CCE-CBD-206

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Emily’s abdominal pain to determine the likelihood of appendicitis?

• Prompt: What key features in history and examination support a diagnosis of appendicitis?
• Prompt: How do you differentiate appendicitis from other causes of abdominal pain?

Q2. What are the next steps in managing Emily’s condition?

• Prompt: What immediate management is required before referral?
• Prompt: How would you arrange appropriate hospital transfer?

Q3. What differential diagnoses should be considered in this case?

• Prompt: What other conditions can present similarly in children?
• Prompt: How do you rule out common differentials such as gastroenteritis or ovarian pathology?

Q4. How would you communicate the diagnosis and management plan to Emily’s mother?

• Prompt: How do you explain the urgency of the condition in a reassuring manner?
• Prompt: What safety-netting advice would you provide?

Q5. What complications of appendicitis should be considered, and how would you counsel the caregiver?

• Prompt: What are the risks of delayed diagnosis?
• Prompt: What signs of deterioration should be monitored for?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Emily’s abdominal pain to determine the likelihood of appendicitis?

A structured assessment of paediatric abdominal pain is essential in identifying appendicitis. The RACGP and RCH Melbourne guidelines recommend a combination of history, examination, and clinical scoring systems.

1. History-Taking

• Pain characteristics:
  • Onset: Gradual over 24 hours.
  • Location: Initially periumbilical, now right iliac fossa (RIF).
  • Radiation: None.
  • Aggravating factors: Worse with movement.
  • Associated symptoms: Nausea, anorexia, vomiting, low-grade fever.
• Red Flags for Appendicitis:
  • Pain migration to RIF.
  • Worsening pain with coughing, movement (peritonism).
  • Loss of appetite.

2. Physical Examination

• General Appearance: Pale, mildly distressed, lying still.
• Vital Signs: Fever (38.2°C), tachycardia (110 bpm).
• Abdominal Examination:
  • RIF tenderness with rebound tenderness (peritonism).
  • Guarding.
  • Positive Rovsing’s sign (pain in RIF when LIF is pressed).
  • Positive Psoas sign (pain with hip extension).
  • Bowel sounds reduced.

3. Clinical Scoring Systems

• Paediatric Appendicitis Score (PAS) or Alvarado Score aid in risk stratification.

Conclusion: Emily’s classic symptom progression, RIF tenderness, and peritoneal signs strongly suggest appendicitis, necessitating urgent hospital referral.

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Q2: What are the next steps in managing Emily’s condition?

1. Immediate Stabilisation

• Nil by mouth (NBM) to prepare for possible surgery.
• Intravenous (IV) fluids if dehydration is suspected.
• Pain relief: Paracetamol ± ibuprofen; consider opioids if severe.

2. Urgent Hospital Referral

• Via ambulance if unstable or severe pain.
• Phone ahead to the emergency department (ED).
• Ensure caregiver understands urgency.

3. Investigations (If Available in General Practice)

• Blood tests: FBC (raised WCC), CRP (elevated in infection).
• Urinalysis: To exclude UTI.
• Pregnancy test (if menarche reached): To rule out ectopic pregnancy.
• Imaging (arranged in ED):
  • Ultrasound: Preferred in children.
  • CT scan: Used if diagnosis is uncertain.

4. Documentation and Safety-Netting

• Document findings clearly.
• Explain to caregiver the need for prompt hospital review.

Conclusion: Emily requires urgent referral to hospital, NBM status, pain relief, and supportive care.

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Q3: What differential diagnoses should be considered in this case?

While appendicitis is the most likely diagnosis, other conditions should be considered:

1. Gastrointestinal Causes

• Gastroenteritis: Diarrhoea, diffuse tenderness, self-limiting.
• Mesenteric adenitis: Viral illness, enlarged lymph nodes on ultrasound.
• Constipation: History of hard stools, no fever or peritonism.

2. Gynaecological Causes (if menarche has started)

• Ovarian torsion: Sudden onset, unilateral pain, Doppler ultrasound required.
• Mittelschmerz (ovulation pain): Mid-cycle pain, self-limiting.

3. Urinary Tract Causes

• UTI/Pyelonephritis: Dysuria, positive urinalysis.

Conclusion: Appendicitis remains the most likely cause, but ruling out other serious conditions is essential.

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Q4: How would you communicate the diagnosis and management plan to Emily’s mother?

1. Establish Rapport and Provide Reassurance

• Validate concerns and explain appendicitis in simple terms.
• Use age-appropriate language for Emily.

2. Explain the Need for Urgent Referral

• “Emily has signs of appendicitis, which is an infection and inflammation of the appendix. This needs to be treated urgently in hospital.”
• “If untreated, it could burst and cause a serious infection.”

3. Address Questions and Provide Clear Instructions

• Transport: “She needs to go to hospital today. You should take her to the emergency department or call an ambulance if she worsens.”
• Fasting: “She should not eat or drink until doctors assess her.”
• Pain Relief: “You can give paracetamol, but avoid strong painkillers as they may mask symptoms.”

Conclusion: Clear, empathetic communication is essential to ensure caregiver understanding and compliance.

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Q5: What complications of appendicitis should be considered, and how would you counsel the caregiver?

1. Potential Complications

• Perforation (ruptured appendix):
  • Increased pain, fever >39°C, worsening peritonism.
  • Requires emergency surgery.
• Appendiceal abscess:
  • May require drainage instead of immediate surgery.
• Sepsis:
  • Signs: Lethargy, confusion, tachycardia, hypotension.

2. How to Monitor for Deterioration

• Worsening pain, vomiting, or fever.
• New onset of diarrhoea (may indicate perforation).

3. Importance of Timely Treatment

• “Early treatment prevents complications and shortens recovery.”
• “Surgery is usually minimally invasive (laparoscopy) with a short hospital stay.”

Conclusion: Providing clear, practical guidance on monitoring signs and seeking prompt medical attention is essential.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive history and examination identifying red flags for appendicitis.
• Application of clinical scoring tools (Alvarado/PAS) to assess risk.
• Clear referral pathway with appropriate management.
• Effective caregiver communication ensuring understanding of urgency.
• Awareness of complications and safety-netting advice.

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PITFALLS

• Failing to identify appendicitis red flags (migratory pain, peritonism).
• Delaying referral and attempting outpatient management.
• Overlooking differentials such as ovarian torsion in a post-menarche patient.
• Inadequate caregiver communication leading to delayed hospital presentation.
• Not considering complications like perforation or sepsis.

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REFERENCES

• RACGP Clinical Guidelines – Abdominal Pain in Primary Care
• GP Exams – Appendicitis

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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

Competency at Fellowship Level

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