How to rule in or out diagnoses

Question 1: List your top three differential diagnoses

1. CT Scan
2. Blood and stool test
3. Urinalysis

Question 2: How to rule in or out diagnoses

1. CT Scan – according to the physical examination, the findings indicate that the patient has an involuntary guarding and rebound tenderness in her right lower quadrant. Additionally, the pelvic examination reveals no cervical discharge. However, cervical motion tenderness and right adnexal tenderness are present. These could be signs and symptoms of pelvic inflammatory disease (PID). While there is no single diagnosis for PID, the physician could request an abdominopelvic CT scan to identify the reason for the tenderness.
2. Blood and Stool test – the patient reports three days of constant pain. The pulse, temperature, respiration rate, and BP of the patient are normal. Other vitals such as skin condition and cardio-pulmonary exam reveal normal findings. However, the patient has palpitations in both right and left lower quadrants, which are a sign of appendicitis. To determine the cause of the positive Rovsing’s sing, test for appendicitis, a blood, and stool test, which helps establish if there is an increase in the white blood cell count, thereby pointing to an infection. However, a stool test would be eliminated since X-ray could detect the fecalith that may cause acute appendicitis.
3. Urinalysis – to differentiate urinary tract infections from acute appendicitis, the provider might order for a urinalysis. Patients with appendicitis might have mild pyuria because of the relationship of the appendix with the right ureter. However, UTIs are commonly found in patients with severe pyuria. Therefore, I would recommend a blood test to establish an infection, a CT scan to identify the infection position that causes tenderness, and urinalysis as the final differential test for acute appendicitis or UTIs.

Question 3: List the most important historical questions you must ask this patient

1. Sexual history
2. Alcohol and drug use
3. Psychosocial stress
4. Tobacco use
5. Previous abdominal or pelvic surgeries
6. Financial concerns for care
7. Family history
8. Recent antibiotic use
9. Previous medical conditions such as pancreatitis, renal stones, diverticulosis, or pregnancy risk to check for ectopic pregnancy

Question 4: Which components of the ROS must you ask?

1. Cardiovascular
2. Respiratory
3. Gastrointestinal
4. Psychiatric
5. Endocrine, and
6. Allergic/immunologic components

Question 5: Do you need to complete further physical exam components?

Yes. The right and left upper quadrants

Question 6: What other laboratory studies are needed, and why?

1. Amylase and Lipase tests are used to measure the amount of the lipase and amylase enzymes that circulate in the patient’s bloodstream. These are confirmatory tests used after the blood tests, urinalysis, and pregnancy lab tests might have suggested the presence. The symptoms of acute pancreatitis or appendicitis or other pancreatic disorders have been found.

Question 7: Considering your location, what diagnostic studies would you order, and why?

I would order for X-rays, medical histories, physical examinations, and laboratory tests considering my location. First, since the patient is a young woman, her social, medical, and psychosocial histories are important in establishing the cause of the pain. For instance, the pain could be a symptom of a urinary tract infection, acute pancreatitis, or acute appendicitis. Since the hospital has sufficient facilities and a well-equipped laboratory, the laboratory tests such as a blood test or a urinalysis would be important in establishing or confirming the tests and suspicions. However, the imaging department is not well equipped with recent technology and equipment, which might hinder the chances of getting the right diagnosis.

Question 8: How do you confirm your final diagnosis?

Through urinalysis. The test would establish the protein levels as a sign of the kidneys’ functioning, acidity or pH levels, glucose levels, nitrates, white blood cells, bilirubin, or blood in the urine. Considering the patient’s hx, urine tests would also indicate signs of illicit drug use or pregnancy.

Question 9: How common is the complaint of abdominal pain in patients presenting to the ED?

Abdominal pain is one of the largest complaints of patients seen by gastroenterologists. More than 7 million patients in the United States present to the emergency department with nonspecific abdominal pain (…). While pain differs from lower to upper abdominal pain, the causes are often related. However, lower abdominal pain’s common causes include fibroids, ovarian cysts, pelvic congestion syndrome, irritable bowel syndrome, inflammatory bowel diseases, appendicitis, and urinary tract infections. On the other hand, upper abdominal pain is often caused by other conditions such as liver damage, blood infections, and abdominal infections. According to a systematic review of symptom-evaluating studies on the etiology, prevalence, and prognosis of abdominal pain, about 28 percent of the patients in the studies presented to the emergency department with abdominal pain (…).

Question 10: In a female, what are the most common etiologies for abdominal pain?

Most of the female patients presenting with abdominal pain are diagnosed with gastroenteritis, irritable bowel disease, urological cause, and gastritis. However, a few other patients are diagnosed with appendicitis, diverticulitis, neoplastic, or biliary/pancreatic that need immediate therapy.

Question 11: If this patient was a female over the age of 65 – what would the most common causes of abdominal pain be?

Different research studies have suggested that biliary tract disease is common among females above 65 years, presenting to the ED with abdominal pain. They also present with gallstones and constipation. However, these patients should be screened for more comorbid illnesses. However, the patient’s social and medical histories are essential in establishing the cause of abdominal pain among these patients.

Question 12: How do you rule out acute pancreatitis in a patient presenting with abdominal pain? Identify the historical factors, ROS, exam, and lab components that would support acute pancreatitis diagnosis.

1. The physical exam revealed an involuntary guarding and rebound tenderness in her right lower quadrant. Additionally, the abdominal exam revealed mild distension, tender to palpitation in both right and lower quadrants. Acute pancreatitis would have these symptoms in the upper quadrant.
2. Historical factors and ROS would remain the same as the above.
3. Lab exams would include tests for cholangitis, epigastric pain, and RUQ.