Chief Complaint:
“My stomach has been hurting really bad over the past 2 weeks.”
Table of Contents
History of Present Illness:
Evita Alonso is a 48-year-old female presenting to the urgent care clinic with a two-week history of intermittent and progressively worsening right upper quadrant (RUQ) pain. The pain has intensified over the past two days and radiates to her right shoulder. She reports associated symptoms of nausea, vomiting, and loss of appetite (anorexia) for the last two days. She mentions similar self-resolving episodes over the past year. Her family history is significant for biliary disease (mother). On examination, she has a low-grade fever, mild scleral icterus, tenderness in the RUQ with guarding, and a positive Murphy’s sign.
- Onset: Two weeks ago, with worsening symptoms in the past two days.
- Location: Right upper quadrant, radiating to the right shoulder.
- Duration: Constant pain since onset; prior episodes lasted 1-2 days.
- Character: Crampy, gnawing, and aching.
- Aggravating/Alleviating Factors: Pain worsens with meals and is unresolved by antacids and NSAIDs.
- Related Symptoms: Nausea, vomiting, and anorexia started two days ago. Denies contact with sick individuals.
- Previous Treatments: Over-the-counter (OTC) antacids and ibuprofen with no relief.
- Severity: Pain fluctuates between 2-3/10, rising to 6-7/10. She has missed work due to the pain.
Primary Diagnosis: Ascending Cholangitis
Ascending cholangitis is an acute or chronic infection of the bile ducts, often due to obstruction caused by gallstones. In this case, the patient exhibits classic symptoms of cholangitis, including RUQ abdominal pain radiating to the right shoulder, nausea, vomiting, anorexia, low-grade fever, and scleral icterus. Given her family history of biliary disease, the diagnosis is supported. The condition requires hospitalization due to the risk of sepsis and liver damage from bile duct obstruction. Diagnostic testing, including magnetic resonance cholangiopancreatography (MRCP), may be required. Surgical intervention such as a cholecystectomy (gallbladder removal) may also be necessary.
Rationale: The patient’s symptoms align with ascending cholangitis, which is characterized by jaundice, abdominal pain, and fever, all resulting from stasis and infection in the biliary tract. Family history of biliary disease further increases her risk of developing this condition.
Evita Alonso iHuman Differential Diagnoses:
1. Cholecystitis:
Cholecystitis occurs when gallstones block the cystic duct, causing inflammation of the gallbladder. Symptoms include severe RUQ pain radiating to the right shoulder, nausea, vomiting, and tenderness over the abdomen, all of which the patient has reported. However, the absence of severe fever and chills makes ascending cholangitis more likely.
2. Acute Pancreatitis:
Acute pancreatitis is inflammation of the pancreas, often presenting with symptoms like nausea, vomiting, fever, and abdominal pain radiating to the back. While the patient’s symptoms could align with acute pancreatitis, the RUQ pain is more suggestive of biliary pathology than pancreatic.
3. Peptic Ulcer Disease:
Peptic ulcers develop when stomach acid erodes the lining of the stomach or small intestine. Symptoms include burning stomach pain, nausea, bloating, and vomiting, all of which are present in the patient. However, the location and radiating nature of her pain make this diagnosis less likely.
Case Management Plan:
Pharmacologic Care:
- IV Fluids: Start IV normal saline (0.9%) bolus 100 ml, then maintain at 50 ml per hour.
- Antibiotics: Administer Ertapenem 1 g IV once daily, and Zosyn 3.375 g IV every 6 hours for 7 days.
- Antiemetics: Give Zofran 4 mg IV every 6 hours as needed for nausea and vomiting.
- Blood Culture: Collect blood culture x2 to check for bacteremia.
- Glucose Monitoring: Check blood glucose every 4 hours due to NPO (nothing by mouth) status.
Supportive Care:
- NPO Status: The patient will remain NPO to prevent further complications and prepare for potential surgery.
- Surgical Consultation: Consult general surgery for evaluation and potential cholecystectomy.
Patient Education:
- Explained the diagnosis of ascending cholangitis and the importance of hospitalization. The patient may require additional imaging (e.g., MRCP) or surgical intervention (cholecystectomy).
- Instructed the patient on post-op care if surgery is performed, including avoiding strenuous activity, following a low-fat diet, and eating small meals.
- Advised her to seek medical attention if pain worsens or if symptoms of infection (fever, chills, bleeding) occur.
Follow-Up:
- Continue monitoring for increased pain, fever, or other symptoms while in the emergency department.
- Post-op follow-up scheduled 1-2 weeks after discharge, with instructions to contact the clinic if necessary.
References:
- Chatterjee, S., Mavani, A., & Bhattacharyya, J. (2022). Chemistry and mechanism of the diseases caused by digestive disorders. In Nutrition and Functional Foods in Boosting Digestion, Metabolism, and Immune Health (pp. 3-14). Academic Press.
- Crowley, K., & Martin, K. A. (2022). Patient education: Gallstones (The Basics). UpToDate.
- Hatnoorkar, S. A., & Rajpal, C. (2022). Homoeopathy and Acid Peptic Disorder. Journal of Medical and Pharmaceutical Innovation, 9(45).