Case 3 Andrew Sitzmann Danielle Paulozzi Andrew Emerson Miguel Linares

Introduction/Summary 45 year old black woman admits to ED -apprehensive and very uncomfortable -her body is bent slightly forward and to the right Frequency of occurrence – After meals, Increasing intensity Associated symptoms – Yellow schlera, “Coke” colored urine, feverish, chills, nausea, vomiting (twice)‏ Radiation of the symptom Character – moderate abdominal pain, increasing intensity Onset – 5 days ago Location – Onset in epigastric, moved to RUQ and back between shoulders Duration – Continuing, progressive Exacerbating/Relieving factors - “Attacks” 1 hr after eating, worse on inspiration She has had no prior illness, is not taking any medications and may drink a beer with her husband on the weekends.

Introduction PHYSICAL EXAMINATION OF THE PATIENT Vital signs: Blood pressure Lying supine: 120/65 left arm and 125/70 right arm Standing: 105/55 left arm and 110/60 right arm Pulse: 115 Rhythm: Regular Temperature: 103.8º F. Respiratory rate: 22 Height: 5’8” Weight: 180 lbs.

Introduction PHYSICAL EXAMINATION OF THE PATIENT Vital signs: Blood pressure Lying supine: 120/65 left arm and 125/70 right arm Standing: 105/55 left arm and 110/60 right arm Pulse: 115 Rhythm: Regular Temperature: 103.8º F Respiratory rate: 22 Height: 5’8” Weight: 180 lbs.

Introduction HEENT Examination : PHYSICAL EXAMINATION OF THE PATIENT HEENT Examination : mucous membrane of the hard palate is yellowish. Lungs: Normal Cardiovascular Examination : tachycardia and the orthostatic changes in blood pressures. Genitourinary Examination : Normal Musculoskeletal Examination : Normal Neurologic Examination : Normal

Introduction Abdomen: PHYSICAL EXAMINATION OF THE PATIENT Abdomen: Hepatic Percussion shows span of 14 cm along the right midclavicular line. Firm, regular, smooth but tender liver edge palpable below the right costal margin on inspiration. Fist percussion applied to the lower ribs above the right costal margin elicits an increase in upper abdominal pain. Light and deep palpation elicit localized tenderness in RUQ only. The gallbladder is not palpable, but Murphy’s sign (interruption of inhaled breath when the patient is palpated underneath the right costal margin) is observed.

What are your thoughts?

Explain the finding of the abdominal examination. PHYSICAL EXAMINATION OF THE PATIENT Mucous membrane of the hard palate is yellowish. Tachycardia and the orthostatic changes in blood pressures. Percussion shows that the combined heights of the zones of hepatic dullness and hepatic flatness span a distance of 14 cm along the right midclavicular line. Firm, regular, smooth but tender liver edge palpable below the right costal margin on inspiration. INTERPRETATION

Explain the finding of the abdominal examination. PHYSICAL EXAMINATION OF THE PATIENT Fist percussion applied to the lower ribs above the right costal margin elicits an increase in upper abdominal pain. The gallbladder is not palpable, but Murphy’s sign (interruption of inhaled breath when the patient is palpated underneath the right costal margin) is observed. Light and deep palpation elicit localized tenderness in the RUQ only. INTERPRETATION

Differential Diagnosis

Differential Diagnosis Liver Inflammation (i.e. hepatitis, cirrhosis)‏ Appendicitis Acute Pancreatitis Acute Cholecystitis (i.e. gallstones)‏ Renal Colic

Differential Diagnosis: What’s Most Likely? Appendicitis Acute Pancreatitis Renal Colic Liver Inflammation (i.e. hepatitis, cirrhosis)‏ Acute Cholecystitis (i.e. gallstones)‏

Differential Diagnosis: What’s Most Likely? Appendicitis Acute Pancreatitis Renal Colic Liver Inflammation (i.e. hepatitis, cirrhosis)‏ Acute Cholecystitis (i.e. gallstones)‏

Basic Anatomy Supporting Signs and Symptoms of the Case Blocking bile ducts causes buildup of bilirubin in blood and deposition in skin and sclera Dark urine due to inability of GI excretion leading to excretion of bilirubin in urine Nausea, vomiting due to inability to get bile into intestine and emulsify fats/digest food Pain in the RUQ region due to inflamed gall bladder Shoulder pain due to irritation of the diaphragm

Basic Anatomy Supporting Signs and Symptoms of the Case

What would you expect radiographic evaluation of this patient to reveal?

Summary: Over forty, female, overweight RUQ pain Jaundice, Dark Urine Fever, tachycardia, tachypnea Elimination of differential Positive Murphy’s Sign

References Greenberger, Norton J. and Paumgartner, Gustav. Harrison's Online. Chapter 292. Diseases of the Gallbladder and Bile Ducts Urbano, Frank L, and Carroll, Marybeth. Murphey's Sign of Cholecystitis. Hospital Physician. 2000 Nov; 51-52, 70. http://www.learningradiology.com http://www.med-ed.virginia.edu/courses/rad/edus/index6.html http://0- www.accessmedicine.com.carlson.utoledo.edu/content.aspx?aID=9 2628 http://prod.hopkins- abxguide.org/diagnosis/surgical_infections/cholecystitis.html?cont entInstanceId=255362