You are an FY2 in the emergency department
Personal Details:
Name: David Jones
Age: 35
Medical Record:
Past medical history: None.
Regular medication: None.
Allergies: None known.
Notes:
A 35-year-old man presents to the Emergency Department with a 5-day history of right-sided abdominal pain.
Task:
1. Take a focused history of the presenting complaint.
2. Perform a relevant examination.
3. Discuss the likely diagnosis and the immediate management plan.
Opening Sentence: “Doctor, I’ve got pain in my tummy. I feel awful.”
Open History (to give freely): “It started about five days ago, a dull pain on my right side. It comes and goes, but it’s been getting worse. I’ve been feeling really hot and shivery, and I’ve thrown up a few times. I took some paracetamol, but it’s not really helping.”
Cues to give: “I also noticed my pee is really dark, and when I went to the toilet this morning, my poo was almost white.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I thought it might be food poisoning, but it’s gone on for too long.”
Concerns: “Is it my appendix? What’s wrong with me?”
Expectation: “I need you to find out what’s wrong and give me something for the pain.”
How to Act: You are in visible pain and distress.
More History (only if asked): The pain is in the right upper part of your abdomen. It’s a 7/10 severity. You have no history of similar pain, no recent travel, and no significant past medical history.
You do not drink alcohol.
Social History: You work as an office manager.
Questions to ask:
“What do you think it is?”
“Do I have to stay in the hospital?”
Examination findings: diffuse abdominal tenderness, on deep palpation, significant in the right upper abdomen. No guarding or rigidity. No rebound tenderness.
Opening & Initial Assessment:
Hello David, I’m Dr. [Name]. You look like you’re in a lot of pain. Tell me what’s been happening.
History of Presenting Complaint (SOCRATES): Where exactly is the pain? Can you point to it? When did it start? What does the pain feel like? Is it sharp, dull, or cramping? On a scale of to , how bad is the pain right now? Does the pain travel anywhere else, for example, to your back or shoulder tip?”
You mentioned feeling hot and shivery and vomiting. How many times have you vomited? You also said your urine was dark and your stools were pale. When did you notice that? Is the pain constant, or does it come and go? Does anything make the pain better or worse?
What about eating?
Past Medical & Social History: Have you ever had any problems like this before? Have you ever been told you have gallstones? Do you have any other medical conditions? Have you travelled anywhere recently? How much alcohol do you usually drink in a week?
ICE (Ideas, Concerns, Expectations):
What were your own thoughts about what could be causing this?
What is your biggest worry right now?
What were you hoping we could do for you here in the Emergency Department?
Explain the possible diagnosis:
David, you’ve clearly been very unwell, and you’re in a lot of pain. Thank you for telling me everything. I’m going to examine your abdomen now, which will help us figure out what’s going on.”
(After examination)
When I pressed on the upper right side of your tummy, it was very tender. That, combined with your symptoms of fever, dark urine, and pale stools, makes me suspicious of a condition called acute cholangitis. This is an infection in the tubes that carry bile from your liver and gallbladder. It’s a serious condition that needs immediate treatment in a hospital.
Addressing and answering the patient’s ICE:
You were worried it might be your appendix, which is a sensible thought, but the location of the pain and the other symptoms, especially the changes in your urine and stool colour, point more towards a problem with your liver or bile ducts. We need to confirm this with some tests.
Next Steps:
My plan is to admit you to the hospital today. I will speak to my senior doctor.
We need to get some painkillers and fluids into you through a drip in your arm to make you more comfortable and hydrated. We will also take some blood tests to check your liver function and look for signs of infection. You will need to stay ‘nil by mouth’ for now, which means nothing to eat or drink, in case you need a procedure.”
I will let the surgeons know to come and see you. They will likely arrange an ultrasound scan or a CT scan of your abdomen to get a clear picture of your bile ducts and find out what’s causing the blockage and infection, which is often a gallstone.
So, to summarise: we are admitting you, giving you pain relief and fluids, running some tests, and getting the specialists involved. We will take good care of you.
Addressing ideas, concerns, and expectations: Acknowledge his pain. Provide a clear, suspected diagnosis. Explain why it’s not appendicitis. Confirm that he needs to be admitted.
The management is a clear, structured plan for admission: 1. Involve the senior. 2. IV access, fluids, analgesia. 3. Keep NBM. 4. Blood tests (FBC, U&E, LFTs, CRP, clotting, amylase). 5. Refer to the surgical/gastroenterology team for further investigation (e.g., ultrasound/CT) and management (e.g., ERCP).
What is scenario testing? This is a classic acute surgical abdomen station. It tests the candidate’s ability to take a focused history, perform a relevant examination (identifying Murphy’s sign and RUQ tenderness), formulate a likely diagnosis of a serious condition (acute cholangitis), and initiate a safe and appropriate immediate management plan.