inhuman Case Study Evita Alonso, 48yrs Old Female Hispanic

American Female CC: Abdominal Pain 3 DIFFERENT VERSIONS OF

THE ANSWER EXPERT FEEDBACK (SOLUTIONS) NRNP 6531 WEEK
7 IHUMAN WALDEN UNIVERSITY

[CONTENTS: OLD-CARTS for the HPI, (PMH, FH, SH as Needed), PHSICAL

EXAM, EXAMS FEEDBACK, CASE FINDINGS, FEEDBACK, DIFFERENTIAL
RANKING, DIAGNOSIS, CASE PLAN, List the differential diagnoses (Must not
Miss/Leading/Alternate/Concluding)
]
CC: 48 y/o F HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in “quotes” Mrs. Alonso is a 48-year-old female patient who presented to the clinic with a
progressive, intermittent right upper quadrant pain for the past 2 weeks and
“My stomach has been hurting really bad over which has increased in severity in the past 2 days. The pain radiates to the right
the past 2 seeks” 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. Pain used to be precipitated by fast food but not
occurs with all foods and unresponsive with antacids and NSAIDS.
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 gnaw 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.

PMHx child/adult Surh type/when/why/complications

illness/hospitalizations/immunizations
Negative for any chronic illnesses. She has Tubal ligation
occasional heartburn and arthritis
Frequent episodes of common colds and as child
No hospitalizations, trauma or other injuries
Immunizations: States her immunizations are
current. She had the influenza vaccine this
season and still got the flu.

Fahm TX
Grandparents (if known)/Parents/siblings/children Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships

Grandparents- states no known history She reports that she drinks a glass of wine with dinner most nights; She denies
Father is 70 years-old and still alive and well any tobacco or recreational drug use
(70): heart disease, peptic ulcer disease
Mother is 69 years-old and alive: breast cancer in
remission; cholecystectomy for cholelithiasis

Reproductive Hex Allergies (Food, Drug, Environmental, etc.)

Female: Age of menarche/menstruation cycle
duration/gravida para status/Childbirth hex/sexual hex No known drug allergies
and concerns/LMP/menopause
Breast/cervical screening (if any)
Male: Sexual hex and concerns/issues with fertility
(if any)/Testicular or prostate screening (if List of Medications/supplements (prescription, OTC, complementary
applicable) Screening for STI’s (if applicable) alternative therapies)

Pertinent sexual history: Not sexually active and Antacids as needed for "heartburn"
denies any sexual concerns Ibuprofen 400 mg three times daily as needed for knee pain
Multivitamins

Review of Systems: (ROS) Use this column to From the ROS: list/highlight the current symptoms/complaints to generate a
document the ROS below. list of “reported or denied” symptoms below:
General: Reports some weight loss, fever, night
sweats, and difficulty sleeping Pertinent positive ROS: Reports some weight loss, fever, night sweats, and
HEENT: Denies headaches, changes in vision, difficulty sleeping; RUQ abdominal that worsens with food and pain scale of 2-
3/10 and progresses to 6-7/10, 6/10. Anorexia, nausea and vomiting at onset.
hearing, pain in ears o sinuses, denies nasal
drainage, denies sore throat or difficulty Pertinent negative ROS: no recent illness, denies headaches denies constipation
swallowing. and diarrhea, no painful urination, no myalgias or recent trauma; Negative for hip
Neck/Thyroid: Denies any pain or swelling. joint deformities or pain.
Pulmonary: Denies SOB, cough, wheezing, or
pain on deep breathing
CV: Denies chest pain, palpitations, edema, or
syncopal episodes.
GI: Report’s nausea vomiting and anorexia.
Denies diarrhea or constipations. RUQ
abdominal pain.
GU: Denies dysuria or difficulty urinating.
MS: Denies muscle or joint pain or swelling
Heme: No complaints of bruising or frequent
epistaxis
Lymph: No complaint of cervical
lymphadenopathy.
Endocrine: No complaint polyuria, polydipsia,
polyphagia, or heat/cold intolerance.
Derma: Denies unusual moles, rashes, lesions.
Neuro: Denies dizziness, seizures or headaches
Psych: No complaints of sadness, hopelessness,
or panic attacks.

Physical Exam: (PE) Use this column to From the PE: list/highlight the presence or absence of objective findings to
document the PE below. generate a list of pertinent “(+) or (-)” symptoms below:
Vitals Temperature: 100.0 F (oral)
Pulse: 92 bpm - regular
Blood pressure: 136/76 mmHg - supine/sitting Pertinent (+) PE findings: Elevated b/p, overweight, low-grade fever; Scleral
Blood pressure: 126/70 mmHg - upon standing icterus; tender to palpation RUQ with voluntary guarding, positive murphy sign,
Respiratory rate: 16 bpm and discomfort with right flank percussion
SpO2: 98% on room air
Height: 5' 6" (168.0 cm) Pertinent (-) PE findings: Bowel sounds normal in all 4 quadrants, Posterior
Weight: 170 lbs. (77.0 kg) (BMI 27.4) pharynx non erythematous, Negative for visible or palpable inguinal hernias,
Skin around RUQ is normal without redness or induration. no sublingual
jaundice.
General: Middle aged woman with abdominal
pain
HEENT: Scleral icterus, oral mucosa moist
No cervical lymphadenopathy, no sublingual
jaundice
Neck: Supple, normal ROM, no pain with ROM.
Negative for cervical lymphadenopathy.
Plum: Lungs are clear to auscultation
anterior/posterior bilaterally. No cough or
wheezes.
CV: HR 92, Normal heart rate and rhythm
GI: BS normal X 4; Soft, tender to palpation of
RUQ with voluntary guarding, positive murphy
sign, and discomfort with right flank percussion.
GU: No visible or palpable inguinal hernias.
Normal pelvic exam, No masses or tenderness
MS: Normal bulk and tone
Derma: Skin warm, dry. Hair and nails normal.
Skin color appropriate for ethnicity. Skin around
RUQ is normal without redness or induration.
No pallor, jaundice, rash, or lesions
Normal skin turgor
Neuro: Negative exam
Psych: Appropriate speech, judgment,
cooperative.
Lab/Radiology or other Diagnostic data: Problem Statement:
EA is a 48-year-old female patient who presented to the clinic with a
CMP and UA unremarkable.
progressive, intermittent right upper quadrant pain for the past 2 weeks and
CBC is unremarkable except for slight elevation which has increased in severity in the past 2 days. The pain radiates to the right
of neutrophils shoulder. She also complains of associated symptoms like nausea, vomiting,
anorexia since the past 2 days. She has had previous recurrent self-resolving
Abdominal ultrasound shows dilated common
symptoms over the last one year. Pain used to be precipitated by fast food but not
bile duct (CBD) and CBD stone.
occurs with all foods and unresponsive with antacids and NSAIDS. She has a
low grade of fever of 100.0 and tachycardia. PE shows mild scleral icterus, RUQ
abdominal tenderness and voluntary guarding as well as a positive Murphy’s
sign. CBC is unremarkable except for slight elevation of neutrophils. CMP and
UA unremarkable. Abdominal ultrasound shows dilated common bile duct
(CBD) and CBD stone.

IHUMAN TOTAL CASE SCORES: Average List the differential diagnoses (Must not
90.5% Miss/Leading/Alternate/Concluding)
#1: 81% *Include ICD 10 codes after each
#2: 100%

Based on patient’s age/risk factors, what

preventive screening would be recommended Leading/Must not miss Diagnosis
at todays or a future visit: Choledocholithiasis (K80.50): is the most likely diagnosis because EA’s
symptoms of colicky intermittent pain that is exacerbated by eating, RUQ
Grade A recommendations location of the pain with radiation to the shoulders, the positive murphy’s sign as
• Cervical Cancer: Screening: women well as the ultrasound that is positive with CBD dilation and presence of CBD
stones.
 aged 21 to 65 years
Alternate diagnosis
• High Blood Pressure adults over age 18.
Check periodically for evidence of Nephrolithiasis (N20.0): is less likely because of the positive murphy’s sign
elevated bop readings (Blood pressure is
Pelvic ulcer disease (PUD) (K27.0): is not likely; the frequent use of NSAIDs
slightly elevated probably secondary to
by the patient is a risk factor, but the location of pain and the fact that food
abdominal pain)
exacerbates pain and not alleviate the pain rules out this condition

Grade B recommendations
(ICD10data.com, 2021)
• Type 2 Diabetes Mellitus: Screening:
adults aged 40 to 70 years who are
overweight or obese (BMI > 25)
• BRCA-Related Cancer: Risk
Assessment, Genetic Counseling, and
Genetic Testing: women with a personal
or family history of breast cancer
(mother of patient had breast cancer)
• Depression in Adults: Screening: general
adult population, including pregnant and
postpartum women (Denies depression)

• STI screening (not currently sexually

active)

• Unhealthy Drug Use: Screening: adults

age 18 years or older (Denies any
inappropriate drug use)
 • Weight Loss to Prevent Obesity-Related
Morbidity and Mortality in Adults:
Behavioral Interventions: adults

(USPSTF, 2021)

*Case Study Template adapted from the following sources: NP H & P (ReNursing.edu, 2018) and Inhuman Patients by Kaplan (2020)

Reflective Thinking Exercises (start a new page)

1. History-Taking: Describe your history taking scores and strengths you identified when gathering data. What went
well? Also, describe your challenges in gathering data and list areas of your personal needed improvement. Note any
missed areas that could be safety issues/errors leading to missed or incorrect diagnosis.
 I have seen good improvement with history taking, but I still cannot get all the required interview questions on the first
attempt. My history taking scores are still low the first attempt was 73% with an improvement with the second attempt of
100%. The Dain textbook was a great resource in focusing my interview questions

2. Physical Exam: Describe your physical exam scores and strengths you identified when performing selected exams on
your patient. Did you perform an excessive amount of exam items? Did you miss any pertinent exam items identified in
the case leading to diagnosis? Note any missed areas that could be safety issues/errors leading to missed or incorrect
diagnosis.

Physical exam scores are 88% for the first attempt and 100% for the second attempt. I see great improvement in this section.
This is the area that I have seen the most growth since the beginning of the semester. I still need to get my auscultation skills
perfected as I still get feedback that I missed something in the sequence

3. Evidence-based decision making: Discuss the evidence-based resource(s) utilized while seeing the patient. These can be
your course readings/IHUMAN lessons/other course info as well as any external articles or supporting literature to
help you gain a better understanding of categorizing possible diagnoses in your case. How did you use the
symptoms/patient presentation, plus your exam findings, to formulate a differential diagnosis list? What specific
feedback from previous case studies has your faculty identified that you plan to incorporate on future cases to avoid
pitfalls in data gathering or decision making? What will you do differently to improve?

The required text readings from S2D and Dain was very beneficial especially S2D with identifying differential diagnosis. As I
get more familiar with the course material, I do not agree with all the expert feedback on the differential diagnosis. Some of
the diagnosis that I chose fit the symptoms of the patient and were still not listed in the expert list.

References

ICD10Data.com. 2021 ICD-10-CM Codes. https://www.icd10data.com/ICD10CM/Codes.

Johnson, N. (2018) NP H & P. Enringed LLC.

Kaplan, Inc. (2020). Case study: Emma Ryan. Inhuman patients by Kaplan.

Pettigrew, M. M., Gent, J. F., Pyles, R. B., Miller, A. L., Nooks-Koivisto, J., & Committee, T. (2011). Viral-Bacterial Interactions
and Risk of Acute Otitis Media Complicating Upper Respiratory Tract Infection. Journal of Clinical Microbiology, 49(11),
3750–3755. https://doi.org/10.1128/jcm.01186-11
United States Preventive Services Taskforce (2021). A and B Recommendations: United States Preventive Services Taskforce. A and
B Recommendations | United States Preventive Services Taskforce.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations.
NRNP 6531 WEEK_7 inhuman Case Study Evita Alonso -
48-year-old Hispanic female CC: Abdominal pain
COMPLETE 2 DIFFERENT EXPERT FEEDBACK
(ANSWERS) 2023 UPDATE

CONTENTS: ALL QUESTIONS, OLD-CARTS for the HPI, (PMH, FH, SH as

Needed), PHSICAL EXAM, EXAMS FEEDBACK, CASE
FINDINGS, FEEDBACK, DIFFERENTIAL RANKING, DIAGNOSIS, CASE PLAN

VERSION A
CC: abdominal pain

HPI:
48- year-old Hispanic female. A&O x 4. Appears well developed, well nourished. Patient reports
having 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
(Statistic 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 (Statistic 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 (pierce) and bile duct
exploration (Vakeel 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 (Shawish, 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 (Statistic 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 (Pericu 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 (Okumoto 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
Zosyn 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 (Statistic et al.,
2020).
➢ Early intervention with single incision laparoscopy reduces the risk for conversion,
decreases incidence of high mortality rate and comorbidities (Okumoto et al., 2015).
The incidence of previous attacks, WBC count, and gallbladder wall thickness can be
a preoperative predictor for risk of conversion cholecystectomy (Nardoni 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
(Statistic 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
Gilbert, D. N., Chambers, H. F., Saag, M. S., Pavia, A. T., Boucher, H. W., Black, D., Freedman,
D. O., Kim, K., & Schwartz, B. S. (2021). The Sanford guide to antimicrobial therapy
2021. Sperryville, VA, USA: Antimicrobial Therapy, Inc.
Okumoto, T., Yamagishi, H., Iwata, M., Sano, Y., Kotaku, M., & Imai, Y. (2015). Feasibility of
single-incision laparoscopic cholecystectomy for acute cholecystitis. World journal of
gastrointestinal endoscopy, 7(19), 1327–1333.
J Korean Soc Radial. The Efficacy of Preoperative Percutaneous Cholecystostomy for Acute
Cholecystitis with Gallbladder Perforation2017 Dec;77(6):372-381.
Miura, F., Takada, T., Strasberg, S.M. et al. TG13 flowchart for the management of acute
cholangitis and cholecystitis. J Hepatobiliary Pancreas Sci 20, 47–54 (2013).
Nardoni, R., Utahan, T. V., Assur, P., Bazooka, R., Singular, V., & Narasinga, B. (2015).
Predicting Difficult Laparoscopic Cholecystectomy Based on Clinic radiological
Assessment. Journal of clinical and diagnostic research: JCDR, 9(12), PC09–PC12.
Pericu, L. L., Emilio-Silva, M. T., Ohara, R., Rodrigues, V. P., Bueno, G., Barbosa-Filho, J. M.,
Rocha, L. R. M. da, Batista, L. M., & Hiruma-Lima, C. A. (2020). Systematic Analysis of
Monoterpenes: Advances and Challenges in the Treatment of Peptic Ulcer
Diseases. Biomolecules, 10(2).
Rice, C. P., Vaishnavi, K. B., Chao, C., Jupiter, D., Schaeffer, A. B., Jenson, W. R., Griffin, L.
W.,
& Mile ski, W. J. (2019). Operative complications and economic outcomes of
cholecystectomy for acute cholecystitis. World journal of gastroenterology, 25(48), 6916–
6927.
Shawish, H., Ma, H. Y., & Ahmed, F. S. (2021). The utility of an under-distended gallbladder on
ultrasound in ruling out acute cholecystitis. Abdominal Radiology (New York), 46(6),
2498–2504.
Shah, A. A., Bhatti, U. F., Petrosian, M., Washington, G., Nizam, W., Williams, M., Tran, D.,
Cornwell, E. E., 3rd, & Fullum, T. M. (2019). The heavy price of conversion from
laparoscopic to open procedures for emergent cholecystectomies. American journal of
surgery, 217(4), 732–738.
Statistic, Vaseline & Milicevic, Miroslav & Kolev, Nikola & Statistic, Balsa. (2020). A
prospective cohort study for prediction of difficult laparoscopic cholecystectomy. Annals
of Medicine and Surgery. 60. 10.1016/j.amsu.2020.11.082.
Sugawara, S., Sone, M., Morita, S., Hijiki, S., Sakamoto, Y., Katsumoto, M., and Yasuaki, Arai,
Y. (2020). Radiologic Assessment for endoscopic US-guided biliary drainage.
Radiographic 2020 40:3, 667-683
Vakeel, V., Clinker, S. T., Sulkier, M. L., Mallick, R., Ragunathan, G., Amateur, S. K., Davido,
H. T., Freeman, M., & Harmon, J. V. (2020). Single-stage management of
choledocholithiasis: intraoperative ERCP versus laparoscopic common bile duct
exploration. Surgical Endoscopy, 34(10), 4616–4625.
Zafar SN, Breeze A, Aesopian B, Cornwell EE 3rd, Fullum TM, Tran DD. Optimal time for
early laparoscopic cholecystectomy for acute cholecystitis. JAMA Surg 2015; 150:129-
136
 VERSION B

HPI: You will type this in the EMR section of the case (NOT the problem statement)

CC: Abdominal pain

Evita Alonso is a 48-year-old Hispanic American female. She has had abdominal discomfort for
two months off and on that has increased over the last two days and now is constant. She
explained the pain is located in the right side of her upper abdomen, under her ribs with radiation
to right shoulder. She describes the character of the pain as crampy, gnawing, and achiness that
increases when she eats a meal and the pain in her shoulder as an ache. She rates her pain at 2-3,
elevates to 6-7. She has also been experiencing nausea and vomiting for the last two days along
with fever and chills for two days, she has not been able to keep any nutrients down. Over the
last 2 months she has noted some bloating, decreased appetite, and increase in symptoms when
she eats fast food. She has tried using antacids to treat this discomfort with no symptom relief.

Plan: Type the information regarding each of the following sections into the I-Human Plan
section of your case. You must address each of the 6 topics. For example, if you will not be
consulting anyone then you must write “no consults indicated”. Each section of the plan is
worth 5 points to total 30 points.

Diagnosis: choledocholithiasis
Symptoms
Pain in the right upper or middle upper abdomen for at least 30 minutes. The pain may be
constant and intense. It can be mild or severe. Fever, yellowing of skin and whites of the eyes
(jaundice), loss of appetite, nausea, vomiting, and clay-colored stools.
Essentials of DX: History of biliary pain, maybe accompanied by jaundice. Patients sometimes
present with painless jaundice. Cholangitis should be suspected with fever, followed by
hypothermia, and gram-negative shock, jaundice, and leukocytosis. Stones in the bile duct are
best detected by EUS or ERCP
Choledocholithiasis refers to the presence of one or more gallstones in the common bile duct.
with the potential development of cholangitis and ascending infections. Acute common bile duct
obstruction produces an acute increase in the lever of liver enzymes ALP, AST and ALT
followed by increased serum bilirubin level. Evita Alonso had an elevation in ALP, AST, and
ALT indicating acute obstruction along with assessment findings that corelate with
choledocholithiasis diagnosis. Mild scleral icterus was noted during visual inspection if the eyes,
this is also known as jaundice indicating accumulation if bile pigment (bilirubin) in the body.

Diagnostic test of choice is a transabdominal ultrasound, can be performed to look for dilation
of the common bile duct, along with the presence of shadowing if the gallstone can be seen.

The ultrasound results indicated cholelithiasis, probable choledocholithiasis with intrahepatic

biliary tree dilation.
Additional labs or diagnostic tests:
CBC- abnormal CBC with differential. Borderline leukocytosis with neutrophilia and mild left
shift.
CBC is indicated to rule out infection, know severity of infection, assist in treatment, and assist
with decision to use antibiotic treatment if necessary. Bile duct obstructions left untreated can
lead to life threatening infections

Chem- elevated BUN/creatinine ratio, abnormal liver enzymes: obstructive pattern.

Chemistry labs are ordered to examine liver function, kidney function and systems involved in
diagnosis.
Consults: Direct admit or emergency room would be indicated for the choledocholithiasis due to
the severity of the potential outcome and infections related to this diagnosis. Gastroenterology
and surgical consult upon arrival to further the treatment plan and decide on further imaging
studies, surgery and needed treatments.
Therapeutic modalities:
Medication is focused on pain, nausea, and infection control. There is no medication that will
eliminate or treat this diagnosis alone.
A one-time dose of 50 mg to 100 mg rectal indomethacin can be used to prevent post-procedure
pancreatitis if the pancreatic duct was manipulated during an ERCP. Antibiotics are typically not
needed for choledocholithiasis unless the patient also has associated cholecystitis or cholangitis.

Treatment options for biliary obstruction include cholecystectomy and ERCP. ERCP may remove
the small stones in the bile duct or a placing a stent in the duct to restore flow may be necessary
depending on the severity.

Health Promotion: The patient is at risk of gallstones, as they are twice as common in first-
degree relatives, and she has direct relatives with similar gallbladder disfunction. Gallstones are
also more common in people over the age of 40 and more likely in females, the patient is a 48-
year-old female. Obesity also presents as a significant risk factor in the development of
cholesterol gallstones. Rapid weight loss associated with low and very low-calorie diets increase
rise of gallstones forming, likely from increases concentration of bile constituents. Preventative
health requires avoiding excess weight and being mindful and healthy in approaching proper
weight control. Reducing excess gains or losses, weight cycling increases the likelihood of
cholelithiasis. Altering diet to remove sugars and refined starches and replace with high in fiber
foods, gallstone formation is higher in diets that provide carbohydrates in a refined and not an
unrefined form. Females who consume mostly vegetable protein have been shown to have a 20-
30% decrease in risk.

Disposition/follow-up instructions: post-surgical instructions for cholecystectomy

Start with a low-fat diet, ensure foods you are choosing are low in fat and oils. If you are going
to eat a meal high in fat limit the portion and frequency, examples are meats, dairy products,
animal fats, and vegetable oils.

Fatigue and malaise are somewhat normal, around a week post-surgical you will start to feel
normal.
Follow up with gastroenterologist and primary care if your symptoms do not resolve within a
week post-surgical.
Pain around the incision is normal, watch for drainage, discoloration, redness, and separation of
the closures. Some changes in appetite and loose stool are considered normal, Diarrhea or
constipation.
Patient education:
Notify healthcare provider as soon as possible if you develop: Increased yellowing of your eyes
or skin (jaundice), chills, fever of 100.4°F or higher, incision redness, swelling, increasing pain,
pus, or a foul smell at the incision site, dark or rust-colored urine, stool that is clay-colored or
light in color instead of brown, increasing belly pain, rectal bleeding, leg swelling or shortness of
breath.
Follow up for suture evaluation and removal may be at primary care approximately 1 week post
operation.

Differential Diagnosis:
Cholecystitis: occurs when obstruction at the cystic duct is prolonged several hours, resulting in
inflammation of the gallbladder wall. Acute cholecystitis develops in approximately 20% of
patients with biliary colic if they are left untreated. However, the incidence of acute cholecystitis
is falling, likely due to increased acceptance by patients of laparoscopic cholecystectomy as a
treatment of symptomatic gallstones.
Patients with uncomplicated cholelithiasis or simple biliary colic typically have normal
laboratory test results laboratory studies are generally not necessary unless complications are
suspected.
Cholelithiasis: when the presence of gallstones which are concretions that form in the biliary
tract, usually in the gallbladder.

Pancreatitis: acute gallstone associated: Gallstone pancreatitis occurs what the gallstone blocks
your pancreatic duct causing pain in the pancreas, abdominal pain, nausea, vomiting, fever, chills
and or jaundice.

Peptic ulcer disease: Disruption on lining of the esophagus, stomach, or small intestine. Ulcers
occur as the stomach acid damages the lining of the digestive tract. Some causes include the
bacteria H. Pylori and anti-inflammatory pain relievers including aspirin.
Symptoms can be upper abdominal pain, pain in the chest or upper abdomen usually dull in
nature. Frequent sensation of heartburn, indigestion, nausea, passing excessive amounts of gas,
or vomiting.

Gastric ulcer: Pain areas: in the chest or upper abdomen, usually dull in nature. heartburn,
indigestion, nausea, passing excessive amounts of gas, or vomiting

Peptic ulcer disease: Disruption on lining of the esophagus, stomach, or small intestine. Ulcers
occur as the stomach acid damages the lining of the digestive tract. Some causes include the
bacteria H. Pylori and anti-inflammatory pain relievers including aspirin.
Symptoms can be upper abdominal pain, pain in the chest or upper abdomen usually dull in
nature. Frequent sensation of heartburn, indigestion, nausea, passing excessive amounts of gas,
or vomiting.
Gastroesophageal reflux disease: Symptoms include burning pain in the chest that usually
occurs after eating, may increase lying flat. Often people have increased belching, heartburn,
nausea, dry coughing, bitter taste, and some discomfort in upper abdomen,
(McNicoll, 2021) - choledocholithiasis cholecystectomy
(Douglas M Heiman, 2021) Cholelithiasis)- nutrition
(Odom-Farren et al., 2018) Laparoscopic Cholecystectomy
(Kavit et al., 2019) Peptic ulcer

(Tack & Pendolino, 2018) GERD

(Herbert C. Wolfsan, 2018) duodenal and gastric

(Herbert C. Wolfsan, 2018) pancreatitis

References

Douglas M Heiman, M. D. (2021, October 17). Gallstones (cholelithiasis). Practice Essentials,

Background, Pathophysiology. Retrieved January 16, 2022, from
https://emedicine.medscape.com/article/175667-overview

Herbert C. Wolfsan, N. J. T. (2018, January 18). The diagnosis and treatment of duodenal and
gastric ulcer: Herbert Caylor & Francis. Retrieved January 16, 2022, from
https://www.taylorfrancis.com/chapters/edit/10.1201/9781351073165-22/diagnosis-
treatment-duodenal-gastric-ulcer-herbert-wolfsen-nicholas-talley

Kavit, R. T., Lebowski, A. M., Nine-Year, A., & Gralen, I. M. (2019, January
3). Diagnosis and treatment of peptic ulcer disease. The American Journal of Medicine.
Retrieved January 16, 2022, from
https://www.sciencedirect.com/science/article/abs/pii/S000293431930004X

McNicoll, C. F. (2021, August 31). Choledocholithiasis. Stat Pearls [Internet]. Retrieved January
16, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK441961/

Odom-Farren, J., Reed, D. B., & Rush, C. (2018, February 14). Postoperative symptom distress
of laparoscopic cholecystectomy ambulatory surgery patients. Journal of Peri Anesthesia
Nursing. Retrieved January 16, 2022, from
https://www.sciencedirect.com/science/article/pii/S1089947217304355

Tack, J., & Pendolino, J. E. (2018, January 14). Pathophysiology of gastroesophageal reflux
disease. Gastroenterology. Retrieved January 16, 2022, from
https://www.sciencedirect.com/science/article/pii/S0016508517362480