Abdominal Pain OSCE - Cholecystitis | Free OSCE Practice

Case Overview

Age/Sex: 51-year-old female
Occupation: Office worker (administrative assistant)
Setting: Emergency department / acute assessment unit
Chief complaint: "Abdominal pain"

Patient Script

Who I Am

I am 51, I work in an office doing paperwork and computer work, and I live with my husband.

What Brings Me In

"I have had a bad pain in the right side of my tummy for the last couple of days and I felt feverish, so I came in."

My Story

About 48 hours ago I started noticing a dull ache under my ribs on the right side of my tummy. It got noticeably worse yesterday evening — it became a sharp, steady pain that is worse when I breathe in deeply and worse if I try to take a big puff. The pain sits under my right ribcage and sometimes seems to go a bit around to my back and up towards my right shoulder. I felt nauseous yesterday and vomited once after supper. I thought it might settle but it’s still bad today, and last night I had chills and felt feverish.

The pain seems worse after I ate a takeaway curry two nights ago — it started after that meal. I haven’t had this exact pain before, although I sometimes get indigestion. The pain hasn’t moved to the centre of my tummy and I haven’t had any vomiting today except that one time. I haven’t noticed yellowing of my eyes or dark urine. My bowels have been a bit sluggish this week (I’ve been constipated), but that’s been happening off and on for a while. I had an abdominal surgery years ago — an appendix removed when I was in my 20s — and I have a few scars from that.

My Medical Background

Past medical history: hypertension (diagnosed 3 years ago), occasional gastro-oesophageal reflux disease (heartburn) for many years.
Medications: lisinopril 10 mg once daily, omeprazole 20 mg once daily as needed.
Allergies: penicillin causes a rash (hives) once when I was a teenager.
Social history: drinks alcohol socially (1–2 glasses of wine at weekend), never smoked, lives with husband, works full-time at a desk.
Family history: my mother had gallstones in her 60s and had her gallbladder removed.

What I Think & Worry About

I think this is something to do with what I ate (that curry) and I’m worried it could be something serious like my gallbladder or maybe my appendix (I had that out though, so I’m not sure).
I’m worried I might need surgery and I can’t take much time off work or have complications.
I worry about what this means at my age — whether it’s something that will come back.

If You Ask Me About Other Symptoms...

Pain location: "Under my right ribs, a bit into my back and up to my right shoulder sometimes."
Appetite: "I haven’t been hungry since it started."
Vomiting: "Just once yesterday night."
Bowel & urine: "A bit constipated this week, no blood in poo, urine seems normal."
Fever/chills: "I felt feverish and had chills last night."
Jaundice: "I haven’t noticed any yellow eyes or dark pee."
Chest symptoms: "No chest pain, only that the right shoulder can ache sometimes when the pain is bad."
Vaginal/menstrual: "Postmenopausal — my periods stopped a couple of years ago."
Recent travel/infections: "No recent travel, no one at work sick, but I’ve been more stressed than usual at work."

Clinical Summary

Examination

General: Alert, mildly uncomfortable due to pain, temperature 38.2°C
Vital signs: HR 96 bpm, BP 132/80 mmHg, RR 18/min, SpO2 98% on air
BMI: ~31 kg/m2 (obese)
Abdominal exam: Localised tenderness in the right upper quadrant (RUQ) with mild guarding, no generalized peritonism
Murphy's sign: Positive (patient stops inspiration with palpation under right costal margin)
No obvious jaundice, no stigmata of chronic liver disease
Respiratory: Clear to auscultation, no focal crackles
Cardiovascular: Normal S1/S2, no murmurs

Investigations

CBC: WBC 14.6 x10^9/L (neutrophils 11.8 x10^9/L) (leukocytosis consistent with infection/inflammation)
CRP: 82 mg/L (elevated)
LFTs: Bilirubin 12 µmol/L (normal), ALP 95 IU/L (within normal range), ALT 48 IU/L (mildly raised), AST 36 IU/L (normal)
Amylase: 58 U/L (normal)
Renal function & electrolytes: Na 139 mmol/L, K 4.1 mmol/L, creatinine 70 µmol/L (normal)
Urine dip: trace blood, no leucocyte esterase or nitrites (no clear urinary infection)
Blood cultures: taken (pending)
Abdominal ultrasound: Gallbladder with 1–2 mobile gallstones; gallbladder wall thickening to 5.0 mm; pericholecystic fluid present; sonographic Murphy's sign positive (non-visualization of CBD dilation)
HIDA scan (if ultrasound equivocal): non-filling of gallbladder consistent with cystic duct obstruction (confirmatory)

Diagnosis

Primary diagnosis:

Acute calculous cholecystitis
- Evidence: Acute RUQ pain radiating to right shoulder/back, onset ~48 hours ago, fever, leukocytosis, elevated CRP, positive clinical Murphy's sign, ultrasound showing gallstones, gallbladder wall thickening and pericholecystic fluid.

Differential diagnoses (and reasoning):

Biliary colic: typically shorter episodes of severe pain without fever or marked inflammatory markers; less likely given fever, raised WBC/CRP and ultrasound inflammatory changes.
Ascending cholangitis: would expect jaundice and biochemical cholestasis (elevated bilirubin, ALP); absent here, so less likely currently.
Acute pancreatitis: pain more epigastric radiating to the back with elevated amylase/lipase — normal here.
Peptic ulcer disease / gastritis / GERD: usually epigastric, related to meals or antacids, less likely to cause fever, leukocytosis and ultrasound findings.
Right lower lobe pneumonia with referred abdominal pain: chest exam and CXR would show focal consolidation; exam normal here.

Management

Admit for inpatient care and surgical review.
NPO (nil by mouth) and IV fluids for hydration.
Analgesia: IV paracetamol and consider IV opioid (e.g., morphine) if pain uncontrolled; avoid NSAIDs if renal dysfunction or other contraindications.
Antiemetic as required (e.g., ondansetron).
Empirical broad-spectrum IV antibiotics covering gram-negative enteric organisms and anaerobes (e.g., ceftriaxone plus metronidazole OR piperacillin-tazobactam), adjusted for allergy (penicillin allergy — consider ciprofloxacin + metronidazole or other regimen guided by microbiology).
Blood cultures before antibiotics where possible.
Urgent surgical consultation for early laparoscopic cholecystectomy — ideally within 72 hours of symptom onset if patient is fit for surgery.
If patient is high surgical risk or septic and not suitable for immediate surgery, consider percutaneous cholecystostomy as temporizing measure.
DVT prophylaxis and routine post-op planning (fasting time, consent, anaesthetic assessment).
If ultrasound inconclusive, consider HIDA scan to confirm cystic duct obstruction.
Plan to review LFTs and inflammatory markers serially and tailor antibiotics to culture results.

Key Learning Points

Typical acute calculous cholecystitis presents with RUQ pain, fever, leukocytosis, positive Murphy's sign and supportive ultrasound findings (gallstones, gallbladder wall thickening, pericholecystic fluid).
Differentiate cholecystitis from biliary colic (inflammatory markers and imaging) and from ascending cholangitis (look for jaundice and cholestatic LFT pattern).
Early surgical management (laparoscopic cholecystectomy within 72 hours) is recommended for most fit patients; provide initial resuscitation, analgesia and appropriate IV antibiotics while arranging surgery.