Acute Abdominal Pain Station

Presenting Complaint:

Fatima complains primarily of severe abdominal pain concentrated in the lower right quadrant alongside persistent nausea. She states, "It started off as a dull ache, but now it's sharp and unbearable."

Symptoms:

- Site: Right lower quadrant - "It's right here on the lower right side, really piercing."

- Onset: Acute onset - "It started suddenly a few hours ago."

- Character: Sharp pain - "It feels like it's stabbing or something."

- Radiation: Initially central abdominal, progressed to localised pain - "Initially it was in the middle and a dull ache, but has now moved lower down to the right and is sharp."

- Associated Symptoms: Nausea and loss of appetite - "I also feel quite nauseous and just can't eat. I haven’t vomited yet"

- Timing: Continuous pain, progressing severity - "It just stays and doesn't go away. I think it’s getting worse."

- Exacerbating and Relieving Factors: Pain worsened by movement; no analgesia taken yet - "Any movement makes it worse."

- Severity: Severe pain, rated 8/10 - "It's about an eight on the painful scale."

Systemic Symptoms:

- Slightly feverish

- Night Sweats: None

- Unintended Weight Loss: None

- Chest or Shoulder Tip Pain: None

- Shortness of Breath or Cough: None

- Oedema: None

- Rashes or Skin Changes: None

- Headache: None

- Change in Bowel Habits: None

- Urinary symptoms: None

Past Medical History:

- No significant medical conditions

- No previous surgeries or hospitalisations

- No previous injuries or traumas

Drug History:

- No current medications

- No use of herbal supplements or alternative therapies

- Not on contraception or HRT

Allergies:

- Allergic to penicillin: Results in an itchy rash 

Family History:

- Mother: Hypertension

- Father: No significant illnesses

- No siblings with known medical conditions

Social History:

- Occupation: Software Developer, often works in a seated position

- Activities of Daily Living & Hobbies: Enjoys reading and arts, sedentary hobbies, balanced diet, walking and yoga

- Smoking: Non-smoker

- Alcohol: Drinks occasionally, 4 units per week

- Recreational Drug Use: None

- No travel history

Ideas, Concerns, and Expectations:

- Ideas: "I think it might be something serious with my stomach.”

- Concerns: "I’m worried this might mean surgery or a long recovery time."

- Expectations: "I’m hoping to get a clear diagnosis and treatment plan today to relieve this pain quickly."

Observations:

- Respirations (Breaths/min): 18

- Oxygen Saturation (%): 98

- Air or Oxygen: Room air

- Blood Pressure (mmHg): 118/76

- Pulse (Beats/min): 101

- Consciousness (AVPU): Alert

- Temperature (Celsius): 37.8

- NEWS Total Score: 1

Physical Examination:

General Inspection:

- Appears in distress due to pain.

- Normal body habitus.

- No jaundice

Hands:

- Colour: Normal

- No tar staining or finger clubbing

- Tremor: None

- Capillary refill time: Less than 2 seconds

- WWP

Face:

- No jaundice or conjunctival pallor.

- Oral cavity: No abnormalities noted.

Neck:

- JVP: Not raised

- No lymphadenopathy or masses detected

Chest:

- Appearance normal; no spider angiomas or scars

- Percussion: Normal

- Auscultation: Normal lung sounds, chest clear

Abdomen:

Inspection:

- No scars, bruising, or obvious distension.

- No visible peritonitis signs.

Palpation:

- Tenderness in the right lower quadrant

- Guarding present

- No rebound tenderness noted

- Rovsing’s sign: positive

- Psoas sign (if performed): positive

Percussion:

- Normal resonance

- Some percussion tenderness present

Auscultation:

- Normal bowel sounds

- No bruits

Other:

- No peripheral or sacral oedema

You are given the following tests results:

- White Blood Cell Count: Elevated at 14 x10^9/L (Normal: 3.6 - 11.0 x10^9/L)

- C reactive protein (CRP): Elevated at 57 mg/L (Normal: <10 mg/L)

- Urinalysis and pregnancy test: Normal

- ECG: sinus tachycardia

Choose EITHER patient questions OR examiner questions.

Patient Questions (1–6):

1. "Is this going to require surgery?"

- Possible Answer: "If this is appendicitis then it’s quite likely to require surgery with antibiotics, as this is the gold-standard treatment, but first we'll evaluate fully to be sure, as there are many causes of acute abdominal pain."

2. “What will the operation involve?”

- Possible answer: “Appendix operations are now usually done with keyhole surgery. First you will be put to sleep in the anaesthetic room. The surgeons will then make several small incisions in your abdomen, and using long instruments and a camera inside your abdomen they will take out your appendix. Then they stitch everything back up and wake you up after the operation.”

3. “What’s caused this to happen?”

- Possible answer: “Appendicitis most commonly occurs in younger people such as yourself. There are several possible causes: the most common is when a hard bit of poo blocks off the inside of the appendix, causing bacteria to multiply and leading to inflammation, swelling and loss of tissue vitality, eventually leading to bursting or perforation of the appendix if left untreated. Rarely the blockage can be caused by bowel tumours, which is why appendices are routinely sent to analysis in the lab afterwards”

4. “Is there anything that can go wrong in the surgery? Am I going to be ok?”

- Possible answer: “There are risks with every procedure we perform. The surgeons will explain these in greater detail, but in brief complications of appendicectomy can include bleeding, blood clot formation, infection typically of the surgical site lungs or urine, abscess formation, pain, sluggish bowels after surgery and damage to other structures within the abdomen. However, it is important to balance these against the risks of not undergoing surgery, which can be detrimental. Appendicectomy is one of the most common surgical procedures and prompt intervention typically results in very good outcomes.”

5. "How long will the recovery take?"

- Possible Answer: "Typically, full recovery to usual activities can take a few weeks after surgery. Length of stay in the hospital usually ranges from same day discharge to several days depending on how the surgery goes, and if any complications occur."

6. "Can I eat or drink anything before knowing more?"

- Possible Answer: "For now, let's hold off on eating until we get a clearer picture. You can take small sips of water. This is standard practice if there’s the possibility you might need a procedure or operation."

Examiner Questions (1–6):

1. “What are your key differentials?”

- Appendicitis – characteristic history of RLQ pain beginning centrally, examination findings consistent with this, pregnancy test negative. Most likely diagnosis and needs to be ruled out either with CT or exploratory laparoscopy.

- Gastroenteritis - Classically presents with systemic symptoms like diarrhoea +/- N+V which are absent here. Appendicitis may present with these symptoms as well, and a stool sample should be taken for culture in patients with loose stools.

- Urinary tract infection - Urinalysis here is normal and the history lacks urinary symptoms, making this less likely.

- Ovarian torsion - More common symptomatology in females but usually has different pain character.

-  Ectopic pregnancy - Negative pregnancy test in this case. Ectopic pregnancy can give a different symptom profile, for example PV bleeding.

-  Crohn's Disease - More likely if there is a more chronic history – this is an acute presentation.

Others may include: Constipation, Meckel’s diverticulum, IBS, Pancreatitis, Cholecystitis, Renal Colic etc as long as reason given why less likely.

2. "What are the key clinical signs indicating appendicitis in this case?"

- Possible Answer: "Right lower quadrant tenderness and guarding, positive Rovsing's and Psoas signs and percussion tenderness, indicating localised peritoneal inflammation."

3. "What further tests would you consider in diagnosing appendicitis?"

- Possible Answer: "Given the risks of delaying surgery in acute appendicitis, the decision to operate can be clinical alone, however selective imaging may be used in cases where the diagnosis is uncertain or other conditions need to be ruled out. These may include abdominal ultrasound, CT and/or exploratory laparoscopy. US is preferred in children and pregnant women to reduce radiation exposure, as well as in cases where gynaecological pathology is suspected. Sometimes MRI is used in cases where US is undiagnostic."

4. “What is the management of Appendicitis?”

- Presurgical resuscitation if necessary with analgesia, antiemetics, IV fluids and antibiotics. G&S +/- crossmatch.

- Surgical removal of the appendix (appendicectomy) is the gold-standard treatment. Laparoscopic (keyhole) surgery is now mainly used due to decreased pain, faster recovery, lower incidence of infection and overall improved quality of life scores.

- Perioperative antibiotics – some selected cases can trial management with antibiotics alone, without surgery e.g. high surgical risk, uncomplicated appendicitis (although importantly carries risk of recurrence).

- Pain management: Paracetamol, NSAIDs, Opioids – in accordance with WHO pain ladder.

- Postoperative care: encourage early mobilisation, optimise pain control and ensure adequate hydration and nutrition. Monitor for postoperative complications.

5. “How would you monitor this patient following surgery?”

- Review daily on ward rounds.

- Monitor vital signs regularly, especially post-surgery.

- Assess the surgical site for signs of infection, be aware of potential complications e.g. ileus, UTIs, atelectasis etc.

- Monitor white blood cell counts and CRP to track inflammation reduction.

6. "What are the potential complications of untreated appendicitis?"

- Possible Answer: "Complications of untreated perforation, peritonitis, appendiceal mass and abscess formation. Eventually, development of perforation and peritonitis can lead to sepsis and death if untreated."