Seen in the ED Quiz: Epigastric Pain with Chills, Nausea

Patient history. A man in his sixties with a history of diabetes and hypertension presents to the emergency department with acute onset of epigastric pain at 5 am associated with chills and nausea. He denies fever or shortness of breath, vomiting, diarrhea, dysuria, or flank pain. He does not volunteer it, but when asked specifically does admit discomfort in the area of the right scapula.

Vital signs and physical examination. Vital signs are normal. Physical examination is normal except for epigastric tenderness.

Initial differential diagnosis: Gastritis, gallstones, angina, pancreatitis.

Initial diagnostic testing

• CBC, LFTs and BMP are normal except for a glucose of 177 mg/dL
• The ultrasound image is shown below

What does the case image show?

What should you do next?

Cholecystitis fromThe Emergency Medicine 1-Minute Consult Pocketbook