In the Evita Alonso iHuman case study, the patient, a 48-year-old female, presents with a chief complaint of severe abdominal pain. This article provides an in-depth review of the diagnostic approach, differential diagnoses, and management strategies for her condition based on iHuman guidelines.
Evita Alonso iHuman Chief Complaint
“My stomach has been hurting really bad over the past two weeks.”
Evita Alonso iHuman History of Present Illness (HPI)
Evita Alonso reports intermittent and progressive right upper quadrant (RUQ) abdominal pain, which has worsened in the past two days. The pain radiates to her right shoulder and is accompanied by nausea, vomiting, and anorexia. Over the past year, she has experienced self-resolving episodes of similar symptoms. Her family history includes biliary disease (mother). Clinical findings include mild fever, scleral icterus, RUQ tenderness with guarding, and a positive Murphy’s sign.
Evita Alonso iHuman Differential Diagnoses
- Primary Diagnosis: Ascending Cholangitis Ascending cholangitis is a medical emergency typically resulting from a biliary obstruction and subsequent bacterial infection. The patient’s symptoms of RUQ pain, nausea, vomiting, anorexia, fever, and jaundice align with this diagnosis. The positive Murphy’s sign and a family history of biliary disease further support this diagnosis.
Key Points:
- Presentation: Severe abdominal pain, right shoulder pain, nausea, vomiting, anorexia, and jaundice.
- Physical Examination: Positive Murphy’s sign (indicative of gallbladder inflammation) and scleral icterus.
- Risk Factors: Family history of biliary disease.
Rationale for Diagnosis: Ascending cholangitis develops due to an obstruction in the bile duct, often caused by gallstones, leading to infection and inflammation. The symptoms, especially the combination of jaundice, fever, and RUQ pain (known as Charcot’s triad), strongly indicate this diagnosis. The patient’s history of recurrent RUQ pain episodes and her current presentation suggest that she might have experienced milder, self-limiting bouts of cholangitis, with the current episode becoming more severe.
Diagnostic Tests:
- Imaging: Ultrasound or MRCP to assess bile duct obstruction.
- Lab Tests: Blood cultures to identify infection, liver function tests (LFTs) to assess bilirubin and enzyme levels, and complete blood count (CBC) to detect infection.
Treatment: Ascending cholangitis is an emergency that requires hospital admission. The patient should receive broad-spectrum antibiotics (such as Ertapenem 1g IV) and surgical consultation for possible gallstone removal or cholecystectomy. If necessary, an endoscopic retrograde cholangiopancreatography (ERCP) may be performed to relieve the bile duct obstruction.
- Alternative Diagnosis: Cholecystitis Cholecystitis, or inflammation of the gallbladder, is another possible diagnosis, given the patient’s RUQ pain, nausea, vomiting, and radiating shoulder pain. This condition is typically caused by gallstones blocking the cystic duct, leading to gallbladder inflammation.
Key Points:
- Presentation: RUQ pain that worsens with meals, radiates to the right shoulder, nausea, and vomiting.
- Physical Examination: Tenderness in the RUQ, guarding, and positive Murphy’s sign.
Rationale for Diagnosis: The patient’s symptoms are classic for cholecystitis, especially given the episodic nature of her previous symptoms and the lack of response to NSAIDs and antacids. Cholecystitis can present similarly to cholangitis but typically without jaundice, which makes ascending cholangitis the more likely primary diagnosis in this case.
Diagnostic Tests:
- Imaging: Abdominal ultrasound to assess for gallstones or inflammation of the gallbladder.
- Lab Tests: LFTs to rule out bile duct obstruction and CBC to check for elevated white blood cells indicating infection.
Treatment: Patients with cholecystitis typically require hospitalization, IV antibiotics, and possible cholecystectomy. The condition can often be treated laparoscopically.
- Alternative Diagnosis: Acute Pancreatitis Another potential diagnosis is acute pancreatitis, an inflammation of the pancreas often caused by gallstones or excessive alcohol use. The patient’s symptoms of RUQ pain radiating to the back, nausea, and vomiting could be consistent with pancreatitis.
Key Points:
- Presentation: Sudden onset of severe abdominal pain radiating to the back, nausea, vomiting, and abdominal tenderness.
- Physical Examination: Tender abdomen with guarding, though typically not a positive Murphy’s sign.
Rationale for Diagnosis: While the patient’s symptoms could fit the profile for acute pancreatitis, the radiating shoulder pain and jaundice point more toward a biliary etiology, such as cholangitis or cholecystitis. However, the possibility of concurrent pancreatitis should be explored, especially in the context of biliary disease.
Diagnostic Tests:
- Imaging: Abdominal CT to assess for pancreatic inflammation.
- Lab Tests: Serum amylase and lipase levels to confirm pancreatitis.
Treatment: Treatment for acute pancreatitis includes IV fluids, pain management, and, if gallstones are the cause, removal of the obstruction.
- Alternative Diagnosis: Peptic Ulcer Disease (PUD) Although less likely, peptic ulcer disease (PUD) could be considered, particularly in light of the patient’s description of gnawing, crampy abdominal pain that worsens with meals. PUD occurs when the lining of the stomach or duodenum becomes eroded due to stomach acid.
Key Points:
- Presentation: Burning, gnawing pain in the epigastrium, nausea, vomiting, and bloating.
- Physical Examination: Tenderness in the epigastrium, though typically without jaundice or a positive Murphy’s sign.
Rationale for Diagnosis: PUD is less likely given the localization of pain to the RUQ and the presence of jaundice. However, the use of NSAIDs for symptom relief could have contributed to gastrointestinal irritation, worsening the patient’s symptoms.
Diagnostic Tests:
- Endoscopy: To visualize the ulcer.
- Lab Tests: Helicobacter pylori test.
Treatment: PUD treatment involves proton pump inhibitors (PPIs) to reduce stomach acid and antibiotics if H. pylori is present.
Evita Alonso iHuman Management Plan
1. Pharmacologic Care:
- IV Access: Start IV fluids to maintain hydration.
- Antibiotics: Administer broad-spectrum antibiotics, such as Ertapenem 1g IV.
- Pain Management: Administer appropriate analgesics for pain relief.
2. Labs/Tests:
- Collect blood cultures to detect bacterial infection.
- Perform liver function tests (LFTs) and a complete blood count (CBC).
- Imaging: Ultrasound or MRCP to assess for gallstones or bile duct obstruction.
3. Consults:
- General Surgery: Urgent consultation for potential cholecystectomy or ERCP.
4. Patient Education:
- Explain the severity of ascending cholangitis and the need for hospitalization.
- Discuss the risks and benefits of potential surgery (cholecystectomy).
5. Follow-Up:
- Schedule follow-up post-surgery or discharge to ensure proper recovery.
Conclusion: The Evita Alonso iHuman case study illustrates the importance of thorough diagnostic workups and appropriate management of biliary tract infections. In this case, ascending cholangitis, cholecystitis, and pancreatitis are critical diagnoses to consider, with each requiring specific interventions to prevent complications.
Supportive Care:
- NPO (nothing by mouth)
- Administer 0.9% IV normal saline: 100ml bolus, then 50ml/hr
- Zosyn 3.375g IV every 6 hours for 7 days
- Zofran 4mg IV every 6 hours PRN for nausea/vomiting
- Monitor blood glucose every 4 hours due to NPO status
Patient Education:
- Educated on diagnosis, continued evaluation, and expected care course. Patient understood.
- Notify staff if experiencing worsening symptoms (pain, nausea, fever).
- Follow-up clinic 1-2 weeks post-discharge (especially if surgery occurs), with diet changes and activity limitations as needed.
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