Triage: Sharp pain in RUQ happened 3 days ago. Since then chills/body aches/indigestion. Unable to sleep.

History of Present Illness: male who presents with right upper quadrant pain on and off for the last few days with which includes an episode 3 days ago lasting hours and then since 2 AM he has had multiple episodes lasting only 5 to 6 minutes. The pain is pleuritic but he is not short of breath and does not have a cough. He has had chills and fever up to 101.9. No exposures at work or with pets or new sexual exposures.

Vital Signs & Physical Exam: T: 36.9 °C (Oral) HR: 88 (Monitored) RR: 16 BP: 117/83 SpO2: 98%

°EYES: Clear without discharge. No photophobia
°ENT: No stridor, drooling, trismus or dysphonia.
°NECK: Trachea midline. Supple
°LUNGS: Unlabored respirations. No splinting. No rales. No wheezing.
°ABDOMEN: Soft, non-tender. No guarding. No rebound

Initial Diagnostic Testing:

  • CBC shows mild pancytopenia and CRP is slightly elevated at 3.3.  These were new
  • Viral swab and urine normal
  • D-dimer elevated at 2.5 so CT done which does not show any pulmonary embolism.
  • LFTs show elevation at 124 and 157 which were new so an ultrasound was done which was negative.

Overall unclear cause of patient’s symptoms. Doubt lupus but it is a possibility which she will need outpatient follow-up.

What is the most likely cause of the RUQ pain?

  • A) Biliary colic
  • B) Hepatitis A virus
  • C) Fatty liver disease
  • D) Mononucleosis
  • E) None of the above

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ANSWER: What is the most likely cause of the RUQ pain?

  • A) Biliary colic
  • B) Hepatitis A virus
  • C) Fatty liver disease
  • D) Mononucleosis – CORRECT.  Can cause fever and LFT elevation though rarely pleuritic RUQ pain.  Best choice but see below for more
  • E) None of the above

1-Minute Consult: Click HERE and scroll to the BOTTOM of page 107.

 

CASE CONCLUSION: Monospot was weakly positive.  HepB and HepC negative.  Referred for EBV IgM and anti-Smooth Ab testing.

 

CASE LESSONS: