General Surgery Station 4

Setting:

You are a junior doctor working in Surgical Assessment Unit. This patient presents with abdominal pain.

Name: Michael Moore

Tasks:

1. Take a history from the patient.

2. State the investigations you would like to the examiner.

3. State you differential diagnosis to the examiner.

4. Interpret the results to the examiner.

5. State your management to the examiner.

You are not required to examine the patient.

Briefing

Diagnosis: Renal colic presenting with abdominal pain
You are Michael Moore (age 32).
You have presented to the surgical assessment unit with abdominal pain.

Appearance and Behaviour

Please act like you are in severe pain on the right side, and therefore cannot sit still or get comfortable..

Opening statement

Doctor, I have such severe pain, I can’t get comfortable. Please help me.

Information to Give Freely

It all started in the night, it woke me up. Such horrible pain on my right side, I’ve never had anything like it.

Presenting Complaint

Site – the right flank
Onset – Unsure as it woke me from sleep about 18 hours ago.
Character – comes and goes in waves. Is it very sharp and crampy when it’s bad, then it fades away to a dull ache.
Radiates - to the right groin
Associated symptoms – one episode of vomiting, feels nauseous. Has felt hot and cold, but doesn’t own a thermometer. Some dysuria and haematuria for the past 12 hours.
Timing – it has stayed the same since onset. No triggers you can think of.
Exacerbating/relieving factors - nothing makes it better or worse, paracetamol doesn’t help.
Severity< – 10/10 severity, worst pain you have ever had.

Past Medical History

Previous similar episodes - nil
Other medical conditions - nil
Previous surgeries - surgery on arm at 15yo after breaking it.

Drug History

Prescribed - nil
Over the counter - paracetamol
Allergies - NKDA

Family History

Nil significant that you can think of.

Social History

Smoking - You've never smoked
Alcohol - You don't drink very often at all, only at weddings.
Home - lives with wife at home, works as estate agent.
Mobility - fully mobile
ADLs - independent

Systems Review

General/red flags - Hot and cold spells
Neuro - Nil
Resp - NO breathlessness
Cardio - NO Palpitations or chest pain
GI - Vomitting and nausea, NO haematemesis, NO melaena
GU - Dysuria and haematuria present for past 12 hours. NO increased frequency or urgency.
Joints - NO joint involvemnet

Ideas / Concerns / Expectation

Ideas - I honestly have no idea
Concerns - I’m worried the pain isn’t going to go away, nothing is helping it
Expectations - Please help this pain stop, that’s all I want

Discussion / Questions

If you don’t feel the candidate is reflecting back that they will get you pain medication, you can get angry (this is at your discretion from glaring disapprovingly to screaming) but settle down when they say they will help you.

Please interpret these results

Name: Michael Moore

Age: 32

Date of Results:

Observations
NEWS	1
Respiratory Rate	16
Heart Rate	71
Blood Pressure	131/71
Oxygen Saturation	98% on Room Air
Temperature	38.4

Blood	Value	Normal Range
White Cell Count	12.9x109/L	4.0-11.0 x109/L
CRP	32 mg/L	<5 mg/L
Sodium	143 mg/L	135-145 mg/L
Potassium	3.8 mg/L	3.5-5 mg/L
Urea	11.9 mg/L	2-7 mg/L
Creatinine	132 umol/L	55-120 umol/L
eGFR	80 umol/L	>90 ml/min

Urinalysis
Hb	+++
Leu	++
Nitrites	Positive
Protein	Negative
Ketones	Negative