Discussion Post-
Mrs. Deer is a 72-year-old female who presents to your office complaining of right upper quadrant pain that has been increasing in intensity over the past 2 days. She would have come sooner, but she lacked transportation and waited until her son could drive her. She states that she has not been sleeping very much because of the pain. She has been nauseous and vomited a couple of times two days ago but has only been drinking fluids. She states that she has not been around anyone else that had an upset stomach. She recalls prior to the onset of pain she had been at a church supper that included meats, refried beans, and many desserts which she sampled. She described the fried pies that she brought to the supper and ate the extras that afternoon.
Vital Signs: BP 130/80, HR 85, RR 20, Temp 99.0°F.
Discuss the following:
1) What additional subjective data are you seeking to include past medical history, social, and relevant family history?
2) What additional objective data will you be assessing for?
3) What are the differential diagnoses that you are considering?
4) What laboratory tests will help you rule out some of the differential diagnoses?
5) What radiological examinations or additional diagnostic studies would you order?
6) What treatment and specific information about the prescription that you will give this patient?
7) What are the potential complications from the treatment ordered?
8) What additional laboratory tests might you consider ordering?
9) What additional patient teaching may be needed?
10) Will you be looking for a consult?
Submission Instructions:
- Post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
Answers
- Additional subjective data:
- Past medical history: Inquire about any previous medical conditions, surgeries, or hospitalizations, particularly those related to the gastrointestinal system. Ask about any chronic conditions such as liver disease, gallbladder disease, or previous episodes of similar pain.
- Social history: Determine Mrs. Deer’s living situation, occupation, and lifestyle factors. Assess her alcohol consumption, as excessive alcohol intake can contribute to liver and gallbladder issues. Inquire about her dietary habits, including any recent changes or consumption of high-fat foods.
- Relevant family history: Ask about a family history of gastrointestinal disorders, particularly gallbladder disease or pancreatic disorders.
- Additional objective data:
- Perform a thorough physical examination, focusing on the abdomen. Palpate the right upper quadrant for tenderness or any masses. Check for signs of jaundice or any other abnormalities.
- Assess vital signs, including temperature, blood pressure, heart rate, and respiratory rate, to monitor for any signs of systemic illness or complications.
- Differential diagnoses:
- Cholecystitis: Inflammation of the gallbladder, often caused by gallstones obstructing the bile ducts.
- Acute pancreatitis: Inflammation of the pancreas, commonly associated with gallstones or alcohol abuse.
- Gastritis: Inflammation of the stomach lining, which can result from the consumption of spicy or fatty foods.
- Gastroenteritis: An infection or inflammation of the gastrointestinal tract, typically caused by a viral or bacterial infection.
- Laboratory tests:
- Complete blood count (CBC): Evaluate for signs of infection or inflammation.
- Liver function tests (LFTs): Assess liver enzymes and bilirubin levels to evaluate liver function and rule out liver diseases.
- Amylase and lipase levels: Elevated levels may indicate pancreatic involvement.
- Serum electrolytes and renal function tests: Assess for any electrolyte imbalances or impaired kidney function.
- Radiological examinations or additional diagnostic studies:
- Abdominal ultrasound: This can help visualize the gallbladder and identify the presence of gallstones or signs of inflammation.
- CT scan of the abdomen: If necessary, a CT scan can provide detailed images of the pancreas and surrounding structures to confirm pancreatitis or rule out other conditions.
- Treatment and prescription information:
- Depending on the diagnosis, treatment may involve supportive measures such as pain management, intravenous fluids, and antiemetic medications.
- If cholecystitis or gallstones are suspected, a referral to a general surgeon may be necessary for further evaluation and potential surgical intervention.
- Potential complications from treatment:
- Complications may include infection, abscess formation, sepsis, or the need for surgical intervention in cases of severe cholecystitis or pancreatitis.
- Additional laboratory tests:
- Depending on the initial results and clinical presentation, additional tests such as viral or bacterial stool cultures may be considered to identify the cause of gastroenteritis if suspected.
- Additional patient teaching:
- Educate the patient on the importance of dietary modifications, such as avoiding high-fat and spicy foods, to prevent further episodes of pain.
- Provide instructions on pain management techniques and the appropriate use of any prescribed medications.
- Emphasize the need to seek medical attention promptly for worsening symptoms or the development of new symptoms.
- Consultation:
- Depending on the severity and complexity of the case, a consultation with a gastroenterologist or a general surgeon may be warranted for further evaluation and management.
