[Fan Favorite] Differential Diagnosis

As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

A 35-year-old w presents complaining of a 15+ year history of recurrent cramping abdominal pain that is often relieved with defecation that occurs intermittently. Symptom onset is often accompanied by bloating and a change in stool frequency and form, particularly when “I eat certain foods.” She denies bloody or tarry stools, nausea, vomiting or fever. The NP notes the patient’s weight is stable, and there is no evidence of anemia. The most likely diagnosis is?

A. Irritable bowel syndrome

B. Paralytic ileus

C. Peptic ulcer disease

D. Ulcerative colitis
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Transcript

Welcome to NP Certification Q&A presented by Fitzgerald Health  Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in.  

A 35-year-old presents with a 15-year history of recurrent cramping abdominal pain that is often relieved with defecation. This occurs intermittently. Symptom onset is typically accompanied by bloating and a change in stool frequency and form, particularly when "I eat certain foods." She denies bloody or tarry stools, nausea, vomiting, or fever. 

The NP notes that the patient's weight is stable and there's no evidence of anemia. The most likely diagnosis is:

A. Irritable bowel syndrome.  

B. Paralytic ileus.  

C. Peptic ulcer disease.  

D. Ulcerative colitis. 

Where do you start with a question like this? 

First, you should determine what kind of a question it is. This is actually a diagnosis or, if you will, a differential diagnosis question as it's focused on the analysis and synthesis of the patient data presented with the goal of choosing the most likely most appropriate diagnosis. And once again, what you want to do is determine probabilities based on the patient's symptoms, history, and risk categories, what is the most likely diagnosis? 

And the most likely diagnosis here then will actually be option A, irritable bowel syndrome. Irritable bowel syndrome is considered to be a functional GI disorder characterized by abdominal pain and altered bowel habits in the absence of unique organic pathology. Note the word absence, and this is why it is considered to be a functional GI disorder. The patient meets Rome III criteria for the diagnosis, which includes discomfort relieved by defecation, symptom onset associated with a change in stool frequency, or symptom onset associated with a change in stool form or appearance. The typical age for onset for irritable bowel syndrome, often abbreviated IBS, is prior to age 40, and symptoms are recurrent, which is what we hear reported by this patient. 

A few things that are key to the data presented on this patient is: the patient denies red flag findings like bloody or tarry stools, no nausea, no vomiting, no fever. And we're also told the patient's weight is stable and there's no evidence of anemia. That really, really helps back up our diagnosis of irritable bowel syndrome. 

Now, let's take a look at the other options that were presented. Option B was paralytic ileus. Now, paralytic ileus results in a partial or complete blockage of the bowel that will prevent the contents from moving through the gut. The patient would no doubt have a report of severe onset abdominal pain that was sudden. Not telling us this has been going on for years as we see with this particular patient. And typically with paralytic ileus, there are tremendous issues with nausea and vomiting. In addition, we would get a risk factor for paralytic ileus such as recent surgery, particularly with opioid use post-op, or some kind of a recent GI infection. 

Now, this is a diagnosis, however, that virtually all nurse practitioner students have seen in their R.N. practice. So this is what I will often refer to as a familiar diagnosis. So you might think to yourself, I'm going to go with this. This is a familiar diagnosis. I've seen people with this and they do have abdominal pain. And one of the things with paralytic ileus is once it resolves and the person defecates, they often say, "Oh, my belly pain is much better." But remember, paralytic ileus is sudden acute onset belly pain with an identifiable risk factor at the same time. Remember, we're talking about an outpatient clinical encounter. 

Option C was ulcerative colitis, and this is a form of inflammatory bowel disease, sometimes abbreviated IBD. And the two major forms of inflammatory bowel disease are ulcerative colitis 

which is exactly what it says— it's limited to the large intestine. Or Crohn's disease, which can be any place in the GI tract. These IBDs are typically associated with recurrent episodes of cramp-like abdominal pain with diarrhea, but usually accompanied by unintended weight loss and blood in the stool. The age at onset is usually between 15 and 35 years. 

You know, we're all health care providers. We throw around terms right and left, some of which can be very, very, very confusing. But let me go through this quickly here. 

IBS, irritable bowel syndrome, which is our best answer as a functional disease, where there is no anemia, the pain is recurrent, the weight is stable. 

IBD, which includes ulcerative colitis, there are typically bouts of flares with severe abdominal pain, diarrhea, unintended weight loss, and blood in the stool. So IBS, IBD can sound similar, but they're very different diseases. 

Option D peptic ulcer disease is typically associated with newer onset, intermittent upper abdominal pain. Remember, this patient is telling us about lower abdominal pain. 

Whenever I hear about upper abdominal pain, I start thinking away from problems with the small and the large intestine and more towards the upper GI tract, like the duodenum, the stomach, the esophagus. And with peptic ulcer disease, again, it's usually associated with newer onset intermittent upper abdominal pain. The pain is often described as gnawing or burning in nature. 

With peptic ulcer disease, eating usually influences the quality of the pain, sometimes with particularly with duodenal ulcer, it makes the pain better. Sometimes, if it's a gastric ulcer, which could be part of the umbrella term of peptic ulcer disease, sometimes with gastric ulcer, putting food in the stomach actually makes things worse. 

But with upper GI problems, typically stooling has no impact on the discomfort this patient here was telling us, when I defecate, my pain is better. 

The age of onset for peptic ulcer disease really varies according to the location of the ulcer. Where duodenal ulcers are most often reported between ages 30 to 50 and gastric ulcers more likely after age 60. 

What's the key takeaway here? For differential diagnosis a thorough symptom analysis coupled with the knowledge of disease, pathophysiology, patient risk groups, and clinical presentation is key. 

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