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.

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.
ANSWER
**1) Additional subjective data to be sought:**
* Past medical history:
* Any history of gallbladder disease, liver disease, pancreatitis, or other abdominal conditions
* Any history of recent abdominal surgery or trauma
* Any history of alcohol or drug abuse
* Social history:
* Occupation and hobbies
* Diet and exercise habits
* Smoking and alcohol use
* Travel history
* Relevant family history:
* Any family history of gallbladder disease, liver disease, pancreatitis, or other abdominal conditions
**2) Additional objective data to be assessed:**
* Physical examination:
* General appearance and vital signs
* Abdominal examination for tenderness, guarding, distention, and organomegaly
* Rectal examination for tenderness, mass, and blood
* Laboratory tests:
* Complete blood count (CBC)
* Comprehensive metabolic panel (CMP)
* Liver function tests (LFTs)
* Lipase
* Amylase
* Radiological examinations:
* Abdominal ultrasound
* Computed tomography (CT) scan of the abdomen and pelvis
**3) Differential diagnoses:**
* Acute cholecystitis
* Acute pancreatitis
* Choledocholithiasis
* Hepatic colic
* Pyelonephritis
* Pneumonia
* Myocardial infarction
* Gastroesophageal reflux disease (GERD)
* Peptic ulcer disease
* Gastritis
* Constipation
* Bowel obstruction
**4) Laboratory tests to help rule out some of the differential diagnoses:**
* CBC: Can be used to assess for signs of infection, such as leukocytosis and elevated neutrophil count.
* CMP: Can be used to assess for liver and kidney function. LFTs can be elevated in acute cholecystitis, acute pancreatitis, and hepatic colic.
* Lipase and amylase: Can be elevated in acute pancreatitis.
* Urinalysis: Can be used to assess for signs of infection, such as pyuria and hematuria.
**5) Radiological examinations or additional diagnostic studies to order:**
* Abdominal ultrasound: Can be used to assess for gallbladder stones, choledocholithiasis, and other abdominal abnormalities.
* CT scan of the abdomen and pelvis: Can be used to further assess the gallbladder, pancreas, liver, and other abdominal organs.
**6) Treatment and specific information about the prescription:**
Treatment will depend on the specific diagnosis.
* Acute cholecystitis: Treatment typically involves hospitalization for intravenous fluids, antibiotics, and pain control. Laparoscopic cholecystectomy (gallbladder removal surgery) is usually performed within 24-48 hours.
* Acute pancreatitis: Treatment typically involves hospitalization for intravenous fluids, pain control, and supportive care. In severe cases, patients may require intensive care unit (ICU) admission.
* Choledocholithiasis: Treatment typically involves endoscopic retrograde cholangiopancreatography (ERCP) to remove the gallstone from the common bile duct.
* Hepatic colic: Treatment typically involves pain control and supportive care.
* Other diagnoses: Treatment will depend on the specific diagnosis.
**7) Potential complications from the treatment ordered:**
* Laparoscopic cholecystectomy: Potential complications include bleeding, infection, bile duct injury, and bowel injury.
* ERCP: Potential complications include pancreatitis, bleeding, and infection.
**8) Additional laboratory tests to consider ordering:**
* If the patient’s symptoms do not improve with initial treatment, or if there is a concern for a more serious condition, additional laboratory tests may be ordered, such as:
* Blood cultures
* Urine cultures
* Stool cultures
* Viral serologies
* Autoimmune markers
**9) Additional patient teaching needed:**
* Patients should be educated about the signs and symptoms of potential complications from their treatment.
* Patients should be instructed on how to take their medications as prescribed.
* Patients should be instructed on how to follow up with their healthcare provider.
**10) Will a consult be looked for?**
A consult may be looked for depending on the specific diagnosis and treatment plan. For example, if the patient is scheduled for laparoscopic cholecystectomy, a consult with a general surgeon may be obtained. If the patient has severe acute pancreatitis, a consult with a gastroenterologist or intensivist may be obtained.
**References:**
* Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Yealy, D. M., & Meckler, G. D. (2023). Tintinalli’s emergency medicine: A comprehensive study guide (10th ed.). McGraw-Hill Education.
* Rosen, P., Marx, J. A., & Walls, R. M. (2023). Rosen’s emergency medicine: Concepts and clinical practice (1