Know Your Limits: Ultrasound may help clarify findings elicited by a thorough history and physical exam.Pearls and Pitfalls: Gallbladder & RUQ Ultrasound Fortunately, she did well and followed up in the post-operative surgical clinic rather than in the septic-shock or ascending cholangitis clinic. The patient received IV ampicillin/sulbactam and was taken emergently to the operating room. Note the pericholecystic fluid but also the fluid collection medial to the posterior liver and lateral to the right kidney, as well as free air anterior and medial to the gallbladder. The second image above focuses on this area and shows a non-descript area with shadowing that is probably free air, consistent with a perforated gallbladder from cholecystitis.Ī confirmatory CT scan (shown below) was requested by the surgical consult. This could be due to an air collection from gallbladder rupture (see labeled ultrasound below). To the right side of the image, near the gallbladder fundus, there is also shadowing but no evidence of stones. The first shows a large gallstone with posterior shadowing that is possibly impacted in the gallbladder neck. The images show two transabdominal views of the gallbladder. It is important to be aware that no single lab value is better than 50% sensitive for cholecystitis, and not infrequently all the labs will be normal. A normal white count is usually reassuring, but in the setting of possible infection the differential includes severe sepsis. Always wait for the results of the differential if one was ordered. The labs are reassuring, but did you notice that the differential was not reported? This patient actually had 22 bands. D-dimer in Pregnancy: Ready for Prime Time?.She is described to you as obese with right-upper-quadrant tenderness and a positive Murphy’s sign, but not other positive findings. Pulse is 97, blood pressure is 93/61, respirations are 22, and temperature is 98.9. She denies any other complaints.įor her physical exam, your resident notes “stable” vital signs although the vitals have only been taken once. She took ibuprofen about an hour ago for the pain, noting that it hasn’t really helped. She states that she vomited once and has chills but doesn’t think she has had a fever. It has been present for over 10 hours and is getting no better. Today it recurred, but is more severe, 9 out of 10, and radiates to the right upper quadrant. The patient states that three days ago she had an episode of epigastric pain that came on suddenly, was bad for about an hour, and then gradually resolved over about three hours. The patient is a 49-year-old female who presents to the ED for abdominal pain. ![]() I t’s another hectic day in paradise when your resident asks if she can present a case to you. Ultrasound and subtle lab findings may convince you to admit that patient with RUQ pain.
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