Immunological Medicine Discussion Paper

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Immunological Medicine Discussion Paper

EPISODIC FOCUSED SOAP NOTE

PATIENT DATA:

JF 65-year-old female

SUBJECTIVE DATA:

Chief Complaint (CC): JF, a 65-year-old female, presents with a chief complaint of abdominal pain.

History of Present Illness (HPI): The patient reports experiencing moderate abdominal pain for the past two weeks, with a recent worsening of symptoms. She describes the pain as burning, colicky, and sharp, primarily located in the epigastric region, with radiation to her back and flank. The pain occurs after meals and is aggravated by the consumption of milk/dairy products and food. There are no identified relieving factors. Associated symptoms include back pain, decreased appetite, moderate diarrhea (lasting one week, occurring 2-3 times daily, intermittent), flank pain, nausea, and an unintended 8-pound weight loss over the last month. Immunological Medicine Discussion Paper

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Medications: The patient’s current medication regimen includes:

  1. Bupropion HCL 100mg – 1 tab daily
  2. Crestor 5mg – 1 tab at bedtime
  3. Lisinopril 2.5mg – 1 tab daily
  4. Metformin 1000mg – 2 tabs BID
  5. NP Thyroid 60mg – 1 tab daily
  6. Ozempic 2mg/dose (8mg/3ml) subq pen injector once weekly
  7. Sertraline HCL 50mg – 1 tab daily

Allergies: No history of allergies.

Past Medical History (PMH): No significant past medical history, including depression, diabetes, hypercholesterolemia, hypertension, and thyroid disease.

Past Surgical History (PSH): No past surgical history was provided.

Sexual/Reproductive History: Sexual and reproductive history is not mentioned.

Personal/Social History: Details about the patient’s personal and social history, including lifestyle factors and habits, are not provided.

Immunization History: The patient’s immunization history is not provided.

Significant Family History: There is no mention of significant family history.

Review of Systems:

Constitutional Symptoms: JF reports an unintended 8-pound weight loss over the last month, which is concerning for constitutional symptoms.

HEENT: She has no issues with dizziness, blurry vision, or headaches. There’s a positive report of a sore throat, and she does not wear glasses or visit an eye doctor regularly. Dental check-ups occur every six months.

Neck: She reports neck pain and tenderness with no stiffness or recent injury.

Breasts: This aspect is deferred and not reported.

Respiratory: Denies dyspnea, cough, or hemoptysis.

Cardiovascular/Peripheral Vascular: No reports of chest pain, heart palpitations, or edema. No history of murmurs or arrhythmias. No leg cramps or intermittent claudication. Immunological Medicine Discussion Paper

Gastrointestinal: The patient presents with a chief complaint of abdominal pain, which is described as burning, colicky, and sharp, primarily located in the epigastric region, with radiation to her back and flank. The pain occurs after meals and is aggravated by the consumption of milk/dairy products and food. Associated symptoms include back pain, decreased appetite, moderate diarrhea (lasting one week, occurring 2-3 times daily, intermittent), flank pain, and nausea. These gastrointestinal symptoms require further evaluation.

Genitourinary: No changes in urinary pattern, penile discharge, or problems with erections are noted.

Musculoskeletal: Report back pain as one of her associated symptoms.

Integumentary: There are no reported issues with skin, nails, or moles.

Neurological: She denies neurological symptoms like weakness, falls, or seizures.

Psychiatric: Currently on Sertraline HCL 50mg for psychiatric management, suggesting a history of depression. Immunological Medicine Discussion Paper

Endocrine: JF is on NP Thyroid 60mg for thyroid management and Metformin 1000mg for diabetes management. These medications indicate a history of thyroid disease and diabetes. However, no specific endocrine symptoms are mentioned.

Hematological: No reported issues with adenopathy, bleeding, or blood clots. Last blood work was done a month ago, and no history of blood product transfusions.

Allergic/Immunologic: Denies seasonal allergies or immune deficiencies.

OBJECTIVE DATA:

Vital Signs: BP 130/80 mm Hg, HR 72 bpm, RR 18 bpm, Temp 98.6°F

Physical Exam: 65-year-old female, NAD

HEENT: NC/AT, PERRLA, TM intact, clear oropharynx

Mouth: Oral mucosa moist, no lesions

Neck: Supple, no palpable lymphadenopathy or masses

Chest/Lungs: Symmetrical chest, clear breath sounds, no wheezing, rales, or rhonchi

Respirations: 18 breaths per minute Immunological Medicine Discussion Paper

CV/PV (Cardiovascular/Peripheral Vascular):

  1. Regular heart rate and rhythm, with a pulse of 72 bpm.
  2. Blood pressure is within normal range at 130/80 mm Hg.
  • No murmurs, gallops, or rubs auscultated.
  1. Peripheral pulses are bilaterally strong and equal, with no signs of peripheral vascular abnormalities.

Abdomen: Mild epigastric tenderness, no guarding or rebound tenderness, present bowel sounds, no palpable masses or hepatosplenomegaly

Genital/Rectal: Genital and rectal exams deferred

Musculoskeletal: No deformities, full range of motion in extremities

Neurological: A&O x3, intact cranial nerves, no focal deficits

Skin: Warm and dry, no rashes, lesions, or ulcerations

Psychiatric: Mild distress due to abdominal pain, history of depression, taking Bupropion HCL and Sertraline HCL

Hematological: No signs of bleeding or bruising, no lymphadenopathy or petechiae Immunological Medicine Discussion Paper

ASSESSMENT:

  1. Gallstone Pancreatitis: This is the highest priority diagnosis to consider. This is because of the patient’s symptoms of moderate abdominal pain, particularly in the epigastric region, radiating to the back and flank, and worsened after meals. The presence of pain aggravated by the consumption of fatty foods (such as milk and dairy products) is suggestive of gallbladder involvement (Moody et al., 2018). The associated symptoms of back pain, nausea, and an unintended weight loss over the last month are also concerning for a potential pancreatitis secondary to gallstones.
  2. Gastroesophageal Reflux Disease (GERD): According to Testoni et al. (2021), GERD can cause burning epigastric pain especially after meals. The fact that the patient’s symptoms are aggravated by the consumption of food and relieved by neither food nor antacids suggests the possibility of GERD. However, the presence of additional symptoms like back pain, diarrhea, and unintended weight loss may indicate a more complex issue.
  3. Peptic Ulcer Disease (PUD): Peptic ulcers can present with epigastric pain, often described as burning or colicky (Jin et al., 2022). The patient’s symptoms of abdominal pain after meals and the potential aggravation by certain foods are consistent with PUD. Additionally, the presence of moderate diarrhea could be associated with PUD complications, such as gastritis or duodenitis. Immunological Medicine Discussion Paper

Primary Diagnosis: Given the patient’s symptoms, history of diabetes, and the potential for complications related to her gastrointestinal symptoms, the primary diagnosis would likely be Gallstone Pancreatitis. This diagnosis is prioritized due to the severity of the symptoms. These symptoms include radiation of pain to the back and flank, and the presence of other concerning signs, like nausea and an unintended weight loss of 8 pounds over the last month.

PLAN

Plan for Diagnostics:

  1. Laboratory Investigations:
    1. Perform a comprehensive metabolic panel (CMP) and a complete blood count (CBC) to assess the patient’s electrolyte levels, liver function, and complete blood count to check for signs of inflammation or infection.
    2. Check serum lipase and amylase levels to evaluate pancreatic function and confirm or rule out pancreatitis.
    3. Monitor HbA1c to assess long-term diabetes control.
    4. Stool studies may be considered to investigate the cause of moderate diarrhea. Immunological Medicine Discussion Paper

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  1. Imaging Studies:
    1. Conduct an abdominal ultrasound or abdominal CT scan to visualize the gallbladder and pancreas, which will help confirm or rule out gallstone pancreatitis.
    2. An upper endoscopy (esophagogastroduodenoscopy or EGD) may be performed to assess the esophagus and stomach for signs of peptic ulcers or other gastrointestinal issues.

Primary Diagnosis

Plan for Treatment and Management:

  1. Pain Management: Provide IV opioids for pain relief during acute episodes, along with anti-nausea medication as needed.
  2. NPO Status and IV Fluids: Begin NPO status to rest the pancreas and ensure hydration with IV fluids.
  3. Consultation with a Gastroenterologist: Consider involving a specialist for a more in-depth evaluation and potential procedures.
  4. Surgical Evaluation: Assess the need for gallbladder removal if gallstones are the cause.
  5. Diabetes Management: Adjust diabetes medications, monitor blood sugar closely.
  6. Nutritional Support: Administer nutrition through a tube as necessary.
  7. Lifestyle Changes: Educate the patient on dietary and lifestyle modifications to prevent future issues. Immunological Medicine Discussion Paper

Alternative Therapies: I would explore complementary therapies like as relaxation techniques or guided imagery to manage pain, reduce anxiety, and promote overall well-being.

Follow-up Parameters:

  1. Schedule regular follow-up appointments to monitor the patient’s progress, adjust medications as needed, and assess the resolution of symptoms.
  2. Imaging studies, such as repeat abdominal ultrasound or CT scans, may be performed to monitor the gallbladder and pancreas and ensure recovery.
  • Continue monitoring HbA1c levels to optimize diabetes management.

Reflection notes:

I would make a few changes in my approach during a similar patient evaluation. Firstly, I would prioritize gathering a more comprehensive social and family history. These would include details about the patient’s lifestyle, habits, and recent life changes. These factors can play a significant role in understanding the patient’s condition. I would thoroughly review the patient’s medications to assess adherence and potential interactions that might affect the symptoms or treatment plan. When it comes to allergies, I would seek clarification on the specific allergens and reactions to ensure safe prescribing. Immunological Medicine Discussion Paper

In terms of diagnosis, while gallstone pancreatitis seemed likely based on the provided data, I would be more diligent in considering alternative diagnoses and conducting relevant tests to rule them out definitively. This could involve further investigations to exclude conditions like peptic ulcer disease or other gastrointestinal disorders. To improve the overall care, I would involve a multidisciplinary team early in the evaluation. This would include involving a gastroenterologist and nutritionist, to ensure a more holistic approach.

Patient education is vital, so I would ensure the patient receives clear and detailed information about her condition, treatment options, and the importance of lifestyle changes. Providing educational materials and involving the patient in shared decision-making can empower her to actively participate in her care. Lastly, I would establish a robust plan for post-discharge follow-up, including appointments and monitoring parameters, to maintain continuity of care and promptly identify any complications or recurrences. Immunological Medicine Discussion Paper

References

Jin, S., Nepal, N., & Gao, Y. (2022). The role of toll-like receptors in peptic ulcer disease. Immunological Medicine, 45(2), 69-78.

Moody, N., Adiamah, A., Yanni, F., & Gomez, D. (2019). Meta-analysis of randomized clinical trials of early versus delayed cholecystectomy for mild gallstone pancreatitis. Journal of British Surgery, 106(11), 1442-1451.

Testoni, S., Hassan, C., Mazzoleni, G., Antonelli, G., Fanti, L., Passaretti, S., … & Testoni, P. A. (2021). Long-term outcomes of transoral incisionless fundoplication for gastro-esophageal reflux disease: systematic-review and meta-analysis. Endoscopy International Open, 9(02), E239-E246. Immunological Medicine Discussion Paper