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What us the best plan for this patient that presents with acute pancreatitis? 

– Plan should include:

Medications (name, dosage, route, frequency, and duration (if applicable like antibiotics), education on medication/ adverse effects, etc.
Diagnostic testing and reasoning (why are you ordering it, what are you looking for, reference)
Symptom management
Patient education (med, testing, diet, social, reasons for emergent evaluation)
Referral for further consultation with another specialist
Follow up (when will the patient follow up with you and/or another specialist

(All details of the plan should include a rationale that is supported with references from the healthcare literature)

 

 

Chapter 10 Abdomen

 

Case Study: Abdomen

Patient Name: Dave Peritoneal

DOB: 3/15/2000

Chief Complaint

A 22 y.o. male comes to the student health center clinic with complaint of RUQ pain for 48 hours, accompanied by nausea and anorexia. Pain started 8 hours after a drinking binge 2 days ago (approximately one-half liter of vodka). Pain has been worsening over the past 2 days from a 2 to a 5 on the pain scale. There was vomiting twice the morning after the binge, but no vomiting since. Patient reports emesis was clear/yellow with no blood and denies diarrhea. Patient has had this pain only one other time some months ago after drinking too much, but it was less severe and went away fairly quickly without any treatment. Patient is very concerned about this pain lasting so long. He is not sleeping at night due to the pain and worry over the cause. Patient admits to drinking binges approximately two times per week for the past 2 years. He denies stress from schoolwork or social relationships but states he has an anxiety disorder with panic attacks. He has only had a short course of Ativan (from TMH ER) about a year ago. He deals with the panic/anxiety attacks with marijuana or just “rides it out.”

 

Past Medical History

Denies surgeries or serious illnesses/hospitalizations
No regular medications; had previously been on SSRI but has not been for a couple of years

Family History

Father, age 55, Parkinson’s disease
Mother, age 52, HTN
No history of ETOH/drug abuse or mental illness in the patient or family

Psychosocial History

Considers health to be good. Usually eats well and exercises five times per week lifting weights. ETOH abuse as above, recreational marijuana use. Doing well in his classes (senior majoring in International Business). Reports being in a monogamous relationship for the past 2 years; no use of condoms.

Review of Systems

General: Denies fever or weight loss but has been unable to eat much over the past couple of days due to abdominal pain and nausea.
HEENT: Denies HA, visual changes, redness or “yellow” color of the eyes. Has blackouts related to ETOH abuse.
CV: Experiences chest tightness with panic/anxiety attacks. Denies chest pain, HTN, hypotension, palpitations.
Respiratory: Experiences SOB with panic/anxiety attacks. No SOB or DOE while lifting weights. No history of asthma or allergies. Does not smoke cigarettes or chew tobacco.
GI: See above under CV. Denies epigastric pain or pain in the RLQ or LLQ. No history of PUD or pylori. No rectal bleeding or melena.
MS: Denies joint pain or swelling. Has pain in the right back but believes it is related to the RUQ pain.
GU: Denies frequency, dysuria, hematuria. No hx of renal calculi. No penile discharge. No hx of STDs.
Neuro: Blackouts with drinking. Denies HA, head injuries, dizziness, or balance difficulties except with ETOH.
Endocrine: Denies polyuria, polydipsia, polyphagia. No heat or cold intolerance. No weight loss or gain.
Hematology: Denies anemia, bleeding, easy bruising.
Psychiatric: C/o panic/anxiety attacks (see above). Reports that attacks started in high school without any specific precipitating event. Stressful situations exacerbate the attacks, but they sometimes come on without an obvious cause.

Physical Examination

Vital signs: T 97.6, BP 150/80, HR 92, RR 18, O2 saturation 99%, HT 72, WT 180 lbs.
General: WDWN male who is visibly anxious with sweat beads on forehead and nose.
HEENT: Sclera non-icteric. PERRLA, no exophthalmos or lid lag. TMs with good light reflex, no inflammation. Posterior pharynx not inflamed, no cervical lymphadenopathy. Thyroid not enlarged or nodular.
CV: RR&R without murmurs, S3, S4, splits, rubs. No lower extremity edema. No carotid bruits.
Respiratory: Rate even, unlabored. No adventitious sounds.
Abdomen: BS present in four quadrants. No aortic or renal bruits. RUQ tender on palpation. Liver percusses 6 cm in MCL. No rebound tenderness. Right CVA tenderness on percussion. No RLQ tenderness, negative psoas sign, negative obturator sign, negative McBurney’s sign. No epigastric tenderness. Stool guaiac negative.
MS: No joint swelling or tenderness. Full ROM all joints. No chest wall tenderness but states that RUQ pain increases with bending forward and lying down. Strength 5/5 in all four extremities.
GU: Negative for hernia, testicular masses, penile lesions, or discharge.
Neuro: CNs II to XII WNL. DTRs 2+ bilaterally. Sensory and motor without deficits. Negative Romberg.
Lab Results                                        Reference Range
WBCs = 13.3                                      (4.5-10.9 × 109/L)
Amylase = 250 U/L                            (30-110 U/L)
Lipase = 200 U/L                               (10-140 U/L)
ALT = 62 U/L                                     (male 10-55 U/L, female 7-30 U/L)
AST = 180 U/L                                   (14-59 U/L)
AST/ALT ratio = 3:1                          (less than 2:1)
Total bilirubin = 2.1 mg/dL                (0.2-1.9 mg/dL)
Direct bilirubin = 0.3 mg/dL              (0-0.3 mg/dL)
Platelets = 125,000                             (140-440 × 103/cu mm)
Blood glucose = 112 mg/dL               (70-110 mg/dL)
Hepatitis panel for A, B, C       Negative
GGT                                          Elevated

 

SCIENCE
HEALTH SCIENCE
NURSING
NUR 642

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