Identifying Information:
Patient: C.M. 37 y/o BF.
DOB: 01/13/1977
Visit: 03/27/15
Source & Reliability: Self-referred, seems reliable
Medical HX: No significant PMH. No childhood or adult diseases. Immunizations
UTD. She received the flu shot 11/01/2015.
Surgical HX: Right inguinal hernia repair at age 2. No negative effects from this
procedure.
OBGYN: G-0 T-0 P-0 A-0 L-0
Medications: Tums 3 tablets TID as needed for abdominal pain.
Allergies: None
Personal/social HX: Married, works at Target. She walks 30 minutes 3x a week. She is
an active member in her Baptist church and teaches Bible study once a month with her
husband.
Drugs, Alcohol, or Smoking HX: No illegal drug use, no alcohol or tobacco use.
Family HX: Mother-gallbladder removed at age 60, Type II DM. Father- Died from MI
at age 80. No siblings.
Subjective
CC: “I have been having pain in my abdomen for an hour or so after eating.”
HPI: 37-year-old black female presents with complaints of pain in right upper quadrant
and sometimes in the right upper shoulder blade (Location) but it does not
radiate in other parts of her body (Radiation). She reports that the pain started 7 days ago
(Onset), after eating ice cream with chocolate sauce (Timing), and will last one hour
after eating (Duration). She reports that the pain is throbbing (Character) and rates the
pain a 9 on a 0-10 pain scale. She reports feeling nauseated and bloating, along with
excess gas after eating (Associating Symptoms). She has taken Tums to alleviate the
pain but it has not helped (Alleviating Factors). She reports having a decrease in appetite
because she is afraid to eat food because it will cause pain (Aggravating Factors).
Review of Systems
General: Reports being “as healthy as can be” (-) fever (-) chills (-) recent weight gain or loss (-) weakness (-) fatigue. States her last physical exam was in 2014.
Skin, hair, & nails: (-) changes in skin (-) changes in hair (-) changes in nails.
HEENT: head – (-) injury (-) headaches (-) hair loss. eyes – (-) decreased vision (-) watery eyes (-) photosensitivity. last eye exam 1/2015. ears – (-) hearing problems (-) tinnitus (-) ear pain (-) drainage. nose – (-) nasal congestion (-) allergies (-) nasal drainage (-) epistasis
throat – (-) sore throat (-) tooth ache (-) pain or difficulty with swallowing. last dental exam 2 years ago.
Thorax/lungs: (-) chest pain (-) lung injury (-) lung disease (-) allergies (-) asthma.
Cardiovascular: (-) chest pain (-) irregular heartbeat (-) palpitations (-) murmurs (-) hypertension.
PVS: (-) extremity edema (-) coldness (-) leg cramps (-) ulcers.
Abdomen: Regular diet. (+) nausea (-) vomiting (-) bowel problems (+) abdominal pain (+) bloating (+) excess gas (-) diarrhea. Last bowel movement was yesterday. Mother had gallbladder removed, see FMH.
GU: (-) urinary frequency (-) hesitancy (-) incontinence (-) nocturia (-) flank pain (-) burning (-) bleeding with urination.
Metabolic/Hematologic: (-) type I or II DM (-) thyroid problems (-) heat/cold intolerance (-) bruising (-) ease of bleeding. No history of blood transfusions.
Musculoskeletal: (-) trauma (-) injury.
Psychiatric: (-) trouble concentrating (-) nervousness (-) anxiety (-) panic attacks (-) mood changes (-) hearing voices (-) frequent unhappiness (-) desire to harm self/others (-) sleep trouble (-) nightmares (-) memory loss (-) excessive life stresses. No recent deaths in family or close friends.
Neurologic: (-) history of stroke (-) seizures (-) frequent/incapacitating headache (-) tremors in right hand (-) numbness in feet.
Objective
Vital Signs: B/P 120/70, P-80, R-20, T-98.4, BMI 38, Wt 200Lbs, HT 5’2.
General: Friendly, well-groomed, AAOX3, good eye contact, and speech, appears relaxed and calm. Reliable historian.
Physical Assessment
Hair: Average texture dark brown, shiny hair. Evenly distributed on scalp with no breakage,
alopecia, dryness or infestations.
Skin: Warm, dry, supple, no bruises, rashes, or suspicious nevi to exposed skin.
Nails: Smooth and well-manicured without clubbing or cyanosis. Capillary refill to finger pad is < 2 sec.
Head/Neck: Normocephalic/atraumatic, no bumps, bruises, lesions. Scalp pink and dry. No sinus tenderness, and no palpable lymph node enlargement or tenderness. Neck supple; thyroid isthmus palpable, lobes not felt. Trachea midline.
Eyes: Pupils 4mm constricting to 2mm, PERRLA, vision 20/20 in each eye, vision fields full by confrontation. negative strabismus and nystagmus, disk margins sharp, without hemorrhages, exudates. No anterior narrowing. Conjunctiva pink; sclera white.
Ears: Acuity good to whispered voice. TM pearly white and intact with no redness or bulging. Cone of light visible bilaterally (5 o’clock right, 7 o’clock left).
Nose: Turbinates intact, nares patent, septum midline, Tenderness over maxillary sinuses. mucosa red and swollen with clear drainage noted from both nares. nasal flaring or discharge.
Throat/mouth: Membranes pink and moist. Uvula is midline, tonsils at pillars, no redness or exudates.
Lungs: Respirations 12 breaths/min, breath sounds vesicular, no rhonchi, wheezes, or crackles present. Lungs resonant. Thorax is symmetric, and the diaphragms descend 4 cm bilaterally.
Heart: No Scratching noise heard at lower left sternal border. Apical pulse 90 bpm on auscultation. S1 and S2 regular rate and rhythm with no splitting, S1 best at apex, S2 best at base, with no S3 or S4. Carotid upstrokes brisk with no bruits. No JVD. PMI palpable at 5th ICS 7cm lateral to the mid-sternal line, discrete and tapping. No heaves, lifts, or thrills. No rubs, gallops, murmurs, or opening snaps. Pain not elicited with chest wall palpation.
Breasts: Deferred per patient’s request.
Abdomen: Protuberant. Slight scar in right inguinal area. Normoactive BS x 4 quadrants. No abdominal pulsations or bruits. Pain felt with light and deep palpation in right upper quadrant. No palpable masses or hepatosplenomegaly. Kidneys not felt, no flank pain or CVA tenderness.
Lymph Nodes: Head, neck, axilla, epitrochlear, and inguinal lymph nodes non-palpable.
Extremities: Extremities are warm without edema. No varicosities or stasis. Calves are supple and non-tender. No femoral bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulse are all 2+ and symmetric. Full range of motion to all extremities.
Genitals: Deferred at patient’s request
Rectum/Anus: Deferred at patient’s request
Neurologic: AAOX3, cooperative and calm. Cranial nerves II-XII intact. Normal gait. Maintains balance with eyes closed. Good, even strength and muscle tone. Reflexes are 2+ and symmetric.
Assessment
Diagnosis- Cholelithiasis
Cholelithiasis is the formation of cholesterol stones in the gallbladder. Gallstones are twice as common in women as in men. Ethnicity, obesity, and rapid weight loss are predisposing factors for the development of gallstones (McCance, 2010). The main symptom of cholelithiasis is biliary colic which is most common in the right upper abdomen and sometimes radiates to the back and is accompanied by nausea, vomiting, sweating, and flatus (Bickley, 2013). Symptoms may be precipitated by a meal but can occur spontaneously. The pain will often last an hour or more then slowly decrease. Other symptoms of cholelithiasis are: fatty food intolerance, belching, excessive gas, and bloating. Many patients with cholelithiasis will have a positive Murphy’s Sign which is a sharp increase in tenderness with a sudden stop in inspiratory effort when pressure is applied to the right upper quadrant (Bickley, 2013).
Differential diagnosis:
- Gastritis/Gastroenteritis
- Bile Duct Strictures
- Peptic Ulcer Disease
- Cholecysitis
- Gallbladder Cancer
- Appendicitis
- Pancreatic Cancer
- Acute Pancreatitis
Plan
Obtain ultrasound of abdomen
Ultrasound of the abdomen is the procedure of choice in evaluation of cholelithiasis (Copstead & Banasik, 2010). The ultrasound will show the presence of gallstones, thickening of the gallbladder wall, and distension of the gallbladder lumen. It may also show any liver neoplasms or hydronephrosis of the kidney which can cause pain (McCance, 2010). The sensitivity and specificity of the ultrasound test for gallstones larger than 2mm is 95% (Copstead & Banasik, 2010). MRI, CT scan, and cholangiography test can be used to diagnose gallstones; however, these tests are no more effective than the standard ultrasound and are not cost effective (McCance, 2010).
Referral to general surgeon
A referral will be made to a general surgeon to assess patient for gallstones and perform surgical removal of the gallstones or gallbladder. A general surgeon can discuss appropriate treatment options available to the patient (McCance, 2010).
Obtain Lab tests
Liver function test (LFT) amylase, lipase, ALT, CBC can be useful markers for the diagnosis of cholelithiasis. The LFP, amylase, and lipase will indicate inflammation if elevated. An elevated WBC may indicate infection. An elevated ALT with amylase and lipase usually indicates acute pancreatitis. The ALT is very specific in identifying gallstone pancreatitis (McCance, 2010). Lab tests can assist the care provider to rule out or confirm a diagnosis for proper treatment of the patient (Bickley, 2013).
Laparoscopic Cholecystectomy
Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones (Copstead & Banasik, 2010). The procedure is usually performed with four small incisions to remove the gallbladder. The advantages of the laparoscopic procedure are: minimal scarring, less post-operative pain, shortened hospital stay, and rapid return to daily activities (McCance, 2010). If laparoscopy is unsuccessful, an open choledocholithotomy is performed.
Patient teaching
Dietary adjustments must be taught to the patient. More than half of patients who have had gallbladder surgery report problems with digesting fat; however, most people can return to a normal diet after gallbladder surgery. If C.M. has gallbladder surgery, high-fat foods must be avoided a few weeks after surgery and must be introduced into the diet slowly (McCance, 2010). In addition to this, high fiber foods after surgery may also cause discomfort. Eating smaller frequent meals will ensure a better mix with available bile and prevent discomfort.
Follow up care
A follow-up appointment should be made 1-2 weeks after surgery. It is important for the
patient to understand his or her disease process, sign and symptoms, causes, and dietary
teaching. It is important to address any issues or concerns the patient may be having post
gallbladder removal and offer treatment options. Many patients may have a difficult time
adjusting their diet post gallbladder removal. If C.M. has incisions, the incisions must be
inspected for any signs of infection and proper care of incisions should be reviewed with
the patient (McCance, 2010).
References
Bickley, L. S. (2013). Bates’ guide to physical examination and history taking (11th ed.). Philadelphia, PA.: Lippincott Williams & Wilkins.
Copstead, L. C., & Banasik, J. L. (2010). Pathophysiology (4th ed.). St. Louis, MO.: Saunders Elsevier.
McCance, K. L., & Huether, S. E. (2010). Pathophysiology: the biologic basis for disease in adults and children (6th ed.). Maryland Heights, MO: Mosby Elsevier.