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Bloating & Back Pain

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 52-year-old female presents to the ED for 4 hours of bloating and right-sides chest pain that radiates to her midline mid-back and epigastrium.  She denies any SOB, fever, vomiting, diarrhea or other complaints.  She has never had this before.

Vital Signs & Physical Exam:

Vital signs are normal including bilateral BP.   Physical exam is otherwise normal except for

Initial Differential Diagnosis:

  • PE
  • Gallstone
  • GERD
  • Aortic dissection
  • Syphilis, the great imitator

Initial Diagnostic Testing:

  • EKG: normal
  • Labs: CBC normal w/o shift & LFT’s all normal
  • Imaging: CXR normal.  US shown below

QUESTIONS:

  1. What does the case image show?  (click two times to enlarge)
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  The image shows two large shadowing gallstones with no wall thickening, sludge or pericholecystic fluid.
  2. What should you do next?  She has ongoing pain lasting more than 6 hours so you should do a HIDA (DESIDA) scan even though the labs and imaging are all normal except for the stones
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

CLICK HERE TO LEAR MORE ABOUT THIS BOOK

CASE CONCLUSION: DESIDA scan was positive.  Patient went to the OR the next day

CASE LESSONS:

  1. Always consider a patient with gallstones and pain lasting >6 hours to have cholecystitis regardless of normal labs unless you also have a normal DESIDA scan.
  2. Never be mean if you can help it
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