A 45 year old female comes into the Emergency Department complaining of a 2 day history of worsening abdominal pain. She localizes the pain to the right upper quadrant and notes that it is worse with meals and currently is 10/10. Vitals at the time are notable for a blood pressure of 95/48, temperature of 39.9C, heart rate of 113, respiratory rate of 28 while maintaining a saturation of 99%.
Her physical exam is notable for exquisite tenderness of her abdomen diffusely but worse at the RUQ, without evidence of rebound. Scleral icterus is also present. She is alert and oriented x 4 and mental status is clear
What is your next step in management?
a) Bolus with 0.9% saline and start ciprofloxacin
b) Emergent cholecystectomy
c) Emergent endoscopic procedure
d) Bolus with 0.9% saline only
e) MS contin 25mg Q 5 minutes
>>27638645
I would say that you should picke
f) Inject her with a lethal dose of morphine
>>27638645
Meant to be MS IR 25Q5, obviously contin doesnt come in 25's
>>27638723
that's e you dingus
>>27638645
>>27638645
I had to look up a bunch of medical jargon, translate this post into Russian, print it out in a word document, and wake up my grandfather, who is a world-renowned abdominal field surgeon, at 4 am in the morning to answer this question.
He said it was cholecystitis and chose c.
Next step after c) is a), after which surgical intervention is needed, but not necessarily a cholecystectomy.
>>27639320
Oh wait, he just came in added that until an endoscopy is conducted, other conditions such as appendicitis cannot be ruled out completely.
>>27638645
Just tell her she has a stomach ache and send her home. We gotta cut costs.
>>27639320
Shut up Ivan
Are you a corpsman or some kind of military medical personnel OP?
The correct answer is e.
>>27639320
I can only hope that this is true
>>27638645
f) give them a lethal dose of morphine
I am a board-certified nephrologist. It is suffice to say that this patient suffers from acute cholecystitis. I would perform an ultrasound on the right upper quadrant.
>>27639346
Appendicitis with acute onset jaundice and lack of rebound tenderness at 48 hours? Incredibly far fetched and I'd rule it out completely, endoscopy is too time wasting for a patient presenting with tachyardia/tachypnea/hypotension. I'd get them into OR immediately for a cholecystectomy.
The amount of knowledge needed to make such an elaborate variant on this shitty forced meme is quite impressive. Made me have quite a giggle.
Keep it up, OP.
>exquisite tenderness of her abdomen
I caress her tum-tum
>>27639671
>>27639320
>>27639676
>Acute cholecystitis
>not noticing charcots triad
Ascending cholangitis should be treated with abx and fluids, endoscopic procedure should then be attempted after the patient is stable. Cholecystectomy is not always necessary, especially not emergently
However before any of that is to happen, the patient must receive a large dose of IV morphine
>>27639671
This was my grandfather's original choice desu.
>>27639676
I asked him and he said:
hypotension isn't really an issue here and that 95 isn't really a critical level. She could just naturally be hypotonic, and some hypotonics walk around with sub 95 without issue. Plus the blood pressure could easily be restored after an IV system is set up.
Tachycardia and Tachypnea are just a result of high temperature.
The jaundice could be "toxic" and not "mechanical" (not sure whether I'm translating this correctly, and thus unrelated to the pain. Pain could be caused by appendecitis, cholecystitis OR chole-pancreatitis and a differential diagnosis between those should be done before surgical action is undertaken, since, in his opinion, her condition is not critical enough for emergency operation.
>>27639994
Your grandfather is fucking retarded, obviously the answer is e
>>27639676
I asked him about the Blumberg response too and he said it didn't really change the overall picture or the response.
>>27640035
I don't get the morphine meme.
>>27638645
Take her to the nearest and power bomb her off it.
