iHuman Gastrointestinal Case:

CC: RUQ 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 to the right shoulder. Pain severity starts as a 2-3, has gone as high as 6-7, but is currently a 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 abdominal pain is brought on by eating food. Patient reports not drinking adequate amounts 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, that has not been 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.

Plan

Additional labs or diagnostic tests: Abdominal US; Labs: CMP, CBC. No additional tests are recommended at this time unless ordered by specialist (Gilbert et al., 2021).

Consults: Referral to gastrointestinal specialist with direct hospital admit for recommended laparoscopic cholecystectomy for acute cholelithiasis as a first-line therapy (Ikumoto et al., 2015).

Therapeutic modalities: Provide supportive therapy. Levofloxacin 500mg PO QD x 5 days, Metronidazole 500mg PO BID x 5 days, Zofran 4mg PO q4h prn. Promethazine rectal suppository 25mg q4-6h prn nausea/vomiting, Acetaminophen 1000mg PO q6h prn pain (Gilbert et al., 2021).

For direct hospital admit; Orders: NPO, peripheral IV; 1 liter 0.9% NS @ 100ml/hr. Start Zozyn 3.375g IVPB q 6h [totaling 13.5 g] (Gilbert et al., 2021). Additional orders to be managed by gastrointestinal specialist.

Health Promotion: Advise patient on low fat dietary regimen, daily exercise for weight reduction, and maintain a BMI below 27.0. Discussed need for yearly gynecological exam and mammogram. Advised Covid vaccine with booster, and mask wearing. Provided literature on preparing for endoscopic cholecystectomy with pre-operative orders. Addressed risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy (Stanisic et al., 2020).

Advised to take complete antibiotic regimen without missing a dose, and to eat yogurt to prevent yeast infections, and maintain good personal hygiene habits after intercourse........ Continue