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Mr. Johnson is a 42-year-old engineer complaining of constant severe right upper quadrant (RUQ) abdominal pain that began gradually about 36 hours ago. He reports subjective fevers and chills, is currently experiencing moderate nausea, and had 1 episode of nonbilious nonbloody emesis. He denies jaundice, reports normal urine and stool color, and incidentally notes a 10-lb weight loss in the last 6 months due to voluntary changes in his diet. He does describe at least 6 previous episodes of postprandial epigastric pain that always resolved within 2 to 4 hours. He notes that the previous pain was different from the current pain in that it is now “more on the right.”

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On physical exam, his vitals are T: 102.3, HR: 110, BP: 150/90, R: 16, and O2: 99% on RA. Abdominal exam reveals mild tenderness in the epigastrium, moderate tenderness in the RUQ, and a positive Murphy sign. Abdomen is otherwise soft and nontender. The remainder of exam is normal. You suspect cholecystitis.

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1. List several diseases that cause RUQ pain.

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2. Which of those diseases commonly cause RUQ tenderness?

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3. What distinguishes a positive Murphy sign from simple RUQ tenderness?

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4. In the case above, can you pick out the 3 clinical features that most strongly support the diagnosis of acute cholecystitis?

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5. If this patient has an elevated serum bilirubin, what do you need to look for?

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6. Assume that his lab values were consistent with acute cholecystitis. If an ultrasound was equivocal, what would you do next?

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RUQ Pain

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Answers
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  1. All RUQ pain is not cholecystitis—although it will sometimes seem like it. While other causes are less common, the differential for RUQ pain is still moderately broad. To generate the differential, one approach is to think anatomically:

    • Stomach/duodenum: peptic ulcer disease
    • Biliary collecting system: biliary obstruction (eg, from a stone or a pancreatic mass)
    • Pancreas: pancreatitis
    • Liver: hepatitis
    • Gallbladder: plain ol’ biliary colic, acute cholecystitis

    Biliary colic can sometimes be confusing because, like acute cholecystitis, it is also caused by gallstones. Biliary colic, however, is not an inflammatory process—hence the reason that it does not have an “-itis” in the name. Instead, it is caused by a gallstone transiently obstructing outflow from the gallbladder. This is perceived as visceral pain that refers to the epigastrium. If, on the other hand, the stone gets stuck and the obstruction therefore persists, the resulting stasis and increased pressure eventually lead to cholecystitis and associated somatic pain in the RUQ.

  2. Focal abdominal tenderness is usually caused by an inflammatory process that will involve the peritoneum. When that peritoneum is irritated by your palpation, the patient feels somatic pain, that is, pain localized to ...

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