History and Physical
1 Exam 2 Main Diagnosis: Acute Cholecystitis Patient Initials: G.M. Age: 44 Years Gender: Female Allergies: She denies any allergies Current Medications: She is only on oral contraceptives PMH: History of hypertension Immunizations: She is immunized up to date Surgical History: He underwent appendectomy at the age of 27 years Family History: No history related to gallbladder disorders within the family Social History: G.M. has been living in Miami since her childhood. She has been living in favorable environmental conditions, free from any harm or pollutants from childhood. She has studied up to the college level and acquired a diploma in procurement. She currently works as a receptionist in a local restaurant. She is married and has two sons. His hobbies involve going out with friends. She is a non-smoker but drinks a glass of beer with dinner only on weekends. She has a supportive social network and has no significant health history. Subjective Data: Chief Complaint: “I have been feeling severe pain on the upper abdomen since last night after dinner.” 3 HPI: G.M., a 44-year-old female patient, visited an emergency department complaining of severe pain in the upper abdomen since last night after having dinner. She reports that the pain has persisted since its onset less than 24 hours ago. She describes the pain as progressive and continuous, making her develop much concern over her health condition. She reports that the pain worsens whenever she takes meals, especially greasy or fatty foods. However, she denied any relieving factor associated with her condition. She reports that the pain has no specific time since it has occurred continuously. She rates the pain as 9/10 on a 1-10 scale. Review of Systems: o General: She denies experiencing unintentional weight loss and chills. o HEENT: She denies dizziness, visual loss, ear pain, nasal congestion, and voice hoarseness. o Lungs: She denies wheezing, sputum production, and sneezing o Cardiovascular: She denies shortness of breath, chest discomfort, and edema o GI: She admits to abdominal pain, vomiting, and nausea but no diarrhea o GU: She denies experiencing changes in urinary habits or the presence of blood in the urine o Neuro: She denies numbness, seizures, tingling, and dizziness o Psychosocial: She admits to anxiousness associated with the unknown cause of her abdominal pain. o Derm: She denies pruritus and lesions on the skin Objective Data 4 Physical Exam: o Vital signs: Blood pressure of 122/81, elevated heart rate of 103bpm, respiratory rate of 17bpm, low-grade fever of 38.2°C, weight of 172lbs, and height of 5’3” o General: The patient appears to be uncomfortable due to the pain she feels in the abdomen o HEENT: Head is atraumatic and normocephalic. Pupils have equal size and are reactive to direct light. The auditory canal has no signs of inflammation. No drainage from the nose. The throat is moist. o Neck: Supple with no signs of stiffness or lymphadenopathy o Pulmonary: Breathing sounds are clear bilaterally o Cardiovascular: Heart rhythm is normal and regular with no murmurs o Abdomen: Tenderness noted on the upper right quadrant on palpation. Murphy’s sign gives a positive result o Auscultation: The bowel sounds are minimal within the right upper quadrant o Musculoskeletal: The patient has no signs of stiffness in the joints and muscles. o Derm: Hair is normally distributed on the skin with no scars or lesions. Assessment Differential Diagnoses Acute Cholecystitis: K81 This refers to a medical condition associated with gallbladder inflammation. It develops when the cystic duct is blocked, thus preventing the flow of bile from 5 the gallbladder. Although there are several aspects that contribute to the development of this condition, some of them include infections and gallstones presence. The blockage of the cystic duct can sometimes contribute to inflammation. Some common signs and symptoms of this condition include adnominal tenderness, vomiting, nausea, severe abdominal pain, low-grade fever, and positive Murphy’s sign (Gallaher & Charles, 2022). Since all these aspects can be evident in G.M., acute cholecystitis is the most likely primary diagnosis. Pancreatitis: K85- This refers to a condition associated with pancreas inflammation. This condition can be acute or chronic depending on the period in which an individual has experienced various signs and symptoms. Some common signs and symptoms of pancreatitis include elevated serum lipase/amylase, epigastric pain that radiates to the back, nausea, vomiting, abdominal tenderness, and negative Murphy’s sign (Mederos et al., 2021). Although G.M. presents the mentioned signs and symptoms, she has a positive Mursphy’s symptom, which makes pancreatitis not to be the primary diagnosis. Peptic Ulcer Disease: This refers to a condition associated with developing open ulcers or sores within the stomach lining or lower esophagus at times. This condition mostly develops due to an imbalance between the acid produced in the stomach and the protective layer on the stomach and duodenum lining. This condition is mostly caused by stress, smoking, increased use of NSAIDs, and the presence of Helicobacter pylori (H. pylori). Some common signs and symptoms of this condition include abdominal pain, vomiting, nausea, and bleeding in severe cases (Shell, 2021). Although G.M. presents most of the signs and symptoms mentioned, she lacks blood in the stool. Besides, she has none of the mentioned aspects considered to be the major causes of the condition. 6 Plan: Pharmacological: o The patient needs to be admitted for pain management and further evaluation with surgery team. o She should be administered with intravenous fluids to enhance her hydration o Prescribe the patient with appropriate antibiotics, such as metronidazole or ceftriaxone, for any potential infection (Gallaher & Charles, 2022). o Prescribe the patient with analgesics, especially acetaminophen, to relieve her pain. Non-Pharmacological: o Monitor the patient for any complication signs such as perforations or sepsis o Consult any need for cholecystectomy (Gallaher & Charles, 2022) Education: o Discuss with the patient about the most appropriate diet she should be taking in case of undergoing cholecystectomy. o Explain to the patient about the possible diagnosis she is likely to be experiencing and the urgent need for an intervention. o Consider follow-up every two weeks to determine whether there is any potential complication. o Inform the patient to avoid taking foods for some time to allow the gallbladder to rest 7 References Gallaher, J. R., & Charles, A. (2022). Acute cholecystitis: a review. Jama, 327(10), 965-975. 10.1001/jama.2022.2350 Mederos, M. A., Reber, H. A., & Girgis, M. D. (2021). Acute pancreatitis: a review. Jama, 325(4), 382-390. 10.1001/jama.2020.20317 Shell, E. J. (2021). Pathophysiology of peptic ulcer disease. Physician Assistant Clinics, 6(4), 603-611. https://doi.org/10.1016/j.cpha.2021.05.005
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