Oct 22, 2012

The Gallbladder

I got paged last night down to the emergency room for a patient with abdominal pain.  The ER physician was fairly sure this was gynecologic in origin, and wanted to me to come evaluate.  This is a common occurence, and one of the jobs of the second year resident.  I pull myself out of bed and head down.

The history is unrevealing.  No pelvic issues in past.  Pain aggravated by eating, particularly fatty and spicy foods.  Hmmm.

The pelvic exam is unremarkable.  But I touch her gently in her right upper quadrant of her abdomen, and she just about jumps off the bed.  She can't take a deep breath in when I push there, because the pain is so bed.

I've only seen a positive Murphy's sign once or twice in medical school.  But, I've read about it, and after seeing this lady, I really know what it looks like.  Textbook case.

I presented the case back to the ER doctor with all my findings, saying I didn't think this pain was gynecologic in origin, but had he considered the gallbladder?  Maybe an abdominal ultrasound was in order?
He stares at me.  "Wow.  I never thought about that.  I was so sure it was gynecologic that I didn't consider anything else."

Come ON.  I know I'm a gynecologist, and my expertise ends well below the belly button, but this seemed so clear.  Did he really have to drag me down for this?  There are like five things in the belly that people commonly present for, and the gallbladder is fighting for the top of the list with the appendix. 

The imaging came back a few hours later, showing cholecystitis (an infection of the gallbladder) along with gallstones.  Annoying, yes.  But I was secretly quite pleased that I could diagnose a cholecystitis on my own, just based on clinical presentation.  I guess that's why they send you to medical school.  Most of what I learned I will never use, but you never know when that textbook case will find you, even out of your specialty. 

No comments:

Post a Comment