Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently a Foundation Year 1 Doctor working in an Emergency Department. Your next patient is Can Yaman, a 34-year-old gentleman presenting with abdominal pain. Please take a history and perform an appropriate examination.
Patient History:
Can Yaman, 34 years old – unemployed.
You started having tummy pain a few days ago, and it has been worsening. The pain is located around the top right-hand side of your tummy. It is aching and is constantly there. Rating it 4/10 in pain score. The pain does not radiate to other parts of the body. Eating fatty food does not make the pain worse. You have tried everything e.g. paracetamol, and the pain doesn’t seem to go away!
You generally feel tired and weak. You sometimes feel little chills with your body shaking – unsure whether you have a fever. You are not sure if there are any changes in the skin. It is not itchy. No nausea and vomiting. No diarrhoea/ constipation. No changes in stool / no pale stool / no blood in the stool. No changes in waterworks (no dark urine). No flu-like symptoms.
You have lost your appetite. Have been eating poorly because of this. You are not sure if you have received any vaccination for hepatitis. You haven’t eaten anything abnormal/ uncooked food recently. Currently sexually active with the new partner which you do not use condoms. No recent travels.
Ideas, Concerns, Expectations:
You think you might have gallstones. You are really concerned about the pain as it is getting worse. You do not feel really well. You would like some painkillers, particularly morphine, to help control the pain. You are scared that you may need to have surgery.
Past Medical History:
Rheumatoid Arthritis, thyroiditis, previous admitted to hospital because of alcohol withdrawal
Drug History:
Methotrexate, ibuprofen PRN , paracetamol PRN
NKDA
Family History:
Mum has severe rheumatoid arthritis + IBD, liver cancer in dad who passed away because of this.
Social History::
You smoke 10 cigarettes/day.
Drink a bottle of vodka almost every day.
If asked about recreational drugs, you also sometimes inject heroin, and you do this with your new girlfriend.
Examination Findings:
Orientated place, person and time
Appears to be jaundiced
No clubbing
No skin rashes or telangiectasia or bruising
No Kayser-Fleischer rings
No ascites
No gynecomastia
No asterixis (flapping tremor)
No palmer erythema
No Dupuytren’s contracture
No xanthomas/ xanthelasma
No Kayser-Fleischer rings
No focal neurology
Tenderness in the upper right quadrant
Hepatomegaly
No splenomegaly
Differentials:
Acute hepatitis (various causes e.g. alcoholic, viral, drug-induced, autoimmune)
Acute cholangitis/cholecystitis
Investigations:
Bedside:
Observations
Consider STI screening
Bloods:
LFT, bone profile, FBC, clotting screen, U&Es (hepatorenal syndrome), TFT
Iron studies (haemochromatosis)
Viral hepatitis screen
Immunoglobulin/autoantibody screen e.g. p-ANCA/ aCL antibodies (PSC), antimitochondrial antibodies (PBC), LKM1 / LC1 / smooth muscle antibodies, antinuclear antibodies (ANA).
Consider caeruloplasmin (Wilsons disease)
Consider CMV/ EBV screen
Enhanced Liver Fibrosis (ELF) blood test – for non-alcoholic fatty liver disease
Consider AFP / CA 19-9
HIV test
Imaging:
Transient elastography / fibroscan (degree of cirrhosis)
Abdominal ultrasound (liver nodularity, enlarged portal vein, ascites, splenomegaly, screening for HCC)
Liver MRI
CT TAP – malignancy staging
CT/MRI Head – if confusion with an unknown cause
Special Test:
Consider OGD for oesophageal varices when portal hypertension is suspected
Consider MRCP/ ERCP if suspecting cholestatic cause
Consider Liver Biopsy +/- Perl’s stain to check for haemochromatosis
Management: