Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email hello@hyperexcision.com.

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email hello@hyperexcision.com.

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 46-year-old woman presents to the emergency department with a 1-day history of constant right upper quadrant abdominal pain.

The pain began after eating fried pork. She describes the severity of the pain as a 7 out of 10. She reports that the pain also seems to radiate to her back near her right scapula. She feels nauseated and has vomited twice. She has had similar pain about once a month for the past month but of less severity. The pain comes on and worsens after eating food but previously it has resolved within an hour. She also reports of fever.

She does not have yellow discolouration of her eyes, has not lost weight, and does not have diarrhea, constipation, bleeding, or dark-colored stools. There is no history of abdominal distension or a mass in her abdomen.

She is Para 6 + 0. She has no significant medical or surgical history, is not on any medication, and has no allergies. She does not smoke, nor does she drink alcohol. Her diet is usually high in fat. Her review of symptoms is unremarkable.

She appears ill on physical exam. Her temperature is 37.7 C, heart rate is 110 beats per minute, and blood pressure is 120/80 mmHg. Her BMI is 33. There is no jaundice. She has marked tenderness to palpation in the epigastric region and right upper quadrant. When the right upper quadrant is palpated while she is taking a deep breath, she abruptly stops inspiration due to the pain. No masses are palpable. There is no rigidity, rebound tenderness, or guarding. The rest of her physical examination is unremarkable.

Her ultrasound shows stones in the gallbladder, gallbladder wall thickness of 6mm, and pericholecystic fluid. The diameter of the Common Bile Duct is 1.8 mm and there are no stones visualized within it. The liver parenchyma appears normal. Sonographic Murphy’s sign is positive.

These are the results of her laboratory investigations:

WBC count 14 x 10 ^3 u/L (4.1 – 10.9 x 10^3 u/L), Total Bilirubin 1.0 mg/dL (0.1 – 1.2 mg/dL), Alkaline phosphatase 70 units/L (33-131 u/L), Amylase 60 units/L (30 – 100 u/L), Lipase 30 units/L (7 – 60 u/L)

Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email hello@hyperexcision.com.

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 23-year-old woman presents to the emergency department with a 12-hour history of right lower quadrant (RLQ) abdominal pain.

The pain originated in the umbilical region and radiated diffusely across the lower abdomen and is now localized in the right lower quadrant. It was of sudden onset, sharp, and constant with increasing intensity. Severity was rated 8 out of 10 on a scale of 1-10 with one being no pain and 10 being the most pain possible. She took over-the-counter Ibuprofen 400mg but this did not alleviate the pain. The pain was exacerbated by lifting the right leg.

She has vomited twice and reports that she has not eaten for 24 hours due to a lack of appetite. She opened her bowel post-onset of the pain with no change in the consistency of the stool, and no blood or mucus. She does not have abdominal swelling, dysuria, increased frequency of micturition, vaginal bleeding, or purulent vaginal discharge. She is nulliparous and her last menstrual period was 2 weeks ago with no complaints of dysmenorrhoea. She also has no history of unintentional weight loss, episodes of dyspepsia, strenuous physical activity or abdominal trauma.

There is no significant past medical and surgical history. Drug history includes the oral contraceptive pill. She has no known drug allergies. There is no relevant family history. She does not smoke nor does she use recreational drugs. She drinks alcohol occasionally.

On examination, she has a temperature of 38.5 degrees Celsius, absent bowel sounds, and marked tenderness to palpation at 1/3 the distance from the anterior superior iliac spine to the umbilicus. While palpating the left lower quadrant, she reports pain in the right lower quadrant. Active flexion and internal rotation of her right hip reproduces the pain. The skin on the RLQ is hypersensitive to touch. Gentle percussion over the right lower quadrant elicits rebound tenderness. There are no hernias. No abnormalities were detected on pelvic and digital rectal exam.

A complete blood count reveals leukocytosis of 13.5 x 10^3/uL with 15% bands. Urinalysis demonstrates 1+ WBCs without bacteria. The pregnancy test is negative.