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:
- What does the case image show? (click two times to enlarge)
- What should you do next?
- Want a 1-minute consult/tutorial on this case?
- Want to know what happened with this patient?
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ANSWERS:
- What does the case image show? The image shows two large shadowing gallstones with no wall thickening, sludge or pericholecystic fluid.
- 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
- Want a 1-minute consult/tutorial on this case? See yellow area from sample page below.
- 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
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CASE CONCLUSION: DESIDA scan was positive. Patient went to the OR the next day
CASE LESSONS:
- 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.
- Never be mean if you can help it