Age: 75 years
Medical Record No: 66543N
History and physical examination conducted: June 21, 2016
Source: The patients presents his own medical history and is a reliable source
Chief Complain presented: Abdominal pain
The History of the Present Illness
Past medical history
The patient presents with diabetes diagnosed 10 years ago, that is well controlled with Metoprolol medication. He also presents with depression and the patient uses Prozac medication for depression management. Mr. X had been previously hospitalized in 2010 due to MI and cardiac catheterization was done therefore, the patient present with a positive history of surgery.
Social history
Family history
The patient parents died many years ago due to unknown causes. The wife also passed on 11 years ago. The family has a positive history of diabetes and hypertension with no history of any other chronic disease reported. All the five children of the patient are married and they live with their families.
Current medication
Prozac 20 mg four times in a day
Asprin 81 mg qd since he was diagnosed with MI
Metoprolol 20 mg qd for hypertension control
Allergies: No known food or drug allergy presented
Review of systems
General review- As indicated in the patient’s HPI, Mr. X has severe epigastric pain accompanied by nausea and a bloody stool. The patient denies instances of fever or chills
HEENT: The patient denies cases of dizziness and headache. He denies tinnitus or any hearing problem. Mr. X denies problems with his vision or any problems on his nasal cavity. The patient complains of a lump in his throat causing dysphagia.
Cardiovascular: The patient denies any instances of chest pain or palpitations
Pulmonary: Mr. X has no any breathing difficulty or cough.
Gastrointestinal: The patient complains of severe abdominal pain and also has a bloody stool.
Genitourinary: The patient denies problems with micturition or dysuria.
Musculoskeletal: Mr. X denies any instances of muscle or joint pain.
Neurologic: The patient denies any associated case of tingling, numbness or paresthesias
Physical examination
Vital signs: Height- 5.1 feet’s tall Weight: 85 kg BMI: 24 HR: 74 RR: 18 BP: 126/94 Temp: 37.0 degrees Celsius
General appearance: Mr. X looks depressed on appearance and is distressed due to the severe pains
HEENT: Not examined
Neck: No masses or engorgement of the thyroid gland
Chest: Normal respirations, lungs clear on auscultation with no crackles or wheezes. Normal heart rhythm with a normal S1, S2 sound with no murmurs heard.
Abdomen: Non-distended and soft with no masses or scars. The liver and the spleen are not palpable. On the area with pain, it is tender on palpation.
Rectus: Hemoccult test positive
Depression
Abdominal pain and bloody stool
Hypertension
Diagnosis: Colorectal carcinoma in a Hypertensive and a Depressed patient
Problem 1: Colorectal carcinoma
Differential diagnosis: GERD, gastric ulcer, pancreatic cancer, intestinal obstruction or abdominal aortic aneurysm
Plan and Discussion
As well, duodenal and gastric ulcers can cause bloody stools and epigastric pains. However, abdominal pain typically occurs after ingestion of a meal or it can also wake the patient during the night. Mr. X does not associate his pain with food, but the pains have made him have sleepless nights. Therefore, gastric ulcer is a differential diagnosis for the patient’s condition. According to Marsicano, Michael Vuong, & Prather (2014), GED can also lead to epigastric pains. From the patient’s symptoms of dysphagia and nausea, GERD is also a possible diagnosis. Other differential diagnoses that can be considered include intestinal obstruction, abdominal aortic aneurysm, and pancreatic cancer. However, these differential diagnoses do not explain the pathophysiology behind bloody stools and hemoccult positive stool results.
Diagnostic and treatment plan
A colonoscopy to be done to evaluate for the stage and location of the colorectal carcinoma tumors
Surgery will be done to remove the tumors to prevent further metastasis
Chemotherapy and radiation therapy to minimize the tumors risk of recurrence (Brenner, Kloor, & Pox, 2014).
Analgesics Diclofenac 50 mg tds will be administered in curing the pain. If the pain is persistent tramadol, 80 mg will be administered every 6 hours.
Patient education
The patient should be educated about his condition and on the importance of colonoscopy cancer screening. Early detection of colon cancer is important, as it is possible to cure the condition when it has not advanced to stages that are more complicated.
Problem 2 & 3: Hypertension and Depression
Treatment plan
The patient should continue with Prozac medication for depression management. For hypertension treatment, the patient should also continue with Metoprolol. These drugs are effective for managing the patient’s conditions.
Patient education
The patient should be educated on the importance of going for counseling therapies to help him in the management of depression. He should also be educated on the importance of dietary restrictions and physical exercise to help him in managing hypertension.
References
Brenner, H., Kloor, M., & Pox, C. P. (2014). Colorectal cancer. Lancet, 383(9927), 1490–502. Retrieved from http://doi.org/10.1016/S0140-6736(13)61649-9
Marsicano, E., Michael Vuong, G., & Prather, C. M. (2014). Gastrointestinal causes of abdominal pain. Obstetrics and Gynecology Clinics of North America. http://doi.org/10.1016/j.ogc.2014.06.002
Society, A. C. (2014). Colorectal Cancer Facts & Figures 2014-2016. Colorectal Cancer Facts and Figures, 1–32. Retrieved from http://doi.org/10.1101/gad.1593107
