Case Study # 1

ADULT CASE STUDY

SCENARIO
Ralph Turner is a 35-year-old Caucasian male who presents with severe sharp LUQ
abdominal pain associated with nausea and vomiting. He states that the pain started
approximately 2 days ago after eating chili. The pain seems to come on as a spasm/
cramping that is quite sharp then either goes away or turns into a burning sensation
that goes to the chest. He states that over the past 7 years he has taken antacids for
indigestion, and it does offer some relief. He is accompanied to the clinic by his
girlfriend.

TENTATIVE DIAGNOSES
Based on the information provided so far, what are the potential diagnoses?

Potential Diagnosis Provide rationale to support for each

potential diagnosis based on
information provided above
Gastric cancer Causes symptoms of indigestion, also
prolonged dyspepsia exacerbated by food
can be caused by gastric CA.
Peptic Ulcer Disease (PUD) Episodes of pain occur after eating as this
did after patient ate chili.
Angina Patient is complaining of this pain
radiating to the chest
Cholecystitis Cholecystitis can present as painful
colicky episodes following eating and
accompany with N/V as similar to the
patient presenting symptoms.
Pancreatitis Sudden onset of LUQ pain that radiates to
the chest. Associated with N/V
GERD Burning pain occurring after patient ate
chili (spicy) and patient is having some
relief with antacids which is common in
patients with GERD. Esophageal spasm is
common with GERD as reported by
patient.
Other – Gastritis; Burning pain accompanied by N/V;
Functional GI disorder; Symptoms are intermittent;
h-pylori infection Recurrent episodes of dyspepsia and
chronic gastritis (7 years according to the
patient)

HISTORY
Below is the history obtained from Ralph. What are the significant findings that will help
you narrow down to a specific diagnosis for Ralph?
Patient takes Advil - NSAIDS increases the risks for gastritis and PUD.
Patient also takes Mylanta which is giving him some relief of his symptoms. Pain
associated with GERD, PUD, Gastritis can respond with antacids.
PMH of Gastritis may show that he has recurring episodes and possibly now PUD, Gastric
CA, or H-pylori infection.
Spontaneous weight loss of 10# - *weight loss in particular associated with continuous
dyspepsia can be related to gastric CA.
Patient intake of increased alcohol can cause gastritis, GERD, and lead to gastric CA.
Patient’s history of being an every day smoker of 1 ½ ppd increases his incidence of
gastric CA, GERD, PUD
Patient’s high caffeine intake can aggravate GERD symptoms.
Ralph’s symptoms occur right after eating which is common with gastritis, PUD,
Pancreatitis, Cholecystitis.
Ralph says if he relaxes after a meal it helps. Resting after a meal, along with no
heaving straining or lifting can minimize GERD symptoms.
Ralph is reporting occasional indigestion at night while lying down which is seen with
GERD, pancreatitis. However pancreatitis does not respond to antacids.
Ralph’s family history of his father being an alcoholic – Alcoholism has a strong familiar
component, which is significant here because alcohol abuse can cause gastritis and
increased incidence of gastric CA. His mother dying of stroke is also important for Ralph
because with his smoking and family history of stroke, his risk for stroke also increases.
Patient is reporting that he “strikes out to those around him” when dealing with stress.
This may be putting those around him at risk for IPV. Ralph is admitting to being under
a lot of stress. He could also be coping by increasing his alcohol intake. Stress also can
cause functional GI disorder.
Ralph is also stating that he feels depressed. His current anti-depressant is Prozac.
Drinking can counteract the benefits of this medication, making his symptoms more
difficult to treat. Alcohol increases symptoms of depression and anxiety.

Requested Data Data Answer

Allergies NKDA
Current Medications Advil/Tylenol prn
Mylanta 1-2 tablespoons every 3-4 hours
Fluoxetine (Prozac) 20 mg OD
Laxative as needed
Surgery/Transfusions Appendectomy at age 14
PMH including: hospitalizations/fractures/ Depression and decreased ability to
injuries/accidents control anger
Gastritis
Measles
Chicken pox
Immunizations TB last year – negative
Tetanus – 6 years ago
Appetite/wt. loss/gain Spontaneous wt. loss of 10# in last 3 wks
24-hour diet recall B: Cold cereal and coffee
L: Sandwich, tuna, with a beer
D: Mexican food with beer
 Relationship of indigestion/abdominal Usually symptoms start right after eating.
pain to eating If he relaxes/rests after eating the
symptoms do not seem to be as bad.
Sleeping No problem falling asleep. Usually sleeps
6 hours. Sometimes has indigestions at
night that is relieved with antacids
Social history Tobacco: 1 ½ ppd
Alcohol: a case of beer/day that is shared
with friends
Caffeine: 7-8 cups of coffee or soda/day
Drugs: only OTC’s
Exercise: rarely
Family History Father: Alive, 61, unsure of health,
history of alcohol abuse
Mother: Deceased from stroke at age 59
Siblings: 2 sisters, one in good health,
one with psychiatric problems. 1 brother,
healthy
Relationship with family Has girlfriend. She recently had a baby.
He finds this very stressful since he is
unemployed and has not income except
for working on cars in the neighborhood.
Lost his job about 3 months ago. Feels
like all he and his girlfriend do now is
shout at each other.
Home Live in a one-bedroom apartment with
girlfriend and infant
Last complete PE 2 years ago when he started a new job
Income/insurance Makes about $1,200/month as an off the
books mechanic and odd jobs around the
neighborhood. Lost health insurance
when he lost his job.
Depression history: How do you usually Strike out at those around me
handle stress?
Have you ever though of harming No
yourself?
Describe how you feel now I feel sad, down in the dumps, and I want
to get a job.

REVIEW OF SYMPTOMS
Below are key points of ROS

SYSTEM REVIEWED DATA ANSWER

General No acute distress but expresses
feeling stressed and unhealthy
GI Denies black, tarry, or bloody stools or
emesis. Occasional constipation
 GU Denies problems with urinating,
burning, frequency, or emptying his
bladder
Lungs Denies SOB except when going up lots
of steps or carrying the baby. Has a
morning smoker’s cough
Cardiac Denies sweating, radiation of pain to
arm or neck. No SOB or palpitations

PHYSICAL EXAM
Significant portions of PE based on Ralph’s complaints

SYSTEM FINDINGS
Vital signs b/p: 110/70
HR: 96; RR: 28; T: 97.8
Ht. 5’10”; Weight 175#
General appearance Neatly dressed, well developed,
anxious. Hair thinning, pale in color.
Turgor fair, no jaundice
Mouth Lips dry, cracked, oral mucous
membranes pale pink, tongue dry and
tender to touch
Lungs Clear to auscultation in all fields
Heart Clear S1 and S2, HRR, No murmurs,
clicks, or gallops
Abdomen 5cm well healed scar RLQ. No venous
distention or striae. Symmetrical
without obvious bulging. No visible
peristaltic waves. High pitched,
hyperactive bowel sounds, no bruits or
venous hums. Liver percussed – 13
cm MCL. c/o tenderness in epigastric
area. Neg. Murphy’s sign, psoas, and
rebound.
Rectum Small noninflammed external
hemorrhoids. No rashes or irritation.
No tenderness on palpation. Normal
sphincter function. Prostate smooth.
No masses. Hard brown stool, guaiac
negative.

DIFFERENTIAL DIAGNOSES
Provide the significant positive and negative data that support or refute your
diagnoses for Ralph.
DIAGNOSIS POSITIVE DATA NEGATIVE DATA
Gastric Cancer Pale skin thinned hair Indigestion is relieved
(pernicious anemia) dry with antacids for Ralph,
oral mucosa indigestion pain with
dehydration), History of gastric Ca is usually
alcohol abuse and persistent and
gastritis, smoker, unrelieved. N/V is
unintended weight loss, usually persistent as
poor socio/economic well. Ralph’s comes and
class goes and is related to
when he eats and lies
down at night. No
epigastric mass on
physical exam
PUD Use of NSAIDS, relief
with antacid, unintended
weight loss, Pale skin
thinned hair (pernicious
anemia) dry oral mucosa
dehydration), and
Ralph’s elevated stress
level, tenderness in the
epigastric region,
hyperactive BS
Angina SOB with exertion, chest Age, No history of heart
pain, smoker disease, Ralph’s pain is
relieved by antacids, not
NTG. Hyperactive BS
not associated,
Cholecystitis Epigastric pain after Negative Murphy’s sign,
meals, N/V no bulging is abdomen,
liver not enlarged which
can happen if bile ducts
are obstructed, also no
venous distension, no
fever, no RUQ
tenderness; stools are
brown instead of pale in
color.
Pancreatitis Epigastric pain after Pain usually is dull and
meals, N/V radiates to back with
pancreatitis whereas
Ralph’s pain is sharp,
burning and radiates to
chest.
 GERD Intermittent epigastric No regurgitation, no
pain and burning after belching or bloating. No
eating spicy foods, pain hoarseness
during night, relief from No obvious peristaltic
antacids, smoker. waves
Symptoms are
somewhat minimize
when patient is “still”
after eating. High intake
of alcohol and caffeine
making can exacerbate
symptoms. Positive for
cough
Other; Gastritis; Hyperactive BS,
indigestion symptoms,
N/V. Some relief with
antacids, alcohol abuse

Functional GI disorder Associated with anxiety Vague symptoms. No

and stress causation finding

DIAGNOSTIC TESTS
Based on the history and PE the following diagnostic tests were ordered. The test
and results are provided. You will need to provide a rationale to support the use
of this test for Ralph or provide documentation why you would not order this
diagnostic test in this case.

DIAGNOSTIC TEST RESULTS RATIONALE

CBC with diff RBC: 4.21 Looking for anemia.
WBC: 6.6 Bleeding ulcer you would
Hbg: 13.2 suspect a decreased H/
Hct: 39.1 H. However you can
MCV: 92.8 normal RBC and WBC
counts with peptic ulcer
disease and GERD. An
elevated WBC can be
positive data for
cholecystitis or
pancreatitis
Albumin 3.2g/dl 3.2 is low. May indicate
liver disease, low protein
intake/absorption
 Electrolytes, LFT’s, Renal NA: 137 Chemistries should be
studies K+: 4.2 ran and any abnormals
Cl: 97 should be a guide for
CO2: 35 further investigation.
BUN: 8 AST and ALT are both
Creat: 0.7 elevated indication some
AST: 51 liver dysfunction.
ALT: 75
Alk Phos: 120
H. Pylori Serum: H. pylori + H. pylori is a high
Breath test: + causation factor of PUD
and gastritis
Abdominal X-ray No evidence of bowel Free air has multiple
obstruction, no evidence causes with a perforated
of free intraperitoneal air peptic ulcer to be one of
the reasons.
Upper GI series No evidence of reflux or Since patient is less than
obstruction 55 years old but has
“alarm features” like
unexplained weight loss
and recurrent vomiting
associated abdominal
pain, an upper GI series
is appropriate.
Endoscopy + CHOtest Positive for H pylori
which causes PUD and
chronic gastritis
Other test?
Vit B-12 level R/O pernicious anemia

DIAGNOSES
Based on the data provided what are the appropriate diagnoses for Ralph?
List all appropriate diagnoses for Ralph in priority order.

H. Pylori
Gastritis
Elevated liver function test
Hypoalbuminemia
Alcohol abuse
Depression
Hemorroid

THERAPEUTIC PLAN
Provide answers with scientific basis for the following questions about Ralph’s
treatment plan. Provide APA references when indicated.

(1) What factors contribute to gastric acidity?

Bacterial infections such as H. pylori

Alcohol
Aspirin or other NSAIDS
Bile reflux
Stress
Pancreatic enzyme reflux
Viral infections
Pernicious anemia
Medications such as antibiotics and antacids, PPI, H2 Blocker
Foods
Caffeine and Carbonated beverages

(2) What are issues to consider when deciding on a treatment plan for Ralph’s
problems with gastric acidity?

Compliance
Motivation
Economic issues such as being able to afford his medication
Alcohol dependence

(3) What lifestyle changes would you recommend for Ralph to help with the
diagnoses you identified?

Stop drinking
Smoking cessation
High protein diet, well balanced diet
Cut down on caffeinated beverages
Stress management
Discourage further use of NSAIDS

(4) What are the pharmacological treatments that are evidence-based to treat
Ralph’s GI complaints?

H-pylori eradication:
The BQT is : Omeprozole 20mg BID plus Pepto Bisol 30ml QID, plus
metronidazole 250-500mg TID, plus tetracycline 500mg QID for 7-10 days.
Continue taking liquid antacid, 30ml 1 hour after meals and at bedtime; useful
mainly as an emollient.
External hemorrhoid – Recommend patient using Witch Hael pads or gel, several
times a day; Sitz baths 2-3 times daily follow up with Preparation H ointment;
avoid constipation.

(5) What side effects can Ralph expect from the pharmacological treatment plan?
Stools will become black because of the bismuth. Photosensitivity from
tetracycline.

(6) What suggestions would you make for Ralph and/or his family related to
stress reduction?
I would ask the patient what has he done in the past to reduce stress and
encourage what has historically has shown to work for him. If patient has
nothing to offer, I would encourage to start taking walks because of the benefits
of exercise related to stress and physical being.

(7) What education should be provided for Ralph prior to leaving the clinic?
Alcohol will interfere with medication absorption, plus it counteracts his anti-
depressant medication. Alcohol also contributes not only to his chronic gastritis
but now his liver function tests are elevated. The patient needs to know how
alcohol is affecting his overall health and cessation is going to be key in his
recovery. Resources may need to be provided like AA or treatment centers if the
patient is unable to quit on his own. Smoking cessation will also be encouraged
to the patient. The medication regime for H-pylori is a bit complicated so
education on this will also be provided. Life style changes related to diet, like
eating a bland, high protein diet should be encouraged.

(8) What prevention strategies for family members should be discusses?

Prevention strategies for family members would be to discuss issues related to

intimate partner violence. I’m concerned because Ralph admitted to “striking out
to those around him”. This may be related to alcohol intake as well. Private
face-to-face with girlfriend to determine the risk assessment.
Girlfriend should also be included in the above treatment plan that includes
lifestyle modification and medication treatment so that she can hopefully
encourage patient to be complaint with treatment and provide emotional
support.

(9) What would be the follow-up plan for Ralph?

Follow up should be in 4 weeks for urea breath test or stool antigen test. Liver
function tests should be reevaluated in 2-3 months. Alcohol intake assessment
could also be done at this time.

(10) Is there any additional information that you feel needs to be provided for
Ralph and/or his family prior to concluding this office visit?
I can’t think of anything at this time. Unemployment office referral? I feel bad
for him.

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