NR603 Week 5 APEA Case Study

subjective, objective, assessment, diagnostic testing Chief complaint, PMHx, Demographics, PSHx, allergies, lifestyle, HPI Associated risk factors/demographics that contribute to the chief complaint and differential diagnoses Three common differential diagnoses represented by the CC including pathophysiology and rationale in the identified body system i.e., if pulmonary was your body system than a chief complaint could be persistent cough and three pulmonary differentials; Discuss how the three differential diagnoses differ from each other in: occurrence, pathophysiology and presentation (NOTE: Simply listing the diagnoses and their occurrence, pathophysiology and presentations separately does not confer an understanding of how they differ. Your discussion should compare and contrast these items against each other among the three differentials chosen); Relevant testing required to diagnose/evaluate severity of the three differential diagnoses; and Review of relevant National Guidelines related to the Diagnosis and Diagnostic testing for these diagnoses Dr. Deering and class, Week 5 APEA Case Study CC: abdominal pain and bloating Subjective HPI: H.M is a 28-year old Caucasian female who presents to the office with complaints of intermittent abdominal pain and bloating for the past six months. She is accompanied by her mother, who reports observing unusual eating patterns of H.M since she moved back home three months ago. H.M was living with her boyfriend in an apartment for about a year until they recently broke up three months ago. In order to save money, H.M had moved back to her parents’ house with her mother, father, and 22-year old brother. Mother reports H.M has always been conscious about her weight, especially since H.M started gaining more of it over the past year. Mother reports that H.M was “slender at 105 pounds at 5”1 but is now probably over 140 pounds.” H.M currently works as a catering manager of a resort hotel. H.M recalled one rigorous day at her job about six months ago. H.M felt sick and vomited after a heavy lunch. She felt much better and realized that the idea of vomiting after eating a large amount of food would help minimize any weight gain. H.M states that she blames the weight gain on the job because she is constantly in contact with food throughout the day. Mother reports seeing H.M eat large amounts of food late at night, particularly desserts, and often finding food wrappers hidden in her daughter’s room. Mother is also worried that H.M isolates herself in the bathroom for ten to twenty minutes after a large meal. When asked about her eating habits, H.M admits to a “loss of control.” H.M reports feeling bad when she eats more than she would like. Even though H.M is currently on a low-calorie diet, H.M reports self-induced vomiting at least three times a week to prevent weight gain from eating large meals. She also participates in yoga and exercise classes six times a week for 1.5 hours. She denies laxative or diet pill use. She denies menstrual irregularity and her last menstrual period was two weeks ago. She states that she is concerned about gaining weight and “hates the way [she] looks.” She denies suicidal ideations or thoughts that she would be better off dead. She reports feeling more fatigued in the past month, and rarely feels motivated to join her co-workers during happy hour. She also reports cramps, muscle weakness, lightheadedness, and constipation. She denies bloody stools, involuntary vomiting, food regurgitation, and heartburn. Ever since she broke up with her boyfriend, she does not participate in social outings and only has one close friend who she talks to occasionally. Past Medical/Surgical History/Allergies: H.M has no significant past medical history. She is allergic to eggs and pollen, and is lactose intolerant. She denies tobacco use or recreational drug use. She is an occasional social drinker (about three glasses of wine in one month). Associated risk factors/demographics: Risk factors for H.M’s case include: female gender, young adult age, low self-esteem, increased stress levels, overweight, and starting a very low-calorie diet. Objective Vital Signs: HR 92, BP 122/72, RR 17 (regular). Height: 5’1; Weight: 144 lbs Physical Assessment: On physical examination, H.M appeared fatigue but was in no respiratory distress. Her respirations were unlabored. She was dressed appropriately. She was awake, alert, and cooperative. The rest of her physical exam revealed no abnormalities, except for mild abdominal distention, small abrasions and calluses on the knuckles of her dominant right hand and mild brown discoloration of her upper and lower teeth. Diagnostic Testing: CBC: WBC 6,300/mm3, Hgb 12.8gm/dl, Hct 35%, RBC 4.6 million, MCV 89 fl, MCHC 30 g/dl, RDW 13.8% UA: pH 5, SpGr 1.017, Leukocyte esterase negative, nitrites negative, negative for protein; negative for ketones Urine Toxicity: Negative Pregnancy Test: Negative CMP: Sodium 136, Potassium 3.2, Chloride 100, CO2 29, Glucose 100, BUN 12, Creatinine 0.7, GFR est non-AA 99 mL/min/1.73, GFR est AA 101 mL/min/1.73, Calcium 9.4, Total protein 7.6, Alkaline phosphatase 72, AST 20, ALT 14, Bun/Creat 17.7, TSH: 2.31, Free T4 0.9 ng/dL, Cholesterol: TC- 192 mg/dl, LDL- 120 mg/dl, VLDL- 36 mg/dl, HDL- 40 mg/dl, triglycerides- 155. EKG: Normal sinus rhythm with occasional PVCs Differential Diagnoses: Bulimia Nervosa, Anorexia Nervosa, and Binge-Eating Disorder Compare and contrast the three differential diagnoses in occurrence, pathophysiology, and presentation: In this particular case study, there are three differential diagnoses to consider: bulimia nervosa (BN), anorexia nervosa (AN), and binge-eating disorder (BED). These three eating disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). While these three eating disorders are similar in topics regarding weight concern and weight-control behavior, they have varying degrees of differences. The pathophysiology of BN, AN, and BED are unclear, but there are possible theories about dysfunctional neurotransmitter systems that regulate hunger, satiety, and food choices (National Institute of Mental Health [NIMH], 2017). Impairment of eating habits may be related to alterations in the secretion of neurotransmitters and neuropeptides. Individuals with anorexia nervosa have an intense fear of obesity associated with significant weight loss. This is an eating disorder characterized by a restriction in caloric intake that results in a low body weight for normal development. Unfortunately, individuals with anorexia nervosa tend to have misperceptions of their body weight and shape (NIMH, 2017). Assessment findings in anorexia nervosa include low energy, denial of problems, swelling of parotid and submandibular glands, flat affect, amenorrhea, dry skin, sparse scalp hair, cardiovascular issues, and Russell’s sign (scarring on the knuckles) (NIMH, 2017). In contrast, individuals with bulimia nervosa engage in harmful eating habits to prevent weight gain (Rushing, Jones, & Carney, 2014). These harmful eating habits include a combination of eating large amounts of food, self-induced vomiting, using laxatives or diuretics, and excessive exercise (Rushing et al., 2014). They often feel that they have no sense of control of their eating habits during the episodes of binge eating. These episodes occur at least once a week for three months. Similar to anorexia nervosa, individuals with BN present with swelling of parotid glands, dry skin, cardiovascular issues, and Russell’s sign. However, they may have erosion of dental enamel from self-induced vomiting, palpitations, hypokalemia, and abdominal pain, which are not seen in anorexia nervosa (Rushing et al., 2014). Also similar to anorexia nervosa, the etiology of BN is unknown. However, studies have shown that a combination of genetics, societal norms, family dynamics and stressful life events can contribute to the development of bulimia nervosa. Individuals with binge-eating disorder engage in uncontrollable eating of large amounts of food than most people would eat in a given time frame (Montano, Rasgon, & Herman, 2018). Unlike bulimia nervosa, individuals with BED do not engage in purging. They often present with sleep-related breathing problems, cardiovascular issues, gastrointestinal reflux, and extreme weight gain (Montano et al., 2018). Patients with BED often exhibit increased impulsivity and compulsivity. Similar to bulimia nervosa, patients with BED often feel guilty and feeling disgusted after the binge-eating episode. Unfortunately, patients with bulimia nervosa will immediately purge themselves after feeling guilty for eating large amounts of food, which does not occur in patients with BN. Similar to anorexia nervosa and bulimia nervosa, the underlying pathophysiology of BED is unknown. However, there are human neuroimaging and animal studies that suggest that altered dopamine function contribute to binge eating, as well as stress and emotional regulation (Montano et al., 2018). While these three eating disorders share similar characteristics, it is important to understand that the central characteristic of AN is a significantly low body weight as a result of low energy intake (NIMH, 2017). They do not engage in binge-eating habits. In contrast, the main features of BN and BED are recurrent binge-eating episodes. While individuals with BN usually attempt to prevent weight gain through compensatory behaviors, such as selfinduced vomiting or use of laxatives and diuretics, those with BED do not make recurrent use of these behaviors (NIMH, 2017). Individuals with BED typically eat large amounts of food until uncomfortably full and even when they are not hungry. One similarity between BED and BN involves feeling uncomfortable around others when eating or simply refusing to eat with anyone. They often engage in binge-eating habits alone. Food rituals in bulimia nervosa are also common, such as hoarding food for future binge-eating episodes, eating only certain foods, and chewing food excessively (Montano et al., 2018). Relevant testing and national guidelines recommendations: While these three eating disorders are more common in women than men, it is important to understand that eating disorders can manifest at any age regardless of racial groups. Young adults and adolescents are at the highest risk of developing eating disorders. The lifetime prevalence of anorexia nervosa, bulimia nervosa, and binge-eating disorder is 0.6%, 0.3%, and 1.2%, respectively (NIMH, 2017). Unfortunately, eating disorders can be difficult to diagnose since primary care providers do not regularly screen for this issue. Therefore, identifying eating disorders through proper screening is imperative for early diagnosis and treatment. In the primary care setting, the American Psychiatric Association guidelines recommend utilizing screening tools, such as Rating of Anorexia and Bulimia Interview (RAB), Eating Disorder Brief Questionnaire (EDBQ), SCOFF, or Patient Health Questionnaire Eating Disorder Module (PHQ-ED), based on questions related to specific eating disorders (Yager et al., 2012). The RAB is a 56-item interview style questionnaire that screens for a wide range of eating disorder symptoms including binging and restricting behaviors. The questions group behaviors into one of three categories: not present, not fully verified, or fully verified. Each answer correlates with a score, which helps define a diagnosis consistent with DSM-V diagnoses. RAB is a valid and reliable tool for the diagnosis of eating disorders, but it can be financially costly and difficult for providers to perform given the time to complete the tool (Yager et al., 2012). On the other hand, SCOFF is one of the most commonly used tools to screen for eating disorders. The advantage of SCOFF is its brevity with only five questions. The acronym “SCOFF” is derived from the five