posted February 3, 2011 Complications with c-sections unknown. transfusions unknown. No icterus. No organomegaly. No fluid wave. Full liver panel was not drawn, since the screening transaminase (ALT) was normal. PT/PTT not checked. Hepatitis panel was not drawn since H pylori was positive. Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted February 3, 2011 Share Posted February 3, 2011 Oh wait! I just re-read that the h. pylori test was positive, not negative. I noticed the urgent care only gave her omeprazole. I wonder where are the rest of the drugs that should be given to her for H. Pylori. If I remember correctly, its a PPI (omeprazole), clindamycin and amoxicillin. Since she has PCN and macrolide allergies, would just the omeprazole and Bismuth suffice? Link to comment Share on other sites More sharing options...
fyrelight74 Posted February 3, 2011 Share Posted February 3, 2011 Oh wait! I just re-read that the h. pylori test was positive, not negative. I noticed the urgent care only gave her omeprazole. I wonder where are the rest of the drugs that should be given to her for H. Pylori. If I remember correctly, its a PPI (omeprazole), clindamycin and amoxicillin. Since she has PCN and macrolide allergies, would just the omeprazole and Bismuth suffice? I believe in our office we use Flagyl (or amoxicillin if no allergy), Biaxin and omeprazole for 14 days, then maintain with a PPI for h. pylori infection. Link to comment Share on other sites More sharing options...
bradtPA Posted February 3, 2011 Author Share Posted February 3, 2011 diagnosis number 1, h pylori gastritis. With her allergies, antibiotics were a difficult choice. I felt that biaxin 500 mg BID would be OK since she had only had vomiting to erythromycin, a common side effect combined with bismuth and flagyl 500 mg BID. for those without allergies, a Prevpac is simple to order and easy to use. is there anything else you want to do? Any additional tests? Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted February 3, 2011 Share Posted February 3, 2011 I believe in our office we use Flagyl (or amoxicillin if no allergy), Biaxin and omeprazole for 14 days, then maintain with a PPI for h. pylori infection. Yes, yes! You're right; I just looked it up. It all floods back to me now! Link to comment Share on other sites More sharing options...
fyrelight74 Posted February 3, 2011 Share Posted February 3, 2011 diagnosis number 1, h pylori gastritis. With her allergies, antibiotics were a difficult choice. I felt that biaxin 500 mg BID would be OK since she had only had vomiting to erythromycin, a common side effect combined with bismuth and flagyl 500 mg BID. for those without allergies, a Prevpac is simple to order and easy to use. is there anything else you want to do? Any additional tests? An EGD would be a good idea, but perhaps could wait till after ABX/PPI regimen. And, the GI docs we have had contact with usually will order a stool antigen test for h.pylori after treatment, rather than a blood test. Link to comment Share on other sites More sharing options...
bradtPA Posted February 3, 2011 Author Share Posted February 3, 2011 After treatment, I use the urea breath test to make sure its eradicated (the serum will still convert). Any other tests or treatments you want to try? Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted February 3, 2011 Share Posted February 3, 2011 I can't think of anything else Brad, and I don't want to cheat by reading up on it, LOL!!! Link to comment Share on other sites More sharing options...
bradtPA Posted February 4, 2011 Author Share Posted February 4, 2011 What would explain the right upper quadrant pain in this patient? Link to comment Share on other sites More sharing options...
merseur Posted February 4, 2011 Share Posted February 4, 2011 What EGD for this patient? Link to comment Share on other sites More sharing options...
bradtPA Posted February 4, 2011 Author Share Posted February 4, 2011 EGD is a good idea. Have we excluded cholecystitis in this patient yet? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 4, 2011 Administrator Share Posted February 4, 2011 What would explain the right upper quadrant pain in this patient? Duodenal ulcer? Dextrocardia situs inversus totalis? If we've figured out what her major complaint is, there's always followup instructions, screenings, patient ed, and an encouragement for her to lose weight... Link to comment Share on other sites More sharing options...
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