Differential Diagnosis for Abdominal Pain

The patient presents with abdominal pain that worsens with eating, starts in the middle of the stomach but moves to the right side, accompanied by fevers, chills, a recent cough and sore throat, and laboratory findings indicating an elevated white blood cell count. Based on these symptoms, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Acute Cholecystitis: This condition is characterized by inflammation of the gallbladder, often due to gallstones blocking the cystic duct. The patient's symptoms of abdominal pain that worsens with eating and localizes to the right upper quadrant, fever, and elevated white blood cell count are classic for acute cholecystitis. The patient's response to deep palpation of the right upper quadrant, where he abruptly holds his breath, suggests Murphy's sign, which is highly suggestive of acute cholecystitis.

• Other Likely Diagnoses

  • Peptic Ulcer Disease: Given the patient's abdominal pain that worsens with eating, peptic ulcer disease is a consideration. However, the localization of pain to the right upper quadrant and the presence of fever and chills make this less likely than acute cholecystitis.
  • Hepatitis: Although hepatitis can cause right upper quadrant pain and fever, the absence of jaundice and the specific pattern of pain worsening with eating make this less likely.
  • Pneumonia: The patient's recent cough and sore throat, along with fever, could suggest pneumonia. However, the primary complaint of abdominal pain and its characteristics point more towards an abdominal rather than a pulmonary issue.

• Do Not Miss Diagnoses

  • Appendicitis: Although the pain started in the middle and moved to the right side, which is atypical for appendicitis (which usually starts in the periumbilical area and then localizes to the right lower quadrant), appendicitis can present atypically, especially in adults. Missing appendicitis can lead to perforation and severe consequences.
  • Perforated Visculitis or Ulcer: A perforation in the gastrointestinal tract can lead to peritonitis, which is a life-threatening condition. The presence of fever, chills, and abdominal pain, especially with guarding (involuntary muscle tension) upon palpation, necessitates consideration of this diagnosis.
  • Cholangitis: Infection of the bile ducts, which can be life-threatening if not promptly treated. The presence of fever, chills, and right upper quadrant pain, especially in the context of jaundice (not explicitly mentioned but should be considered), makes this a critical diagnosis not to miss.

• Rare Diagnoses

  • Gallbladder Cancer: Although rare, gallbladder cancer can present with similar symptoms to acute cholecystitis. It is more common in older adults and those with a history of gallstones.
  • Acalculous Cholecystitis: Inflammation of the gallbladder without the presence of gallstones, more common in critically ill patients or those with significant comorbidities.

For a patient with acute cholecystitis, the next best steps would include:

• Imaging: Ultrasound of the abdomen to confirm the presence of gallstones and gallbladder inflammation.
• Antibiotics: Initiation of antibiotic therapy to cover for potential bacterial infection.
• Fluid Resuscitation: Ensuring the patient is well-hydrated.
• Pain Management: Appropriate analgesia for pain control.
• Surgical Consultation: Arranging for surgical consultation for potential cholecystectomy, which may be urgent or elective depending on the patient's condition and response to initial management.