Patient presentation: E.C. is a 58 year old female who has a history of hypertension, type 2 diabetes, and obesity. She presents to the emergency department at 6 AM with nausea and severe abdominal pain to the right upper quadrant. She reports the pain is an 8/10 and radiates to her right shoulder and back. The pain is constant and she states that it started about an hour after she ate dinner at Popeye’s last night. She states she has had pains like this before, but that they usually eventually go away and have never been so severe and lasted so long.
E.C.’s vital signs are as follows: T 38.3, BP 160/80, HR 108, RR 22, 98% on RA. Upon examination her lungs are clear bilaterally, heart sounds normal, abdomen is soft but mildly distended and very tender upon palpation. Positive bowel sounds x4 quadrants. Neuro exam is WNL.
Differential list: Acute cholecystitis, biliary colic, pancreatitis, appendicitis, peptic ulcer disease, acute hepatitis.
Diagnosis/prognosis: CBC, BMP, amylase, lipase, and LFTs are sent. All come back WNL except the WBC which is 18. An abdominal ultrasound is completed which shows a grossly inflamed gallbladder wall and also reveals several stones in the gallbladder. The diagnosis of acute cholecystitis is made.
Treatment: E.C. is made NPO, 1/2NS is started at 100ml/hr, and E.C. is started on IV Ciprofloxacin and IV Flagyl. She has IV morphine available for pain control.
Outcome: After a few days the WBC starts trending down and the abdominal pain lessens. E.C. is discharged home with instructions to avoid fatty foods and finish her course of the Cipro and Flagyl PO. After a few weeks, once the gallbladder inflammation had subsided, E.C. came back for a cholecystectomy. The procedure was uncomplicated and E.C. was discharged home with instruction for continuation of the low fat diet.