Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 35 year old female with abdominal pain of 1 day duration. She states she has had pain in her stomach. It has been there since yesterday and it is getting worse. It is in the upper part of the abdomen and toward the right side. It feels like a really bad steady ache. She has had similar in the past three or four times, but never this bad, and it always went away after a couple of hours. It seems to come on soon after she eats, but it is not worse at night. She has tried TUMS and Tylenol, but they have not helped. She felt warm before coming to the hospital, but didn’t take her temperature. She vomited twice this morning, no diarrhea, no constipation. She is very nauseated. She had a normal BM yesterday. No blood in stool, no dark stool. No skin color changes. LMP 2 weeks ago. No vaginal discharge. No urinary frequency, urgency or hematuria. No chest pain, dyspnea, or cough. No recent trauma. No known gallstones. She drinks alcohol occasionally. She takes naproxen once or twice a year for occasional headaches. She has had a similar sensation in her upper abdomen before, but have never gone to the doctor for it, because it didn’t lasted long. No steroid use. No smoking. No recent hospitalization.
General: Vital Signs: BP 110/70, P 104, R 16, T 100.8 F, O2 98% on RA. The patient is alert and oriented x3and appears to be in pain.
Skin: Normal. No rash. (No stigmata of liver disease. No jaundice. No bruising. No Cullen’s or Grey-Turner sign).
HEENT: PERRLA. EOMI. Normal. (No icterus, No pallor)
Abdominal: Tender to palpation in the epigastric region with involuntary and voluntary guarding. Very tender in the RUQ to superficial palpation – she grimaces and catches her breath during inspiration while the RUQ is palpated. No RLQ, LLQ, or suprapubic tenderness. No rebound. No costovertebral angle tenderness. No bruising or skin changes, no caput medusa liver edge is normal. Spleen not palpable. Normal bowel sounds.
Rectal: Brown stool. Hemoccult negative.
Genitourinary: Normal external genitalia. No vaginal discharge. No cervical discharge, no cervical motion tenderness, no mass.
Labs: Lipase – Negative, Urine Pregnancy Test – Negative, Urinalysis – Negative, WBCs – elevated with left shift, Liver Enzymes – Normal, Bilirubin – Normal