You are an FY2 in the emergency department
Personal Details:
Name: John Smith
Age: 55
Medical Record:
Past medical history: None known.
Regular medication: None.
Allergies: None known.
Notes:
A 55-year-old man presents to the Emergency Department with a two-month history of worsening abdominal distension.
Task:
1. Take a focused history.
2. Perform an abdominal examination.
3. Discuss the likely diagnosis and discuss the management plan.
Opening Sentence: “Doctor, my stomach is aching and has been swelling up like a balloon for the last couple of months, and it’s getting worse.”
Open History (to give freely): “I used to be quite slim, but now I look like I’m pregnant. It’s really uncomfortable. I haven’t had any pain or other problems, just this swelling.”
Cues to give: “I work in a pub, so I have a few drinks after my shift.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I thought maybe I was just putting on weight, but it’s all on my belly. It feels like it’s full of water.”
Concerns: “Is it something serious? Is it cancer?”
Expectation: “I want to know what’s causing it”
How to Act: You are anxious and uncomfortable. You are a bit cagey about your alcohol intake initially.
More History (only if asked): You have no other symptoms, such as a change in bowel habits or vomiting. You feel generally well. When asked about alcohol, you admit to drinking “almost every day” and having a bottle of vodka over the weekend. You have been drinking heavily for many years. You smoke 10 cigarettes a day.
Social History:
Occupation: Pub landlord.
Alcohol: Admits to 1 bottle of vodka over the weekend plus daily drinks (likely >100 units/week).
Smoking: 10/day for 20 years.
Questions to ask:
“So you think it’s my liver because of the drinking?”
“What tests will I need?”
Examination findings: a distended abdomen with shifting dullness, suggestive of ascites.
Explain the likely diagnosis or DD:
John, thank you for coming in. That sounds very uncomfortable for you.
(After examination, which would show a distended abdomen with shifting dullness, suggestive of ascites)
I’ve examined your abdomen, and as you suspected, it does feel like it is filled with fluid. This condition is called ascites. There are a few causes for this, but given your history of heavy, long-term alcohol use, the most likely cause is liver disease. Years of heavy drinking can cause the liver to become scarred and damaged, a condition called cirrhosis, which then causes fluid to build up in the abdomen.
Addressing and answering the patient’s ICE:
You’re worried this could be cancer, and that is a possibility we have to consider, but liver disease from alcohol is a much more common cause of this picture. We need to do some tests to be sure.
Next Steps:
You will need to be admitted to the hospital today for investigations. We need to do some blood tests to check your liver and kidney function, your blood count, and your clotting. The most important test will be an ultrasound scan of your abdomen. This will give us a clear picture of your liver and confirm the fluid. We may also need to take a small sample of the fluid from your abdomen with a needle, which we can test.
Lifestyle changes
I have to be very direct with you. The most important thing you can do for your health is to stop drinking alcohol completely, starting from today. Continuing to drink will cause further damage to your liver. We have a specialist alcohol liaison team here in the hospital who can come and see you to provide support, advice, and medication to help you stop safely.
Possible next steps
Once we have the results of the tests, we can make a clear plan. This will likely involve starting you on some medication called water tablets, or diuretics, to help your body get rid of the excess fluid, and making a referral to the liver specialists.
History of Presenting Complaint
Tell me more about this swelling. When did you first notice it? Has it been getting progressively worse? Have you had any other symptoms along with it? Any pain, shortness of breath, or changes in your bowel habits?
Have you noticed any yellowing of your skin or eyes, any itching, or any confusion?
Alcohol History (Non-judgmental): You mentioned you work in a pub and have a few drinks. Can you tell me a bit more about your usual pattern of drinking? What do you typically drink, and how much would you get through on an average day? What about on a weekend? Have you ever felt you needed to cut down on your drinking?
Exploring Other Causes: Just to be thorough, I need to ask a few other questions. Have you ever used intravenous drugs or had a tattoo in a non-professional place?
Have you travelled anywhere outside of the UK recently?
ICE (Ideas, Concerns, Expectations): You said it feels like it’s full of water. What were your thoughts on what might be causing that?
Your main worry is that it could be cancer. What made you think of that?
What were you hoping we could do for you today?
Addressing ideas, concerns, and expectations: Provide a clear, likely diagnosis linking it to his alcohol use. Acknowledge his fear of cancer but frame it as a less likely possibility.
The management is admission for investigation. The plan should include: 1. Blood tests (LFTs, U&Es, FBC, clotting). 2. An ultrasound scan of the abdomen. 3. Referral to the alcohol liaison team. 4. Referral to the gastroenterology/hepatology team.
What is scenario testing? This case tests the candidate’s ability to link a clinical presentation (ascites) with a social history (alcohol abuse) to form a diagnosis. It requires a non-judgmental approach to history-taking and the ability to give firm, life-changing advice (stop drinking) while initiating a clear plan for inpatient investigation.