Refined and Complete History of Present Illness
Chief Complaint
76-year-old Chinese gentleman with diabetes mellitus, hypertension, and ischemic heart disease presenting with 3 days of severe right upper quadrant abdominal pain and 2 days of progressive jaundice.
History of Present Illness
Abdominal Pain Characteristics
- Location: Right upper quadrant
- Onset: Sudden, 3 days prior to presentation
- Quality: Colicky in nature
- Severity: 9/10 on pain scale
- Radiation: No radiation to back, shoulder, or other locations
- Timing: Worse postprandially, causing significant dietary restriction over the past 2 days
- Alleviating factors: None reported
- Aggravating factors: Meals
Associated Symptoms
- Jaundice: Progressive yellowing of sclera and skin over 2 days, suggesting obstructive biliary pathology 1
- Urine changes: Dark, "tea-colored" urine consistent with conjugated hyperbilirubinemia 2
- Stool changes: Pale-colored stools indicating reduced bile flow into intestinal tract 2
- Fever: Intermittent low-grade fever, predominantly evening occurrence, without rigors, chills, or night sweats (Charcot's triad incomplete; Reynolds pentad absent) 1
- Constitutional symptoms: Reduced oral intake for 2 days secondary to postprandial pain exacerbation
Pertinent Negatives
- Gastrointestinal: No nausea, vomiting, anorexia, weight loss, hematemesis, melena, abdominal distension, or pruritus
- Previous episodes: No prior similar episodes of RUQ pain or jaundice
- Cardiovascular: No chest pain, palpitations, or orthopnea (important given history of ischemic heart disease) 3, 4
- Respiratory: No shortness of breath or cough (excludes cardiac cause of jaundice) 5
- Peripheral: No lower extremity edema (argues against congestive hepatopathy) 5
Risk Factors and Relevant History
- Alcohol use: Chronic alcohol consumption, approximately one bottle per week; last drink 2 days before presentation (relevant for alcoholic hepatitis vs. biliary pathology) 2
- Medication history: No recent hepatotoxic medication use
- Travel history: No recent travel
- Comorbidities:
Clinical Impression Based on Presentation
This presentation is highly suggestive of acute cholangitis or choledocholithiasis with biliary obstruction 1, 2. The combination of RUQ colicky pain, jaundice, dark urine, pale stools, and low-grade fever constitutes an incomplete Charcot's triad (fever, jaundice, RUQ pain), warranting urgent imaging with right upper quadrant ultrasound as the initial study 1, 2. The postprandial exacerbation pattern is classic for biliary colic 8. Alternative diagnoses including acute cholecystitis, hepatic congestion from cardiac disease, or alcoholic hepatitis must be considered but are less likely given the clinical pattern 1, 5.