response.
Please respond to discussion
Mrs. Deer, 72, presents to the physician’s office complaining of pain in her right upper quadrant, and additional subjective information is required to develop an accurate diagnosis and an effective treatment plan. This subjective information includes the patient’s social, medical, and family history. Critical social history information that will be obtained entails whether the patient has had any recent travel history, dietary consumption, and any exposure to toxins. Regarding additional medical history, I will inquire from the patient, such as any history of gallbladder disease, liver disease, or gastrointestinal issues. Finally, I will obtain pertinent information about the patient’s family history, such aspects as any chance that some of her family members have had gallbladder disease, liver disease, or gastrointestinal issues.
Additional Objective Data
Objective data that will be assessed for Mrs. Deer includes an evaluation of jaundice to determine if the patient’s clinical manifestations are attributable to this condition. An abdominal physical examination will focus on tenderness, rigidity, and guarding. Abdomen percussion will determine if it is tympanic and if all quadrants produce normal bowel sounds. Superficial and deep palpation of the quadrants will be done to check for soreness or organomegaly. Neurological functioning, specifically any neurological deficits or changes in mental status, will also be assessed.
Differential Diagnoses
Based on the patient’s clinical manifestations and the tests therein, three primary differential diagnoses for her condition include acute cholecystitis due to her complaints of right upper quadrant pain, vomiting, and nausea (Peterson et al., 2019). The second differential diagnosis is acute pancreatitis because the patient exhibits such symptoms as vomiting, nausea, and a history of recent high-fat meal consumption. The third differential in the patient’s case is biliary colic, as the condition has clinical manifestations similar to acute cholecystitis without inflammation. div>Laboratory Tests to Rule out Differential Diagnoses
Additional laboratory tests are necessary to rule out differential diagnoses and develop a more accurate and reliable diagnosis. The Liver Function Test (LFT) will be ordered to evaluate liver function and assess for possible biliary obstruction. A serum lipase and amylase test will be conducted to confirm the diagnosis of pancreatitis. The patient will also undergo a complete blood count (CBC) and an electronic panel of tests. These tests will provide crucial data to confirm or rule out the differential diagnoses.
Radiological Examinations/Diagnostic Studies
As part of the radiological examination, I shall conduct an abdominal ultra-scan of the patient to evaluate the patient’s gallbladder for signs of inflammation or stones (Hasnain et al., 2018). As part of my evaluation, I will also conduct Mrs. Deer’s abdominal CT scan if the ultrasound findings are inconclusive and to inform the findings of the first radiological examination.
Treatment and Prescription Information, Possible Complications
The patient’s treatment will be pharmacological interventions to address her symptomatic relief, address dehydration issues, and counter any possible infections. The recommended pharmacological option for pain management is the utilization of NSAIDs such as acetaminophen (Miravent et al., 2023). The patient shall further be administered IV fluids to address the dehydration caused by her condition. The patient shall be administered antiemetics and antibiotics for possible infections to relieve nausea and vomiting. Some notable complications from the ordered treatment include allergic reactions to medications and adverse effects of antibiotics. Complications of untreated cholecystitis include gallbladder perforation, abscess formation, or bile duct obstruction.
Additional Laboratory Tests
Further tests will be conducted to investigate her renal and liver functions (Hasnain et al., 2018). Concerning this aspect, the most formidable tests shall be a serum bilirubin level test to evaluate liver function and assess for biliary obstruction and a comprehensive metabolic panel to assess Mrs. Deer’s renal function and electrolyte balance. These two tests shall further inform the patient’s treatment options and the accuracy of the diagnosis.
Additional Patient Teaching and Possible Consultation
I will provide the patient with additional teaching, specifically on the need for medication adherence and follow-up appointments, to enhance the effectiveness of the treatment. Owing to the dietary cause of the patient’s current condition, I shall educate the patient on the need for dietary modification and, more specifically, the essence of low-fat diet consumption to avoid exacerbating symptoms. The possible consultation to be considered is a gastroenterology consultation for further evaluation and management if necessary.
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