1. Use medical/clinical terminology — replace lay terms with proper anatomical or clinical descriptors.
2. Be brief — one sentence, no more than 10–15 words.
3. Include duration — always state how long the symptom has been present.
4. List all major complaints — if there are multiple, separate them with commas.
5. Use the patient's primary symptoms — not your interpretation or diagnosis.

• "Burning epigastric pain, intermittent fever, and vomiting after meals × 1 month."
• "1-month history of epigastric burning, on-and-off fever, and postprandial emesis."

Subjective (S) — History of Presenting Illness

Written Narrative Form (for SOAP note):

The patient is a known hypertensive for 10 years who presents with a 1-month history of burning epigastric and left upper quadrant pain, rated 7/10 in severity. The pain began gradually approximately 1 month prior to admission. She reports associated postprandial vomiting (after every meal), intermittent fever, chest pain, and shivering in hot weather. She also notes bilateral nocturnal leg cramps. Symptoms are partially exacerbated by eating, with some relief noted when consuming porridge. She sought GP consultation in the first week of symptom onset and was prescribed medications, which provided minimal relief. Her background history is significant for hypertension, diagnosed 10 years ago.

• The shivering in hot weather may indicate rigor/chills — worth clarifying whether this accompanies the fever episodes (suggesting a febrile rigour pattern).
• Bilateral leg cramps at night in a hypertensive patient could suggest electrolyte imbalance (e.g., hypokalemia from diuretics) or peripheral vascular issues — worth documenting her antihypertensive medications.
• Postprandial vomiting + burning epigastric pain + 1 month raises concern for peptic ulcer disease or gastritis — important to document in the Assessment section.

Specific Physical Examinations for This Patient

1. General Inspection

• Assess depth of jaundice — scleral icterus, skin yellowing (face, trunk, palms)
• Look for pallor (hemolytic cause), cachexia, or signs of weight loss
• Skin findings: spider telangiectasias, palmar erythema, xanthelasma, bruising (coagulopathy)
• Urine and stool color history — dark urine / pale stools suggest obstructive jaundice

2. Vital Signs

• Temperature — confirm intermittent fever pattern; high fever + jaundice = cholangitis until proven otherwise
• BP — monitor given known hypertension × 10 years
• Pulse, RR, O₂ saturation

3. Abdominal Examination (most critical)

• Abdominal distension, visible peristalsis, prominent veins (caput medusae → portal hypertension)

• Bowel sounds (reduced = ileus, increased = obstruction)
• Hepatic/renal bruits (relevant in hypertensive patient)

• Epigastric tenderness — epigastric pain + burning suggests peptic ulcer disease or gastritis
• Right upper quadrant (RUQ) tenderness — Murphy's sign (cholecystitis)
• Hepatomegaly — palpate from RIF upward; span >12 cm on percussion = hepatomegaly
• Splenomegaly — begin with percussion in LUQ for dullness, then palpate (patient may be in right lateral decubitus)
• Courvoisier's sign — palpable, non-tender gallbladder + jaundice = obstructive jaundice (pancreatic head carcinoma)
• Ascites — shifting dullness, fluid thrill (sign of portal hypertension / advanced liver disease)

• Liver span (upper border by percussion; edge by palpation)
• Splenic dullness in LUQ

4. Neurological / Hepatic Encephalopathy Screen

• Asterixis (liver flap) — ask patient to extend arms and dorsiflex wrists; flapping tremor = hepatic encephalopathy
• Orientation and mental status

5. Eyes

• Scleral icterus — yellowish discoloration of sclerae (earliest visible sign of jaundice)
• Kayser-Fleischer rings — if Wilson disease is suspected (rare but important)

6. Lymph nodes

• Virchow's node (left supraclavicular) — suggests GI malignancy
• Troisier's sign — enlarged left supraclavicular node

7. Hands & Periphery

• Palmar erythema — chronic liver disease
• Leukonychia / Terry's nails — hypoalbuminemia (liver disease)
• Dupuytren's contracture — associated with liver cirrhosis
• Peripheral edema — dependent pitting edema (portal hypertension / hypoalbuminemia)
• Leg cramps — assess calves for tenderness; check tone and reflexes (electrolyte imbalance from antihypertensives?)

8. Cardiovascular

• Assess for rub or murmur (she has chest pain — rule out pericarditis, cardiac cause)
• JVP elevation (fluid status)

Summary Table

Provisional Diagnoses & Differential Diagnoses

⭐ Provisional Diagnoses (Most Likely)

1. Acute Cholangitis

• ✅ Fever (intermittent, with shivering/rigors)
• ✅ Jaundice
• ✅ Abdominal pain (RUQ/epigastric)

2. Choledocholithiasis (Common Bile Duct Stones)

• Biliary obstruction → jaundice
• Biliary tract infection → fever, rigors
• Ductal distension → epigastric/RUQ pain
• Nausea and vomiting

3. Acute Cholecystitis

• ✅ RUQ/epigastric pain
• ✅ Fever
• ✅ Nausea and vomiting
• ⚠️ Jaundice — less typical in pure cholecystitis unless complicated by Mirizzi syndrome (stone in cystic duct compressing the common hepatic duct)

Differential Diagnoses (Alternative Possibilities)

Clinical Priority Summary

Most Urgent to Exclude:
1. Acute Cholangitis (Charcot's Triad present)
2. Choledocholithiasis
3. Acute Cholecystitis

Must Not Miss:
4. Pancreatic Head Malignancy (painless jaundice variant)
5. Liver Abscess

Common but Less Urgent:
6. Peptic Ulcer Disease
7. Viral/Drug-induced Hepatitis

Immediate Investigations to Support Diagnosis

Percussion Findings

1. Liver

2. Gallbladder / RUQ

3. Spleen (LUQ — relevant given LUQ pain)

4. Ascites

5. Epigastric / General Abdomen

Summary of Expected Percussion Findings in This Patient

Liver       → Dull, span likely >12 cm (hepatomegaly)
RUQ         → Tender percussion (Murphy's percussion sign)
Traube's space → Possibly dull (splenomegaly if portal HTN)
Abdomen     → Shifting dullness (check for ascites)
Epigastric  → Dull/tender over enlarged liver

Case Summary, Investigations & Treatment Outline

📋 Case Summary

🔬 Investigations & Expected Results

Bloods

Urine

Imaging

💊 Treatment Outline

Phase 1 — Immediate (Emergency Stabilisation)

• IV access + IV fluids — resuscitation, correct dehydration from vomiting
• NBM (Nil By Mouth) — rest GI tract, prepare for possible ERCP
• Blood cultures — take BEFORE starting antibiotics
• IV antibiotics (empirical, broad-spectrum) — target gram-negative rods:
  • Piperacillin-tazobactam OR ceftriaxone + metronidazole
  • Duration: 4–7 days after source control; 14 days if bacteraemia confirmed
• Analgesia — IV paracetamol or opioid analgesia for pain 7/10
• Antiemetics — metoclopramide or ondansetron for vomiting
• Monitor: Vitals, urine output, LFTs, FBC daily

Phase 2 — Biliary Drainage (Definitive)

• Preferred method for biliary drainage
• Allows stone extraction + stent placement to re-establish bile flow
• Drainage within 24 hours of diagnosis is associated with improved survival

Phase 3 — Definitive Surgery (Elective)

• Laparoscopic cholecystectomy — after acute episode resolves, to prevent recurrence
• Ideally performed during the same admission or within 6 weeks

Phase 4 — Managing Co-morbidities

Summary Flow

Jaundice + Fever + Abdominal Pain
         ↓
Charcot's Triad → Suspect Acute Cholangitis
         ↓
Blood cultures → IV Antibiotics → Abdominal USS
         ↓
CBD dilated + stones confirmed
         ↓
ERCP within 24–48 hours (stone extraction + stent)
         ↓
Recover → Elective Laparoscopic Cholecystectomy

In Clinical Note / SOAP Format:

"The patient was catheterised with a urethral catheter in-situ, draining dark amber/cola-coloured urine into the urine drainage bag."

Breakdown — What to Include:

Full Example in General Examination Write-up:

"On general examination, the patient was alert and conscious, lying comfortably in bed. She appeared jaundiced with icteric sclerae. She was catheterised with a Foley catheter in-situ, connected to a urine drainage bag containing dark cola-coloured urine, consistent with bilirubinuria. No signs of haematuria noted."

Key Clinical Points to Add:

• Dark urine (bilirubinuria) in this patient supports obstructive jaundice — always note the colour
• If urine output is being monitored (as it should be in cholangitis), state: "urine output adequate at approximately ___ mL/hr"
• If the urine bag shows sediment or cloudiness, document that too — it may suggest UTI or pyuria