Topic: LLQ pain evaluation
Subject: Surgery
What The Candidate Reads
Candidate's Instructions

OPENING STEM: You are about to see a 65-year-old man who presents to the emergency department with left lower quadrant pain.

CANDIDATE'S TASK: In the next 6 minutes, conduct a focused and relevant physical examination.

At the next station, you will be asked to answer questions about this patient.


PATIENT INFORMATION

PATIENT STARTING POSITION: Lying supine on a stretcher.

CLOTHING: Patient is wearing a hospital gown and socks.

MAKE-UP: Patient appears pale and diaphoretic.

PATIENT'S OPENING STATEMENT: "I've got a terrible pain on the left side of my belly."

PATIENT BEHAVIOR, AFFECT AND MANNERISMS: The patient is in obvious discomfort. He has a hard time lying still and is restless. He will periodically press his hands onto his left lower abdomen where he is experiencing pain.

QUESTIONS PATIENT MUST ASK: 1. Patient: "Can I have something to help my pain?"
Suggested Examinee Response: "I'd like to examine you so I can better understand where your pain is. Once I have assessed you, I can help manage your pain."

2. Patient: "Am I going to have surgery?"
Suggested Examinee Response: "It is possible, but I would like to perform an exam so that I can determine what the potential causes of your pain may be."

QUESTIONS PATIENT MAY ASK: Patient: "Do I have cancer?"
Suggested Examinee Response: "I can see that you are very worried about your pain. Once I have performed your physical exam I will be better able to determine what tests I need to order to confirm a diagnosis."

HISTORY OF PRESENT PROBLEM: N/A

PATIENT ISSUES: The patient's perception of the problem is serious. He is concerned that he has bowel cancer.

RELEVANT MEDICAL HISTORY | ALLERGIES | MEDICATIONS: N/A

RELEVANT SOCIAL / FAMILY HISTORY: N/A

REVIEW OF SYSTEMS: N/A

PATIENT SIMULATION: The patient must simulate obvious discomfort in the abdomen. He has a hard time lying still during the exam and presses his hands over his left lower abdomen to simulate pain. The patient must simulate an anxious affect as he is worried that he has cancer.

PHYSICAL FINDINGS: The patient is restless and has trouble lying still with his legs flat on the bed during the exam. His hands are pressed onto his left lower side and he points to this as his area of pain. The patient demonstrates guarding when the examinee attempts to palpate the left lower abdomen. He will abruptly withdraw when the left lower quadrant is palpated, and yell "oh, that's where the pain is." He also demonstrates rebound tenderness in the left lower abdomen when assessed by the examinee. He does not demonstrate significant pain when other areas of the abdomen are assessed.

INFORMATION GIVING: The patient's perception of the problem is serious. He is anxious but shows good eye contact and answers questions directly when asked. He is very concerned when he experiences pain as the examinee palpates the left lower quadrant and may ask "is it cancer?"

PERTINENT NEGATIVES: N/A


What the examiner completes

EXAMINER'S CHECKLIST

Fill in the bubble for each item completed satisfactorily

1) Initiates checking vital signs  [Answer: Temperature 38.5°C, oxygen saturation 99% on room air, blood pressure 110/70 mmHg, heart rate 80 bpm, respiratory rate 16 bpm]

2) Inspects abdomen  [Answer: Normal; no distension, no obvious masses, no skin changes]

3) Percusses abdomen  [Answer: Normal in all 4 quadrants; no dullness or hyperresonance]

4) Palpates abdomen for tenderness  [Answer: Tender on palpation at the left lower quadrant, guarding and rebound tenderness present in the left lower quadrant; nontender to palpation elsewhere on abdomen ]

5) Auscultates abdomen  [Answer: Normal bowel sounds present in all 4 quadrants]

6) Assesses liver by palpation and percussion  [Answer: Normal size; no hepatomegaly]

7) Assesses spleen by palpation and percussion  [Answer: Normal size; no splenomegaly]

8) Offers to perform digital rectal exam  [Answer: EXAMINER: report no mass palpable, no blood]

9) Assesses for Murphy's sign  [Answer: Negative]

10) Assesses for Rovsing's sign  [Answer: Negative]

SCORING TABLE

If UNSATISFACTORY, please specify why:
Inadequate medical knowledge and / or provided misinformation
Could not focus in on this patient's problem
Demonstrated poor communication and / or interpersonal skills
Actions taken may harm this patient
Actions taken may be imminently dangerous to this patient
Other:
Did this candidate demonstrate a lapse in professional behaviour? Yes No
Disrespectful to others (e.g., to patient, nurse)
Over-investigated / over-managed the patient
Actions raised ethical and / or legal concern
Briefly describe the behaviour for any of the above reasons or any other observed lapse:




PATIENT INTERACTION RATING SCALES

Up to a total of seven interaction items may be added to a 10 minute case, depending on the task that candidates are asked to complete. One or two interaction items may be added to a 6 minute case.

Individual interaction items are weighted on their relative importance to each other for a specific station. The weight for the combined items ranges from 10% to 50% of the total score for any one station. The MCC OSCE interaction rating scales are here:

PATIENT INTERACTION RATING SCALE ITEMS

FOR THIS 6 MINUTE CASE, YOU MAY BE EVALUATED ON ONE OR TWO OF THE FOLLOWING PATIENT INTERACTION ITEMS:

10, 12


What the candidate receives

POST-ENCOUNTER PROBE (PEP)

Q1. What are the most likely diagnoses on your differential?

Q2. What investigations, if any, are necessary at this point?

Q3. If the diagnostic evaluation confirms your presumptive diagnosis, what are the most appropriate initial steps in inpatient management?

What the post-encounter probe marker receives

ANSWER KEY
Q1.What are the most likely diagnoses on your differential?Score
A1Diverticulitis2
 Inflammatory Bowel Disease1
 Bowel Obstruction1
 Colorectal Cancer0
 Constipation0
 Maximum4
 
Q2.What investigations, if any, are necessary at this point?Score
A2CT scan2
 Complete blood count1
 Stool cultures 0
 Colonoscopy0
 Maximum3
 
Q3.If the diagnostic evaluation confirms your presumptive diagnosis, what are the most appropriate initial steps in inpatient management?Score
A3Keep patient nil per os2
 Administer IV fluids2
 Administer analgesic (ex: IV morphine)1
 Administer IV antibiotics1
 Administer a fleet enema0
 Maximum6
 


Explanation

Q1.
This case presents an elderly male with focal left lower quadrant pain. Based on the physical exam findings, the examinee should be able to discern that the most likely diagnoses on the differential would include: diverticulitis, inflammatory bowel disease, and bowel obstruction. These can all manifest as focal left lower quadrant pain and can lead to complications that would produce an "acute abdomen" on physical exam with fever, rebound tenderness and guarding as is the case. While constipation and colorectal cancer may cause left lower quadrant pain, this should not be among the most likely diagnoses as the patient is febrile and demonstrating guarding and rebound tenderness on physical exam, which would not be expected with simple constipation and would be an atypical initial presentation for colorectal cancer.

Q2.
As the patient is presenting with focal left lower quadrant pain with rebound tenderness and guarding on the exam, the examinee should recognize the urgent nature of the problem and determine the appropriate investigations that would be required in the ED setting. A CT scan would be the imaging test of choice work up of pain in this region, both to clarify the diagnosis and assess for potential complications such as abscess formation or bowel perforation. A complete blood count would also be important in this case as the patient is febrile on exam and an elevated white blood cell reading may indicate acute infection associated with the diagnosis. Stool cultures are not a necessary test at this time given that the patient is not demonstrating diarrhea. While a colonoscopy may be indicated after the complete resolution of symptoms the examinee should recognize that it is a test to avoid in this case.

Q3.
As part of the assessment of left lower quadrant pain in the ED setting, the examinee should be able to propose initial management steps. The examinee should recognize that it is likely that this patient may require surgical management and treatment will be in the inpatient setting. The initial steps in inpatient management should, therefore, be to keep the patient nil per os and administer IV fluids. Given that the patient is demonstrating severe pain on the exam, it would be appropriate to offer an analgesic such as IV morphine for pain control. Administering IV antibiotics would also be a reasonable choice if the initial investigations have confirmed the presumptive diagnosis (diverticulitis), as the examinee should recognize that this case is likely complicated (the patient is febrile and demonstrating an "acute abdomen" with guarding and rebound tenderness on exam). Administering a fleet enema would not be useful in the case as it should be clear from the physical exam that the patient is presenting with abdominal pain that is more severe than would be expected with simple constipation.