Wednesday, March 16, 2011

Intern Report Case Presentation 3.4

Case Presentation by Dr. Kevin Sprague

An otherwise healthy 42 year old female presents to the Emergency Department complaining of 4 hours of constant epigastric pain and vomiting that began 30 minutes after eating lunch.  The pain is sharp, constant, radiates to her shoulder blade, and is 8/10 in severity.  She has been unable to hold any food or liquid since the vomiting began.  She has vomited 3 times  She denies hematemesis.  She is concerned this is food poisoning.  She states she has never had this happen before.  However, she has had some episodes of mild abdominal sharp pain after eating that resolved after roughly an hour.  After she gives you the history, she vomits yellow liquid in a basin before your eyes.

Physical Exam
Vitals: Temp 38.2, BP 128/62, HR 108, RR 20, Sat 99% on RA
General: Uncomfortable, in no acute respiratory distress
Lungs: CTAB
Cardiac: S1S2, RRR, tachycardic rate, normal rhythm
Abdomen: RUQ tenderness, involuntary guarding, rebound tenderness, normal bowel sounds throughout the abdomen
Otherwise normal physical exam

EKG demonstrates a tachycardic sinus rhythm.  Chest X-Ray is negative for any acute process.  WBC is mildly elevated at 13.4.  The rest of the CBC, electrolytes, U/A, AST/ALT, alk phos, lipase, bilirubin are within normal limits.

You obtain an ultrasound which demonstrates the following.


1.  What is the most sensitive test for cholecystitis?
  1. X-Ray
  2. Ultrasound
  3. CT
  4. HIDA scan
  5. MRI
2.  Which infectious agent causes the majority of cholecystitis in the United States?
  1. E. Coli
  2. Klebsiella
  3. Enterococcus
  4. Bacteriodes
  5. No infectious etiology
3.  Porcelain Gallbladder is associated with which of the following?
  1. Primary hyperparathyroidism
  2. Carcinoma
  3. Ascending cholangitis
  4. Paget’s disease
  5. Hypercholesterolemia
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