The Process of Clinical Judgement

The Rank of Scenarios in Order of Priority

The first priority patient on the list is EH, a 40-year-old female admitted within the past hour with acute onset severe right upper quadrant pain and vomiting for the past 36 hours. Her ECG monitoring shows occasional premature ventricular contractions (PVC), and she is waiting on labs. The second priority patient on the list is BW, a 21-year-old-male athlete admitted yesterday with a fever of 103 and a diagnosis of Influenza. He rested well overnight, and his morning chest x-ray revealed mild infiltrates in the left lower lobe. The third priority patient on the list is JR, a 55-year-old male admitted 8 hours prior for a 24-hour hold to evaluate for possible myocardial infarction. His serial troponins are within normal range, and the 12 lead ECG indicated evidence of prior right anterior wall myocardial damage.

Defense of the Priority Rankings

Patient EH is the first priority because she has acute onset severe right upper quadrant pain, which classifies her as an acute abdomen. She has also been vomiting for the last 36 hours; therefore, she is at risk of hypovolemic shock and electrolyte imbalances. Her ECG monitoring also shows occasional premature ventricular contractions that predispose her to fatal cardiac arrest. Patient BW is the second priority because he has a fever, a diagnosis of Influenza, was well-rested overnight, and a morning x-ray of the chest showed mild infiltrates in the left lower lobe. The symptoms and signs of patient BW are less likely to cause death than those of patient EH. Patient JR is the third priority because his serial troponins are within normal range, and the 12 lead ECG indicated evidence of prior right anterior wall myocardial damage. Furthermore, the reason for his admission is to evaluate for possible myocardial infarction. The signs that patient JR has presented with and lab findings are less likely to cause death than those of patient EH and patient BW.

Review of Data for Priority Client

The patient’s chest x-ray is normal, but the abdominal x-ray shows diffuse gas throughout the intestine, meaning there could be an intestinal obstruction. There are hyperactive bowel sounds in all four abdominal quadrants, and the abdomen is painful to touch, meaning there could be both intestinal obstruction and perforation, which led to peritonitis. Both intestinal obstruction and peritonitis could be synergistically causing the 10/10 pain level. The sodium level is slightly raised, potassium is low, chloride is normal, magnesium is low, calcium is normal, phosphorus is low, and glucose is normal. The serum albumin is low, serum amylase is raised, serum creatinine is slightly low, blood urea nitrogen (BUN) is normal, alkaline phosphatase is raised, protein is raised, and bilirubin is raised.

Three Hypotheses Formulated

From the data provided, the first hypothesis that can be formulated is peritonitis due to intestinal perforation caused by intestinal obstruction. The second hypothesis is electrolyte imbalance caused by vomiting for the past 36 hours as evidenced by laboratory results. The third hypothesis formulated is carcinoma of the head of the pancreas resulting in intestinal obstruction and biliary tract stones (choledocholithiasis) evidenced by right upper quadrant pain and raised serum bilirubin levels (Qureshi et al., 2020). Carcinoma of the head of the pancreas is the priority hypothesis.

Defense of Selected Hypothesis

Carcinoma of the head of the pancreas resulting in intestinal obstruction and choledocholithiasis is the priority hypothesis. This hypothesis can explain all of the symptoms, signs, and laboratory findings of the patient. Obstruction of the common bile duct is probably the cause of the right upper quadrant pain that the patient is experiencing. Cancerous enlargement of the head of the pancreas blocks the common bile duct since it passes behind the pancreatic head. Obstruction of the common bile duct led to the formation of biliary stones that resulted in right upper quadrant pain and elevation of the bilirubin levels (Qureshi et al., 2020). The choledocholithiasis compromised the liver functions and resulted in low serum albumin, as shown in the laboratory data.

Cancerous enlargement of the pancreatic head can also lead to obstruction of the duodenum, evidenced by hyperactive bowel sounds on all four quadrants of the abdomen. The obstruction of the intestine then led to perforation of the intestines causing peritonitis that made the abdomen painful to touch. One of the signs of intestinal obstruction is vomiting, and patient EH had experienced vomiting for the past 36 hours. The vomiting caused the electrolyte imbalances evidenced by low potassium and low magnesium.

The electrolyte imbalance, especially the low potassium levels, caused occasional premature ventricular contractions that were a finding on ECG. The raised amylase supports the hypothesis of carcinoma of the head of the pancreas. The pancreas produces the enzyme amylase, and blood levels usually increase during acute pancreatitis, chronic pancreatitis, or pancreatic cancer. Biliary obstruction by pancreatic carcinoma leads to the increase of alkaline phosphatase levels in the blood, supporting the priority hypothesis.

Evaluation Plan for Priority Hypothesis

Intravenous fluids containing potassium, magnesium, and phosphorus should be administered to the patient after obtaining intravenous line access. This should be followed by monitoring the electrolyte levels by drawing blood samples regularly and using the ECG to check for the persistence of premature ventricular contractions and the development of arrhythmias. It is essential to regularly check for potassium levels because administering too much potassium can cause hyperkalemia resulting in cardiac arrest. Blood pressure, pulse rate, and percentage oxygen saturation should also be evaluated continuously because of the risk of hypovolemic shock.

A CT scan of the abdomen should be done for the patient to rule out other causes of intestinal obstruction like adhesions. The CT scan will also help make a definitive diagnosis of carcinoma of the head of the pancreas. The patient should have an ultrasound of the liver done to check if there are other possible explanations like cholecystitis, choledochal cysts, and hepatocellular carcinoma, which can cause right upper quadrant pain. A head-to-toe evaluation of the skin and mucous membranes should also be performed to check for jaundice and hemorrhages under the skin. Renal function tests and radionuclide bone scans of the vertebrae should also be performed regularly to check for metastases. A nasogastric tube should also be inserted to decompress the obstructed intestines.

Actions if Satisfied with Client Outcomes

Suppose the electrolyte imbalance has resolved and the blood pressure and the pulse rate are normal. In that case, the patient should be prepared for surgery to resolve the intestinal obstruction, peritonitis, and biliary tract obstruction. The patient can only have surgery after the levels of potassium, magnesium, and phosphorus have returned to normal. A surgical procedure will also resolve the elevated bilirubin levels and the right upper quadrant pain.

Actions if Not Satisfied with Client Outcomes

If electrolyte imbalance does not resolve, then intravenous fluid administration must be continued to restore electrolyte levels to normal. If hyperkalemia develops, then calcium gluconate should be administered intravenously to protect the heart and prevent cardiac arrest. If blood pressure, pulse rate, and percentage oxygen saturation do not return to normal, judicious fluid administration should be continued. Surgery should be kept on hold until electrolyte imbalance and euvolemia are achieved.

Reference

Qureshi, S. A., Altaf, S., Noor, S., Bashir, S., Shahbaz, J., & Qureshi, A. A. (2020). Frequency of stones, strictures and carcinoma head of pancreas in patients with obstructive jaundice. Medical Forum Monthly, 31(10), 16-19. Web.