Cases/Urgent & Unscheduled care

Abdominal Pain and Vomiting — Free SCA Practice Case

Newly diagnosed diabetic man with abdominal pain and vomiting

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Neil Chadwick

Age

47 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation, booked as a routine call.

Reason for Encounter

"I've been getting stomach pain and I keep being sick. I wondered if it's these new diabetes tablets disagreeing with me."

Medical Records

●PMH: Type 2 diabetes — diagnosed 5 weeks ago (HbA1c 94 mmol/mol; presented with thirst, polyuria, and weight loss). No other conditions.
●Medications: Metformin 500 mg twice daily, started 5 weeks ago.
●Allergies: NKDA.
●Recent notes (5 weeks ago): New diagnosis of type 2 diabetes. Lifestyle advice given, metformin commenced, diabetes nurse review arranged. BMI 24 kg/m². No autoantibody testing performed.
●Note: Nurse review not yet attended.

Patient Script

For the friend playing the patient role

Character Overview: You are Neil, a 47-year-old delivery driver, told five weeks ago that you have type 2 diabetes and started on metformin. For the past two days you have had generalised abdominal pain and repeated vomiting — you cannot keep fluids down. You feel exhausted and your breathing feels "heavy", as though you cannot get a deep enough breath, though you are not wheezy. You are drinking a lot and passing a lot of urine, and you have lost about a stone since your diagnosis despite not trying. Your mouth is very dry. You booked a routine call because you assumed the tablets are upsetting your stomach and you want them changed. You are not especially alarmed and you will initially resist the idea of going to hospital because you have deliveries booked and you "don't want to sit in A&E all day". If it is clearly explained you will accept it.

Opening Sentence: "Hello Doctor. I've had stomach pain and I've been sick a lot for a couple of days now. I can't keep anything down. I reckon it's these diabetes tablets — metformin, is it? Can you swap me onto something else?"

History if Asked (Data Gathering Phase)

●The symptoms: "Two days of stomach pain — all over, not one spot — and vomiting. I can't keep fluids down at all today."
●How he feels: "Wiped out. Weak. My breathing feels heavy, like I can't get a proper deep breath, but I'm not wheezy or coughing."
●Thirst and urine: "I'm drinking constantly and I'm up all night passing water. My mouth is bone dry."
●Weight: "I've lost about a stone since they told me I was diabetic, and I've not been trying to."
●His theory: "It'll be the tablets, won't it? They said they can upset your stomach."
●His plan: "I just want them changed. I've got deliveries booked tomorrow — I can't be sat in A&E all day."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Neil is convinced this is metformin intolerance. "It's got to be the tablets upsetting my stomach."
●Concerns: He is not particularly worried medically; his concerns are being unable to work and losing income. "I'm not that worried about the illness. It's the work I'm bothered about."
●Expectations: He expects his medication to be changed. "Just swap the tablets and I'll be right."

If Asked — DKA, HHS, and Differential Screen

The patient answers these only when directly asked.

●If asked about breathing (deep sighing breathing, breathlessness at rest): "It feels heavy and deep — like I'm having to breathe more than I should be, even sitting still." (Kussmaul respiration.)
●If asked about a sweet or fruity smell on the breath: "My wife did say my breath smelled odd — sweet, she said, like pear drops." (Ketotic fetor.)
●If asked about fluid intake and urine output: "Drinking constantly, passing loads of urine, though maybe less today."
●If asked about weight loss: "About a stone in five weeks."
●If asked about confusion, drowsiness, or feeling faint: "I'm groggy and I felt dizzy standing up earlier. My wife says I'm not quite with it."
●If asked about whether he has taken his metformin: "I've not kept it down the last two days."
●If asked about capillary blood glucose (if he has a meter): "The nurse gave me a meter but I've barely used it. I did check this morning — it said 27." (Marked hyperglycaemia.)
●If asked about ketone testing: "I haven't got ketone strips and nobody's mentioned them."
●If asked about infection (fever, cough, dysuria, diarrhoea, rash): "No fever that I know of, no cough, no burning when I pass water, and no diarrhoea."
●If asked about the abdominal pain in detail (site, radiation, peritonism, bowels): "It's generalised, a deep ache, not in one spot. It doesn't go through to my back. My bowels have been normal."
●If asked about alcohol: "I hardly drink."
●If asked about family history of autoimmune conditions or diabetes: "My sister has an underactive thyroid. No diabetes in the family that I know of."
●If asked about who is with him and how he would get to hospital: "My wife's here and she could drive me."

Responses to Management (The Negotiation Phase)

●If the Doctor explains this is not simply the tablets — key: "So it's not the metformin at all? You think the diabetes itself has gone badly wrong?" (The tested point is resisting the anchor of metformin intolerance.)
●If the Doctor explains diabetic ketoacidosis: "Ketoacidosis? What does that actually mean? Is it dangerous?" (The tested point is explaining DKA accessibly and conveying its seriousness.)
●If the Doctor says he must go to hospital today — the negotiation: "Today? Right now? I've got deliveries booked tomorrow. Can it not wait until the morning?" (The tested point is converting a routine call into same-day emergency assessment and holding firm.)
●If the Doctor explains he may actually have type 1 diabetes: "But they told me it was type 2. You're saying that might be wrong?" (The tested point is recognising that adults can develop type 1 diabetes.)
●If the Doctor arranges emergency transfer: "So an ambulance, or my wife drives me straight there? Alright. If it's that serious I'll go."
●If the Doctor gives interim advice: "What do I do in the meantime — should I keep taking the tablets, or try to drink?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Diabetic Ketoacidosis — Recognition

●DKA presents with hyperglycaemia, vomiting, abdominal pain, dehydration and thirst, weight loss, and progressive drowsiness, with the cardinal signs of Kussmaul respiration (deep sighing breathing) and ketotic (pear-drop) fetor. Abdominal pain is a recognised feature of DKA itself and is frequently misattributed to a gastrointestinal cause.

Beware the Anchoring Trap

●A recent diagnosis and a new medication create a powerful anchor: vomiting in someone recently started on metformin invites the explanation of gastrointestinal intolerance. Anchoring on this — or on "gastroenteritis" — is the classic route to missing DKA. Osmotic symptoms, weight loss, breathing changes, and conscious level distinguish them.

Adults Can Develop Type 1 Diabetes

●Type 1 diabetes is not confined to children. A normal BMI, marked weight loss, rapid deterioration, presentation in DKA, or a personal/family history of autoimmune disease should prompt reconsideration of a "type 2" label, with autoantibody and C-peptide testing in due course and appropriate insulin treatment.

DKA Is a Medical Emergency

●DKA requires immediate hospital assessment and treatment — intravenous fluids, insulin, and electrolyte correction. It cannot be managed remotely or deferred. Where there is vomiting, inability to tolerate fluids, or altered conscious level, arrange emergency ambulance transfer and hand over to the receiving team.

Practical Interim Measures

●Advise stopping oral agents for now, sipping fluids if tolerated, remaining with someone, and calling 999 if drowsiness, breathlessness, or collapse occur. Obtain a capillary glucose (and ketones, if the patient has strips) to support the assessment and handover.

Look for the Precipitant

●Common precipitants include infection, missed or vomited medication, new-onset diabetes, and intercurrent illness. Identifying the precipitant is part of the assessment but must not delay transfer.

The Systemic Learning

●This presentation exposes gaps to address after recovery: classification of diabetes, structured education including sick-day rules, provision of ketone-testing strips, and timely nurse review.

Common Candidate Mistakes in This Case

●Attributing symptoms to metformin or gastroenteritis: the defining error, leading to remote management of a medical emergency.
●Not asking about breathing, breath odour, or conscious level: missing the cardinal signs of DKA.
●Failing to obtain the glucose reading: overlooking readily available information that transforms the assessment.
●Allowing work commitments to delay care: softening the advice instead of holding firm.
●No emergency transfer or handover: arranging a routine review, or sending him in without warning the receiving team.

Free MRCGP SCA practice case for GP registrars covering Abdominal Pain and Vomiting — Urgent & Unscheduled care. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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