Biliary cholic without cholecystitis

Biliary colic without acute cholecystitis Essay

 

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, 1month, 3 months.

What are some follow up labs or test. Referrals

Why are they following up? What outcome do you wish to assess?