Who you are:
You are an F2 in A&E.Who the patient is:
Martin Atkinson, 60 years old, came to the emergency department with pain in his abdomen.What you should do:
Please talk to him, assess and discuss your plan of management with him and address his concerns.
D: Hello I am one of the doctors here in the emergency department, can I get your full name and age please ?
P: I am Martin Atkinson I am 60 years old.
D: How can I help you? (Acknowledge if he is maintaining any specific posture)
P: I am having really bad pain in my right upper tummy doctor (right
hypochondrium)
D: Oh it seems like you are in real pain, I am sorry about that, can you tell more about this pain Martin ?
P1 SOCRATES (recap whatever he mentions instead of asking again)
D: Site : You mentioned that the pain is in your right upper tummy / Can you point with your finger to the pain?
P: (Patient will point to his right hypochondrium)
D: Onset: How did it start?
P: It started suddenly doctor.
D: Character: Can you describe that pain for me?
P: It is a very sharp pain doctor.
D: Radiation: Does it go anywhere else?
P: Yes it goes to my right shoulder.
D: Was it continuous or comes and goes?
P: It has become continuous since it started doctor.
D: Duration (time): When did it start exactly?
P: It started this morning.
D: Alleviating factors: Does anything make it better?
P: No doctor it’s always bad.
D: Exacerbating Factors: Anything that makes it worse?
P: Whenever I try to inhale the pain gets worse.
D: Severity: Can you score the pain for me on a scale from 1 to 10, 1 being the least and 10 being the highest pain possible?
P: Around 8-9 doctor.
D: Have you tried anything for the pain?
P: No.
D: Anything else with the pain? Open Q before asking about DDx
D: Any fever, N/V or sweating or feeling sick or dizzy? Infection and sepsis
P: No (maybe fever)
D: Have you noticed any change in your skin colour lately? Jaundice
P: No.
D: Have you got any bowel problems lately? Diarrhoea or constipation?
GUT
D: Do you have a cough or any chest pain that goes to your left side?
Chest
D: Any problems with your waterworks? Urine
D: Have you sustained any trauma to this area?
P: No.
D: Have you noticed any lumps or bumps , weight loss , appetite changes
recently ? FLAWS
ICE
IDEA
D: Any idea what might be causing the pain? / Were you doing anything
specific before the pain started?
CONCERN
D: Do you have any specific concern regarding this pain?
EXPECTATION:
D: Are you expecting anything today in particular from us?
P2:
D: Have you had any similar problem in the past?
P: No (maybe yes if recurrent Calculi)
D: Have you been diagnosed with any medical condition in the past?
P: I have had hypertension for ten years now and I am on Amlodipine for it.
D: Any DM, heart disease or cholesterol problems?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
MAFTOSA
D: Are you taking any medications including OTC or supplements? (If female ask about COCP)
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical conditions?
P: No.
DESAS (if very severe pain and an emergency don’t go in depth)
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes.
D: Tell me about your diet?
P: I try to eat healthy. Or, eating a lot of fatty food fast food. Etc
D: Do you do physical exercise?
P: I don’t have much time.
D: Do you have any kind of stress?
P: No.
D: Who do you live with?
P: With my wife.
Examination:
D: Thank you for bearing with me so far. If you don’t mind, I would like take your observations BP, temperature, pulse and breathing rate, I will examine your tummy and especially your right upper tummy for a specific type of pain called a Murphy sign. I will also do a general physical examination.
I would like to send for some initial investigations including Routine Blood Test, kidney and liver function tests. I would also check for infection and
inflammatory markers called CRP.
Examiner may give you findings as Temperature: 38.5 or CRP high.
WATCH OUT: ALWAYS SCAN THE ROOM. MIGHT BE AN ABDOMINAL EXAMINATION COMBINED STATION AND YOU WILL HAVE TO CUT THE HX SHORT AND DO THE ABD EXAM
Provisional Diagnosis
From the information that you have given me I suspect that you have an
inflamed Gall bladder. Sometimes it accumulates stones that causes blockage and infection making the bladder swollen and painful. The condition is called Acute cholecystitis.
Types of Acute cholecystitis:
Calculous cholecystitis
Calculous cholecystitis (most common, and less serious) it develops when the main opening to the gallbladder, (cystic duct), gets blocked by stones that are formed from concentrated bile that is usually used to digest fat.
This bile builds up in the gallbladder, increasing the pressure inside it and
causing it to become inflamed or even infected (1 in every 5 cases)
Acalculous cholecystitis
Acalculous cholecystitis is less common, but a more serious type that develops as a complication of a serious illness, infection or injury that damages the gallbladder. (Major surgery, burns, sepsis, severe malnutrition or HIV/AIDS) no stones are involved here.
Management
- We need to Admit you for regular monitoring of your observations and
symptoms. - Senior: I will also need to involve my senior to run some further testing.
- Investigations: FBC, infection markers, LFT/KFT/U&E, S. cholesterol, S. Calcium, urine dipstick. ECG Imaging: erect X-Ray, Abdominal US.
- Symptomatic treatment:
− Supportive: NPO - O2- IV fluids- IV antibiotics (broad spectrum
according to hospital protocol)- Painkillers.
− Elective surgical removal following the specialist surgical advice.
− Long-term management of the cause: manage high cholesterol, Statins if needed, if taking OCPs, it can be changed after consultation with the patient.
− Advice about DESA: healthy lifestyle avoid too much fast food ,
exercise regularly, Alcohol and smoking. - Specialist referral for evaluation and further investigations and imaging such as CT or MRI. Elective surgery may be required after resolution of infection to prevent recurrence.
- Surgical options depend on patient’s condition:
– Laparoscopic cholecystectomy – a type of keyhole surgery where the
gallbladder is removed using special surgical instruments inserted through a number of small cuts in your abdomen.
– Single-incision laparoscopic cholecystectomy – where the gallbladder is removed through a single cut, which is usually made near the bellybutton. It is only done by more experienced surgeons.
– Open cholecystectomy – where the gallbladder is removed through a single larger cut in the tummy.
- Safety net: Fever, jaundice, persistence of symptoms.
Keyhole surgery to remove the gallbladder
• Also known as a laparoscopic cholecystectomy.
• 2-3 small cuts are made in your right abdomen side (each 1cm or less)
and a larger one (about 2 to 3cm) by the belly button. Your abdomen is
temporarily inflated using harmless gas making it easier to see and
operate inside.
• A special thin video camera called laparoscope is inserted through one ofthe cuts to help the surgeon see and remove your gallbladder using
special surgical instruments.
• X-ray or ultrasound scan of the bile duct for residual stones will be done
and if found will also be removed during the operation.
• Finally the gas in your tummy escapes through the laparoscope and the
cuts are closed with dissolvable stitches and covered with dressings.
• The operation is done under general anesthesia, which means you’ll be
unconscious won’t feel any pain while it’s carried out.
• The operation takes 60 to 90 minutes, and you can usually go home the
same day.
• Full recovery typically takes around 10 days.
If the operation can’t be done this way, or an unexpected complication occurs, it may have to be converted to open surgery.
A laparoscopic cholecystectomy may not be recommended in these cases:
− Pregnancy third trimester
− Extremely overweight
− Unusual gallbladder or bile duct anatomical structure making the
procedure more difficult or dangerous.
Open surgery
• A 10 to 15cm incision is made in the abdomen, underneath the ribs, so
the gallbladder can be removed.
• Also under general anesthesia, so you won’t feel a thing.
• It is as effective as Keyhole surgery, however it requires a longer recovery time (up to 5 days in the hospital and 6 weeks to fully recover) and causes more visible scarring.
Endoscopic retrograde cholangio-pancreatography (ERCP)
• It is a procedure in which a special long a thin flexible camera called an endoscope is passed through your mouth down to where the bile duct
opens into the small intestine.
• It can diagnose and remove gallstones from the bile duct as it can widen
this opening by small heat induced incisions allowing the stones to be
removed or pass later to the intestine and come out with stools. A small
supporting piece called stent can then be permanently left in the duct to
keep it wider and prevent recurrence.
• The gallbladder isn’t removed, and further surgeries may be required to
remove the stones there depending on their size.
• Usually done under sedation, which means you’ll be conscious but won’t
experience any pain.
• It lasts from 15 minutes to over an hour with an average of 30 mins.
• You may need to stay in hospital overnight to be monitored and make
sure that you are recovering well.