Case of the Month: December, 2012

Submitted by Christine Ghatan, MD and Thomas Learch, MD .

History: 41-year-old male presents to the Emergency Department with sudden-onset right upper quadrant pain radiating to the flank. He also complains of nausea and vomiting, but denies dysuria or fever. He reports that several years ago, he had a gun-shot injury to the abdomen and needed a left nephrectomy.

His vital signs are remarkable for a temperature of 99.8F, otherwise normal. On physical exam, he has right lower quadrant and low back tenderness to palpation.

His urine analysis is remarkable for trace protein, trace leukocyte esterase, 5 white blood cells, 2 red blood cells. Complete blood count is remarkable for WBC 16.9 and RBC 5.83, otherwise normal.

Question: What is at the top of your differential?

  1. Appendicitis
  2. Nephrolithiasi
  3. Pyonephritis
  4. Cholelithiasis
  5. Ruptured aortic dissection.
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