Assessing a Patient with Stomach Pain

Assessing the Abdomen
The chief complaint of JR is that his “stomach hurts” and he is experiencing diarrhea, from which he has been unable to obtain any relief. His pain in his abdomen started 3 days earlier and he has taken no medication for it. The pain is midrange, though it was very high today when it began. He ate but experienced nausea afterwards. JR is 47, suffers from hypertension, diabetes and had an issue of gastrointestinal bleeding four years ago. He is on a number of medications to address his high blood pressure and diabetes. He has no known drug allergies, no history of colon cancer. His father and mother both had hypertension; his father has type 2 diabetes; his mother suffered from Gastroesophageal reflux disease and high fatty concentration in the blood (hyperlipidemia).
JR occasionally imbibed alcohol. He is overweight at 248 lbs with a 5’10” height. He has a regular heart rate but soft, hyperactive bowel sounds and pain in his left lower quadrant.
What History Should be Collected
A history of how long he has been taking the medications he is currently on should be obtained. Metformin is one drug he is taking for his diabetes, but one of the side effects of this drug can be diarrhea, so if JR has only recently begun taking this drug, his body could be having an adverse reaction to it (Dujic et al., 2016).
Whether diverticulitis runs in his family is a question that might also be asked, as this is the presumed diagnosis. However, some other information could be collected, such as the story behind his gastro-intestinal bleeding from 4 years ago. What caused the GI bleed is something that should be asked: was it caused by peptic ulcers, which are a common cause of GI bleed, or was it caused by enlarged veins in the esophagus that tore? If JR has a history of peptic ulcers, an ulcer could very easily be considered as a differential diagnosis in this case, since stomach ulcers can cause cramps and pain in the lower abdomen as well.
Other questions should be asked about stress levels, as stress can inflame an ulcer and make the symptoms feel much worse over time (Mustafa et al., 2015). If the patient is experiencing a high level of stress at work or in his home life, an ulcer could be bleeding more and causing him to experience sharp pains in his stomach. A question about whether he experienced stress or anxiety today or the day before should be asked to help prepare a differential diagnosis.
Likewise, since JR says he enjoys ethyl alcohol, there could be a link between his alcohol intake and his symptoms if indeed an ulcer is the cause of the pain. A question about when the last time he consumed alcohol was and how much was consumed going back over the past week at least to establish a possible connection between the alcohol and the symptoms.
What Physical Exams and Diagnostic Tests Should be Conducted
The patient should be tested for allergies to the medications he is taking for hypertension. Allergies to Lisinopril are rare, but the drug could cause abdominal pain (Rastogi et al., 2018). Amlodipine could also cause stomach pain. Metformin could be causing stomach pain along with Lisinopril and the other medications.
A CT scan of the abdomen should be conducted to test for diverticulitis. Blood tests, urine tests and stool tests could all be conducted as well to complete the diagnosis of diverticulitis.
A physical exam—endoscopy—should be conducted to examine the stomach and small intestine and look for ulcers. A biopsy may be ordered if ulcers are detected.
A skin test could also be conducted in order to examine the effect of the drugs JR is taking on his body to see if there is indeed an allergic reaction.
Differential Diagnosis w/ Possible Conditions
I would not accept the diagnosis of diverticulitis without testing for ulcers first. The subjective and objective information only marginally supports this diagnosis, and the symptoms are so common of other factors that there needs to be more information obtained before JR is treated for diverticulitis.
Three possible conditions that could explain his stomach pain are: 1) peptic ulcers (Mustafa et al., 2015), 2) an allergic reaction to metformin (Dujic et al., 2016), and 3) a reaction to Lisinopril (Rastogi et al., 2018).
Of the three, the ulcer is the most likely to be the case, as the patient already has a history of GI bleeding, which is commonly caused by ulcers. An examination of the patient’s medical history more closely would show whether indeed his GI bleeding was caused by ulcers. His alcohol drinking would also not be good for ulcers and his stress, related to his hypertension would also be an aggravating factor. Since stress runs in his family, his environment is likely stressful for him and this is the diagnosis I would first check for to eliminate before moving on to test the others—though I believe they should also be tested as there could be more than one factor involved in this case.
References
Dujic, T., Causevic, A., Bego, T., Malenica, M., Velija?Asimi, Z., Pearson, E. R., &
Semiz, S. (2016). Organic cation transporter 1 variants and gastrointestinal side effects of metformin in patients with Type 2 diabetes. Diabetic Medicine, 33(4), 511-514.
Mustafa, M., Menon, J., Muiandy, R. K., Fredie, R., Sein, M. M., & Fariz, A. (2015).
Risk factors, diagnosis, and Management of Peptic ulcer disease. J Dent Med Sci, 14, 40-6.
Rastogi, V., Singh, D., Mazza, J. J., Yang, D., Parajuli, D., & Yale, S. H. (2018).
Flushing Disorders Associated with Gastrointestinal Symptoms: Part 2, Systemic Miscellaneous Conditions. Clinical Medicine & Research, cmr-2017.