Woman With an Acute Onset of Nausea and Vomiting
Background
A 46-year-old woman presents to the emergency department (ED) with a history of worsening, constant right upper quadrant pain that radiates to her back and side. She has had nausea and has vomited twice in the past several hours. She underwent a laparoscopic cholecystectomy 2 weeks ago, without complications, and returned to her normal diet. She has not had any bowel movements or flatulence since the pain began. She denies having any fever, chills, or rigors. Her medical history is significant only for high blood pressure, high cholesterol levels, and gallbladder disease. She takes lisinopril, aspirin, multivitamins, and ginseng. She denies smoking or drinking alcohol.
On physical examination, the patient is awake, alert, and oriented. Her vital signs are within the normal range, with a heart rate of 84 bpm and a blood pressure of 124/76 mm Hg. She appears to be in mild distress. The cardiorespiratory examination yields normal findings, with clear lungs and a regular heart rhythm. Her abdomen is soft, but her bowel sounds are decreased, and she has marked tenderness in the right upper quadrant. The rest of her abdomen is minimally tender, with no evidence of guarding or rebound and no palpable masses. The other physical findings are normal.
The laboratory investigation reveals an elevated WBC count of 14.0 × 109/L (14.0 × 103/µL), with a left shift of 87% neutrophils. Her liver function tests, lipase level, and basic chemistry panel are unremarkable.
Contrast-enhanced computed tomography (CT) scans of the abdomen and pelvis are ordered. Figure 1A shows an anteroposterior (AP) scout image, and Figure 1B shows a selected axial section.
