The case is based on acute right quadrant abdominal pain of Mrs. DC who comes to the emergency department. She states that the pain occurred after dinner and has steadily increased. She complains that the pain has increased substantially which has moved towards her back. She also reports to feel bloated and gassy (Yarmish, et al. 2014).
The cause of upper right quadrant pain can be due to varied reasons which is based on the general conditions, age, and sex of the patient (Mazzei, et al. 2013). The medical history and physical examination of the patient would help in determining the differential diagnosis. Some of the key factors that can help in diagnosis Mrs. DC include weight loss, acute or chronic onset, urinary/bowel symptoms, general malaise, and pyrexia (Grock, Chan, & deSouza. 2016).
As a nursing professional, it is empirical to assess the patient’s signs and symptoms to help in differential diagnosis (Macaluso, & McNamara 2012). The initial signs of the patient such as pulse rate, temperature, and blood pressure would be evaluated. The patient should also be differentially assessed based on general condition and presentation such as being well, shocked, dyspnoeic or pyrexial (Mccance 2014). Abdominal examination of the patient, specifically if she points out at a single location or if the pain is diffused through the abdominal region. A full body physical examination including respiratory system and other systems is highly recommended (Mazzei, et al. 2013).
The symptoms of the patient should also be assessed based on the area of pain (whether single point or diffused pain), the actual time of pain or start of pain, determine if the onset of pain was gradual or sudden, determine if the pain is intermittent or continuous, assess the nature of the pain such as gripping, burning, or stabbing, and if there are any relieving or aggravating factors. Lastly, it is important to determine if the pain is radiating. As a professional nurse, I would also assess the appetite, bowel movements, urine, weight changes, smoking, alcohol consumption, and medication (Macaluso, & McNamara 2012).
Based on the assessment (differential diagnosis) of Mrs. DC, she could be diagnosed with liver/gallbladder disease, bowel lesions, cardiovascular disease, renal disorders, respiratory disease, endocrine/exocrine disease, or generalized infections. Gallstones are a common manifestation of abdominal pain (Yarmish, et al. 2014). However, most cases appear to be asymptomatic. Liver disease often represents abdominal pain wherein physical damage to the liver and acute trauma could result in upper quadrant pain (Grock, Chan, & deSouza. 2016). A case of atypical acute appendicitis could also result of pain. Irritable bowel symptoms could also cause abdominal pain. Bowel lesions associated with ischaemic colitis, diverticular disease, carcinoma, and constipation could also lead to upper right quadrant pain (Macaluso, & McNamara 2012). In rare or extreme cases, the liver capsule could be stretched due to congestive cardiac failure or cardiac pain. A case of abdominal aortic aneurysm could also be determined that may have caused acute abdominal pain (Mazzei, et al. 2013). A history of renal disorders such as nephrolithiasis, hydronephrosis, pyelonephritis, renal cancer, and obstruction of the urinary tract could also lead to acute upper right quadrant pain (Mccance 2014).
Some of the key endocrine or exocrine diseases such as adrenal tuberculosis, diabetic ketoacidosis, metastatic carcinoma, addisonian crisis, carcinoma of the pancreas, intestinal obstruction due to pancreatitis, or pain from the pancreas could also cause acute abdominal pain (Mazzei, et al. 2013). Infections such as herpes zoster or subphrenic abscess are probable diagnosis that could related to Mrs. DC’s case. Lastly, a rare condition known as Fitz-Hugh and Curtis syndrome could also result of acute abdominal pain (Mccance 2014).
The first-line treatment for acute upper quadrant abdominal pain could be to wait out until symptoms decline followed by increase in intake of water or dietary fibre in the case of constipation and gassy feeling (Grock, Chan, & deSouza. 2016). The use of over the counter dietary products such as Metamucil is highly recommended to relive gassy or bloated feeling in Mrs. DC. Fluid intake and avoidance to spicy food products is a key to relieving symptoms (Yarmish, et al. 2014).
References
Grock, A., Chan, W., & deSouza, I. S. (2016). A Curious Case of Right Upper Quadrant
Abdominal Pain. Western Journal of Emergency Medicine, 17(5), 630–633.
Macaluso, C. R., & McNamara, R. M. (2012). Evaluation and management of acute abdominal
pain in the emergency department. International Journal of General Medicine, 5, 789–797.
Mazzei, M. A., Guerrini, S., Cioffi Squitieri, N., Cagini, L., Macarini, L., Coppolino, F.,
Volterrani, L. (2013). The role of US examination in the management of acute abdomen. Critical Ultrasound Journal, 5(Suppl 1), S6.
Mccance K (2014). Pathophysiology: The Biologic Basis for Disease in Adults and Children.
Elsevier - Health Sciences Division. 7th Edition.
Yarmish, G. M., Smith, M. P., Rosen, M. P., Baker, M. E., Blake, M. A., Cash, B. D.,
Tulchinsky, M. (2014). ACR Appropriateness Criteria Right Upper Quadrant Pain. Journal of the American College of Radiology : JACR, 11(3), 316–322.
