Chronic Abdominal Pain — Free SCA Practice Case
Young female with chronic abdominal pain
Station Timer
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
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Emily Thorne
Age
24 years
Consultation Type
TelephoneAge
24
Situation
Telephone Consultation.
Reason for Encounter
"Stomach pain is getting worse. Bloating is unbearable. Worried it's something serious."
Medical Records
- ●PMH: Generalized Anxiety Disorder (Diagnosed 2023), Dysmenorrhea (Painful periods).
- ●Medications: Sertraline 50mg OD (Stable for 1 year), Mefenamic Acid 500mg TDS (during menses), Buscopan (bought over counter).
- ●Allergies: NKDA.
Recent Notes
- ●6 Months Ago: Presented with tummy ache and loose stools. Examination soft abdomen. Bloods taken: FBC, CRP, U&E, LFT, Tissue Transglutaminase (Celiac screen) — all normal.
Patient Script
For the friend playing the patient role
Character Overview: You are Emily, a 24-year-old graphic designer working freelance from home. You are visibly uncomfortable, holding your stomach. You are frustrated because you feel "dismissed" as just having anxiety, but the physical symptoms are ruining your life. You have convinced yourself you have Crohn's Disease because a friend has it and the symptoms sound similar.
Opening Sentence: "Hi Doctor. I'm back because the pain isn't going away. I look six months pregnant by the end of the day, and the cramps are so bad I had to leave work yesterday. I need to know what's wrong with me."
History if Asked (Data Gathering Phase)
The Symptoms (Rome IV Criteria): Pain: Crampy, lower abdominal pain. It is definitely relieved by going to the toilet. Bowel Habit: Alternating. Sometimes you don't go for 3 days (constipated), then you have urgency and loose stools for 2 days (diarrhoea). Bloating: Flat stomach in the morning, visibly distended by 5 PM.
Red Flags (To be ruled out): Weight Loss: No, weight is stable. Blood: No blood in stool (vital negative). Nocturnal Symptoms: You sleep through the night; the pain never wakes you up.
Diet: You have been trying to eat "healthy" to fix it—lots of apples, lentils, and stone fruits (High FODMAPs). You noticed this makes the bloating worse, not better.
The "Celiac" Query: You stopped eating bread before the blood test 6 months ago because you thought it was gluten. (This makes the negative Celiac screen invalid – a key clinical nuance).
The Fear: "My friend has Crohn's disease and she started like this. Do I need a colonoscopy?"
ICE — Ideas, Concerns, Expectations
(The patient does not volunteer any of this unprompted. These responses surface only if the candidate directly explores the patient's perspective.)
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Ideas: You think this might be Crohn's disease because your friend was diagnosed with it and her symptoms sounded just like yours — the cramping, the bloating, the unpredictable bowel habit. You've read about it online and it all seemed to fit. Part of you also wonders whether the healthy eating you've been doing is somehow not agreeing with you, but you can't understand why fruit and vegetables would be a problem.
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Concerns: Your biggest worry is that this is something serious that's being missed. You feel like last time you were brushed off — bloods came back normal and that was that, but nothing has improved. You're also worried about the impact on your work; you're freelance, so if you can't deliver to clients on time, you don't get paid, and the unreliability of the symptoms is making that harder and harder.
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Expectations: You want a proper investigation — ideally something definitive like a scan or a camera test — so you can stop guessing. You'd also like something that actually works for the pain and bloating because the Buscopan you bought yourself does nothing. You need to feel like you're being taken seriously this time, not just told it's stress.
If Asked — Medical History and Medications
(The patient does not volunteer medication details unprompted. These responses are for when the candidate asks directly about each item.)
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Sertraline 50mg: "I've been on that for about a year for my anxiety. It's helped a lot actually — I feel much more settled in myself. I don't want to change it or add anything to it. The stomach stuff started before the sertraline, so I don't think it's related."
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Mefenamic Acid 500mg: "I take that for my period pains — just for the first couple of days when it's really bad. It does help with the cramps during my period, but it doesn't touch the stomach pain I'm getting the rest of the month."
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Buscopan (over the counter): "I bought that myself from Boots because I read it was for stomach cramps. Honestly, it doesn't really do anything. I've been taking it for a few weeks and I can't tell the difference."
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Previous consultation (6 months ago): "Yes, I came in about six months ago with the same sort of thing — tummy ache and loose stools. The doctor did some blood tests and they all came back normal. I was told it was probably nothing to worry about, but it's only got worse since then. I felt a bit fobbed off, to be honest."
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Gluten-free before the blood test: "I'd already cut out bread and pasta for about three weeks before that blood test because I thought gluten might be the problem. Nobody told me I needed to be eating it for the test to work."
Social History and Lifestyle Impact
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Occupation: You work as a freelance graphic designer from home. You set your own hours but you have to meet client deadlines, which means you can't just take days off when you feel rough.
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Lifestyle impact: The symptoms are concretely disrupting your ability to work and socialise. "I had to leave a client meeting yesterday because the cramps hit and I couldn't sit still — I was mortified. I've started turning down in-person meetings altogether because I'm terrified the bloating will kick in or I'll need the toilet urgently. Last week I cancelled dinner with friends because by 6 PM I looked and felt six months pregnant and I just couldn't face going out like that. It's making me withdraw from everything."
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Stress and anxiety: You acknowledge your anxiety has been well controlled on sertraline, but you are clear that the stomach symptoms are not anxiety — they are physical. If a doctor implies the symptoms are stress-related, you become frustrated: "I know what my anxiety feels like and this isn't it. This is physical pain."
If Asked — Associated Symptoms
(The patient does not volunteer any of these unprompted. These are responses for when the candidate directly asks about specific symptoms.)
If asked about nausea or vomiting: "I do feel a bit nauseous sometimes when the bloating is really bad, but I've never actually been sick."
If asked about fever: "No, no temperatures or anything like that."
If asked about joint pain: "No, nothing like that."
If asked about mouth ulcers: "No, I don't get those."
If asked about skin rashes or skin problems: "No, my skin's been fine."
If asked about eye problems (redness, pain, blurred vision): "No, nothing wrong with my eyes."
If asked about blood in the stool: "No, I've never noticed any blood."
If asked about mucus in the stool: "Actually yes, sometimes there's a bit of mucus — like a slimy coating. Is that bad?"
If asked about pain related to eating: "It does seem worse after eating, especially in the afternoon. By evening it's at its worst."
If asked about urgency: "Yes, when I get the loose stools I have to go right away — I can't hold it."
If asked about incomplete evacuation: "Yes, sometimes I go and I still feel like I haven't finished, like there's more to come."
If asked about back passage pain or perianal symptoms: "No, nothing like that."
If asked about appetite: "My appetite is fine, I eat normally."
If asked about fatigue or tiredness: "I am tired, but I think that's because I'm stressed about all of this rather than anything else."
If asked about family history of bowel disease: "My friend has Crohn's but nobody in my actual family has anything like that."
If asked about recent travel abroad: "No, I haven't been abroad in ages."
If asked about recent antibiotic use: "No, I haven't taken any antibiotics recently."
If asked about urinary symptoms: "No, that's all fine."
If asked about periods and whether the symptoms are linked to the menstrual cycle: "Now you mention it, the cramps and bloating do seem worse around my period, but they happen at other times too — it's not just a period thing."
Responses to Management (The Negotiation Phase)
If the Doctor diagnoses IBS immediately: Reaction: Resistant. "But how do you know? You haven't done a scan or a camera test. Just guessing it's IBS feels like a cop-out."
If the Doctor suggests a stool test (Calprotectin): Reaction: "Will that tell you if it's Crohn's? I'm happy to do that if it gives a definitive answer without a camera."
If the Doctor discusses Diet/FODMAPs: Reaction: "I eat really healthily! Fruit and veg all day. Are you saying healthy food is making me sick?"
If the Doctor suggests Amitriptyline (low dose): Reaction: Defensive. "Is that an antidepressant? I'm already on Sertraline. I don't want more mental health drugs, my pain is physical." (Tests doctor's ability to explain neuropathic pain modulation).
If the Doctor explains the need to repeat the Celiac screen while eating gluten: Reaction: "So the first test might not have been accurate? That's really frustrating — I wish someone had told me that at the time. But fine, I'll start eating bread again if it means getting a proper answer."
If the Doctor validates the physical symptoms and explains the gut-brain axis without dismissing them as anxiety: Reaction: Softens noticeably. "That actually makes sense. Nobody's explained it like that before. So you're saying the gut has its own nervous system and that's why it's playing up — not because I'm making it up?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Diagnosing IBS: Rome IV Criteria and Positive Diagnosis
- ●IBS is a positive diagnosis, not a diagnosis of exclusion. Apply the Rome IV criteria: recurrent abdominal pain at least one day per week in the last three months, associated with two or more of — pain related to defecation, change in stool frequency, or change in stool form.
- ●Additional supportive features include: straining or urgency, sensation of incomplete evacuation, mucus in stool, and abdominal bloating or distension that worsens through the day.
- ●A positive diagnosis can be made confidently in primary care once red flags are excluded (see Section 6) and the symptom pattern fits — no further investigation is required to confirm IBS.
- ●The characteristic diurnal bloating pattern (flat abdomen in the morning, progressive distension through the day) is a strongly supportive functional feature; structural causes of bloating do not follow this pattern.
The Coeliac Screen: A Critical Validity Nuance
- ●Coeliac disease is confirmed (or excluded) by serum tissue transglutaminase IgA (tTG-IgA) — but this test is only valid if the patient has been consuming gluten-containing foods (at least 10g of gluten per day, roughly equivalent to 4 slices of bread) for a minimum of 6 weeks before testing.
- ●A patient who has already self-excluded gluten before the blood test will have a falsely negative result — a clinically important and commonly missed error.
- ●If the prior test was taken after dietary gluten exclusion, arrange a repeat tTG-IgA after confirmed gluten reintroduction for 6 weeks. Explain to the patient that the first test was not invalid through anyone's fault — gluten reintroduction requirements are not widely known and she should not have been expected to know this.
- ●Always check total serum IgA alongside tTG-IgA to exclude IgA deficiency, which causes false-negative coeliac serology.
Investigating to Exclude IBD: Faecal Calprotectin
- ●Faecal calprotectin is the recommended first-line investigation to differentiate IBS from inflammatory bowel disease (IBD: Crohn's disease, ulcerative colitis) in primary care. It is non-invasive, inexpensive, and has a high negative predictive value for IBD.
- ●NICE CKS recommends offering faecal calprotectin to adults with recent-onset lower GI symptoms where IBD is a clinical consideration and colorectal cancer is not suspected.
- ●Interpretation: A result below 50 µg/g makes IBD very unlikely (IBS diagnosis supported). A result above 200 µg/g warrants urgent secondary care referral. Results in the 50–200 µg/g grey zone should be repeated in 4–6 weeks; persistent elevation warrants further investigation.
- ●A normal calprotectin result is a powerful tool for reassuring a patient who fears Crohn's disease — frame it as a definitive objective test, not just another normal result.
Dietary Management: FODMAPs and Fibre
- ●FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) are short-chain carbohydrates that are poorly absorbed in the small bowel and rapidly fermented by colonic bacteria, producing gas, bloating, and altered bowel habit. Common high-FODMAP foods include apples, stone fruits (peaches, plums, cherries), lentils, onions, garlic, and wheat.
- ●A low-FODMAP diet is an evidence-based approach for IBS symptom management. It should be offered as a structured, time-limited intervention — typically 4–8 weeks of restriction followed by systematic reintroduction to identify individual trigger foods. It is not intended as a permanent exclusion diet.
- ●Refer to a dietitian for supervised low-FODMAP guidance wherever possible. Unsupervised long-term FODMAP restriction risks nutritional inadequacy and is harder to sustain; a dietitian ensures correct implementation and safe reintroduction.
- ●When explaining FODMAPs to a patient who eats "healthily," reframe sensitively: certain foods that are nutritious for most people happen to be poorly tolerated by an overactive gut — this is not a criticism of their dietary choices.
- ●Fibre advice must be specific: recommend soluble fibre (ispaghula husk/Fybogel, oats) for constipation-predominant symptoms. Avoid insoluble fibre (wheat bran, bran cereals) — it accelerates gut transit but worsens bloating and abdominal pain in IBS.
- ●General IBS lifestyle advice (NICE CKS): eat regular meals without skipping, avoid large meals, limit caffeine, alcohol, and fizzy drinks, and encourage regular physical activity.
Pharmacotherapy: First- and Second-Line Options
- ●First-line for pain and bloating: Prescription antispasmodics — mebeverine 135mg three times daily (taken 20 minutes before meals) or alverine citrate 60–120mg up to three times daily. Peppermint oil capsules (enteric-coated) are an alternative. Over-the-counter hyoscine butylbromide (Buscopan) has a weaker evidence base; if it has already failed, step up to a prescription antispasmodic rather than repeating it.
- ●For diarrhoea-predominant episodes: Loperamide taken as needed (PRN) — not regularly — at the lowest effective dose. Advise the patient to use it reactively for urgency episodes rather than as a daily preventive.
- ●For constipation-predominant episodes: Macrogol (polyethylene glycol) is preferred. Avoid lactulose — it is itself a FODMAP (a disaccharide) and will worsen bloating and flatulence in IBS.
- ●Second-line for refractory pain: Low-dose amitriptyline (starting at 5–10mg nocte) acts as a gut-pain modulator via its effect on visceral afferent nerves — this is entirely distinct from its antidepressant use at higher doses (typically 75–150mg). Explain this clearly and proactively: "I'm recommending this at a very low dose specifically to calm the nerve signals from your gut — it's a completely different use from treating depression." Do not introduce it without this explanation; a patient already on sertraline will be understandably resistant.
- ●Amitriptyline and sertraline: Combination use is generally safe at these doses but is worth acknowledging. The main interaction concern (serotonin syndrome) is primarily relevant at higher doses; at 5–10mg nocte, the risk is low. There is no absolute contraindication, but document the rationale.
Red Flags and Safety Netting
- ●Red flags requiring urgent review or same-day action: unintentional weight loss, rectal bleeding, symptoms that wake the patient from sleep (nocturnal pain or diarrhoea is almost never functional), new palpable abdominal or rectal mass, iron deficiency anaemia, age over 60 with new change in bowel habit.
- ●Nocturnal symptoms are a critical differentiator: IBS symptoms do not wake patients at night. If a patient reports being woken by pain or diarrhoea, this points strongly to organic disease (IBD, microscopic colitis) and warrants urgent investigation.
- ●Safety-netting instruction: advise the patient to return promptly if she develops any of the above, and to re-attend if her symptoms significantly worsen despite treatment. Do not rely on vague instructions to "come back if it gets worse" — name the specific features.
- ●Follow-up: arrange a structured review at 6–8 weeks to check faecal calprotectin and repeat coeliac results, assess response to dietary and pharmacological management, and agree next steps. Proactive follow-up reinforces that the diagnosis is being taken seriously and maintains the therapeutic relationship.
The Gut-Brain Axis: Explaining IBS Mechanisms
- ●IBS is classified as a disorder of gut-brain interaction (DGBI) — formerly called functional bowel disorder. The enteric nervous system (the gut's own intrinsic nervous system) becomes sensitised, so normal amounts of gas or luminal content trigger disproportionate pain signals. This is visceral hypersensitivity.
- ●A useful patient-friendly explanation: "Your gut has its own nervous system, and in IBS the volume is turned up too high — signals that wouldn't bother most people cause significant pain in you. This is a real neurological process in your gut, not something you're imagining."
- ●This framing is clinically important: it explains the mechanism without attributing symptoms to anxiety or psychological causes, validates the physical reality of symptoms, and provides a rationale for treatments targeting nerve sensitisation (such as low-dose amitriptyline or gut-directed psychological therapies).
- ●Avoid the phrase "functional" without explanation — patients often interpret it as "there's nothing wrong with you." Prefer "disorder of gut-brain interaction" or "your gut nerves are overactive."
Multimorbidity Awareness: IBS, Anxiety, Dysmenorrhoea, and NSAIDs
- ●IBS, generalised anxiety disorder (GAD), and dysmenorrhoea share pathophysiological mechanisms — central sensitisation and altered pain processing — which explains their frequent co-occurrence. Recognising this is important, but these shared mechanisms must never be used to dismiss GI symptoms as "just anxiety."
- ●Menstrual cycle and IBS are closely linked: oestrogen and progesterone influence gut motility, and IBS symptoms frequently worsen perimenstrually. This is not coincidence — it is a recognised physiological relationship. For Emily, the worsening of cramps and bloating around her period is consistent with both her IBS and her dysmenorrhoea.
- ●NSAIDs and the GI tract: Mefenamic acid (an NSAID) can cause or worsen GI symptoms including abdominal pain, diarrhoea, and nausea. In a patient with IBS, consider whether NSAID use during menstruation is contributing to symptom flares. This does not necessarily mean stopping mefenamic acid — its benefit for dysmenorrhoea is established — but it warrants acknowledgement and monitoring.
- ●If IBS symptoms remain refractory after first- and second-line measures, consider gut-directed psychological therapies (gut-directed CBT, gut-directed hypnotherapy) — these have a robust evidence base for IBS and are recommended by NICE CKS as third-line options.
Mapped to the RCGP curriculum topic: Gastroenterology.
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