History Taking for Cholelithiasis ( pg 92 Waynes notes)

Name
Age
D.O.B.
How did they reach to ward

Presenting Complaint/ Clinical Manifestation:

 Abdominal Pain
 Vomitting

 • Epigastric distress

• Feeling of Fullness

• Abdominal distention

• Fever

• Palpable abdominal mass

• Constant pain, restless in all position

• Jaundice

• Obstruction of the flow of bile into the duodenum results in

• Yellow colour skin and mucous membrane

• Marked itching of the skin

• Changes in urine and stool colour

• A very dark colored urine

• Grayish, like putty, and usually described as “clay-colored” stool.

• Vitamin deficiency

• Obstruction of bile flow also interferes with absorption of the fat-soluble vitamins A,D,E, and K

• If gallstone continues to obstruct the duct

• Abscess

• Necrosis

• Perforation

• Generalized peritonitis

 Nausea
History of Presenting Complaint

History of Presenting Complaint

SOCRATES

1. Abdominal pain
  Site - Where is the pain? => Right hypochondrium & epigastrium
  Onset - When did the pain start, and was it sudden or gradual? (acute and sudden)
  Character - What is the pain like? An ache? Stabbing? => Excruciating, constant,
colickly “spasmodic”, Intermittent
 Radiation - Does the pain radiate anywhere? => Radiating to chest,back & shoulder
  Associations - Any other signs or symptoms associated with the pain?
  Time course - Does the pain follow any pattern? How long is pain=> Constant
lasting less than 6 hours
  Exacerbating: => occurs within hours after meal, usually self limiting and recurring,
precipitated by fatty meal.
 Relieving factors - Does anything change the pain?
  Severity - How bad is the pain? Mild to severe

NB:
Biliary colic: constant, dull RUQ pain lasting < 6 hours  (Pain is usually constant and is caused by
impaction of a gallstone in the neck of the gallbladder)

Especially postprandial  (- Vagal stimulation (e.g., cholecystokinin release following a fatty meal)

→ gallbladder contraction → attempts to force the stone into the cystic duct)

May radiate to the epigastrium, right shoulder, and back (referred pain) => Biliary pain due to
increased intraluminal pressure also causes referred pain secondary to diaphragmatic irritation via
the phrenic nerve, which innervates both the diaphragm and the shoulder

2. Vomiting

 Onset - When did the pain start, and was it sudden or gradual?

 Character – colour, how often, blood, mucus

 Associations - Any other signs or symptoms associated with the pain?

 Time course - Does the pain follow any pattern?

 Exacerbating/Relieving factors - Does anything change the pain?

 3. Fever
 Onset - When did the pain start

 Character – intermittent, constant

 Associations - Any other signs or symptoms associated with the pain?

 Time course – How long did it last

 Exacerbating/Relieving factors - Does anything change the pain? Any

meds? How did you assess the temp?

Past Medical/Surgical History

 Crohn disease, ileal resection, cystic fibrosis (Results in malabsorption which is a cause to of

choleclithiasis)

Mnemonic – JAM THREADS

 J - jaundice
 A - anaemia & other haematological conditions
 M - myocardial infarction
 T - tuberculosis
 H - hypertension & heart disease
 R - rheumatic fever
 E - epilepsy
 A - asthma & COPD
 D - diabetes
 S – stroke

Drug History/ Allergy History

 Names and doses of all drugs Compliance Allergies – nature of allergy very
important
 Drugs: fibrates (inhibition of cholesterol 7-α hydroxylase), estrogen therapy, oral
contraceptives

NB: During pregnancy, increased estrogen levels cause increased secretion of

lithogenic bile (rich in cholesterol), resulting in the formation of cholesterol gallstones.
Increased progesterone levels cause smooth muscle relaxation, decreased and
impaired gallbladder contraction, and subsequent bile stasis and formation of gallstones.
Differential diagnoses

 Differential diagnosis of acute abdomen

 Differential diagnosis of RUQ pain
 Abdominal
 Acute hepatic capsule swelling (e.g., acute hepatitis,
perihepatitis, congestive hepatopathy)
 Gastroesophageal reflux, gastritis, gastrointestinal ulcers 
 Early appendicitis
 Acute pancreatitis
 Right-sided diverticulitis 
 Sphincter of Oddi dysfunction
 Extra-abdominal
 Nephrolithiasis
 Posterior wall infarct
 Differential diagnoses of intraluminal gallbladder wall pathology
 Gallbladder polyp

Pain locat Causes Typical findings Laboratory Next diagnostic

ion tests step

Liver Recent biliary or ↑ Bilir Ultrasound

RUQ
abscess systemic infection ubin
Fever, malaise, ↑ AP
weight loss ↑ Tra
Tender hepatome nsaminases
galy

Acute Fever ↑ Bilir

cholecystitis Right ubin
shoulder referred pain ↑ AP
Nausea, vomiting ↑ GG
Murphy sign T

Acute Charcot ↑ Bilir

cholangitis triad: RUQ pain, fever, ubin
and jaundice ↑ AP
↑ GG
T
Pain locat Causes Typical findings Laboratory Next diagnostic
ion tests step

Splenic History of Anem Ultrasound 

LUQ
rupture recent trauma ia (late (FAST exam)
Shock finding)
Leuk
ocytosis
Thro
mbocytosis

RLQ Appendi Onset: periumbilic Ultrasound

citis al or epigastric pain
Signs
of appendicitis
Fever

LLQ Sigmoid  Fever CT

diverticulitis Possible constipati
on
Elderly patients

Gastric History X-ray or CT

Epigastric
or duodenal of NSAID or glucocorticoi
ulcer d use
perforation Dyspepsia

Acute Possibly fever ↑ Lip Ultrasound 

pancreatitis Circumferential pa ase or CT
in ↑ Am
History of ylase
gallstones or alcoholism

Acute Chest pain may be Trop ECG

coronary absent, especially in onin
syndrome women, diabetics, and CK-
elderly patients MB
History
of atherosclerosis
Pain locat Causes Typical findings Laboratory Next diagnostic
ion tests step

Intestinal History of Abdominal 

Generaliz
obstruction abdominal surgery x-ray
ed
Bloating
No bowel activity
Progressive
nausea and vomiting (late
finding)

Mesenter Minimal ↑ CT with an

ic ischemia tenderness to palpation Serum lactat giography
History of atrial e
fibrillation or hypercoagul
ability
Elderly patients

Abdomin History Ultrasound

Radiating
al aortic of arteriosclerosis, hypert
to the
aneurysm ension, or smoking
flanks
Elderly patients
and back
Shock (if ruptured)

Pelvic Cervical motion Ultrasound

Lower
inflammatory tenderness
abdomen
disease History of high-
risk behavior/STD
Purulent cervical/v
aginal discharge

Ectopic Amenorrhea ↑ hC Transvagin

pregnancy Vaginal bleeding G al ultrasound
Hypotension (if
ruptured)