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Candy Diasis is a 40 year old lady presenting to A+E with abdominal pain. You are an FY1 working in the department. Please take a history and undertake the relevant examination. You will then be asked to discuss the case with the examiner.

You are Candy Diasis. You are 40 years old and came to A+E with excruciating sharp pains in the centre of your abdomen. PC: You first noticed the pain after getting home from shopping this afternoon. It suddenly got very painful, and is now its making you feel extremelynauseous. You vomited once before coming to hospital and twice sat in the waiting room. If asked where the pain is specifically, it is right in the middle of your abdomen, above your belly button, but you can also feel it all the way through to your back. It feels like you’ve been stabbed. You have realised if you sit forward it eases the pain a bit. You’ve taken 2 Rennies but they haven’t really helped. You’re feeling very hot and a bit sweaty and just want it all to go away! You haven’t noticed any changes in the colour of your skin, bowel motions or urine. You’re bowels and water works seem okay. You have never had anything like this before. Sometimes you get a bit of a grumbly tummy after your evening meal, but never as painful as this. It’s usually just a bit of an ache that goes away without you even realising. ICE: You thought it was indigestion, so you took a few Rennies, but when this didn’t help, and the pain got worse, you got worried you might be having a heart attack. You rung 111, who suggested you came to A+E. You really hope the doctor will do a few tests and tell you everything will be okay. PMH: You have rheumatoid arthritis, this got diagnosed in in your 20s. You have high blood pressure and high cholesterol, but you drink special yogurts on a morning for that. DH: Prednisolone 10mg OD, methotrexate 10mg once weekly, paracetamol 2x 500mg whenever your joints get too painful, but you make sure you never have more than 8 a day! FH: Both your sisters have rheumatoid arthritis,. Your mum has hypothyroidism but is currently fit and well. SH: You live at home with your husband. Your two children live in student accommodation at University, but they still come home now and again, usually when they want something or run out of money. You gave up work as a hairdresser when you had the children. Reluctantly, you admit you drink more than you should. You drink about half a bottle of wine every night before dinner, and then on weekends you usually have about 10 cocktails or gin and tonics (slimline though) on a Saturday with the girls. You used to smoke 15 cigarettes a day for about 20 years, you gave up 2 years ago because you didn’t want COPD like the old woman next door.

Observe the student taking the history, it should include a detailed SOCRATES pain history, addressing the patient’s abdominal history. A good differential diagnosis may sound like this: “My main differential in this lady would be acute pancreatitis. This is due to the characteristic abdominal pain, radiating towards the back, relieved by sitting forward and associated with nausea and vomiting. The patient also has several risk factors for pancreatitis including: significant alcohol history, steroids, rheumatoid arthritis, and possibly gallstones considering her age, gender and history of abdominal pain after eating some meals. Other differentials would include: gallstones, cholecystitis, cholangitis” Points for discussion: • What are the causes of acute pancreatitis? • What signs may be seen on examination of this patient? • What tests and investigations would you like to carry out if you suspected acute pancreatitis in a patient? • How would you manage this patient? •What risk factors does this patient have for developing pancreatitis? •What are some early complications that can be seen in acute pancreatitis? • What criteria can be used to predict the severity of pancreatitis?