A Case Study Of Samantha Parker

HISTORY OF PRESENT ILLNESS: This 46-year-old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis, presents to the emergency room after having had three days of abdominal pain. It initially started three days ago and was a generalized vague abdominal complaint. Earlier this morning, the pain localized and radiated to the right lower quadrant. He had some nausea without emesis. He was able to tolerate p.o. earlier around

HISTORY OF PRESENT ILLNESS: This 46-year old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis presents to the emergency room after having had 3 days of abdominal pain. It initially started 3 days ago and was a generalized vague abdominal complaint. Earlier this morning the pain localized and radiated to the right lower quadrant. He had some nausea without emesis. He was able to tolerate p.o earlier around 6am, but he now

Narrowing the problem down takes a CT scan of the abdomen and pelvis. Which could reveals a mass. When your examine the patient start with the left iliac region, this area is dull to percussion: when you palpate it, you will comment on a mass (if this is the diagnosis). Always ask patient where does it hurt? How long has she had this pain? Check her blood work, look for discharge, sourness, or check her urine, if often tells or leads to localized pain. Since some causes are life threating abdominal pain patients need to be triage rapidly and precisely. (Simmons,

B.S. is an 81 year old Caucasian female presenting with abdominal pain, diarrhea, nausea and vomiting in the emergency room on February 3, 2013. B.S. has a history of glaucoma, hypothyroidism, degenerative arthritis and diverticulosis. She has allergies to iodine and vicodin. B.S. is admitted for diverticulitis with possible partial bowel obstruction and hydronephrosis. B.S. was admitted on February 3, 2013 here at Verdugo Hills Hospital.

Upon inspection the contour of the patients abdomen was rounded, symmetric, color appropriate to genetic background, striae present, 6 to 8 round bruises from subcutaneous injections. No apparent pulsations, masses, lesions, rashes, wounds, ascites, scars, or hernias present. Auscultated bowel sounds in all four quadrants; hyperactive sounds heard in lower right quadrant, hyperactive sounds heard in upper right quadrant, normoactive bowel sounds in upper left quadrant, and hyperactive bowel sounds heard in lower left quadrant. Auscultated the aorta, renal arteries, and iliac arteries for vascular sounds, no bruits heard. Lightly palpated the abdomen in all four quadrants, patient felt tenderness on bruised areas, no masses present, abdomen distended. Percussed the abdomen in all four quadrants noting the predominately tympanic in all four quadrants and minimum dullness. The patient’s last bowel movement was around 0830, loose, with no pain. The patient stated having three to five loose bowel movements daily and that, “several bowel movements a day was common for her.” The patient describe the characteristics of her bowel movement as “watery, stinky, and not a large amount”. No prescription medication related to the abdomen. However, patient takes over the counter medication for frequent bowel movements at home. No surgeries related to the abdomen. No laboratory data related to the

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Abdominal pain with nausea and vomiting. This is intermittent and she is currently now being evaluated by Dr. Paciulli. She has tests pending for the end of the week. I will await the results of that testing and the note from Dr. Paciulli will follow along. Certainly, a consideration would be to have her see gastroenterology.

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The initial plan started with ordering a CBC, CMP, amylase and lipase STAT. These are all standard labs that help to rule out gallbladder pathology as well as our other differential diagnoses. Her vital signs were stable and the physical exam revealed only moderate TTP of the RUQ and epigastric region. The lab results revealed no leukocytosis, no elevation of liver enzymes, bilirubin, amylase, lipase, alk phos or any other signs of cholecystitis, cholangitis, pancreatitis or other potential signs of infection. The plan of care began with keeping the patient NPO. This is recommended as this keeps the patient from further pain secondary to food stimulating gallbladder contraction.5 It also allows the patient to be prepared for surgery if urgent cholecystectomy is required. The next step was beginning IV normal saline to keep her well hydrated. After this we began to give her medication through the IV including Zofran for her nausea. Zofran is an effective anti-emetic and there were no contraindications for use in this patient. We also gave her Morphine 2 mg IV for pain control. Opioids are an effective option for a patient with significant biliary colic.6 Although NSAIDS are another option for pain control, PUD was part of the differential diagnosis so NSAIDS were not an appropriate therapy. We ordered an abdominal ultrasound as this is the diagnostic test of choice for cholelithiasis. The ultrasound revealed multiple gallstones in the gallbladder, some mild gallbladder thickening, and some dilatation of the common bile duct. At this point we consulted GI who scheduled the patient for MRCP in the morning in order rule out choledocholithiaisis. We also consulted the surgery team who admitted the patient. The stated they would likely plan for laparoscopic

A referral to the cardiologist was made to exclude any cardiac causes since the pain Mr. A.M felt was epigastric. Physical examination along with ECG as the preferred test by the cardiologist did not reveille any abnormalities. CBC count and LFT’s were ordered. Mr. A.M was later on referred to a gastroenterologist for focused examination on the gastrointestinal system.

Patient N.L. was brought into the emergency room (ER) and was admitted to the medical-surgical unit on Tuesday at 1700 complaining of sudden onset of diffuse contraction-like peri-umbilical pain radiating all over her abdomen on and off for an hour after having lunch at home. Patient was a 9/10 on a pain scale with nausea and vomiting x 2. Her admitting diagnosis were small bowel obstruction and systemic inflammatory response with leukocytosis.

She says that it was mainly in the lower abdomen yesterday across her lower belly. However, today that part seems to be better. She has not had any fevers with it. She has not had any nausea or vomiting. She has been feeling constipated. She is not sure if her belly discomfort is related to constipation or not. There has not been any blood in her stool. No diarrhea. No fevers, chills or body aches and she is otherwise not feeling ill at this time. She is planning a colonoscopy with Marylyn Grondin, MD, but has not scheduled that

The patient's symptoms along with the lab results provided a very similar match to Acute Acalculous Cholecystitis. Acalculous Cholecystitis refers to inflammation of the gallbladder where gallstones are NOT the contributing factor. This is significant because patient had a negative test result for gallstones. In this case, i think that it was most likely caused by an increase in bile viscosity that occurs from stasis. And in turn, leads to blockage of the cystic duct. The cystic duct connects the gallbladder to the common bile duct.

The most common presentation of cholecystitis in patients is intermittent, moderate to severe pain in the upper right quadrant of the abdomen, often radiating towards the back or between the shoulder blades due to accompanying inflammation of the peritoneum of the diaphragm, which is innervated by spinal cord segments C3-C5, which also supply sensation to the skin of the shoulder (Munson & Traister, 2005) (Drake et al., 2009). If the biliary tract is blocked or inflamed, patients may present with jaundice; or if gallstones are passed along the duct, a constant pain may be experienced in the upper right abdomen (Munson & Traister, 2005).

Patient M.E. was admitted to Selma Hospital after receiving a diagnosis of acute cholecystitis after an abdominal ultrasound revealed an enlarged gallbladder with gallstones, in which she is now waiting to be transferred to the OR for a laparoscopic cholecystectomy. In short, cholecystitis is a condition in which the gallbladder becomes inflamed due to a gallstone occluding the cystic duct (Huether & McCance, 2012). In addition, many symptoms can accompany this condition that can vary on the progression on the severity of the inflammation of gallbladder and the amount of gallstones. However, the signs and symptoms that revealed upon her assessment were pain in the right upper abdominal quadrant along with rebound tenderness and nausea. In the