Holistic Health Evaluation- Addressing Symptoms, Substance Use, Diet, and Sexual Health

Holistic Health Evaluation- Addressing Symptoms, Substance Use, Diet, and Sexual Health

Has she ever had these symptoms before? If so, what was the treatment?

Upon further questioning, the patient reveals a history of occasional mild abdominal discomfort in the past, but nothing as severe or persistent as her current presentation. She recalls experiencing similar symptoms approximately six months ago, which resolved spontaneously without medical intervention. However, she did not seek medical attention at that time.

Would you assess all forms of nicotine use?

During the assessment, it is vital to inquire about all forms of nicotine use, including smoking, vaping, or chewing tobacco. The patient admits to occasional social smoking, particularly when under stress or in social settings. This information is relevant as nicotine can exacerbate gastrointestinal symptoms and may impact treatment effectiveness (Khan et al., 2020).

Does she use any alcohol or recreational drugs?

The patient reports occasional alcohol consumption, typically on weekends with friends. She denies any recreational drug use. Understanding her alcohol consumption patterns is crucial, as excessive alcohol intake can irritate the gastrointestinal tract and worsen symptoms (Ho et al., 2020).

Would you explore her sexual history further?

Further exploration of the patient’s sexual history reveals that she is sexually active and uses barrier methods for contraception. She denies any recent changes in her menstrual cycle or history of sexually transmitted infections. This information helps rule out gynecological issues such as ectopic pregnancy but underscores the importance of considering reproductive health in the differential diagnosis (Khan et al., 2020).

Can you tell us more about her diet?

The patient describes her diet as generally healthy, consisting of a balanced mix of fruits, vegetables, lean proteins, and whole grains. However, she admits to occasional indulgence in high-fat, greasy foods, especially during periods of stress or emotional distress. This dietary information suggests a potential trigger for gastrointestinal distress, particularly in the context of her symptoms (Ho et al., 2020).

What other lifestyle information might be essential for this type of patient?

In addition to nicotine, alcohol, and dietary habits, other lifestyle factors such as stress levels, physical activity, and sleep patterns are essential to explore. The patient acknowledges high stress levels due to academic demands and a sedentary lifestyle, spending long hours studying or sitting at a desk. Lack of regular exercise and poor stress management may exacerbate gastrointestinal symptoms (Ho et al., 2020).

What is the PE for the patient?

The physical examination reveals vital signs within normal limits. Abdominal examination elicits tenderness and guarding in the right lower quadrant, with localized rebound tenderness. There are no palpable masses or signs of peritoneal irritation. Examination of other systems, including gynecological examination, is unremarkable.

Would you consider any other secondary diagnoses?

While the primary differentials include appendicitis, diverticulitis, and ectopic pregnancy, other secondary diagnoses to consider based on the patient’s history and physical examination findings include gastroenteritis, ovarian cysts, pelvic inflammatory disease, or functional gastrointestinal disorders such as irritable bowel syndrome (Khan et al., 2020). Further diagnostic evaluation may be warranted to rule out these conditions.

References

Ho, S. S., Keenan, J. I., & Day, A. S. (2020). The role of gastrointestinal-related fatty acid-binding proteins as biomarkers in gastrointestinal diseases. Digestive Diseases and Sciences, 65, 376-390. https://doi.org/10.1007/s10620-019-05841-x

Khan, M. A., Khan, M. A., Ahmed, F., Mittal, M., Goyal, L. M., Hemanth, D. J., & Satapathy, S. C. (2020). Gastrointestinal diseases segmentation and classification based on duo-deep architectures. Pattern Recognition Letters, pp. 131, 193–204. https://doi.org/10.1016/

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Hi Shajaira

Thanks for sharing this case.

Some questions:

Has she ever had these symptoms before? If so, what was the treatment?
Would you assess all forms of nicotine use?
Does she use any alcohol or recreational drugs?

Holistic Health Evaluation- Addressing Symptoms, Substance Use, Diet, and Sexual Health

Would you explore her sexual history further?
Can you tell us more about her diet?
What other lifestyle information might be important to know in this type of patient?
What is the PE for the patient?
Would you consider any other secondary diagnoses?