· · Bates Assessment Videos – OSCE 2 – Abdominal Pain(tran…
Assessment:
In this case study, we are presented with a 64-year-old stock broker who recently separated from his wife and is complaining of increased epigastric pain over the past two days. The patient also has a history of excess drinking. On examination, his blood pressure is slightly elevated at 140 over 88, his heart rate is elevated at 110, and his temperature is slightly elevated, suggesting alcohol withdrawal. The heart and lung examinations are normal, but there is epigastric tenderness and liver tenderness on abdominal examination. There is no CVA tenderness, and the patient does not exhibit any nystagmus, tremor, or asterixis commonly seen in alcohol withdrawal.
Possible Causes of Abdominal Pain:
Given the patient’s history of excess drinking and presenting symptoms of epigastric tenderness and liver tenderness, several possible causes of abdominal pain should be considered. The most likely cause in this case is alcoholic gastritis or alcoholic hepatitis, which occur due to prolonged alcohol abuse. These conditions can lead to inflammation and injury to the stomach and liver, resulting in abdominal pain.
Other potential causes that should be considered include peptic ulcer disease, pancreatitis, and gallbladder disease. Peptic ulcer disease is characterized by the presence of sores in the lining of the stomach or small intestine, often caused by infection with Helicobacter pylori bacteria. Pancreatitis, on the other hand, involves inflammation of the pancreas and can cause severe abdominal pain. Gallbladder disease, such as cholecystitis or gallstones, can also present with abdominal pain, particularly in the right upper quadrant.
Further Questions Regarding Drinking Pattern:
Considering the patient’s excessive drinking, it is essential to inquire about the frequency, quantity, and duration of alcohol consumption. This information will help gauge the severity of alcohol abuse and determine if there are any patterns of binge drinking. Additionally, it would be valuable to inquire about any previous episodes of alcohol withdrawal, as this could provide insight into the patient’s susceptibility to alcohol-related complications.
Furthermore, it would be important to assess the patient’s level of motivation and readiness to change their drinking behavior. This could be done by exploring the patient’s perception of the impact of alcohol on their physical and mental health, as well as their social and occupational functioning. Understanding the patient’s perspective will aid in developing a tailored treatment plan.
Important Areas of Physical Examination:
In this case, the key areas of the physical examination to focus on would be the abdominal examination, as it has already revealed significant findings of epigastric tenderness and liver tenderness. Careful palpation and percussion of the abdomen can help determine the specific location and nature of the pain. Additionally, assessing for any signs of peritoneal irritation, such as rebound tenderness or guarding, would be crucial to rule out emergent surgical causes of abdominal pain.
Furthermore, a thorough examination of the cardiovascular system is necessary, given the patient’s elevated blood pressure and heart rate. This would involve auscultating for any abnormal heart sounds, assessing for the presence of murmurs, and evaluating peripheral pulses. It is important to assess for any signs of hypertensive urgency or emergency, such as evidence of end-organ damage.
Diagnostic Considerations and Rationale:
In order of importance, the following diagnostic considerations should be taken into account for this patient:
1. Alcoholic gastritis/alcoholic hepatitis: Given the patient’s history of excessive drinking and the findings of epigastric tenderness and liver tenderness, alcoholic gastritis and hepatitis are the most likely causes of abdominal pain. The patient’s symptoms and examination findings support this diagnosis.
2. Peptic ulcer disease: Peptic ulcer disease should be considered as a potential cause due to the patient’s abdominal pain and the possibility of chronic alcohol abuse. Further investigation, such as an endoscopy, may be needed to confirm this diagnosis.
3. Pancreatitis: Although the patient does not exhibit classic signs of pancreatitis, such as elevated amylase or lipase levels, it is still important to consider this condition given the patient’s history of excessive drinking. Repeat testing may be necessary if the clinical suspicion remains high.
4. Gallbladder disease: As the patient presents with right upper quadrant abdominal pain, gallbladder disease, such as cholecystitis or gallstones, should be considered. Imaging studies, such as an ultrasound, may be necessary to evaluate the biliary system.
In summary, this case study highlights the importance of considering the potential causes of abdominal pain in a patient with a history of excessive alcohol consumption. Alcoholic gastritis/alcoholic hepatitis, peptic ulcer disease, pancreatitis, and gallbladder disease are among the significant diagnostic considerations. Further exploration of the patient’s drinking pattern and a thorough physical examination, particularly focusing on the abdomen, will aid in the diagnostic process.