Reference no: EM133836799

Assignment: Diagnostic Reasoning

Include the following:

• Identify the patient's chief complaint.
• Identify what physical exams and diagnostic tests would be most appropriate to gather more information about the patient's condition. Be specific and explain your reasoning.
• Explain how the results would be used to make a diagnosis.
• Identify three to five (3-5) possible conditions that may be considered in a differential diagnosis for the patient. Explain your thinking.

Case Study

Patient Profile:

• Name: John Doe
• Age: 45
• Gender: Male
• Occupation: Office Worker
• Medical History: Hypertension, Hyperlipidemia
• Medications: Lisinopril 10 mg daily, Atorvastatin 20 mg daily
• Allergies: None

Chief Complaint: The patient presents with complaints of abdominal pain that started 24 hours ago.

History of Present Illness: John reports the pain began suddenly in the upper abdomen and has been persistent. He describes the pain as sharp and cramping, with an intensity of 7/10. The pain radiates to his right shoulder. He denies any previous episodes of similar pain. He also reports nausea and one episode of vomiting but denies diarrhea or constipation. There has been no fever or chills.

Review of Systems:

• Gastrointestinal: Nausea, vomiting, no changes in bowel habits
• Cardiovascular: Denies chest pain or palpitations
• Respiratory: Denies shortness of breath
• Genitourinary: No dysuria or hematuria

Physical Examination:

• Vital Signs: Blood Pressure 140/85 mmHg, Heart Rate 88 bpm, Respiratory Rate 18 breaths/min, Temperature 98.6°F
• General: Alert and oriented, appears in mild distress due to pain
• Abdominal Exam:
• Inspection: No visible distention or masses
• Auscultation: Normal bowel sounds
• Palpation: Tenderness in the right upper quadrant with guarding, positive Murphy's sign
• Percussion: No tympany or dullness indicative of fluid