Case 7: Differential Diagnosis

Pick your top 3 differential diagnoses.
Correct! This patient has acute pain in the epigastrium and right side of the abdomen, with prior episodes of abdominal pain triggered by eating fatty foods. The prior episodes might have been biliary colic and currently the patient might have acute calculous cholecystitis. This should be high on the differential.
Choledocholithiasis with cholangitis
Less likely. While the patient’s epigastric abdominal pain triggered by fatty foods might suggest prior episodes of biliary colic, he currently shows no features of jaundice and fever. 
Correct! This patient has acute onset epigastric abdominal pain, that is worse with eating and laying flat and radiates to his flank. It is associated with a severely tender abdomen without rebound. This presentation is classic for pancreatitis.
Urinary Calculus
Less likely. While the pain is of acute onset and radiates to the flank, the worsening with food intake and the epigastric tenderness with rebound place this lower on the differential.
Peptic ulcer disease with perforation
Correct! The epigastric pain, worse with eating maybe encountered with ulcer disease. Peptic ulcer may be complicated by a gastric or duodenal perforation which would have such an acute presentation.
Acute Coronary Syndrome
Less likely. This life-threatening condition may present with atypical features such as epigastric pain but given the lack of chest pain and shortness of breath and presence of abdominal tenderness make it less likely.
Ruptured Aortic Aneurysm
Less likely. This life-threatening condition may present with acute onset epigastric abdominal pain, but the presentation would also be notable for hemodynamic instability
Intestinal Obstruction
Incorrect. While bowel obstruction can present with acute epigastric pain, since the patient has unchanged bowel movements and no absence of bowel sounds, the diagnosis is unlikely.
Should be further down on differential. Hepatitis rarely causes acute onset epigastric pain. Also, it is often associated with jaundice or fever.


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