DESCRIBE DIAGNOSIS AND TREATMENT OF IRRITABLE BOWEL SYNDROME (CHRONIC DISEASE)
PATIENT INFORMATION
Name: John Kidd
Age: 47 years old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies:
Penicillin – causes rash and anaphylaxis
Morphine – causes itching
Current Medications:
Fluticasone Fluroate Nasal Spray 27.5 mcg PRN
Albuterol Inhalation Aerosol 17 g PRN
Omacor 900 mg QID
Fluticasone/Salmeterol (Advair Diskus) 250/50 PRN
Protononix 40 mg q day
Sitalgliptin/Metformin (Junamet) 50/500 mg q day
Nexium 40 mg q day
Cymbalta 60 mg po qday
Mesalamine(Pentasa) 500 mg QID
Ambien CR 12.5 mg q HS PRN
Palidperidone (Invega) 3 mg q day
Lisinopril 5 mg q day
Mercaptopurine 50 mg BID
Clonazepam 1.5 mg BID
Omega -3-acid supplement q day
PMH:
Immunized for:
Polio
Tetanus
PPD
Preventive Care: No regular check up
Surgical History: None
Family History:
Mother – bipolar and schizophrenia, “drank herself to death”
Father – living with diabetes, s/p CABG
Sister with HTN
Maternal grandfather – leukemia
Social History:
Mr. John Kidd lives in Burlington with his wife. He has 6 children who are in good health but do not live with him. Mr. Kidd is on disability for his bipolar diagnosis and usually spends his days at home and caring for a sick older relative. He smokes half a ppd and has done so for the past 30 years. He states that he does not use any other drugs and that he does not consume alcohol. He has been involved in the distribution of crack cocaine for years in the past but stopped two years ago. While his wife is a crack user, he states that he has never been a user of any illicit drugs or narcotics. He suffers from chronic abdominal pain secondary to his Crohn’s, and also chronic right knee and lower back pain from a fall injury and osteoarthritis. He uses a cane when his knee and back pain become debilitating. He has a history of narcotic-seeking behavior and has left during past hospital visits when narcotic medications would not be prescribed for his pain. He no longer receives narcotics from UNC after breaking his pain contract with his family medicine provider but it is unclear if he receives pain medications from an outside hospital. He has been incarcerated in the past for arson and attempted murder.
Sexual Orientation: Heterosexual
Nutrition History: He is not physically active and his diet consists of small food portions but is generally unhealthy.
Subjective Data:
Chief Complaint: Abdominal Pain
Symptom analysis/HPI:
The patient is Mr. John Kidd a 47-year-old African American male with Crohn’s Disease, DM, and HTN who presented to the ED after two days of severe abdominal pain, nausea, vomiting, and diarrhea. He stated that on Wednesday evening after being in his usual state of health he began to experience sharp lower abdominal pain that radiated throughout all four quadrants. The pain waxed and waned and was about a 4/10 and more intense than the chronic abdominal pain episodes he experiences periodically from his Crohn’s disease. The pain was sudden and he did not take any medications to alleviate the discomfort. The abdominal pain was quickly followed by two episodes of partial diarrhea and soft stool that was tan in color with no signs of blood. His abdominal pain continued and he developed nausea and then vomited six times that evening before going to sleep. Overnight his abdominal pain worsened and he stayed in bed for most of the day on Thursday. He had nausea again all day but had no other episodes of diarrhea or vomiting that day and did not eat anything for fear of vomiting. He was able to drink water and keep it down. By late Thursday night, his pain had intensified to a 10/10 and he called 911 and was brought to the ER by ambulance from his home in Burlington.
Mr. Kidd also stated that he had just ended a three week course of prednisone four days ago, which he had started about a month ago at 60 mg and tapered himself down over a few days by 10 mg. He began the course of prednisone last month because he felt as if he was about to have a Crohn’s flare at the time. Mr. Kidd was last hospitalized at UNC for Crohn’s disease exacerbation in March 2007. He denies any recent hemoptysis, constipation, hematochezia, melena, and changes in his bowel habits since Wednesday. He has been compliant with taking his medications for Crohn’s and has been stable on his mesalamine, mercaptopurine, and omega -3-acid supplement.
Upon arrival to the ED, Mr. Kidd was put on IV fluids, given fentanyl 50 mcg IVP, Phenergan 12.5 mg diluted with 10 mL NS IVP, and Mg sulfate IVP. Radiological images were obtained through an abdominal CT scan, ultrasound, and 2V XR. Mr. Kidd was not given any other narcotics for his pain because of a past violation of a pain contract after a positive toxicology screen for cocaine resulted in his discharge from his family medicine provider and due to suspicions that he was narcotic-seeking.
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL: : denies anorexia and weight loss
NEUROLOGIC: chronic weakness in his left knee; denies transient paralysis, paresthesia, seizures, syncope, tremors, vertigo
HEENT: denies decreased hearing blurring, diplopia, irritation, discharge, vision loss, eye pain, photophobia, ear pain or discharge, tinnitus, nasal obstruction or discharge, nosebleeds, sore throat, hoarseness, dysphagia
RESPIRATORY: denies cough and wheezing
CARDIOVASCULAR: dyspnea on exertion; denies chest pains, palpitations, syncope, orthopnea, PND, edema
GASTROINTESTINAL: denies jaundice
GENITOURINARY: denies incontinence, dysuria, hematuria, urinary frequency
MUSCULOSKELETAL: arthritis in left knee and pain in lower back pain from past injury; denies other joint pain, joint swelling, muscle cramps, muscle weakness, stiffness,
SKIN: denies rash, dryness, suspicious lesions
Objective Data:
VITAL SIGNS:
Temperature : 36.3 C
Pulse : 79 bpm
Respiratory Rate : 16 bpm
Blood Pressure : 116/82 mmhg
Oxygen Saturation%: 97% on RA
Pain Score : 10/10
GENERAL APPREARANCE: Obese, sleepy but oriented man lying in bed
NEUROLOGIC: Cranial nerves: II – XII grossly intact; 2+, symmetric, reflexes; intact to touch, pin, vibration, and position in lower extremities; normal finger-to-nose, Rhomberg and Pronator drift deferred because patient was supine and would not stand
HEENT: External ears normal, no lesions or deformities; external nose normal, no lesions or deformities; canals clear bilaterally, tympanic membranes intact with good movement, no fluid; hearing grossly intact bilaterally; nasal mucosa, septum, and turbinates normal; poor dentition and missing a few teeth on both sides of top and bottom but does not wear dentures, tongue normal, posterior pharynx without erythema or exudates. Neck is supple, no masses, trachea midline; no thyroid nodules, masses, tenderness, or enlargement
CARDIOVASCULAR: S1, S2, normal rhythm, no murmur, rub, or gallop; no thrill or palpable murmurs on palpation, no JVD, no displacement of PMI; no carotid or abdominal bruits; no enlargement of abdominal aorta. Carotid, radial, posterior tibialis, and pedal pulses 2+ symmetric, no edema
RESPIRATORY: Clear to auscultation bilaterally, normal tactile fremitus, no egophony, normal respiratory effort with no use of accessory muscles.
GASTROINTESTINAL: obese, soft, non-tender, and non-distended abdomen with no masses; bowel sounds hyperactive, liver size appears within normal limits but not measured in midclavicular and midsternal line because of RUQ pain and tenderness to palpation; no liver nodularity or masses, no splenomegaly
MUSKULOSKELETAL: normal alignment, mobility and no deformity of head and neck, spine, ribs, pelvis; normal ROM and 5/5 strength in all extremities except compared to 4/5 strength in LLE, no joint enlargement or tenderness; no clubbing, cyanosis, petechiae, or nodes of digits and nails; gait and station deferred because patient supine
INTEGUMENTARY: no rash, lesions, ulcerations, subcutaneous nodules or induration
ASSESSMENT:
Mr. Kidd is a 47 year old African American man with Crohn’s disease, HTN, and DM who presented to the ER after two days of acute abdominal pain, nausea, vomiting, and diarrhea most likely due to Crohn’s disease exacerbation.
Main Diagnosis
Irritable bowel syndrome
Differential diagnosis (minimum 3)
– Psychiatric disorders (such as depression, anxiety or somatization disorder)
– Malabsorption syndromes (such as celiac disease or pancreatic insufficiency)
– Inflammatory bowel disease as in Crohn’s disease (ulcerative colitis)
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
Abdominal C/T
CBC
Total bilirubin
Abdominal acute 2V XR
Pharmacological treatment:
Anti-inflammatory include corticosteroids and aminosalicylates, such as mesalamine
Immunosuppressant drugs include azathioprine (Azasan, Imuran), mercaptopurine (Purinethol, Purixan)
Antibiotics like ciprofloxacin
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Sometimes you may feel helpless when facing inflammatory bowel disease. But changes in your diet and lifestyle may help control your symptoms and lengthen the time between flare-ups.
There’s no firm evidence that what you eat actually causes inflammatory bowel disease. But certain foods and beverages can aggravate your signs and symptoms, especially during a flare-up.
Limit dairy products. Many people with inflammatory bowel disease find that problems such as diarrhea, abdominal pain and gas improve by limiting or eliminating dairy products. You may be lactose intolerant — that is, your body can’t digest the milk sugar (lactose) in dairy foods. Using an enzyme product such as Lactaid may help as well.
Eat small meals. You may find you feel better eating five or six small meals a day rather than two or three larger ones.
Drink plenty of liquids. Try to drink plenty of liquids daily. Water is best. Alcohol and beverages that contain caffeine stimulate your intestines and can make diarrhea worse, while carbonated drinks frequently produce gas.
Consider multivitamins. Because Crohn’s disease can interfere with your ability to absorb nutrients and because your diet may be limited, multivitamin and mineral supplements are often helpful. Check with your doctor before taking any vitamins or supplements.
Talk to a dietitian. If you begin to lose weight or your diet has become very limited, talk to a registered dietitian.
Smoking increases your risk of developing Crohn’s disease, and once you have it, smoking can make it worse. People with Crohn’s disease who smoke are more likely to have relapses and need medications and repeat surgeries.
Smoking may help prevent ulcerative colitis. However, its harm to overall health outweighs any benefit, and quitting smoking can improve the general health of your digestive tract, as well as provide many other health benefits.
Exercise. Even mild exercise can help reduce stress, relieve depression and normalize bowel function. Talk to your doctor about an exercise plan that’s right for you.
Biofeedback. This stress-reduction technique may train you to reduce muscle tension and slow your heart rate with the help of a feedback machine. The goal is to help you enter a relaxed state so that you can cope more easily with stress.
Regular relaxation and breathing exercises. One way to cope with stress is to regularly relax and use techniques such as deep, slow breathing to calm down. You can take classes in yoga and meditation or use books, CDs or DVDs at home.
Follow-ups/Referrals
Symptoms of inflammatory bowel disease may first prompt a visit to your primary doctor. However, you may then be referred to a doctor who specializes in treating digestive disorders (gastroenterologist).
Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance, such as restrict your diet.
Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you made the appointment.
Write down key personal information, including any major stresses or recent life changes.
Make a list of all medications, including over-the-counter medications and any vitamins or supplements that you’re taking.
Take a family member or friend along. Sometimes it can be difficult to remember everything during an appointment. Someone who accompanies you may remember something that you missed or forgot.
Write down questions to ask your doctor.