Case Scenario:

Y.E. is a 42 year old female who complains of sharp epigastric pain that started 6 hours ago.

History:

Onset: Today at 9 AM

Location: Epigastrum, right upper quadrant, radiates to the right shoulder and back

Duration: constant pain

Character: sharp, stabbing

Pain is not alleviated by anything, worsens with movement

Patient reports eating a large fast food meal of cheeseburger and french fries for dinner last night

Patient reports a similar episode of pain occurring several weeks ago but spontaneously resolved

Confirms occasional alcohol use, denies smoking

Past medical history significant for type II diabetes mellitus

Patient reports taking metformin as her only medication, denies NSAID use

Denies surgical history

Patient confirms being sexually active and uses barrier protection

Patient reports inability to tolerate food since onset of pain

Denies known drug allergies

ROS Pertinent Positives: Nausea, abdominal pain, fever, chills, loss of appetite

ROS Pertinent negatives: No chest pains, shortness of breath, jaundice, blood in stool, diarrhea, constipation, vomiting, burning while urinating,

Physical Exam:

Vitals:

BP: 132/78, right arm, sitting

HR: 115 beats/minute, regular

RR: 20 breaths/minute, unlabored

Temperature: 101.1F oral

SpO2 Sat: 97%, Room air

Height: 5’5”

Weight 175

BMI: 29.1

General appearance: Patient is alert and oriented x3, no acute distress.

Skin: Patient is diaphoretic, skin is warm and moist with good turgor. Non-icteric

Lungs:  Clear to auscultation bilaterally, no crackles, ronchi or wheezes appreciated.

Heart: S1 and S2 distinct, regular rate and rhythm, patient is tachycardic. No murmurs, rubs or S3, S4 appreciated.

Abdomen: Obese abdomen. Patient is tender to the epigastrum and to the right upper quadrant. Murphy’s sign is present. No rebound or guarding. 

Differential Diagnosis:

Cholecystitis – Patient is febrile, tenderness in the upper right quadrant with positive Murphy’s sign, pain began the morning after a large fatty meal.

Appendicitis – Patient is febrile, has focal abdominal tenderness and has not had appendix removed.

Pancreatitis – Has epigastric pain that radiates to the back, nausea, alcohol use

Perforated duodenal ulcer – Radiating epigastric pain, nausea, tachycardia

Ectopic pregnancy – Focal tenderness, has not gone through menopause, is sexually active

Tests:

CBC- Leukocytosis of 16,000 with left shift.

CMP –  within normal limits 

Urinalysis – Within normal limits, no blood or protein

Lipase – Within normal limits

Pregnancy test – Negative

Imaging:

RUQ Ultrasound –

Thickening of the gallbladder wall, biliary sludge and calculi are found on ultrasound.

Treatment:

Patient requires admission to the hospital for treatment.

Empiric antibiotics – Ceftriaxone 2g IV once per day plus Metronidazole 500mg IV Q8H

Supportive care – Pain control with Ketorolac 30mg Q6H, IV fluids and hydration, keep patient NPO

Pt Counseling/Education:

Patient is advised to proceed with surgical removal of gallbladder with laparoscopic cholecystectomy due to high chance of recurrence and presence of gallstones. Patient is also advised to avoid large fatty meals. Losing weight may also help decrease incidence of symptomatic gallstones.