Discussion Week 4:
What additional subjective data are you seeking to include past medical history, social, and relevant family history?
According to Kennedy-Malone et al. (2019), 90% of cholecystitis cases are associated with gallstones, and in the older adult, can present with atypical features. Considering the older adult population may present with symptoms differently than other populations, it is essential to obtain an accurate and thorough history of any abdominal complaints. As the healthcare provider for Mrs. Deer, I would ask additional questions to determine the sequence of events that triggered her symptoms as well as any aggravating or alleviating factors, and what therapeutic measures she has tried to relieve her symptoms. I would ask her to describe the characteristics of her pain including her pain level on a scale of 1-10 from onset compared to now and if her pain radiates. I would ask about the color, consistency, and amount of vomiting and when her last bowel movement was. Finally, I would inquire about her nutritional habits, and has she experienced any rapid loss of weight as this increases her risk of gallstone formation.
Subjective data that is important for proper diagnosis as it pertains to past medical history would include asking the patient if she has ever experienced similar pain in her past. Does she have any prior history of gallstones, hyperlipidemia, diabetes, metabolic syndrome, abdominal surgeries, heart disease, or peripheral vascular disease? I would inquire about any history of jaundice or drug or alcohol abuse as well as a complete list of current medications and any known allergies.
Family history is an important aspect to assess in our subjective collection of data, especially if remarkable for any gallbladder disease and race, as certain races are more susceptible to cholecystitis. Social history is relevant for many reasons. While the patient is at risk for cholecystitis due to nonmodifiable risk factors such as her advancing age, female gender, and possible race and family history, there could be modifiable factors that she could change in her lifestyle. Alcohol abuse (alcoholic cirrhosis) and high fat diet are all contributors in the development of gallstones. Her social history also would describe her living environment. Is she married, widowed, and does she live alone? Is her environment safe? What is her support system like? Are there other children or family members that can support her in the future in addition to her son? According to Cash & Glass (2019), sudden starvation or prolonged fasting in the elderly is a trigger of cholecystitis. It would be important to ask her about food shopping, meal prepping, and transportation. Transportation for medical services is crucial and she and her son can be given resources to help avoid this delay in care in the future.
What additional objective data will you be assessing for?
Objective data includes assessment of her vital signs, BMI, and any presence of weight loss. General appearance is assessed noting if she appears frail, dehydrated, or appropriate. A neuro assessment is important in the elderly as a change in mental status may the only outward sign in this population in change of health status (Kennedy-Malone et al., 2019). Skin color assessment may reveal jaundice if there is obstruction of the common bile duct (Hollier, 2018). In her physical exam I would be assessing right upper quadrant subcostal tenderness, masses, guarding, and pain on inspiration (Murphy’s sign) (Hollier, 2018).
What are the differential diagnoses that you are considering?
The primary diagnosis of the patient would be cholecystitis considering her acute onset of right upper quadrant pain, nausea, and vomiting, after the ingestion of a large, fatty meal. Differential diagnosis could include peptic ulcer disease, appendicitis, diverticulitis, irritable bowel syndrome, and hepatitis.
What laboratory tests will help you rule out some of the differential diagnoses?
Laboratory tests that are useful in ruling out differential diagnoses includes a CBC (leukocytosis), bilirubin, amylase, lipase, ALT/AST, ALP, and GGT. These lab values can assist in distinguishing a diagnosis of classic cholecystitis, with bile duct obstruction, or with pancreatitis (Hollier, 2018).
What radiological examinations or additional diagnostic studies would you order?
Ultrasound is the most sensitive and specific test to diagnose cholecystitis by demonstrating presence of gallstones, thickening of gallbladder wall, fluid, and enlargement (Hollier, 2018). Hepatobiliary (HIDA) scan is useful if gallbladder cannot be visualized due to cystic duct obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) can be used to see biliary and pancreatic ducts to detect common bile duct stones following a special MRI (MRCP) which provides detailed imagining of hepatobiliary and pancreatic systems.
What treatment and specific information about the prescription that you will give this patient?
Treatment options are based on the grading (mild, moderate, or severe) of her acute cholecystitis and results of diagnostic and laboratory testing. The treatment I would recommend for this elderly patient who has been experiencing this pain with nausea and vomiting for two days is hospitalization for intravenous antibiotics and possible cholecystectomy. She will also be given analgesics and antiemetics as needed. If surgery is contraindicated for any reason, the consideration can be made to give ursodeoxycholic acid for dissolution of gallstones.
According to Kennedy-Malone et al. (2019), for uncomplicated cases of cholecystitis, agents such as amoxicillin/clavulanic acid or ceftriaxone and metronidazole are given.
What are the potential complications from the treatment ordered?
Complications of acute cholecystitis include ischemia and inflammation within the gallbladder lumen, gallbladder necrosis with perforation or abscess, sepsis, cholangitis, and pancreatitis (Kennedy-Malone et al., 2019). Should the patient have undergone a cholecystectomy, complications include postoperative infection, adverse drug reactions and interactions, and changes in functional and mental status.
What additional laboratory tests might you consider ordering?
A CBC that shows an elevated white blood cell count above 15,000 cells/uL indicated a non-resolving inflammation and is a predictor of treatment failure (Cash & Glass, 2019) Liver function panels will also be followed.
What additional patient teaching may be needed?
Pt. can be educated to maintain a healthy weight, avoid rapid weight loss, and eat a healthy diet with minimal fried foods. She should be made aware that even if she undergoes a cholecystectomy, stones may recur in bile ducts. All of her medications will be thoroughly explained to her and her son as well as arrangements for follow up appointments.
Will you be looking for a consult?
A surgical consultation is necessary, as acute cholecystitis is expected. Additionally, the patient would be referred to a gastroenterologist for consideration of ERCP for detecting and managing bile duct stones and may be performed before, during, or after gallbladder removal (Cash & Glass, 2019).
References
Cash, J. C., & Glass, C. A. (2019). Adult-gerontology practice guidelines. Springer Publishing Company, Llc.
Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Advanced Practice Education Associates.
Kennedy-Malone, L., Lori Martin Plank, & Evelyn Groenke Duffy. (2019). Advanced practice nursing in the care of older adults (2nd ed.). F.A. Davis Company.