NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Figure 7-1: Ultrasound study shows a sonolucent density ( arrow ) in the gallbladder.

than 3 cm, which are associated with the development of gallbladder carcinoma. Experts once believed that it was necessary to remove gallstones in asymptomatic diabetic persons because of high complication rates; however, this practice is no longer performed. Studies have found that the natural history of asymptomatic gallstones is benign. Case 7.2 Right Upper Quadrant Pain A 24-year-old woman presents to the emergency department with a 12-hour history of pain in the upper right abdomen, nausea, vomiting, and anorexia. Physical exam- ination shows guarding and tenderness in the RUQ. Q: What are the most likely diagnoses? A: The most likely diagnoses are symptomatic cholelithiasis, biliary colic, or acute chole- cystitis . Without fever, acute cholecystitis is unlikely. In a young patient, the differential diagnosis of RUQ pain includes gastroenteritis, peptic ulcer disease (PUD), acute hepatitis, renal colic, pleural-based pneumonia, and pyelonephritis. Q: What specific items in the history or physical examination would you look for to support these diagnoses? A: The factors that predispose to gallstone formation include increasing age, family history of gallstones, female sex, obesity, history of recent pregnancy, and previous diagnosis of gallstones. Symptoms of gallstone disease include fever, pain or guarding in the RUQ, and biliary colic. Examination of the abdomen may elicit Murphy sign , which is inspiratory arrest during deep palpation of the RUQ due to pain. Q: What historical information and physical examination findings would lead you to suspect that another diagnosis is more likely? A: A history of indigestion, long-term nonsteroidal antiinflammatory drug (NSAID) use, ant- acid use, tarry stools, and ethanol abuse should prompt consideration of PUD or gastritis . The patient has no suspicious history or physical examination findings that suggest a diagnosis other than gallstone disease. SAMPLE