History Taking · Intermediate · Surgery

Right Upper Quadrant Pain with Fever and Tenderness

Practise this PLAB 2 history taking station on Acute Cholecystitis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the emergency department. Mrs Jia Lin, a 52-year-old woman, has presented with right upper quadrant pain, fever, and tenderness over the gallbladder region. Please take a focused history and discuss your initial assessment and management plan.

Background notes: PMH: Obesity, Type 2 diabetes, Hyperlipidaemia

What this station tests

  • Distinguishing cholecystitis from biliary colic: constant pain >6 hours with fever and tenderness versus episodic self-resolving pain
  • Screening for cholangitis: Charcot's triad (pain, fever, jaundice) and Reynolds' pentad (adds confusion and hypotension)
  • Murphy's sign as the clinical sign for cholecystitis: arrest of inspiration on RUQ palpation
  • USS abdomen as gold standard for gallstone diagnosis: stones, wall thickening, pericholecystic fluid
  • Early cholecystectomy: NICE recommends within 1 week rather than delayed (reduces recurrence and hospital stay)

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Right upper quadrant pain with fever and tenderness is acute cholecystitis until proven otherwise. The candidate must distinguish cholecystitis from biliary colic, cholangitis, and other surgical causes, and assess for sepsis. Mrs Lin is 52, presenting with 2 days of RUQ pain, fever, and nausea. She has obesity, diabetes, and hyperlipidaemia (risk factors for gallstones). Open with: 'Mrs Lin, I can see you are in pain. Tell me about the pain and the fever.'

Core approach

Characterise the pain. Started as vague ache 2 days ago, now severe and constant in the RUQ. Radiates to the right shoulder blade (referred pain via phrenic nerve). Worse with deep breathing, coughing, and movement. Worse after fatty food (the takeaway last night made it dramatically worse). She has had similar milder episodes after fatty meals previously (suggesting gallstones with previous biliary colic that has now progressed to cholecystitis).

Distinguish from biliary colic. Biliary colic: episodic, resolves within 6 hours, no fever, no tenderness on examination. Cholecystitis: constant pain lasting >6 hours, fever, RUQ tenderness with positive Murphy's sign (arrest of inspiration on palpation). Her constant pain and fever indicate cholecystitis, not simple colic.

Screen for cholangitis (ascending infection of the bile duct). Charcot's triad: RUQ pain plus fever plus jaundice. Check for jaundice: she has not noticed yellow skin or eyes, urine is normal colour. No jaundice makes cholangitis less likely, but check LFTs. Reynolds' pentad (adds confusion and hypotension) would indicate severe cholangitis requiring emergency ERCP.

Risk factors: she fits the classic 'F' mnemonic (though this is an oversimplification): female, fifty-ish, fat (obese), fertile. Her mother had gallstones. She has diabetes and hyperlipidaemia.

Closing and safety netting

Investigations: bloods (FBC, CRP, LFTs including bilirubin and ALP, amylase to exclude pancreatitis, lipase if available, blood cultures if febrile). USS abdomen (gold standard for gallstones: will show stones, gallbladder wall thickening, pericholecystic fluid). ECG (RUQ pain in a 52-year-old with diabetes needs cardiac exclusion).

Management: admission, IV fluids, IV antibiotics (per local protocol, typically co-amoxiclav or cefuroxime plus metronidazole), IV paracetamol, nil by mouth. Surgical review for cholecystectomy: NICE recommends early cholecystectomy (within 1 week of presentation) rather than delayed, as it reduces recurrence and total hospital stay.

Address her concerns: cancer is unlikely (gallstones, not tumour). Surgery: laparoscopic cholecystectomy is the definitive treatment ('keyhole surgery, usually home within 1 to 2 days'). Safety net: 'If you develop jaundice, worsening pain, confusion, or feel significantly worse, these could indicate a complication that needs urgent attention.' She is admitted, so monitoring is in-built.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for acute cholecystitis. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Cholecystitis distinguished from biliary colic (duration, fever, tenderness). Cholangitis screened (jaundice, urine). Previous episodes identified (biliary colic history). Risk factors noted. Pain characterised with radiation.

Costs marks: Not distinguishing from biliary colic. Not screening for cholangitis. Not asking about previous episodes. Not checking jaundice.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Admission with IV antibiotics and fluids. USS arranged. Amylase checked. Blood cultures if febrile. Early cholecystectomy discussed. ECG for cardiac exclusion in diabetic. Cholangitis safety netting.

Costs marks: Outpatient management. No USS. No amylase. No surgical referral. No cholangitis safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing cancer concern (gallstones not cancer). Explaining cholecystectomy practically (keyhole, 1-2 days stay). Acknowledging work and family impact. Honest about the need for surgery.

Costs marks: Not addressing cancer fear. Being vague about surgery. Not explaining what happens next.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not distinguishing cholecystitis from biliary colic. Biliary colic resolves within hours and does not cause fever. Cholecystitis is constant, febrile, and requires admission and antibiotics. Candidates who diagnose 'gallbladder pain' without making this distinction miss the severity assessment.
  2. Not screening for cholangitis. Cholangitis is a life-threatening complication requiring emergency ERCP. Candidates who do not check for jaundice and ask about urine colour miss this critical differential.
  3. Not ordering amylase. Gallstone pancreatitis is a complication that presents similarly. Amylase or lipase must be checked to exclude it. Candidates who investigate cholecystitis without checking amylase miss a potentially serious complication.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take an acute cholecystitis history in PLAB 2?

Right upper quadrant pain with fever and tenderness is acute cholecystitis until proven otherwise. The candidate must distinguish cholecystitis from biliary colic, cholangitis, and other surgical causes, and assess for sepsis. Mrs Lin is 52, presenting with 2 days of RUQ pain, fever, and nausea.

Where are marks won and lost in this acute cholecystitis station?

Examiners reward: Cholecystitis distinguished from biliary colic (duration, fever, tenderness). Cholangitis screened (jaundice, urine). Previous episodes identified (biliary colic history). Candidates are penalised for: Not distinguishing from biliary colic. Not screening for cholangitis. Not asking about previous episodes. Not checking jaundice.

Where do candidates most often go wrong in this station?

Not distinguishing cholecystitis from biliary colic. Biliary colic resolves within hours and does not cause fever. Cholecystitis is constant, febrile, and requires admission and antibiotics.

Can I do well in this station without real-world experience of acute cholecystitis?

This station rewards process over personal experience. The skill being assessed: Screening for cholangitis: Charcot's triad (pain, fever, jaundice) and Reynolds' pentad (adds confusion and hypotension). Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

Related cases