A 47-year-old male came to the emergency department complaining about abdominal pain, diarrhea, and nausea that started three days ago. He rates his pain as 9 out of 10 on the acuity scale when it first started, but now it is five. However, the patient does not mention pain radiation to other parts of the body. Moreover, the possible inciting event, the color of the stool, recent travel history, previous episodes, and other associated symptoms are not indicated. The information on what aggravates and alleviates pain is not provided. The man claims that he did not take any medication before arriving at the hospital. According to the patient, he had hypertension, type 2 diabetes mellitus, and a history of gastrointestinal bleeding four years ago. He reports taking Lisinopril 10 mg and Amlodipine 5 mg for hypertension, Metformin 1000 mg, and Lantus for diabetes; the patient does not have any drug allergies. The man’s father had hypertension, diabetes, GERD, and hyperlipidemia, but he denies having a family history of colon cancer. The patient does not smoke, consumes alcohol occasionally, but the information about illicit drug use is not available.
Objective
The patient’s vital signs were checked and found to be within the normal range except for his elevated blood pressure, 160/86mmHg. The man’s BMI is 35.6, which classifies him as obese. Physical examination revealed regular heart rate and rhythm with no murmurs. Lungs were clear to auscultation; the chest wall was symmetrical. A review of the skin did not show urticaria, lesions, or any other visible changes. Locally, abdominal examination revealed that the abdomen was soft, non-tender, with active bowel sounds, and left lower quadrant pain. However, the rectal examination was not mentioned in this case, and it should be performed to check for the presence of blood.
Assessment
Mr. J.R. is a 47-year-old obese male with diabetes and hypertension, was admitted to the hospital with acute left lower quadrant pain and diarrhea. After assessing the history of the patient’s present illness and physical examination findings, the initial diagnosis was established to be gastroenteritis. However, the differential diagnoses can also be diverticulitis, lactose intolerance, ulcerative colitis, Crohn’s disease, and pseudomembranous enterocolitis. Additional laboratory tests and radiologic examination may need to be performed to exclude or confirm these conditions.
In this case, the most likely diagnosis is gastroenteritis, which could be caused by an infectious agent. This condition can occur in patients of all ages, and the symptoms include diarrhea, nausea, vomiting, and fever (Dains et al., 2019). This disease is usually self-limiting and does not require any diagnostic procedures to be conducted (Dains et al., 2019). Since the man, in this scenario, presented with abdominal pain and diarrhea, there is a chance that the patient will recover with rest and fluids. However, stool examination and microbiological culturing can help to determine the causative organism.
The first alternative diagnosis that can be considered in this case is diverticulitis. Although diverticulosis is an asymptomatic disease, an obstruction can cause inflammation and perforation, manifesting as left lower quadrant pain and tenderness (LeBlond, 2014). Furthermore, diverticulitis usually causes nausea, vomiting, and constipation rather than diarrhea (Ball et al., 2019). Establishing the definitive diagnosis requires performing computer tomography (CT) for the patient with such symptoms (LeBlond, 2014). The presence of dilated parts of the colon may suggest local obstruction (Colyal, 2015). Although the patient complains about pain on the left lower abdominal pain, the physical examination did not reveal tenderness or masses. Still, abdominal CT should be performed to exclude any condition that may require immediate surgical intervention.
Second, lactose intolerance could also be considered in this case. It causes malabsorptive or osmotic diarrhea, which is associated with the ingestion of milk products and results from a lactase enzyme deficiency (Dains et al., 2019). Since history lacks the information on similar episodes in the patient previously, more questions should be asked about the possible cause of his condition. Still, the patient will be recommended to remove milk products from his diet until his diarrhea stops.
The third and fourth differentials are Crohn’s and ulcerative colitis, which are inflammatory bowel diseases. These two diseases result in chronic diarrhea with multiple complications to other organs and systems (LeBlond, 2014). The diagnosis is established with laboratory tests and colonoscopy with biopsy (Dains et al., 2019). Since this is the first episode in this patient, it is challenging to suggest performing all the tests for this patient; thus, such extensive evaluation should be withheld.
Fifth, pseudomembranous colitis can also be included in the list of possible diagnoses in this clinical scenario. This condition is primarily caused by Clostridium difficile infection after antibiotic treatment (Abdul Jabbar et al., 2019). The diagnosis is made by stool testing for the bacterial cytotoxin (Abdul Jabbar et al., 2019). According to the presented case, the patient does not recall taking antibiotics or immunosuppressive drugs. Still, the literature reports unique cases of C. difficile colitis in people without prior history of chronic intake of medications (Abdul Jabbar et al., 2019). Therefore, the man’s stool should be assessed for the presence of the cytotoxin.
To sum up, the presented case suggests that this patient had diarrhea and abdominal pain due to enterocolitis, a self-limiting disease. However, other conditions like inflammatory bowel diseases, lactose intolerance, pseudomembranous colitis, and diverticulitis should be considered. Stool specimens can be sent for microbiological culture and cytotoxin test to confirm or disproof some of these diseases. Finally, I would accept the initial diagnosis after computer tomography to exclude any surgical emergencies.
References
Abdul Jabbar, S., Sundaramurthi, S., Elamurugan, T. P., Goneppanavar, M., & Nelamangala Ramakrishnaiah, V. P. (2019). An unusual presentation of pseudomembranous colitis. Cureus, 11(4), 1-10. Web.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Elsevier Mosby.
Colyal, M. R. (2015). Advanced practice nursing procedures. F. A. Davis.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care. Elsevier Mosby.
LeBlond, R. F. (2014). DeGowin’s diagnostic examination. McGraw-Hill Medical.