Paediatrics Station 3

Setting:

You are a junior doctor working in A+E. A mother has brought her son in because he is complaining of abdominal pain.

Name: James Smith

Tasks:

1. Take a history from the patient’s mother.

2. Give your top 3 differential to the examiner.

3. Suggest 3 targeted initial investigations to the examiner with clinical justification for your requested investigations.

4. Give your initial management plan to the examiner.

You are not required to examine the patient.

Briefing

Diagnosis: Appendicitis
You are Lucy Smith, James’ mother. James is 8 years old and has been complaining of tummy pain for the last 2 days. You have brought him to A&E today because you are worried it’s getting worse.

Parent Name - Lucy Smith (age: 33)

Patient Name - James Smith (age: 8)

Opening statement

“James has been complaining of tummy pain for the last couple of days and it seems to be getting worse. I thought I’d better get him checked out to make sure it’s nothing serious.”

Information to Give Freely

It started two days ago when he was getting ready for school. He mentioned he had a tummy ache. I thought it might be nerves, because he had a test at school that day, so didn’t think much of it. But it hasn’t gone away and now he seems really sore and just looks a bit unwell, he’s not his usual self.

Presenting Complaint

Site – pain started around the middle of his belly but now he is pointing more to his lower right side of his tummy
Onset – gradually came on two days ago in the morning, when getting ready for school
Character – – initially he described it as an ache but for the last few hours he has been saying it feels like he’s been stabbed and is clutching his tummy
Radiation – he hasn’t complained of pain anywhere else
Associated symptoms – he has vomited 3 times over the past 24 hours (foodstuffs only, no bile or blood) and has not eaten or drunk much over the past 2 days. He also had a temperature this morning and did a loose stool this morning. He is lethargic and the mother is concerned that he is not his normal self.
Timing – it is definitely getting worse over time and never goes away
Exacerbating/relieving factors - he says it's really sore to walk and has been curled up on the sofa all morning. He has had paracetamol and ibuprofen but these don’t seem to be working very well.
Severity - I think when it started it was probably a 4/10 but now he says it is 9/10

Key Paediatric History Points

Birth - born at 38+6 weeks. Vaginal delivery - spontaneous. No antenatal or postnatal complications. No admission to NICU.
Immunisations - up to date.
Nutrition/feeding - usually has a good appetite and eats a healthy diet, he has not eaten in 24 hours due to nausea and vomiting
Development - no concerns in any of the 4 domains

Past Medical History

No episodes like this before
Other conditions - Nil

Drug History

Prescribed - Nil
No over the counter meds - paracetamol and ibuprofen has been used for the stomach ache, it did not help
Allergies - Nil

Family History

No relevant history

Social History

Who’s at home - lives with mum, dad and two younger sisters + 2 dogs
Smokers in the house? - No
Housing situation - Fixed abode
Social service involvement - No
School - in P4, enjoys school, has lots of friends

Systemic Review

General/red flags - Fever for last 24 hours, appears lethargic and not normal energetic self. As a parent YOU ARE CONCERNED.

Neuro - nil

ENT - nil

Resp - nil

Cardio - nil

GI - loose stool this morning (usually opens bowels regularly every other day), 3x vomits, no testicular pain

GU - nil

Joints & skin - nil

Ideas / Concerns / Expectation

Ideas - “I’m wondering whether this is just a sick bug or whether it could be something more serious?”
Concerns - “I’m worried it's not getting better and that he now seems unwell”
Expectations - “I would like to know what’s causing his pain and what we can do to help him feel better”

Discussion

After the history is complete, the doctor will discuss their differential diagnosis, investigations they’d like and their proposed management plan. There will be no further input from the patient.