EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Daniel’s abdominal pain and determine the likely cause?

• Prompt: What key aspects of history and examination are important?
• Prompt: What differentials should be considered?

Q2. What investigations would you order, and why?

• Prompt: What laboratory tests and imaging are appropriate in suspected appendicitis?
• Prompt: How do investigations help differentiate other causes of RLQ pain?

Q3. What is your immediate management plan for Daniel?

• Prompt: What are the key steps in managing acute appendicitis?
• Prompt: When is surgical intervention required?

Q4. What are the potential complications of appendicitis, and how would you monitor for them?

• Prompt: What are the signs of appendiceal perforation or abscess formation?
• Prompt: How would you adjust management if complications arise?

Q5. What discharge advice and follow-up care would you provide post-appendicectomy?

• Prompt: What post-operative recovery expectations should be discussed?
• Prompt: What lifestyle modifications and signs of complications should be monitored?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Daniel’s abdominal pain and determine the likely cause?

Daniel presents with acute right lower quadrant (RLQ) pain, raising concern for appendicitis. A structured approach includes history, examination, and differential diagnosis.

1. History

• Onset and progression – sudden vs gradual, worsening or improving
• Pain character – dull, sharp, cramping, or constant
• Associated symptoms – nausea, vomiting, fever, bowel changes, urinary symptoms
• Aggravating/relieving factors – movement, eating, position changes
• Red flags – persistent vomiting, peritonism, haematemesis, weight loss

2. Differential Diagnosis

• Appendicitis – RLQ pain, nausea, fever, McBurney’s tenderness
• Renal colic – sudden, severe flank pain, haematuria
• Diverticulitis – LLQ pain more common, but RLQ possible
• Gastroenteritis – diffuse pain, diarrhoea, viral contacts

3. Physical Examination Findings

• Positive Rovsing’s sign → appendiceal irritation
• Localised RLQ tenderness with guarding → possible peritoneal irritation
• Negative Murphy’s sign → cholecystitis less likely

Daniel’s symptoms are consistent with appendicitis, requiring further investigation.

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Q2: What investigations would you order, and why?

1. Laboratory Tests

• Full Blood Count (FBC) – WCC elevation suggests infection
• C-Reactive Protein (CRP) – inflammatory marker for appendicitis
• Urinalysis – rules out UTI, renal colic

2. Imaging

• Abdominal ultrasound – first-line in young adults
• CT abdomen (if diagnosis uncertain) – gold standard for appendicitis

Daniel’s elevated WCC and CRP, combined with ultrasound findings, confirm appendicitis.

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Q3: What is your immediate management plan for Daniel?

1. Hospital Referral for Appendicectomy

• NPO (nil per os) – prepare for possible surgery
• IV fluids – prevent dehydration
• IV antibiotics – ceftriaxone + metronidazole (if delayed surgery)
• Analgesia – paracetamol ± opioids as needed

2. Conservative Management (Only in Selected Cases)

• Non-operative management with antibiotics (if surgery contraindicated)

Daniel requires urgent surgical review for appendicectomy.

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Q4: What are the potential complications of appendicitis, and how would you monitor for them?

1. Appendiceal Perforation

• Persistent high fever, worsening peritonitis
• Requires emergency surgery and IV antibiotics

2. Abscess Formation

• Delayed presentation with persistent RLQ pain, fever
• Managed with drainage and IV antibiotics

3. Post-Surgical Complications

• Wound infection, ileus, adhesions
• Requires monitoring post-operatively

Timely surgical intervention reduces complications.

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Q5: What discharge advice and follow-up care would you provide post-appendicectomy?

1. Recovery Expectations

• Return to normal activity within 2-4 weeks
• Gradual reintroduction of diet

2. Signs of Complications

• Fever, worsening pain, wound discharge → seek urgent review

3. Lifestyle Modifications

• Maintain hydration, fibre-rich diet to prevent constipation

Daniel requires follow-up to ensure recovery without complications.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history and examination to identify appendicitis
• Orders appropriate investigations (FBC, CRP, ultrasound/CT)
• Recognises need for urgent surgical referral
• Provides pain relief and pre-operative care
• Monitors for complications and ensures appropriate follow-up

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PITFALLS

• Failing to recognise appendicitis in atypical presentations
• Delaying referral when appendicitis is suspected
• Overlooking alternative diagnoses (renal colic, diverticulitis)
• Not addressing pain management adequately
• Ignoring post-operative care and lifestyle modifications

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REFERENCES

• RACGP – RACGP Guidelines on Acute Abdominal Pain

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Uses clear and structured communication to assess abdominal pain.
1.3 Provides appropriate explanations about differential diagnoses and management.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a thorough history and abdominal examination.
2.3 Identifies red flags that warrant urgent investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common causes of abdominal pain.
3.3 Recognises when further investigations or hospital referral are necessary.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides initial pain management and determines appropriate investigations.
4.4 Develops a management plan tailored to the patient’s clinical condition.

5. Preventive and Population Health

5.1 Identifies risk factors for gastrointestinal conditions and provides lifestyle advice.

6. Professionalism

6.2 Ensures patient-centred and empathetic communication in discussing symptoms.

7. General Practice Systems and Regulatory Requirements

7.1 Documents history, examination findings, and management plan appropriately.

8. Procedural Skills

8.2 Performs bedside assessments including abdominal palpation and special tests.

9. Managing Uncertainty

9.1 Recognises when empirical management is appropriate vs when urgent action is required.

10. Identifying and Managing the Patient with Significant Illness

10.2 Identifies serious causes of abdominal pain, such as appendicitis or bowel obstruction.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD