Mrs. Deer is a 72-year-old female who presents to your office complaining of right upper quadrant pain that has been increasing in intensity over the past 2 days. She would have come sooner, but she lacked transportation and waited until her son could drive her. She states that she has not been sleeping very much because of the pain. She has been nauseous and vomited a couple of times two days ago but has only been drinking fluids. She states that she has not been around anyone else that had an upset stomach. She recalls prior to the onset of pain she had been at a church supper that included meats, refried beans, and many desserts which she sampled. She described the fried pies that she brought to the supper and ate the extras that afternoon.
Vital Signs: BP 130/80, HR 85, RR 20, Temp 99.0°F.
Discuss the following:
1) What additional subjective data are you seeking to include past medical history, social, and relevant family history?
2) What additional objective data will you be assessing for?
3) What are the differential diagnoses that you are considering?
4) What laboratory tests will help you rule out some of the differential diagnoses?
5) What radiological examinations or additional diagnostic studies would you order?
6) What treatment and specific information about the prescription that you will give this patient?
7) What are the potential complications from the treatment ordered?
8) What additional laboratory tests might you consider ordering?
9) What additional patient teaching may be needed?
10) Will you be looking for a consult?
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Expert Solution Preview
Introduction:
In this case, we encounter a 72-year-old female patient who complains of right upper quadrant pain. The patient has also experienced nausea and vomiting, and has a recent history of attending a church supper. As a medical professional, it is important to identify the potential causes of Mrs. Deer’s symptoms and provide a treatment plan that promotes positive health outcomes.
1) What additional subjective data are you seeking to include past medical history, social, and relevant family history?
To gather additional subjective data about Mrs. Deer’s condition, it is important to ask about her medical history, including any pre-existing conditions such as liver disease, gallstones, or gastrointestinal disorders. Family health history is also crucial as it may help to reveal any potential genetic predisposition to certain ailments. In addition, the medical professional should inquire about the patient’s social and dietary habits, looking for any potential exposure to food-borne pathogens or other environmental toxins.
2) What additional objective data will you be assessing for?
Additional objective data that should be assessed for includes vital signs, abdominal exam, liver function tests, and gallbladder function tests. An ultrasound or CT scan may also be necessary to visualize the internal organs and diagnose potential causes of the patient’s discomfort.
3) What are the differential diagnoses that you are considering?
The differential diagnoses for this case include cholecystitis, a liver abscess, and hepatitis. Other conditions that may be considered include gastritis, pancreatitis, and gastroenteritis.
4) What laboratory tests will help you rule out some of the differential diagnoses?
Blood tests and urinalysis may reveal abnormalities in liver function, as well as potential infections. Testing for viral and bacterial infections may also be necessary to rule out specific differential diagnoses such as hepatitis and gastroenteritis.
5) What radiological examinations or additional diagnostic studies would you order?
An ultrasound or CT scan may be required to evaluate the internal organs and aid in the differential diagnoses of the patient’s condition.
6) What treatment and specific information about the prescription that you will give this patient?
The treatment of the patient’s condition will depend on the diagnosis. If Mrs. Deer is diagnosed with cholecystitis, antibiotics and analgesics may be prescribed along with dietary modifications. If a liver abscess or hepatitis is identified, specific treatment goals and medications will be recommended. Specific information such as dosing instructions and potential side effects of prescribed medications should be provided to the patient.
7) What are the potential complications from the treatment ordered?
The potential complications from the treatment ordered will depend on the specific diagnosis and treatment prescribed. In general, possible outcomes may include gastrointestinal discomfort, drug interactions, or an allergic reaction to medications prescribed.
8) What additional laboratory tests might you consider ordering?
Additional laboratory tests such as a blood culture, stool culture, or serological testing may be necessary to diagnose potential infectious etiologies.
9) What additional patient teaching may be needed?
In addition to providing information on medication dosing and potential side effects, it is important to educate the patient on any necessary dietary modifications and how to avoid potential sources of food-borne or environmental toxins. The patient should also be advised on how to properly take prescribed medications and follow-up appointments for continued diagnosis and treatment.
10) Will you be looking for a consult?
Depending on the diagnosis and specific treatment goals, a referral to a specialist may be necessary. A gastroenterologist or hepatologist may be consulted to assist with the treatment plan and follow-up care.
