History of RUQ Pain

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DC is a 46-year-old female who presents with a 24-hour history of RUQ pain.  She states the pain started about 1 hour after a large dinner she had with her family.  She has had nausea and on instance of vomiting before presentation.

PMH:Vitals:HTNTemp:  98.8oFType II DMWt:       202 lbsGoutHt:        5’8”DVT – Caused by oral BCPsBP:       136/82HR:       82 bpm

Current Medications:Notable Labs:Lisinopril 10 mg dailyWBC:                13,000/mm3HCTZ 25 mg dailyTotal bilirubin:    0.8 mg/dLAllopurinol 100 mg dailyDirect bilirubin:  0.6 mg/dLMultivitamin dailyAlk Phos:           100 U/LAST:                   45 U/LALT:                   30 U/L

Allergies:

  • Latex
  • Codeine
  • Amoxicillin

PE:

  • Eyes: EOMI
  • HENT: Normal
  • GI:Nondistended, minimal tenderness
  • Skin:Warm and dry
  • Neuro: Alert and Oriented
  • Psych:Appropriate mood

history of RUQ pain

Based on the information provided, DC is a 46-year-old female presenting with a 24-hour history of right upper quadrant (RUQ) pain. The pain started approximately 1 hour after a large dinner with her family. She has also experienced nausea and vomiting.

Here is a summary of DC’s relevant medical history and findings:

Past Medical History (PMH):

  • Type II diabetes mellitus
  • Gout
  • Deep vein thrombosis (DVT) caused by oral birth control pills

Current Medications:

  • Lisinopril 10 mg daily
  • Hydrochlorothiazide (HCTZ) 25 mg daily
  • Allopurinol 100 mg daily
  • Multivitamin daily

Allergies:

  • Latex
  • Codeine
  • Amoxicillin

Vitals:

  • Blood pressure (BP): 136/82 mmHg
  • Heart rate (HR): 82 bpm
  • Temperature: 98.8°F
  • Height: 5’8″
  • Weight: 202 lbs

Notable Labs:

  • White blood cell count (WBC): 13,000/mm3
  • Total bilirubin: 0.8 mg/dL
  • Direct bilirubin: 0.6 mg/dL
  • Alkaline phosphatase (Alk Phos): 100 U/L
  • Aspartate aminotransferase (AST): 45 U/L
  • Alanine aminotransferase (ALT): 30 U/L

Physical Examination (PE):

  • Eyes: Extraocular movements intact (EOMI)
  • Head, ears, nose, throat (HENT): Normal
  • Gastrointestinal (GI): Nondistended abdomen with minimal tenderness
  • Skin: Warm and dry
  • Neurological: Alert and oriented
  • Psychological: Appropriate mood

Based on the history and findings, the patient’s presentation is consistent with an acute episode of cholecystitis, which is inflammation of the gallbladder. The classic symptom of RUQ pain that worsens after a fatty meal, along with associated nausea and vomiting, supports this diagnosis.

Further diagnostic evaluation may include:

  1. Abdominal ultrasound: To assess the gallbladder for signs of inflammation, gallstones, or other abnormalities.
  2. Complete blood count (CBC): To evaluate for signs of infection or inflammation.
  3. Liver function tests: To assess liver enzyme levels and bilirubin levels.
  4. Lipid profile: To evaluate lipid levels, as high cholesterol or triglycerides can contribute to gallstone formation.

Treatment options may include:

  1. NPO (nothing by mouth): To rest the gallbladder and prevent further stimulation of pain.
  2. Intravenous fluids: To maintain hydration and correct electrolyte imbalances if present.
  3. Pain management: Administration of analgesics to relieve pain, typically non-opioid options due to the patient’s allergy to codeine.
  4. Antibiotics: If signs of infection are present or suspected, antibiotics may be prescribed.
  5. Cholecystectomy: Surgical removal of the gallbladder may be indicated if the cholecystitis is recurrent or severe.

It is important for DC to follow up with a healthcare professional for a thorough evaluation, accurate diagnosis, and appropriate management.

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