Professional Documents
Culture Documents
Case: You are an HMO in the ED and a 55-years-old male was brought in by ambulance complaining of severe upper
abdominal pain, fever, and jaundice for the last 2 days.
Task
a. History (RUQ pain worse with breathing, no relieving factor, 1st episode, + nausea, no travel history, SOB, shaking,
yellowing of skin x 2 days, no itching or change in color of urine or bowels)
b. Physical examination (ill, dehydrated, moderate jaundice, T: 38.2, tachycardia, tachypnea, chest clear, no pleural
rub, abdomen no scars or deformity, tenderness on RUQ on superficial or deep palpation, Murphy sign negative,
urine dipstick pending)
c. Investigations FBE (WBC increased with left shift), ESR/CRP, LFTs (bilirubin increased, conjugated
hyperbilirubinemia, AST/ALT raised), USD (liver is normal, stone in common bile duct)
d. Diagnosis and management
Case 2: Joseph aged 45 years was brought into your surgery by his wife Julia. Joseph had upper abdominal pain for a few
day associated with nausea, feeling unwell and tiredness. He also had fever and this AM had shakes with fever. Julia tells
you he was looking very unwell and seeks your help. Joseph lives at home with his wife and two children. He had no
significant medical or any surgical problems in the past. He is not on any regular medications. He is an occasional smoker
but drinks alcohol every evening.
Task
a. Further history (RUQ pain, severe, 3-4 SD per day;)
b. Physical examination (jaundice, 120 regular, 100/70, T: 38.5, RR 16, O2 97%)
c. Investigations
d. Probable diagnosis and management
History
- Please tell me more about the pain? Where is it? How bad is the pain? Can you point with one finger? Does
anything relieve or aggravate it? Does it go anywhere (back, tummy)? Do you think it is getting worse? Any
associated N/V? SOB? Chest pain? Cough? Palpitation?
- Fever? Since when? How high is it? Did you take any medications? Did it help?
- Please tell me more about the discoloration of your skin? When did it start? How did it start? Any associated
change in the color of your urine or stool (urine dark, stool pale)? Have you noticed itchiness anywhere else in the
body? Diarrhea? Constipation? Have you noticed any relationship of food with this pain? Is this the first episode?
Any previous similar complaints of fever and jaundice with pain?
- Did you travel recently? Did you come into contact with a person with similar symptoms? What is your occupation?
Any chance of contact with blood products? Have you had blood transfusions previously? Any surgeries? Any
illnesses in the past? Were you ever diagnosed with gallstones or liver disease? Have you noticed any changes to
your weight? Appetite? Lumps or bumps? Night sweats? SADMA? Any chance of needle sharing? Have you had
tattooing over the body? Are you on any medications at the moment? Any FHx of liver disease or gallstone
disease?
Physical examination
- General appearance: ill and septic? Degree of jaundice? Dehydration? Stigmata of liver disease
- Vital signs
- Lymph nodes
- Chest: auscultate for any added sounds, pleural rub
- Abdomen: distention, tenderness on palpation, Murphy sign, organomegaly
- DRE
- Urine dipstick and BSL
Differential Diagnosis
- Acute cholangitis: RUQ pain + fever and chills + jaundice
- Acute cholecystitis
- Acute hepatitis
- Choledocholithiasis
- Right lobar Pneumonia
Investigation
- FBE, ESR/CRP, LFTs, USD of abdomen, CXR, blood culture, lipase/amylase