See attached example for a write-up of this case study.
Mr. Keenan, age 42, is a local volunteer firefighter man and baseball instructor who has been experiencingexcruciating right upper quadrant pain. His previous medical history includes GERD, chickenpox, andobesity. The general state of his health is great. Omeprazole is a prescription medication. There are noadditional drugs or supplements. Surgery: At the age of 11, his appendix was removed. Apart from anappendectomy, there have been no hospitalizations. No one in the family has ever had a stroke or coronary artery disease. Keenan is a local volunteer firefighter and baseball instructor who has been experiencing excruciatingabdominal pain. Previous medical history includes GERD, chickenpox, and obesity. The general state of hishealth is great. Omeprazole is a prescription medication. There are no additional drugs or supplements.Surgery: At the age of 11, his appendix was removed. Apart from an appendectomy, there have been nohospitalizations. No one in the family has ever had a stroke or coronary artery disease. A decade ago, he gaveup smoking, and he proudly says he has never had a cigarette since. It appears that he prefers to drink on theweekends. When you inquire about how much exercise he gets on a daily basis, he responds that farming is alot of work. For the past year, he has not been able to leave the county he lives in. He admits that he isstruggling to make ends meet and that he has been worried about running out of money lately.
Diagnosis: Biliary colic
DIFFERENTIAL DIAGNOSIS: Renal colic and Acute cholecystitis
Explanation of the Diagnostic Plan (including tests, labs, imaging studies, etc.) Labs-
Electrolytes, urinalysis, CBC, hepatic panel, abdominal ultrasound
Treatment Plan:
Surgical plan for cholecystectomy
Pharmacotherap
Stop drinking alcohol
Citations should be clinical practice guidelines and scholarly or peer-reviewed articles no older than 5 years(2018).
