Simulated Patient Scenario

Renal Calculi (Kidney Stones)

Scenario Details

Scenario: Adult with acute severe flank pain - Suspected Renal Calculi

Simulated Patient: 35-year-old Male Actor

Actor/Actress: Patient (can provide own history)

MDT Information

Urgent response - Severe Abdominal/Flank Pain
35-year-old male
Patient awake and alert, severe pain
Patient breathing normally
Patient at home

On Arrival

Patient is found pacing restlessly in his living room, clutching his right flank. He appears pale and is sweating. There is a vomit bowl nearby with a small amount of clear fluid.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Alert, in severe distress due to pain, restless, pale, diaphoretic.
Response	Alert and oriented, answers questions appropriately between waves of pain (AVPU=A).
Airway	Clear and self-maintaining.
Breathing	Rate slightly increased due to pain, depth appears normal. Symmetrical chest expansion.
Circulation	Pale, diaphoretic. Radial pulse strong but rapid. Capillary refill < 2 seconds.
Disability	No focal neurological deficit. GCS 15.
Exposure/Environment	Indoor home environment. Patient wearing normal clothes.

Secondary Survey and Simulation Progression

History

Allergies	NKDA (No Known Drug Allergies)
Medications	None regular. Took Paracetamol 1g approx 2 hours ago with minimal effect.
Past Medical History	Previous episode of kidney stones 3 years ago (left side), managed conservatively. Otherwise generally fit and well.
Last Oral Intake	Dinner last night, approx 12 hours ago. Small sips of water since pain started.
Events Preceding	Woke up around 4 hours ago with a dull ache in the right flank. Pain rapidly escalated over the last hour to become severe, sharp, and colicky (comes in waves). Pain radiates down towards the groin/testicle. Felt nauseous and vomited once about 30 minutes ago. Unable to find a comfortable position. Noticed urine was slightly pink-tinged this morning.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	20
Lung Sounds (L/R)	Clear bilaterally
SpO2 (%)	98% (Room Air)
EtCO2 (mmHg)	N/A
Pulse Rate (/min.)	110, regular
CRT (sec.)	< 2 sec
ECG rhythm	Sinus Tachycardia
12-lead ECG	Sinus tachycardia, no acute ischaemic changes.
BP (mmHg)	155/90 (Likely elevated due to pain)
Skin	Pale, diaphoretic.
Pain (/10)	10/10 during waves, describes as "worst pain ever". Settles slightly between waves but remains severe (e.g., 7/10).
GCS (/15: E,V,M)	15/15
BGL (mmol/L)	5.9
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive
Pupil reac. (L/R)	Equal and Reactive
Temp. (°C)	37.1 (Afebrile - fever might suggest associated UTI)

Physical Examination (Focused Abdominal/Renal)

**General:** Patient is restless, unable to lie still.
**Abdomen:** Soft on palpation, non-distended. Mild tenderness in right lower quadrant, but maximal tenderness elicited on palpation of the right flank / Costovertebral Angle (CVA tenderness). No rebound tenderness or guarding suggesting peritonitis. Bowel sounds present.
**Back:** Marked tenderness over right CVA.
**Genitalia:** (Verbalise check if appropriate for scenario/mannequin) No obvious abnormalities. Patient reports pain radiating to right testicle.
**Urinalysis:** (If point-of-care testing available) May show haematuria (blood), leukocytes, or nitrites (latter two suggest infection).
Consider differentials: AAA (especially if older/risk factors), appendicitis, cholecystitis, pyelonephritis, testicular torsion, musculoskeletal pain.

Assessment and Treatment

Appropriate Management

Recognise presentation consistent with acute renal colic, likely due to renal calculus.
Primary survey (ABCDE).
**Pain Management:** This is the priority.
- Consider NSAIDs (e.g., IV Ketorolac or Diclofenac) if not contraindicated (renal impairment, peptic ulcer disease, allergy, anticoagulation, heart failure, third trimester pregnancy). Often first-line for renal colic.
- If NSAIDs contraindicated or ineffective, use IV opioids (e.g., titrated Fentanyl or Morphine).
- Methoxyflurane may be used for initial rapid relief while establishing IV access/administering other analgesia.
**Antiemetics:** Administer IV antiemetic (e.g., Ondansetron) for nausea/vomiting.
**IV Access:** Establish IV access.
**Fluid Therapy:** Administer IV fluids (e.g., 500-1000ml Sodium Chloride 0.9%) especially if patient has been vomiting, is diaphoretic, or unable to tolerate oral fluids. Avoid fluid overload.
Monitor vital signs frequently, including pain score reassessment after analgesia.
Consider differentials and perform focused examination to rule out red flags (e.g., check for pulsatile mass for AAA).
Transport to hospital for further assessment, imaging (CT KUB often preferred), and management.
Provide reassurance to the patient.
Pre-notify receiving hospital with suspected diagnosis, vitals, and treatments given.