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Difficulty: MediumDiagnostic Workup and Test Sequencing

Following a heavy dinner, a 41-year-old female is brought to the emergency department by her partner due to sudden, unremitting right upper abdominal pain radiating to the right scapula. She reports intense nausea and has vomited twice over the past few hours. She is a non-smoker with a BMI of 34 kg/m² and a history of hypertriglyceridemia. Upon triage, her temperature is 38.5°C (101.3°F), pulse is 112/min, blood pressure is 135/85 mm Hg, and respiratory rate is 18/min. Abdominal examination demonstrates focal tenderness below the right costal margin, which sharply worsens on deep inspiration, causing her to abruptly halt her breath. There are no signs of clinical jaundice. To properly evaluate this patient's acute presentation, which of the following are the most appropriate initial diagnostic tests to order? (Select exactly 3 options)

  1. Right upper quadrant abdominal ultrasoundAnswer
  2. Complete blood countAnswer
  3. Hepatic function panelAnswer
  4. D
    Computed tomography of the abdomen and pelvis with intravenous contrast
  5. E
    Endoscopic retrograde cholangiopancreatography
  6. F
    Hepatobiliary iminodiacetic acid (HIDA) scan

Answer

The correct initial diagnostic tests are a right upper quadrant abdominal ultrasound, a complete blood count, and a hepatic function panel.
This patient's presentation of postprandial right upper quadrant pain, fever, and a positive Murphy sign is classic for acute cholecystitis. The most appropriate initial diagnostic workup consists of a right upper quadrant abdominal ultrasound, a complete blood count (CBC), and a hepatic function panel. Ultrasound is the imaging modality of choice due to its high sensitivity and specificity for identifying gallstones, gallbladder wall thickening, and pericholecystic fluid, without exposing the patient to ionizing radiation. A CBC is required to evaluate for leukocytosis, which supports an infectious or inflammatory process. A hepatic function panel (including transaminases, bilirubin, and alkaline phosphatase) is essential to evaluate for potential biliary obstruction (choledocholithiasis) or ascending cholangitis, which would significantly alter subsequent management.

Step-by-Step Solution

1
Analyze the clinical presentation and vital signs.
The patient exhibits signs of systemic inflammation (fever, tachycardia) and localized right upper quadrant findings (positive Murphy sign) that are highly suspicious for acute cholecystitis.
Establishing the most likely working diagnosis determines the immediate sequence of diagnostic testing.
2
Determine the optimal first-line imaging modality.
Right upper quadrant abdominal ultrasound is identified as the best imaging step.
Ultrasound is the most sensitive, specific, non-invasive, and cost-effective initial test for detecting gallstones and signs of gallbladder inflammation.
3
Identify the necessary initial laboratory investigations.
A complete blood count and a hepatic function panel are selected to accompany the imaging.
These labs assess the severity of the infection (leukocytosis) and check for biliary tree obstruction (elevated transaminases, bilirubin, or alkaline phosphatase), which would alter downstream management.

Key Concept

In patients with suspected acute cholecystitis, the standard initial diagnostic workup involves a right upper quadrant abdominal ultrasound combined with a complete blood count and hepatic function panel to confirm the diagnosis and screen for complications.
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Diagnostic Workup and Test Sequencing

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