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You are an F1 on an A&E rotation. The next patient to see is Sue Docyst, a 41 year old lady who is presenting with abdominal pain.

Please take a focussed history of this lady’s presenting complaint, and perform the appropriate examination. You will then be asked to discuss the case with the examiner.

You are Sue Docyst, a 41 year old lady who has presented to A&E with abdominal pain. You are a bright and bubbly woman normally, but you are really struggling to cope with this pain. At times it is so bad it has moved you to tears.

HPC The pain started last night when you came back from a curry, and has got worse over night. It’s in the middle and near the top of your stomach (epigastric), and occasionally spreads to your back. It came on quite quickly, and is constantly there, but at the start was coming in waves. It is a sharp stabbing pain. You were sick several times overnight, but now you’re just retching, as there’s nothing left to bring up. There was no blood in your vomit, and it was just the food you had eaten, no bile or anything like that. You’ve had a bit of a temperature overnight, feeling hot and cold. You haven’t been shaking or anything like that. You haven’t had anything to eat since yesterday, and even water is struggling to stay down, so now you’re feeling very weak and washed out You’ve taken Paracetamol and ibuprofen but it hasn’t settled the pain. You haven’t noticed any change of colour in your skin, but your husband did say that your eyes had a yellowy tinge to them. You haven’t opened your bowels yet today, which is normal for you. You wee this morning did look very dark, but you thought that was just dehydration. You have just finished a period, which have been becoming a bit irregular recently as you have started ‘the change.’ You’re adamant you could not be pregnant as your husband has had a vasectomy following your last child.

ICE You have no idea what could be causing it, but you’re really worried as you’ve never had a pain like this before. You really want something to help with the pain and the nausea to make it all go away.

PMH You like to think of yourself as fit and healthy, but in the last couple of years you’ve started to have a couple of problems. The biggest problem is probably your weight, which has crept up since your last child 5 years ago, you’re now around 16stone and have really struggled to lose it – especially as you have 3 children to look after. You’ve had a lot of heartburn, which your doctor says is probably due to a hernia in your stomach, you’ve been started on some tablets which have helped a lot. The pain from the heartburn is different to this pain, as the heartburn you feel up in your chest and get a horrible taste in the back of your throat. A few months ago you did have some pain like this, but nowhere near as severe. It was in the same place, but was more crampy. It went away on its own after a couple of hours so you weren’t too worried about it.

SH You live with your husband, 3 children, dog, cat and two guinea pigs. You work in the office for the local newspaper. You’ve never smoked, but you do drink a couple of bottles of wine a week. You perfectly fine doing all the housework, and your mobility isn’t a problem – even if you do find yourself getting out of puff a bit more now you’ve gained the weight.

FH Breast cancer runs in the family, your elder sister and aunt have both had it, but are both doing really well. You check your breasts regularly now because of that, and encourage everyone else to do the same!

Drugs and allergies You are allergic to penicillin; you had a dose after some dental problems and came out in a big rash. You take lansoprazole 15 once a day. Nothing else regularly, and as you said before you’ve been using Paracetamol and ibuprofen but that hasn’t helped the pain.  

The student should take a focussed history of this lady’s presenting complaint. They should perform an abdominal examination. Biliary disease, specifically biliary colic and cholecystitis should be in the student’s differentials. Pancreatitis or hepatitis would also be a reasonable differential.

Topics for discussion could include: • Initial investigations and management for this lady • Risk factors for gallstones, and which would be present in this patient • What gallstones are commonly formed from, and what imaging is best to see them • Management of cholecystitis – including medical and surgical options • Management of biliary colic - • Triad of symptoms of cholangitis • The pattern of LFTs you might see in cholecystitis • The different types of jaundice, how to tell them apart on LFTs, and common causes • What signs and symptoms would help you differentiate biliary colic from cholecystitis