PC 617 Module 4 study guide
Constipation: Margaret is a 30 year old, G3 P3 who is complaining of constipation.
1.
Describe the history (subjective data) you need in order to determine the etiology of her
complaint. Begin with finding out what “constipation” means to Margaret.
 How do you feel?
 “describe your bowel movements to me”- include frequency and consistency
 Medications you are taking/ herbals/ otc
 Diet recall- is this diet typical
 Fluid recall- is this typical
 Physical activity in a week
 History of this in the past
 How long has this been going on/ when did it start
 Any pain/ or blood
 Anything make it better
 Health history& recent changes in health
2. Margaret’s physical findings are normal. Will you do any laboratory studies?
 Yes
 Urinalysis to look for dehydration and chronic cystitis
 Stool= occult blood
 TSH
 CBC with diff
 Chem profile (calcium, potassium, serum glucose
3. You have excluded vulvulus and obstruction and you have determined that there are no life
threatening conditions (What an extraordinary advance practice nurse you are!) You have
decided based on history and physical that it is irritable bowel syndrome.
4. How will you manage Margaret’s complaint now? I will utilize combination of dietary
modifications, medications, supportive/ behavioral therapy, and reassurance. Must help her
find a way to cope and to acknowledge that it is a chronic disorder. I will assess for depression,
anxiety, and other psychological disorders.
Dietary changes- use a diary to record what you eat and when you have issues
 Stop eating any food that you have noticed an intolerance to
 Food and such that may exasperate the problem
 Drinks with artificial sweeteners
 Soft drinks, caffeine, and alcohol
 Spicy foods and fatty foods
 Gas forming foods may cause issue (really need I list these )
 R/O lactose intolerance

Increase fiber at times of constipation
Medications to try
 Antispasmodics- dicyclomine (bentyl) 30 minutes-hour before meals
 Antidiarrheal drugs- lopermaide (Imodium)- (not now while she is
constipated but figure we should know all drugs utilized in IBS)
 Anticonstipation agents- fiber, increase fluids, exercise, osmotic stool
softeners only, no stimulant laxatives.
 Psychotropic agents if needed SSRI’s not tricyclics
Alternative therapies such as reducing stress, hypnosis, and
relaxation may help
How will this affect the education you provide Margaret?
See above- pretty much covered it 
5. Describe the follow up care for Margaret.
 Evaluate if diet and behavioral changes are working
 Determine if medications are needed
 Assess for knowledge related to managing diarrhea and constipation
exacerbation
 Evaluate if quality of life has improved
 Evaluate for need of referral for therapy of some kind
6. List the outcome criteria used to evaluate Margaret.
 Regular soft/ formed stools that pass without difficulty
 Decrease in diarrhea and constipation episodes
 Able to function
 Making good food choices
Dyspepsia and heartburn
List the differential diagnoses for dyspepsia and heart burn


GERD
Some other stuff  I will keep working on this one
Melena – dark tarry stools associated with blood
What are the most common causes for dark tarry stools that are negative for blood?

Still working on this one as well, will get something to you tomorrow
Gastroesophageal Reflux Disease
Remember Robert B? He is a 45 year old sedentary educator whose wife has urged him to come in for
his 3-4 month complaint of burning chest pain. Pain is substernal, burning, aggravated by food
ingestion, and bending over after meals. Antacids do not relieve his discomfort. His father had
coronary artery disease at the age of 55 treated surgically. Mr. B is 5’8 and weighs 250. Your
examination is normal except for a blood pressure of 140/92. Your diagnosis for this man included
GERD.
1. For his initial treatment and education what is the best plan in relation to the GERD?
a. Avoid: fatty foods, chocolate, peppermint, excessive alcohol, foods that you have
noticed cause you a problem.
b. Lower the head of the bed
c. Decrease fat intake
d. Stop smoking
e. Do not lay down for three hours after you eat
f. Eat smaller meals
2. What is the best follow up plan for Robert related to his GERD?
 See him back in the office in two weeks to evaluate improvement following lifestyle
changes.
3. Under what conditions would you refer Robert to a gastroenterologist?
 If his symptoms do not improve/ If after stopping medications symptoms reoccur- he
needs a scope
 If he was 50 and had signs of dysphagia, odynophagia, unexplained IDA, lb loss, fecal
occult bleeding, anorexia, or obstructive symptoms (nausea, vomiting, and early satiety)
4. List the outcome criteria for evaluation of Robert’s GI care.
 Prompt and sustained symptom control
 Healing of the injured esophageal mucosa
 Prevention of complications (stricture formation, Barrett’s esophagus,
adenocarcinoma)
Peptic ulcer disorder
26 year old Allen S presents with a two- week history of epigastric pain, that is interfering with his
ability to study for his CPA exam. The pain is relieved by food, but returns about two hours after the
meals and is worse after spicy Mexican food. He smokes a pack a day, drinks a couple of six packs a
week, and drinks six cups of coffee a day. Milk gives him diarrhea so he avoids it. He was treated last
year for “heartburn” with cimetidine, but did not have any particular work up for this at the time.
1. What is dyspepsia?
 Really bad upset tummy with pain and a feeling of being “overfull”
2. What additional history would be helpful a d why?
 Is he taking NSAIDS or a COX-2 inhibitor- they are second and third most common
cause of PUD
 H. pylori?- number one causative agent
 Anybody in his family have a history of this?
 Other than food has anything helped make the pain better?- antacids will help the
pain for a bit with PUD
 Blood type? O= high rate of PUD
3. Are any diagnostic test indicated? Give your rationale.

Yes- test for H. Pylori with a C-urea= noninvasive breath test (must assess for PPI
use= will be inaccurate if used in the last fourteen days)
 CBC to rule out anemia
4. What are the most likely diagnosis? Explain why.
 I read this question as what are differential diagnosis
 Cholecystitis= epigastric pain
 Peptic ulcer disease- he has epigastric pain, stress, pain relieved by pain,
worse after spicy foods, smokes, moderate/ large alcohol consumption,
and caffeine intake, and history of being treated for heartburn
 Other differential diagnosis that do not fit this patient= vague abdomen
pain, with diarrhea or constipation could be: diverticulosis IBS, or
nonulcer dyspepsia.
5. Would you consider antibiotic treatment? Why or why not?
 Confusing question, first line therapy is 2 weeks of antiulcer therapy,
and then if that does not work refer/ other options. However there are
treatment regains for H. Pylori listed and it involves antibiotics- and
there is a non-invasive h-pylori test so I guess I would say no unless he is
found to have active h-pylori and then yes to treat the h-pylori (mainly
PCN is used, if they are allergic than use metronidazole.
 Also- if objective findings include: anemia, GI bleeding, rigid abdomen,
lb loss, or new onset dyspepsia and patient is 50+ refer immediately
6. How do long term implications of gastric and duodenal ulcers differ?
 Gastric and duodenal ulcers can perforate= death/ really not fun
hospital stay
7. Outline the educational needs of this patient.
 “Look dumb ass unless you want to die before you are 30 stop
smoking”
 You need to stop or at least drastically cut back you alcohol and
caffeine intake
 Look for ways to reduce your stress
 If spicy Mexican makes it worse stop taking it
 Listen to me and do everything I say because I totally rock and you see
pretty stupid
8. This patient comes back in 3 months after therapy with similar complaints. What is your plan
now>
 After getting on to him for not coming back in two weeks like he was
supposed to I am going to evaluate to see if he has made the changes I
encouraged him, look for any new history/physical, and determine if he
took medications as instructed, also find out if he ever got any relief. In
the end though I am going to refer him to a gastroenterologist for
endoscopy.
Acute Pancreatitis
Travis is a 50 year old male who comes to clinic complaining of severe epigastric pain that began early
this morning and is getting progressively worse. Travis is acutely ill and has been vomiting. He sits
leaning forward and cannot lie down for very long due to the pain. He denies use of tobacco or
alcohol. On questioning he admits to mild episodes of RUQ pain over the last four months, but
nothing as severe as this. On examination he is very tender in the epigastric area.
1. What is the “gold standard” for diagnosing acute pancreatitis?
 Serum amylase- it rises 6-12 hours after onset and return to normal in
3-5 days- oops most common not best. Hmm not sure what she
wants as gold standard, serum lipase is more diagnostic- several days
after the fact, will keep looking for this answer.
2. Because of Travis presentation and the elevation of both the pancreatic enzymes and the liver
function test, what would be the next test ordered?
 A C-reactive protein, greater than 150mg/dl at 48 hours distinguished
mild from severe
3. To whom would you refer Travis to care?
 A physician, specifically a surgeon
Older female with bowel complaint (Diverticular Disease)
Betty B is a 70 year old who is complaining of irregular defecation, intermittent abdominal pain,
bloating and flatulence. She describes her stools as “hard pellets”. The cramping is mostly in her
lower left abdomen. You suspect diverticulitis.
1. What might you find on physical exam?
 Mild abdominal distention
 hyperactive bowel sounds= obstruction, normal= no obstruction
 May or may not palpate a mass
 Guarding/ percussion tenderness in RLQ= peritoneal inflammation
(can be mistaken for appy pain)
 Rectal exam (fun times)= may have pelvic tenderness and (rare)
palpate a mass anteriorly
 Stool= most likely no blood
 Tend to be afebrile
2. What diagnostic examination will you order for Betty?

A CT scan of the abdomen and pelvis as it give an accurate estimate of the
degree of inflammation. (some clinicians say only to get it with complications)
 Supine and upright plain x-ray will show: ileus (small or large bowel
obstruction), free air= perforation.
3. Management of Betty’s care will include
 Clear liquid diet for 2-3 days
 Temporary cessation of physical activity
 Oral antibiotics ( Bactrim, augmentin, cipro,)
 Maybe probiotics
4. Describe the patient education indicated for Betty.
 Low fiber diet until asymptomatic and then high fiber diet for life
 No: whole grain breads, cereals, raw fruits and veggies, nuts, seeds, or
legumes.
 No enemas or laxatives.
 Need to develop a regular bowel routine
 Call promptly if you have pain like this again, especially if you have fever or
chills
5. Under what conditions would you refer Betty to a gasteroenterologist?
a. If I am uncertain about the diagnosis
b. Attacks are recurrent
c. Hospitalization is required for a second attack
6. What outcome criteria will you use to evaluate Betty’s care?
 Improvement in two- three days
 No reoccurrences
 Demonstration of understanding of education Development of a regular
bowel routine 1-2 times a day to once every 2-3 days