Differential Diagnosis for James Wright

Single most likely diagnosis

• Cholecystitis: The patient's symptoms of right upper quadrant abdominal pain, vomiting, pale stools, and orange-brown urine are suggestive of a liver or gallbladder issue. The positive Murphy's sign, which is tenderness in the right upper quadrant that worsens with deep inspiration, is a classic indicator of cholecystitis. The patient's presentation is consistent with acute cholecystitis, which is inflammation of the gallbladder, often caused by gallstones.

Other Likely diagnoses

• Gallstone pancreatitis: Although the patient does not have the typical severe abdominal pain radiating to the back, gallstone pancreatitis is a possible diagnosis given the gallbladder symptoms. The pale stools and orange-brown urine could indicate a bile duct obstruction, which can lead to pancreatitis.
• Bile duct obstruction: The patient's symptoms of pale stools and orange-brown urine suggest a possible bile duct obstruction, which could be caused by a gallstone or another lesion. This would lead to a buildup of bilirubin, causing the urine to darken.
• Peptic ulcer disease: Although less likely given the specific location of the pain and the presence of a positive Murphy's sign, peptic ulcer disease could still be a consideration, especially if the patient has a history of NSAID use or Helicobacter pylori infection.

Do Not Miss (ddxs that may not be likely, but would be deadly if missed)

• Hepatic artery aneurysm or rupture: Although rare, a hepatic artery aneurysm or rupture can present with abdominal pain and could be life-threatening if not promptly diagnosed and treated.
• Liver abscess: A liver abscess could present with right upper quadrant pain, fever, and jaundice, although the patient's temperature is only slightly elevated. It's essential to consider this diagnosis, especially if the patient has a history of biliary disease or recent travel.
• Perforated viscus: A perforated viscus, such as a perforated gallbladder or ulcer, can lead to peritonitis and sepsis, which would be life-threatening if not promptly treated.

Rare diagnoses

• Hemobilia: Hemobilia, or bleeding into the biliary tree, can cause abdominal pain, jaundice, and melena (black, tarry stools). Although rare, it's essential to consider this diagnosis if the patient has a history of liver disease or recent instrumentation.
• Sclerosing cholangitis: Primary sclerosing cholangitis is a rare chronic liver disease characterized by inflammation and scarring of the bile ducts, which can lead to abdominal pain, jaundice, and liver failure.