responsee.

This week we will look at a case involving a 72-year-old female with right upper quadrant pain that has been increasing in intensity over the past two days. The pain has led to nausea, vomiting, insomnia, and has restricted intake to fluids only. Start of symptoms coincides with a church supper consisting of meats, beans, and deserts.

Vital Signs – BP: 130/80, HR: 85, RR: 20, Temp 99.0

1) What additional subjective data are you seeking to include past medical history, social, and relevant family history?

My immediate suspicions are gall bladder, pancreas, and liver, with a more distant consideration to acute nephrolithiasis, so my additional data requests are going to follow those pathways. I would want to know her alcohol use history, any history of pancreatitis, any history of difficulty with fatty foods, pain location and any radiation of pain specifically to the right shoulder and with a deep breath, any history of liver disease or hepatitis. Family history of gall stones, pancreatic or hepatic tumors would be within reason. I have a lower suspicion for GERD or PUD because of the location of the pain as RUQ versus epigastric, or for PUD which would be relieved by food (Kennedy-Malone et al., 2019; Zakko, 2022). I would think that a more telling sign of kidney stones would be present in the stem, such as blood in urine or change in character of the urine. At her age, UTI considerations would often also include altered mental status, which is why I focused more on liver/pancreas/gall bladder.

2) What additional objective data will you be assessing for?

Percussion and palpation of the abdomen for abnormalities in expected dullness (liver), tenderness to palpation at costovertebral angle (kidney), masses or enlargement to palpation in the liver area (Kennedy-Malone et al., 2019). We could examine the eyes and skin for jaundice to see if there is evidence of chronic or sub-acute gallstones or liver issues, where hepatic disease may also have belly bloating and ascites (John Hopkins Medicine, 2019).  

3) What are the differential diagnoses that you are considering?

Acute cholecystitis – presenting symptoms are consistent with signs of this, and the acute nature of presentation could be from a blockage in either the gall bladder or common bile duct (Jones et al., 2023; Kennedy-Malone et al., 2019).

Pancreatitis – stronger lean towards this if there is a history of ETOH or known previous pancreatitis. This could also be secondary to several of the other differentials listed here (except renal origin) due to complications resulting from blockage of the common bile duct (Kennedy-Malone et al., 2019; Mayo Clinic, 2023).

Pancreatic Cancer – higher suspicion of this if objective findings include masses, recent weight loss, change in stools (American Cancer Society, 2024; Kennedy-Malone et al., 2019).

• Nephrolithiasis/AKI – diagnosis of exclusion OR if CVA tenderness is present on palpation (Kennedy-Malone et al., 2019).
• others that could be considered depending on answers to subjective questions include hepatitis, cirrhosis, or peptic ulcer disease.
• 4) What laboratory tests will help you rule out some of the differential diagnoses?
• Blood work would include CBC, LFT, BMP, lipase, amylase (Kennedy-Malone et al., 2019; Vollmer, Jr et al., 2022; Walkowska et al., 2022; Zakko, 2022).
  5) What radiological examinations or additional diagnostic studies would you order?
• While the first test indicated is an abdominal ultrasound, the most definitive imaging test I could order would be an abdominal CT which would be able to detect masses smaller than palpation could detect in the liver or pancreas, as well as identify stones or blockage of the gall bladder (Kapoor, 2019).

6) What treatment and specific information about the prescription that you will give this patient?

This patient should receive supportive care and pain management in a hospital setting. While considering differential diagnoses and deciding on clinical course, we should be providing fluids, correcting electrolytes, and controlling pain (Jones et al., 2023; Kennedy-Malone et al., 2019; Lee et al., 2011; Vollmer, Jr et al., 2022; Walkowska et al., 2022; Zakko, 2022).

Specific treatment information will vary depending on the diagnosis. In what is the most favorable outcome for the patient, the treatment information for acute cholecystitis is the supportive treatment above and if she is a good candidate, laparoscopic removal of the gall bladder (Vollmer, Jr et al., 2022).

7) What are the potential complications from the treatment ordered?

Complications of laparoscopic cholecystectomy are rare, and are more common among male patients than females, but they include the following at less than 5% occurrences: intraabdominal bleeding, infection of surgical wound, biliary duct leak, or conversion to open cholecystectomy; it is also of note that the rate at which these complications happens is lessened when the patient is more stabilized, so getting preemptive supportive care can reduce the incidence of complications (Radunovic et al., 2016).

8) What additional laboratory tests might you consider ordering?

The diagnostically relevant labs are listed above. In the case of that lab work ruling out GI based pathology, I would look for urinalysis to point back towards the less likely renal pathway.

9) What additional patient teaching may be needed?

Common post-surgical teaching for laparoscopic cholecystectomy include early activity, diet modification, activity restrictions while the surgery site heals, wound care, and follow up. I taught all of these today for my PACU patient.

10) Will you be looking for a consult?

Yes, general surgery. Pending the results of imaging, we could also consider oncology, nephrology, or urology.