Ivy Tee
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You are an FY1 working on acute medical admissions. Your patient is Ivy, a 47 year old woman who presented with abdominal pain and fever.
Please take a history from Ivy and perform an appropriate examination. You will then be asked to provide a summary of the case, present a differential diagnosis and discuss aspects of the case with the examiner.
Your name is Ivy, you’re 47 and you have been sent to the medical admissions unit at the hospital by your GP after you presented with abdominal pain.
HPC: You’ve been having pain in your tummy on and off for the last week, but today it was much more severe and you have started to feel very unwell with it, which is why you went to your GP.
The pain is at the top of your tummy on the right hand side and into the middle. It came on gradually over the last week and it’s been coming and going in waves, but now it’s a constant, stabbing pain that won’t go away. The pain doesn’t move anywhere else, it’s just in your stomach, but it’s very severe and, if asked, you’d rate it 9/10.
Over the last week you’ve lost your appetite a bit, especially since at the beginning you noticed that the pain seemed to be made worse if you ate big meals. Now you’re feeling nauseated, but haven’t vomited, so you don’t feel like eating anything at all and haven’t eaten anything since lunchtime yesterday.
You’re feeling very unwell in yourself today and have been feeling very hot and sweaty, and a couple of times you’ve been very shaky and shivery even though you’ve been hot. Your husband mentioned a couple of days ago that he thought your eyes looked a funny colour. You didn’t notice at first but this morning you definitely think your eyes and face look a bit yellowy.
You haven’t opened your bowels today, but think that’s because you’ve not eaten. You had noticed over the past few days, though, that your stools have been very light in colour compared to normal. You hadn’t noticed any blood in your stool.
You’ve not had any trouble passing water, but it has been very dark, and you wondered if it was blood and you maybe had a water infection, but didn’t think this was related to your tummy pain.
You don’t think you’ve lost any weight recently; maybe a pound or so since you’ve had little appetite for the last week.
ICE:
PMH: You’re usually fit and well and don’t see your GP for anything regularly.
A couple of years ago you’d had similar tummy pains, but not as bad as this, and were told you have gallstones. This hasn’t given you any problems since then.
FH: Your dad had a heart attack last year, but there is no other family history of medical problems.
DH: You don’t take any regular medications. You tried paracetamol for the pain but it hasn’t helped at all.
SH: You live with your husband and your 13 year old son. You work as a project manager in a recruitment firm, and you’ve been off work for the last couple of days because you’ve felt so unwell. You’re a non-smoker, and have never smoked. You drink alcohol on the weekends, usually a couple of glasses of wine on a Saturday night, but you don’t drink during the week.
If asked about travel, you haven’t been on holiday abroad anywhere recently.
Please observe the student taking a history from Ivy. The student should take a full history, eliciting ideas concerns and expectations, and perform an examination of the Gastrointestinal System. The student should observe for the patient complaining of pain during the examination and make reasonable adjustments if this is the case.
Please ask the student to summarise the case, examination findings and suggest differential diagnoses.
An example of a good differential diagnosis would be similar to:
“My primary differential diagnosis is ascending cholangitis, due to the triad of fevers, obstructive jaundice and right upper quadrant pain and the past history of gallstones. Another differential would be cholecystitis however the significant jaundice is more fitting with cholangitis. I would also be concerned about malignancy due to the obstructive jaundice, although the acute presentation and no history of weight loss makes this less likely.”
Points for discussion: • How would you assess and manage this patient as they present acutely? • What would you expect to see on LFTs in this case? • What is the management of ascending cholangitis? • What are the potential complications of ERCP?
