Ongoing Abdominal Pain Following Normal Gastroenterology Discharge — Free SCA Practice Case
Woman with ongoing abdominal pain following normal gastroenterology discharge
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
Clara Jenkins
Age
38 years
Consultation Type
VideoAge
38
Reason for Encounter
"Patient wishes to discuss the recent letter from the Gastroenterology clinic regarding her ongoing abdominal pain."
Medical Records
- ●PMH: Mild Asthma.
- ●Medications: Omeprazole 20mg OD, Mebeverine 135mg TDS (Neither are currently helping).
- ●Allergies: NKDA.
Recent Notes
- ●Gastroenterology Clinic Letter (Received this week): "Dear GP, I reviewed Clara in the clinic today. As you know, she has had 6 months of severe, generalized abdominal pain. Her recent investigations (Upper GI Endoscopy, Colonoscopy, MRI Small Bowel, Abdominal Ultrasound) are all entirely normal. Her coeliac screen, CA125, FIT test, and faecal calprotectin are also negative. There is no evidence of inflammatory bowel disease, malignancy, or other organic pathology. I have reassured her, diagnosed severe Irritable Bowel Syndrome / Functional Abdominal Pain, and discharged her back to your care."
Patient Script
For the friend playing the patient role
Character Overview: You are Clara. You are utterly exhausted, deeply frustrated, and genuinely in daily physical agony. When you read the copy of the specialist's letter, you felt entirely dismissed. To you, "functional pain" and "reassurance" feels like they are saying "it's all in your head." You are hiding a massive, consuming terror. Six months ago, your older sister died of advanced ovarian cancer. Her symptoms started exactly like yours—vague abdominal pain that her GP initially dismissed as "just IBS." You are absolutely convinced the gastroenterologist has missed a hidden cancer. You spend hours every night Googling your symptoms and pressing your stomach checking for lumps. You will not volunteer the information about your sister's death or your cancer fear unless the doctor actively explores your underlying worries, asks about your family history, or picks up on your profound anxiety.
Consultation Flow & Responses:
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The Opening
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If the doctor asks an open question: "Hi Doctor. I made this appointment because I got copied into the letter from the gastroenterologist. He said all the scans are normal and he discharged me. But I am still in agony every single day. He has clearly missed something, and I need you to refer me for a second opinion or a whole-body scan."
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Data Gathering (The Layers)
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Layer 1: The Reality of the Pain:
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"The pain is real. It's a deep, constant ache all over my stomach. It wakes me up at night."
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"The Mebeverine and Omeprazole you gave me do absolutely nothing."
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"My bowel habits are fine, maybe a bit constipated sometimes, but it's the pain that is ruining my life. I can barely focus at work."
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Layer 2: The Reaction to the Specialist:
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"He barely listened to me. He just looked at the computer, said my bowels looked fine on the camera, and told me it's 'functional'. He basically told me I'm stressed and it's IBS. IBS does not feel like you are being stabbed."
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Layer 3: ICE & The Core Revelation (The Hidden Trauma) - ONLY REVEAL IF ASKED:
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If the doctor asks: "What are you worried the specialist has missed?" or "Has something happened recently that makes you feel so frightened about this pain?"
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Reaction (The Reveal): Your eyes well up with tears. "My sister. She died six months ago. She went to the doctors for months with a stomach ache, and they kept telling her it was just IBS and stress. By the time they actually did a proper scan, the ovarian cancer was everywhere. She died in a hospice at 42. I have the exact same pain. How can you be sure it's not the same thing? How do I know he didn't miss it?"
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Layer 4: The Psychological Impact (Health Anxiety):
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If asked how she is coping or sleeping: "I'm not. I stay up half the night reading medical forums. Every time I get a twinge, I have a panic attack thinking it's a tumor growing. I'm checking my stomach for lumps in the shower every morning."
ICE — Ideas, Concerns, Expectations
Actor guidance: Do not volunteer any of the following unprompted. These responses surface only when the candidate directly explores the patient's perspective using open questions about ideas, concerns, or expectations.
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Ideas: Clara believes the gastroenterologist has missed something serious — specifically, a hidden cancer like the one that killed her sister. She does not accept that "functional pain" is a real diagnosis. In her mind, normal test results simply mean they haven't looked hard enough or in the right place. She has no alternative explanation for the pain other than something sinister being missed.
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Concerns: Her overwhelming, consuming fear is that she has ovarian cancer — the same disease that killed her older sister six months ago. She is terrified of the same pattern repeating: months of being told it is "just IBS" until it is too late. Beneath this is a broader terror of dying and leaving things unfinished, compounded by unresolved grief. She is also worried that no one is taking her pain seriously and that she is being labelled as a "difficult" or "anxious" patient.
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Expectations: She came in wanting a referral for a second opinion or a whole-body scan — something definitive that would either find the cancer or categorically rule it out. However, if the doctor genuinely validates her pain, acknowledges her grief, and explains the diagnosis in a way that makes physiological sense (e.g. visceral hypersensitivity / brain-gut axis), she is open to trying a different approach. What she needs most is to feel believed and not dismissed.
If Asked — Medical History and Medications
Actor guidance: Respond naturally in patient voice only when the candidate asks about specific medications or medical history. Do not recite a list unprompted.
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Omeprazole 20mg (once daily): "I've been on that for about three months now. The GP before you started me on it when the stomach pain first got really bad, thinking it might be an acid thing. It's done absolutely nothing. I still take it because I was told to, but honestly I don't know why I bother."
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Mebeverine 135mg (three times daily): "That was added when they first said it might be IBS. I take it before meals like I was told. It doesn't make any difference at all — the pain is exactly the same whether I take it or not."
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Asthma: "I've had mild asthma since I was a teenager. It's never been a big deal — I use my blue inhaler maybe once or twice a month if I'm exercising or if it's cold. It's got nothing to do with my stomach. I haven't had an asthma attack in years."
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Allergies: "No, no allergies to anything that I know of."
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Gastroenterology investigations: "I had the lot — the camera down my throat, the camera up the other end, an MRI, and an ultrasound. They took blood tests too. He said everything came back normal. But normal doesn't mean they've found what's wrong, does it? It just means they haven't found it yet."
Social History and Lifestyle Impact
Actor guidance: This context can be shared naturally during conversation, particularly when discussing how the pain affects daily life or when the candidate asks about work, home, or support.
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Occupation: Clara works as an office manager at a small recruitment firm. She has been in the role for five years. It is a busy, deadline-driven job that she normally handles well.
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Family situation: She lives with her partner, Tom, and their two children (aged 6 and 9). Tom is supportive but increasingly worried about her. She has not told him about her cancer fears because she does not want to frighten him — he was also very close to her sister.
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Lifestyle impact of the condition: "I'm barely functioning at work. I used to be the one holding things together in the office, but now I'm making mistakes, losing track of conversations. My boss has noticed. At home it's worse — I can't play with the kids properly because I'm either doubled over or I'm so anxious I can't concentrate. Tom keeps asking me what's wrong and I just say I'm tired. Last weekend I couldn't even go to my daughter's swimming gala because I was in so much pain. She asked me why Mummy never comes anymore."
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Bereavement context (if explored): Clara was very close to her sister, who was her main confidante and support. The grief is raw and unprocessed — she has not accessed any bereavement support. Her sister's death has fundamentally changed how she interprets any physical symptom in her own body.
If Asked — Associated Symptoms
Actor guidance: Respond only when the candidate directly asks about specific symptoms. Keep answers brief and natural.
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If asked about weight loss: "No, my weight has been the same. If anything I've put on a couple of pounds because I'm comfort eating and not exercising."
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If asked about appetite: "It's up and down. Some days I don't feel like eating because the pain puts me off, but I'm not losing weight or anything."
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If asked about nausea or vomiting: "I feel a bit queasy sometimes when the pain is really bad, but I'm not actually being sick."
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If asked about blood in the stool or rectal bleeding: "No, nothing like that. They checked for that — the stool test came back normal."
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If asked about diarrhoea: "No, not really. If anything it's the opposite — I get a bit bunged up sometimes."
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If asked about bloating: "Yes, actually. My stomach blows up like a balloon by the end of the day. It's really uncomfortable. I sometimes have to undo my trousers at my desk."
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If asked about relationship of pain to food: "I've tried cutting things out — gluten, dairy — but it doesn't seem to make any consistent difference. The pain is just there all the time."
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If asked about urinary symptoms: "No, nothing like that. Weeing is fine."
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If asked about menstrual changes or irregular periods: "My periods are regular, maybe a bit heavier than they used to be, but nothing dramatic. They checked my CA125 and it was normal."
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If asked about fever or night sweats: "No fevers. I do wake up in the night but that's because of the pain and the worry, not because I'm sweating."
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If asked about jaundice or changes in skin/eye colour: "No, nothing like that."
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If asked about back pain: "A bit of lower back ache sometimes, but I think that's just because I'm tense all the time. It's not a separate problem."
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If asked about fatigue: "I'm exhausted, but that's because I'm not sleeping. I'm up half the night either in pain or on my phone reading about symptoms."
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If asked about mood or anxiety: "I mean, yes, I'm anxious — wouldn't you be? But I'm not depressed. I'm frightened. There's a difference."
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If asked about dysphagia (difficulty swallowing): "No, swallowing is fine."
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If asked about recent travel abroad: "No, I haven't been abroad since before my sister got ill — over a year ago now."
Negotiation & Collaborative Management Plan
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If the Doctor tells you "It's just stress/anxiety causing the pain" or "It's all in your head":
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Reaction: Furious and defensive. "It is NOT in my head! I am not making this up! I feel the physical pain! You are doing exactly what they did to my sister!" (Testing the doctor's ability to explain the Brain-Gut axis without invalidating the physical symptom).
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If the Doctor suggests Amitriptyline as an "antidepressant":
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Reaction: Suspicious. "An antidepressant? I'm not depressed, my stomach is hurting. Why are you giving me psychiatric drugs for a stomach ache?" (Doctor must specifically frame it as a 'nerve painkiller' that turns down the volume of the gut nerves).
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If the Doctor explains 'Visceral Hypersensitivity' / Brain-Gut Axis effectively:
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Reaction: Intrigued and slightly relieved. "So you're saying the nerves in my stomach have basically become overly sensitive because my brain is on high alert since my sister died? The pain is real, but it's a nerve misfire, not a tumor?"
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If the Doctor gives in and orders another urgent scan without addressing the anxiety:
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Reaction: "Thank you." (Note: Candidate fails for giving in to clinically unindicated investigations, fueling the health anxiety cycle, and failing to manage the somatic disorder).
Safety Netting / Follow-up
- ●If the Doctor sets a specific follow-up in 2-3 weeks to check the new medication:
- ●Reaction: "Okay. I will try to stop Googling, and I'll start the nerve medication tonight. I feel a bit better just knowing you actually believe I'm in pain."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Diagnosing Functional Abdominal Pain: The Role of Normal Investigations
- ●A diagnosis of Functional Abdominal Pain or severe Irritable Bowel Syndrome (IBS) is made positively — not simply by exclusion. Normal structural investigations confirm the gut architecture is intact; they do not mean pain is fabricated.
- ●The term "medically unexplained symptoms" (MUS) is increasingly avoided. Preferred language includes functional gastrointestinal disorder, somatic symptom disorder, or specific diagnoses such as IBS or functional abdominal pain syndrome (FAPS).
- ●Clara's investigation set — upper and lower GI endoscopy, MRI small bowel, abdominal ultrasound, CA125, FIT test, and faecal calprotectin — constitutes a thorough exclusion of organic pathology, including IBD, malignancy, and coeliac disease.
- ●The CA125 and pelvic ultrasound are the primary investigations used to screen for ovarian cancer. Their normality is directly relevant to her specific fear and must be communicated explicitly — not summarised vaguely as "tests were normal."
Visceral Hypersensitivity and the Brain-Gut Axis
- ●Visceral hypersensitivity is the central mechanism of functional abdominal pain. The enteric nervous system becomes sensitised: normal physiological stimuli — peristalsis, gas transit, mild distension — are transmitted to the brain as severe, often constant pain.
- ●The gut and brain communicate bidirectionally via the vagus nerve and the hypothalamic-pituitary-adrenal (HPA) axis. Prolonged stress, trauma, or grief shifts the nervous system into a sustained threat state, directly lowering the visceral pain threshold.
- ●In Clara's case, the timing is clinically significant: her pain began in the months following her sister's death, a classic pattern of bereavement-triggered visceral sensitisation.
- ●Explaining this mechanism using an accessible analogy is essential. A fire alarm framing works well: the scans confirm there is no fire (no cancer, no inflammation) — but grief and fear have set the alarm system to hair-trigger, so it fires constantly. The pain is the alarm misfiring, not the fire itself.
Health Anxiety: The Reassurance-Seeking Cycle
- ●Health anxiety (classified under Somatic Symptom and Related Disorders in DSM-5, or Illness Anxiety Disorder where somatic symptoms are absent) is characterised by persistent, disproportionate fear of serious illness despite adequate medical evaluation.
- ●The maintaining cycle is self-reinforcing: perceived bodily sensation → catastrophic interpretation ("it's cancer") → anxiety → heightened physiological arousal → increased pain and bodily focus → reassurance-seeking (Googling, body checking, demanding investigations) → temporary relief → return of doubt.
- ●Ordering unindicated investigations feeds this cycle. Each scan or referral granted without clinical indication provides short-lived reassurance before doubt returns — "what if that MRI missed it?" — escalating the pattern. This is the single most important clinical boundary in this case.
- ●Late-night health searching and compulsive body checking are maintaining behaviours that must be addressed in the management plan, not ignored.
Family History and Ovarian Cancer Risk Assessment
- ●A first-degree relative with ovarian cancer is a recognised risk factor. However, Clara's sister died at 42 with no known BRCA status mentioned in the records, and Clara's own CA125 and pelvic ultrasound are normal.
- ●NICE CKS and NICE guideline CG122 (Familial breast cancer) recommend genetic risk assessment where family history is significant — this may warrant a brief mention of future genetics referral if there is a pattern of early-onset ovarian cancer in the family, but this should not be the focus of this consultation.
- ●The immediate clinical priority is to connect Clara's specific cancer fear to the specific investigations that have already excluded it.
Medication Rationalisation Before Adding New Treatment
- ●Omeprazole 20mg OD was started empirically for abdominal pain; with no acid-related pathology identified and no ongoing indication, it can be stopped. There is no requirement for a dose taper at 20mg.
- ●Mebeverine 135mg TDS is a gut antispasmodic with modest efficacy in mild-to-moderate IBS. It has no established role in central visceral pain or functional abdominal pain syndrome and is not providing benefit in this case. It should be stopped.
- ●Rationalising both medications before starting a neuromodulator demonstrates safe prescribing, simplifies the regimen, and avoids the perception that treatment is simply being accumulated without clinical logic.
Pharmacological Management: Neuromodulators for Visceral Pain
- ●Standard analgesics — paracetamol, NSAIDs, opioids — have no established role in functional visceral pain and opioids carry significant risk of worsening gut motility and opioid-induced bowel dysfunction.
- ●Low-dose Amitriptyline is the first-line neuromodulator for IBS and functional abdominal pain, recommended by NICE CG61 (IBS in adults). Typical starting dose: 10mg at night, titrated upward in 10mg increments to a maximum of 30–50mg depending on response and tolerability.
- ●Framing is critical. Introducing Amitriptyline as an antidepressant will cause immediate refusal. It must be framed as a gut nerve painkiller: it reduces the sensitivity of the overactive nerve fibres in the gut, "turning down the volume" on the pain signals reaching the brain. The doses used are a fraction of antidepressant doses.
- ●Key prescribing points to cover: taken at night (helps sleep; drowsiness is an intended initial side effect), allow 4–6 weeks for meaningful effect, dry mouth and constipation are common and usually transient, avoid abrupt discontinuation after prolonged use.
- ●Asthma consideration: Amitriptyline is not contraindicated in mild asthma. Clara's asthma is mild and well-controlled (SABA use monthly or less); no prescribing modification is required, but it is good practice to confirm this.
- ●SSRIs (e.g., low-dose sertraline) are a reasonable second-line neuromodulator alternative if Amitriptyline is not tolerated.
Non-Pharmacological Management
- ●Evidence-based lifestyle measures for IBS/functional abdominal pain per NICE CG61 include: regular meal pattern (avoid skipping meals), adequate fluid intake (1.5–2L daily, preferably non-fizzy), reduction of caffeine and alcohol, and gentle regular physical activity.
- ●A low-FODMAP diet (under dietitian supervision) has good evidence for IBS symptom reduction and is appropriate to mention if dietary factors are a concern — though Clara has already tried dietary exclusions without benefit, suggesting this is not a primary driver.
- ●Stress reduction and relaxation techniques — including guided mindfulness and progressive muscle relaxation — have an evidence base in functional pain and are accessible via apps and self-referral.
- ●These measures should be framed as complementary to medication, not as a substitute or an implication that lifestyle is the cause of the pain.
Psychological Therapy: CBT and Bereavement Support
- ●Cognitive Behavioural Therapy (CBT) has the strongest evidence base for health anxiety (NICE CG91). It targets catastrophic appraisal, reassurance-seeking behaviours, and body checking — the core maintaining factors in this case.
- ●Referral is via NHS Talking Therapies (formerly IAPT). This should be framed as practical skills training for a brain stuck in threat mode after trauma — not as psychiatric treatment or an implication of mental illness.
- ●Bereavement counselling is a separate and distinct therapeutic need. Clara has experienced a traumatic, sudden loss of her primary confidante within the last six months, with no bereavement support accessed. Referral options include: GP surgery counselling, local hospice bereavement service (many offer community bereavement support regardless of whether the patient died there), or national charities such as Cruse Bereavement Support.
- ●These are two different referrals with different purposes and should not be conflated.
Safety-Netting: Specific Red Flag Symptoms to Monitor
- ●Functional abdominal pain can only remain a safe diagnosis if the clinical picture remains consistent. Advise Clara to return if she develops any of the following:
- ●Unintentional weight loss
- ●Rectal bleeding or melaena
- ●Persistent vomiting
- ●A palpable abdominal or pelvic mass
- ●Fever or unexplained night sweats
- ●Fundamental change in the character of the pain (e.g., new onset of localised, severe, acute pain)
- ●New onset of symptoms after the age of 50 (not applicable here but a standard safety criterion)
- ●Frame safety-netting as evidence that the door remains open — not as a reason to worry. The plan does not mean "we are done looking"; it means "the investigations have been thorough, and these are the signs that would change our approach."
- ●Book a specific, proactive follow-up appointment in 2–3 weeks to review Amitriptyline tolerability and early response, assess her psychological state, and check in on her bereavement — not an open-ended "come back if needed."
Common Candidate Mistakes in This Case
- ●Failing to explore ICE — missing the sister entirely. The most common failure is accepting her demand for a second opinion or scan at face value without asking what she specifically fears the specialist has missed. The sister's death from ovarian cancer is the entire clinical context. A candidate who does not uncover it cannot manage the case safely or effectively.
- ●Introducing Amitriptyline as an antidepressant. This is a guaranteed breakdown in concordance. The medication must be introduced in its own right as a pain modulator, with the low dose contrasted explicitly against antidepressant doses.
- ●Caving to scan demands. Ordering an unindicated CT or whole-body MRI feels like a compassionate response in the moment but represents a clinical failure — it reinforces health anxiety, exposes the patient to unnecessary risk, and does not address the underlying problem.
- ●Saying "it's just stress" or "it's all in your head." This invalidates real, physiologically-generated pain and destroys the therapeutic relationship. The pain is neurologically real; the aetiology is functional, not fabricated.
- ●Not rationalising the existing medications. Leaving a patient on two ineffective medications and adding a third without explanation signals poor prescribing and misses a clear domain 2 indicator.
- ●Neglecting the bereavement. Acknowledging the sister's death as a fact ("I see your sister passed away") without addressing it as an unmet therapeutic need in its own right — separate from the somatic presentation — misses a central component of this case.
Mapped to the RCGP curriculum topic: Mental Health.
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