Diagnosing Gastrointestinal Disorders

In primary care settings, patients often present with abdominal pain. Although this is frequently a sign of a gastrointestinal (GI) disorder, abdominal pain could also be the result of other systemic disorders, making this type of pain difficult to assess. While abdominal pain is most common, many other GI symptoms also overlap multiple disorders, further increasing the difficulty in diagnosing and treating patients. This makes provider-patient communication essential. You must be able to formulate questions that will prompt the patient to provide the necessary information, as this will guide your assessment and diagnosis. For this Discussion, consider potential diagnoses for the patients in the following case studies.

Case Study 1:
A 49-year-old man presents to the office complaining of vague abdominal discomfort over the past few days. He states he does not feel like eating and has not moved his bowels for the last 2 days. His patient medical history includes an appendectomy at age 22 and borderline hypertension, which he is trying to control with diet and exercise. He takes no medications and has no known allergies. Positive physical exam findings include a temperature of 99.9 degrees Fahrenheit, heart rate of 98, respiratory rate of 24, and blood pressure of 150/72. The abdominal exam reveals abdominal distention, diminished bowel sounds, and lower left quadrant tenderness without rebound.

Case Study 2:
A 40 year-old female presents to the office with the chief complaint of diarrhea. She has been having recurrent episodes of abdominal pain, diarrhea, and rectal bleeding. She has lost 9 pounds in the last month. She takes no medications, but is allergic to penicillin.  She describes her life as stressful, but manageable. The physical exam reveals a pale middle- aged female in no acute distress. Her weight is 140 pounds (down from 154 at her last visit over a year ago), blood pressure of 94/60 sitting and 86/50 standing, heart rate of 96 and regular without postural changes, respiratory rate of 18, and O2 saturation 99%. Further physical examination reveals:
Skin: w/d, no acute lesions or rashes
Eyes: sclera clear, conj pale
Ears: no acute changes
Nose: no erythema or sinus tenderness
Mouth: membranes pale, some slight painful ulcerations, right buccal mucosa, tongue beefy red, teeth good repair
Neck: supple, no thyroid enlargement or tenderness, no lymphadenopathy
Cardio: S1 S2 regular, no S3 S4 or murmur
Lungs: CTA w/o rales, wheezes, or rhonchi
Abdomen: scaphoid, BS hyperactive, generalized tenderness, rectal +occult blood

Case Study 3:
A 52-year-old male presents to the office for a routine physical. The review of symptoms reveals anorexia, heartburn, and weight loss over the past 6 months. The heartburn is long standing, occurring most days during the week. He takes TUMS or Rolaids to relieve the discomfort. The patient describes occasional use of ibuprofen for back pain, but denies other medications including herbals. He has no known allergies. He was adopted so does not know his family history. Social history reveals that, although he stopped smoking ten years ago, he smoked for 20 years. He occasionally consumes alcohol on the weekends only. The only positive physical exam finding for this patient was slight epigastric tenderness. The remainder of his exam was negative and the rectal exam was negative for blood.

To prepare:

• Review this week’s media presentations and Part 12 of the Buttaro et al. text in the Learning Resources.
• Select one of the three case studies listed above. Reflect on the provided patient information including history and physical exams.
• Think about a differential diagnosis. Consider the role the patient history and physical exam played in diagnosis.
• Reflect on potential treatment options based on your diagnosis.

Post on or before Day 3 an explanation of the differential diagnosis for the patient in the case study that you selected. Describe the role the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis.

Patient Presentation of Dementia, Delirium, and Depression

With the prevalence of dementia, delirium, and depression in the growing geriatric population, you will likely care for elderly patients with these disorders. While many symptoms of dementia, delirium, and depression are similar, it is important that you are able to identify those that are different and properly diagnose patients. A diagnosis of one of these disorders is often difficult for patients and their families. In your role as the advanced practice nurse, you must help patients and their families manage the disorder by facilitating necessary treatments, assessments, and follow-up care. Consider the patient presentations in the following case studies. What distinct symptoms or factors would lead you to a diagnosis of dementia, delirium, or depression?

Case Study 1:

HPI: Mrs. Mayfield is a 75-year-old woman who is brought to the emergency room by the police at 11 p.m. She was found wandering and confused in a local neighborhood. The police were called when Mrs. Mayfield tried to use her key on a neighbor’s door. When confronted by the police she became abusive, confused, and frightened and looked very pale and agitated. The police could not establish her correct address and they subsequently brought her to the emergency room.

Review of Symptoms (ROS): Unable to obtain at this time.

Objective Data:
PE:
VS: Pulse 96 and regular; B/P 150/90; Axillary temperature 99°F.

General: She appears clean and well nourished, with no signs of injury, trauma, or neglect.

Her physical exam is unremarkable except –

Neuro: No gross focal neurological signs, but she is only intermittently cooperative. Her mental status fluctuates and a full neurological evaluation is not possible at this time.

Psych: A & O x 1 to person only.  She has episodes of agitation and alternating withdrawal/somnolence. During the examination, it takes several attempts to gain Mrs. Mayfield’s attention to answer questions, but once focused, she rambles on in a disorganized and incoherent way.

Case Study 2:

CC: “irritable and forgetful”

HPI: Mrs. White, a 78-year-old married woman, is brought to the office of her primary care provider by her husband because of increasing forgetfulness and irritability over the past 3 months. Mr. White claims that his wife has had problems for several years now, but has just gotten “worse in her memory” in the past few months. She recently misplaced her purse and accused her son of stealing it.

On three occasions, she left the stove on and boiled a pot dry, nearly causing a fire. She recently put a container of ice cream into the washing machine instead of into the freezer and her husband did not discover it for more than a week. Mrs. White claims her family wants to take her money and leave her with nothing. “No matter what they say, there is nothing wrong with me,” she states.

Past Medical History (PMH) includes: hypothyroidism, treated with Synthroid, and successful treatment of breast cancer approximately 15 years prior. She also takes over-the-counter ibuprofen for chronic lower back pain and occasional Benadryl to help her sleep at night.

Objective data: Her physical examination is within normal limits.

Case Study 3:

HPI: Mr. George is a 72-year-old male who has lived alone since his wife died approximately 1 year ago. He has lived in the same house for 45 years. He is brought in by his son who is concerned that his father has lost more than 35 pounds over the past year. Mr. George admits to not eating well because “I don’t know how to cook for myself.”

PMH: He has been in good health with the exception of hypertension, which is well controlled.

Social history: He spends most of his time watching sports on television. He occasionally drinks one or two cans of beer when he is watching TV. He does go to his son’s house to visit with his grandchildren about once a week, and he says he enjoys that. He does not receive any social services, he still drives but only in the daytime, and he does not participate in any other leisure activities.

Objective data: His physical examination is normal. He responds correctly to questions, although he appears to have a flat affect.

To prepare:

• Review Chapters 6–8 of the Holroyd-Leduc and Reddy text.
• Select one of the three case studies. Reflect on the way the patient presented in the case study you selected, including whether the patient might be presenting with dementia, delirium, or depression.
• Think about how you would further evaluate the patient based on medical history, current drug treatments, and the patient’s presentation. Consider whether you would modify drug treatments, use additional assessment tools, and/or refer the patient to a specialist.

Post on or before Day 3 an explanation of whether you suspect the patient in the case study you selected is presenting with dementia, delirium, or depression and why. Then, explain how you would further evaluate the patient in the case study based on medical history, current drug treatments, and the way the patient presented. Include whether you would modify drug treatments, use additional assessment tools, and/or refer the patient to a specialist.

Complications of asthma can be sudden. Consider the case of Bradley Wilson, a young boy who had several medical conditions. He appeared in good health when he went to school, returned home, and ate dinner. However, when he later went outside to play, he came back inside wheezing. An ambulance took him to the hospital where he was pronounced dead (Briscoe, 2012). In another case, 10-year-old Dynasty Reese, who had mild asthma, woke up in the middle of the night and ran to her grandfather’s bedroom to tell him she couldn’t breathe. By the time paramedics arrived, she had passed out and was pronounced dead at the hospital (Glissman, 2012). These situations continue to outline the importance of recognizing symptoms of asthma and providing immediate treatment, as well as distinguishing minor symptoms from serious, life-threatening symptoms. Since these symptoms and attacks are often induced by a trigger, as an advanced practice nurse, you must be able to help patients identify their triggers and recommend appropriate treatment options. For this reason, you need to understand the pathophysiological mechanisms of chronic asthma and acute asthma exacerbation.

To prepare:

• Review “Asthma” in Chapter 26 of the Huether and McCance text. Identify the pathophysiological mechanisms of chronic asthma and acute asthma exacerbation. Consider how these disorders are similar and different.
• Select a patient factor different from the one you selected in this week’s Discussion: genetics, gender, ethnicity, age, or behavior. Think about how the factor you selected might impact the pathophysiology of both disorders. Reflect on how you would diagnose and prescribe treatment of these disorders for a patient based on the factor you selected.
• Review the “Mind maps—Dementia, Endocarditis, and Gastro-oesophageal Reflux Disease (GERD)” media in the Week 2 Learning Resources. Use the examples in the media as a guide to construct two mind maps—one for chronic asthma and one for acute asthma exacerbation. Consider the epidemiology and clinical presentation of both chronic asthma and acute asthma exacerbation.

To complete:

Write a 2- to 3-page paper that addresses the following:

• Describe the pathophysiological mechanisms of chronic asthma and acute asthma exacerbation. Be sure to explain the changes in the arterial blood gas patterns during an exacerbation.
• Explain how the factor you selected might impact the pathophysiology of both disorders. Describe how you would diagnose and prescribe treatment for a patient based on the factor you selected.
• Construct two mind maps—one for chronic asthma and one for acute asthma exacerbation. Include the epidemiology, pathophysiology, and clinical presentation, as well as the diagnosis and treatment you explained in your paper.

***DUE IN 8-10 HOURS! 

Assignment:

In Chapter 12, we talked about stress. Stress is a common phenomenon in healthcare.

Using the attached required reading, Write a complete 4-7 pages paper about stress in healthcare and the impact it can have on employees, organizational performance, the delivery of patient care, etc.  In your paper address the following:

• 1. Define stress – when is it good and when is it bad?
• 2. Identify and describe the different kinds of stress that can occur.
• 3. What does the healthcare environment look like currently?
• 4. Why is stress more prevalent in healthcare? What impact can it have on an organization, employees, and patients?
• 5. Discuss why stress in a healthcare environment may be more of a pressing issue as compared to other industries (be sure to address factors, such as, professional hierarchy, personalities, ethnicity, gender, etc.).
• 6. What can administrators do to address employee stress? What can employees do to better manage stress? Describe if / how employee burnout (due to stress) is impacting the delivery of care.
• 7. Identify some best practices to alleviate the negative effects of stress in the workplace. How should managers behave so that employees experience less stress on the job? What strategies can the organization use so that the employees experience less stress on the job?
• 8. Write established theories to describe stress in a healthcare environment This write-up has to be supported by current facts and literature.

Submission Requirements:

In presenting your work, include the following sections in your paper:

• – Introduction (one-two paragraphs)
• – Case Inquiries Addressed Introduction (body of paper; use sub-sections as you deem necessary)
• – Review and Application of Theory (body of paper; use sub-sections as you deem necessary)
• · You need to demonstrate a significant degree of knowledge regarding the theory you choose
• · Support with theories that are appropriate for each case
• · Recommend you review the existing literature to further explore that theory and how it has been applied
• – Discussion (Tie the theory back to the case problem)
• – Conclusion (one – three paragraphs)
• – References (minimum 10 scholarly references cited in APA style)

****DUE IN 8-10 HOURS! 

Assignment:

In Chapter 12, we talked about stress. Stress is a common phenomenon in healthcare.

Using the attached required reading, Write a complete 4-7 pages paper about stress in healthcare and the impact it can have on employees, organizational performance, the delivery of patient care, etc.  In your paper address the following:

• 1. Define stress – when is it good and when is it bad?
• 2. Identify and describe the different kinds of stress that can occur.
• 3. What does the healthcare environment look like currently?
• 4. Why is stress more prevalent in healthcare? What impact can it have on an organization, employees, and patients?
• 5. Discuss why stress in a healthcare environment may be more of a pressing issue as compared to other industries (be sure to address factors, such as, professional hierarchy, personalities, ethnicity, gender, etc.).
• 6. What can administrators do to address employee stress? What can employees do to better manage stress? Describe if / how employee burnout (due to stress) is impacting the delivery of care.
• 7. Identify some best practices to alleviate the negative effects of stress in the workplace. How should managers behave so that employees experience less stress on the job? What strategies can the organization use so that the employees experience less stress on the job?
• 8. Write established theories to describe stress in a healthcare environment This write-up has to be supported by current facts and literature.

Submission Requirements:

In presenting your work, include the following sections in your paper:

• – Introduction (one-two paragraphs)
• – Case Inquiries Addressed Introduction (body of paper; use sub-sections as you deem necessary)
• – Review and Application of Theory (body of paper; use sub-sections as you deem necessary)
• · You need to demonstrate a significant degree of knowledge regarding the theory you choose
• · Support with theories that are appropriate for each case
• · Recommend you review the existing literature to further explore that theory and how it has been applied
• – Discussion (Tie the theory back to the case problem)
• – Conclusion (one – three paragraphs)
• – References (minimum 10 scholarly references cited in APA style)