Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249

Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249

This paper escri!es the initial presentation of "r# $ %the
patient&' to the emergency epartment %(D& of the local hospital
)ith se*ere acute a!ominal pain to the right upper +uarant
%,-.&# The initial iagnosis' general appearance' meical
history' current meications )ill !e iscusse# /linical
e0amination finings' iagnostic tests performe on "r# $'
follo)e !y the formulation of a iagnostic ecision an
conclusion )ill !e iscusse )ith reference to literature# The
)riter met "r# $ the same ay he )as amitte to the surgical
)ar *ia (D# All personal' presenting an historical information
o!taine from "r $' as )ell as the physical e0amination' has
!een consente to !y "r $ himself# All reasona!le steps ha*e
!een ta1en to ensure that pri*acy an confientiality is
maintaine throughout this paper#
The preliminary meical e0amination of "r $ re*eale
epigastric pain raiating to the !ac1 an up to the scapula#
/arroll et al#' postulates that common etiology of epigastric pain
inclue' !ut is not limite to' aci reflu0' gastritis' peptic ulcer
isease' inflammation of the pancreas %pancreatitis&' gallstones
%cholelithiasis&' an infection in the gall !laer %cholecystitis&#
2n 1992 the 2nternational $ymposium on Acute 3ancreatitis
initiate a classification system for acute pancreatitis# Their
o!4ecti*e )as to regulate efinitions of pancreatitis an it5s
complications # 2n recent years these guielines neee re*ision
2
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
ue to the a*ances mae in unerstaning pancreatitis
pathophysiology an *ast a*ances in technology an iagnostic
testing# 2n 2012 a re*ise efinitions an classification of acute
pancreatitis )ere aopte #
The ne) re*ise efinition of acute pancreatitis iagnosis
re+uires t)o of the follo)ing three features to !e present6
%1& A!ominal pain consistent )ith acute pancreatitis
%2& ,aise serum lipase acti*ity at least three times greater
than the normal7
%3& /ontrast-enhance compute tomography %/(/T& #
Acute pancreatitis %A3& is efine as the suen inflammation of
the pancreas )hich causes se*ere sharp a!ominal pain )ith a
raise serum lipase acti*ity of at least three times higher than the
normal range of an can to !e confirme !y iagnostic tests #
Although the hallmar1 symptom of acute pancreatitis %,-. pain
accompanie )ith nausea an *omiting& )as present' these
clinical features alone )ere not conclusi*e enough to form a
iagnosis that e0clues cholecystitis or cholelithiasis an
iagnostic tests )ere orere to confirm the iagnosis # "r $
)as amitte to the surgical )ar for a series of iagnostic tests
to confirm the iagnosis#
As part of their 8igesti*e alliance8 the pancreas an the li*er
secretes the ma4ority of the igesti*e en9ymes an !ile neee in
the igesti*e tract# Nestle *irtually hien ami the stomach'
3
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
the spine an in the cur*e of the uoenum lays the only glan
in the human !oy that ser*es a ual purpose' the pancreas #
3atton : Thi!oeau state that the pancreas can function uner
great a*erse conitions %functional reser*e&' an that the glan
has t)o main functions6 firstly' as an e0ocrine glan %eli*ere
through a uct&' the pancreas prouces inacti*e igesti*e
en9ymes' mainly through the Acinar cells' once present in the
small !o)el' these en9ymes !ecome acti*ate an assist an
spee up the igestion of proteins' car!ohyrates' acis an fats
foun in the uoenum an the rest of the small intestine #
$econly' as an enocrine glan %irectly into the !loo supply&'
the pancreas secretes hormones through the alpha an !eta cells'
such as insulin' glucagon an pancreatic polypeptie #
2nflammation of the pancreas arises ue to either the e0istence
of gallstones in the common !ile uct or e0cessi*e alcohol
consumption # Accoring to 3orth the inflammation occurs
)hen the igesti*e en9ymes prouce !y the pancreas are
acti*ate )hile still insie the pancreatic ucts' commonly ue
to a elay or !loc1age that pre*ent the en9ymes from reaching
the uoenum *ia the common !ile uct # This !loc1age allo)s
the en9ymes to lea1 through )alls of the ucts an attac1 the
parenchyma of the pancreas an surrouning tissue of the
peritoneal ca*ity # This inflammatory tissue estruction may
a*ance !eyon the pancreas' causing systemic inflammatory
response synrome %$2,$& an multi organ failure #
4
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
The other partner in the 8igesti*e alliance8 is the li*er'
supporte !y the gall!laer )hich acts as a storage meium for
the !ile prouce !y the li*er # The gall!laer stores !ile
prouce !y the li*er an through a process concentrates the !ile
fi*e to ten fol# The gall!laer secretes the !ile through the
common !ile uct' )hich runs through the pancreas' as an
)hen neee !y the igesti*e system to help igest foo #
/holecystitis or cholelithiasis )as the reason for ou!t uring
the initial iagnosing phase an neee to !e eliminate as a
possi!le cause to ensure the initial iagnose of pancreatitis )as
correct #
;!4ecti*e an su!4ecti*e ata recoring is consiere the
founation of the nursing process # <e!er an =elly conten
that ongoing assessment ocumentation is a *alua!le
communication meium for the multi isciplinary team %"DT&
in*ol*e in the treatment of the patient# Accoring to >ic1ley et
al# e*ery effort must !e ta1en to recor the patient5s o)n )ors
in ocumenting su!4ecti*e ata#
The patient' "r $' is a )ell-groome ?1 year ol /aucasian
male' 1#@6m tall an )eights 10?1g' )ho presente at (D )ith
se*ere a!ominal pain' nausea an *omiting# "r $ )as !rought
to the (D !y his partner after he e0perience se*ere a!ominal
pain for a!out si0 hours prior to presentation# The patient state
an inicate !y gesture that the pain )as in the right upper
?
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
+uarant' raiating to the !ac1 an up to the left scapula an that
8nothing seems to stop the pain8# Ae also ha se*eral episoes
of nausea follo)e !y *omiting small amounts of clear mucousy
flui an sai he felt e0hauste' )hich is also one of the
presenting symptoms of /arroll et al# # The patient ha 8a large
meal of fish an chips8 the pre*ious night an the pain starte
soon after)ars# "r $ enie alcohol a!use' stating 82 on5t
rin1 any alcohol or use any rugs an o not smo1e8# Ae 1eeps
fit !y cycling t)ice a )ee1 an plays golf on a regular !asis# Ae
also li*es )ith his partner in their o)n house an oes the la)ns
an garen himself#
"r $ e0perience similar pain three )ee1s pre*iously after a
8greasy !acon an eggs !rea1fast8# That episoe )as not as
se*ere' laste se*eral hours an self-resol*e prior to the patient
see1ing meical help# The patient claims he is fit an healthy
other)ise an has no other meical pro!lems# Ae has no 1no)n
allergies an is not ta1ing any regular meication# >ecause of
family history in*ol*ing ia!etes an asthma' "r $ ha a recent
8chec1-up8 a!out si0 months pre*iously an recei*e a clean !ill
of health#
Accoring to >ic1ley et al# it is reasona!le an a*isa!le to
inclue a full re*ie) of systems %,;$& )ith the clinical
e0amination to etermine a iagnosis# ,;$ is a +uestion an
ans)er techni+ue' an may !e conucte in a 8hea to toe8
6
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
manner# >ic1ley et al# further a*ise a physical e0amination
incluing palpation to etermine aetiology#
General: No recent )eight change or fatigue#
Skin: No recent changes in colour te0ture#
Respiratory: ,espiratory rate )ithin normal range at16 No
yspnea' or asthma note
Cardiovascular: >loo pressure 120B70 )ithin normal
range' no chest pain or iscomfort#
Urinary: No !urning or pain uring urination reporte# No
change in colour o!ser*e#
Peripheral vascular: No s)elling or tenerness in legs or
feet# No change in colour' )armth' sensation or mo*ement
in finger or toes note#
Musculoskeletal: No muscle or 4oint pains reporte#
Psychiatric: No change reporte
Neurologic: No num!ness or loss of sensation reporte#
;rientate to time an place#
Endocrine: Nil o!ser*e or reporte#
Gastrointestinal: 3atient reporte some loss of appetite an
no yspepsia# 3atient states 8foo is tolerate in
moeration8# >o)el mo*ements )ere regular prior to
current presentation# 3atient thin1s his 8li*er is healthy as
7
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
he oes not rin1 alcohol8# Call!laer intact an no
history of gall!laer pro!lems# -pon inspection' a!omen
istension )as note' s1in )as pin1 an ry an no 4aunice
)as o!ser*e# No e*ience of trauma or !ruising )as
o!ser*e# A!ominal pain as escri!e in ,-.' raiating
to !ac1# Dight an eep palpitation re*eale tenerness to
the ,-. )ith eli!erate guaring# 3alpation cause patient
to gasp )ith pain an una!le to palpate for masses# During
auscultation !o)el souns )ere present !ut iminishe #
Diagnostic tests to !e conucte to assist )ith iagnosis
inclue measurement of the pancreatic en9ymes' serum
amylase an lipase# 2n acute pancreatitis the serum amylase )ill
!e at least three times the upper normal range 30-110 -BD #
/hase et al# further claim that the lipase )ill !e t)o to three
time a!o*e the normal range of ?-20@ -BD# The -= guielines
for the management of acute pancreatitis propose that lipase has
superior specificity an sensiti*ity than serum amylase to
confirm pancreatitis' # To eliminate other possi!le conitions
the patient )ith acute a!omen pain shoul also ha*e a full
!loo count %E>/& incluing renal' li*er' an pancreatic
function tests # Do) serum calcium le*els are relati*ely common
in acute pancreatitis )hereas raise !iliru!in an serum amino-
transferase accompanie !y change in urine colour to ar1
orange is suggesti*e of cholelithiasis #
@
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
As the eep location of the pancreas contri!utes to the ifficulty
in iagnosing acute pancreatitis one or more of the follo)ing
tests coul !e orere to assist in iagnosing pancreatitis6
Abdoinal ultrasound !USS": -$$ allo)s e0amination of
the gall!laer an !ile uct system an if cholelithiasis is
present' the -$$ can sho) their location#
#$ray: To e0clue other possi!le causes of the a!ominal
pain such as intestinal o!struction or perforation #
Coputeri%ed &oography !C&" scan: As the gol
stanar iagnostic test the /T scan sho) three-imensional
images of the !oy an is much clearer than F-rays# <ith
the use of contrast the /T scan can inicate gallstones an
the le*el of in4ury to the pancreas# /T $can pro*ies the
!est imaging techni+ue to e0clue other conitions that can
imitate symptoms of acute pancreatitis #
Endoscopic Resonance Cholangio$Pancreatography
!ERCP": An (,/3 can pinpoint e0actly )here the
gallstone is in !iliary acute pancreatitis# An a*antage of
(,/3 is that it has inter*entional capacity # (,/3 can !e
use to perform minor surgical proceures such as stone
remo*al' stent placement' an sphincterotomy # (,/3 is an
in*asi*e treatment that is highly sensiti*e for confirming the
iagnosis of cholelithiasis #
Magnetic Resonance Cholangio$Pancreatography
!MRCP"' ",/3 is a more recent non-in*asi*e test that
9
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
creates cross-section imagery of parts of the !oy#
Accoring to /arroll et al# a slight isa*antage of ",/3
is that it lac1s the inter*entional capa!ility that (,/3
possesses' !ut it is non-in*asi*e an is highly sensiti*e an
specific for gallstone etection #
(arly treatment an s)ift iagnosis in acute pancreatitis is
important for successful clinical outcome# Amist *arying
results stuies using the urinary trypsinogen-2 ipstic1 test there
are promising potential using the -rinary trypsinogen-2 as a
iagnostic mar1er # ;ther serum mar1ers that sho)s promising
potential in early ientification se*ere acute pancreatitis is
interleu1in 2D-6 an 2D-@ # Aoun et al# recommens more
stuies !een one to impro*e preicti*e accuracy of the
interleu1in %2D&-6 an 2D-@ mar1ers#
/onsiering the ifferential iagnoses it appears that pancreatitis
or cholelithiasis is the most li1ely iagnosis !ecause the
presenting signs an symptoms met the classification system for
acute pancreatitis# 3ain assessment uring the clinical
e0amination re*eale se*ere pain ranging !et)een 6-@ B 10' on a
pain scale )here 9ero is no pain an ten is the most e0cruciating
pain patient has e*er e0perience# The patient5s !oy language'
lying curle up in foetal position' )as consistent )ith the
e0pression of pain uring the clinical e0amination # "r# $5s
!loo )as ta1en an results sho)e raise amylase of 21@0 uBl
10
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
)ell a!o*e the normal range of 30-110 -BD # "r $ ha a ",/3
that inicate gall stones in the common !ile uct# Accoring to
"arshall an supporte !y *an Ceenen et al# gallstones are the
single most common cause of acute pancreatitis# After
consiering all rele*ant iagnostic ata the primary symptoms
isplaye !y the patient in this case are suggesti*e of a iagnosis
of pancreatitis' 7' /ollins 7 an "arshall #
2n conclusion this paper has introuce a patient )ho presente
)ith se*ere ,-. a!ominal pain# The aetiology of the isease
)as iscusse along )ith a comprehensi*e efinition of acute
pancreatitis# The clinical e0amination unerta1en an
information from iagnostic testing contri!ute to ma1ing an
appropriate iagnosis !ase on rele*ant an current literature#
"r $ met all three of the re+uire elements of the re*ise
efinition of acute pancreatitis )hich inclue se*ere pain'
raise amylase more than three times higher than normal an an
",/3 )hich emonstrate the presence of gall stones #
11
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
,eference
Ale0a1is' N#' : Neoptolemos' G# 3# %200?&# Algorithm for the
iagnosis an treatment of acute !iliary pancreatitis#
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: Aansen' "# ># %2010&# -rinary trypsinogen-2 ipstic1 in
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Aoun' (#' /hen' G#' ,eighar' D#' Cleeson' E# /#' <hitcom!' D#
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interleu1in-6 an interleu1in-@ in preicting se*ere acute
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oi6 10#11?9B000214191
Aycinena' E#' : Daley' ># %2013&# Acute pancreatitis Best
Practice# ,etrie*e 20 Gune 20136 from
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>an1s' 3# A#' >ollen' T# D#' Der*enis' /#' Coos9en' A# C#'
Gohnson' /# D#' $arr' "# C#' # # # Acute 3ancreatitis
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GUT, 62' 102-111# oi6 10#1136Bgut4nl-2012-302779
>an1s' 3# A#' Ereeman' "# D#' : 3ractice 3arameters /ommittee
of the American /ollege of Castroenterology# %2006&#
12
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
3ractice Cuielines in Acute 3ancreatitis# Aerican
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for acute pancreatitis# $ummary of the 2nternational
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Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
Ean' >#-C#' : AnrIn-$an!erg' A# %2010&# Acute pancreatitis#
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14
Nursing 770 - Assignment 1 Analysis of Diagnostic Decision 6630249
$te*ens' T#' 3arsi' "# A#' : <alsh' ,# "# %2009&# Acute
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1?