RE: Discussion - Week 7

COLLAPSE

Comprehensive SOAP Template

Case Study 3: Nausea and Vomiting

Patient Initials: S.T                 Age:  20                        Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): Nausea and vomiting with a low-grade fever.    

History of Present Illness (HPI): S.T is a 20 year-old African American female who came to the clinic with a complaint of nausea and vomiting with abdominal pain in the past 2 day. She stated she started feeling symptoms after eating shellfish at a new restaurant with friends who are also having the same symptoms. Patient also verbalized having a low-grade fever this morning. Patient denies taking any medication to relieve her symptoms.  Patient stated drinking ginger Ale which has been the only thing she could keep down and settle her stomach. She denies vomiting any blood or undigested food and verbalized she has been unable to eat anything else without becoming nauseated or vomiting. She stated that she had bowel movement a day ago and there was no abnormality.

Medications:

None

Allergies:

 NKA

Past Medical History (PMH):

Denies any medical history.

 Past Surgical History (PSH):

Denies any surgical history.

 Sexual/Reproductive History: She is single, sexually active heterosexual with one partner and uses condoms as a method of contraception. G0P0A0 with a 28 day menstrual cycle. LMP: March 28, 2017.

 Personal/Social History: Does not smoke, drink alcohol, or use of any illegal drugs.  Able to perform her ADLS independently and eats a healthy diet with plenty of fruits and vegetables. Patient eats out with friends and family members once every 2 weeks. She still lives with her parents and in college close to her parents.   

Immunization History: Patient up to date with her immunization. She got her flu vaccination last year December 2017 but has not received her pneumonia vaccine.

Significant Family History:

            Father: Diabetes, hyperlipidemia, and hypertension

            Mother: Hypertensive and hyperlipidemia

            Brother: Healthy and no medical concerns.

            Grandparents: unable to provide any information but all deceased.

 Lifestyle: A 20 year-old female student who attends community college. The patient works 24 hours a week at a local department store. She is active in the college band and plays a viola. The patient currently lives with her parents.

 Review of Systems:

General: Patient alert and oriented x 4 (person, place, time and event) and well dressed. Appears anxious and having abdominal discomfort and actively holding and rubbing her abdomen. She stated having a fever this morning before coming to the clinic but did not check her temperature. No weight changes, chills or night sweat episodes according to the patient.

 HEENT: No headaches or dizziness and able to support head with no difficulty. Denies any changes in vision, hearing, & equal bilateral smile. No missing teeth noted. Last dental visit 2 months ago. Denies sinus discomfort, congestion and throat discomfort or pain.

·         Neck: Denies neck stiffness. Denies throat pain. Denies problems swallowing.

·         Breasts: Denies breast pain, soreness, lumps or discharge.

·         Respiratory: Denies smoking. Denies SOB/difficulty breathing.

·         Cardiovascular/Peripheral Vascular: Denies chest pain or discomfort. Denies palpitations. Denies any history of heart disease or conditions.

·         Gastrointestinal: Verbalized nausea and vomiting with abdominal pain. Denies diarrhea or constipation. Denies hematemesis. Denies anorexia.

·         Genitourinary: Denies dysuria, hematuria or urgencies. Sexually active with the use of condoms as method of contraceptive.

·         Musculoskeletal: Denies any fractures, trauma or muscle pain

·         Psychiatric: Denies any depression or suicidal thoughts but noted with anxiety due to abdominal pain.

·         Neurological: Denies any headaches, seizure activities, or dizziness.

·         Skin: Denies any skin rash, lesions and wounds.       

·         Hematologic: Denies anemia. Denies any abnormal bleeding. Denies easy bruising.

·         Endocrine: Denies any unexplained weight loss. Denies polyphagia. Denies polydipsia and polyuria.

·         Allergic/Immunologic: Denies any allergic or immunologic deficiencies. Denies pruritus and swelling.

 OBJECTIVE DATA:

 Physical Exam:

General: A 20 year-old African American female in good health with good posture and steady gait. Client well dressed and groomed with no foul odor noted. Client alert and oriented x 4 and answers well to all questions and discussion. Patient noted with grimace holding and rubbing all four quadrants of abdomen.

·         Vital signs: BP: 150/84, HR: 89, R: 20, T: 100.1, ht: 5’6, wt: 150 & O2 sats 98%

·         HEENT: Neck: No deviation, nodules, or bruits noted

• Head: Normocephalic with no visible or palpable masses, depressions, or scaring.
• Eyes: Visual acuity intact, conjunctiva clear, and sclera non-icteric intact. Pupils equal, round and reactive to light with accommodation. Fundi with normal optic disc and vessel. No exudate or hemorrhage noted.
• Ears: canals clear bilaterally, left and right tympanic membrane pearly grey with light reflex and visible bony landmarks. Oropharynx clear with no exudates and hearing intact, no concerns.
  Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal
• Mouth: Mucous membranes moist, no mucosal lesions. No obvious caries or periodontal disease. No gingival inflammation noted.
• Pharynx: Mucosa non-inflamed with no tonsillar hypertrophy or exudate

·          

·         Chest: Thorax symmetrical.  

·         Lungs: Respirations even and unlabored. Breath sounds clear to all lung lobes.

·         Heart: No cardiomegaly. S1/S2 sounds noted with no S3 or S4 noted.

·         Peripheral Vascular: Pedal pulses 2+ with no peripheral edema noted.

·         Abdomen: Abdomen flat with symmetric rise and fall. No pulsation noted. No lesions or abdominal scars noted. Hyperactive bowel sounds noted. Abdomen soft and tender to touch. No masses noted. No hepatosplenomegaly. RUQ dullness noted with tympanic sound noted in RLQ, LUQ, and LLQ.

·         Genital/Rectal: External genitalia intact. Normal sphincter tone. No masses noted.

·         Musculoskeletal: Full ROM to all extremities with normal gait.

·         Neurological: Alert and oriented x 4. Cooperative with appropriate mood and affect.

·         Skin: Skin intact and warm to touch.

ASSESSMENT:

Labs:

·         CBC: WBC 12.4

·         CMP: Potassium 2.5, Cr 1.4

·         Troponin: negative

·         Glucose: 88

·         Urinalysis: negative

·         Urine Drug screen: negative

Diagnostic Test:

·         Abdominal x-ray: no abnormalities

·         Abdominal ultrasound: negative

·         EKG: Normal Sinus Rhythm with HR: 89

Differential Diagnosis:

A.Food Poising: The patient exhibits all the signs and symptoms of food poisoning.  Her symptoms started after consuming the shellfish from the restaurant and 2 of her friends are exhibiting the same symptoms as well. Food poisoning, also called foodborne illness, is illness caused by eating contaminated food. Infectious organisms including bacteria, viruses and parasites or their toxins are the most common causes of food poisoning. Infectious organisms or their toxins can contaminate food at any point of processing or production. Contamination can also occur at home if food is incorrectly handled or cooked. Food poisoning symptoms, which can start within hours of eating contaminated food, often include nausea, vomiting or diarrhea. Most often, food poisoning is mild and resolves without treatment. But some people need to go to the hospital.

B.Cholecystitis: “Acute cholecystitis is a common cause of acute abdominal pain” (Supanne, et al., 2016). Signs and symptoms of cholecystitis may include: Severe pain in your upper right abdomen, pain that radiates from to your right shoulder or back, tenderness over your abdomen when it's touched, nausea, vomiting, and fever. This is the symptoms the patient has.

C.Small Bowel Obstruction: The blockage prevents food, fluids, and gas from moving through the intestines in the normal way. The blockage may cause severe pain that comes and goes. Most bowel obstructions are partial blockages that get better on their own. Some people may need more treatment. These treatments include using liquids or air (enemas) or small mesh tubes (stents) to open up the blockage.

D.Gastritis: Gastritis can be caused by irritation due to excessive alcohol use, chronic vomiting, stress, or the use of certain medications such as aspirin or other anti-inflammatory drugs. Gastritis describes a group of conditions with one thing in common: inflammation of the lining of the stomach. The inflammation of gastritis is most often the result of infection with the same bacterium that causes most stomach ulcers. Injury, regular use of certain pain relievers and drinking too much alcohol also can contribute to gastritis. Gastritis may occur suddenly (acute gastritis), or it can occur slowly over time (chronic gastritis). In some cases, gastritis can lead to ulcers and an increased risk of stomach cancer. For most people, however, gastritis isn't serious and improves quickly with treatment.

E.Myocardial Infarction: Most heart attacks occur during several hours -- so never wait to seek help if you think a heart attack is beginning. In some cases there are no symptoms at all, but most heart attacks produce some chest pain. Other signs of a heart attack include shortness of breath, dizziness, faintness, or nausea.

Although S.T is positive for a low-grade fever, abdominal pain, tenderness, nausea and vomiting. She does not show any signs of jaundice, does not verbalize pain from the right shoulder that radiates to her back and denies any clay like color stools which rules out cholecystitis.  Gastritis can be ruled out because she denies vomiting blood or coffee ground material. She also denies indigestion and abdominal bloating after every meal.  Her symptoms only occurred after eating shellfish at a restaurant. Small bowel obstruction can be ruled out because there is no obstruction of the bowels noted on the x-ray. The client also denies constipation prior to be coming sick. Vomiting can occur sometimes with heart attack due to the overlapping pathway of the left atrium of the heart and esophagus of the gastrointestinal track compression (Cunningham, Ravich, Jones and Donner, 1992). The vagus nerve plays a vital role in allowing the changes in esophageal function to affect cardiac physiology (Cunningham, Ravich, Jones and Donner, 1992). Although Myocardial infarction could have occurred it can be ruled out because the troponin and EKG is negative and the patient denies chest pain or discomfort and shortness of breath.

Reference:

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th Ed.). St. Louis, MO: Elsevier Mosby.

Cunningham ET Jr, Ravich WJ, Jones B, Donner MW. Vagal reflexes referred from the upper aerodigestive tract: an infrequently recognized cause of common cardiorespiratory responses. Ann Intern Med. 1992;116:575–582.

Dains, J. E., Baumann, L. C., & Scheibel, P., (2012). Advanced health assessment & clinical diagnosis in primary care. St. Louis, MO: Elsevier Mosby.

http://www.mayoclinic.org/diseases-conditions/food-poisoning/basics/definition/CON-20031705.

Supannee, R., Pakpoom, T., & Nugent, K. (2016). Percutaneous gallbladder aspiration for acute cholecystitis. Baylor University Medical Center Proceedings, 29(4), 381-384.

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