Diagnostic Reasoning Case

Introduction

Professional nursing practice in environments characterized by a high level of clinical complexity requires strong analytical skills. Problem-based learning can assist nursing students in developing thinking patterns that will facilitate sharp diagnostic reasoning, which is essential across all specialty areas (Zunkel, Cesarotti, Rosdahl, & McGrath, 2004). The aim of this paper is to develop four diagnoses for a case study on a patient who presents with abdominal discomfort, bloating, and constipation. The paper will detail the following diagnoses: irritable bowel syndrome with constipation, functional constipation, functional dyspepsia, and colorectal cancer.

Symptom Analysis

• How long have you had the feeling of discomfort? Longer than 2 weeks?
• When did it begin?
• What was its pattern over the last 24 hours?
• What makes it worse?
• Is the recurrent discomfort accompanied by nausea?
• Have you had heartburn or regurgitation?
• Have you had difficulty swallowing or cough?
• How is your appetite?
• When have you noticed changes in your bowel function?
• Can you please describe your normal defecation pattern in terms of its frequency?
• How your current pattern differs from the normal one?
• What is the color of the stools (Bickley, 2013)?
• What is their perceived hardiness?
• Do you have to strain during defecation?
• Have you tried to facilitate the process by taking laxatives?
• Have you had a recent dietary change?
• How much fluid do you usually consume?
• Do you smoke?
• Is there any anal or rectal pain?
• Have you had rectal bleeding?
• Have you experienced nocturnal abdominal discomfort?
• Have you been prescribed opioid therapy (Kumar, Barker, & Emmanuel, 2014)?
• Are there other symptoms that you would like to discuss?

Focused History of Presenting Illness

Medical History

• Have you had a weight loss?
• Is the onset of the abdominal discomfort associated with a change in your normal defecation pattern?
• Is there an improvement after defecation?
• Are the symptoms food sensitive?
• Do you consume large quantities of animal fats?
• Do you have a family history of colorectal cancer?
• Have you had an unpleasant sensation in the stomach after having a meal?
• Have you experienced early satiation?
• How often does the satiation prevent you from finishing your meals (Tack & Talley, 2013)?

Family History

• Has someone in your family had a history of gastroenterological diseases (Chey, Kurlander, & Eswaran, 2015)?
• Do you have a family history of dyspepsia (Tack & Talley, 2013)?

Physical

General. Weakness, fever, anxiety?

Respiratory. SoB, wheeze, cough?

Gastrointestinal. See above

Urogenital. Abdominal pain, dysuria, micturition, haematuria?

Central nervous system. Psychiatric disorders, spinal cord trauma, brain tumors, Parkinson’s disease (Mearin et al., 2016)?

Physical Examination

• Abdominal exam
• Rectal exam
• Assess mental status
• Inspect endocrine system

Hypotheses

Irritable Bowel Syndrome with Constipation

History findings

A family history of irritable bowel syndrome, gastrointestinal blood loss, or iron deficiency anemia (Chey et al., 2015).

• The symptoms do not worsen progressively
• Improvement with defecation
• The onset of the symptoms is associated with the change in stool consistency (El-Salhy, 2012).
• Urinary urgency
• Nausea

Physical exam findings

• Tense and anxious
• Palpable sigmoid cord
• Palpable stool (ascending or descending)

The following symptoms suggest organicity: fever, anemia, nocturnal symptoms, and anemia (Mearin et al., 2016).

Pathophysiology

Although the exact pathophysiological processes behind the IBS are not completely understood, two pathophysiological dimensions are recognized in irritable bowel syndrome: gastrointestinal motility and visceral hypersensitivity (Keszthelyi, Troost, & Masclee, 2012). Some researchers believe that gastrointestinal motor disturbances do not constitute the primary source of abnormalities in the gastrointestinal tract, as they do not completely explain the mixed or alternating cases of IBS. The patient’s psychological state remains a primary suspected pathophysiological factor to influence IBS (Keszthelyi et al., 2012).

Visceral hypersensitivity is another factor that may contribute to the IBS disturbance. There is increasing evidence that IBS is tied to the development of organic diseases in the gastrointestinal tract, among patients who fulfill the ROME criteria. According to new findings, IBS is associated with subtle inflammatory bowel disease, serotonin level irregularities, central dysregulation, and overwhelming bacterial growth in the gastrointestinal tract (Keszthelyi et al., 2012). IBS-PI remains the only clear indicator for diagnosing the disease. In addition, some patients are likely to be genetically predisposed towards IBS (Keszthelyi et al., 2012).

Functional Constipation

History findings

• Reduced intake of dietary fibers (Bassotti & Villanacci, 2013)
• Reduced intake of water
• Straining (25 percent of defecations or more) (Bassotti & Villanacci, 2013)
• Lumpy stools (25 percent of defecations or more)
• Manual maneuvers during defecation
• Fewer than 3 stool discharges per week (Mearin et al., 2016)
• Sensations of anorectal blockage and incomplete evacuations (25 percent of defecations or more) (Bassotti & Villanacci, 2013)
• Medical history: anticholinergics, antidepressants, opioids, psychotropics, narcotics, and antihistamines (Bassotti & Villanacci, 2013)

Physical exam findings

• Cutaneous pigmentation changes
• Abdominal distention
• Abdominal masses
• Distress and anxiety
• Rectal masses (Shin et al., 2016).

Pathophysiology

The disease is multifactorial and may be caused by medical neurological, and metabolic conditions (Shin et al., 2016). The main pathophysiological mechanisms involved in the process of functional dyspepsia include psychosocial disturbances, motility alterations, and visceral hypersensitivity (Shin et al., 2016). Motor disorders are common symptoms among functional dyspepsia patients, as it is associated with small bowel dysmotility, abnormal duogenogastric reflexes, gastroparesis, and other secondary pathophysiological responses (Shin et al., 2016). Researchers are uncertain about the role of Helicobacter Pylori in the development of the disease. While the rates of development across the majority of controlled studies remain non-significant, impaired accommodation is a common symptom in patients infected with Helicobacter Pylori (Shin et al., 2016). Pain and discomfort associated with delayed gastric emptying is the primary pathophysiological symptom of the disease. Modern therapeutic strategies used against functional constipation focus on nociception and improving the gastrointestinal tract’s timely accommodation response (Shin et al., 2016).

Functional Dyspepsia

History findings

• Family history of functional dyspepsia
• Use of NSAIDS and COX2 inhibitors (Goswami & Phukan, 2012)
• Intake of foods containing irritants
• High consumption of coffee and alcohol
• Anxiety and depressive disorders
• Reduced quality of life
• Nausea
• Postprandial fullness

Physical exam findings

• Epigastric tenderness (positive Carnett sign)
• Palpable abdominal mass
• Pallor
• Pain in the epigastrium (Goswami & Phukan, 2012).

The following red flags suggest a serious disease requiring more extensive investigation: unintended weight loss, persistent vomiting, and family history of cancer (Loyd & McClellan, 2013).

Pathophysiology

The disease is not associated with a definite pathophysiologic mechanism; however, disturbance of gastric emptying and accommodation is closely associated with the condition (Loyd & McClellan, 2013; Miwa et al., 2015). Other factors are H. pylori infection, smoking, a history of an abusive childhood, and psychological distress (Miwa et al., 2015). Normal transit, slow transit, and evacuation disorder remain the primary causes of the disease. However, recent research has found evidence of other pathophysiological factors and processes affecting the process of constipation. Some of them involve obstruction of the rectum (cancer, stricture), metabolic or neurological dysfunctions (hypercalcemia, Parkinsonism, multiple sclerosis), systemic failures (scleroderma, amyloidosis), and psychiatric (depression, eating habits) (Goswami & Phukan, 2012). Neither of these factors shows particular dominance over others, and every individual case has its own prevalent pathophysiological signature (Goswami & Phukan, 2012).

Colorectal Cancer

History findings

• Iron-deficiency anemia
• Rectal bleeding
• Passage of mucus
• Unwanted weight loss
• Fatigue
• Family history of colorectal cancer
• Removal of adenomatous polyps

Physical exam findings

• Abdominal tenderness
• Ulceration
• Ascites
• Palpable abdominal mass (Labianca et al., 2013).

Pathophysiology

Colorectal cancer is a genetically complex disease, which is associated with the progression of invasive adenocarcinoma and premalignant lesion (Labianca et al., 2013). While the mechanisms of the disease development are not fully understood, the sequence of molecular and genetic processes that transform the adenomatous polyps into cancerous malignancies was excessively studied and characterized by Vogelstein and Fearon (Labianca et al., 2013). Their findings constitute the basis for the present understanding of colorectal cancer processes. Other factors that potentially increase the chances of developing colorectal cancer include epigenetic events, such as abnormal levels of methylation in DNA, which can compromise the genetic balance through silencing tumor-suppressor genes and activating an oncogenetic response, which would eventually lead to a malignancy (Labianca et al., 2013).

Summary

When approaching the diagnostic assessment of the patient’s symptoms, an analytical focus was on the onset of the patient’s symptoms, their duration, and frequency. The patient was inquired about his dietary habits in order to ascertain whether they can account for functional dyspepsia (Tack & Talley, 2013). Taking into consideration the fact that patients with constipation and functional dyspepsia may suffer from psychological disorders, a history of mental illness was also evaluated.

There is a substantial overlap between symptoms of functional gastrointestinal disorders; therefore, Rome criteria were used (Mearin et al., 2016). Taking into consideration that the patient is older than 50, which is an alarming symptom, the ordering of additional diagnostic tests to rule out organicity is needed (Mearin et al., 2016). Other alarm criteria applicable to the patient’s symptoms are nocturnal discomfort, anemia, inexplicable weight loss, fecal blood, or abnormal findings of digital rectal examination (Mearin et al., 2016). It has to be borne in mind that patients diagnosed with either functional constipation or irritable bowel syndrome require a colonoscopy exam regardless of the presence of red flags.

Diagnostic Tests

The choice of diagnostic tests is based on a clinical practice guideline developed by a workgroup consisting of members of the Asociacion Espanola de Gastroenterolgoia (AEG) (Mearin et al., 2016). Fecal immunochemical tests (FITs) should be conducted to confirm the presence of colorectal cancer. Several independent lines of the investigation show that the reliability of tests approximates 95 percent (Lee, Liles, Bent, Levin, & Corley, 2014). Sensitivity and specificity for the tests are 79 percent and 94 percent, respectively (Lee et al., 2014). The predictive value of FITs in the context of colorectal cancer is 95 percent (Lee et al., 2014).

Fecal occult blood test (FOBT) will be needed to diagnose colorectal cancer. A study conducted by Shin et al. (2013) shows that the sensitivity of the test approximates 60 percent. However, the sensitivity of the test tends to change with different rounds. The validity, reliability, specificity, and predictive value of the test for colorectal cancer are also sufficiently high (Shin et al., 2013).

A cell blood count will be used to evaluate the presence of anemia/infection (Mearin et al., 2016). Due to high reliability, validity, specificity, and predictive value, it is recommended to use it for patients who meet diagnostic criteria for irritable bowel syndrome (Mearin et al., 2016).

Rome III diagnostic questionnaire will be used to assess functional dyspepsia. A study conducted by Kanazawa et al. (2015) shows that sensitivity, specificity, and predictive value of the questionnaire for the condition are 53.2 percent, 98.2 percent, and 94.4 percent, respectively. However, when it comes to the use of the test for irritable bowel syndrome, its sensitivity, specificity, and predictive value are 61.2 percent, 100 percent, and 100 percent, respectively (Kanazawa et al., 2015). It means that the test is more reliable for the latter condition.

Conclusion

The paper has presented four diagnoses for a patient who presents with abdominal discomfort, bloating, and constipation. Based on the abdominal complaints the following diagnoses have been proposed: irritable bowel syndrome with constipation, functional constipation, functional dyspepsia, and colorectal cancer. It has been argued that in addition to the patient’s age, it is important to be cognizant of other alarm criteria such as anemia, nocturnal symptoms, fecal blood, and fever. To facilitate the diagnosis, four tests have been suggested.

References

Bassotti, G., & Villanacci, V. (2013). A practical approach to diagnosis and management of functional constipation in adults. International Emergency Medicine, 8(1), 275-282.

Bickley, L. (2013). Bates’ guide to physical examination and history taking. Philadelphia, PA: Lippincott, Williams & Wilkins.

Chey, W. D., Kurlander, J., & Eswaran, S. (2015). Irritable bowel syndrome: A clinical review. JAMA, 313(9), 949-958.

El-Salhy, M. (2012). Irritable bowel syndrome: Diagnosis and pathogenesis. World Journal of Gastroenterology, 18(37), 5151-5163.

Goswami, B. D., & Phukan, C. (2012). Clinical features of functional dyspepsia. JAPI, 60, 21-22.

Kanazawa, M., Nakajima, S., Oshima, T., Whitehead, W. E., Sperber, A. D., Palsson, O. S., & Fukudo, S. (2015). Validity and reliability of the Japanese version of the Rome III diagnostic questionnaire for irritable bowel syndrome and functional dyspepsia. Journal of Neurogastroenterology and Motility, 21(4), 537-544.

Keszthelyi, D., Troost, F. J., & Masclee, A. A. (2012). Irritable bowel syndrome: Methods, mechanisms, and pathophysiology. Methods to assess visceral hypersensitivity bowel syndrome. American Journal of Physiology – Gastrointestinal and Liver Physiology, 303(2), 141-154.

Kumar, L., Barker, C., & Emmanuel, A. (2014). Opioid-induced constipation: Pathophysiology, clinical consequences and management. Gastroenterology Research and Practice, 12(1), 1-6.

Labianca, R., Nordlinger, G. D., Beretta, S., Mosconi, M., Mandala, M., Cervantes, A., & Arnold, D. (2013). Early colon cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Annals of Oncology, 24(6), 64-72.

Lee, J. K., Liles, E. G., Bent, S., Levin, T. R., & Corley, D. A. (2014). Accuracy of fecal immunochemical tests for colorectal cancer: Systematic review and meta-analysis. Annals of Internal Medicine, 160(3), 171-174.

Loyd, R. A., & McClellan, D. A. (2013). Update on the evaluation and management of functional dyspepsia. Indian Journal of Clinical Practice, 24(2), 110-114.

Mearin, F., Ciriza, C., Minguez, M., Rey, E., Mascort, J. J., Pena, E.,… Judez, J. (2016). Clinical practice guideline: Irritable bowel syndrome with constipation and functional constipation in the adult. Revista Espanola de Enfermedades Digestivas, 108(6), 332-363.

Miwa, H., Kusano, M., Arisawa, T., Oshima, T., Kato, M., Joh, T.,… Shimosegawa, T. (2015). Evidence-based clinical practice guidelines for functional dyspepsia. Journal of Gastroenterology, 50, 125-139.

Shin, A., Choi, K. S., Jun, J. K., Noh, D. K., Suh, M., Jung, K. W.,… Park, E. C. (2013). Validity of fecal occult blood test in the national screening program, Korea. PLOS, 8(11), 1-13.

Shin, J. E., Jung, H. K., Jo, Y., Lee, H., Song, K. H., Hong, S. N.,… Lim, H. C. (2016). Guidelines for the diagnosis and treatment of chronic functional constipation in Korea. Journal of Neurogastroenterology and Motility, 22(3), 383-411.

Tack, J., & Talley, N. J. (2013). Functional dyspepsia—Symptoms, definitions, and validity of the Rome III criteria. Nature Reviews Gastroenterology & Hepatology, 10(3), 134-141.

Zunkel, G., Cesarotti, E., Rosdahl, D., & McGrath, J. (2004). Enhancing diagnostic reasoning skills in nurse practitioner students: A teaching tool. Nurse Educator, 29(4), 161-165.