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You are the FY1 on call for surgery on nights. A GP out of hours clinic has just handed over a patient to you, Mr Al Opecia. He is a 21 year old man who has no past medical problems. He has presented with pyrexia and abdominal pain. The GP is concerned that the gentleman might have appendicitis. Al is not on any regular medication, and the GP has not started any medication either.

Please take a history from Al and perform the appropriate examination. Ensure that you undertake a relevant history of presenting complaint and address his concerns.

You are Al Opecia, a 21 year old psychology student. You are pretty terrified at the moment as you have never really been unwell before, let alone admitted to hospital. Your psychology finals exams are starting next Wednesday, and this week was already stressful enough!

HPC: You first started feeling unwell two days ago, when you really didn’t feel yourself. Since then, things have gotten worse as you have had hold and cold episodes, and really bad stomach pain. You threw up once or twice, but this was mostly due to not being able to keep your food down.

The pain is worst on your right hand side. It started down in your lower abdomen but has since moved to your right side and your back. It moves down to your right groin occasionally. It’s sore to touch at the moment. Paracetamol takes the edge off it a little, but not enough to make it bearable. Nothing in particular seems to make it worse. It is pretty constant.

The temperatures have come and gone in episodes. It was at its highest when you went to the GP. You last opened your bowels 2 days ago, but this is normal for you, and you haven’t been eating anyway. Your appetite has been awful this week. You have had 2 episodes of vomiting but it was just food that came up. You haven’t had any swallowing problems and you haven’t had a cough.

You have been going to the toilet to pass water a lot more than usual in the past week. You have been drinking a lot more energy drinks when trying to revise, and put this down to that. You haven’t had any pain in passing water, but you did think it looked quite dark when you saw it last. There was no blood in it though. Your skin looks the same and you don’t have any itch.

ICE: You have been staying up long nights to do assignments and revise for your exams, so felt originally that you were just run down. However, your GP thinking this is appendicitis has scared you to no end, and really want a quick test to be able to tell if this is appendicitis. Your friend had his appendix out last year and that left him with a horrible scar: this is something you really want to avoid as you are supposed to be going on holiday after your exams!

SH: You binge drink on occasional nights out, but these have dried up recently when entering the exam season, so you haven’t drunk alcohol in a while now. A typical night out might include half a bottle of vodka. You haven’t been anywhere abroad recently. You live in university halls.

PMH: You have always been well and don’t take any regular medications.

FH: Everyone in your family has been well. Your dad has diabetes and your mum has osteopenia.

The student should demonstrate a clear and logical history of presenting complaint for acute abdomen. In terms of examination, an abdominal exam would be appropriate.

The student’s differential diagnosis should sound something like:

My differential diagnosis would include a urological cause, more specifically pyelonephritis. I would also want to include other urological causes, such as cystitis or renal colic. Other abdominal cause would include any cause of acute abdomen, such as acute appendicitis, pancreatitis and biliary colic. Example for discussion may include:

  • How would you investigate this patient in the acute setting?
  • How would you manage this patient acutely?
  • How is appendicitis diagnosed?
  • Do you know any scoring systems for pancreatitis?