You are an FY2 in the emergency department   

Personal Details:

Name: Michael Johnson

Age: 46

Medical Record:

Past medical history: None.

Regular medication: None.

Allergies: None known.

Notes:

A 46-year-old man presents to the Emergency Department with a 5-hour history of severe right flank pain. He is visibly distressed and unable to get comfortable. An initial dose of diclofenac has not helped.

Initial assessment by the nurse:

BP 120/80 RR 18 HR 78 T 37 SPO2 98 

Urine dip: +++ blood, nitrate -ve, leucocyte -ve, protein -ve 

Abdominal examination: mild tenderness on the right lower abdomen, no guarding or rigidity, no rebound tenderness, no lumps or swelling.

Task:

1. Take a focused history of his pain and discuss the likely diagnosis.

2. Discuss the management plan

Opening Sentence: “Doctor, you’ve got to help me. This is the worst pain I’ve ever had in my life.”

Open History (to give freely): “It came on suddenly about five hours ago, this agonising pain in my right flank. It comes in waves, and I can’t sit still. It’s moving down into my groin now. I feel like I’m going to be sick, and I’ve already thrown up twice.”

Cues to give: “The nurse gave me a painkiller, but it’s done nothing at all.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I don’t know what it is. I thought I’d pulled a muscle, but it’s too severe for that.”

Concerns: “What is causing this much pain? Is it something serious?”

Expectation: “I need something strong for the pain, and I want to know what’s going on.”

How to Act: You are in severe pain. You are restless, pacing, and unable to find a comfortable position. You are focused only on the pain.

More History (only if asked): You have also had some pain when passing urine. You have not seen any blood in the urine. You have no other medical problems. You are a smoker and drink alcohol socially.

Social History: Works as a delivery driver.

Questions to ask:

“A kidney stone? How did I get that?”

“What are you going to do now?”

Opening & Acknowledging Pain: Michael, I can see you are in agony. We are going to get you some strong pain relief right now. While we do that, can you tell me what happened?

History of Presenting Complaint (SOCRATES): Where did the pain start? In your back? Was it a sudden onset? What does the pain feel like? Is it constant or does it come in waves? Does it move anywhere? You said it’s going into your groin? Apart from the vomiting, have you had any other symptoms? Any problems passing urine? Any blood in the urine? On a scale of one to 10, with 10 being the worst pain imaginable, where would you put this pain?

Associated symptoms: Have you had any fever?

Past Medical History: Have you ever had anything like this before?

ICE (Ideas, Concerns, Expectations): What did you think could be causing such severe pain? What’s your biggest worry right now? You need strong pain relief. What else were you hoping for from us today?

Explain the situation, the likely diagnosis or DD:

Michael, I can see you are in an incredible amount of pain, and we are going to get on top of that for you right now. The type of pain you are describing – the sudden onset, the severity, the fact that it comes in waves and moves from your loin to your groin, in addition to presence of blood in urine suggest what we call a renal colic. This is caused by a small stone, which has formed in your kidney, trying to pass down the narrow tube to your bladder.

Addressing and answering the patient’s ICE:

The pain is so severe because the stone is scraping its way down and causing the tube to spasm. It is known to be one of the most painful conditions you can have. Kidney stones are very common, and often we don’t know exactly why one person gets them, but not drinking enough fluids can be a factor.

Next Steps:

My immediate priority is your pain. The painkiller you had, diclofenac, is a good first choice, but as it hasn’t worked, we are going to give you something much stronger, like morphine, through a drip in your arm. We will also give you some anti-sickness medication. At the same time, we will do some blood tests to check your kidney function and check for any signs of infection.”

Once we have your pain under control, we need to get a picture to see exactly where the stone is. The best test for this is a CT scan, which is a special type of X-ray. We will arrange this for you today. Most stones are small enough to pass by themselves with the help of strong painkillers and by drinking plenty of water. If the stone is too large to pass, the urology specialists may need to intervene to break it up or remove it.

So, the plan is: strong painkillers now, blood test, a CT scan to confirm the diagnosis, and then a decision on whether you can go home to pass the stone or if you need to be admitted for the specialists to get involved.

Addressing ideas, concerns, and expectations: Acknowledge the severity of his pain. Provide a clear and confident diagnosis of renal colic. Manage his expectation for immediate pain relief.

The management is a clear, stepwise plan for an acute medical emergency. 1. Provide strong analgesia (IV opiates) and antiemetics. 2. Perform investigations (blood tests, urine dipstick). 3. Arrange the definitive investigation (urgent non-contrast CT KUB). 4. Explain the role of the urology team.

What is scenario testing? This case tests the candidate’s ability to recognise and manage a common and very painful acute medical emergency. The priority is demonstrating an immediate and effective plan for analgesia. It also tests knowledge of the correct investigation pathway (CT KUB is the gold standard).