Case Study Week 8 A 63 years old obese female presents with 4 to 5 months history of mid-epigastric pain that is worse after eating. She is unable to identify any specific foods that may be triggering the symptoms. She denies excessive gas, denies regurgitation of food or a water brash. She has normal daily bowel movements but states that sometimes her stools are very dark. She denies nausea and vomiting. She has no previous history of these symptoms and they are becoming disruptive in her daily life. She has been taking TUMs, “like they are candy.” Past Medical History: surgical menopause at age 35 secondary to endometriosis, hypertension (HTN), diabetes mellitus Type II, morbid obesity, dyslipidemia. Surgical History: T&A as child, total abdominal hysterectomy with bilateral salpingo-oophorectomy, appendectomy, cholecystectomy. Her medication regimen includesPremarin 0.625mg q day, lisinopril 10mg q day, metformin 500mg bid, and atorvastatin 40mg q HS. VS: BP 145/94, P 90, R 18, T 98.2. The patient’s height is 5’4” and her weight is 225lbs., consequently her BMI is 38.6.  Physical examination is within normal limits.

Introduction

This case study presents a 63-year-old obese female who is experiencing mid-epigastric pain after eating for the past 4 to 5 months. The pain is not related to any specific food triggers and is becoming disruptive in her daily life. She also mentions that her stools are sometimes very dark. The patient has a significant medical history, including surgical menopause, hypertension, diabetes mellitus Type II, morbid obesity, and dyslipidemia. She is currently taking several medications for her conditions. This paper will analyze the patient’s symptoms, medical history, and medication regimen in order to arrive at a differential diagnosis and formulate an appropriate management plan.

Symptoms and History

The patient reports mid-epigastric pain that worsens after eating. She is unable to identify any specific foods that may be triggering the symptoms. The pain is not accompanied by excessive gas, regurgitation of food, or water brash. She denies nausea and vomiting. Additionally, she mentions that her stools are occasionally very dark. This information suggests that her pain may be related to the gastrointestinal (GI) system, possibly indicating a digestive disorder.

Medical History

The patient has a significant medical history, including surgical menopause at age 35 due to endometriosis, hypertension (HTN), diabetes mellitus Type II, morbid obesity, and dyslipidemia. It is important to note that surgical menopause can have long-term effects on hormonal balance and overall health. HTN, diabetes, and dyslipidemia are all risk factors for cardiovascular disease and can also contribute to a variety of other health issues. Morbid obesity is likely contributing to the patient’s symptoms and overall health as well.

Medication Regimen

The patient’s medication regimen includes Premarin 0.625mg once daily, lisinopril 10mg once daily, metformin 500mg twice daily, and atorvastatin 40mg once daily at bedtime. Premarin is a form of estrogen used to treat symptoms of menopause, while lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used to manage HTN. Metformin is an oral medication used to control blood sugar levels in patients with diabetes, and atorvastatin is a statin used to lower cholesterol levels. It is important to consider the potential side effects and interactions of these medications in relation to the patient’s symptoms.

Analysis

The patient’s symptoms, medical history, and medication regimen provide several important clues for formulating a differential diagnosis. The mid-epigastric pain that worsens after eating, along with the occasional dark stools, may indicate a digestive disorder. The patient’s obesity and history of surgical menopause may also be contributing factors. Considering these factors, several possible conditions should be considered:

1. Gastroesophageal reflux disease (GERD): GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, causing symptoms such as heartburn and regurgitation. While the patient denies regurgitation of food or a water brash, GERD can present with a wide range of symptoms. The patient’s obesity and history of surgical menopause may increase the risk of developing GERD.

2. Peptic ulcer disease (PUD): PUD is characterized by open sores that develop on the lining of the stomach or the first part of the small intestine. These ulcers can cause pain and discomfort, particularly after eating. The occasional dark stools mentioned by the patient could be indicative of bleeding from the ulcer.

3. Gallbladder disease: The patient’s previous cholecystectomy indicates a history of gallbladder issues. However, it is still possible for complications to arise post-surgery, such as the development of gallstones or inflammation of the bile ducts.

4. Pancreatic disease: The pancreas plays a crucial role in digestion, producing enzymes that help break down food. Symptoms such as mid-epigastric pain and dark stools can be seen in conditions such as pancreatitis or pancreatic cancer.

These are just a few potential differential diagnoses based on the information provided. It is important to further investigate the patient’s symptoms through appropriate diagnostic tests and consult with specialists in order to arrive at a definitive diagnosis and develop an effective management plan.