- Patient Initials: _______
- Age: 88
- Gender: F
Chief Complaint (CC): “After visiting a restaurant, I had a bellyache. Later, I started vomiting and having diarrhea.”
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History of Present Illness (HPI): An 88-year-old Caucasian female has had severe abdominal pain for two days after eating at an Italian restaurant. The pain started one hour after she left the restaurant and worsened in the following hours. The patient also reports that she frequently vomits and has diarrhea.
- Lopressor 50 mg twice a day
- Aspirin 81 mg daily
- VESIcare 10 mg daily
- Prilosec 20 mg daily
- Vitamin D 3, 5000units daily
- Multivitamin with mineral 1 tab daily
- Os-Cal 500mg twice a day
- Remeron 7.5 mg daily
All medications are safe, the daily dose of aspirin is low enough (Davidoff et al., 2015).
Past Medical History (PMH): Hypertension, incontinence, Gastroesophageal Reflux Disease (GERD).
Past Surgical History (PSH): No history of major surgeries.
Sexual/Reproductive History: Not applicable to the CC.
Personal/Social History: The patient does not smoke, consume alcohol, or use illicit drugs. She maintains a diet due to having GERD but eats out with family members sometimes. The patient needs assistance with ADLs but maintains a certain level of independence.
Immunization History: All immunizations are in check; the last Tdp shot was five years ago.
Significant Family History: Mother died of heart attack, father died in a car accident. History of hypertension, but no food allergies or intolerances.
Lifestyle: The patient has an active social life, her family (children and grandchildren) visit her often. She does not work and lives at home with some of the family members. She has all the necessary accommodations and can afford to maintain a healthy diet.
Review of Systems
General: The patient states that she feels fatigued and dehydrated.
HEENT: No changes in vision, no sore throat, no headaches, no ear or nose problems.
Cardiovascular/Peripheral Vascular: Denies palpitations.
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Lungs: No difficulty breathing.
Gastrointestinal: The patient reports persistent abdominal pain and diarrhea. The stool is non-bloody and watery.
Genitourinary: Urinary incontinence managed with medication; the patient denies changes in frequency.
Musculoskeletal: She takes medication to relieve joint pain and back pain.
Neurological: No complaints of drowsiness or lack of coordination.
Skin: She does not report any changes, rashes, sores.
Allergic/Immunologic: She does not know about any food, seasonal, medication allergies.
Vital signs: BP 139/86, Pulse 91 bpm, Temp 98.1°F, H 5’5”, W 141 lbs, BMI 23.5.
General: The patient appears dehydrated, but well-oriented, alert, and responsive.
HEENT: Head does not have any traumas, palpable masses, or depressions. Eyes are clear, no hemorrhages visual acuity impaired. Ears are clear, hearing intact. The nose is clear, mucosa pink, no inflammation or lesions. Teeth and gums are not inflamed, no caries visible.
Chest/Lungs: Lungs are clear to auscultation.
Heart/Peripheral Vascular: Regular heart rare, no changes in rhythm, no murmurs or gallops.
Abdomen: Abdomen is non-tender to palpation; bowel sounds hyperactive in all quadrants; no masses.
Musculoskeletal: No changes in motion range.
Skin: Skin is pink, no rashes or sores present. It is soft, warm, dry to touch.
Primary diagnosis: Gastroenteritis, a viral or bacterial infection of the stomach that causes watery non-bloody diarrhea and vomiting and can be contracted through undercooked or dirty food. The patient felt pain after eating at a restaurant – her age is a risk factor for being responsive to viruses/bacteria in food (“Food safety,” 2011). Such tests as stool culture and a blood test should confirm this diagnosis (Humphries & Linscott, 2015).
- Clostridium difficile is an infection of the bacterium C. diff. Symptoms include vomiting, abdominal pain, watery diarrhea, and fever. While the symptoms align with the patients’ CC, she did not take any antibiotics or go to the hospital recently. The diagnosis can be eliminated based on stool culture analyses and the patient’s recent use of antibiotics (Putsathit, Morgan, Bradford, Engelhardt, & Riley, 2015).
- Ulcerative colitis, an inflammatory bowel disease (IBD), is characterized by diarrhea, fever, and abdominal pain. These symptoms are present in the patient, but she does not experience rectal pain and bleeding, inability to defecate, or bloody diarrhea. This diagnosis can be eliminated with a stool sample and a blood test (Cleynen et al., 2016).
- Chron’s disease is an IBD with symptoms similar to Ulcerative colitis. The patient has diarrhea and abdomen pain, but in Chron’s disease mouth sores, bloody stool, and weight loss are also often present (Cleynen et al., 2016). This differential diagnosis can be eliminated with a fecal occult blood test and an infection blood test.
The patient should drink water to replace the fluids, and monitor her diet to exclude fried, salty, and fatty foods (“Food safety,” 2011). She should also make sure that her food is well-prepared and avoid going out to restaurants or ordering takeout. She already has multivitamins in her treatment plan, so additional supplements are unnecessary. A stool culture test will reveal whether the cause is a virus or bacteria – then, options for medical treatment can be revised (Holroyd-Leduc & Reddy, 2012).
The patient has GERD, and her diet is already restricted to lower the disorder’s symptoms (Sethi & Richter, 2017). She should exclude some risk foods (such as spices and garlic) to avoid exacerbations. Raw or undercooked meat, poultry, eggs, and milk-based products may carry bacteria or viruses dangerous for older people (“Food safety,” 2011). The patient should ensure that her meals are well-prepared. The patient should abstain from visiting restaurants with these options on the menu, because some products may leave traces in other meals.
The patient should adhere to the diet described above and monitor her responses to foods. Her children and grandchildren should serve as a support network for ensuring that she eats healthily. Medications that she takes currently help her with GERD and hypertension, but her diet is also crucial for all of these conditions.
I learned that geriatric patients might be more exposed to issues that younger people can avoid. Older people’s response to foods is sensitive, and their risk of developing infections is high (“Food safety,” 2011). I would be more attentive to the patient’s description of her medical history to ask questions and obtain more potentially useful information. I would also find a way to contact the patient’s family to ensure that she receives the necessary care. I agree with the preceptor based on the presented evidence.
Cleynen, I., Boucher, G., Jostins, L., Schumm, L. P., Zeissig, S., Ahmad, T.,… Brant, S. R. (2016). Inherited determinants of Crohn’s disease and ulcerative colitis phenotypes: A genetic association study. The Lancet, 387(10014), 156-167.
Davidoff, A. J., Miller, G. E., Sarpong, E. M., Yang, E., Brandt, N., & Fick, D. M. (2015). Prevalence of potentially inappropriate medication use in older adults using the 2012 Beers criteria. Journal of the American Geriatrics Society, 63(3), 486-500.
Food safety for older adults. (2011). Web.
Holroyd-Leduc, J., & Reddy, M. (Eds.). (2012). Evidence-based geriatric medicine: A practical clinical guide. Hoboken, NJ: Blackwell Publishing.
Humphries, R. M., & Linscott, A. J. (2015). Laboratory diagnosis of bacterial gastroenteritis. Clinical microbiology reviews, 28(1), 3-31.
Putsathit, P., Morgan, J., Bradford, D., Engelhardt, N., & Riley, T. V. (2015). Evaluation of the BD Max Cdiff assay for the detection of toxigenic Clostridium difficile in human stool specimens. Pathology, 47(2), 165-168.
Resnick, B. (Ed.). (2016). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (5th ed.). New York, NY: American Geriatrics Society.
Sethi, S., & Richter, J. E. (2017). Diet and gastroesophageal reflux disease: Role in pathogenesis and management. Current Opinion in Gastroenterology, 33(2), 107-111.