Clinical Case Study


Roadmap of the Diagnosis Report

The report begins with a summary of patient’s complaints and remarks, then the evaluation of the prospective diagnosis is made with recommendations on the necessary clinical analyses administration. The final section of the report concludes on the findings of the blood test that the patient was subjected to privately in his cousins laboratory.

Summary of the Complaints

The patient is 58 years of age and reports having increased feeling of fatigue, decreased appetite, and discomfort in a form of heaviness. The feeling of bloating and nausea are specifically intensified after patient’s intake of meals with saturated fat with the approximate timeframe being the latest two years. Three weeks ago, the patient noted that his stool was of specific black colour, the perspiration considerably increased, and most importantly, he was physically unable to leave the bed because he felt feebleness. The general stool of the patient was apprised to be loose and pale. The consumption of heavy meals invariably leads to the sense of pain in the upper belly. Furthermore, the patient reported that the nature of the pain is intense, lasting, dull, and constantly accompanied by the sense of nausea. Within the period of three latest months, patient reports to have experienced irregular heaviness in the chest cavity when excessive physical activity was exercised by him. Physical examination of his body indicated increased abdominal cavity, the sense of tenderness in the episgastrium while deep palpation was administered. Blood pressure measurement has been administered and it was ascertained to be above average. i.e. 155/195. The yellowish tinge in the eyes was noticed. The patient relayed that he consumes alcohol on a regular basis, apart from having being an inveterate smoker for the latest 35 years. Averagely, the patient apprised that he smoked 25-30 cigarettes daily. Genealogical survey revealed that his father had increased blood pressure, was diagnosed with diabetes, and took heart medication.

Possible Diagnoses

The Possibility of Cholecystitis

Cholecystitis is regarded as one of the potential physical disorders in this very case. In accordance with scholarly and practical descriptions of this disease, the patient suffering from this physical disorder experiences intensive, intermittent, but rather regular pain in the section of the upper abdominal quadrant located in the epigastric area of human body. The primary roots of this disease are active physical intervention into the bodily abdominal area, or indirect influence perpetrated by the regular excessive alcohol consumption (Derici et al, 2006), which is the most viable hypothesis in this case. Under the most common development of this disease, the pain is expected to evolve from intermittent to constant one. Moreover, the pain is often reported to intensify. Among the core reasons that generate this disorder is the consumption of fried, greasy, and fat saturated foodstuff that is fully consistent with this case study. Other symptoms of this disorder are diarrhea and nausea. However, in this very instance, the patient deliberately highlights the fact that his stool loose, although nausea was present, so both symptoms of this disorder do seem to be present Academics stipulate that presence of diarrhea shall not be considered as the determinative symptom, therefore, administering of this diagnosis shall remain among the working ones (Rao et al, 2005). One of the major symptoms of this disease is high fever, which was not mentioned by the patient during the conversation. The rest of the symptoms, such as tender in the right upper quadrant and in the right coastal arch, were not identified.

Blood test results reveal the following findings: : RBC 3.5 x 1012/L, Hb 115 g/L, Hct 36%, MCH 26 pg, MCHC 27%, MCV 70 fL, WBC 5 x 109/L. Indications clearly demonstrate that the blood compound of the targeted patient is reflecting that aenemia is highly possible in this very instance . The facts that bilirubin is positive and urobilinogen is decreased are another facets that suggest the presence of this diagnosis. With regard to the most reasonably relevant diagnosing procedures, it shall be accentuated that the following measures seem to be relevant to be conducted. First and foremost, it is highly recommended to measure fever of the patient. In this case it differs significantly from the stipulated standards to conduct further diagnostic investigations. Secondly, the most indispensable procedure in this instance involves ultrasound examination, which is aimed to evaluate abdominal processes and ascertain whether the gallbladder has thickened or not (Sonnenberg et al, 1981). The ultimate goal of these procedures is to find out whether cystic dust is surrounded with inflammatory processes and to detect any contaminating agents in the right upper quadrant of the abdomen (Sonnenberg, 1981).

The Possibility of Cholestasis

In contemporary and classical medical sciences, cholestasis is defined as a situation when the gall cannot freely migrate from the liver to the duodenum (Strasberg, 2008). In other words, the duct system is blocked artificially. The factors that do contribute to the development of this ailment include excessive alcohol consumption, obesity then followed by the rapid and unintentional weight reduction of the patient (Pashankar et al, 2001). Among other roots of this disorder is the consumption of the products that are excessively saturated with fat and that lack carbohydrates among their nutritional compound (O’Keefe, 2001). Among the main symptoms of this physical disorder is the itching feeling in the abdominal area of the patient, in particular pruritus is intensified intermittently because of the gall-generated acid contact with the nerve system (the opiodergic extremities ones) (Rao et al, 2005). Secondly, jaundice is among the symptoms of second importance that are to be considered. The change of skin colour is this case must be evident and shall transpire within a period of one week from the beginning of the illness progress. With regard to the stool of the patient, it must be highlighted that in accordance with the postulates and set of practices of the contemporary medical science, the stool is to be pale, which implicates that cholestasis is obstructive in its essence (Kurata et al, 1997). Lastly, urine of the patient is to be dark in colour.

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Evaluation of patient's symptomatology reveals that this diagnosis can hardly be administered due to a number of evident reasons. First and foremost, the jaundice has not been detected. Secondly, the stool of the patient is loose in its nature. Thirdly, irritation of the abdominal cavity of the patient suggests another reason that it can hardly be cholestasis (Pashankar, 2001). Overall, having encapsulated these factors, additional diagnosing measures are to be most indispensably taken in order to be fully assured of the correctness of the administered diagnosis. The following analyses are to be performed in order to find out whether cholestasis is present:

  • The biochemical analysis of the abdominal cavity;
  • Ultrasound analysis of the abdominal cavity.

Provided that that the rest of symptoms are duly corroborated, this diagnosis can be administered. However, urine analysis conducted clearly demonstrates deviations from the urine colour and composition if one suffers from this disease. Therefore, additional urine test is to be carried out, while the findings of blood analysis can be remised since for this type of disease they are not relevant.

The Possibility of Liver Disease

One of the most viable diagnoses in this very case is liver disease. Among the roots of this disease is excessive alcohol consumption, hereditary predisposition and infectious hepatitis. Considering the fact that in this very instance the patient reports alcohol abuse this reason does seem to be the most viable to have generated this disorder.

First and foremost, the blood analysis, in particular the haemoglobin rate 115 indicates that liver disease can be probable in this very clinical instance (Kurata et al, 1997). The second most conspicuous symptom of this disease are digestion-related problems. In this very case, the patient reports having extensive nausea attacks and problems with stool, although in the past the situation was relatively normal. Moreover, the patient reports having painless feeling in the abdominal area. This feeling is often ascribed to be among the most popular symptoms of this disease (McCoy, 1976). Particular attention of the diagnosing team shall be linked to the presence of nervous disorders, which are not found in this very case. Exasperation and anger feelings are not viewed to take place. Although in accordance with the popular scholarly opinion, they are detected on individual cases and these symptoms cannot be considered commonplace in this types of diseases (O’Keefe, 2001).

What is particularly notable in this case, is the fact that the patient can consume fat and greasy food, whereas typical features of this physical disorder involve natural intolerance to this type of food and beverages, and consequently the inability of individuals to take them in. Moreover, when patients have this disease, they are not capable of consuming alcohol beverages, whereas in this case the patient revealed that he is alcohol abusive. However, contemporary medical practice indicates that ramifications of this disease include the possibility to tolerate alcohol-based substances (Derici et al, 2006). Vomiting and abdominal bloating are considered to be another popular characteristics of this ailment (Collier et al, 2010). Vomiting was not reported to have occurred, but in accordance with the scholarly studies, it was revealed that this symptom develops in the course of disease progress. Although constipation processes were not indicated among the complaints of the patient, further studies are necessary in order to ascertain whether the patient has a liver disorder.

Recurrent headaches are among the most conspicuous distinguishing elements that facilitate in the process of illness diagnosing. In this case, the patient did not report having them, although contemporary clinical medicine science indispensably attributes this symptom to this particular disorder.

Most importantly, a special portion of attention shall be put to the administered blood test. Moreover, the administered urinal analysis is another indication that presence of this ailment is very highly probable due to the fact, that the level of urobilinogen is decreased. This fact is considered among the most apparent symptoms of the assailing disease.

With regard to urgent diagnosing measures that are to be most indispensably administered, analysts are required to test the blood additionally in order to ascertain the presence of enzymes in it as well as serum protein. If these substances are duly detected in the blood of the diagnosed individual, then biochemical analysis is to be administered in order to identify deviations from the standards set forth.

The second step of biochemical analysis is to be the evaluation of alkaline phosphatase. Precise analysis of this enzyme blood element is required in order to find out whether the ALP level in blood liquid is normal and if the increased rates of this substance are identified. The presence of the discussed disease then can be diagnosed.

The Possibility of Peptic Ulcer

Considering peculiarities of patient's complaints, it can be reasonably inferred that peptic ulcer is another highly probable clinical disease here. Primary causes of this disease, in accordance with the popular medical opinion include the presence of the ailment-generating H-pylori bacteria, frequent alcohol and tobacco consumption, and excessive mental stress incurred by the affected person (McCoy et al, 1976). In this clinical case, the fact that the person consumes alcohol on a regular basis can be used to assume a presence of this disease. Among the most frequently encountered symptoms of this ailment is abdominal pain, which was reported by the patient in this case. Moreover, in full accordance with scholarly and practical descriptions of this disorder, the pain appears immediately after the patient takes his daily regular meals and is often accompanied by bloating. Internal water exchange processes is another symptom that frequently is observed among the people diagnosed with this disease. Waterbrash internal processes are, therefore, common among them. One of the most conspicuous symptoms is hematemesis, also known as external blood discharge that occurs due to internal bleeding processes (Kato et al, 1992).

Under the normal course of development of this physical disorder, weight and appetite of patients are reduced (Pashankar et al, 2001). However, in this very case, while the weight has reduced significantly, the appetite remained normal. Moreover, the patient apprises that he is entirely capable of consuming fat and greasy food. Among the most conspicuous symptoms of this disease is the reported inability of the individual to consume such food substances.

Significant weight oscillations (the patient reported to have lost 10 kg unintentionally during the latest 6 months) are other facets that clearly illustrate high probability of this physical disorder presence, although it has been proved that deviations from this rule are remissible.

Although the big part of the symptomatology of this physical disorder is present, the diagnosis cannot be administered as to guarantee 100% accuracy before a number of other tests are performed. Urinal and blood analysis taken fully indicate that presence of this disease is very likely in this case since positive bilirubin and decreased urobilinogen are recognized by practicing medical communities as one of the most illustrative symptoms of this disease. In order to verify this diagnosis, the team is expected to conduct a biochemical analysis and to test the blood additionally in order to estimate the level of RBC and Hct one more time since under the course of development of this disease, these figures are expected to manifest substantial weekly vacillations. Moreover, in order to find verify the assumption the stool analysis shall be prescribed.

As far as the deviations with heart beating tempos are concerned, it seems to be relevant to proceed with a due electrocardiography analysis in order to find out the apparent heart disorders. It is highly possible that the initial diagnosis will be aggravated with the presence of cardio-based disorder that is to be regarded separately.


Having summarized the main findings of the primary clinical observation, the presence of peptic ulcer does seem to be the most valid diagnosis in this case. Nevertheless, the ultimate diagnosis can be made only upon the accomplishment of all the recommended diagnostic procedure.

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