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Your next patient is a 28 year old female who has been triaged by one of the new nurses as” right lower quadrant pain for about nine hours”. Knowing that clothes generally stay on in the triage area, and the belly button usually remains unseen, the first thing you do after you close the curtain and introduce yourself is to have the patient pull up her blouse and point to where she feels the pain. You are not surprised to find that she is actually pointing to her right upper quadrant. She is not all the way up at the costal margin, but definitely is gesturing superior to the level of the umbilicus. It’s not Murphy’s area, but at least it’s a lot closer to Murphy than it is to McBurney and the pelvis. “Hopefully we can save this woman from an ED pelvic exam” you think silently to yourself.

After localizing the area of interest more accurately, you proceed with the rest of your history. She states the pain started about nine hours ago after eating Mexican food from a street cart. She then developed some generalized abdominal pain, two episodes of non-bloody, non-bilious vomiting, and diarrhea. She seems certain that she has food poisoning and wants the cart owner to be held responsible. You are too seasoned to put the wastebasket diagnosis of “gastroenteritis” at the top of your differential and so you say to her, “You may be right, but let’s make sure it isn’t your gallbladder or your appendix before we blame the food.” Probing deeper into what she means by “diarrhea” you discover she had one non-watery, non-bloody, semi-formed stool, not exactly impressive for a toxigenic food-borne illness. She denies any fever, but states that she came to the ED because she is still nauseated and the pain has become gradually worse and worse. She feels it all over her abdomen, but the right-upper quadrant is where it seems to be most severe.
Triage vital signs were all essentially normal, but you do notice her oral temperature was a tad above normal at 99.2°F. Her head and neck exam shows that she has anicteric sclera and a moist oropharynx.

Except for being overweight, the rest of her exam is essentially normal other than some tenderness in the right upper abdomen and possibly some very mild right CVA tenderness. You order a dose of ondansetron, a dose of morphine, IVF’s, and standard blood and urine tests. Her hCG and UA come back normal. Her CBC and CMP are unremarkable.  But her pain is still present and it’s not actually getting better. Based on this, she may be right and have a case of “gastro”, but you are still suspicious for a gallstone. Since it is late and you don’t want to call in the ultrasound tech from home on a patient you think you can safely discharge, you decide to use the ED’s ultrasound machine to look for gallstones. Above is the image you capture.

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What do you see? Is it safe to discharge this woman home with a diagnosis of biliary colic? Conclusion on next page

 

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