Khalaf's Appendicitis

Click to see Khalaf's booking sheet

You are on placement with the Emergency department, working with one of the FY2's. The case you have picked up is a 31-year-old man called Khalaf, who has self presented with abdominal pain. Your task is to assist the FY2 with taking the history, examining the patient and proposing a diagnosis. I'd advise taking notes as you go along to help you make a diagnosis later on.Lets start by looking at Khalaf's Emergency department booking sheet...

Futher guidance will appear in this bar. Click the blue arrows to move through the resource.

Review Khalaf's booking sheet and make a note of any salient information

Complete this question to move on to the Khalaf's consultation.

One of the other junior doctors on shift speaks Arabic and is able to interpret for you. How do you want to open your consultation with Khalaf, after you've introduced yourself?

I have had pain for about 3 days, it is getting worse. I have been sick as well 3 or 4 times.

It is here (pointing to abdomen)

I am not well, I have had pain for 3 days and I have been sick, I can't eat anything and today I feel shivery.

Can you tell me about your pain?

Where is the pain?

Can you tell me why you have come to hospital today?

Click a question to reveal Khalaf's answer.

Thinking about SOCRATES method for exploring pain, click on the options below to find out more about Khalaf's abdominal pain:

When did the pain start?

Three days ago

It’s there all the time

Is the pain there all the time or does it come and go?

What does the pain feel like? For example is it sharp or dull, or squeezing?

It was dull at first, but now it's stronger - although not sharp

Is there anything that makes the pain better?

Not yet, the medication you just gave me hasn't helped yet

It's quite bad, I think 8

On a scale of 0 to 10, what score would you give this pain now?

No

You said the pain is on the right side, does it go anywhere else on your body?

Have you had any other symptoms?

I have been sick 2 times now

Where is the pain?

It was all over my tummy to start with but now it’s moved a bit to the right side

Is there anything that makes the pain worse?

It's much worse when I move around, coughing is really painful

I was just sitting in my flat. I'd had something to eat a few hours before

What were you doing when the pain started?

Click a question to reveal Khalaf's answer.

With the information you have, what are your top 3 diagnoses from the lists below [if you haven't heard these terms before, don't worry, this is a great opportunity to look them up]

From the list below, are there any diagnoses you feel able to completely exclude at this point?

Which 2 body systems should you focus your questioning on to aid narrowing your differential diagnosis?

Here are some further questions you can ask Khalaf. Click a box to hear his response.

No

One of my back teeth is sore, I haven't been able to see a dentist since I came to England

No

No

No

Yes, I've lost weight in the last 3 years

Did you vomit any blood?

Do you have any problems with your mouth, teeth or tongue?

Has your tummy been bloated

Have it been difficult to swallow or painful to swallow?

Have you had any heartburn or reflux of acid?

Have you lost weight?

Click a question to reveal Khalaf's answer.

Here are some further questions you can ask Khalaf. Click a box to hear his response.

No

No, I did a poo this morning and it was normal

No

No

Yes

No

Have you had any pain when passing urine?

Have you had any diarrhoea?

Have you noticed any pain in your penis or testicles?

Have you noticed any blood in your poo when you did go?

Have you been passing a normal amount of urine?

Have you noticed and lumps or bumps in your penis, testicles or groins?

Click a question to reveal Khalaf's answer.

Based on the further information, are there any diagnoses you feel you can remove from the list of differentials?

Click each box to reveal a summary.Move on to the next slide to examine Khalaf.

Click the boxes below to recap some core features of Khalaf's case.

Past medical historyAsthma Depression

Past medical history

Systematic enquiryCVS: no symptoms RS: Wheezy, coughing at night, hasn't been taking regular inhaler MSK: nil MH: low mood, related to social issues Neuro, Vascular, Endocrine: Nil

Systematic enquiry

Social history

Social historyFrom Syria, been in the UK 2 years Had a brother but he was killed in Syria. Struggling financially here, feels frightened where he lives

Medication history

Medication historySalbutamol 100mcg MDI

Click on each region to reveal your examination findings. Click forward to diagnose Khalaf.

Khalaf's blood pressure is 110/65. His pulse is 90 reg.

HS 1 and 2 heard with no added sounds or murmurs.Chest resonant, widespread wheeze on ausculation.

Very tender in RIF, guarding. Not able to palpate deeply to check for organomegaly. BS normal. No inguinal hernias, Genitalia appear normal. PR exam – soft stool with no tenderness.

You would need to examine hernial orifices, genitalia and complete a PR examination in this case – you should find a chaperone for this part of the examination.

Refer to the surgical registrar

Click on each box to explore each step.

Order a test

Click the question mark to choose which test(s) to order

Refer to the medical registrar

Prescribe a treatment

Click the pencil to choose what to prescribe

Situation

Background

Assessment

Recommendation

You can use the 'SBAR' approach to frame your referral. Click on each box to find out more.

You're now ready to prepare your referral. Think about what you'd say, then check your answer against the examples below:

S

B

A

R

Try using the SBAR approach to create Khalaf's referral. Click on each box to reveal a recommended answer.

What is missing from the plan? What other problems is Khalaf facing that may impact on his recovery and long term health? Click each box to learn more.

Consent

Readiness for theatre

Support to manage long-term conditions

Social challenges

1

2

4

3

Congratulations, you've successfully diagnosed Khalaf with appendicitis and handed him over to the surgical registrar on call.To review Khalaf's medical record summary click here. To learn more about the management of appendicitis click here.

31 year old man Non English speaking – history via interpreter (medical staff) Acute onset abdominal pain – central>>right iliac fossa 8/10 severity No radiation Associated vomiting, no exacerbating or relieving factors Normal bowels, no other GI symptoms, no genitourinary symptoms Weight loss over 3 years SE: nil additional symptoms PMHx: Asthma, Depression DHx: Salbutamol 100mcg MDI SHx: In UK 2 years, from Syria, alone, recent traumatic bereavement, reports financial difficulty and concerns re safety at accommodation

Exam: NEWS 2 score \X RR 22, BP 110/65, P 90, Sp02 98% on airHS normalChest resonant, widespread wheeze bilaterally Abdo: tender throughout, guarding RIF, BS active Neuro: GCS 15, mobilizing independently. Diagnosis: Suspected appendicitis Plan: Bloods sent – FBC, U&E, LFT, CRP, Blood culturesRefer Surgical registrar for urgent review and decisions re imaging

Situation

You start by describing this situation to the person you are referring to.

• Identify yourself and the site/unit you are calling from
• Identify the patient by name and the reason for your report
• Describe your concern

This should be short, to the point and make clear what you are asking the person for. Common examples are:

• Advice
• Opinion
• Review + the urgency of this
• Take over care
• Arranging a test e.g urgent CT scan

Consent

Khalaf is likely to need to give his consent for various aspects of his ongoing care. This may include:Further testsSurgical treatmentGeneral anaestheticIt should be part of the plan to arrange a formal interpreter to be present to allow Khalaf a full understanding of his treatment options, risks and complications so that he can make informed decisions.

I would like you to review him and make further recommendations about imaging and management.

I have a case of suspected appendicitis that I would like you to review in ED please.

Background

This section is to give the person you are referring to enough information to contextualise the the patient's current medical conditions and situation.Give brief information about:

• The reason for admisson
• The working or current diagnosis
• PMHx or other diagnoses relevant to the situation
• Test results
• Current therapies

Support to manage long-term conditions

• Is Khalaf registered with a GP?
• If not, does he understand his rights to register with a GP?
• Does he need signposting and support to register?

Click this text to view a leaflet that could be translated into Arabic and provided to Khalaf.

The patient is a 31 year old Syrian man who does not speak English. Via an interpreter we have a history of 3 days of worsening abdominal pain that has now localised to the right Iliac fossa. On examination he is very tender with guarding in the RIF. Hernial and genital examination normal, normal bowel sounds. He has a fever, and initially had a high RR and tachycardia which have improved after 500ml stat normal saline.

Recommendation

This is where you state what you would like to happen at the end of the conversation. This is the most important part to get right to avoid misinterpretation of what is required.Be clear about what you need and the time frame, e.g. 'I would like you to come and see her in the next 30 minutes.'Make a suggestion of what you will do in the mean time.Clarify and confirm that you are both in agreement with the plan.

Readiness for theatre

Khalaf may need emergency surgery as part of his treatment for appendicitis.If a patient is likely to go to theatre is is helpful to plan ahead and send samples for:Coagulation screenGroup and save Did you notice that Khalaf is wheezy? This is an indication that his asthma is not controlled and this would pose a risk for general anaesthesia. He will therefore need immediate treatment for this while undergoing the rest of his investigations so the plan should include prescribing of Salbutamol nebulisers in the first instance.

• Plan the structure of your communication.
• Give it a hierarchy and give visual weight to the main point.
• Add secondary messages with interactivity.
• Establish a flow through the content.
• Measure results.

Contextualize your topic

Opportunities

Assessment

Your assessment should include objective measures (such as vital signs) to help the referer make an assessment of the acuity of the situation.Plus, your diagnostic assessment, e.g 'The patient's NEWS 2 score has increased from 2 to 7 and clinically I am concerned they have developed a pulmonary embolus.'

Social Challenges

Khalaf's recent live events have impacted on him in a number of ways. Could you support Khalaf further by signposting to local voluntary organisations able to help him? Consider: Language barrier, social isolation , abuse, poverty Two local Leeds organisations are LASSAN and PAFRAS - check out their websites via the links below to see what support they could offer Khalaf. It is very helpful to be aware of key local organisations that can support patients (this will be discussed further in I&P2) https://lassn.org.uk/ https://pafras.org.uk/

• Plan the structure of your communication.
• Give it a hierarchy and give visual weight to the main point.
• Add secondary messages with interactivity.
• Establish a flow through the content.
• Measure results.

Contextualize your topic

Threats

I am concerned about acute appendicitis and have sent bloods and blood cultures.