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You are a doctor working in an emergency department. The next patient is Mahla Ria, a 36 year old lady. Mahla originates from Syria, and is currently a refugee in the United Kingdom. She speaks very little English. The triage notes state that she is concerned about ‘pain in her belly’.

Please take a history from Mahla and identify the cause of the pain. You may require appropriate assistance with communication. You will then be asked to discuss the case with the examiner.

NB: This encounter may require an additional role-player, in the form of an interpreter. This should be put in place only if the student requests an interpreter. If not, please play the role of Mo, Mahla’s brother, who speaks English.

You are Mo, Mahla’s brother. You both came to the UK as refugees recently. You would not like to discuss why you fled your country, however it was quite traumatic. Things have been much nicer in the UK, though the weather is not so good. The people have been very friendly. You were reluctant to bring Mahla to the hospital initially, as you do not want to be judged for using the NHS as a refugee, however everyone here has been really friendly and supportive.

HPC: Mahla says that she has had left sided abdominal pain that is excruciating. It started 2 hours ago, that starts in the side of her tummy and spread downwards. The pain varies in intensity but never goes away. The pain is a stabbing pain. Mahla vomited twice since the pain started: this is what convinced you to take her to hospital. The pain is a 9/10 in terms of severity. Mahla’s urine is a normal colour, and she does not think she has seen any blood. She says she feels hot but are not sure if she has a temperature – you couldn’t find a thermometer earlier. The pain does not get worse when she moves around, and there is no pain on passing urine. Mahla says that she has never felt anything quite like this! She is unable to sit down for an extended period of time, cannot get comfortable and is up and moving around right now!

PMH: Mahla is normally fit and well, and has not been to a doctor in 15 years. She has 3 children who are all healthy.

DH: Mahla is not on any regular medication, and is not allergic to anything that you know of.

FH: Your Father had problems with his legs and used a stick later in life.

SH: You have recently moved to the UK, and are living in a house provided by the council. Mahla lives with you and her three children, her husband, and your wife. She does not smoke, or drink alcohol. She does not currently have a job, but plans to work in catering.

ICE: Mahla is quite worried about her health and does not understand the way the UK health system works. You are both worried you will have to pay a lot of money, but the pain has got so severe that she have been unable to continue your activities. You are all also under a lot of stress at the moment as moving to the UK has been quite overwhelming at times. However you are doing your best to cope, and are starting to learn how things work. Mahla does not know what the pain is, and is hoping the doctor will help the pain go away.

This is a challenging communication case, which requires the use of an interpreter for success. It is important that a successful student focuses on the patient throughout the consultation, rather than a one-way conversation with the interpreter. A differential diagnosis for the surgical presentation may include renal colic, ovarian cyst rupture or torsion, ectopic pregnancy, or pyelonephritis. Example questions for examination:

  • What would be your initial investigations in this case?
  • What would be your initial management?
  • What are the challenges of using an interpreter, and how did you try and reduce them in your consultation?
  • What are the different causes of renal colic?
  • What patient factors increase a patient’s risk of renal stones?
  • In a patient with renal calculi, what would be some indications for immediate intervention?