Evita Alonso iHuman

Evita Alonso iHuman

Chief Complaint: “My stomach has been hurting really bad over the past 2 weeks.”

History of Present Illness:

Mrs. Alfonso is a 48-year-old female patient who present to the urgent-care clinic with a two-week history of intermittent, and progressive RUQ pain that has now increase over the past 2 days. The pain radiates to the right shoulder. She also complains of associated symptoms like nausea, vomiting, anorexia since the past 2 days. She has had previous recurrent self-resolving symptoms over the last one year. Family history is positive for biliary disease (mother) Evita Alonso iHuman. The patient is found to have low-grade temp elevation, mild scleral icterus, RUQ abdominal tenderness with guarding, and a positive Murphy’s sign

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Onset: 2 weeks ago, with symptoms becoming more dreadful 2 days ago

Location: Right upper quadrant and occasionally radiated to the right shoulder Duration: Pain has been constant since it started this time; in the past it only lasted 1-2 days.

Character: Crampy, gnawing, achiness

Aggravating/alleviating factors: Pain gets worse with meals and unresolved with antacids and NSAIDs Related symptoms: Nausea. Vomiting, anorexia with onset of symptoms 2 days ago. Denies any recent exposure to other ill contacts. She has had similar symptoms previously

Treatments: Has tried OTC antacids and ibuprofen without relief

Significance: Pain starts with a scale of 2-3 and gets up to 6-7. She reports pain has kept her home from work Evita Alonso iHuman.

Primary Diagnosis

Ascending Cholangitis

This diagnosis may be acute or chronic. The gallbladder is a small organ that is a part of your gastrointestinal system which stores and excretes bile to help the body break down fat. Gallstones can form and clog the organ. In your case the gallstones have caused symptoms such as abdominal pain, right shoulder pain, nausea, and vomiting. You need to be admitted to the hospital because according to the tests we ran you may have a clogged duct leading to inflammation and infection. This is not a disease process that is typically treated as an outpatient. You may require surgery or additional testing such as an MRCP to look at the ducts. The surgery which may be needed is called a cholecystectomy. It is a very common procedure performed and is often done laparoscopically and can sometimes be performed as an outpatient procedure. The procedure itself does have some risks since anesthesia is required, but after the gallbladder is removed there will be no return of gallstones. You have an increased risk of forming gallstones when you are overweight (Crowley & Martin, 2022).

The diagnosis for Pt is ascending cholangitis. It is characterised by jaundice, abdominal pai, and fever that develops due to infection and stasis in the biliary tract. Fever, chills, malaise, rigors, widespread abdominal discomfort, pruritus, and pale stools are among the ascending cholangitis symptoms (Chatterjee, Mavani, & Bhatttacharyya, 2022). The Pt reported vomiting nausea, stomach pain, and anorexia. The Pt has a family history of biliary disease and ascending cholangitis develops as a result of biliary tract infection. The family history is a risk factor for developing ascending cholangitis.

Alternative Diagnosis

Cholecystitis

Cholecystitis is an alternative diagnosis. Stones that obstruct the tube connecting the gallbladder to the small intestine can cause cholecystitis. Bloating and excruciating upper-right abdominal pain are symptoms for cholecystitis. The Pt reported pain that radiate at the right at the right shoulder meaning he can be suffering from cholecystitis. Other symptoms for cholesystitis reported by the Pt include nausea, fever, vomiting, and tenderness over the abdomen, pain spreading to the right shoulder or back, and sever pain at the abdomen (Chatterjee et al., 2022),

Pancreatitis Acute

Another possible diagnosis is pancreatitis acute.  It is a condition that leading to inflammation and enlargement of pancreas for a short time. The systems of pancreatitis acute include nausea, vomiting, fever, abdomen tenderness, abdominal pain radiating to the back, and rapid pulse. The symptoms reported by the Pt resemble most of the pancreatitis acute disorder symptoms.

Peptic Ulcer Disease

The last alternative diagnosis is peptic ulcers. It develops when acid digestive tract acid eats ways to the small intestine or stomach’s inner surface. The symptoms for peptic ulcers include burning stomach pain, heartburn, nausea, bloating and heartburn (Hatnoorkar & Rajpal, 2022) Evita Alonso iHuman. Since the patient reported stomach pain, nausea, and vomiting is possible to consider peptic ulcers as a possible diagnosis.

Case: Management Plan:

Pharmacologic Care:

• Start IV
• Collect blood culture x2
• Give Ertapenem 1g IV
• Consult general Surgery for the next steps

Supportive Care:

Make NPO

Give 0.9% IV normal Saline 100ml bolus, then 50 ml per hours

Give Zosyn 3.375 g IV every 6 hours for 7 days

Zofran 4mg IV every 6 hours as needed for nausea/vomiting.

Check blood glucose every 4 hours to monitor for hypoglycemia due to NPO status.

Patient Education

• Offered education on diagnosis, need for continued evaluation in the emergency department given fever and anticipated course. Patient expressed understanding and had no further questions.

Follow-Up:

• Alert staff if has increased pain, nausea, fever, lightheadedness, fatigue, or any other needs while in the emergency department.
• Follow up in clinic post-Op 1-2 weeks after discharge. If gallbladder is removed, decrease fat in diet and eat small meals. Avoid any strenuous activities or lifting. Take pain medication as prescribed.
• Contact a physician if pain is not adequately controlled. If you have symptoms of infection such as fever/chills or bleeding contact the urgent care as soon as possible Evita Alonso iHuman.

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.

https://www.uptodate.com/contents/gallstones-the-basics?search=cholecystitis

%20diagnosis&topicRef=666&source=related link

Hatnoorkar, S. A., & Rajpal, C. (2022). Homoeopathy and Acid Peptic Disorder. Journal of

Medical and Pharmaceutical Innovation, 9(45).

I-HUMAN CASE STUDY: EVALUATING AND MANAGING GENITOURINARY OR GASTROINTESTINAL CONDITIONS

Urinary frequency is an example of a genitourinary condition that presents problems for adults across the lifespan. It can be the result of various systemic conditions such as diabetes, urinary tract infections, enlarged prostates, kidney infections, or prostate cancer. Many of these conditions have very serious implications requiring thorough patient evaluations. When evaluating patients, it is essential to carefully assess the patient’s personal, medical, and family history prior to recommending certain physical exams and diagnostic testing, as sometimes the benefits of these exams do not outweigh the risks.

For this Case Study Assignment, you will analyze an i-Human simulation case study about an adult patient with a gastrointestinal condition. Based on the patient’s information, you will formulate a differential diagnosis, evaluate treatment options, and then create an appropriate treatment plan for the patient.

RESOURCES

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE:

• Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with GI or GU conditions.
• Access i-Human from this week’s Learning Resources and review this week’s i-Human case study. Based on the provided patient information, think about the health history you would need to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
• Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
• Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
• Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with GI or GU conditions.

Assignment

As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.

BY DAY 7

• Complete your Assignment in i-Human
• Upload your PDF from i-Human to this assignment

SUBMISSION INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

1. To submit your completed assignment, save your Assignment as WK7Assgn+last name+first initial
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.