solved

Mrs Janice Atkinson is a 59 yr old female who presents to ED after experiencing a 3/52 (3 week) history of intermittent vomiting. P/C – Vomiting and abdominal pain last 3/52. Hx of P/C – 1 month of gradually increasing upper abdominal (epigastric) pain.
Pain described as the following:
Past med Hx
• Hypertension
• Knee pain from car accident 15 years ago
• gallstones
Surgical Hx
• Caesar with second child
• Cholecystectomy 6 years ago Medication
• ‘Brufen two tablets when I need it’
• ‘Tritace for my blood pressure’ 10 mg daily
• ‘Cartia 100 mg daily for my heart’
Family Hx
• older brother an parents have IHD Alcohol, Tobacco and Other drugs
• States that she has a few wines during the week, vague about details Work environment
• Sales in a curtain and blind shop
Hobbies and leisure
• Close network of friends
• Social tennis
Education
• Year 10
Systems review
CNS:
• Describes malaise over last few weeks ‘lacking energy’, dizziness on exercise in last few weeks
• States that she has been very stressed as the business has not been going well
Resp:
• SOB on exertion
CVS:
• Chest pain as above
• Dizziness on exercise
GIT:
Pain: o C- burning in nature o O – exacerbated with food o L – epigastric region o D – pain lasts for hours o S – 7/10 at its most severe o P – exacerbated with food intake, not relieved by usual mylanta o A – vomiting, malaise • Vomiting occurs during the episodes of intermittent pain • Vomitus described as dark and granular ‘like lumps of black pudding’ • Denies change in bowel habits
UGS: Nil Noted
MSK:
• Knees have been very sore lately I am looking at seeing the specialist again
• Upon further questioning – ‘I am taking complementary medicine for my knee pain – willowbark’
Integumentary: Nil Noted
Metabolic: Nil noted
Vital Signs: RR: 20; SpO2=98% on RA; HR: 80, reg; BP: 135/90 T: 37o Urinalysis:
• SG 1.030
• Otherwise NAD
Q1) In your teams brainstorm the likely pathophysiology that best fits the symptoms described by the patient.
Q2) focus your discussion on one major hypothesis.
Q3) Form hypotheses Develop your hypothesis. You will need to demonstrate the aetiology – what is the mechanism behind the disease – how does this fit his history?
You will need to consider the following questions:
• What is the evidence that supports my hypothesis?
• What is the evidence that refutes my hypothesis?
• Is there an alternative hypothesis that also fits the patient’s signs and symptoms?
You might already have a good idea of what fits but is this correct? Be careful about falling into confirmation bias (finding data that fits your preconceived ideas).
Let’s use the clinical reasoning cycle. Your first step is to consider the patient situation and collect cues and to cluster the data.
Q4) Identify three factors (i.e risk factors) that may have contributed to your hypothesis :
Q5) Which factor might have played the most significant role and why?
Q6)Why might the RN have asked about chest pain and shortness of breath on exercise?
Q6)now lead a discussion on the patient case and the likely diagnosis for Ms Atkinson.

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