 Welcome back to our MedSmarter question of the day. Let's get right to that question. Which of the following is the most likely diagnosis in this patient? An obese 49 year old G3P3 woman presents to the physician with right upper quadrant pain and fever that was preceded by nausea and vomiting. Ultrasound shows hyperechoic structures in the right upper quadrant. Fever testing reveals white blood cell counts of 15,000 per cubic millimeter, 15,000 per cubic millimeter, an erythrocyte sedimentation rate of 45 millimeters per hour, and a serum amylase level of 75. Which of the following is the most likely diagnosis in this patient? Take a minute, look at these answer choices, come up with your answer, and then write your answer in the comment box below. Alright, let's look through this question and find out what are the important things. We start out as an obese 49 year old G3P3 female. She's having right upper quadrant pain, had nausea and vomiting, on the ultrasound she had hyperechoic structures in the upper quadrant. White blood cell count is 1500, ESR is 45, and amylase is 75. Okay, so let's look at those lab values. A white blood cell count of 1500. A normal white blood cell count is going to be between 4500 and 11000. So a 1500 white blood cell count is an elevated white blood cell count. Our ESR in females is typically between 0 and 20, and our amylase levels, normal values are between 25 and 125. So ESR is 45, which is greater than our normal values, so we have an elevated ESR. An amylase of 75 falls right within our normal range for amylase. So what that tells me is that we have ruled out any possible pancreatitis causes associated with this. So I can go through my answer choices and mark out anything that has to do with the pancreas. So carcinoma of the pancreas and acute pancreatitis are out. So that leaves us with two cholecystitis and a cholecystitis. So let's break those down. An acute calculus cholecystitis. Gallstones seem to be a possible answer choice here. So this is something I think I will leave in as a possible answer. De-cholesterolysis, while cholecystitis does have effects on the gallbladder, it typically doesn't show inflammatory changes. So we wouldn't see an elevated ESR in cholesterolysis and we also wouldn't probably see an elevated white blood cell count either. So I'm going to say D is not the correct answer. So we're down between acute calculus or an acute a-cholesterolysis cholecystitis. So what does a-cholesterolysis cholecystitis mean? That means there is an absence of gallstones. Based upon this ultrasound, there is hyper-echogenic structures that typically mean that we have gallstones. So I think we are dealing with a calculus cholecystitis, not an a-cholesterolysis cholecystitis. Therefore B will be my final answer. And B is the correct answer. So this right upper quadrant in an obese middle-aged, multiparous female with the ultrasound findings consistent of gallstones, including having nausea and vomiting probably after she ate a meal, a high-fatty meal, this is all indicative of acute calculus cholecystitis. So what's happening here are gallstones are getting stuck in the gallbladder neck or in the cystic duct and those gallstones are causing pain. Sometimes we can also get a referred pain up to the shoulder. Don't forget our 4 F's associated with our risk factors of acute calculus cholecystitis. What are the 4 F's? Female, fat, fertile, and 40 are the 4 F's associated with risk factors with gallstones. So this patient, 49-year-old female that is fertile, she has had multiple children and is obese or fat, fits classically into our acute calculus cholecystitis diagnosis.