Respond to other students responses with substantive comments.

Respond to other student’s responses with substantive comments. Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment.The postings should be at least one paragraph (approximately 100 words) and include references.

1. References and citations should conform to the APA 6th edition.
2. Remember: Please respect the opinions of others, even if their views differ. In other words, disagree professionally and respectfully.Plagiarism is never acceptable – give credit when credit is due – cite your sources

Hollie’s Response

S-70-year old female patient presents with complaints of right lower quadrant abdominal pain. She describes the pain as sharp and also states she has accompanied nausea and vomiting. She states that food appears to make the pain worse. She has attempted to use her PRN medications which has not provided pain relief. Past medical history: hypertension, type 2 diabetes, obesity, and arthritis of the knee.

Additional information needed: onset of the pain, duration of the pain, radiation of the pain, relieving factors, type and dosage of PRN medication used, what foods make the pain worse; allergies; family history; current medications; review of systems, including gastrointestinal, genitourinary, cardiovascular, and respiratory. Ask about patient’s bowel movements, color, consistency, and if any steatorrhea. Ask about urinary frequency, urine color or cloudiness, pain or burning on urination, and if any low back pain. Ask if any vaginal bleeding. Ask about sexual history, including if any new partners.

O-B/P 150/88, P: 84, R: 23, T: 102, Weight: 186, Height: 5’5” She is awake, alert, and oriented X 3. She is resting quietly in her bed without any apparent distress or pain. Skin: w/d. Lungs: Clear. Heart: No abnormal sounds heard. No murmurs.

Additional information: A full abdominal assessment should be performed, including, inspection, auscultation, percussion, and palpation. Palpate for hepatosplenomegaly. Palpate for costovertebral angle tenderness. Assess abdominal aorta. Assess for appendicitis, including McBurney point tenderness, Rovsing sign, the psoas sign, and the obturator sign. Assess for cholecystitis, including Murphy’s sign. Include pelvic exam if clinically indicated. Asses for any hernias.

Labs: CBC to check for infection and/or blood loss; CMP to check for electrolyte disturbances, liver and kidney function; urinalysis if clinically indicated;

Imaging: Ultrasound or CT scan if indicated.

A-Problem list

1. Abdominal Pain
   1. Differential diagnoses
      1. Appendicitis: Common symptoms of appendicitis include RLQ pain, fever, nausea, and vomiting (Nshuti, Kruger, & Luvhengo, 2014). Lack of appetite or pain after eating can also occur (Nshuti et al., 2014).
      2. Diverticulitis: The sigmoid colon is the most common place for diverticulitis to occur, however, right-sided diverticulitis can occur (Chiu et al., 2017). Signs and symptoms often resemble appendicitis (Chiu et al., 2017).
      3. Cholecystitis: This is often in the right upper quadrant, however, in older adults it can span across the entire right side of the abdomen (Lyon & Clark, 2006). Age related changes in the biliary tract make cholecystitis a common cause of abdominal pain (Lyon & Clark, 2006). Symptoms often include pain, fever, and vomiting (Lyon & Clark, 2006).
      4. Intestinal obstruction or bowel perforation: symptoms of intestinal obstruction include: diffuse, colicky pain, nausea, and vomiting (Lyon & Clark, 2006). Peritoneal signs will occur if bowel wall perforates (Lyon & Clark, 2006).
      5. Other cannot be ruled out with the information provided: colitis, UTI, abdominal aortic aneurysm, urinary stone, colon cancer, ovarian cancer.

P-First plan of action is to rule out all causes of that require emergent intervention, including appendicitis. Additional assessments should be performed as described above. A CT of the abdomen should be performed. If appendicitis is expected, antibiotics should be started immediately along with surgery evaluation (Salminen, Paajanen, & Rautio, 2015). Patient should be started on IV fluids for management of hydration (Salminen et al., 2015). Pharmacologic therapy should also include pain medication and antinausea medication. Educate patient on diagnosis and plan of action.

References

Chiu, T. Chou, Y. Tiu, C., Chiou, H., Wang, H., Lai, Y. & Chiou, Y. (2017). Right-sided colonic diverticulitis: Clinical features, sonographic appearances, and management. Journal of Medical Ultrasound, 25(1), 33-39. https://doi.org/10.1016/j.jmu.2016.10.007

Lyon, C., & Clark, D. (2006). Diagnosis of acute abdominal pain in older patients. American Family Physician, 74(9), 1537-1544. Retrieved from https://www.aafp.org/afp/2006/1101/p1537.html

Nshuti, R., Kruger, D., & Luvhengo, T. E. (2014). Clinical presentation of acute appendicitis in adults at the Chris Hani Baragwanath academic hospital. International Journal of Emergency Medicine, 7, 12. http://doi.org/10.1186/1865-1380-7-12

Salminen, P., Paajanen, H., & Rautio, T. (2015). Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: The APPAC randomized clinical trial.JAMA, 313(23), 2340–2348. doi:10.1001/jama.2015.6154

Steven’s Response:

S:

A 70 year old female c/o sharp right lower quadrant pain associated with nausea and vomiting and worsening after meals. History of hypertension, diabetes, obesity, and osteoarthritis.

O:

Resting comfortably w/o apparent s/s of distress. Skin warm and dry. Lungs clear equal bilaterally. Heart sounds S1 and S2 w/ negative murmurs.

A:

1. Abdominal pain. Differential: Bowel obstruction, appendicitis, colon cancer, UTI, PID

P:

1. Abdominal pain: Order CBC, BNP, liver enzymes, amylase, lipase, urinalysis, occult stool, CT of abdomen w/ contrast. Administer iv fluid NS 1000 ml over 1 hr. Admin 4 mg MSO4 IV bolus. Admin 4 mg Zofran IV bolus.

Appendicitis

Appendicitis is the most commonly missed surgical emergency in older adults (Brewer, Golden, Hitch, Rudolf, & Wangensteen, 1976). Common symptoms of appendicitis include pain to the umbilical region or right lower quadrant and nausea or vomiting (Mayo Clinic, 2018). Additionally, this patient presents with an elevated temperature. Patients present with a temperature greater then 100 in 20 percent of cases and RLQ in 90 percent of cases (Lyon & Clark, 2006). In order to confirm this diagnosis, a band count higher then 6 and a positive abdominal CT scan would be necessary.

Uncomplicated acute appendicitis can be managed by both antibiotic therapy or surgical intervention. Surgical appendectomy is the most common and most successful treatment course (Salminen et al., 2015).

References

Brewer R, Golden G, Hitsch D, Rudolf L, Wangensteen S. Abdominal pain: an analysis of 1,000 consecutive cases in a university hospital emergency room. Am J Surg. 131:219–224. doi: 10.1016/0002-9610(76)90101-X.

Lyon, C. & Clark, D. (2006). Diagnoses of acute abdominal pain in older adults. American Family Physician, 74(9): 1537-1544.

Mayo Clinic. (2018, March 8). Appendicitis. Retrieved from https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543.

Salminen, P., Paajanen, H., Rautio, T. et al. (2015). Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis. JAMA, 313(23): 2340-2348.

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