1. Case 3
Andrew Sitzmann
Danielle Paulozzi
Andrew Emerson
Miguel Linares

2. 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.

3. 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:
Rhythm: Regular
Temperature: º F.
Respiratory rate: 22
Height: 5’8”
Weight: lbs.

4. 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:
Rhythm: Regular
Temperature: º F
Respiratory rate: 22
Height: 5’8”
Weight: lbs.

5. 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

6. 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.

9. What are your thoughts?

10. 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

12. 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

13. Differential Diagnosis

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

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

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

17. 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

18. Basic Anatomy Supporting Signs and Symptoms of the Case

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

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

24. 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 Nov; 51-52, 70.
abxguide.org/diagnosis/surgical_infections/cholecystitis.html?cont entInstanceId=255362