Acute Cholecystitis


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 in General Surgery

Patient: 40 year old patient presents to A&E with upper abdominal pain

Task:
– Take a focused history from the patient
– After 6 minutes you will be asked a series of questions by the examiner.
– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 40 year old female patient.

You came to A&E 1 week ago with similar pain. You were given some pain killers and you felt better so you were keen to go home.

This time the pain is much worse. The pain in worse in the upper region (you make a fist and rub it over the epigastric and RUQ region.) The pain is sharp and goes through to your back. You have been feeling nauseous and have been sick once.

For the last 6 months you have been having abdominal pain that comes in waves when you have a fatty meal, so you have cut these out of your diet.

Your last period (LMP) was 3 weeks ago

You have not been experiencing any lower urinary tract symptoms (increased frequency, burning or discharge)

Your bowels last opened this morning

You are not known to have gallstones although you have never had a scan

PMH
– Tonsillectomy

SH
– You live at home alone
– You are a non-smoker
– You drink socially

DH
– You are not on any regular medications
– You have no allergies

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Role
Clarifies who they are talking to
Asks patient for preferred name


PC Presenting complaint
Site
Onset
Character
Radiation
Timings of pain
Exacerbating and relieving factors
Severity


Associated features
Nausea and vomiting
Loose stools / change in bowel habit
Rigors / fevers / chills
Lower urinary tract symptoms
Not recently been unwell / not in contact with anyone unwell


PMH Past Medical History
Past medical history appropriately explored


DH Drug History
Drug history appropriately explored
Drug allergies


SH Social History
Alcohol
Smoking
Job
Living situation


FH Family history
Family history appropriately asked about


ICEF ICEF
Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions


Question Given your history what are your differentials?
Acute cholecystitis
Biliary colic
Cholangitis
Pancreatitis
Gastritis
Gastroenteritis
Pyelonephritis
Ureteric colic


Question On examination, the patient has tenderness in the epigastric region and right upper quadrant. Given the history and examination findings what bloods would you like to request?
FBC
U&Es
LFTs
CRP
Amylase
Clotting
2 x G&S


Question Given your history and examination what other investigations apart from bloods would you do?
CXR
AXR
Urine dip
Blood Gas
Pregnancy test


Question
Please review the following bloods and comment on your findings

Increased WCC
Neutrophilia
LFTs deranged
Increased CRP


Question
Please review the following imaging and comment on your findings

Chest radiograph (X-Ray) - projection unknown
Good quality - not rotated / good exposure
No pneumoperitoneum
Airway central
Lung fields clear
Normal cardiomediastinal contour
No fractures


Plan
Review the following imaging. Given your history and the investigations given, what is your initial management plan?

Treat as acute cholecystitis
Appropriate IV antibiotics
IV fluids
Analgesia
Blood cultures if temp spikes
VTE prophylaxis
Senior review
Nil by mouth (NBM)



Score