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What additional questions should you ask the patient and why?
The provider would ask about the location, and timing of the abdominal pain including onset, duration, frequency, and relation to other symptoms. What makes the pain worse or better including eating certain foods, changing to different positions, or taking medications? Does the patient have any nausea, vomiting, fever, chills, diarrhea, constipation, last bowel movement, description of stool, characteristics of abdominal pain, weight loss, rectal bleeding, or referred pain? The provider should also determine if the patient has any past medical history of jaundice, ulcers, GERD, abdominal surgeries or trauma. The provider would ask these questions to differentiate what could be the cause of the abdominal pain and to rule out the acute abdomen.
What should be included in the physical examination at this visit?
The patient’s vitals should be assessed for any abnormalities such as hypertension and tachycardia related to pain. The provider should inspect, auscultate, and palpate the abdomen. The purpose is to determine any distention, location of pain, presence of hyper or hypoactive bowel sounds, rebound tenderness, which will help determine if the patient has tension, inflammatory or ischemic pain.
What are the possible differential diagnoses at this time?
The possible differential diagnoses include celiac disease, irritable bowel syndrome, diverticular disease, or colitis (Cleveland Clinic, 2019).
What test should you order and why?
A complete blood count, chemistry, liver function tests, urinalysis, pregnancy test, and abdominal films decide the severity of the issue (Dunphy, Winland-Brown, Porter, & Thomas, 2019). The provider would also order the following test: total IgA, IgA-tTG, IgA-EMA. If IgA is deficient, the IgG/IgA-DGP should be ordered. The labs would be ordered to determine if the patient has anemia, electrolyte imbalances, elevated liver enzymes, infections, protein or glucose in urine, pregnancy, any abdominal obstructions, or constipation.
How would you manage this patient based on your diagnosis?
If it’s determined that the patient has celiac disease, the patient would be educated on a gluten-free diet which means eliminating any wheat, barley, or rye. A gluten-free diet consists of meat, poultry, vegetables, fruits, fish, beans, legumes, and most dairy products (Beyond Celiac, 2019). The patient would be referred to a dietitian for further education on the lifelong need to adhere to a gluten-free diet. A support group would be beneficial to help the patient cope with the new diagnosis and determining what to expect. The patient would need to return for routine follow-ups and labs. The following test should be completed annually to manage Celiac disease:
Antibodies (IgA-tTG)
Nutritional anemia profile (hemoglobin, hematocrit, folate, ferritin, vitamin B12)
Vitamin profile (thiamin, vitamin B6, 25-hydroxy vitamin D)
Mineral profile (copper, zinc)
Lipid profile
Electrolyte and renal profile
Complete blood count (CBC)
Thyroid-stimulating hormone (TSH) (Beyond Celiac, 2019)
Beyond Celiac. (2019). Celiac disease testing and diagnosis.
Cleveland Clinic. (2019). Gastrointestinal disorders.
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary care: Art and science of advanced practice nursing – an interprofessional approach (5th ed.). [[Bookshelf Ambassadored]].
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