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Abdominal assessment
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You have a 48 year old woman present to your office with complaints of abdominal pain after meals. She also complains of some distension and seems to link it to fatty foods. She has a history of HTN well managed with a low dose beta blocker. Her history if otherwise unremarkable except for C-sections x3.
Vitals:
Temp 98.8
HR: 56
BP 128/86
RR: 16
Pain: 0
BMI: 38
Exam: She is calm and appropriate, non-toxic appearing.
Her abdominal exam is obese/soft/mildly tender. She has mild guarding in the right upper quadrant and her inspiration halts with deep palpation in this area. She has no rebound tenderness. The remainder of her examination is unremarkable.
What is your diagnosis? What would be your next step in terms of intervention?
What is the difference between biliary colic/gall stones/cholangitis? How do their treatments differ?
You recommend a change in diet and she states that her abdominal pain and distention have improved after meals. She is also working on losing weight. She appreciates the advice you have given her until… a few months later she develops severe acute abdominal pain.
You see her in the emergency room and she has severe diffuse abdominal pain which radiates into her back and is associated with nausea/vomiting. She is afebrile but appears ill. Her exam is now remarkable for abdominal distention, guarding, and rebound tenderness diffusely.
What is your concern now in terms of diagnosis? What initial testing would you order and what would be your treatment? Do any scoring/prognostic systems exist to determine morbidity/mortality from this diagnosis?
Finally, is it a good idea to take her gall bladder out acutely?

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