Case Study

CHIEF COMPLAINT: "I have pain in my stomach." History of Present Illness:

Ms. G. is a 42-year-old housewife who makes an appointment at your clinic because she has been experiencing pain in her upper abdomen for the past 3 months. She describes the pain as an "ache" that sometimes radiates into her right upper back and right shoulder. The pain gets worse after eating fatty or greasy foods, so she has eliminated these foods from her diet. She feels nauseated when the pain occurs and sometimes vomits. She denies fever or chills, weight loss, chest pain, diarrhea, constipation, melena, rectal bleeding, or dysuria. She has not been exposed to anyone who has been sick.

Ms. G. is healthy. She does not smoke, drink, or use illicit drugs. Her family history is significant for hypertension in her mother and diabetes in her father. Her mother had gallbladder surgery in her mid-40s.

What parts of the exam would you like to perform? (Circle the appropriate areas.)

General Survey Breasts and Axillae

Vital Signs Female Genitalia

Skin Male Genitalia

Head and Neck Anus, Rectum, and Prostate

Thorax and Lungs Peripheral Vascular/ Extremities

Cardiovascular Musculoskeletal

Abdomen Nervous System

What physical findings are you looking for to help determine the diagnosis?

These are the actual findings on physical examination:

General Survey

Vital Signs

Skin HEENT

Neck

Thorax and Lungs Cardiovascular

Abdomen

Alert, obese, middle-aged woman, sitting comfortably on the examining table

BP 120/80 mm Hg; HR 80 bpm and regular; respiratory rate 16 breaths/min; temperature 99.2°F

No rash

Normocephalic, atraumatic

Pupils equal, round, and reactive to light and accommodation; constrict from 5 mm to 3 mm Disc margins sharp, fundi without hemorrhages or exudates

External ear canals patent; tympanic membranes with good cone of light Oral mucosa pink; dentition good; pharynx is without exudates

Supple, without thyromegaly; no lymphadenopathy

Thorax symmetric, with normal AP diameter Lungs resonant and clear

JVP 6 cm above right atrium; carotid upstrokes brisk, without bruits PMI tapping and nondisplaced Good Si, S2; no S3, S4; no murmurs

Abdomen is obese, with active bowel sounds Abdomen is soft but tender to palpation in the right upper quadrant during inspiration, with a liver span of 9 cm in the right MCL

The liver edge is smooth and palpable one finger-breadth below the RCM Spleen is nonpalpable

No CVA tenderness; no femoral or abdominal bruits

Based on this information, what is your differential diagnosis?

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