General Surgery Station 5

Setting:

You are a junior doctor working in A&E. This patient has presented with abdominal pain.

Name: Sophie Bungard

Tasks:

1. Take a history from the patient.

2. Interpret the investigations to the examiner.

3. State your top diagnosis and 2 differentials to the examiner.

4. State your management to the examiner.

You are not required to examine the patient.

Briefing

Diagnosis: Appendicitis presenting with acute abdominal pain
You are Sophie Bungard (age 20).
You have presented to the Emergency Department with abdominal pain.

Appearance and Behaviour

Act like you’re in significant pain…we’re sure you have the ‘act like a student bit’ down so go give your best Oscar winning performance of 'Generic Uni Student 1'.

Opening statement

I’m having this horrible stomach pain, it’s getting worse and I can’t stand it anymore

Information to Give Freely

It’s really bad, it started yesterday night and I just feel awful so I came into hospital this morning.

Presenting Complaint

Site – right lower abdomen. However if specifically asked: say that it started around your belly button, and then moved to the right lower abdomen this morning.
Onset – started at 10pm last night, came on within half an hour, no triggers.
Character – dull ache, constant, turns to stabbing if I move.
Radiation – no radiation.
Associated symptoms – 2 episodes of vomiting (no blood, just stomach contents), had a fever of 38C overnight, anorexia. Bowels normal. Urine normal.
Timing – it has worsened since onset
Exacerbating/relieving factors – no relieving factors, but is worse on movement and things like coughing. The speed bumps on the car ride over were absolute agony. Paracetamol did not help.
Severity – currently is a 7/10, started at about 4/10.
Gynae - No PV bleeding/discharge. LMP: 3 weeks ago (usually is regular at 28 days). Is on the progesterone only pill so doesn’t think she is pregnant, no sex for 5 months.

Past Medical History

Previous similar episodes - nil
Other medical conditions - anxiety
Previous surgeries - nil

Drug History

Prescribed - combined oral contraceptive pill
Over the counter - paracetamol
Allergies - nil

Family History

Your grandad had diverticulitis that caused him a lot of abdominal pain.

Social History

Smoking - socially (around 5 cigarettes per month)
Alcohol - socially (about 1 bottle of wine per month)
Home - lives in flat with university housemates (studying psychology)
ADLs - fully independent

Systems Review

General/red flags - Fevers
Neuro - Nil
ENT - Nil
Resp - Nil
Cardio - Nil
GI - Vomiting with NO haematemesis. Anorexia present. NO malaena
GU - NO increased frequency, urgency, dysuria, or haematuria

Ideas / Concerns / Expectation

Ideas - Food poisoning?
Concerns - Am I pregnant? I know some people can become pregnant without knowing!
Expectations - Please make the pain go away!

Discussion / Questions

If the candidate mentions you having surgery, then you can become scared and upset as you are afraid of hospitals, especially staying overnight. You respond to them well if they offer clear and calm explanations.

Please interpret these results

Name: Sophie Bungard

Age: 20

Date of Results:

Observations
NEWS	3
Respiratory Rate	16
Heart Rate	98
Blood Pressure	98/62
Oxygen Saturation	97% on Room Air
Temperature	37.8

Blood	Value	Normal Range
Haemoglobin	121 g/L	120-155 g/L
White Cell Count	11.9x109/L	4.0-11.0 x109/L
CRP	72 mg/L	<5 mg/L
Sodium	141 mg/L	135-145 mg/L
Potassium	3.9 mg/L	3.5-5 mg/L
Urea	5.3 mg/L	2-7 mg/L
Creatinine	92 umol/L	55-120 umol/L
eGFR	110 umol/L	>90 ml/min