NSG 6420 Adult & Geriatric Health sample solution

NSG 6420 Adult & Geriatric Health sample solution

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CASE STUDY 2

 

Chief Complaint

A 22 year old male comes to the student health center clinic with complaints 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 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 given at the 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, palpations
• Respiratory: Experiences SOB with panic/anxiety attacks. No SOB while lifting weights. No history of asthma or allergies. Does not smoke cigarettes or chew tobacco.
• GI: See above under CC. Denies epigastric pain or pain in the RLQ or LLQ. No history of PUD or H. 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 history of renal calculi. No penile discharge. No hx of STIs.
• Neuro: Blackouts with drinking. Denies HA, head injuries, dizziness, or balance difficulties except with ETOH.
• Endocrine: Denies polyuria, polydipsia, polyphagia. No heat or cold intolerances. No weight loss or gain.
• Hematology: Denies anemia, bleeding, easy bruising.
• Psychiatric: C/O panic/anxiety attacks. 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 72, RR 18. O2 saturation 99% HT 72, WT 180 lbs.
• General: Appearance 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.
• Lungs: 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 guiac 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.

 

 

 

Questions

1. What three conditions would be considered in your differential diagnosis, with most likely condition listed first (provide rationale)?
2. What further history, further reexamination, and diagnostic studies are warranted to evaluate your differential diagnosis?
3. What further evaluation or work up should be done for this patient?

 

4. What is the final diagnosis?

 

 

All Questions in Case Study Answered Correctly	10
Introduction & Background: Give the reader a description/scenario of the patient in the case study.  Since this is worth 20 points please make sure you have at least 3-4 well-structured paragraphs.	15
Pathophysiology: Discuss the pathophysiology related to your final diagnosis for this patient. Since this is worth 15 points please make sure you have at least 3-4 well-structured paragraphs.	15
Diagnostics & Labs: Identify all possible lab and other diagnostic tests which could be potentially ordered in the care of patient.	10
Treatment Plan: discuss appropriate treatments (pharmacologic and non-pharmacologic) regimens and interventions	15
Conclusion & Articles: Identify a minimum of two peer-reviewed evidence based article that support your treatment/care plan. Summarize your case and treatment plan in a 1-2 paragraph conclusion/summary	15
APA format: title page & reference page. Please review APA 6th edition for what is expected in an APA 6th ed. paper. Proper use of grammar and clarity of writing style to include spell check.	10
References: Cites in AP format throughout paper to include a minimum of three peer-reviewed evidence based practice nursing journals.	10
Total:	100

Case Study & Care Plan Grade Rubric

NSG 6420 Adult & Geriatric Health sample solution 

Case Study 2

The patient is a male who is 22 years old and comes in complaining of RUQ pain that has been present for the last 48 hours. He also has nausea and anorexia. The pain began around eight hours following a drinking binge that occurred two days earlier. Over the last couple of days, the pain has been more severe. The patient had only experienced this pain once before, a few months ago, after consuming too much alcohol, although it was considerably milder during that episode.

Differential Diagnosis

Three conditions would be considered in the differential diagnosis for this patient, including the following:

• Acute Pancreatitis- This illness is characterized by the patient’s experiences of anorexia, nausea, and pain in the RUQ region, particularly after repeated bouts of excessive drinking. Patients who suffer from this ailment will generally exhibit severe epigastric pain that lasts for many hours or days and may look to be in a severe state of illness (Dunphy et al., 2019).
• Cholecystitis- This condition is characterized by severe inflammation of the gallbladder wall and is associated with gallstones in ninety percent of patients (Dunphy et al., 2019). Pain and discomfort in the RUQ area are common symptoms patients may report, along with leukocytosis, fever, vomiting, and nausea.
• Acute Peritonitis- This condition involves irritation of the membrane that borders the inner abdominal muscles and guards abdominal organs. It manifests itself with symptoms like stomach tenderness and pain and soreness, bloating, fever, vomiting, and nausea (Kumar et al., 2021).

 

Diagnostic Tests

I would request a test for lipase and amylase, a complete metabolic panel, a complete blood count, and a test for C-reactive protein to aid in the diagnosis of acute pancreatitis. In addition, I would recommend getting a CT scan of the abdomen and an ultrasound to rule out any potential causes (Avegno & Carlisle, 2018). In order to determine whether or not there are gallstones, I would recommend getting an x-ray and ultrasound of the abdomen. To rule out more serious complications, including necrosis or perforation in the gallbladder, a CT scan would be ordered (Avegno & Carlisle, 2018).

Further Evaluation

The patient’s history will be reviewed as part of the further evaluation. The history of a patient who is experiencing abdominal pain involves assessing whether the pain is acute or persistent, as well as providing a full account of the pain and related symptoms.

Final Diagnosis

The final diagnosis for this patient is acute pancreatitis. The pathophysiology of acute pancreatitis is founded on the early activation of trypsinogen and zymogen, which then leads to the damage of the pancreas locally, which in turn activates the inflammatory reaction (Manohar et al., 2017). This results in systemic inflammatory response syndrome, which is a condition that is frequently related to acute pancreatitis.

Treatment Plan

The severity of the patient’s condition will determine the treatment that he will get. The initial treatment will consist of controlling pain with morphine or meperidine, monitoring fluid balance to avoid hypotension and hypovolemia, and inserting an NG tube to minimize ileus owing to prolonged nausea (Dunphy et al., 2019). As soon as the patient is no longer in pain, clear fluids may be given to him, and ultimately he will be transitioned to a diet reduced in fat if he is able to handle it.

Conclusion

RUQ pain may be brought on by a variety of conditions, some of which are organic and others of which are functional. Before considering the potential functional problems of the gallbladder or Oddi’s sphincter, it is important to rule out organic causes, including pancreatitis, cholelithiasis, and tumors.

 

 

References

Avegno, J., & Carlisle, M. (2016). Evaluating the patient with right upper quadrant abdominal pain. Emergency Medicine Clinics of North America, 34(2), 211-228. https://doi.org/10.1016/j.emc.2015.12.011

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary care: The Art and Science of Advanced Practice Nursing- An Interprofessional Approach. Davis Company.

Kumar, D., Garg, I., Sarwar, A. H., Kumar, L., Kumar, V., Ramrakhia, S., Naz, S., Jamil, A., Iqbal, Z. Q., & Kumar, B. (2021). Causes of acute peritonitis and its complication. Cureus. https://doi.org/10.7759/cureus.15301

Manohar, M., Verma, A. K., Venkateshaiah, S. U., Sanders, N. L., & Mishra, A. (2017). Pathogenic mechanisms of pancreatitis. World Journal of Gastrointestinal Pharmacology and Therapeutics, 8(1), 10. https://doi.org/10.4292/wjgpt.v8.i1.10