Case Study

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This week, complete the Aquifer case titled Family Medicine 20: 28-year-old female with abdominal pain.

· Discuss the questions that would be important to include when interviewing a patient with this issue.

Abdomen pain can have a multitude of causes and can present differently with every patient. Chest pain is always ruled out first for abdomen pain is an atypical symptom of a Myocardial infarction. Being this patient is under increased stress and has a history of chest pain, panic attacks and ongoing pain. I would like to address cardiac in my examination. This patient has been without medical treatment for the last four years to which was specialized care of an active pregnancy. She does not have a primary provider thus her medical history is incomplete. I would want to address her past history in detail prior to making a diagnosis.

Some questions to ask would be:

When did the pain first start, when did you first notice discomfort? What were you doing at the time you noticed the pain?

Were you doing any activity prior that day?

Have you had any bleeding and was it spotting or large clots? If bleeding what color is the blood, bright red, dark red?

How regular are your menstrual cycles? Tell me about your pregnancy?

Did you breastfeed?

Do you have mood swings, depression, fatigue, irritability with menstruation? At what age did you start menstruation?

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Have you ever had an abortion or miscarrage? When was your last pelvic exam?

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We know of the one four years ago have you seen any other providers? What is your diet like, do you drink lots of fluids?

Do you use alcohol, smoke or use any drugs? Do you take any medications?

Have you had any injuries? Have you had any surgeries

Have you ever thought of suicide or harming yourself? Have you had intercourse recently?

Has intercourse been painful?

Have you felt this pain before or cramping before that resembles this pain? Do you have any stabbing pain in your lower back?

Have you used any medication today or yesterday?

Have you felt that you are coming down with a cold or flu? Do you have burning when you urinate or itching?

Have you ever had a yeast infection before or a history of UTI’s?

What are your bowel movements like any issues and have you been constipated? Last time you had a bowel movement?

Have you ever been tested for STD’s? Have you ever had an STD or been treated?

With previous or current sexual partners was intercourse consensual? How often have you had unprotected intercourse?

Do you have any allergies?

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Have you had immunizations, as a child, and current influenza, pneumonia, or chickenpox?

After your pregnancy how long was it before your menstrual cycle returned? What birth control medication were you on previously?

Have you missed a menstrual cycle recently or any thoughts you could be pregnant? Do you exercise on a regular basis and what activities do you do?

Do you feel bloated or distended in your bowels frequently? What is your family history in terms of medical diagnosis?

(Bickley, 2016.)

· Are there any diagnostic studies that should be ordered on this patient? Why?

The case study was geared toward the patients possible trauma and abuse from her husband. I would agree there is a large concern there and possibility that she has endured trauma due to the multiple bruising at different stages of healing. With a diagnosis of trauma I would want to first do an abdomen and pelvic ultrasound to ensure there is not ongoing trauma to organs in this area. I would perform an examination to assess for a positive psoas sign, this would rule out her appendix. Due to changes in bowels an occult blood test would be helpful in assessing blood in the stool thus signalling a gastric intestinal bleed or ulcer. Lab testing such as a CBC and CMP would also help to evaluate blood loss, kidney and liver function or infection, (Fischbach, & Fischbach, 2017.) A pregnancy test should also be performed due to unprotected intercourse and not using birth control. She is concerned about pain that comes and goes in different areas of the abdomen to which signals me to think there is some other pathology occurring. As stated above I would like to rule out cardiac involvement with a EKG or ECHO,

cardiac enzymes, and if these showed any abnormalities I would investigate further with a heart catheterization, (Fischbach, & Fischbach, 2017.)

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Differential Diagnosis include:

Pelvic inflammatory disease with ongoing untreated trichomoniasis infection:

Patient stated she has had a trichomoniasis diagnosis prior, the treatment was unclear due to what the patent can recall. The current pelvic exam was positive for the organism, prior abdominal pap smear that was not addressed. Patient has had ongoing pain for the last month, changes to menstrual cycle, painful intercourse, and cervical tenderness. The patient does not have any urinary concerns, has not had vaginal discharge or spotting, no redness or swelling was observed on genitalia, patient denies burning or itching symptoms, (Graesslin, Verdon, Raimond, Koskas, & Garbin, 2019.)

Community acquired SARS-COV-2:

I realize this is not the correct diagnosis for this patient due to the case study was developed prior but in the current moment she does have some of the symptoms such as the increase in headaches, a fever with no origin, abdominal pain, (Sheposh, 2020.) She is a teacher and her son is in daycare, her husband is out at the bars drinking so exposure is likely, and her son is having similar symptoms. She has prior chest pain and hives. This could be ruled out quickly with a test, she does not have any SOB, chest congestion or cold like symptoms or sensory changes, (Sheposh, 2020.)

Abdominal aortic aneurysm related to trauma:

The patient has inconsistent pain to which is stated to be in her upper and lower abdomen and aggravated by things that cause pressure or distention. She is under increased stress and I

would assume her blood pressure fluctuates throughout the day. She has had chest pain prior. There was only bruising observed in her abdomen and it was at different stages of healing which indicates she has had ongoing repeated trauma in that area. She stated that her husband is usually intoxicated and pushes her thus internal injury from the force or if she were to have impact with objects is suspect. Pain has recently increased in severity. She is a former smoker. There was no pulsating mass observed in the case study and the patient did not complain of back pain, (Belloch García, 2018.)

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My primary diagnosis is:

Ectopic pregnancy with additional complication of trichomoniasis:

The patient stated she thought she may be pregnant, has not had a menstrual cycle in last four weeks, has had nausea and vomiting, a fever with unknown origin, has had unprotected sex, and no contraception measures in place. Abdomen trauma observed to which could be self inflicted or by her husband to cause miscarrage. She was positive with trichomoniasis which would add symptoms of painful intercorse and variations to the abdomen pain. Patient does not have rectal pressure, dizziness or bleeding, (Layden, & Madhra, 2020.)

This diagnosis would be confirmed by an ultrasound and a pregnancy test. Labs to address anemia or infection would include a CBC and CMP. Treatment for this diagnosis would include removing the products of conception that can be accomplished a couple of different ways depending on what the patient prefers or risks involved. Methotrexate is a medication which causes destruction of fast growing cells, cells of a growing fetus would be targeted thus eliminating the ectopic pregnancy, (Layden, & Madhra, 2020.) Surgical laparoscopic procedure can also be performed to remove the ectopic tissue from the fallopian tube and repair any

damage that may have occurred by the mass, (Layden, & Madhra, 2020.) The patient should be restarted on birth control measures to prevent future pregnancies due to her not wanting to have any more children. She should also have a gynecologist follow up to monitor any further concerns after the pregnancy is terminated. The patient will also need treatment for the trichomoniasis and a followup with a primary provider for monitoring of the medication and retesting to ensure the infection is resolved, (Workowski, & Bolan, 2015.) Follow up testing for the husband and any of his sexual partners to stop further spreading. This patient also is in need of resources and counseling in regard to the abuse to which is speculated to be occurring in her current relationship. This abuse could also be occurring to the child which may need further evaluation but I don't feel there is evidence at this point to make a call to authorities regarding the concern.

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References:

Belloch García, L. (2018). Abdominal aortic aneurysm. Prevalence and associated risk factors in a population of patients hospitalised in Internal Medicine. Revista Clínica Española (English Edition), 218(9), 455–460. https://doi- org.su.idm.oclc.org/10.1016/j.rceng.2018.04.005

Bickley, L. (2016). Bates' Guide to Physical Examination and History Taking (12th Ed.).

Philadelphia, PA: Lippincott,William & Wilkins. ISBN: 9781469893419

Fischbach, F., Fischbach, M. (2017). Fischbach's A Manual of Laboratory and Diagnostic Tests, (10th Ed.). Philadelphia, PA: Lippincott,William & Wilkins. ISBN: 9781496380111

Graesslin, O., Verdon, R., Raimond, E., Koskas, M., & Garbin, O. (2019). Management of tubo- ovarian abscesses and complicated pelvic inflammatory disease: CNGOF and SPILF

Pelvic Inflammatory Diseases Guidelines. Gynecologie, Obstetrique, Fertilite & Senologie, 47(5), 431–441. https://doi-org.su.idm.oclc.org/10.1016/j.gofs.2019.03.011

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Layden, E., & Madhra, M. (2020). Ectopic pregnancy. Obstetrics, Gynaecology & Reproductive Medicine, 30(7), 205–212. https://doi-org.su.idm.oclc.org/10.1016/j.ogrm.2020.03.011

Sheposh, R. (2020). Coronavirus 2019 (COVID-19): Overview. Points of View: Coronavirus 2019 (COVID-19), 1.

Workowski, K., & Bolan, G. (2015). Sexually Transmitted Diseases Treatment Guidelines, 2015.

MMWR Recommendations & Reports, 64(3), 1–134.

Abdomen pain can have a multitude of causes and can present differently with every patient. I felt it was important not to just look at the obvious symptoms and ensure there were not other underlying complications. Chest pain is always ruled out first, for abdomen pain is an atypical symptom of a Myocardial infarction. Being this patient is under increased stress and has a history of chest pain, panic attacks and ongoing pain. I would like to address cardiac in my examination. This patient has been without medical treatment for the last four years to which was specialized care of an active pregnancy. She does not have a primary provider thus her medical history is incomplete. I would agree with you addressing her past history in detail prior to making a diagnosis. I think you were also thinking out of the box when you suggested appendicitis. It is completely reasonable to assess that. I do also realize domestic violence is a concern for this patient due to many factors. This is why I suggested trauma related abdominal aneurysm, do I think that is her current concern no but blunt force trauma to her abdomen can

cause significant damage. Great job on your post. It's nice to see someone else giving ideas that are not all the same simple diagnoses.

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Bickley, L. (2016). Bates' Guide to Physical Examination and History Taking (12th Ed.). Philadelphia, PA: Lippincott,William & Wilkins. ISBN: 9781469893419

Abdomen pain can have a multitude of causes and can present differently with every patient. I felt it was important not to just look at the obvious symptoms and ensure there were not other underlying complications. Chest pain is always ruled out first, for abdomen pain is an atypical symptom of a Myocardial infarction. Being this patient is under increased stress and has a history of chest pain, panic attacks and ongoing pain. I would like to have addressed cardiac in my examination. This patient has been without medical treatment for the last four years and she does not have a primary provider thus her medical history is incomplete. I would have liked to address her past history in more detail, there is alot to which a patient does not indulge unless asked and the information could be relevant to her current concerns. I think you were also thinking out of the box when you suggested abdomen trauma and gastritis. It is completely reasonable to assess that. I do also realize domestic violence is a concern for this patient due to many factors. This is why I suggested trauma related abdominal aneurysm, do I think that is her current concern no but blunt force trauma to her abdomen can cause significant damage. Great job on your post. It's nice to see ideas that are not all the same simple diagnoses such as PID. This patient is a strong lady and she would not be in the office if her concern was not acute, and

causing more pain then what she could handle.

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Bickley, L. (2016). Bates' Guide to Physical Examination and History Taking (12th Ed.). Philadelphia, PA: Lippincott,William & Wilkins. ISBN: 9781469893419