Cases/Gastroenterology

Woman Seeking A Diagnosis After A&e Discharge for Abdominal Pain That Resolved On Vomiting — Free SCA Practice Case

Woman seeking a diagnosis after A&E discharge for abdominal pain that resolved on 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

Denise Holloway

Age

60 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The patient attended A&E three days ago and has booked a follow-up call to discuss what happened.

Reason for Encounter

"I ended up in A&E with the worst pain of my life a few days ago, then it just went after I was sick. They sent me home saying everything was normal but nobody actually told me what it was. I want to know what caused it."

Medical Records

●PMH: Cholecystectomy (open, ~15 years ago). Right nephrectomy (~8 years ago). Otherwise well.
●Medications: None regular.
●Allergies: NKDA.
●A&E discharge letter (3 days ago): "60F, sudden-onset severe colicky central abdominal pain, associated with distension and not passing flatus or stool. Observations normal, afebrile. Bloods (FBC, U&E, CRP, amylase) and lactate normal. Symptoms resolved following an episode of vomiting; pain settled and patient opened bowels prior to discharge. Diagnosis: resolved/self-limiting; ?subacute adhesional obstruction. Advised to follow up with GP and return if symptoms recur."

Patient Script

For the friend playing the patient role

Character Overview: You are Denise, a 60-year-old retired librarian. You are articulate and a little frustrated — the pain was terrifying, and you feel you were "patched up and pushed out" without a proper explanation. You feel completely well now. You want to understand what happened and, above all, whether it will happen again. You are not anxious to the point of distress, but you want answers and a plan.

Opening Sentence: "Hello, Doctor. So, a few days ago I had this sudden, gripping pain right across my middle — honestly the worst pain I've ever had, worse than childbirth. My tummy swelled up, I couldn't pass wind, then I was violently sick and the pain just... went. A&E did lots of tests, said they were all normal, and sent me home. But nobody explained what it actually was, and I'm scared it'll come back."

History if Asked (Data Gathering Phase)

●The episode: "It came on out of nowhere, mid-afternoon. Severe, gripping, came in waves. My tummy blew up like a balloon. I felt really sick and couldn't pass wind at all. After a few hours I vomited — quite a lot — and almost straight after, the pain eased right off."
●Since then: "I feel fine now, honestly. Bowels are working, I'm passing wind, eating small amounts. No pain since."
●Previous episodes: "I've had a couple of milder 'gripey' episodes over the last year that settled on their own. Nothing like this one though."
●The surgeries: "I had my gallbladder out years ago — open operation, big scar. And I lost a kidney to a problem about eight years ago, another operation. Could that be relevant?"
●What A&E said: "They mentioned something about my bowel and old scarring, but it was rushed and I didn't take it in. That's why I'm ringing."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Denise does not really know what happened; she wonders vaguely if it was "something she ate" or "a blockage," but no one has joined it up for her. "I've been going round in circles wondering — a bug? A blockage? Nobody's actually told me."
●Concerns: Her dominant concern is that the excruciating pain will return, and a quieter fear that "normal tests" might have missed something serious like cancer. "What really frightens me is it coming back when I'm on my own. And part of me worries — if the tests were normal, could they have missed something?"
●Expectations: She wants a clear explanation of the likely cause and a definite plan for what to do if it recurs. "I want to understand what it was, and to know exactly what to do if it happens again — I never want to be caught out like that."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Surgeries: "Open gallbladder removal about fifteen years ago. Right kidney removed about eight years ago."
●Bowel history: "Normally regular. No long-term tummy problems, no blood in my stool, no ongoing diarrhoea or constipation."
●Weight: "Weight's been steady. I've not been losing weight."
●Medications: "Nothing regular. The odd paracetamol."
●Family history: "No bowel cancer in the family that I know of."

Social History and Lifestyle Impact

Denise is a retired librarian who lives alone; her daughter lives in the next town.

●Living situation: "I live on my own. My daughter's about half an hour away. That's partly why the idea of it happening again frightens me."
●Diet: "Fairly normal diet. Since the episode I've been nibbling small meals, a bit scared to eat properly."
●Smoking/alcohol: "Never smoked. A glass of wine at the weekend."
●Function: "I'm active, I walk, I'm out and about. This came completely out of the blue."

If Asked — Associated Symptoms and Red-Flag Screen

The patient answers these only when directly asked.

●If asked whether she is currently in any pain: "No, no pain at all right now. It settled completely after I was sick."
●If asked about passing wind and opening bowels now: "Yes, both — everything's moving normally again."
●If asked about ongoing or recurring vomiting: "No, just that one big episode. I've not been sick since."
●If asked about the vomit (bilious/faeculent): "It was greenish-yellow, quite bitter. Not like anything worse than that."
●If asked about fever or feeling unwell: "No fever, I feel well in myself now."
●If asked about weight loss, blood in stool, change in bowel habit: "No weight loss, no blood, my bowels are normally regular."
●If asked about appetite: "Appetite's okay, I'm just being cautious with food."
●If asked about abdominal distension now: "No, my tummy's gone back to normal, no swelling now."

Responses to Management (The Negotiation Phase)

●If the Doctor explains this was likely an adhesion-related bowel obstruction that resolved: "Adhesions — from my old operations? So the scarring inside can still cause this years later?" (The tested point is explaining, in plain terms, how previous abdominal surgery causes adhesions that can lead to a bowel obstruction, and that this one settled on its own.)
●If the Doctor gives recurrence safety-netting: "So what exactly do I do if it comes back? How do I know if it's serious versus just a gripe?" (The tested point is specific red-flag safety-netting with a clear disposition, not "come back if worse.")
●If the Doctor explains the normal tests are reassuring: "So they definitely didn't miss anything? The normal bloods mean it's not cancer?"
●If the Doctor advises about diet: "Is there anything I should or shouldn't eat to stop it happening again?"
●If the Doctor suggests they may involve the surgeons or arrange follow-up: "Do I need to see a specialist, or a scan? Or do I just wait and see?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Recognising Bowel Obstruction from the History

●The cardinal features of bowel obstruction are colicky abdominal pain, distension, vomiting, and absolute constipation (failure to pass flatus or stool).
●Small-bowel obstruction tends to present with earlier, more prominent vomiting and central colicky pain; large-bowel obstruction with more distension and later vomiting.
●Relief of pain following an episode of vomiting — as here — suggests the obstructed segment has decompressed, consistent with a self-resolving (subacute) obstruction.

Adhesions Are the Commonest Cause

●Adhesions from previous abdominal or pelvic surgery are the most common cause of small-bowel obstruction, and can arise years or decades after the operation.
●This patient's open cholecystectomy and nephrectomy are the likely source. Other causes to keep in mind include herniae and, particularly in older patients, malignancy.

Interpreting the Discharge Letter

●"Normal bloods and observations" do not mean nothing happened — an early or resolved obstruction can have normal inflammatory markers and lactate. Raised lactate or inflammatory markers would raise concern for ischaemia/strangulation.
●A GP's role at follow-up is to translate the episode for the patient, confirm current stability, and put a robust safety-net in place.

Red Flags and Strangulation

●A future obstruction may not resolve spontaneously and can progress to strangulation (compromised blood supply → ischaemia, perforation, sepsis) — a surgical emergency.
●Warning features: constant (rather than colicky) severe pain, fever, tachycardia, peritonism, and a rising lactate — these mandate urgent hospital assessment.

Safety-Netting with a Clear Disposition

●Give specific red flags: severe or persistent colicky pain, repeated (especially bilious or faeculent) vomiting, abdominal distension, and inability to pass flatus or stool.
●Attach a clear disposition: attend A&E or call 999 promptly if these occur — not "come back if it doesn't settle." Account for patients who live alone.

Dietary and Self-Care Advice

●Advise gradual return to normal eating and good hydration. For patients with recurrent adhesional episodes, smaller meals and a lower-residue approach during episodes can help; blanket long-term restriction is unnecessary.

When to Refer or Image

●Recurrent adhesional obstruction warrants discussion with or referral to the surgical team. Acute episodes are imaged with CT abdomen/pelvis, which confirms obstruction, identifies the level and cause, and detects ischaemia.
●Surgery is considered for recurrent, complete, or strangulating obstruction; many adhesional episodes settle conservatively.

Colorectal Malignancy as an Alternative

●In a patient of this age, keep colorectal cancer in mind as a cause of obstruction. Screen for weight loss, change in bowel habit, and rectal bleeding, and investigate if the pattern or symptoms suggest it — even when an adhesional cause is likely.

Common Candidate Mistakes in This Case

●Accepting "normal tests / self-limiting" uncritically: failing to recognise and explain that this was a resolved bowel obstruction.
●Weak safety-netting: giving vague advice rather than specific red flags with a clear disposition — the key safety failure.
●Not linking adhesions to prior surgery: missing the mechanism and so giving an unconvincing explanation.
●Missing an evolving obstruction: not confirming she is currently passing flatus/stool and pain-free.
●Ignoring the person: addressing the discharge letter but not her fear of recurrence, her living alone, or her worry that something was missed.

Free MRCGP SCA practice case for GP registrars covering Woman Seeking A Diagnosis After A&e Discharge for Abdominal Pain That Resolved On Vomiting — Gastroenterology. 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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