A 47-Year-Old Woman With Acute Abdominal Pain

Introduction: A previously healthy 47-year-old woman presents to an urgent care facility with chief complaint of acute abdominal pain.

Patient history: The patient noted that the pain (subchondral on the right side with a component of radiation to the back) is severe and awakened her overnight. There is a baseline steady component to the pain with occasional colicky exacerbations. She has also experienced several episodes of nausea and emesis. When questioned, she noted that she’s had several similar episodes in recent weeks, although those instances were of much less intensity and with spontaneous resolution within several hours. The current episode is much more severe in intensity and unremitting overnight. There is no history of concomitant symptoms of diarrhea, melena, or hematemesis. No one else in the household has any known illnesses.

The patient’s past medical history is unremarkable. She delivered three children vaginally without complications. She works in a clerical position and enjoys a glass of wine with meals several times a week. She continues to have normal and regular menses.

Physical examination. Her physical examination included a temperature of 100.6°F, pulse of 108/min, and blood pressure of 124/80. She is visibly uncomfortable from significant abdominal pain and wants to lie down on her right side in a semi-flexed position. Head, eyes, ears, nose, and throat examination is negative for jaundice. Heart and lung examinations are normal. Focusing on the abdomen, bowel sounds are diminished and there is marked tenderness to pressure palpation of the epigastrium, particularly in the right upper quadrant. There is some radiation into the back. Murphy's sign (increased tenderness into the right upper quadrant when taking a deep inspiration) is present.

Diagnostic testing. The patient’s laboratory tests reveal hemoglobin and platelets within normal ranges, but a white blood cell count of 15,900 with a left shift. Her metabolic tests were within normal ranges, but her biochemical profile reveals slight elevations of aspartate transferase, alanine transaminase, and serum amylase levels. Both serum creatinine and creatinine clearance are normal within normal ranges.