Triage: Sharp pain in RUQ starting 3 days ago. Since then nausea, chills and body aches. Unable to sleep.
History of Present Illness: A man in his early 20’s presents with right upper quadrant pain on and off for the last few days lasting minutes to hours. 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: T: 36.9 °C, HR: 88, RR: 16, BP: 117/83, SpO2: 98%
Physical Exam
- HEENT: Eyes clear without discharge. No photophobia. Oropharynx without swelling or exudate. Palpable posterior cervical nodes.
- LUNGS: Unlabored respirations. No splinting. No rales. No wheezing.
- ABDOMEN: Soft, RUQ slightly tender. No guarding. No rebound
Initial Diagnostic Testing:
- CBC shows mild pancytopenia and CRP is slightly elevated at 3.3.
- Viral URI swab and urine normal
- D-dimer elevated at 2.5 so CT done which does not show any pulmonary embolism.
- AST 124, ALT 157 which were new so an ultrasound was done which was negative.
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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THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA
- Emergency Medicine 1-Minute Consult, 5th edition
- A-to-Z EM Pharmacopoeia & Antibiotic Guide, 5th edition
- 8-in-1 Emergency Department Quick Reference, 5th edition
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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 RUQ pain. He is a typical age for this
- 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 were negative. EBV IgM was positive
CASE LESSONS: Mono often starts with GI symptoms rather than throat symptoms. ALT often mild to moderately elevated