Ep 7: A 46-year-old with right upper quadrant abdominal pain

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Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 46-year-old woman presents to the emergency department with a 1-day history of constant right upper quadrant abdominal pain.

The pain began after eating fried pork. She describes the severity of the pain as a 7 out of 10. She reports that the pain also seems to radiate to her back near her right scapula. She feels nauseated and has vomited twice. She has had similar pain about once a month for the past month but of less severity. The pain comes on and worsens after eating food but previously it has resolved within an hour. She also reports of fever.

She does not have yellow discolouration of her eyes, has not lost weight, and does not have diarrhea, constipation, bleeding, or dark-colored stools. There is no history of abdominal distension or a mass in her abdomen.

She is Para 6 + 0. She has no significant medical or surgical history, is not on any medication, and has no allergies. She does not smoke, nor does she drink alcohol. Her diet is usually high in fat. Her review of symptoms is unremarkable.

She appears ill on physical exam. Her temperature is 37.7 C, heart rate is 110 beats per minute, and blood pressure is 120/80 mmHg. Her BMI is 33. There is no jaundice. She has marked tenderness to palpation in the epigastric region and right upper quadrant. When the right upper quadrant is palpated while she is taking a deep breath, she abruptly stops inspiration due to the pain. No masses are palpable. There is no rigidity, rebound tenderness, or guarding. The rest of her physical examination is unremarkable.

Her ultrasound shows stones in the gallbladder, gallbladder wall thickness of 6mm, and pericholecystic fluid. The diameter of the Common Bile Duct is 1.8 mm and there are no stones visualized within it. The liver parenchyma appears normal. Sonographic Murphy’s sign is positive.

These are the results of her laboratory investigations:

WBC count 14 x 10 ^3 u/L (4.1 – 10.9 x 10^3 u/L), Total Bilirubin 1.0 mg/dL (0.1 – 1.2 mg/dL), Alkaline phosphatase 70 units/L (33-131 u/L), Amylase 60 units/L (30 – 100 u/L), Lipase 30 units/L (7 – 60 u/L)