Acute Cholecystitis: Correct

Good job, this is the most likely diagnosis. Given the history of a constant RUQ pain, mild nausea and vomiting, and a moderate fever, one should begin to focus on cholecystitis. The physical exam was notable for a temperature of 100.5 and a relatively localized RUQ tenderness with a positive Murphy's sign. To confirm this diagnosis, a RUQ ultrasound is usually the first radiographic study ordered. This study demonstrated stones in the gallbladder and a relatively normal size common bile duct. It is important to note that just the finding of stones on ultrasound is not enough to make the diagnosis of acute cholecystitis. In fact, most patients who have gallstones are asymptomatic or have short episodes of biliary colic. Acute Cholecystitis is differentiated from biliary colic by severity. In the history part, the patient revealed that she had one similar but milder episode of RUQ pain in the past, which resolved in a short time. (Likely an episode of biliary colic) Aside from the radiographic studies, the laboratory results also support the diagnosis of acute cholecystitis. A moderate leukocytosis (12 ­ 15k WBC) is commonly found. One would also expect relatively normal LFTs with possibly slightly elevated Bilirubin. A more significantly elevated level of Bilirubin ( +4 mg/dl) as well as elevated liver enzymes (SGOT and SGPT) would indicate an obstruction in the hepatic duct or common bile duct.

Although acute cholecystitis is the most likely diagnosis, one must consider the relatively broad differential diagnosis including a myocardial infarction, acute appendicitis, or acute gonoccocal perihepatitis. These are discussed elsewhere in the tutorial.

Congratulations on completing the Diagnosis section. You may now choose to go back and review other parts of the differential diagnosis or you may go on to the Treatment section.