Middle-aged Man Has Abdominal and Loin Pain. Examination Expected. — Free SCA Practice Case
Middle-aged man has abdominal and loin pain. Examination expected.
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
David Thorne
Age
56 years
Consultation Type
VideoAge
56
Situation
Video Consultation.
Reason for Encounter
"Patient booked an urgent video appointment. Triage note states: 'Sudden onset severe back and stomach pain. Sweating. Needs painkillers.'"
Medical Records
- ●PMH: Hypertension, Smoker (20/day for 35 years), Hyperlipidaemia.
- ●Medications: Ramipril 5mg OD, Atorvastatin 20mg OD.
- ●Allergies: NKDA.
Recent Notes
- ●Routine BP review 2 months ago: 145/88.
Patient Script
For the friend playing the patient role
Character Overview: You are David, a 56-year-old warehouse manager. You are currently in agony. About an hour ago, you developed a sudden, excruciating pain in your left flank/lower back that is shooting down into your left groin. The pain comes in intense waves. Because of the severity of the pain, you cannot sit still. Throughout the video call, you are constantly shifting in your seat, standing up, pacing the room, and groaning. You look pale and are visibly sweating. You feel nauseous but haven't vomited. You feel a constant urge to pass urine, but when you go, it's only a trickle. You believe you have severely pulled a muscle in your back from lifting a heavy pallet at the warehouse yesterday. You just want the doctor to prescribe some strong painkillers (like Diazepam or Codeine) so you can lie down and sleep it off. You will not volunteer information about the pain moving to your groin, the urinary symptoms, or your smoking history unless the doctor specifically takes a structured pain history.
ICE — Ideas, Concerns, Expectations
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Ideas: You are convinced you've pulled a muscle in your back. You lifted a heavy pallet at work yesterday and that's when you think the damage was done. You have no concept that this could be anything to do with your kidneys or blood vessels — it's just a back injury to you.
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Concerns: You are worried about missing work. You're a warehouse manager and physically can't do the job if you can't move properly — you've got a big delivery coming in tomorrow and there's no one else to oversee it. Underneath the frustration, you're also frightened by how severe the pain is — you've never felt anything like it and that scares you, though you wouldn't readily admit that.
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Expectations: You want strong painkillers prescribed immediately so you can take them, lie down, and sleep it off. You expect this to be a quick call — tell the doctor what's wrong, get a prescription sent to the pharmacy, and get off the phone. You are not expecting to be told to go to hospital.
(The patient does not raise ICE unprompted — these surface only when the candidate directly explores the patient's perspective.)
Consultation Flow & Responses:
- ●The Opening:
- ●If the doctor asks an open question: (You are pacing the room, holding your phone) "Doctor, you need to give me something strong. I've pulled a muscle in my back and it is absolute agony. I can't even sit down to talk to you. Please, just send some strong painkillers to the pharmacy."
- ●Data Gathering (The Layers):
- ●Layer 1: The Pain History (SOCRATES):
- ●If asked to describe the pain/location: "It's right here in my left side, just under my ribs at the back. But it's shooting all the way down into my left groin. It's easily a 9 out of 10."
- ●If asked about the character/timing: "It comes in massive waves. It grips me, eases off a tiny bit, and then grips me again."
- ●Layer 2: Associated Urological Symptoms:
- ●If asked about urine/waterworks: "I feel like I need to pee constantly, but when I try, hardly anything comes out. I haven't noticed any blood, but it's hard to tell."
- ●If asked about fever/nausea: "I haven't taken my temperature, but I'm sweating buckets. I feel really sick to my stomach."
- ●Layer 3: Recognition of Examination Need
- ●If the candidate attempts any form of remote self-examination: "I don't really know what I'm feeling for — I'm in too much pain to concentrate on that."
- ●If the candidate says they need to examine you and directs you to attend in person or go to A&E: respond with relief and compliance — "So you think I need to be seen in person? Okay, if you think that's necessary."
- ●Note for role player: Do not facilitate or reward remote examination attempts. The correct clinical behaviour being tested here is whether the candidate recognises that this presentation cannot be safely assessed without physical examination, and acts on that by escalating to a setting where examination can take place.
- ●Layer 4: Red Flag Screen (AAA):
- ●If asked about dizziness, fainting, or leg weakness: "No, I haven't fainted. My legs are fine, they don't feel cold or numb. It's just this agonizing back pain."
If Asked — Medical History and Medications
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If asked about blood pressure / hypertension: "Yeah, they told me my blood pressure was a bit high a few years back. I'm on a tablet for it — Ramipril, I think. I take it every morning. I had a check about two months ago and the nurse said it was still a bit high but not to worry too much."
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If asked about cholesterol: "They said my cholesterol was up as well. I'm on one of those statin tablets — Atorvastatin. I take it at night. I don't really think about it much, to be honest."
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If asked about smoking: "Yeah, I smoke. About 20 a day, have done since I was about 21. I know, I know — I should stop. The nurse goes on about it every time I go in. I've just never got round to it."
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If asked about allergies: "No, no allergies to anything that I know of."
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If asked about other medications or tablets: "Just the two — the blood pressure one and the cholesterol one. Nothing else."
Social History and Lifestyle Impact
You've been a warehouse manager at a building supplies firm for 18 years. It's a physical job — you're on your feet all day, lifting stock, operating the forklift, managing deliveries. You live with your wife, Sandra, who works part-time at a primary school. You have two grown-up kids who've moved out.
The pain is making it impossible to function. You can't stand upright for more than a few seconds without doubling over. You were supposed to be at the warehouse right now supervising a delivery, and instead you're pacing around your kitchen in agony. You're worried about letting the lads down at work — there's no deputy manager and if you're not there, things don't get done properly. You haven't been off sick in years and the idea of being stuck at home is frustrating.
(This context is volunteered naturally during conversation — for example, when explaining why you need painkillers quickly, or if asked about your work.)
If Asked — Associated Symptoms
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If asked about blood in the urine: "No, I haven't seen any blood. But honestly I've only been a couple of times and it was barely a dribble, so I might not have noticed."
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If asked about pain on passing urine / burning: "No, it doesn't burn or sting when I go. It's just this constant feeling that I need to go, and then nothing really comes out."
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If asked about testicular pain or swelling: "No, nothing like that — it's all in my side and my groin area, not down there."
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If asked about bowel symptoms / change in bowel habit: "No, bowels are fine. Nothing different there."
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If asked about chest pain or shortness of breath: "No, no chest pain. I'm a bit out of breath from pacing around, but it's not like I can't breathe."
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If asked about back pain before / previous episodes: "I've had the odd twinge over the years — comes with the job — but nothing like this. This is completely different. This is the worst pain I've ever had."
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If asked about recent weight loss or appetite change: "No, nothing like that. Appetite's been fine until today — I couldn't eat anything now, I feel too sick."
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If asked about recent travel abroad: "No, haven't been anywhere. Last holiday was Tenerife about two years ago."
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If asked about fever or rigors: "I don't think I've got a temperature. I'm sweating, but I think that's just from the pain. I haven't had any shivering fits or anything like that."
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If asked about previous kidney stones: "No, never had anything like this before."
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If asked about family history of kidney problems or aneurysms: "My dad had a heart attack at 62 and my mum's got high blood pressure. I don't know about anything else — nobody's mentioned kidneys or blood vessels."
Negotiation & Collaborative Management Plan:
- ●If the Doctor agrees to prescribe oral painkillers and tells you to rest:
- ●Reaction: "Thanks. I'll go pick them up now." (Candidate critically fails for under-assessing a surgical emergency and prescribing oral meds for severe acute pain without a physical exam).
- ●If the Doctor diagnoses a kidney stone but tells you to just go to the GP surgery for a check later:
- ●Reaction: "Drive to the surgery? I can barely stand up straight. Is it really just a stone? Why does it hurt this much?"
- ●If the Doctor explains they suspect Renal Colic but must urgently rule out a serious blood vessel issue (AAA), directing you to A&E:
- ●Reaction: Scared but compliant. "A blood vessel? You mean like a burst artery? Oh my god. Okay, my wife is downstairs, I'll tell her to drive me straight to A&E right now."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Diagnostic Distinction: Renal Colic vs. Leaking AAA
- ●The classic trap: a 56-year-old male with loin-to-groin pain, colicky character, and urinary symptoms is a textbook presentation of ureteric colic (renal colic). However, a leaking or ruptured abdominal aortic aneurysm (AAA) can present identically — severe back or flank pain, nausea, sweating, and haemodynamic instability — and cannot be safely excluded on history alone.
- ●The high-risk demographic is specific: male sex, age >55, long-term smoker, hypertensive, hyperlipidaemic. David meets every criterion. This combination of cardiovascular risk factors must trigger an explicit AAA screen before renal colic is managed remotely.
- ●The critical differentiating red flags for AAA include: syncope or pre-syncope, a tearing or ripping quality to the pain, bilateral leg weakness, coldness, or numbness (suggesting aortoiliac ischaemia), and a pulsatile abdominal mass on palpation. Their absence reduces but does not exclude the diagnosis.
- ●The clinical rule: any patient with this demographic presenting with their first episode of apparent renal colic must be assessed in person, with imaging, to exclude AAA. A remote video consultation cannot safely do this.
Visual Diagnosis: Colic vs. Peritonism
- ●The inability to find a comfortable position — writhing, pacing, constantly shifting — is the hallmark of visceral colicky pain (ureteric or biliary obstruction). The smooth muscle of the ureter contracts in spasm; movement does not worsen the pain.
- ●Contrast this with peritonism: patients with peritoneal irritation (appendicitis, perforated viscus, advanced ectopic pregnancy) lie completely still, because any movement — coughing, shifting position, the car going over a bump — exacerbates the pain. This is the opposite sign.
The Sepsis Pathway: Obstructed and Infected Kidney
- ●Fever in the context of a ureteric obstruction constitutes a urological emergency — an infected, obstructed kidney (obstructive uropathy with urosepsis) — and is managed differently from uncomplicated renal colic.
- ●This patient reports sweating but denies fever and rigors, making sepsis less likely — but the screen must be explicit. Ask directly about temperature, rigors (uncontrollable shivering fits), and confusion. If fever is present alongside obstruction, the patient requires urgent IV antibiotics and emergency urology review, not just analgesia.
- ●Absence of fever does not fully exclude early sepsis in a patient who is diaphoretic and unable to mobilise. The hospital assessment will include temperature, heart rate, blood pressure, and lactate.
Investigations
- ●The gold-standard investigation for suspected renal colic is a non-contrast CT KUB (CT of the kidneys, ureters, and bladder). It is superior to ultrasound for stone detection, identifies the stone size and location, and can simultaneously assess the aorta for aneurysm.
- ●Alongside CT, the hospital will perform: urine dipstick ± microscopy, culture and sensitivity (MC&S), and bloods including FBC, U&E, creatinine/eGFR, CRP, and coagulation if surgery is anticipated.
- ●Note on haematuria: Microscopic or macroscopic haematuria supports the diagnosis of renal colic but is absent in up to 15–30% of confirmed cases. Its absence does not exclude the diagnosis.
Analgesia and Antiemetics for Renal Colic
- ●First-line analgesic: An NSAID is the gold-standard agent for renal colic per NICE CKS. NSAIDs reduce ureteric smooth muscle spasm and prostaglandin-mediated inflammation at the stone site, providing superior analgesia to opioids for this presentation.
- ●Route matters: In a patient who is nauseous, sweating, and writhing, oral absorption is unreliable. The correct route is intramuscular (IM) or intravenous (IV). Common choices: diclofenac 75 mg IM, or ketorolac IV in hospital. PR diclofenac 100 mg is an alternative if IV/IM access is delayed.
- ●Contraindications to NSAIDs: active peptic ulceration, eGFR <30, known severe asthma triggered by NSAIDs. In these cases, escalate to IV paracetamol or IV opioids (e.g. morphine titrated) in a hospital setting.
- ●Antiemetics: The patient is significantly nauseous — antiemetic therapy is part of the acute management plan. In hospital: IV ondansetron or IV metoclopramide. Do not prescribe oral antiemetics for a patient who cannot reliably swallow.
- ●Oral codeine or oral diazepam prescribed and dispensed to a patient in this state — nauseous, unable to sit still, with an undifferentiated surgical differential — is a critical management error.
Referral and Same-Day Assessment
- ●This presentation cannot be managed remotely, regardless of how confident the working diagnosis is. A patient in severe acute pain with an undifferentiated surgical differential (renal colic vs. AAA) requires in-person examination, urgent imaging, and parenteral analgesia.
- ●The correct disposition is immediate attendance at A&E or a Surgical Assessment Unit (SAU) — not a GP surgery appointment later in the day.
- ●Conditions that escalate to emergency urology on the same day include: fever with obstruction (infected obstructed kidney), solitary kidney, bilateral obstruction, renal impairment, and stone >10 mm (unlikely to pass spontaneously).
Safety Netting During Transit
- ●Ending the call with 'make your way to hospital' is insufficient. Provide specific, structured safety netting for the period between ending the call and hospital arrival:
- ●Do not drive — confirm a responsible adult (wife) can drive immediately.
- ●Call 999 if he feels faint, dizzy, or collapses before leaving the house — this is the critical escalation trigger given the AAA differential.
- ●Confirm his understanding of the urgency: 'Not later today — now.'
- ●This safety-net instruction — particularly the 999 trigger — is what distinguishes a safe disposition from a dangerous one in this case.
Post-Acute Follow-Up and Recurrence Prevention
- ●Once the acute episode resolves, ongoing management includes:
- ●Urology or nephrology review for metabolic stone workup (24-hour urine collection for calcium, oxalate, urate, citrate; serum calcium and urate).
- ●Stone analysis if the stone is passed or retrieved, to guide dietary and pharmacological prevention.
- ●Medical expulsive therapy: For distal ureteric stones ≤10 mm, tamsulosin 400 micrograms once daily (an alpha-blocker) may be considered per NICE guidance (NG118) to relax ureteral smooth muscle and facilitate spontaneous stone passage — though the evidence base is modest and this remains an off-label use of tamsulosin. It is prescribed after the acute episode, not during it.
- ●Fluid intake: Recommend >2.5 litres of fluid per day to maintain dilute urine and reduce recurrence risk — this is the single most effective prevention measure for all stone types (NICE CKS).
- ●Dietary advice depends on stone type: for calcium oxalate stones (most common), reduce oxalate-rich foods (spinach, nuts, rhubarb) and maintain adequate calcium intake. Do not restrict dietary calcium — this paradoxically increases stone risk.
Cardiovascular Risk — The Broader Picture
- ●This acute presentation sits within a significant, undertreated cardiovascular risk profile: 35-pack-year smoking history, blood pressure 145/88 on ramipril (suboptimally controlled), and hyperlipidaemia on atorvastatin 20 mg.
- ●The acute consultation is not the moment to address these in depth — the priority is hospital referral. However, flagging to the patient that these will need follow-up after recovery is appropriate and demonstrates holistic thinking.
- ●Post-acute priorities: smoking cessation referral (GP smoking cessation service or NHS Stop Smoking), BP optimisation (consider increasing ramipril dose or adding a second agent — NICE step 2: ACE inhibitor + calcium channel blocker), and review of statin dosing given the overall cardiovascular risk (consider high-intensity statin if 10-year QRISK3 >10%).
Common Candidate Mistakes
- ●Prescribing oral analgesia remotely (oral codeine, oral diazepam) without physical assessment is the most critical error in this case — it fails the patient on two levels: inadequate analgesia route for a nauseous, severely distressed patient, and dangerous under-investigation of an undifferentiated surgical emergency.
- ●Accepting the patient's self-diagnosis ('I've pulled a muscle') without systematically assessing the pain character and radiation. The loin-to-groin radiation and colicky character are not consistent with musculoskeletal injury — eliciting and acting on this distinction is a core positive indicator.
- ●Failing to elicit the AAA risk profile from the existing medical record. The PMH (hypertension, smoking, hyperlipidaemia) and demographics (male, 56) are visible in the notes before the consultation begins. Using this information to frame the differential from the outset — not as an afterthought — is what separates a safe clinician from an unsafe one.
- ●Accepting negative self-palpation findings as definitive. The patient reports no pulsatile mass and a soft abdomen — this reduces but does not exclude AAA. The candidate must explicitly state this limitation.
Mapped to the RCGP curriculum topic: Renal and Urology.
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