Patient details
- Name
- Mrs S.A.
- Age / sex
- 42-year-old woman
- Occupation
- Schoolteacher
- Marital status
- Married, four children
- Admitted
- Emergency department, 21:30
- Clerked
- Surgical ward, 23:00
- Source
- Patient herself, reliable
- Referred by
- Self-referred
Presenting complaint
“Pain in the upper right side of my tummy for two days.”
History of presenting complaint
Mrs S.A. was well until two days before admission, when she developed pain in the right upper abdomen about one hour after a heavy, fatty evening meal. The pain came on gradually over half an hour, building to a severe, constant ache that she scores 8 out of 10. It radiates to the tip of the right shoulder blade, is worse on deep breathing and on movement, so that she prefers to lie still, and was little relieved by paracetamol. It has not eased at any point over the last 48 hours. She has had nausea throughout and has vomited three times; the vomit contained recently eaten food, with no blood and no bile. She has lost her appetite, and she felt hot yesterday and measured a temperature of 38.4 °C at home, without rigors. Over the previous six months she has had four or five similar but milder attacks, each after a fatty meal, each lasting one to two hours and settling on its own, for which she did not seek medical advice; the present attack differs in being more severe, lasting two days and bringing fever. She has not noticed yellow discolouration of her eyes or skin, dark urine, pale stools or itching. The pain does not pass straight through to the back and is not eased by sitting forward. She has no heartburn, no previous ulcer and no black stools, and she does not take anti-inflammatory painkillers. She has no cough, breathlessness or chest pain on breathing or on exertion, and no burning on passing urine, blood in the urine or loin pain. Her bowels opened normally yesterday, with no change in bowel habit and no weight loss. Her last menstrual period was two weeks ago and her cycles are regular. She has not travelled recently and has had no contact with anyone jaundiced.
Past medical history
No diabetes, hypertension or heart disease. No previous jaundice. Never had an abdominal ultrasound, and has not been told she has gallstones. No blood disorders.
Past surgical history
Two caesarean sections (2012 and 2016), both under spinal anaesthesia with no complications.
Drugs and allergies
Combined oral contraceptive pill for five years. Paracetamol as needed. No anticoagulants, no steroids, no anti-inflammatory drugs.
Allergy: penicillin, which caused a widespread rash.
Family history
Her mother had her gallbladder removed for gallstones. No family history of blood disorders or bowel cancer.
Social history
Lives with her husband and four children. Does not smoke or drink alcohol. Independent in all daily activities. Diet is high in fried food.
Last ate at 14:00 today; last drank water at 19:00.
Systems review
Cardiovascular, respiratory, urinary, neurological and musculoskeletal systems: no symptoms other than those already described.
General examination
A woman who looks unwell and in pain, lying still in bed. Alert and orientated. Not jaundiced, not pale, not cyanosed. Mucous membranes slightly dry. Weight 84 kg, height 162 cm, body mass index 32.
Hands warm, capillary refill under two seconds, no flapping tremor. Sclerae white. No enlarged lymph nodes in the neck, including the left supraclavicular fossa. No ankle swelling.
Abdominal examination
Inspection
Abdomen not distended. It moves with respiration, though movement is reduced in the right upper quadrant. Healed low transverse (Pfannenstiel) scar. No visible masses, pulsation or dilated veins. Hernial orifices intact, with no cough impulse.
Palpation
Marked tenderness with guarding in the right upper quadrant. Murphy's sign positive: she catches her breath on inspiration when the examining hand is under the right costal margin; the same test on the left is negative. No rebound tenderness elsewhere and no generalised rigidity. No palpable gallbladder mass. Liver edge, spleen and kidneys not palpable. No renal angle tenderness.
Percussion
Liver span 11 cm in the mid-clavicular line; liver dullness preserved. No shifting dullness.
Auscultation
Bowel sounds present and normal.
Rectal examination not performed, as not indicated at present.
Other systems
Chest: equal expansion, resonant percussion, normal breath sounds at both bases with no crackles.
Heart: first and second heart sounds normal, no murmurs.
Legs: calves soft and not tender.
Summary
Provisional diagnosis
Acute calculous cholecystitis.
Initial plan
- Nil by mouth, intravenous fluids, analgesia, antiemetic.
- Bloods: full blood count, C-reactive protein, liver function tests, amylase or lipase, urea and electrolytes, glucose. Pregnancy test.
- Abdominal ultrasound. ECG and chest X-ray.
- Intravenous antibiotics, chosen with her penicillin allergy in mind.
- Discuss with the senior surgeon regarding early laparoscopic cholecystectomy.
Differential diagnosis of right upper quadrant pain
For the OSCE, do not recite a random list. Group the causes by organ, start with the most likely, and for each one give the feature that supports or excludes it in your patient.
| Diagnosis | Points to it in the history | Points to it on examination | In this patient |
|---|---|---|---|
| Gallbladder and bile ducts | |||
| Acute cholecystitis | Constant pain for more than six hours, radiating to the right scapula, fever, vomiting, earlier attacks after fatty food | Fever, tenderness and guarding, positive Murphy's sign, no jaundice | Most likely |
| Biliary colic | Pain after fatty meals that settles within hours; no fever | Normal temperature, mild or no tenderness, Murphy's sign negative | Her earlier attacks |
| Bile duct stone | Pain with jaundice, dark urine, pale stools, itching | Jaundice; often no fever | No jaundice |
| Ascending cholangitis | Pain, jaundice and fever with rigors (Charcot's triad) | Jaundice, high fever; confusion and low blood pressure when severe | No jaundice, no rigors |
| Acute pancreatitis | Epigastric pain through to the back, eased by leaning forward, repeated vomiting; gallstones or alcohol | Epigastric tenderness, patient may be shocked | Pain pattern does not fit; check lipase |
| Liver | |||
| Acute hepatitis | Malaise and loss of appetite before jaundice; contacts, travel, drugs | Jaundice, tender smooth enlarged liver | No jaundice, liver not enlarged |
| Liver abscess or infected hydatid cyst | Swinging fever, sweats, weight loss; contact with dogs or sheep | Tender enlarged liver, tenderness between the lower ribs | Ultrasound will exclude |
| Congested liver | Breathlessness, ankle swelling, known heart disease | Raised neck veins, tender enlarged liver, leg oedema | No cardiac features |
| Stomach and bowel | |||
| Peptic ulcer, perforated ulcer | Epigastric burning related to meals, anti-inflammatory drugs; sudden severe pain if perforated | Epigastric tenderness; board-like rigidity and loss of liver dullness if perforated | Gradual onset, no rigidity |
| High or retrocaecal appendicitis | Central pain moving to the right side, loss of appetite, short history | Tenderness lower and more lateral than the gallbladder | Unlikely; no pain migration |
| Above the diaphragm | |||
| Right lower lobe pneumonia | Cough, sputum, breathlessness, pain on breathing | Fast breathing, crackles or bronchial breathing at the right base | Chest clear |
| Inferior myocardial infarction | Older patient, cardiac risk factors, sweating, exertional pain | Abdomen soft with little tenderness | Unlikely; ECG to exclude |
| Pulmonary embolism | Sudden breathlessness, pleuritic pain; recent immobility, the pill | Fast pulse and breathing, low oxygen saturation, swollen calf | Saturation normal, calves soft |
| Kidney and others | |||
| Right pyelonephritis | Loin pain, fever with rigors, burning urine, frequency | Renal angle tenderness | No urinary symptoms |
| Renal colic | Colicky loin-to-groin pain, blood in urine, restless patient | Little abdominal tenderness | Pain constant, patient lies still |
| Shingles | Burning skin pain in a band on one side, before the rash | Vesicles in one dermatome | No rash |
| Pregnancy-related causes | Missed period; late pregnancy with headache and swelling | Raised blood pressure, pregnant uterus | Pregnancy test in every woman of childbearing age |
Clinical signs related to this case
The signs you should look for in any patient with right upper quadrant pain. For each one, know how to elicit it and what a positive result means.
| Sign | How to elicit it, or what you see | What it means |
|---|---|---|
| Gallbladder, bile ducts and pancreas | ||
| Murphy's sign | Hand under the right costal margin in the mid-clavicular line; the patient stops breathing in because of pain. Negative on the left. | Acute cholecystitis |
| Boas' sign | Increased skin sensitivity below the right scapula | Acute cholecystitis |
| Courvoisier's law | A palpable, non-tender gallbladder in a patient with painless jaundice | The cause is unlikely to be stones; think of cancer of the head of the pancreas or periampullary region |
| Charcot's triad | Right upper quadrant pain, fever with rigors, jaundice | Ascending cholangitis |
| Reynolds' pentad | Charcot's triad plus low blood pressure and confusion | Severe cholangitis with sepsis; needs urgent drainage of the bile duct |
| Cullen's sign | Bruising around the umbilicus | Bleeding behind the peritoneum: severe pancreatitis, ruptured ectopic pregnancy |
| Grey Turner's sign | Bruising in the flanks | Bleeding behind the peritoneum: severe pancreatitis, leaking aortic aneurysm |
| Signs that point away from the gallbladder | ||
| Guarding and rigidity | Guarding: muscles tighten when you press. Rigidity: muscles are board-hard all the time. | Local guarding fits cholecystitis. Generalised rigidity means generalised peritonitis, for example a perforated ulcer. |
| Loss of liver dullness | The area over the liver is resonant on percussion | Free gas under the diaphragm: perforated ulcer |
| Tender enlarged liver | Smooth, tender liver edge felt below the costal margin | Hepatitis, liver abscess or a congested liver |
| Renal angle tenderness | Pain on firm pressure or gentle percussion between the twelfth rib and the spine | Pyelonephritis |
| Signs at the right lung base | Dull percussion note, crackles or bronchial breathing | Right lower lobe pneumonia |
Teaching case. The patient is fictional and written to illustrate format and reasoning. Local protocols decide investigation and treatment.