Case study:

This is a 48-year-old female who presents to the urgent-care clinic with a two week history of intermittent, colicky RUQ pain that has now increased over the past two days. She reports associated nausea and emesis (nonbilious; nonbloody) x two days, with associated anorexia. Family history is positive

for biliary disease (mother). The patient is found to have low-grade temperature elevation, mild scleral icterus, RUQ abdominal tenderness with guarding, and a positive Murphy’s sign.

 

Instructions: Answer the following questions. As you can see, I already have the primary, differential diagnosis, and laboratory/diagnostic test.

 

Management Plan Template: 

(Every section of your management plan must have intext citations to support your plan).

 

Primary Diagnosis and ICD-10 code: Also include any procedural codes.

3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.

 

Primary Diagnosis:

     Choledocholithiasis K80

 

Differential Diagnosis:

    1. Peptic Ulcer Disease (PUD) K27.9

    2. Nephrolithiasis/kidney calculi N20.0

    

Additional laboratory and diagnostic tests: May be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.

         – Laboratories: CBC, CMP, Urinalysis

         – Diagnostic tests: Abdominal ultrasound

 

Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending to hospital, what orders would you write for a direct admit?

 

Therapeutic modalities: pharmacological and nonpharmacological management.

 

Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.

 

Patient education: Explanations and advice given to patient and family members.

 

Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.

 

 Scholarly references (minimum of 3, timely, that prove this plan follows current standard of care).\\\”

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