History of Present Illness:
A 52-year-old female presents to the ED for 7 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 RUQ tenderness with guarding
Initial Diagnostic Testing:
- EKG: normal
- Labs: CBC normal w/o shift & LFT’s all normal
- Imaging: CXR normal. US shown below
What is the most likely diagnosis?
- A) Aortic dissection
- B) Biliary colic
- C) Cholecystitis
- D) PE
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ANSWERS:
- A) Aortic dissection
- B) Biliary colic
- C) Cholecystitis – CORRECT – The image shows two large shadowing gallstones with no wall thickening, sludge or pericholecystic fluid. However even with normal labs, pain lasting more that 6 hours from gallstones is more likely early cholecystitis than uncomplicated biliary colic -you should do a HIDA (DESIDA)
- D) PE
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