Test Stations

Surgery / General Surgery: Appendicitis


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: FY1 doctor on the Surgical Assessment Unit (SAU)

Patient: 25 year old female patient has an acute history of lower abdominal pain

Task:
- Take a focused history from the patient
- After 6 minuets you will be asked a series of questions by the examiner.
- Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering to much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 25 year old female. You were out for dinner last night and felt a bit sick, with some abdominal pain, went home and went to bed. Woke up at 2am and vomited. You had severe abdominal pain much worse over the right hand side. You vomited again and was unable to sleep because of the pain. You decided to wait until the morning and booked an appointment with your GP, they have sent you straight into hospital and you don’t know what is going on. You are completely off your food, you have not had anything to eat and drink since yesterday evening.

If asked your periods are regular, you have just had your period over the last couple of days. You are not sexually active and take the combined pill. You do not think you could be pregnant.

Past Medical History

  • Asthma

Drug History

  • Salbutmaol when you need it
  • Combined oral contraceptive pill
  • If asked you are allergic to Clarithromycin (you have diarrhoea when you have this)

Social History

  • Drink socially on the weekends
  • You are a non-smoker and you have never smoked

Ideas, Concerns, Expectations & Feelings

  • You are worried about the pain as it does not seem to be getting any better.

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

CategoryQuestion
Done
Excellent
IntroductionCandidate appropriately introduced themselves with:
Full name
Role
Clarifies who they are talking to
Asks patient for preferred name


SOCRATESSOCRATES
Site
Onset
Characteristic
Radiation
Timing
Exacerbating and relieving factors
Severity


ExtraExtra history
Low grade fever
Loss of appetite


GI reviewGastrointestinal system review
Weight loss
Appetite
Dysphagia
Reflux / heartburn
Nausea or vomiting
Change in bowel habit


UI reviewUrinary system review
Increased frequency
Dysuria
Foul smelling urine
Incomplete emptying


EctopicExcludes ectopic pregnancy
Last period = 2/7 ago
Sexually active?
Contraception


PMHPast Medical History
Asthma
No previous operations


DHDrug History
Salbutamol + combined pill
Asks about drug allergies


SH + FH Social and Family History
Social history asked about (alcohol, smoking, residence)
Family history appropriately asked


ICEFICEF
Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions


QuestionWhat are your differentials for this patient given the history?
Appendicitis
Ovarian pathology = ovarian cyst, ovarian torsion, ovarian haemorrhage
Ureteric colic
Ectopic pregnancy
Strangulated inguinal hernia
Other appropriate answer


QuestionGiven the history, what investigations would you like to do?
Bloods = FBC, U&E, LFTs, CRP, Group and save
Pregnancy test
Urine dip


Question
Given the history and investigations, what is your working diagnosis?

Appendicitis


QuestionWhat clinical examination findings are associated with appendicitis?
McBurney’s sign
Localised rebound tenderness
Rovsing’s sign – compressing the left lower quadrant elicitis pain in the right lower quadrant
Psoas sign – pain is elicited with the patient lying on their left side and slowly extending the right thigh to cause a stretch in the iliopsoas muscle
Obturator sign – pain caused by internal rotation of the flexed right thigh


QuestionWhat is your management of this patient in A&E?
Nil by mouth (NBM)
Analgesia
IV ABx e.g IV co-amoxiclav 1.2G TDS
IV fluids
General observations every 4 hours
VTE Prophylaxis
TEDS
Other appropriate measure



Score


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