Case 1: Abdominal pain

Opening scenario

Marcia Billings, a 47-year-old female; , comes to the emergency department because of abdominal pain.

Vital signs

• Temperature: 99.5°F (37.5°C)
• Blood pressure: 116/70 mm Hg
• Heart rate: 102/minute
• Respirations: 20/minute
• BMI: 30 kg/m²

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination.
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Sit hunched forward and act as if you have severe abdominal pain.
• Point at the middle and upper right part of your abdomen when the examinee asks you about the location of your pain.
• Tell the examinee that the pain is especially bad when they press on the middle and upper right part of your abdomen.
• When the examinee asks you to breathe in while they press on the upper right part of your abdomen, start to breathe in and then stop suddenly because of severe pain.
• You are not aware of the meanings of medical terms (e.g., ultrasound) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: If the examinee mentions your weight during the encounter, act offended and say, “Are you saying I'm fat?!”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• Pain in my stomach.
• Location
• In the middle and upper right part.
• Intensity (on a scale from 1–10)
• 8–9.
• Quality
• Dull.
• Onset
• 12 hours ago.
• Precipitating events
• It started pretty soon after dinner yesterday.
• Progression/constant/intermittent
• It has not really gone away since yesterday evening. I think it is actually getting worse.
• Previous episodes
• None like this. I have had some stomach pain after meals before, but it has always gotten better after a couple of hours.
• Radiation
• It hurts really bad all the way around to my back; . And I also have some pain in my right shoulder.
• Alleviating factors
• I tried a warm water bottle, but that did not do anything. Sitting hunched; over or lying on my side seems to help a little.
• Aggravating factors
• Moving and lying down on my back.
• Associated symptoms
• I felt sick to my stomach after dinner and threw up three times last night. I also feel a little warm, like I might have a little bit of a fever.
  • Color and amount of emesis
  • First I threw up what I ate for dinner. Afterwards it was just yellow liquid.
  • Blood in emesis
  • Not that I noticed. Sounds awful!

Review of systems specific to recurrent abdominal pain

• Recent travel
• Our last family vacation was 4 months ago.
  • Where to?
  • We went camping in Yosemite.
• Fatigue
• Just the normal tiredness that comes from chasing after kids.
• Rash/skin changes
• No.
  • Yellow skin color
  • No.
• Urinary problems
• No.
  • Changes in urine color
  • No.
• Bowel problems
• No.
  • Changes in stool color
  • No.
  • Blood in stool
  • No.
• Appetite
• Before this episode I was eating the same amount as usual.
• Weight changes
• Not that I have noticed.
• Recent infections
• No.

Past medical history, family history, and social history

• Past medical history
• My doctor just says I should lose weight.
• Allergies
• No.
• Medications
• Sometimes I take antacids at night when I cannot sleep because of heartburn.
  • Frequency
  • A couple times a month, after a big dinner late at night. But when I take the antacids it goes away and I can sleep.
• Hospitalizations
• Just for the birth of each of my 2 children.
• Ill contacts
• No.
• Past surgical history
• None.
• Family history
• My father died of a stroke when he was 65. My mother has gallstones.
• Work
• I am a financial consultant.
• Home
• I live with my husband and 2 children. It is chaotic sometimes, but we do well together.
• Alcohol
• 1–2 glasses of wine with dinner most nights. I had a little more than that the past 2 days because we had guests.
  • Felt need to cut down on your drinking?
  • No.
  • Felt annoyed by people criticizing your drinking?
  • No.
  • Felt guilty about drinking?
  • No.
  • Felt the need to drink first thing in the morning?
  • No.
• Recreational drugs
• Never.
• Tobacco
• Never.
• Exercise
• I just cannot find the time.
• Diet
• I cook what the kids like to eat best – mac 'n' cheese, spaghetti and meatballs – comfort food like that.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the sclera
• Cardiovascular examination
  • Auscultation of the heart
• Chest examination
  • Auscultation of the lungs
• Abdominal examination
  • Inspection of the abdomen
  • Auscultation of the abdomen
  • Percussion of the abdomen
  • Palpation of the abdomen
    • Tenderness in the epigastrium and right upper quadrant
  • Murphy sign
    • Positive
• Skin examination

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used nonmedical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on support options for weight and diet changes.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Ms. Billings, I understand that you may be sensitive about your weight, and it is not my intention to lecture you. I can assure you that, as your physician, I want you to be in the very best possible health, and it is my job to look for ways for the two of us to get you there, together. Would you be interested in discussing some options for how we can do that?”

Patient note

Differential diagnoses

1. Cholecystitis: The pain associated with cholecystitis is usually constant and prolonged (> 6 hours), which is the case in this patient. It is also typically worse after meals and associated with nausea and vomiting. Even though this patient does not have jaundice and only has a low-grade fever, a positive Murphy sign is characteristic of acute cholecystitis, making this the most likely differential diagnosis.
2. Biliary pancreatitis: This patient's risk factors for cholelithiasis also put her at risk for biliary pancreatitis. Symptoms such as nausea, vomiting, pain after eating, pain radiating to the back, and improvement of the pain on leaning forward are common in acute pancreatitis. However, the presence of right upper quadrant pain and a positive Murphy sign make this diagnosis less likely than cholecystitis.
3. Choledocholithiasis: This patient has a number of risk factors for cholelithiasis (obesity, female sex, multiparity, > 40 years of age, and family history), which puts her at an increased risk for choledocholithiasis as well. Her past episodes of abdominal pain after meals might have been due to choledocholithiasis, and her right upper quadrant pain and nausea and vomiting are also consistent with this diagnosis. However, the pain in choledocholithiasis is usually colicky rather than constant, and the Murphy sign would not be present in uncomplicated choledocholithiasis, making this diagnosis less likely than acute cholecystitis.

The risk factors for cholelithiasis can be remembered with the 6 F's: Fat, Female, Fertile, Forty, Fair-skinned, Family history. Cholelithiasis can lead to cholecystitis, biliary pancreatitis, and choledocholithiasis.

Diagnostic studies

• Ultrasound of the abdomen: best initial imaging test in gallstone disease and suspected biliary pancreatitis
• Alkaline phosphatase, GGT, total and direct bilirubin: Laboratory signs of cholestasis are ↑ alkaline phosphatase, ↑ GGT, ↑ total and ↑ direct bilirubin.
• AST, ALT: used to assess for possible liver cell damage
• Amylase, lipase: important markers of pancreatic inflammation
• CBC: Leukocytes are likely to be elevated in this patient, especially if she has cholecystitis or biliary pancreatitis.
• Electrolytes, calcium: Calcium is an important prognostic marker in pancreatitis.
• CT of the abdomen: not routinely used for the suspected main differentials but can be used in acute pancreatitis to assess for severity and complications
• ERCP: can be both diagnostic and therapeutic, as it can help to visualize and extract gallstones from the bile ducts

Other differential diagnoses to consider

• Acute cholangitis
• Acute hepatitis (e.g., hepatitis A, hepatitis B, hepatitis C)
• Gastroesophageal reflux, gastritis, gastrointestinal ulcers
• Nephrolithiasis
• Posterior wall myocardial infarction
• For more differentials, see also differential diagnoses of acute abdomen and other causes of acute pancreatitis.