21: RUQ Pain

Thirty minutes into your shift you take pass-ons from your colleague. The one case with loose ends is a 26-year-old woman who presented with 5 days of worsening right upper quandrant pain. The pain is pleuritic and non-radiating without fever, vomiting, shortness of breath, cough or urinary symptoms. Her past medical history and systems review is unremarkable. On exam she is very tender in the right upper quadrant, but otherwise normal, including a pelvic exam with no discharge or cervical motion tenderness. All labs including UA, LFT’s, lipase, beta-HCG, CBC and wet mount are normal except for a very elevated D-dimer. A CXR and CT of the abdomen have already been done and are negative. Your colleague leaves you with a request to “check a V/Q scan” and send her home if it’s normal – which it is.

What test needs to be done to confirm the correct diagnosis?

HINT: This is a classic case of a rare presentation for a common disease with significant morbidity. You’ve probably heard of this condition, and even seen it, though maybe not diagnosed it.

Scroll down for answer

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ANSWER: You need to screen for gonorrhea and chlamydia. The correct diagnosis is Fitz-Hugh Curtis Syndrome.

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FITZ-HUGH CURTIS from “QUICK ESSENTIALS: EMERGENCY MEDICINE“

General: 5% of PID, perihepatitis usually without cervicitis. Consider in all at-risk women.

Sx: Pleuritic RUQ pain (usually pleuritic) >> (pelvic pain).

Exam: Tender RUQ. Pelvic exam usually unremarkable, but Chlamydia > GC come back positive.

Dx: LFTs & US WNL. Chlamydia > gonorrhea (see ID section: PCR on cervix, not urine, best)

Rx/Dispo: Cefoxitin + Zithromax or alternate. Consult GYN. Admit.

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