LAUSR

A 25 year-old woman with a history of gastroesophageal reflux disease (GERD) presented to her primary care physician with a 2-week history of daily 9/10 right upper quadrant (RUQ) stabbing pain without radiation. The pain started after lifting heavy boxes, was intermittent throughout the day, occurred at rest and with activity, and worsened when running or walking for long distances. She had no relief with naproxen, warm compresses, or massage. She denied fever, nausea, vomiting, diarrhea, weight loss, or anorexia. She had experienced intermittent constipation for 1 year. On exam, the vital signs were normal. She had tenderness in the RUQ, and the pain was reproduced with full forward flexion at the hips. Her physician diagnosed a muscle strain and prescribed tramadol. Common causes of right upper abdominal pain include cholecystitis, choledocholithiasis, and hepatitis. The lack of fever and time frame renders acute infection less likely. GERD is a conceivable cause of her pain, although the association with activity is not characteristic. The working diagnosis of muscle strain was reasonable given the association with hip flexion, but muscle injuries are usually relieved with analgesics and rest. Constipation causes abdominal discomfort and may be prominent in irritable bowel syndrome (IBS) but can also be a symptom of hypothyroidism or hypercalcemia. However, isolated RUQ pain worsened by movement is not characteristic of constipation. Ectopic pregnancy should be excluded. The discussant combines regional anatomy in the abdomen and epidemiology to generate a differential diagnosis. The patient’s age, pain with mechanical stress, and absence of signs of systemic inflammation dissuade him from examining serious processes including ischemia, obstruction, perforation, or organ-based infection or inflammation, although a few plausible causes from the latter category were mentioned.