This is the case of Mrs. A, a 46 years old Maori female who presented at midnight to ED complaining of RUQ pain with some nausea. On arrival, Mrs. A was restless with severe 10/10 RUQ pain. She had taken Paracetamol an hour prior to presentation with nil effect. She has history of cholelithiasis which was diagnosed in January 2013 based on abdominal USS, presented to ED three weeks ago with the same complaint however was discharged with pain relief. She has been experiencing monthly episodes of RUQ pain since diagnosis in January and reoccurring weekly since April. Denies urinary problems, denies chest pain, no change in appetite, denies rectal bleeding and with regular bowel motions. Has medical history of UTI and uterine fibroids which she underwent subtotal laparoscopic abdominal hysterectomy. Nil known allergies, current smoker, smoking cessation declined. Used to drink alcohol but stopped since diagnosed with gallstones.
On physical exam, alert, cooperative, uncomfortable due to pain, restless, standing and leaning at the side of the bed with right hand holding the abdomen, tried sitting and lying on the bed to make self comfortable. Vital signs stable as follows: BP: 119/76, T: 36.4C, PR: 77 regular, RR: 20, SpO₂: 100%, BSL 5.6 mmol. Skin warm to touch, intact and no reddened areas. Tar staining at right index and middle fingers noted. Well kept nails, capillary refill of 1-2 seconds, no clubbing noted, no palmar erythema seen. No flapping tremor elicited. No central cyanosis noted, nil fatty deposits on eyebrows’ seen, pink conjunctiva. No neck stiffness or pain. No palpable masses on neck, nil lymph node swelling or tenderness on palpation. Trachea is at midline. Abdominal exam showed even skin tone, no discoloration, no visible veins seen. Old scars noted, a 5mm scar below umbilicus, 3mm scars at LLQ and RLQ of abdomen which are smooth and lighter in color. Abdomen evenly rounded. No visible pulsation seen. Bowel sounds present in all quadrants upon auscultation. No bruits heard over abdominal aorta, iliac and renal area, no friction rub heard over liver and spleen. Tympany on percussion over all quadrants, no evidence of fluid distention on peritoneum, normal dullness on percussion of liver and spleen obtained. Abdomen soft on palpation, mild tenderness at RUQ, no guarding noted, no rebound tenderness, negative Murphy’s sign elicited. No presence on peritonitis elicited. No abdominal hernias felt. No edema on both legs, no bruises seen, pedal pulses present.
Treatment plan commenced with blood chemistry, pain relief, anti-emetics and urinalysis. Urine dipstick showed leucocytes +3, nitrates (+)ve, blood +2, negative pregnancy test, sent for MC&S. Pain relieved with IV opiates. Blood results were all within normal limits.
Based on this exam, differential diagnosis that may cause RUQ pain includes biliary colic, acute cholecystitis, peptic ulceration, gall bladder dysfunction, metastasis/cancer abscess, hepatitis, liver tumor, other causes of acute liver swelling, appendicitis, acute pancreatitis, irritable bowel syndrome (Martin & Talley, 2006, p. 76). On the basis of patient’s history and physical exam, it is therefore concluded that probable diagnosis would be biliary colic. Signs and symptoms at hand suggestive of this includes severe pain, reaching a peak in the first minutes after onset and continuing for hours or until an…