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EM Clinical Case Presentation Arpan Patel. Triage 25 yo Male with abdominal pain Afebrile, VSS - nausea + vomiting and diarrhea.

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Presentation on theme: "EM Clinical Case Presentation Arpan Patel. Triage 25 yo Male with abdominal pain Afebrile, VSS - nausea + vomiting and diarrhea."— Presentation transcript:

1 EM Clinical Case Presentation Arpan Patel

2 Triage 25 yo Male with abdominal pain Afebrile, VSS - nausea + vomiting and diarrhea

3

4 History 11 hours ago, sudden onset of sharp stabbing pain in the epigastric area (pt points there) Pain is non-radiating, not associated with meals or certain foods, and is not relieved by antacids. (He has been on Omeprazole for past 3 months) Explains he has had similar episodes for the past 4 years, last was 2 weeks ago, pain abates when he takes 12 Tylenols at once. Now denies nausea, vomiting, and diarrhea

5 More History Denies chest pain, SOB, UTI sx, GERD sx, constipation, blood in stool, cough, and fever. PMH: none PSH: none Meds: Omeprazole since 3/2012 Allergies: NKDA SH: Occasional smokes cigs, EtOH socially

6 Physical BP 143/74, P 64, R 17, T 97.0F, O2 Sat: 100% on RA General: Pt lying in bed, appears uncomfortable CV: RRR, S1S2, no mrg Resp: CTAB Abd: soft, non-distended, tender in epigastrium and RUQ, no guarding/rebound, +bs in all quadrants Back: No CVA tenderness

7 Differential Diagnosis RUQ: - Cholelithiasis - Biliary Colic - Acute Cholecystitis - Cholangitis - Acute Hepatitis - Perf. Duodenal Ulcer - RLL Pneumonia Epigastric: - Peptic Ulcer Disease - Pancreatitis - GERD - Myocardial Infarction Atypical Px’s of: - Appendicitis - R sided Kidney disease: Pyelonephritis or Nephrolithiasis

8 Let’s get some Labs BMP: 139/ / /0.9 Glu 102 CBC: 13.4 > 14.3/45.5 < 292 UA completely negative Coags, LFTs, Lipase and Amylase all wnl

9 For you EM US Fellowship Chasers: Bedside US: Unable to visualize gallbladder, pt had not eaten in over 12 hours, but tells us he had an US done 4 years ago and was told he had many stones Official US: Gallbladder completely filled with calculi limiting evaluation of GB wall thickness Minimal pericholecystic fluid, no intra/extra hepatic bile duct dilation, CBD is 0.3 cm Positive sonographic Murphy’s sign R Kidney is 10.8 cm & nl, no hepatomegaly, some steatosis Likely cholelithiasis vs Acute chole, can confirm with HIDA

10 Final Diagnosis Acute Cholecystitis Started on Cefoxitin, Morphine for pain, and admitted to surgery. GB was removed 2 days later Why treat/remove? Even though AC may resolve in 7-10 days on its own, it has a high rate of progressing to gangrenous chole and perforating which increases morbidity and mortality

11 Diagnostic Criteria for Acute Chole Based on physical exam, labs, and imaging Physical: RUQ pain, Murphy’s sign, fever, tachy Labs: Leukocytosis (left shift), shouldn’t have elevated bili or Alk Phos in simple Acute Chole Imaging: On US - GB wall thickening (>4-5 mm), pericholecystic fluid, sono Murphy’s sign. On HIDA - the GB will not be visualized due to obstruction of the cystic duct by a stone or edema

12 What about the AC triad of RUQ pain, fever, and leukocytosis? He was afebrile! Retrospective review of pts with AC dx’d with HIDA: fever defined as oral T>100 and rectal T>104, and leukocytosis as 11k or more Of these cases 52% were nongangrenous AC, 26% gangrenous AC, and 22% chronic chole In those with non-gangrenous AC, 71% were afebrile, 32% lacked leukocytosis, 28% lacked both In those with gangrenous AC, 59% afebrile, 27% no leukocytosis, 16% lacked both. Take home point: Do not rely on the presence of fever and leukocytosis to make a diagnosis of AC! Gruber PJ, Silverman RA, Gottesfeld S, Flaster E. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med Sep;28(3):273-7


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