Gastrointestinal Case Study

Gastrointestinal Case Study

A 35-year-old Indian female presents with recurrent, cramping abdominal pain that has been occurring over the past several years. This pain has become increasingly severe and debilitating over the past few months. It is usually relieved by a bowel movement. She has a pattern of intermittent constipation and loose stools. She denies blood in the stool. The pain tends to be diffuse in nature and seems unrelated to diet, exercise, and/or stress. She is new to your practice, having moved to this geographic area only recently (over the past few months) related to her husband’s job. She has stayed with the same firm, although is in a new location. She does not smoke, drinks only socially, has a good job, denies excessive stress, and is married without children—no recent weight loss.

CC: “I want to find out what is wrong. I am tired of always worrying about where a bathroom is!”

Physical exam:

Vital signs are WNL.

Essentially normal abdominal exam and an overall negative general exam.

Lab results: Stool is negative for blood and mucus.

Students are to respond to all of the following questions:

What additional subjective data (list 5) would you collect? ( 15 points)

What additional objective data (excluding laboratory or diagnostic studies, list 5) would you collect? ( 15 points)

List and prioritize differential diagnoses (list 4) you would consider. For each differential diagnosis proposed, list specific information from the case study or from your suggested data that supports the diagnosis. ( 20 points: 3 points for each appropriate diagnosis, 2 points for each RATIONALE of diagnosis)

What laboratory or diagnostic studies should be considered to assist with or confirm the diagnosis, and what would be the EXPECTED FINDINGS of these studies? ( 15 points)

Outline your treatment plan:

· Recommended prescription therapy: ( 10 points)

· 5 points for appropriate prescriptive therapy (including dosing)

· 5 points for RATIONALE of therapy

· Recommended non-prescription (OTC, complementary) therapy (list 3): ( 10 points)

· 5 points for each non-prescription therapy, including dosing, if applicable

· 5 points for each RATIONALE of therapy

Propose referrals to other health care professionals and indicate the purpose (goal) of the referral. ( 3 points)

Describe patient/family teaching topics (list 3) that would be appropriate for this case. ( 3 points: 1 point for each DISTINCT and SPECIFIC topic)

Identify any cultural, socioeconomic, religious, or psychosocial issues (list 3) that you have considered in your treatment plan. ( 3 points: 1 point for each DISTINCT and SPECIFIC issue)

Case-specific questions. ( 3 points)

· What complementary therapies might be appropriate for this patient?

· What specific directions would you give the patient regarding a follow-up visit?

Identify preventative care that would be appropriate for this patient (immunizations, screenings, etc.). ( 2 points)

Which Centers for Medicare & Medicaid Services Evaluation & Management (CMS

E&M) code would you assign this visit? Provide a rationale for your answer. ( 1 point)

Total possible points: 100Gastrointestinal Case Study