Clinical cases involving abdominal right upper quadrant or RUQ pain

Before we look at a clinical case involving right upper quadrant (RUQ) pain, let’s review two key components of a medical evaluation.

First, remember the OLD CARTS (onset, location, duration, character, alleviating factors, radiation, temporal patterns, and symptoms) acronym, which can help you develop your history of present illness questions. Also, recall how to take SOAP (subjective, objective, assessment, and plan) notes. The subjective portion involves allowing the patient to tell you their symptoms. The objective portion includes your physical exam findings. As well, the assessment portion involves your differential diagnoses. Finally, the plan portion is how you plan to treat the patient.

A 41-year-old female patient with obesity presents with a two-day history of RUQ pain.

When you ask what brings her in today, she reports that the pain is worse with fatty and greasy foods. Bread and salad do not seem to cause the problem, and nothing in particular makes it better. The pain is associated with nausea but no vomiting, diarrhea, or constipation.

The patient has provided a lot of detail about the pain. You can organize her description using the OLD CARTS acronym, which will guide your questions and help create the differential diagnosis.

The onset (O) of the pain was two days ago, and it’s located (L) in the RUQ. Fatty and greasy foods worsen the pain, and bland foods alleviate it (A, T). The pain is associated (S) with nausea.

When you guide the patient to answer questions that give more specific details about the duration (D) and character (C) of the pain, she reports that the pain has been occurring for about two weeks off and on but has been constant for the last two days.

In addition to the details of her history of present illness, you remember to get her other pertinent history details:

• She has been pregnant three times and has three live children.
• Her past medical history is significant for pre-hypertension.
• She has had no previous surgeries.
• She currently takes no medications.
• She has no allergies to any medications.

It’s important to focus on the abdominal findings, but the patient may have other findings that are helpful. For example, a patient with cholecystitis may also have jaundice, scleral icterus (e.g., yellowing of the eyes due to elevated bilirubin), and some right shoulder pain on a musculoskeletal exam.

The patient has abdominal obesity with no surgical scars or other gross abnormalities. She has bowel sounds in all four quadrants and no abdominal aortic bruits. She has appropriate dullness over her liver and mild tympany over the small bowel near her umbilicus.

The patient has tachycardia with a heart rate of 110 beats per minute and a 100.6°F (38.1°C) fever. But, all other values are normal. She has RUQ pain with palpation and a positive Murphy’s sign.

The finding of a positive Murphy’s sign should trigger a possible diagnosis. Murphy’s sign involves the cessation of inspiration with deep palpation of the RUQ along with pain and is suggestive of cholecystitis.

Based on the patient’s presentation, a gallbladder etiology is high on the differential. The patient is obese, has RUQ pain associated with fatty foods, and has a positive Murphy’s sign. The positive Murphy’s sign helps to distinguish between cholelithiasis (e.g., gallstones) and acute cholecystitis (e.g., inflamed gallbladder).

A duodenal ulcer should also be considered because of the location of the pain. But, her pain is worse with foods (especially fatty foods) and is not improved by food consumption. Often, pain from duodenal ulcers is decreased after food intake.

Now that you have a differential diagnosis based on the patient’s history and physical exam, you’re well on your way to diagnosing and treating the cause of the pain. The diagnosis may require further assessment with imaging modalities and laboratory findings.

The plan could involve surgery with or without the addition of antibiotics. This final component completes the SOAP for your patient with RUQ pain.

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