A 42-year-old male, obese with a history of GERD presented to the clinic complaining of moderated abdominal pain in the right upper quadrant. The pain started after he consumed a large fatty meal. The pain radiated to his back. Denied fever, chest pain, diarrhea or any change in his bowel movements. Admitted vomiting. She took medications for the pain with proton pump inhibitors but did not relieved his pain. He consumes alcohol on the weekends. Quite smoke since 10 years ago. Physical examination is normal. Murphy’s sign was negative
Introduction
Should be a paragraph that provides a brief overview of the case and main diagnosis:
1-Biliary colic without cholecystitis:
Differential Diagnoses
Differential Diagnosis:
Provide EACH (3 of them) differential diagnosis with the rationale and supporting evidence with the REFERENCE for each one. Also explain why differentials (2&3) were not the primary diagnosis.
1- Biliary cholic without cholecystitis:
2- Acute cholecystitis:
2- Duodenal ulcer:
Diagnostics
1- Identify the lab, radiology, or other tests needed for the main diagnosis (Biliary cholic without cholecystitis): and the other 2 possible diagnosis provided (Acute cholecystitis and Duodenal ulcer) with supporting evidence.
Treatment
- Include the initial treatment plan for the main diagnosis. It should include medication names, dosages, and frequencies. (Please use specific treatment plan supported by recent clinical Guidelines treatment as the Reference)
Education
Patient/family education:
Follow-Up
Appropriate follow up plan.
Please include when will patient follow up: 2 weeks, 1 month, 3 months.
What are some follow up labs or test. Referrals
Why are they following up? What outcome do you wish to assess?
References
APA format, one to three pages of scholarly writing in paragraph format, no counting the title page or reference in APA format with in-text citation
In-text citation
References at least 4 high-level scholarly reference per post within the last 5 years in APA format.
EACH differential diagnostic gets 1 reference
Plagiarism free.
Turnitin receipt.
Biliary Colic without acute cholecystitis
- One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
- Brief introduction of the case
- A 42-year-old male obese, with a history of GERD presented to the clinic complaining of moderated abdominal pain in the right upper quadrant. The pain started after he consume a large meal. The pain radiated to his back. The pain was not relieved by Proton pump-inhibitor medications. Denied fever, chest pain, diarrhea, constipation, or any changes in his bowel movements. No history of recent trauma. He quit smoking 10 years ago. Admitted to drink alcohol on the weekends. Denied illicit drugs. Vital signs are normal. Physical exam was normal. Murphy’s sign was negative.
- main diagnosis:
Biliary Colic without acute cholecystitis: due to gallstones in the gall bladder. Need surgical consultation for cholecystectomy. For laparoscopic cholectomy
2-Acute cholecystitis: is an acute inflammation, need urgent cholecystectomy
3-Duodenal ulcer:
- with supporting rationale
- Identification of at least two additional differential diagnoses with a brief rationale for why these were ruled out
- Diagnostic plan with supporting rationale or references
- CBC: complete blood count: looking for elevated leukocytes as seen in infections and acute inflamtions as in acute cholecystitis
- Electrolytes; since he had vomit electrolytes need to be assessed
- Liver chemistry to assess for asses for liver function AST and ALT, alkaline phosphatase, total bilirubin.
- Urinalysis: to asses for urinary tract infection, blood such as ureteral and kidney stones
- Lipase to rule out acute pancreatitis
- Abdominal ultrasonography
- A specific treatment plan supported by recent clinical guidelines