Module 4 Discussion
Mrs. Deer, a 72-year-old female, presents to the office with complaints of right upper quadrant pain with increasing intensity x2 days. She states 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 since. Additional subjective data to inquire about should include: how severe the pain is presently; when did the pain first start; what type of pain are you having – dull, sharp, steady, or intermittent; when does it occur, before or after eating; does it radiate to the back or shoulders; describe the emesis; is there any family history of gallstones, pancreatitis, or cancer; what medications are you currently taking and for what medical conditions; what does your usual diet consist of; do you drink alcohol; and is there any history of past bariatric surgery (Kennedy-Malone et al., 2019)? Additional objective data to assess for can include: fever; tachycardia; RUQ or epigastric region tenderness, with guarding or rebound; palpable gallbladder; jaundice (Bloom, 2021). On further assessment, the patient may also indicate that they more intense pain with deep breathing; that the pain may radiate from the abdomen to the right shoulder or back; labs will reveal a high white blood cell count (Brazier, 2018). She can also present with abdominal bloating, decreased appetite, and diaphoresis (Brazier, 2018).
The differential diagnoses that I am considering for Mrs. Deer include cholecystitis, pancreatitis, and diverticulitis. Pancreatitis symptoms include pain in the center of the upper abdomen, vomiting, and diarrhea. The pain will gradually become more intense and then turn to a constant ache (Brazier, 2017). The aching can intensify and become severe, and also spread to the back. Eating may further exacerbate the pain. A fever of at least 100.4* F will accompany the previously listed symptoms (Brazier, 2017). Diverticular disease is one of the most common health problems in the Western world, and diverticulitis is the most serious form of diverticular disease (Parsons, 2019). It can cause some uncomfortable symptoms and, in some cases, very serious complications. Abdominal pain is the most common symptom of diverticulitis, and will most likely occur in the lower left side of the abdomen, but it has been known to also develop on the right side (Parsons, 2019). Diverticulitis also presents with constant or severe pain in the abdomen, nausea and vomiting, fever and chills, and bleeding from the rectum or blood in the stool (Parsons, 2019). Cholecystitis is an inflammation of the gallbladder that usually occurs because a gallstone gets stuck at the opening of the gallbladder (Brazier, 2018). It can present with fever, nausea and vomiting, pain, and severe complications. Without treatment it can result in perforation of the gallbladder, tissue death and gangrene, or secondary bacterial infections (Brazier, 2018). Gallstones are involved in approximately 95% of all cholecystitis cases. They may form from cholesterol, bilirubin, or a combination of the two. It can also be caused by sludge when bile collects in the biliary ducts (Brazier, 2018).
Laboratory tests can help rule out some of the differential diagnoses, so in being thorough, I would choose to run the following tests: Alanine aminotransferase (ALT) and aspartate aminotransferase (AST), as their levels can be elevated in cholecystitis or with a common bile duct obstruction; bilirubin and alkaline phosphatase assays; amylase/lipase assays can assess for pancreatitis, or amylase can also be elevated with cholecystitis; CBC with leukocytosis with a left shift may be observed in either cholecystitis or pancreatitis (Bloom, 2021). Radiological and additional diagnostic tests should also be considered to eliminate and confirm differential diagnoses. I would look to include x-rays, CT and ultrasounds of the abdomen, ERCP, HIDA scan, and an MRI (Bloom, 2021; Brazier, 2017; Kennedy-Malone et al., 2019; Parsons, 2019). If Mrs. Deer’s case of cholecystitis is considered a complicated one, she will need to be hospitalized for treatment, including IV antibiotics. Penicillin, ceftriaxone, or metronidazole would be administered, depending on the patient’s allergies, if she had any. Treatment of the symptoms of nausea, vomiting, and pain would all be included as well while she was hospitalized (Kennedy-Malone, 2019). If her particular case is classified as uncomplicated cholecystitis, she could be treated on an outpatient basis with the same antibiotics in pill form, as well as an antiemetic to help control the nausea and prevent fluid and electrolyte disorders, and analgesics for the pain (Bloom, 2021). Hydration is very important in either scenario as well. Depending on the course of antibiotics, the patient should be educated about possible side effects of any medication she receives, as well as the progression of the acute disease she is experiencing. Surgical interventions could be deemed necessary, and all risks related to surgery, whether laparoscopic or open, should be made aware to the patient prior to proceeding. The only additional lab I would consider at this time would be to include a blood culture, to check for systemic infection.
The patient will require additional education about the disease process and how to prevent future occurrences from happening. Certain measures can be taken to help reduce the risk of developing gallstones, which in turn can decrease the chance of a recurrence of cholecystitis: avoid saturated fats in your diet; keep to a regular schedule of meals, and do not skip any; exercise for at least 30 minutes per day, 5 days a week, as safely tolerated; and maintain a healthy weight or lose weight, because obesity increases the risk of gallstones (Brazier, 2018). I would refer the patient to a gastroenterologist for evaluation and further treatment of her cholecystitis. I would like to see her back in the office for follow up once this acute episode has resolved, just to make sure she has recovered well.
Bloom, A. (2021, May 20). Cholecystitis. https://emedicine.medscape.com/article/171886-over…
Brazier, Y. (2018, January 22). What to know about cholecystitis? https://www.medicalnewstoday.com/articles/172067
Brazier, Y. (2017, December 19). All about acute pancreatitis. https://www.medicalnewstoday.com/articles/160427
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Advanced practice nursing in the care of older adults. (2nd ed.). F. A. Davis Company.
Persons, L. (2019, March 6). Everything you need to know about diverticulitis. https://www.healthline.com/health/diverticulitis