Table of Contents
The patient's presenting condition.
Past medical history.
Finding of the health assessment
Diagnosis and differential diagnosis.
Recommendations for a person-centred treatment plan.
The rationale for physical assessment
The rationale for diagnosis and differential diagnosis
The rationale for the clinical investigation.
There are various things that are taken into consideration when the treatment of a patient is to be done. In the recent times when the patient flow is increasing every day, it is often seen that the time that is allocated to each patient might be reduced which can affect the diagnosis as well as the treatment plan (Kc&Terwiesch, 2017). When patient present to the hospital it is seen that the patients might not have just one condition but they might be suffering from more than that. Proper diagnosis is an important aspect of patient care as it determines the emergency, palliative and other cares that are required for the patient (Ko et al., 2020). One of the important aspects that are vital for diagnosis is to take a proper history of the patient in terms of medication and others. After the history, it is important that the assessment of the patient is done properly followed by any diagnostic test and all of these together might let the healthcare professional to arrive at a diagnosis (Waller & Fox, 2020). When a diagnosis is made, it is required that it is specific and differentiated from other similar condition which is called differential diagnosis and is an important aspect of the patient evaluation (Goodman et al., 2017). The aim of the present report is to show the presenting condition of the patient followed by the past medical history and the health assessment findings. Next, based on these, diagnoses of the patient will be arrived at and differential diagnosis will be conducted and person-centred treatment plan will be given.
The present case is of Mrs. Brown who is a seventy-year-old lady and is presented to the emergency department in an ambulance along with her son. The main complaint of the patient was that she was feeling dizzy when she was at home and was nauseated. When she went to the washroom and vomited she realized that it was just blood and she tried calling her son for help. She tried to reach her son but as she got up, she felt dizzier and lost consciousness and collapsed.To elicit other details for supporting the presenting illness, few questions were asked related to the incident. It was seen that the blood she emitted was fresh and was about a cupful. She never had a previous incident where she emitted blood and she confirmed that there was no presence of blood in her stool.
The encounter between the patient and the healthcare provider is such that it can have five important components and that includes the collection of vital signs, taking a detailed history of the patient, physical examination, laboratory test and ancillary studies (Scott et al., 2019). Among these, clinician-intensive components are those which are history taking of the patient and physical examination of the patient (Curtis et al., 2019). Past medical history can give helpful insight into the condition a patient might be suffering from and help the healthcare provider to arrive at a diagnosis and even helpful in the differential diagnosis (Wright et al., 2019). From the present case, it is seen that the patient reports that she does not have any medical condition that she is aware of except for chronic back pain for which is taking a painkiller regularly. She does not have any history of smoking or drinking alcohol and is taking no medication regularly except the painkillers. The patient is aware of the painkiller that she is taking and reports it as ibuprofen and she is taking it for the duration of the last three years and she has never missed a dose. The patient has been taking a painkiller for a longer duration which might be a useful point of information to arrive at a diagnosis.
Collateral history is also important and it can be elicited by the first responder on the scene. In the present case, it was the son of the patient who reached his mother as she collapsed and called for the ambulance. This can also be asked to the paramedics who arrived on the scene to help the patient arrive at the hospital. It was reported that the patient was very pale when the help arrived and she had some blood in and around her mouth. Though she had lost her consciousness, she was not confused rather she was well alert only she was upset and worried about her condition.The character of the blood during the initial emesis was tried to be elicited but it was not very conclusive. It was reported that there was blood on the floor and toilet which could have been about one or two cups and the blood around her mouth was bright red but due to time that was elapsed it was difficult to ascertain whether the blood was bright or dark red. This characteristic of blood might be helpful in arriving at the conclusion of what the origin of the blood might be and what might have been the cause for the same. While taking the history, it is also important to take other components which were not completed in the present case. For example, last consumed meal, any family history of similar condition, any pain other than the one reported and lastly any allergy to any known drug or any food items.
For the initial health assessment of the patient ABCDE health assessment is conducted. Along with this, the other assessments conducted are Glasgow Coma scale as the patient was dizzy, pain assessment scale and PR rectal examination.
Before anything else is done, it has to be made sure that everyone who is involved including the patient is safe (Smith & Bowden, 2017). First, it has to be made sure that that airway is patent. Since the patient was awake, conscious and responsive in the clinical setting even after her collapse. It is seen that her airway is patent and the brief loss of consciousness has not affected the perfusion of the brain (Olgers et al., 2017). Next component of the assessment is breathing and the characteristics of the breathing are determined by look to listen and feel. It is seen that the expansion of the chest is normal and is not strained. The auscultation of the chest is clear and there is no crackling which is characteristic of the use of accessory muscle of respiration. The respiratory rate of the patient is 10 cycles of breath per minute. This makes the patient bradypnea as for an adult patient, the normal rate of respiration ranges between 12-20 breaths per minute (Flenady et al., 2017). Due to the reduced rate of respiration, it is seen that the oxygen saturation of the blood is reduced and it is at 92%. The patient is resting and the respiratory rate which is less than 12 cycles and the one more than 25 cycles per minute is troublesome and it needs to be rectified.
Next component of the assessment is the circulation of the blood. It was noted that the patient is pale when she arrived. For the assessment of the circulation of the patient, the colour, temperature, capillary refill time, blood pressure and pulse are measured which are the components of effective circulation (RabelloFilho&Corrêa, 2018). From the assessment of the patient Mrs. Brown, it is seen that she is pale, her skin feels cool and clammy. The capillary refill time is increased to 3 seconds. The normal capillary refill time in a healthy circulation should be less than 2 seconds (Smith & Bowden, 2017). The patient is tachycardiac with the heart rate at 100 beats per minute and hypotensive with her blood pressure as 100/70 mmHg. The normal heart rate is ranged between 60-90 beats per minute when the patient is resting while the normal blood pressure for a patient without any underlying pathology is 120/80 mmHg (Salvetti et al.,2018). For monitoring the circulation, ECG is used which reflected that the patient had sinus tachycardia.
Next is the disability of the patient and it is seen that the patient has BM of 6 and the pupils of the patient are equal and reactive to light and the patient is alert and conscious with respect to time, place, person and situation. Lastly, exposure is measured but there was no significant finding and there was no suggestion of chronic liver condition and the abdomen was mildly tender but there was no guarding or rebound.
As the patient was dizzy and nauseated which led to the further series of event which led to her presentation to the hospital. For the physical assessment of the same, Glasgow Coma scale was used. There are three components for the scale which are relevant to the eye movement, verbal response and motor response of a patient (Chandrasekhar et al., 2017). When the case of Mrs. Brown was considered, her Glasgow coma scale score was 15 which show that she is completely alert and responsive. For a patient to be completely alert and responsive, the required score of Glasgow coma score should be more than 13.
Next to physical assessment that is required and is conducted for the patient is for the pain as the patient reported that she had back pain and she had been taking medication for the same and there is mild tenderness in her abdomen. A ten-point pain scale is used for the assessment of pain in her back and abdomen. Mrs. Brown reports that the pain in her back is a 5 and that in her abdomen is 3. She says it is more of a discomfort rather than a pain in her abdomen.
Lastly, as the patient presented with hematemesis and to assure that there is no rectal bleed PR rectal examination was conducted. From the rectal examination, it can be judged whether there is any residual blood from the lower gastrointestinal bleed or if there is any melaena or haematochezia which can be suggestive of ongoing bleeding (Phillips et al., 2016). From the examination, it was seen that Mrs. Brown did not have any bleeding.
After the complete physical assessment, it is seen that there is ongoing bleeding in the gastrointestinal tract which led to the feeling of nausea and actually vomiting. The patient was pale and her skin was cool and clammy which can be due to the fact she had lost blood which is supported by the lowering of her blood pressure (Hancock et al., 2019). Since she had given the history of taking pain medication for her back pain which is ibuprofen and it is a non-steroidal anti-inflammatory drug. Use of the non-steroidal anti-inflammatory drug for a prolonged period of time can cause ulceration in the gastrointestinal tract leading to bleed (Tringali&Gheda, 2019). Depending on all these, the diagnosis is peptic or duodenal ulcer. There are other conditions as well which can give a similar presentation and they are differential diagnoses (Kalhor& Moran, 2019). In the present case, it can be due to the presence of ulcerations in other parts, laceration in the tract due to wear and tear of the mucosa, andcancerous condition.
Firstly, based on the physical assessment of the patient, it is seen that her breathing is altered and her oxygen saturation is reduced. Her blood pressure is reduced and her heart rate is increased to manage the perfusion of the body and this is because of loss of blood that is faced by the patient. The loss of fluid needs to be replaced and also the depleted level of oxygen is to be rectified and the recommendations are fluid replacement therapy by crystalloid and administration of oxygen (Svensen&Rodhe, 2019).These are the measures that are taken immediately after the initial assessment. For the further management of the bleeding first, it has to be made sure if the bleeding is due to the medication and if that is the reason the medication has to be reviewed. Firstly, it might require weaning off the current medication so that the symptoms improve and the current level of back pain can be assessed. After this, if required considering the current condition different pain medication can be prescribed. It needs to be decided if the patients can be managed as out-patient or if the management is required in the hospital and for the same Blatchford Score can be used.
Lower score patients can be treated on an out-patient basis as they are associated with the least probability of mortality (Abougergi et al., 2016). From the Blatchford score, it was seen that Mrs. Brown's score was seven and it is recommended that she is required to be managed in a clinical setting. It is recommended that Mrs. Brown since she is stable she is to be given endoscopy for further evaluation within the first 24 hours of her arrival. Based on the finding of the results of the endoscopy where there are suggestive findings of upper gastrointestinal bleeding. Based on this, it can be recommended that to arrest the bleeding immediately by the use of short-acting coagulant. It is also recommended that the risk for re-bleeding is assessed as it is required for the measurement of prognosis (Robertson et al., 2016). Rockall score is used for the same and a score of less than three is associated with good prognosis while more than eight is related to a higher risk of death (Robertson et al., 2016). The Rockall score for Mrs. Brown is 5 which is not high.
ABCDE approach is used for assessing the current condition of the patient along with the clinical deterioration of the patient which can help in getting the required emergency care for the patient (Smith & Bowden, 2017). After an initial assessment, it is required that it has to be monitored and reassessed regularly and the life-threatening conditions are treated immediately so that the negative outcome or consequence is avoided (Smith & Bowden, 2017). The important part of the assessment is to recognize when assistance is required and seek help by the most effective way of communication possible. One of the most common types of communication that are used in the clinical setting is SBAR for communication among the healthcare professional. Any intervention that is provided during this time is to be documented in the chart of the patient and the effectiveness of the same is to be continuously monitored. The aim of the initial assessment is to make sure that the condition of the patient does not deteriorate further and arrive at a diagnosis and conduct further tests (Smith & Bowden, 2017).
Ulceration in the gastrointestinal tract is related to the medication, its dose type and method of administration (Tringali&Gheda, 2019). The ulceration in the gastrointestinal tract can rupture and lead to bleeding during the normal physiological process like eating or regurgitation and can cause bleeding or it bleeds spontaneously. Taking medications like the non-steroidal anti-inflammatory drug is one of the most commonly associated with ulceration and subsequent gastrointestinal bleeding (McDonald, 2019). The painkiller like ibuprofen is a non-selective COX inhibitor which has a dose-dependent relation to the effect it has on the gastrointestinal bleeding (McDonald, 2019). If a person is taking the non-steroidal anti-inflammatory drug orally over a long period of time like in the present case where Mrs. Brown is taking the drug for over a period of three years the reason for gastrointestinal bleeding can be more associated with this.
There are other conditions in which there can be bleeding in the gastrointestinal tract. One of them can be related to the age of the patient as the age of the person increase the integrity of the skin and mucosa decreases which increases the chances of wear and tear and cause bleeding(Ziebell et al., 2016). There can be underlying undiagnosed cancerous lesion which on rupturing can lead to bleeding from the gastrointestinal tract. There can be the presence of varices in the gut which can rupture spontaneously and can result in the bleeding from the gastrointestinal tract (Ziebell et al., 2016). The patient should be evaluated for the H. pylori infection as one of the most common complications of the infection is the formation of ulcer and bleeding (Ziebell et al., 2016). These conditions which might cause the bleeding are considered as differential diagnoses for the present condition.
For the confirmation of the present condition, it is required that clinical investigations are undertaken. A complete blood culture is required to get an idea of platelet content, red blood cells and white blood cells (Bateson &Bouchier, 2017). The blood investigation should also be conducted for the coagulant factors as an imbalance in the coagulant factor can lead to spontaneous bleeding which can develop at later ages. When there is upper gastrointestinal bleeding it is always recommended to get an endoscopy of the gut as it will give a visual of the structure, its integrity and presence of anything (Bateson &Bouchier, 2017). These clinical investigations are required for considering the initial diagnosis and differential diagnosis and get a definitive diagnosis.
When a patient is presented to the hospital as a self-admission or in the emergency it is required that each patient is given adequate time to get the presenting condition and history of the patient as it can help in determining the direction of treatment. These components along with initial health assessment help the healthcare professional to decide what investigations are needed and arrive at the diagnosis. In the present case of Mrs. Brown, it is seen that she had one episode of hematemesis and the blood was red and frank. On eliciting history it was seen that she is taking painkiller (ibuprofen) for her back pain for over a period of three years. Physical assessments conducted were ABCDE, pain assessment, Glasgow coma scale, and PR rectal examination. She had bradypnea, she was tachycardiac and hypotensive and her oxygen saturation levelwas reduced. She had mild to moderate pain and she is conscious and alert and the rectal examination was insignificant. Mrs. Brown is diagnosed with peptic or duodenal ulcer and differential diagnoses were cancerous lesion, varices, wear and tear due to age and H. pylori infection.It is recommended that she is treated in the hospital to reduce mortality and medication review is to be done. For everything, a methodological approach is to be followed to reduce the mortality and get a positive health outcome.
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