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Surgery - Case Study Example

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Surgery

The patient is physically active and does not have any known allergies. Her height and weight on admission were 70 kg and 178 cm high respectively. She currently presented to the emergency department on the 27th April 2009 with a history of sudden, acute right sided abdominal pain which was associated with nausea. The patient was thus admitted with a diagnosis of acute right sided abdominal pain and her code status was full.
History of presenting illness: According to the patient she was in her usual state of health until late this morning when she developed sudden right sided abdominal pain. The pain was colicky in nature and was associated with a feeling of nausea. It was localized in the right lower quadrant and there was no radiation. There were no particular aggravating factors. The pain was slightly reduced in supine position. The intensity of the pain increased gradually throughout the day and by the evening it became unbearable. Thus, the patient was rushed to the ER.
Menstrual History: The patient reported having regular menstrual cycles of 4/28 days with normal flow. She has no complains of dysmenorrhea or intermenstrual bleeding. Her last menstrual period (LMP) was on the 20th of December 2008 and currently she is 18 weeks pregnant with twins.
Sexual History: The patient lives with her steady boyfriend of 10 years. The couple report having regular, unprotected sexual intercourse. The frequency of intercourse is at least twice a week. There are no complains of dysparunea, post coital bleeding or any other problems.
Past Obstetric History: The woman has had two previous deliveries, seven years and three years back. Both were normal vaginal deliveries. Both pregnancies followed an uncomplicated course and there were no issues like pre-eclampsia and gestational diabetes.
Social History: The woman did not have any addictions or allergies. She works as a full time employ in an education center and lives with her two children, a boy and a girl, aged seven years and three years, respectively. The patient is physically active and likes to engage in sports such as netball. Moreover, she also reports going to the gym five days a week.
Findings on Examination: On inspection, there were no visible signs of any abnormalities. On palpation, the abdomen was soft, but significant guarding was present. There was localized tenderness in the right lower quadrant. No palpable masses were found. The gut sounds were present. Shifting dullness and fluid thrill were absent.
Pain score on arrival: 7 out of 10
Investigations ordered and their results: On arrival in the ward and abdominal ultrasound was ordered to elucidate the cause of the abdominal pain and it revealed a right sided ovarian cyst which was 16 cm in diameter.
Nursing Assessment: A young female patient, 18 weeks pregnant with twins, presenting with right sided abdominal pain, tender on palpation, feeling nauseated on arrival and has a pain score 7 out of 10.
Nursing Diagnosis: Acute right side abdominal pain
Management Plan: On the basis of the ultrasound, it was decided ...Show more

Summary

Patient Profile: The following is the case study of a 31 years old, Caucasian female, who works as a full time employ in an education center. She belongs to middle socioeconomic status family and lives with her steady boyfriend of 10 years and two children…
Author : boehmaliyah
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