T.B. is a 65 year old retiree who is admitted to your unit from the emergency department (ED). On arrival you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid back as a deep, sharp boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but “none as bad as this.” He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fish and chips at a fast-food restaurant earlier today. He is not happy to be in the hospital and is grumpy that his daughter insisted on taking him to the ED for evaluation.

 

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After orienting him to the room, call light, bed controls, and lights, you perform your physical assessment. The findings are as follows: he is awake, alert, and oriented (AAO) x3, and he moves all extremities well (MAEW). He is restless, is constantly shifting his position, and complains of (C/O) fatigue. Breath sounds are clear to auscultation (CTA). Heart sounds are clear and crisp, with no murmur or rub noted and with a regular rate and rhythm (RRR). Abdomen is flat, slightly rigid, and very tenderto palpation throughout, especially in the RUQ. Bowel sounds are present. A sharp inspiratory arrest and exclamation of pain occur with deep palpation of the costal margin in the RUQ (positive Murphy’s sign). He reports light colored stools for 1 week. The patient voids dark amber urine but denies dysuria. Skin and sclera are jaundiced. Admission vital signs (VS) are 164/100, 132, 26, 36 C, Sao, 96% on 2Lof oxygen by nasal cannula.

 

 Based on the above symptoms what other assessments, tests or procedures would the MD order or perform to help diagnosis the problem?

What results would you expect to find and why?

Based on your results what is the cause and pathology?

What are the patient’s risk factors?

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