1. Case studies
December 2007
C.M.R.I.

2. BACKGROUND
A 46-year-old woman presents to the emergency department with a history of worsening, constant right upper quadrant pain that radiates to her back and side. She has had nausea and vomited twice the past several hours. She has not had any bowel movements or the passage of flatus since the pain began. She denies having fever, chills, or rigors.
Her medical history is significant only for high blood pressure, high cholesterol levels, and gallbladder disease. She underwent laparoscopic cholecystectomy 2 weeks ago, without complications, and returned to her normal diet.
She takes lisinopril, aspirin, multivitamins, and ginseng. She denies smoking or drinking alcohol.

3. BACKGROUND
On physical examination, the patient is awake, alert, and oriented. Her vital signs are in the normal range, with a heart rate of 84 beats per minute and a blood pressure of 124/76 mm Hg. She appears to be in mild distress.
Cardio-respiratory examination yields normal findings, with clear lungs and a regular heart rhythm.
Her abdomen is soft, but her bowel sounds are decreased, and she has marked tenderness in the right upper quadrant. The rest of her abdomen is minimally tender, with no evidence of guarding or rebound and no palpable masses. Other physical findings are normal.

4. BACKGROUND
Laboratory investigation reveals an elevated WBC count of 14.0 X 109/L (14.0 X 103/µL) with a left shift of 87% neutrophils. Her liver function tests, lipase level, and basic chemistry panel are unremarkable.
Contrast-enhanced CT of the abdomen and pelvis is ordered. Images 1 and 2 show an anteroposterior (AP) scout image and a selected axial section, respectively.

5. IMAGE 1

6. IMAGE 2