.

Blandine Sandwidi

Master of Science in Nursing, Walden University

NRNP/ PRAC 6531: Prim Care Adt Acrss Lfspn Prac-Spring 2024
Professor Renea Krtalic

April 4, 2024, 2024

Patient Initials: B.M Age: 62 Gender: F Race: Caucasian

SUBJECTIVE DATA:
Chief Complaint (CC): Abdominal cramping/pain x10 days
History of Present Illness (HPI): The patient is a 62-year-old Caucasian female who present to

the clinic with left lower quadrant abdominal pain, patient stated pain has been going for 10- 12

days. He described the pain as intense and intermittent stabbing sensations, located from the mid

to lower left abdomen. She denies any fever, changes in urinary habit, or new medication or new

foods. The patient rated her pain 8-10 out of 10 at the time of the consultation.

Medications:
Omeprazole (PriLOSEC) 20MG capsule
Zolpidem (AMBIEN) 10 mg tablet
Vraylar 3 mg capsule
Albuterol. 90: 2 puffs every 6 hours as needed for wheezing
Acetaminophen 500 mg by mouth every 4 hours as needed.
Calcium carbonate 600 mg vitamins D3 400-unit (Caltrate 600 + D) 1500mg/400 unit per tablet
B complex vitamins tablet:
Fluoxetine (PROzac) 20 MG capsule
Hyoscyamine 9LEVSIN): 0.125 mg SL tablet
lamotrigine (LaMICtal) 200MG
medical marijuana: As needed.
STELARA injection 90 mg every mg month.
Allergies:
Phenobarbital
Celecoxib
Clarithromycin
Codeine
Doxycycline
Metronidazole
Naproxen

Immunization: Up to date with all vaccines

COVID 19: 12/20/2023
Refused pneumonia vaccine.
Influenza vaccine this season
Past Medical History (PMH):
Vitamins D deficiency, B12 deficiency, Crohn’s disease of small and large intestines, GERD,

hyperlipidemia, Bipolar I disorder, osteopenia of mu;tiple areas, chromic low back pain,

diaphragmatic hernia, IFG, diarrheacgronic fatigue pain, diverticulosis of colon

Past Surgical History (PSH):

Lumbar Laminectomy

Personal/Social History: Mr. B.M. lives alone in a regular home. His mode of transportation is

a car. He spends time volunteering in a local library and goes to bible study once a week at his

church. He speaks English at home and feels safe there.

Health Maintenance: Mr. B.M mentioned he has access to healthcare. Ensures that he eats three

balanced meals daily. He admitted to using medical Marijuana, He does not smoke nor vapes, no

past tobacco use. She denies drinking alcohol.

Significant Family History:

Father: Hypertension, Hyperlipidemia, dementia Obesity, died of heart attack, Age 75

Mother: Type 2 diabetes, Hypertension, died from heart attack at age 70

Brother: Age 60 history hypertension, cardiomegaly.

Review of Systems:

General: Mrs. B.M is positive for nervous/anxious and pain. She denies having fever, fatigue,

weight loss, palpitations, syncope, or night sweats. Neither irregular heartbeats, edema, nor

coagulopathy is present in cardiovascular history. denies shortness of breath or productive cough.

There are no muscle and skeletal issues such as arthritis, or recent injuries. No weight loss

reported.

HEENT: denies headache, dizziness, loss of consciousness, denies vision problem, denies

discharge or yes redness. no sore throat reported.

Respiratory: Denies shortness of breath nor used of accessory muscle. Denies coughing.

Cardiovascular/Peripheral Vascular: denies chest pain, chest pressure. No palpitation, no

edema

Gastrointestinal: denies anorexia, positive for abdominal pain, nausea, and diarrhea. Last bowel

today 5x. Denies blood in stool, change in bowel habits, constipation, heartburn, indigestion,

poor appetite, rectal pain, and vomiting. Abdominal tenderness.

Genitourinary: Denies hematuria, urgency, frequency, or dysuria.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or

polydipsia

Musculoskeletal: positive for arthralgia, back pain, extremity pain and difficulty walking.

Negative for myalgias.

Neurological: denies seizure, syncope, dizziness, paresthesia, or seizures. Ambulates with no

support or difficulties. He denies weakness, denies abnormal coordination. Report memory loss,

occasional confusion.

Psychiatric: Positive for stress, denies being homicidal, or suicidal. Patient report being anxious

and nervous. Has no auditory, tactile, or visual hallucinations. Negative for sleep disturbance

Skin/hair/nails: The patient denies skin lesions, pruritis, air changes, or discharge from their

nipple. Denies rashes or itchiness.

OBJECTIVE DATA:

Physical Exam

Vital signs: R arm blood pressure: 152/87; O2 Sat 96%, Heart rate 82, RR 19, Temperature 37.2

C, Weigh is 139 lbs, Height 5 ft 2 inches. BMI: 25.57

General: Alert and oriented to person, time, situation, and place. Calm and cooperative. B.M

appears fatigue.

HEENT: Symmetrical face. An atraumatic skull with normal cephalic shape. No visible lesions,

no palpable masses. Pink and moist conjunctivae. EOM intact, sclera is anicteric. PERRLA.

Intact tympanic membrane without deformities or inflammation. There is no discharge or polyps

present. Frontal and maxillary sinuses are intact, no exudate or erythema. The gums are pink.

Moist oral mucosa with no vesicles, no lesions. Intact soft palate. There is no abnormality in the

size of the tonsils. No presence of adenopathy, tonsils symmetric.

Neck: Right carotid present for bruit with 3+ amplitude, Left carotid no bruit present. No JVD,
no thyromegaly noted.
Chest/Lungs: Lungs are symmetrical, clear on room air. No shortness of breath.
Heart/Peripheral Vascular: In the 5th left intercostal space at the midclavicular line, the heart
auscultated S1, S2, and an S3 gallop.
Abdomen: crampy abdominal pain and tenderness, sounds present at all four quadrants.
Genital/Rectal: No redness or lesions noted.
Musculoskeletal: Bearing full weight. Active, intact range of motion in all extremities. The
joints do not have effusions or clubbing. Kyphosis and scoliosis are not present in the spine.
Neurological: Alert and oriented x4. The cranial nerves I-XII are intact. All extremities have
muscle strength of 5/5.
Skin: No clubbing, cyanosis, or edema; no palpable nodes.

Diagnostic results
Comprehensive metabolic panel, complete blood test, C-reactive protein, Urea and electrolytes,

Liver biochemistry, Albumin, Haematinics tests: Anaemia, thrombocytosis, elevated

inflammatory markers, hypoalbuminaemia findings are correlated with crohn’s disease

(Cockburn et al., 2023).

Stool studies: To investigate Faecal calprotectin: Faecal calprotectin is elevated due to intestinal

inflammation in IBD. (Cockburn et al., 2023)

C difficile toxin assay and Stool MCS/OCP depending on clinical history: to rule out infection

(Cockburn et al., 2023)

Flexible sigmoidoscopy is often performed in cases of acute severe colitis, Ileocolonoscopy to

further delineate bowel involvement. In crohn’s disease, skip lesions, aphthous ulcers, linear

ulceration, cobblestone pattern, fat wrapping, strictures, fistula are found (Cockburn et al., 2023)

CT Abdomen and pelvis: to evaluate small and large bowel and to examine transmural and

extra-intestinal activity. CT scan of the abdomen and pelvis is the most appropriate initial
imaging modality in the assessment of suspected diverticulitis. Grade of Recommendation:

Strong recommendation based on moderate quality (Cockburn et al., 2023)

Urine tests include urinalysis and urine culture: to assess kidney and liver function, electrolytes

and potential urinary tract infection.

Differential diagnostic

Crohn's disease

The patient has a history of Crohn's disease. Referring to her symptoms could be a flare-up of

her Crohn's disease, which clinically means the period during which the disease symptoms are

active (Williams et al., 2022). Crohn's disease is a chronic, relapsing, and remitting inflammatory

disease that can affect any portion of the gastrointestinal tract, from the mouth to the perianal

area. Classic symptoms include crampy abdominal pain, prolonged diarrhea, urgency and

frequency, fatigue, fever, and weight loss (Williams-Hall et al., 2022). The patient in the case

study presents with symptoms of abdominal pain, diarrhea, nausea, arthralgia, extremities pain,

and difficulty walking, which are present in Crohn's disease. Possible exacerbation of Crohn's

disease is stress and NSAIDS use.

Acute diverticulitis. Diverticulitis is a complication of diverticulosis affecting the sigmoid and

the ascending colon (Long et al., 2023). The symptoms of acute diverticulitis include abdominal

pain and tenderness in the left lower quadrant, which are the most common symptoms and signs

(Long et al., 2023). Laboratory testing reveals leukocytosis and elevated C- C-reactive protein

may be present (Long et al., 2023). In this case, the patient presents with a high WBC of 15.1.

Ulcerative colitis
Ulcerative colitis is a persistent and recurrent inflammatory bowel disease affecting the rectum

and colon, leading to intestinal wall impairment (Yang et al., 2024). The diagnosis of ulcerative

colitis is based on clinical presentation and biological, endoscopic, and histological findings (Le

Berre et al., 2023). Clinical manifestations of ulcerative colitis include diarrhea that may be

bloody and systemic gradual symptoms over days to weeks, such as fever, fatigue, weight loss,

abdominal tenderness, and tachycardia. The patient in the case study is tachypnea and has been

experiencing symptoms for ten days.

Plan

Crohn's disease: The patient is known to have Crohn's disease and had surgery in the past. It is

crucial to understand that Crohn's disease is a chronic condition, and the patient is prone to

relapse. There is a strong correlation between raised inflammatory markers such as C-reactive

protein and clinical severity of Crohn's disease. Therefore, clinicians need to target this

diagnostic study when establishing a final diagnostic. Hypoalbuminaemia can also indicate

extended inflammation and malnutrition (Cockburn et al., 2023). Patients can be referred to a

gastroenterologist and a psychiatrist. Therapeutic management depends on the severity of the

disease. Corticosteroids such as prednisolone and 6- 6-methylprednisolone are beneficial during

periods of exacerbation. In addition, antibiotics can be initiated because bacteria play an essential

role in the manifestation of CD, such as abscesses and fistulae (Kumar et al., 2022). Another

consideration is the combination of a tumor necrosis factor-alpha (TNF) inhibitor (e.g.,

infliximab) and an immunomodulator (e.g., Azathioprine [AZA], six mercaptopurine [6-MP], or

methotrexate and 5- aminoglycosides (Irani & Abraham., 2024). Educate the patient about

limiting caffeine, spicy foods, and milk products, eating small meals several times during the day
instead of big meals, drinking plenty of water, and recommending a colonoscopy. Advise follow-

up with a gastroenterologist.

Acute diverticulitis: Lower abdominal pain and tenderness are associated with acute

diverticulitis, mainly in the left lower quadrant. An abdominal ultrasound shows mural and per

diverticular abscess formation with or without gas bubbles, bowel wall thickening (segmental

mural thickening more significant than 4 mm) at maximal tenderness, and diverticula in the

surrounding segments. A computed tomography (CT) demonstrates the presence of localized

bowel wall thickening (Cockburn et al., 2023)). Therapeutic management includes pain

management with NSAIDS and oral antibiotics. Patient education includes a high-fiber diet.

Follow-up assessment: The patient should be reassessed six to eight weeks after successful

treatment. Refer the patient to a gastroenterologist for further workouts.

Ulcerative colitis is a chronic inflammatory condition involving the large intestine. Therapeutic

management depends on the severity of the disease with the goal of complete mucosal healing.

Aminosalicylates (5-ASA), such as mesalamine, are the preferred initial treatment with a dose of

2- 4.8g/day, and a combination of therapy is indicated in severe UC (Burri et al., 2020). Teach

patients about adequate nutrition, encourage sufficient protein, limit calories, and decrease fiber

during active disease. In the presence of diarrhea, consume a low-residue diet, and in

constipation, consume a high-residue diet. Refer to a gastroenterologist for a confirmatory

diagnosis with a colonoscopy. Follow-up consideration: colonoscopy referral, consider limiting

steroids to prevent the risk of osteoporosis, monitor labs frequently, and assess the patient's

mental state to address any depression.

Reflection: During the encounter, the preceptor completed the patient's assessment and

recommended several tests and recommendations. I agree with the preceptor because, based on

the clinical presentation of the patient's symptoms, the patient is experiencing an inflammatory

bowel syndrome. The preceptor ordered labs and imagery to come up with a diagnostic. The

patient has extensive medical conditions, including PMH of Crohn's disease and diverticulosis,

increasing the patient's risk for exacerbations and worsening condition. Therefore, it is crucial to

take steps to diagnose the patient in order to offer qualitative treatment adequately. The patient

was also referred to a specialist for focus care.

 References
Burri, E., Maillard, M. H., Schoepfer, A. M., Seibold, F., Van Assche, G., Rivière, P., Laharie, D.,

Manz, M., & Swiss IBDnet, an official working group of the Swiss Society of

Gastroenterology (2020). Treatment Algorithm for Mild and Moderate-to-

Severe Ulcerative Colitis: An Update. Digestion, 101 Suppl 1, 2–15.

https://doi.org/10.1159/000504092

Cockburn, E., Kamal, S., Chan, A., Rao, V., Liu, T., Huang, J. Y., & Segal, J. P. (2023). Crohn's

disease: an update. Clinical medicine (London, England), 23(6), 549–557.

https://doi.org/10.7861/clinmed.2023-0493

Kumar, A., Cole, A., Segal, J., Smith, P., & Limdi, J. K. (2022). A review of the therapeutic

management of Crohn’s disease. Therapeutic Advances in Gastroenterology, 15,

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Le Berre, C., Honap, S., & Peyrin-Biroulet, L. (2023). Ulcerative colitis. Lancet (London,

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https://doi.org/10.1016/j.ajem.2023.10.051

Irani, M., & Abraham, B. (2024). Choosing therapy for moderate to severe Crohn’s

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