OSCE

Jane is a 49 y/o female c/o RUQ abdominal pain x 2 days.

History elements:

Onset: 2 days ago after eating take-out from McDonald
Location: Pain begins in the epigastric region and then localized to RUQ, radiating to the right shoulder
Duration: 2 days
Characteristic: Intermittent, sharp pain
Aggravating factors: greasy food makes the pain worse
Relieving factors: nothing makes the pain better
Severity: 7/10 currently
Progression of pain: pain has become more frequent and intense over the past 2 days.
Patent tried Tylenol with minimal relief
Reports nausea and 2 episodes of NBNB emesis. Last episode was this morning. Patient vomited up food 30 minutes after eating.
Reports history of gall stone and states she has experienced similar symptoms before.
No change in bowel habits
No blood in stool or melena
No recent weight loss
No fever, chills, SOB, chest pain, weakness, cough, skin rash, joint pain
Regular menstrual cycle, LMP was 2 weeks ago
No past medical history
No prior surgeries
Not taking any medication
NKDA
Admits to alcohol use (1 glass of wine every day). Denies tobacco or illicit drug use

Physical Exam:

Vital signs – BP 139/86, HR 90, RR 20, Temp 97.6 F, SpO2 99%, BMI 29.1
General – AAO X3. Appears uncomfortable but not in acute distress. Appears her stated age, well-developed and well-groomed.
Skin – Warm and dry, good turgor, no jaundice.
Heart – RRR, no murmurs, gallop, or rubs.
Lung – Clear to auscultation bilaterally, no wheezes/rhonchi/rales.
Abdomen – Guarding and significant tenderness to RUQ upon palpation. Positive murphy’s sign. No rebound tenderness. Abdomen soft, bowel sound present in all 4 quadrants. No masses, lesions, or scars. No evidence of organomegaly. No CVA tenderness.

Differential Diagnosis:

Acute cholecystitis: RUQ pain, positive Murphy’s sign
Biliary colic: RUQ pain, nausea and vomiting, history of gall stones
Pancreatitis: Epigastric pain moved to RUQ, nausea and vomiting. Given patient’s history, could be gallstone-induced pancreatitis

Tests

Urine pregnancy test: Negative
RUQ Ultrasound: Gallbladder contains small calculi. Thickened gallbladder wall. Positive sonographic Murphy sign.

Diagnosis

Acute cholecystitis

Treatment

Admits to surgery for laparoscopic cholecystectomy
NPO
IV fluid – normal saline
IV analgesic – start with NSAIDS, switch to morphine if no significant improvement
IV antiemetic – ondansetron 4mg IV
IV antibiotic – Piperacillin/tazobactam 3.375 g q6h

Patient counseling

Explain the diagnosis of acute cholecystitis and its treatment (laparoscopic cholecystectomy).
Explain the next step of care, which is admission to surgery. Tell patent she needs to remain NPO.
Explain the medications that will be given that this point, including IV fluids, analgesics, antiemetics, and antibiotics.
Address any questions or concerns from the patient.

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