Consultant360A 47-Year-Old Woman with Acute Abdominal Pain

🧩 Diagnostic Reasoning Exercise / Teaching Case

A previously healthy 47-year-old woman presents to urgent care with acute right upper quadrant pain that awakened her overnight, accompanied by nausea, emesis, low-grade fever, tachycardia, and a positive Murphy’s sign. She reports several milder self-resolving episodes in recent weeks. Labs show leukocytosis with left shift and minimally elevated transaminases and amylase. The question: which imaging modality is most appropriate, and how should analgesia be approached?

Diagnostic Considerations

• Recurrent, self-resolving episodes followed by an unremitting severe attack narrow the differential toward biliary tract pathology over perforation or ischemia
• Murphy’s sign carries close to 100% sensitivity and 90% specificity for biliary etiology, a high-yield physical exam finding in the NP/PA urgent care setting
• Minimally elevated transaminases and amylase are nonspecific; values this low do not meaningfully elevate pancreatitis or hepatitis in the differential
• Withholding analgesia, including opioids, to preserve diagnostic accuracy is not supported by evidence; studies confirm appropriate analgesia does not increase morbidity or delay diagnosis

Practice Pearls

• Recognize ultrasound as the first-line imaging choice when biliary disease is suspected; readily available, no radiation risk, and guideline-supported
• Reserve contrast-enhanced CT for suspected appendicitis, diverticulitis, bowel ischemia, or pancreatic disease
• Consider ultrasound as a default first step for any reproductive-age patient with acute abdomen regardless of suspected etiology
• Integrate Murphy’s sign, pain location, and episodic history to build diagnostic confidence before imaging