Case Study Assignment #3: Digestion

List of conditions that could cause Ron's symptoms

Ron T., age 58, arrives in Orlando for the annual Medical Device Convention. This year, Tom is a speaker at the conference and is presenting at a poster session, so he is busy preparing his agendas and speeches. He starts to feel discomfort in his abdomen so, thinking he is just hungry since he has not taken time to eat a meal that day, he orders a hamburger and fries from room service. He also drinks two cups of black coffee. About an hour after eating, he experiences cramping pain in his upper abdomen. This comes and goes for a time and spreads across the right upper quadrant of the abdomen.

At times, the pain gets worse and seems to be located under the breastbone. Because of the persistent pain, he sleeps little during the night. Ron has a history of gastric ulcers, but after undergoing treatment to eradicate H. pylori, his condition has been under control recent years. The pain he now experiences lacks the "burning" sensation heremembers from his bouts of ulcers. He is overweight and on a statin for high cholesterol but otherwise has no known medical problems. The next morning he continues to have pain, now accompanied by waves of nausea, so he asks his colleagues to take over his responsibilities and makes plans to return home. Ron calls his wife to arrange for her to meet him at the airport and take him to see his physician.

1. List some conditions that could be causing Ron’s symptoms (there are several)

2. What is the primary treatment for gastric ulcers and how does it work?

Arriving home late afternoon, he immediately goes to the emergency clinic and meets Dr. Morris, who examines him and arranges for laboratory tests. The pain is still intense. Ron feels pain when he takes a deep breath as Dr. Morris presses the upper right quadrant. The doctor also notes that the sclera of Ron’s eyes seem to have a yellowish color. At this point, labs and an abdominal ultrasound are ordered for Ron. 

Laboratory findings:

WBC count: elevated

Temperature: 99.5

Serum bilirubin: elevated

Alkaline phosphatase (ALP): elevated

Alanine aminotransferase (ALT): normal

Lipase, amylase: normal

3. Why might Ron feel more pain when taking a deep breath?

4. What does the yellowing of Ron’s sclera suggest?

5. Why are Ron’s WBCs and temperature elevated?

6. Ron’s serum bilirubin is elevated. Would you expect the elevation to be conjugated or unconjugated bilirubin and why?

7. What do you think Ron’s ultrasound will show (i.e., what is Ron’s diagnosis)?

8. If Ron had shown an elevated ALT, lipase, and amalyse as well, what condition would that have indicated? How is that condition related to the condition Ron has?

Ron’s abdominal ultrasound demonstrates gallstones lodged within the cystic duct and the common bile duct. There is thickening of the gallbladder wall measuring 5.2 mm. Dr. Morris diagnoses acute cholecystitis, or inflammation of the gallbladder wall, with partial duct obstruction. Ron is admitted to the hospital and has his gallbladder removed by laparoscopic surgery (cholecystectomy). Antibiotics are also prescribed. He leaves the hospital after one day and returns to work the following week.

9. What advice should the doctor give Ron upon his discharge regarding eating habits following the surgery?