Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working at Accident & Emergency. Your next patient is Karen Perkins, a 45-year-old lady complaining of abdominal pain. Please take a history and perform a relevant examination.
Patient History:
You have some dreadful pain below your right ribs; it started gradually before you went to bed last night. But it's suddenly much worse today. It is a constant deep but sharp 7/10 pain in your right upper quadrant. You've been feeling the pain shooting up to your back on the right. Nothing seems to make it worse, and nothing's improving it either!
This isn't the first time you've had tummy pain. For the past few months, you've been getting episodes of sharp pain in that area, which usually lasts a few hours and then goes away, usually starting after lunch. You've been taking ibuprofen for the pain. But the pain this time is different, and you don't feel like yourself at all!
You vomited once about four hours ago and have generally been sick. You've had no change to your bowels. You last opened your bowels this morning. The stool was not pale and wasn't difficult to flush. You have no jaundice. You have chronic reflux, and no recent changes have happened. No difficulty swallowing. You haven't had any cough or chest pain.
Gynae-wise, you haven't had any issues, your last period was two months ago, but they have been a bit irregular recently – you wonder why! No problems with waterworks thankfully!
You have been feeling hot and flushy this morning. You haven't noticed any recent changes in your weight. You cannot recall eating anything troublesome before this.
Ideas, Concerns, Expectations:
You were warned by your GP that you were at risk of getting ulcers because of your reflux, so you're worried this is what's going on. The pain is quite severe, and you just want to get something stronger than ibuprofen.
Past Medical History:
GORD
NAFLD
Drug History:
Omeprazole
Allergic to penicillin (swollen mouth)
Family History:
None.
Social History:
You are an office worker, but you've been working from home this past year and have gained quite a bit of weight.
You also broke up with your partner last year, so you now live alone in a flat.
Your diet isn't the greatest, often buy fast foods and the occasional Indian takeaway.
You stopped smoking 3 years ago but restarted smoking about 10 cigarettes a day last year.
You occasionally drink alcohol, but nothing over 5-6 units per week.
Examination Findings:
Sweaty and hot to touch
Tachycardic (104bpm)
No jaundice
Abdomen tender to light palpation
Murphy's positive (only mention if tested or whilst palpating for hepatomegaly)
Abdominal aorta palpable and pulsatile, not expansile
Differentials:
Cholecystitis (RUQ pain on a background of biliary colic associated with fever in the absence of jaundice. Worry about associated sepsis)
Other biliary pathology e.g. biliary colic, choledocholithiasis, cholangitis
Peptic ulcer disease (history of reflux and taking ibuprofen)
Ectopic pregnancy
Hepatitis
Pancreatitis
Investigations:
Bedside:
Vital signs (shock, sepsis)
Pregnancy test
Bloods:
FBC (bleeding ulcer, infection)
U&E (dehydration, AKI)
LFT (obstructive picture, bilirubin levels)
CRP/ESR (infection)
Amylase (pancreatitis)
Imaging:
Abdominal USS (look for gallstones, gallbladder wall thickening and surrounding fluid)
MRCP
Erect CXR (perforated PUD)
AXR (Rigler's sign may indicate perforated PUD)
Endoscopy
Management: