Evita Alonso iHuman Case scenario
Chief Complaint: “I have been experiencing severe stomach pain for the past two weeks.”
History of Present Illness:
Mrs. Alonso, a 48-year-old female patient, presents to the urgent care clinic with a two-week history of intermittent RUQ (right upper quadrant) pain that has progressively worsened over the last two days. The pain radiates to her right shoulder. She also reports associated symptoms such as nausea, vomiting, and anorexia, which started two days ago. Over the past year, she has had similar recurrent self-resolving symptoms. Her family history includes a positive case of biliary disease (mother). Physical examination reveals low-grade temperature elevation, mild scleral icterus, RUQ abdominal tenderness with guarding, and a positive Murphy’s sign.
Onset: 2 weeks ago, with worsening symptoms in the last 2 days
Location: Right upper quadrant, occasionally radiating to the right shoulder
Duration: Constant pain since onset this time, previously lasting 1-2 days
Character: Crampy, gnawing, achiness
Aggravating/Alleviating Factors: Pain worsens with meals and is not relieved by antacids or NSAIDs
Related Symptoms: Nausea, vomiting, anorexia, denies recent exposure to ill contacts
Treatments: Attempted OTC antacids and ibuprofen without relief
Significance: Pain starts at a scale of 2-3 and increases to 6-7, keeping her from work
Primary Diagnosis
Ascending Cholangitis
The primary diagnosis for the patient is ascending cholangitis, which can be acute or chronic. Gallstones can cause clogging of the tube connecting the gallbladder to the small intestine, leading to symptoms such as abdominal pain, right shoulder pain, nausea, and vomiting. Hospital admission is required due to possible clogged ducts leading to inflammation and infection. Surgery, like cholecystectomy, may be needed to address the issue. Obesity is a risk factor for gallstones (Crowley & Martin, 2022).
Ascending cholangitis is characterized by jaundice, fever, and abdominal pain resulting from infection and stasis in the biliary tract. Symptoms include fever, chills, malaise, rigors, abdominal discomfort, pruritus, and pale stools (Chatterjee, Mavani, & Bhatttacharyya, 2022). The patient reported symptoms of vomiting, nausea, stomach pain, and anorexia. Family history of biliary disease is a risk factor for ascending cholangitis.
Alternative Diagnosis
Cholecystitis
Cholecystitis is an alternative diagnosis. It occurs when gallstones obstruct the tube connecting the gallbladder to the small intestine, resulting in severe upper-right abdominal pain and bloating. The patient’s right shoulder pain and other symptoms suggest a possibility of cholecystitis, but additional symptoms like fever, vomiting, and abdominal tenderness must be considered for diagnosis (Chatterjee et al., 2022).
Pancreatitis Acute
Another possible diagnosis is acute pancreatitis, which causes inflammation and enlargement of the pancreas. Symptoms include nausea, vomiting, fever, abdominal tenderness, and pain radiating to the back. The patient’s reported symptoms align with those of acute pancreatitis.
Peptic Ulcer Disease
Peptic ulcers could also be considered as an alternative diagnosis. It occurs when stomach acid erodes the inner surface of the stomach or small intestine. Symptoms include burning stomach pain, heartburn, nausea, and bloating (Hatnoorkar & Rajpal, 2022). Given the patient’s symptoms of stomach pain, nausea, and vomiting, peptic ulcers could be considered.
Case: Management Plan
Pharmacologic Care:
Start IV
Collect blood culture x2
Administer Ertapenem 1g IV
Consult general Surgery for the next steps
Supportive Care:
Make NPO (nothing by mouth)
Administer 0.9% IV normal Saline 100ml bolus, then 50 ml per hour
Administer Zosyn 3.375 g IV every 6 hours for 7 days
Administer Zofran 4mg IV every 6 hours as needed for nausea/vomiting
Monitor blood glucose every 4 hours due to NPO status
Patient Education:
Provided education on diagnosis and the need for continued evaluation in the emergency department given fever and anticipated course. Patient expressed understanding and had no further questions.
Follow-Up:
Instructed the patient to alert staff if experiencing increased pain, nausea, fever, lightheadedness, fatigue, or any other needs while in the emergency department.
Scheduled a follow-up in the clinic post-op 1-2 weeks after discharge. If the gallbladder is removed, advised to decrease fat in the diet, eat small meals, avoid strenuous activities, and take pain medication as prescribed.
Advised the patient to contact a physician if pain is not adequately controlled or if there are symptoms of infection such as fever/chills or bleeding.
References
Chatterjee, S., Mavani, A., & Bhatttacharyya, J. (2022). Chemistry and mechanism of the diseases caused by digestive disorders. In Nutrition and Functional Foods in Boosting Digestion, Metabolism, and Immune Health (pp. 3-14). Academic Press.
Crowley, K., & Martin, K. A. (2022). Patient education: Gallstones (The Basics). UpToDate.
Hatnoorkar, S. A., & Rajpal, C. (2022). Homoeopathy and Acid Peptic Disorder. Journal of Medical and Pharmaceutical Innovation, 9(45).
