Case Study: Assessment and Management of Abdominal Pain Case

This case study presents a patient experiencing abdominal pain, detailing the subjective and objective findings during assessment. The patient reported pain in the upper right quadrant, tenderness, and other symptoms. The assessment includes the patient's medical history, vital signs, and physical examination. The case study then delves into the diagnosis of choledocholithiasis, exploring advanced imaging techniques like MRCP and ERCP, and discussing the use of medications like indomethacin and ibuprofen for pain management. The plan of care focuses on providing comfort, managing pain, and improving bowel function. The expected outcome is consistent, semi-soft stools and improved intestinal motility. The case study also includes references to relevant medical literature.

Running head: CASE STUDY ASSESSMENT
Case Study Assessment
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1CASE STUDY ASSESSMENT
Subjective
The patient reported tremendous abdominal pain, which progressed from the upper
right quadrant of the abdomen towards his back. He reported that he did not feel this kind of
excruciating painful discomfort in the previous outburst. He felt nauseatic with no vomiting
symptoms. He preferred walking or sitting through bending forward; lying flat on stomach
was discomforting for him. He reported that a mild abdominal pain initiated after consuming
fried fish and chips in a fast food restaurant.
Objective
The patient reported clear breath sounds upon auscultation. Heart sounds were found
clear; no rubbing or murmuring sounds were reported. The patient showed regular cardiac
rate and rhythm. Assessment of abdomen revealed a slightly flat and rigid abdominal
structure, which showed tenderness upon palpations throughout. Clear bowel sounds were
noted. Dark and amber coloured urine and light coloured stools were reported in the patient
for the past one week. The bile stones are obstructed during their passage from lover to the
common bile duct, as a result this gives jaundiced appearance (Wilkins et al., 2017). During
admission, a high blood pressure of 164/100 with an increased cardiac pulse rate of 132 beats
per minute were observed. A respiratory rate of 26 breaths per minute in resting position was
observed which is abnormal. These higher values are significant of epigastric pain.
Assessment
Advanced imaging techniques such as MRCP and ERCP, laparoscopic
cholecystectomy. Historical examination of previous pain episodes. No medications can cure
choledocholithiasis, however, a dosage of 50-100 mg of indomethacin was administered on a
one time basis (Baiu & Hawn, 2018). Ibuprofen was administered for pain management.

2CASE STUDY ASSESSMENT
Plan
To provide comfort measures such as touch therapy and relaxation techniques such as
breathing exercises to alleviate discomfort. To administer stool softeners and perform
monitoring to check for its effectiveness. To provide additional pain relievers, moist heat
compression. The expected outcome would be consistent semi soft stools; bowel movement
would be improved along with intestinal motility.

3CASE STUDY ASSESSMENT
References
Baiu, I., & Hawn, M. T. (2018). Choledocholithiasis. JAMA, 320(14), 1506-1506.
doi:10.1001/jama.2018.11812
Wilkins, T., Agabin, E., Varghese, J., & Talukder, A. (2017). Gallbladder dysfunction:
cholecystitis, choledocholithiasis, cholangitis, and biliary dyskinesia. Primary Care:
Clinics in Office Practice, 44(4), 575-597. doi.org/10.1016/j.pop.2017.07.002