Question

A 37 year old WF presents to your clinic with CC of RLQ abd pain that has been present/persistent for 3-4 days; today she says it's so bad that she can't stand up straight and she is guarding her RLQ. When she walks into the clinic, her hips are flexed and she is bent over, holding her RLQ. She has had fever for a couple days, she says, and tylenol and ibuprofen aren't helping with the pain or with the fever. She says she has been vomiting persistently since yesterday, hasn't been able to keep anything down and now is vomiting a greenish thin clear liquid that "tastes really bad." NKDA, no medical problems, no daily medications. G9T5P0A4L5. Unsure when she had her last normal menstrual period, states that "I don't really keep up with that anymore." Refuses to answer many questions about her sexual history. States, "I just want you to do something about this pain!" No previous surgical history, unsure when she had her last pelvic exam/Pap smear, denies that she has ever had a mammogram. She smokes 2 ppd cigarettes and has since she was 13 years old. Admits to regular marijuana use and methamphetamines "only on the weekends," admits to ETOH on the weekends too, usually about 12 beers/weekend. VS: T101.4 oral, HR 117, BP 98/60, RR 25, O2 sat 95% on RA, height 66", weight 115#.

1. What other information do you want from this patient to aid in putting together a differential diagnosis/illness script?

2. What are the risk factors for abdominal and/or genitourinary disease that this patient has?

3. What are the Guidelines for Treatment recommendations for the top diagnosis on your differential diagnosis/illness script?

4. What do you expect to find on physical examination of this patient when you do a physical evaluation?

5. Describe the diagnostic workup you would order for this patient and the rationale behind each test/study you would order.

6. What treatment if any do you want to order now, after your lab results and before results are back, and why?

Answer 1

ANSWER 1: - 1Menstrual history

2 previous intercourse history

3 past history of UTI

4 site of onset & characteristic of pain

5 radiation of pain

6 history of hyperlipidemia

7 history of constipation

ANSWER 2:- 1 smoking

2 excessive alcohol intake

3 marijuana & amphetamine consumption

4 history of 4 abortions

5 obese

6 no history of pap smear or pelvic examination

ANSWER 3 :- DIFFERENTIAL DIAGNOSIS ARE -》

• APPENDICITIS
• Cholecystitis

Treatment guidlines for appendicitis:

Immediate appendectomy need to done either open or laparoscopy

Treatment guidlines for cholectstitis:

acute cholecystitis, the initial treatment includes bowel rest, intravenous hydration, correction of electrolyte abnormalities, analgesia, and intravenous antibiotics. For mild cases of acute cholecystitis, antibiotic therapy with a single broad-spectrum antibiotic is adequate.

ANSWER 4:- expected physical examinationsfindings:

Rovsing sign positive

Tenderness at mcburneys point

Poas sign positive

obturator sign positive

rebound tenderness

pain on percussion

rigidity of abdomen

Guarding

ANSWER 5:- DIAGNOSTIC WORKUP:-

1 ) CBC - to check the levels of wbc to rule out infections

2)CT SCAN OR USG - to check for gal bladder & appendix

3) pregnancy test - to rule out ectopic pregnancy

4) urine culture & microscopy -  to rule out UTI

5) HIDA SCAN : - to check functioning of gallery bladder

6) MRCP - to check for anatomy of gallbladder & biliary tree

ANSWER 6 :- 1) start patient on broad spectrum antibiotics

2) give her analgesics (iv)  

3) start giving iv fluids

4) make patient bill per oral

5) manage fever with antipyretics