Simulated Patient Scenario

Acute Abdominal Pain

Scenario Details

Scenario: Acute Abdominal Pain (Suspected Appendicitis)

Simulated Patient: 22-year-old Male

Actor/Actress: Student Actor (Patient)

MDT Information

Urgent Response - Abdominal Pain
22-year-old male complaining of severe abdominal pain
Pain started yesterday, worsening today
Patient reports feeling nauseous
Location: University Dorm Room

On Arrival

You arrive at a university dormitory. The patient, a 22-year-old male, is lying curled up on his bed, guarding his abdomen. He appears pale and uncomfortable, grimacing with pain. He looks up as you enter but is reluctant to move.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Alert young adult, appears unwell, in significant pain, guarding abdomen.
Response	Alert and oriented, responds appropriately but distracted by pain. (AVPU = A, GCS 15)
Airway	Clear and self-maintaining.
Breathing	Rate slightly elevated, depth appears shallow due to pain/guarding. No respiratory distress.
Circulation	Skin pale, slightly cool peripherally, dry. Radial pulse palpable, tachycardic, regular.
Disability	Alert (GCS 15). Significant abdominal pain.
Exposure/Environment	Indoor dorm room. Need to expose abdomen for assessment.

Secondary Survey and Simulation Progression

History (obtained from patient)

Allergies	NKDA
Medications	None regular. Took Paracetamol ~6 hours ago with little relief.
Past Medical History	Generally healthy. No previous abdominal surgery or significant medical conditions.
Last Oral Intake	Small amount of toast yesterday evening. Poor appetite since yesterday. Sips of water today.
Events Preceding / Pain Assessment (SOCRATES):	Site: Pain started vaguely around the umbilicus yesterday afternoon. Has now moved and localised to the Right Iliac Fossa (RIF). Onset: Gradual onset yesterday, steadily worsening. Character: Started as dull ache, now sharp and constant. Radiation: Does not radiate significantly. Associated Symptoms: Loss of appetite (anorexia) since yesterday. Felt nauseous this morning, vomited once (non-bilious, non-bloody). Feels slightly feverish. Timing: Pain has been constant since localising to RIF. Exacerbating/Relieving Factors: Worse on movement, coughing, or any pressure on abdomen. Lying still helps slightly. Paracetamol provided minimal relief. Severity: Rates current pain 7-8/10. Other: Denies diarrhoea or constipation (last BM normal yesterday morning). Denies urinary symptoms, testicular pain, recent trauma.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	20 (Slightly elevated/shallow)
Lung Sounds (L/R)	Clear bilaterally.
SpO2 (%)	98% (Room Air)
EtCO2 (mmHg)	Not indicated
Pulse Rate (/min.)	105, regular (Tachycardic)
CRT (sec.)	< 2 sec
ECG rhythm	Sinus Tachycardia
12-lead ECG	Sinus Tachycardia. No acute changes.
BP (mmHg)	130/80
Skin	Pale, slightly cool peripheries, dry.
Pain (/10)	7-8/10 RIF pain.
GCS (/15: E,V,M)	15/15 (E4, V5, M6)
BGL (mmol/L)	5.5
Pupils (mmL/mmR)	Equal and Reactive (PERL).
Temp. (°C)	37.9°C (Mildly febrile)

Physical Examination (Abdomen)

Inspection: Abdomen flat, not distended. Patient guarding RIF. No obvious scars, masses, or bruising.
Auscultation: Bowel sounds present but may be slightly hypoactive.
Percussion: Tenderness on percussion over RIF. No generalised tympany or dullness.
Palpation: Maximum tenderness on palpation over McBurney's point (RIF). Voluntary guarding initially, progressing to involuntary guarding/rigidity over RIF. Possible rebound tenderness over RIF (assess gently). Rovsing's sign (pain in RIF on palpation of LIF) may be positive. No palpable masses.
Other Systems: Cardiovascular and Respiratory exams unremarkable apart from tachycardia.

Assessment and Treatment

Appropriate Management Focus

Primary Survey (ABCDE): Confirm stability. Identify likely surgical abdomen (appendicitis).
Differential Diagnosis: While appendicitis is suspected, consider other causes of RIF pain (e.g., mesenteric adenitis, Meckel's diverticulum, Crohn's disease, renal colic, testicular torsion in males, ovarian/gynaecological causes in females).
Pain Assessment: Use 0-10 scale. Assess frequently.
Positioning: Allow patient to adopt position of comfort (often lying still with knees flexed).
IV Access: Establish IV access. Consider blood sampling if within scope/protocol.
Fluid Therapy: Consider IV fluids (e.g., Sodium Chloride 0.9%) for potential dehydration (poor intake, vomiting, fever) and pre-operatively. Administer bolus (e.g., 500mL) if signs of dehydration, then consider maintenance rate.
Pain Management: Provide adequate analgesia. IV opioids (e.g., Morphine or Fentanyl titrated doses) are appropriate for moderate-severe pain.
Antiemetic Therapy: Administer an antiemetic (e.g., Ondansetron IV) for nausea/vomiting.
Nil By Mouth (NBM): Keep patient NBM in anticipation of potential surgery.
Monitoring: Frequent vital signs reassessment. Monitor pain score, level of guarding/rigidity, and overall clinical condition.
Transport Decision: Urgent transport to an Emergency Department with surgical capabilities is required for definitive diagnosis and management.
Teamwork & Communication: Reassure patient. Explain interventions. Provide clear pre-notification to ED (Young male, suspected appendicitis with localised RIF peritonism, vitals, analgesia/antiemetic given). Detailed handover.

Debrief Focus Points

Recognizing the classic presentation of appendicitis (migrating pain, anorexia, nausea, localised RIF signs).
Performing a systematic abdominal assessment (Inspect, Auscultate, Percuss, Palpate).
Identifying signs of peritonism (guarding, rigidity, rebound tenderness).
Considering key differential diagnoses for acute abdominal pain.
Appropriate pain management strategies for acute abdominal pain.
Role of antiemetics and IV fluids.
Importance of NBM status.
Recognizing the need for urgent surgical review and transport to an appropriate facility.
Effective communication and pre-notification for suspected surgical abdomen.