Current Medical Diagnosis and Treatment †MyAssignmenthelp.com

Question: Discuss about the Current Medical Diagnosis and Treatment. Answer: Introduction The following is a case assessment for patient Kasim, aged 49 years old suffering from cholecystitis. The report will be based on clinical reasoning cycle. It is a model which nurses and clinicians use to collect cues, information processing, understanding patient problem and implementing interventions, outcome evaluations and reflection on the learning process of a case study. The outline below shows a detailed assessment report for the patient. Cholecystitis is the inflammation of the gall bladder, (ICGT, 2014) and it occur major on patience of previous history of gall stones. Blockage of cystic duct contributes to the inflammation of the gall bladder. Common symptoms of the condition are the abdominal pain and severe prolonged pain. The patient is admitted with right upper quadrant abdominal pain, fever and vomiting. The patients vitals are the blood pressure is 100/45; heart beat rate is 126 and temperature measuring 38.8oc. The patient further has pale dry mucous membrane his score on pain at the shoulder is at 7/10. For typical confirmed case, inflammation causes effects on the outside body. Pain occurs deeply with inspiration which often leads to breathe termination when the right upper quadrant causes pain. Another key observation is the yellowing of skin pr jaundice which is often a mild appearance. Patience who may have multiple conditions like diabetes and chronic illness and those with immune compromised immune ma y have vague symptoms which include fever and tenderness at a specific region, (Demehri Alam, 2014). The highest risk factor for cholecystitis is gall stones due to increased inflammation. The risk factors for gall stone s include gender, pregnancy, obesity , age, oral contraceptives and eight loss, (Greenberger Paumgartner, 2012). Typical examination for cholecystitis reveals presence of fever, tachycardia and tenderness in the right upper quadrant with rebounding, palpability of the gall bladder or fullness by 30%-40% and jaundice occurrence however it occurs on 25% of the patients. Symptoms of cholecystitis often appear suddenly or develop slowly for a period of time. These symptoms include severe abdominal pains, nausea, vomiting, loose, light coloured tools, fever, abdominal cramp, chills, jaundice and itching, typical attacks last for 2-3 days depending on the person status. Complications can occur which include, pancreatic due to the inflammation, gall bladder perforation due t the infection, enlarged gall bladder, infection build upper and tear of the gall bladder. The most prevalent observed symptoms of cholecystitis are the upper pain in the abdomen, physical examination has tachycardia and the type of tenderness on right upper quadrate is missing from the information. In the case study blood tests are missing, in a case of cholecystitis, blood tests are done for the biomarkers of inflammation. These test include complete blood count and C- reactive protein and the assessment of levels of bilirubin for bile blockage assessment, (Friedman, 2015). In cholecystitis assessment of blood there is an increase in the white blood count with level range of 12,000- 15,000/mcL. The reactive protein is usually increased, bilirubin level is mildly elevated at 1-4 mg/Dl. Blood amino transferees are elevated. The elevation levels of the laboratory values depend on the degree of gall bladder inflammation. Abdominal upper quadrate on the right side is used as diagnosis for cholecystitis, (Strasberg, 2008). Ultra sound results suggest acute cholecystitis which illustrates gall stones, fluid with the gall bladder and the thickening of the gall bladder walls. CT scan diagnostics tests are also not utilised, however it is utilised in severe conditions such as gangrene or perforation. Boazs sign can be used for assessment as it applies on the right scapula and can be an alarm for acute cholecystitis. The patient is exhibiting various vital signs for cholecystitis however they are few for confirmation of diagnosis. Further diagnostic tests need to be done for the patient. A complete blood count should be conducted, and results obtained should be segregated into white blood cells, red blood cells, lymphocytes. The results obtained should be cross checked with reference values. the normal range of white blood cell is 4.3 10 g/l, red blood cell120-175 g/l and platelets 140-450g/l. Creatin levels should also be assessed, it is used as an indicator for renal function tests, normal values ranges at 0.60 1.7 mg/dl. Another focused assessment is BUN, which shows renal function perfusion and the dietary intake of carbohydrates and the level of protein metabolism, referenced based on the normal range values. Another important assessment to be carried is the urinalysis test. It is important for testing in acquisition of information regarding the disorders of the kidney and the lower urinar y tract, and associated disorders that affect urine composition. In the urinalysis assessment, data such as colour, gravity, the Ph and protein availability, red blood cells, white blood cells, bacteria, esterase, ketones, bilirubin and crystals casts are measured. In the preoperative assessment, the patient is experiencing pain at a scale score of 7/10, the acute pain is linked to the increased inflammation and the gall bladder dislocation. This can be largely attributed to the stone availability in the gall bladder, it causes blockage in the cystic duct thus causing acute pain in the right side. There is need for pre-operative assessment which is conducted to run from head to toe and running of objective assessments, which include test such as over the counter drugs, anti-coagulant drugs, smoking history, respiratory problems and nutritional status of the patient. Further focussed assessment of various body organs should be done, these include, the heat, abdomen and lungs. A complete ECG should be conducted so as to asses any previous myocardial infarction and chest x-rays. Full pain assessments and nausea should be done. The patient may appear to be ill with presence of fever and tachycardia, the patient pain score reveals elevated level of pain. Cholecystitis often results in the pain localized at the peritoneal area which causes inflammation and disturbance in the patient is characterized with a lot of pain. Physical examinations should be conducted efficiently and effectively. Accurate measurement soft he vital signs forms the basis of assessments. The physical exam guide should follow inspection, auscultation, percussion, palpation and relevant tests such pelvic positioning. Procedure involves assessing the general appearance of the patient, if the patient is moving around and is not able to find comfortable positions, can be an indicative of renal colic while abdominal scars may be an indicative of distension. Laboratory tests conducted can be no specific and are used to boost the evidence of clinical support, (Liau, Teh Serrablo, 2014). Initials test include complete blood count, leukocytosis is observable in cholecystitis. Urinalysis tests can be able to identify any urinary infection. Chest x rays can be done on the patent as this will assist in ruling respiratory causes of pain. Fluid balance measure can be used to assess the patient, the ratio of intake and output of the patient are used. This data on the patient reflects causes of fluid imbalance such as decrease and increase in fluid levels. Even though laboratory findings may appear to suggest presence of cholecystitis, imaging might be conducted. Procedures such as ultra sonography might be conducted, which asses the right upper quadrate, gall stones can be observed using the ultrasound. Conducting Murphy sign by sonographic method is done by applying pressure on the transducer of the ultra sound linking to the gall bladder and displayed on the screen. Computer tomography can be utilized to assess the patient. Acute condition state, with similarities as gall bladder, edema on the walls and fluid in the periphery can be displayed. Ultra sonography is the readily and more accurate tool for assessment of cholecystitis, (RUQ, 2017) In a more precise manner on tests and assessments for the patient, maintenance of accurate records of intake and output data in fluid management are essential. Skin assessments and the mucous membranes for this patient are evident; they provide clear information on the fluid state and circulating volume of fluid. Monitoring of vital signs and the presence of nausea, cramps on the abdomen, seizures and depressions on the respirations are useful for identification of deficiencies which are associated like decline in sodium, potassium, and chloride. Encourage the patient to perform regular oral hygiene proper treatment mouth wash, this assist in decreasing the dryness of the mucous membrane of the oral cavity. Conclusion Hence in the patient assessment there is need to focus planning goals on pain management with an aim of alleviating pain. Prompt diagnosis of the patient is effective in the overall care strategy, (Baron Grimm, 2015). There is need for maintaining balance of the fluid and the electrolytes in the body of the patient. Clear respiratory are essential for respiratory ability of the patient. In patient assessment, there is need for comprehensive history evaluation and effective physical and laboratory examinations, as this ensures clear and appropriate diagnosis of cholecystitis condition. Reference Baron, T. H., Grimm, I. S. (2015). Nonsurgical management of cholecystitis: a tailored approach. Gastrointestinal endoscopy, 82(6), 1037-1038. Demehri, FR; Alam, HB, (2014). "Evidence-Based Management of Common Gallstone-Related Emergencies". Journal of intensive care medicine. doi:10.1177/0885066614554192. PMID25320159. Friedman L.S. (2015). Liver, Biliary Tract, Pancreas Disorders. In Papadakis M.A., McPhee S.J., Rabow M.W. (Eds), Current Medical Diagnosis Treatment 2015. Greenberger N.J., Paumgartner G (2012). Chapter 311. Diseases of the Gallbladder and Bile Ducts. In Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J, Loscalzo J (Eds), Harrison's Principles of Internal Medicine, 18e Internal Clinical Guidelines Team, (2014). "Gallstone Disease: Diagnosis and Management of Cholelithiasis, Cholecystitis and Choledocholithiasis. Clinical Guideline 188": 101. PMID25473723. Liau, K. H., Teh, C., Serrablo, A. (2014). Management of acute cholecystitis and acute cholangitis in emergency setting. Central European Journal of Medicine, 9(3), 357-369. RUQ Acute Cholecystitis -The Medical University of South, (2017). Carolinaacademicdepartments.musc.edu/surgery/education/medstudents/.../ruqacutechole.pps. Accessed online 2017-05-04. Strasberg, SM, (2008). "Clinical practice. Acute calculous cholecystitis.". The New England Journal of Medicine. 358 (26): 280411. doi:10.1056/nejmcp0800929. PMID18579815.