Question

A 75-year-old gentleman was referred to an orthopedic physician because of shoulder pain. Upon examination, the physician finds that the man has had shoulder pain for more than five weeks. However, he doesn’t feel the pain when moving his shoulder. Instead, he feels pain after eating. His abdomen is distended, making him uncomfortable, but he states that he has no pain in this area. He has a history of drinking more than six beers per day for many years.

Question: What further information would you need for a definitive diagnosis and why? 

Answer 1

The patient is a 75-year-old elderly gentleman who has had right shoulder pain after eating for more than 5 weeks. He has abdominal distension. He has a history of drinking six beers per day for many years. Since the right shoulder pain is felt only after eating, this is a referred pain. This pain is caused due to some underlying abdominal disease, which is evident from referred shoulder pain and abdominal distension. The right-sided referred shoulder pain is often associated with conditions like cholecystitis, gallstones, or pancreatitis. Cholecystitis and pancreatitis can be ruled out because of the absence of abdominal pain. Since the patient has abdominal distention and referred right shoulder pain, the referred pain is probably due to gallstones or other related issues. The patient is an alcoholic, which complicates the situation further. Further information is required to rule out certain conditions and for a definitive diagnosis. Further information required includes lab test values, abdominal ultrasound, HIDA scan etc., to assess the signs and symptoms and functioning of various abdominal organs. A definitive diagnosis is the final diagnosis made after getting the results of tests such as blood tests, imaging studies etc., done to confirm a disease condition. An endoscopic ultrasound, MRI, abdominal ultrasound, or a CT scan can be used to view pictures of the gallbladder to reveal signs of cholecystitis or stones in the bile ducts and gallbladder. HIDA scan tracks the production and flow of bile from your liver to your small intestine and shows blockage. Blood tests like CBC, CRP, ESR, liver panel, amylase, and lipase should be done to reveal the signs of an infection, gallbladder problems, or other underlying abdominal conditions. ERCP (endoscopic retrograde cholangiopancreatography) can also be done, when the cause of inflammation is difficult to diagnose by other diagnostic methods, to arrive at a proper conclusion or definitive diagnosis.