Differential Diagnosis for Right Upper Quadrant Pain

The patient's presentation of right upper quadrant pain, fever, anorexia, nausea, vomiting, and a positive Murphy's sign suggests a gallbladder pathology. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • a. Cholecystitis: The patient's symptoms, including right upper quadrant pain that worsens with inspiration and radiates to the right shoulder, fever, and a positive Murphy's sign, are classic for acute cholecystitis. The patient's obesity and diabetes also increase her risk for gallstones, which are a common cause of cholecystitis.

• Other Likely Diagnoses

  • b. Pancreatitis: Although the patient's symptoms could suggest pancreatitis, the presence of a positive Murphy's sign and the specific location of the pain make cholecystitis more likely. However, pancreatitis is still a possibility, especially given the patient's history of diabetes.
  • c. Pyelonephritis: The patient's symptoms of fever, nausea, and vomiting could also be seen in pyelonephritis, but the location of the pain and the positive Murphy's sign make this diagnosis less likely.
  • d. Appendicitis: Although appendicitis typically presents with lower abdominal pain, it can occasionally present with right upper quadrant pain, especially if the appendix is retrocecal. However, the patient's symptoms and physical exam findings are not typical for appendicitis.

• Do Not Miss Diagnoses

  • Perforated Visculitis: This is a rare but potentially life-threatening condition that can present with abdominal pain, fever, and vomiting. Although it is unlikely, it is important to consider in patients with risk factors for vasculitis.
  • Hepatic Abscess: A hepatic abscess can present with right upper quadrant pain, fever, and vomiting, and can be life-threatening if not treated promptly.
  • Pneumonia: Right lower lobe pneumonia can cause right upper quadrant pain that worsens with inspiration, and can be associated with fever, nausea, and vomiting.

• Rare Diagnoses

  • Fitz-Hugh-Curtis Syndrome: This is a rare condition characterized by inflammation of the liver capsule and surrounding tissues, often due to a bacterial infection. It can present with right upper quadrant pain, fever, and vomiting.
  • Hepatocellular Carcinoma: Although rare, hepatocellular carcinoma can present with right upper quadrant pain, fever, and vomiting, especially in patients with risk factors such as cirrhosis or hepatitis B infection.