Failure to Diagnose & Delay in Treatment of Acute Abdomen Due to Cholecystitis (Gallbladder Inflammation, Gallstones)

Evaluate breaches in the standard of care relating to Failure to Diagnose & Delay in Treatment of Acute Abdomen Due to Cholecystitis (Gallbladder Inflammation, Gallstones)

Answer the following questions to find out if the standard of care was followed for your case.

  • With which of the following risk factors did the patient present? (Choose all that apply)
    Primary / metastatic neoplasms
    Infectious agents (cytomegalovirus, cryptosporidium)
    Immunocompromised (patients with AIDS)
    Hemolytic disease
    Alcoholic liver diseases / Cirrhosis of liver
    Use of oral contraceptives
    Prolonged starvation / fasting / rapid weight loss
    Obesity
    Pregnancy
    Elevated triglyceride levels
    Pancreatitis
    Terminal ileal disease
    None of the above
    Not elicited
    Answer unknown
    Why is this important?
    A risk factor is a variable that has a causal association with a disease or disease process; the presence of the variable in an individual or a population is associated with an increased risk of the presence or future development of the disease. Thus, risk factors may be useful for identifying subjects at increased risk for a disease or for a particular outcome that results from a disease process.
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  • With which of the following symptoms did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    Positive symptoms on screening including fever, right upper quadrant or epigastric pain for longer than 6 hours, nausea, vomiting, and signs of localized peritonitis; older patients may present with altered mental status and sepsis.
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  • Was a medical history obtained? Why is this important?
    Answer this question
    A complete medical history and carefully focused physical examination serve as the core of the diagnostic process. The information obtained guides the further direction of the patient's evaluation and enables the clinician to make the most judicious use of additional tests. It helps determine the value of incongruent and conflicting results that can emerge during the diagnostic process, and it can obviate the need for tests that are costly or expose the patient to discomfort or risk. The deep understanding of the patient that can be obtained only through the immediacy of the history and physical examination also plays a pivotal role in treatment decisions that must be addressed at various points throughout the patient's lifetime.
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  • Was a physical examination performed? Why is this important?
    Answer this question
    A complete and carefully focused physical examination serves as the core of the diagnostic process. The information obtained guides the further direction of the patient’s examination, enables the clinician to make educated evaluations, and be better equipped to advise the patient.
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  • Was the patient discharged and later diagnosed with acute cholecystitis? Why is this important?
    Answer this question
    Conditions that may mimic acute cholecystitis are those that cause significant abdominal pain, upper gastrointestinal symptoms, and fever. They include: acute hepatitis, complicated peptic ulcer disease, biliary colic, acute cholangitis, acute pancreatitis, pyelonephritis, right basal pneumonia, acute myocardial infarction,abdominal aortic aneurysm, hepatic abscess, and gonococcalperihepatitis (Fitz-Hugh-Curtis syndrome).
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  • Which of the following diagnostic laboratory studies were performed? (Choose all that apply) Why is this important?
    Answer this question
    Routine laboratory studies can provide important clues to diagnosis.
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  • Which of the following diagnostic imaging studies were performed? (Choose all that apply) Why is this important?
    Answer this question
    Patients with suspected acute cholecystitis need to have an expedited evaluation.
    (2006) 33 EPCCOP 3 659-684

  • To which of the following specialists was the patient referred? (Choose all that apply) Why is this important?
    Answer this question
    Once priorities and goals have been agreed on, referral to the appropriate professionals should be made in a timely manner. To deliver care requires a coordinated approach that allows sharing of skills and expertise. The skills of members from all professional disciplines should be utilized to enable all patients to achieve their maximum potential.
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  • Was the patient diagnosed with acute cholecystitis? Why is this important?
    Answer this question
    Formal diagnosis is made through laboratory tests and imaging studies.
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  • Were follow-up evaluations advised? Why is this important?
    Answer this question
    Routine follow-up evaluations are necessary to offset any complications that may arise.
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  • What type of cholecystitis was the patient diagnosed with? Why is this important?
    Answer this question
    Calculous cholecystitis is defined as acute or chronic inflammation of the gallbladder due to cystic duct obstruction secondary to gallstones; bile duct stricture or neoplasm may also be the cause. It occurs most frequently in women between 40 and 60 years of age.
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  • Was an Endoscopic Retrograde Cholangiopancreatography (ERCP) performed? Why is this important?
    Answer this question
    Retrograde examination of the biliary duct via endoscopic technique is useful in suspected cases of common bile duct obstruction. It may be therapeutic if common bile duct stones are found and removed.
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  • Was the patient hospitalized? Why is this important?
    Answer this question
    Patients with acute cholecystitis should be hospitalized because of the high risk of complications, particularly gangrene
    (20 percent).
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  • Was the patient kept nil per oral (nothing by mouth)? Why is this important?
    Answer this question
    If acute cholecystitis is suspected, the patient must refrain from eating or drinking until definitive diagnosis is made.
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  • Were intravenous fluids administered? Why is this important?
    Answer this question
    If acute cholecystitis is diagnosed, it is necessary to admit the patient and start intravenous fluids.
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  • Were intravenous antibiotics administered? Why is this important?
    Answer this question
    Medical management with antibiotics, pain relief, and bowel rest results in complete remission in 70 percent to 75 percent of patients within 1 to 4 days.
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  • Were pain medications provided for pain management? Why is this important?
    Answer this question
    It is important to provide analgesics , intravenous fluids , and intravenous antibiotics ( penicillins , third-generation cephalosporins , and quinolones ) and to treat underlying conditions.
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  • Were surgical treatment options recommended? Why is this important?
    Answer this question
    The first and optimal treatment for acute cholecystitis is early cholecystectomy . Laparoscopic cholecystectomy is preferred over conventional open cholecystectomy for patient recovery. The optimal timing of laparoscopic cholecystectomy for treatment of acute cholecystitis is usually within 72 hours of diagnosis during the hospital stay.
    (2006) 33 EPCCOP 3 659-684

  • Was surgery contraindicated? Why is this important?
    Answer this question
    Severe dehydration, anorexia, or obesity may warrant extra caution when selecting medical treatment options. Referral for surgery may be indicated later than usual for patients with coexisting morbidity, allowing the primary care provider to confirm that the patient is in best possible health for the surgical procedure.
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