General Surgery Station 1

Setting:

You are a junior doctor working in the surgical assessment unit. This patient presents with abdominal pain.

Name: Caroline Douglas

Tasks:

1. Take a history from the patient.

2. Interpret the initial investigations provided.

3. Give your preferred diagnosis to the examiner.

4. Give your initial management plan to the examiner.

You are not required to examine the patient.

Briefing

Diagnosis: Bowel Obstruction presenting with acute abdominal pain
You are Caroline Douglas (62 years old)
You have presented to the surgical assessment unit with abdominal pain

Appearance and Behaviour

Please act as if you are in significant pain.

Opening statement

“Well Doctor, I hate to be a bother but I have this pain in my tummy and it seems to be getting worse. I’m very worried about it”

Information to Give Freely

The pain is really quite bad, it’s all been going on for about 24 hours now. This has all come out of the blue - I just want to feel okay again.

Presenting Complaint

Site – Pain all over the abdomen.
Onset – Gradual onset over a few hours yesterday. Has lasted continuously for 24 hours now.
Character – Dull crampy pain, comes in waves but doesn’t go away completely at any point.
Radiation – none
Associated symptoms – Nausea, loss of appetite, 3x episodes of vomiting - yellow, bile coloured vomit. No blood, non-projectile. Bowels opened 4 days ago with no meleana/blood/diarrhoea/constipation. NO gas passed in the last 24hours. Some abdominal distension over the last 12 hours - describe it as “bloating” or swelling.
Timing – not worse at certain times of day. It has gotten worse since onset 24 hours ago.
Exacerbating/relieving factors - nothing makes it worse but I think if you pressed on my tummy it would hurt a lot, and I've tried paracetamol and it did not help.
Severity – ranges from 5/10 between waves to 9/10 during a wave.

Past Medical History

Previous similar episodes - Nil
Other medical conditions:

Hypertension

Type 2 diabetes

Obesity

Menopause aged 48 (No HRT used)

Currently in remission from stage 1 endometrial cancer diagnosed 15 years ago, no PV bleeding/problems since remission (did not receive chemo/radiotherapy, only surgery - see below).

Previous surgeries - Total hysterectomy 15 years ago due to stage 1 endometrial cancer.

Drug History

Prescribed medicationsAmlodipine, metformin.
Over the counter - Tried paracetamol for the pain - it didn’t do anything.
Allergies - None known

Family History

Nil relevant

Social History

Smoking - Ex-smoker (smoked 10/day for 30 years but stopped 15 years ago with her cancer diagnosis).
Alcohol - Drinks 2 units alcohol/week.
Occupation - Retired secondary school headmistress.
Home - Lives in a 2 story house with stairs and bannisters. Lives with partner.
ADLs - Fully independent. You don't feel you need any help.
Carers No input from any carers.

Systems Review

Red flags - no weight loss/fever/night sweats.
Neuro - no headaches/dizziness/weakness/visual changes.
Cardio - no chest pain/palpitations/ankle swelling/orthopnea.
Resp - no SOB/pain on breathing/calf pain.
Gastro - lots of nausea+vomiting (see SOCRATES), bowels opened 36 hrs ago with no blood/meleana/diarrhoea/constipation (see SOCRATES).
Urogynae - no urinary symptoms. Went through menopause at age 48, did not use HRT. No PV bleeding since hysterectomy.
MSK/derm - no joint pain/rashes/muscle pain.

Ideas / Concerns / Expectation

Ideas - "I don’t know what is going on, maybe it’s food poisoning?"
Concerns - "I’m quite worried that it might be my cancer somehow returning."
Expectations - "Please could you help me with the nausea and vomiting, it’s making me feel very unwell."

Discussion / Questions

At the point of ICE, you can ask “Do you think my cancer is back, Doctor?”.

You don’t want to bother anyone with coming to the hospital.

Please interpret these results

Name: Caroline Douglas

Age: 62

Date of Scan:

Time of Scan: 09:30am

Location: Radiology Department, City Hospital

Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org. From the case rID: 72508