RUQ Pain in a Young Woman

A 35-year-old sexually active, single woman presents to the emergency department (ED) with 18 hours of constant right upper quadrant (RUQ) abdominal pain associated with non-bloody but bilious vomiting and chills. She denies diarrhea, dysuria, and vaginal discharge and has no other complaints. She states that she has had similar pain before that was milder and only lasted a few hours so she never saw a doctor for it. This time it is not going away.

On physical examination her vital signs are normal although she appears to be in moderate distress with a half-filled emesis bag in her left hand. She is tender in the right upper quadrant and has a positive Murphy’s sign. The rest of the exam is normal.

Blood work including a CBC, metabolic panel, LFTs, UA, and pregnancy test are all completely normal except for 79% PMN’s on the differential. An abdominal ultrasound is performed and one of the images is shown in Figure 1 (please click on image to enarlge).

Question 1. What is notable on this ultrasound image?Question 2. Would you discharge this patient to home?

For answer and discussion, please click here.