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
Thorax and Lungs Peripheral Vascular/ Extremities
Abdomen Nervous System
What physical findings are you looking for to help determine the diagnosis?
These are the actual findings on physical examination:
Thorax and Lungs Cardiovascular
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
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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