Case Study Analysis-Shannon a 32-Year-Old Mother of Two

Case Study Analysis-Shannon a 32-Year-Old Mother of Two

I would perform a general and abdominal exam for Shannon. Expected findings on general examination are a fever and an increased heart rate. There may also be signs of dehydration or electrolyte imbalances, especially since she has been vomiting. On the abdominal exam, there would be tenderness and guarding in the right upper quadrant (RUQ) of the abdomen (Vintila et al., 2020). The pain may be elicited upon palpation of the area or with a deep breath. Moreover, there may be the presence of a palpable mass or hepatomegaly. Signs of jaundice, such as yellowing of the skin or sclera, can also be present.

Based on the presented symptoms, Shannon may have an acute episode of cholecystitis. This is the inflammation of the gallbladder. The RUQ pain, which is tender to palpation, suggests an involvement of the gallbladder. The guarding could indicate peritoneal irritation. The light-colored emesis and chalky stool indicate a possible obstruction in the bile ducts, which could result from a gallstone.

The most appropriate investigation to confirm the suspected diagnosis would be an abdominal ultrasound. The ultrasound can identify the presence of gallstones and gallbladder inflammation (Pereira et al., 2020). It can also identify complications such as gallbladder perforation or abscess formation. In addition, blood tests such as a complete blood count (CBC) and liver function tests (LFTs) can also help evaluate the severity of the inflammation and the extent of liver involvement.

Pharmacological treatment typically involves pain management, antibiotic therapy, and addressing emesis (Gallaher & Charles, 2022). Pain can be managed with intravenous (IV) opioids such as morphine sulfate 2-4mg every 4-6 hours as needed. Antibiotic therapy can be IV ceftriaxone 1g once daily and metronidazole 500mg every 8 hours. For emesis, IV ondansetron 4mg every 8 hours can be given. The educational plan should include dietary modifications, such as avoiding high-fat foods, as well as the importance of hydration and rest. It is also important to provide education on the signs of worsening symptoms and when to seek medical attention.

References

Gallaher, J. R., & Charles, A. (2022). A Review of Acute Cholecystitis—Reply. JAMA, 328(1), 77-77. https://doi.org/10.1001/jama.2022.7771

Pereira, J., Bass, G. A., Mariani, D., Dumbrava, B. D., Casamassima, A., Da Silva, A. R., … & Zago, M. (2020). Surgeon-performed point-of-care ultrasound for acute cholecystitis: indications and limitations: a European Society for Trauma and Emergency Surgery (ESTES) consensus statement. European Journal of Trauma and Emergency Surgery, 46, 173-183. https://doi.org/10.1007/s00068-019-01197-z

Vintilă, A. M., Horumbă, M., & Vintilă, V. D. (2020). History and Physical Examination. Liver Diseases: A Multidisciplinary Textbook, 397-406. https://doi.org/10.1007/978-3-030-24432-3_34

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Case Study

Shannon, a 32-year-old mother of two, comes into your office with complaints of recent abdominal pain. She presents with pain in her right upper quadrant (RUQ), which is tender to palpation, and with the patient guarding in that area. She also complains of emesis (which was light in color) with the onset of pain not long after her BBQ dinner. Her stool this morning was chalky in appearance.

Please provide a specific answer, the exact medications, and dosing.

What exam would you perform for this patient?
What would be your diagnosis?
What diagnostic exam would be needed?
What would the pharmacological treatment and educational plan be?