NRNP 6531 WEEK_7 iHuman Case Study Evita Alonso - 48-

year-old Hispanic female CC: Abdominal pain COMPLETE

EXPERT FEEDBACK (ANSWERS) 2023 UPDATE
 CC: abdominal pain

HPI:
Evita Alonso 48-year-old Hispanic female. A&O x 4. Appears well developed, well nourished.
Patient reportshaving intermittent upper right quadrant abdominal pain that started 2 weeks ago.
Has progressively gotten worse over the last 2 days and is now constant. Describes it as a
constant deep abdominal cramping, gnawing, and achiness under right ribs deep inside which
radiates with pain in the right shoulder. Severity 4/10. Reports nausea and vomiting and fever for
2 days.Reports history of acid reflux. Use of antacids and Ibuprofen provides no relief for her
current abdominal pain. Patient reports pain is brought on by eating food. Patient reports not
drinking adequate amount of fluid because of the vomiting. History of abdominal pain a few
times over the last year that has always gone away on its own, but never this severe. Patient
denies dysphagia, chest pain, SOB, blood in emesis, blood in stool or blood in urine. Denies any
one event or activity associated with the onset of her abdominal pain.
Location: Abdomen
Onset: 2 weeks ago
Character: constant cramping, gnawing, achiness in upper right abdomen under ribs
Associated signs and symptoms: nausea, vomiting, fever, radiating pain to right shoulder.
Timing: After eating meals
Exacerbating/relieving factors: Eating food makes it worse. No relieving factors, antacids do not
work.
Severity: 4/10 today. Starts as a 2-3/10 and increases up to 6-7/10 on other days.
Allergies: NKDA
Medications:
• Ibuprofen 400mg TID prn pain
• OTC antacids prn acid reflux
PMH:
• Occasional acid reflux, heartburn, relieved with OTC antacids
• Occasional knee pain and stiffness, with frequent use of Ibuprofen prn
Hospitalizations: No open surgeries. Childbirth. G3P3. Bilateral tubal ligation with last delivery.
Preventative Health:
 • CA Screening modalities for gender/age: Regular annual health screening 4 months ago,
yearly gynecologic exam last year.
• Fitness: walks daily, light weight training 3 x week at the gym.
• Nutrition: Mediterranean diet, avoids fast food.
• Stress reduction: enjoys family time.
Social history:
• Marital status/Support system: Married x 18 years. Parents live 3 hours away.
• Children: 3 children, doing well in school, and physically active.
• Housing: Off base private housing
• Occupation: Army Lieutenant Colonel
• Substance/Alcohol use: Reports 2 glasses of wine with dinner. Has not had any alcohol
for last 2 days. Denies tobacco products and illicit drug use.
Family Medical History:
• Father: age 70, well health. History of heart disease, Peptic ulcer disease
• Mother: age 69, well health. Breast CA in remission; s/p cholecystectomy for
cholelithiasis.
ROS:
General: Reports abdominal pain, radiating right shoulder pain x 2 weeks. Reports nausea and
vomiting, fever x 2 days.
HEENT: Denies dysphagia
Cardiovascular: Denies heart disease, chest pain, angina.
Respiratory: Denies respiratory difficulty, SOB.
Gastrointestinal: Reports upper right quadrant abdominal pain 4/10 x 2 weeks, getting worse
over last 2 days. Reports nausea and vomiting x 2 days. Denies blood in emesis. Denies
constipation, diarrhea, or blood in stool.
Genitourinary: Reports decreased urine output with dark colored urine. Denies blood in urine.
Denies menstrual problems, or irregular menses.
Musculoskeletal: Reports radiating right shoulder pain 4/10.
Neurologic: negative
Integument/Breasts: negative
Psychiatric: Reports eating Mediterranean diet. Exercising regularly.
Endocrine: Reports fever x 2 days
Hematologic/Lymphatic: Denies bleeding.
Allergic/Immunologic: Reports up to date on vaccinations, and flu vaccination current.
Objective
Vitals: Ht. 5’6”, 170.0 lbs, BMI 27.4. Temp. 100.0 ° F. B/P left arm, lying: 136/78, narrow,
elevated pulse pressure. HR 92, Resp. 12, SPO2 98% on ambient air.
General: 48-year-old Hispanic female. A & O x 4. Appears stated age, well developed, well-
nourished.
HEENT: Head, neck, and face appear symmetrical. Mild conjunctival icterus OU. No unusual
breath odor. Swallow normal, thyroid moves with swallowing, no edema.
Cardiovascular: RRR, no murmurs, gallops. PMI at 5th intercostal space at mid-clavicular line.
No visual peripheral edema. Peripheral pulses less than 3 seconds bilateral fingers and toes.
Quincke’s test negative.
Respiratory: Chest symmetrical. AP diameter is normal. The excursion with respiration is
symmetrical and there are no abnormal retractions or use of accessory muscles. Unlabored,
regular respiratory rate. Clear to auscultation in all fields. No splinting.
Gastrointestinal: Abdomen atraumatic, soft, round, mildly obese, non-distended. Hyperactive
bowel sounds. No hepatosplenomegaly, palpable gallbladder, mass, herniation, or abnormal
pulsations. Tender to RUQ palpation, voluntary guarding present, no rebound. Positive Murphy’s
sign. Reported discomfort with right flank percussion. Non-tender throughout remainder of
exam. No scars, masses, or rashes.
Genitourinary: oliguria. Drinking Gatorade.
Musculoskeletal: Well-developed, good tone and musculature. MAEW.
Neurologic: CN I-XII intact. Thought processes and speech appropriate.
Integument/Breasts: Skin warm and dry. Quincke’s test; blanching observed. Normal skin turgor.
No pallor, jaundice, rash, or lesions. No ecchymosis, or petechiae.
Psychiatric: Appropriate mood and affect.
Endocrine: Febrile. Temp 100° F.
Hematologic/Lymphatic: No lymphadenopathy.
Allergic/Immunologic: negative
Assessment
Problem Statement:
This patient presents with two-week onset of RUQ abdominal pain, radiating right shoulder pain,
which has progressively worsened in the last two days with nausea vomiting and fever. Patient
presents with Temp 100.0° F, conjunctival icterus OU, a positive Murphy’s sign, RUQ
tenderness. Patient is negative for jaundice, hematemesis, hematuria, and hematochezia.
Suspected cholelithiasis.
Assessment
DX:
1. Cholelithiasis

1. Cholelithiasis refers to gallstones in the biliary tract, usually in the gallbladder. This
patient has a history of intermittent colicky RUQ abdominal discomfort of several
months’ duration. Pain is now constant and lasting over 30 minutes and not relieved with
NSAIDS or antacids. In addition, she presents with associated symptoms of nausea,
vomiting, radiating right shoulder pain, fever, jaundice, and a positive Murphy’s sign. All
are key diagnostic factors for symptomatic cholelithiasis (Gilbert et al., 2021). US of
abdomen confirmed cholelithiasis which requires referral to specialist for surgical
intervention with laparoscopic cholecystectomy, which is considered the “Gold Standard”
of treatment (Stanisic et al., 2020).
DDX:
1. Choledocholithiasis.

➢ Choledocholithiasis refers to the presence of gallstones that block the common bile duct.
Obstructed bile will back up into the liver and lead to jaundice. Which this patient is
positive for icterus. Signs and symptoms of cholelithiasis and choledocholithiasis are
similar and overlap (Stanisic et al., 2020). In this patient’s case, laparoscopic
cholecystectomy is the treatment for gallstones as recommended in the abdominal
ultrasound. However, the reported standard treatment for the common bile duct stones in
single-stage techniques include laparoscopic common bile duct exploration (LCBDE),
and intraoperative endoscopic retrograde cholangiopancreatography (iERCP) and bile
duct exploration (Vakayil et al., 2020).

2. Cholecystitis

➢ Cholecystitis is inflammation of the gallbladder and commonly presents with a positive

Murphy’s sign, history of previous colicky biliary pain in the RUQ, abdominal mass,
right shoulder pain, anorexia, nausea, vomiting, jaundice, and fever. Abdominal US is the
first-line test for diagnosis of cholecystitis (Shaish, Ma, & Ahmed, 2021). This patient
presents with all of the listed symptoms, except for the abdominal mass as outlined in the
US. As previously mentioned, those symptoms are similar to the signs and symptoms of
cholelithiasis and choledocholithiasis. However, it was not a finding on US (Stanisic et
al., 2020).
 3. Cholangitis-

➢ Classic symptoms of cholangitis are the Charcot triad: fever & chills, jaundice, and RUQ
abdominal pain, but can also present with pale stools and pruritis, hypotension, and
changes in mental status. People with cholangitis typically have diffuse pain and a
negative Murphy’s sign (Miura et al., 2013). This diagnosis requires MRI for
confirmation and is unlikely.

4. Peptic Ulcer Disease (PUD)

➢ Peptic Ulcer Disease is linked to H. pylori infection and described as an inflammation of

the epithelial lining of the stomach and duodenum (Périco et al, 2020). Erosion and
perforation of the lining can cause bleeding with severe epigastric pain and burning,
bloody emesis, and bloody stools. This patient does have a history of acid reflux, but does
not present with epigastric pain, hemoptysis, or hematochezia, at this time. This diagnosis
can be ruled out.
Plan
Additional labs or diagnostic tests: Tests performed: Abdominal US, CMP, CBC. No additional
tests are recommended at this time unless ordered by specialist.
Consults: Referral to specialist with direct hospital admit with recommended first-line therapy
of laparoscopic cholecystectomy for Acute cholelithiasis (Ikumoto et al., 2015).
Therapeutic modalities: Provide supportive therapy. Levofloxacin 500mg PO QD x 5 days,
Metronidazole 500mg PO BID x 5 days, Promethazine suppository 25mg q4-6h prn
nausea/vomiting, Oxycodone/APAP 5/325mg PO q4-6h prn pain (Gilbert et al., 2021).
For direct hospital admit; Orders: NPO, peripheral IV; 1 liter 0.9% NS @ 100ml/hr. Start
Zozyn 3.375g IVPB over 30 minutes q 6h [totaling 13.5 g] (Gilbert et al., 2021).
Health Promotion: Advise patient on low fat dietary regimen, weight reduction and provide
literature on preparing for endoscopic cholecystectomy and pre-operative orders. Addressed risk
factors for conversion of laparoscopic cholecystectomy to open cholecystectomy (Stanisic et al.,
2020).
➢ Early intervention with single incision laparoscopy reduces the risk for conversion,
decreases incidence of high mortality rate and comorbidities (Ikumoto et al., 2015).
The incidence of previous attacks, WBC count, and gallbladder wall thickness can be
a preoperative predictor for risk of conversion cholecystectomy (Nidoni et al., 2015).
Patient education: Discussed with patient and family, and provided written literature on the
risks and benefits of surgical intervention for the treatment of acute cholelithiasis, possible
complications, use of stents, etc. (Rice et al., 2019; Sugawara et al., 2020). Discussed the need
for early surgical intervention, use of anesthesia, length of procedure and recovery period
(Stanisic et al., 2020; Rice et al., 2019). Patient educated on post operative discomfort and home
care.
Disposition/Follow up instructions: Patient is to follow up 1 week postoperatively or sooner if
needed. Advised to be alert for suspected signs and symptoms of post operative infection, e.g.,
fever, bleeding, uncontrolled vomiting, or extreme pain that could be manifestations of
complications, and is advised to come to office or go directly to the ER.
References
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