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Case Analysis: Patient Assessment

Introduction

Appendicitis is a health condition caused by a blockage in the appendix of the human body. It is regarded as one of the most common surgical emergencies and severe abdominal pain in the patients (Jaschinski et al., 2018). In Australia, appendicitis has been associated with about 179-360 hospitalizations per million (Ferris et al., 2017). The disease is caused by the blockage in the opening of the appendix that may be caused by a bacterial infection, stool or gases. It may also be associated with other inflammatory bowel diseases like Crohn’s disease and ulcerative colitis. The common symptoms of the health condition include severe pain in the bottom right abdomen coupled with weight loss and loss of appetite (Rentea & Peter, 2017).

The patient may also present with nausea and vomiting and swollen belly. Most of the signs and symptoms of the health condition overlap with other gastrointestinal anomalies. Therefore, it is essential for the physicians and the health care -professionals to perform multiple tests for the accurate diagnosis and the management of the condition (Jaschinski et al., 2018). This essay is based on the case analytics of an individual patient who presented with the symptoms of appendicitis. To maintain the privacy of the patient, the identity has been concealed and a pseudonym (Bob) has been used in this analysis.

As per the ethical and legal guidelines of the nursing practice, informed consent has been obtained from the patient to use his information for this assessment. This essay aims to provide insights into the detailed case analysis of a patient with appendicitis to reveal the priorities of the health assessment and explain the process of decision making in the clinical setting. This essay will also summarize the importance of the patient’s medical history assessment and provide a comprehensive analysis of the diagnostic data retrieved through primary clinical tests.

Case Background and Patient History

To have a detailed understanding of the health condition of the patient, physical and social and family history is collected. The physical assessment of the patient reveals that Bob is a 40 year old Australian male who had presented himself to the emergency department at the XYZ hospital and complained about the presence of severe pain in the lower right abdomen. The patient revealed that he is experiencing this pain from the last two days, however, its severity has increased many folds today and have become “intolerable”. The patient also asserts that the pain is sharp and non-radiating and presents with a stabbing like sensation in the patient. The patient history reveals that the patient has had weight loss and loss of appetite.

Further, the patient has been nauseous and has had multiple vomiting. It has been noted that experienced pain is enhanced by movement. The pain score of the patient has been assessed using the Wong Baker scale and has been recorded at 8/10. The patient does not possess any medical history of allergies and is not only other prescriptions. The purpose of collecting a detailed physical assessment of the patient allows the development of clear notions and highlights any underlying condition that could be associated with the current present problem (Paganelli et al., 2017). In the case of Bob, the physical health history reveals that the pain and the current health problems are not associated with any diagnosed health condition of the patient.

The social history of the patient presents that bob is a socially active member of the community and an avid smoker. He also consumes an unhealthy diet frequently that has low fiber content. The patient possesses a good socio-economic status and lives in a private society in Melbourne. The importance of assessing the social history of the patient can be associated with the social determinants of health established by the World Health Organization. It has been asserted that different social conditions like education, social and cultural background and economic status of the patient can be intricately associated with certain health conditions (Artiga & Hinton, 2019). The family history of the patient has also been taken at the time assessment. The family history of the patient reveals that there is a genetic predisposition of Crohn’s disease in the family.

Further, both the father and the mother of the patient were both diabetic. It is of crucial consideration that the patient possesses a genetic factor that can contribute towards the development of inflammatory bowel disease and therefore it must be kept in consideration through the process of assessment and differential diagnosis. Articulation and collection of family history of the patient are important as it may reveal crucial insights into the health condition of the patient and narrow down the process of diagnosis. When patients present with a genetic history or familial predisposition of the condition it can help the clinician to perform specific tests to confirm the condition. This makes the process faster and more efficient (Paganelli et al., 2017).

Physical Assessment Conducted

For the physical assessment, the patient vitals were analyzed as a priority. It was revealed that Bob presented with lowered blood pressure and a weak peripheral pulse. Oxygen saturation levels in the patient were normal and there was a mild fever. The pain assessment of the patient was done using the pain assessment tool: Wong Baker scale. It was revealed that the patient possessed severe pain of an 8/10 score. Physical examination of the health condition was done. The physical examination of the patient was inclusive of inspection, auscultation, palpation, and percussion. The inspection of the abdomen was done through visual examination and notation of shape and skin anomalies were observed.

The abdomen of the patient appeared to be inflated and movement of the abdominal wall along with respiration was observed. This was done by placing the patient in a supine position (Imran et al., 2017). Further, auscultation was done to detect the abnormal sounds in the abdomen. This was done by placing the stethoscope on the abdomen with gentle pressure and warming up of the diaphragm (Schultz et al., 2017). This process of auscultation is done by placing the patient in the supine position. In the absence of any bowel sounds the observation is done for at least three minutes to confirm the absence. Auscultation of the abdominal bruits is also done for the abdominal examination. Palpation and percussion in the patient are done in the supine position. The abdominal wall of the patient is examined with the fingertips to check the presence of fluid or gas in the subcutaneous tissues of the patient.

Deep palpation is also performed by placing the hand flat on the abdomen of the patient firmly with steady pressure. The upper hand of the clinician is used to exert and maintain the pressure where the lower hand is placed to feel the sensation (Imran et al., 2017). Tenderness and pain in the patient are observed through this technique. In the case of appendicitis, Rosving’s sign is observed, that is, palpation in the left low quadrant increases the tenderness in the right lower quadrant. Percussion is also done to identify the presence of ascites and the nature of the abdominal mass. The tympany of the abdominal mass is estimated to identify gas in the abdomen (Paganelli et al., 2017).

Other than physical examination, visual examination of the abdomen was also conducted for Bob. The ultrasonic gel was placed on the patient’s abdomen and a transducer was used to obtain the sonographic images (Imran et al., 2017). The ultrasound was done for the lower abdomen to test and validate the presence of inflamed appendix and assessment of the appendiceal wall layers.

Biochemical and Microbiological Assessments Conducted

The blood test of the patient was conducted to identify the presence of infection indicated by the fever in the initial analysis. The blood cell count was evaluated and analyzed for final results along with other tests. The urine and stool samples of the patient were also collected. The stool sample of the patient was collected to identify the presence of bacterial infection through smear analysis. This allowed for the identification of the bacterial strain that was responsible for appendicitis in the patient. Urine tests of the patient were also conducted to eliminate the possibility of urinary tract infection in the patient (Kang et al., 2019).

These assessments were done to eliminate any alternative causes of the symptoms that were expressed by the patient. This allows for the resolution of ambiguity and provides a form diagnosis for effective treatment of the patient. Through a comprehensive examination and complete assessment, the healthcare professional is able to infer the true cause of the symptoms and take the required steps for the management and the treatment (Inoue et al., 2019).

Analysis of Diagnosed Data

Post the assessments, the healthcare professionals possess the data regarding patient physical history, social and familial history. The healthcare professionals also have information regarding the current physical and biochemical status of Bob. Based on the severity of pain and inflammation observed by physical assessment it can be said that appendicitis is likely. Further examination in the patient reveals a lack of sounds observed through auscultation. However, palpitations have been found positive in the patient. Rovsings sign positivity in the patient also indicates the presence of appendicitis (Gorter et al., 2016). The abdomen of the patient appears to be inflated. It can be deduced that the patient has appendicitis.

Along with physical examination, visual examination through ultrasound indicates the presence of appendicitis due to observed inflammation in the appendiceal walls (Kang et al., 2019). However, to eliminate the secondary causes of abdominal pain and inflammation, biochemical analysis is undertaken. The blood test of the patient has been done to evaluate the cell count. The blood tests provide an elevated count of the white blood cells indicating the presence of infection. The urinary analysis was conducted to confirm is this infection was a urinary tract infection (UTI) or a bacterial infection in the appendix of the patient. The analysis revealed that the infection was in the appendix and the urinary tract of the patient was clear.

Further, a stool examination of the patient was done to deduce the nature of the infection and to identify the infection-causing organism. This microbiological analysis revealed that the patient had a bacterial infection in the appendix of the patient was caused by the E.coli overgrowth in the appendix of the patient. The analysis of the patient indicated that the patient has appendicitis (Gorter et al., 2016). Therefore, the medications and the interventions for the management of the condition were further indicated in consideration of the same. 

Health and Decision-Making Priorities

It is crucial to undertake a prompt decision while maintaining the health of the patient. Making effective decisions is crucial in the clinical setting as they affect the welfare of the patient directly. The decisions made by healthcare professionals must be ethical and should be based on the code of conduct established by the government. The clinical decisions are directed towards the patient’s beneficence, justice and autonomy, and non-malevolence (Legare et al., 2018). In the case scenario of Bob, the primary consideration was pain management. The vitals of the patients were assessed before performing any medical intervention. It was noted that the patient was suffering from a very high pain at the degree of 8/10, it becomes important to manage his condition.

Therefore, analgesia was administered as per the guidelines of the clinician. Further, the patient was positioned in the supine position to perform assessments. It is also important to take the patient’s physical, medical and social history into consideration to identify the cues that can be used for diagnosis. However, it is crucial to perform a multidimensional approach to eliminate the overlapping causes of the symptoms (Stokes et al., 2017). Both physical and chemical assessment of the condition is necessary. The decision-making process in the healthcare system is based on detailed analysis. Therefore, all the assessments must be crucially for a complete inference of the health condition. Visual assessments like ultrasound and CT scans are of extreme importance as they also aid in diagnosis and assist in the treatment of the patient.

Once the cause is identified management and treatment can proceed as directed by the clinician. The process of critical decision making has been classified as a four-step process (Stokes et al., 2017). The first step is focused on the determination of the probabilities. This is done by assessing the symptoms expressed by the patient and form the basis for the “likelihood of diagnosis”. The second step in the process of critical decision making is the gathering of data for further evaluation of the patient. This process of data collection is done by performing multiple assessments of the patient to infer the cause and diagnose the disease.

The probabilities that have been gathered in step one is updated as per the observations and the analysis made by the third step. The final step of critical decision making in the process of the healthcare system includes the selection and application of suitable intervention. Therefore, a multistep critical decision-making process was followed for the treatment and care of Bob to provide him complete care and treatment.

Recommendations

Recommendations for Clinical Assessment 

The essential recommendations for the correct diagnosis are to identify the condition of the patient accurately for the suitable treatment of the patient. It is important to consider the patient vitals. Prognosis and monitoring of the patient are essential. The genetic and non-genetic causes must be identified. Healthcare professionals must also focus on the ongoing and future trials of the patient. The clinical assessment must be done through a detailed procedure so that a final diagnosis can be achieved. The clinicians and healthcare professionals are suggested to monitor the vitals of the patient frequently (Legare et al., 2018). The vital assessment allows for the monitoring of the interventions applied and helps in the recovery and management of the condition.

Since Bob was suggested to undergo appendectomy, pre-operative care and patient education become crucial steps to be taken by the healthcare professionals. Since the patient had multiple episodes of vomiting, it is crucial to maintain the hydration balance of the patient. This must be done by the administration of fluids. The vitals of the patients in the pre-operative stage must be checked every 2-4 hours to determine the suitable time for the surgical procedure (Gorter et al., 2016). The patient must be given essential knowledge about the surgical procedure and should be informed about the necessary details.

Recommendations for The Patient

 The clinician had suggested Bob undergo an appendectomy. The surgical removal of the inflamed appendix or appendectomy can be achieved either through an open approach or the laparoscopic approach. The severity of appendicitis is associated with the risk of the development of post-operative health complications. The antibiotics are prescribed to the patients to minimize the risk of secondary infections (Legare et al., 2018). As the patient comes out of the operative care, the vitals of the patient are monitored critically and the pain medication is provided only when required. The patients are often discharged after 24 hours of the operative procedure (Kang et al., 2019). As the patient is discharged, several recommendations are provided to help the patient recover from the surgery efficiently.

The patient is recommended to take care of the incision wound and report if there is excessive pain or any drainage observed. It is also recommended for the patient to not participate in heavy-duty exercises that involve weight lifting and excessive bending. Exercises like cycling are prohibited and only restrictive movement is suggested until complete recovery (Ferris et al., 2017). The clinical priorities that are of essential consideration of the patient include following high nutrition and a balanced diet to assist in fast recovery.

A follow up check up post-operation is also essential as aids in the assessment of the recovery procedure. The patient is advised to wear loose clothes to prevent irritation around the incision. The patient must also keep his body hydrated by consuming about 8 glasses of water, bland and low-fat diet is suitable (Imran et al., 2017) A fiber-based laxative can be taken in cases of digestive problems post the clinical procedure. The physical activity should be increased gradually so that successful recovery can take place. 

Conclusion

This essay provides a detailed summary of the medical and clinical considerations that are associated with the case analysis of Bob. The patient is a 40-year-old man who had presented to the emergency department after severe pain in the lower abdomen. This document discusses the clinical procedure of diagnosis and healthcare. This essay also summarizes the medical history of the patient along with the social and family history of the patient. This essay also asserts how the assessment of patient history aids in the procedure of diagnosis of the health condition of the patient. This essay also highlights the primary physical assessment of Bib that led to the diagnosis of appendicitis. The diagnosis was made using a four-step clinical decision-making procedure and analysis. The physical examination of the abdomen of the patient through inspection which led to the identification of inflammation of the appendices in the patient.

Further, auscultation was performed to identify any abnormal sounds in the abdomen. Percussion and palpation analysis were performed. It was elucidated that the patient is likely to possess appendicitis as the Rovsings sign of the abdominal assessment was positive. A visual test of ultrasound was also performed that indicated the presence of inflammation in the appendix of the patient. To confirm the diagnosis, biochemical and microbial analysis of the patient was performed. A blood test of the patient was done and the elevated white blood cell count indicated infection. The UTI was eliminated by performing urinary analysis. The stool sample of the patient was also tested to identify the causing organism. It was identified that Bob had developed appendicitis due to the overgrowth of E.coli in the patient.

The patient was suggested to undergo an appendectomy. This essay also provides the details of decision making in the clinical setting about this particular case and also provides the crucial recommendations that must be followed by the clinicians as well as the patient. 

References

Ferris, M., Quan, S., Kaplan, B. S., Molodecky, N., Ball, C. G., Chernoff, G. W., ... & Kaplan, G. G. (2017). The global incidence of appendicitis: a systematic review of population-based studies. Annals of surgery, 266(2), 237-241.

Gorter, R. R., Eker, H. H., Gorter-Stam, M. A., Abis, G. S., Acharya, A., Ankersmit, M., ... & Bruntink, M. (2016). Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surgical Endoscopy, 30(11), 4668-4690.

Imran, J. B., Madni, T. D., Minshall, C. T., Mokdad, A. A., Subramanian, M., Clark, A. T., ... & Cripps, M. W. (2017). Predictors of a histopathologic diagnosis of complicated appendicitis. Journal of Surgical Research, 214, 197-202.

Inoue, A., Furukawa, A., Nitta, N., Takaki, K., Ota, S., Zen, Y., ... & Saotome, T. (2019). Accuracy, criteria, and clinical significance of visual assessment on diffusion-weighted imaging and apparent diffusion coefficient quantification for diagnosing acute appendicitis. Abdominal Radiology, 44(10), 3235-3245.

Jaschinski, T., Mosch, C. G., Eikermann, M., Neugebauer, E. A., & Sauerland, S. (2018). Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database of Systematic Reviews, (11), 445.

Kang, C. B., Li, W. Q., Zheng, J. W., Li, X. W., Lin, D. P., Chen, X. F., ... & Qu, J. (2019). Preoperative assessment of complicated appendicitis through stress reaction and clinical manifestations. Medicine, 98(23).

Légaré, F., Adekpedjou, R., Stacey, D., Turcotte, S., Kryworuchko, J., Graham, I. D., ... & Donner‐Banzhoff, N. (2018). Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews, (7),42.

Paganelli, A., Garbarino, F., Fiorentini, C., Bigi, L., & Magnoni, C. (2017). Old but Gold: The Importance of Medical History in Diagnosing Neutrophilic Dermatoses Characterized by Pathergy. A case of appendicitis, Annals of Surgery 8(416), 2.

Rentea, R. M., & Peter, S. D. S. (2017). Pediatric appendicitis. Surgical Clinics, 97(1), 93-112.

Schultz, H., Qvist, N., Pedersen, B. D., & Mogensen, C. B. (2017). Time delay to surgery for appendicitis: no difference between surgical assessment unit and emergency department. European Journal of Emergency Medicine, 24(4), 290-294.

Stokes, T., Tumilty, E., Doolan-Noble, F., & Gauld, R. (2017). Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study. BMC Family Practice, 18(1), 51.

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