Case-Based Learning, June 2024
81-year-old female presented to the emergency department with complaints of generalized body aches and increasing illness over the past week. She reported fever, nausea, vomiting, and anorexia at home for the previous 8 days. She stated that because of the decreased appetite and nausea with vomiting, she has lost 15 pounds in the past week and a half. She also noted that she has a history of gallstones. On initial examination, she is afebrile. She does not meet SIRS criteria. Blood pressure is 116/73. She had tenderness in the right upper quadrant with palpation. She was administered hydromorphone 0.5 mg IV per pain protocol and morphine 4 mg IV per pain protocol. Workup included CBC, CMP, lactic acid, CRP, sed rate, urinalysis, and nasopharyngeal PCR 4 plex swab. She had both a limited right upper quadrant ultrasound and a CT angiography of the chest, abdomen, and pelvis during her evaluation in the emergency department. White blood cell count was 16.7 with left shift. ESR 94. Sodium 131. Alkaline phosphatase 317. AST 92. A LT 415. Lactic acid 1.3. CRP 36.8. 4 plex swab is negative for COVID-19, influenza, and RSV. Urinalysis with small bilirubin, otherwise normal. Ultrasound demonstrated gallbladder distention with gallbladder wall thickening and cholelithiasis. There also appeared to be an oval shaped structure in the gallbladder lumen that probably represented tumefactive sludge. The overall appearance was concerning for cholecystitis although it is reported that a sonographic Murphy sign was absent per TeleRadia report. CT chest, abdomen, and pelvis demonstrated central lobular emphysema. Cholelithiasis was noted and the gallbladder wall thickness was measured as much as 9 mm. Findings were reported consistent with cholecystitis per TeleRadia report. General surgery was consulted. At the time of the general surgeon’s examination, patient had received IV pain medication and was feeling better…