Station 16 · Abdominal pain

Candidates: do not open until you have consulted.

Persona and manner

• Kevin Marsh, 45; friendly, anxious to please; short sentences; you say “yes” to things you do not understand; you look at the door when questions are long or fast.
• You understand well when spoken to simply, one idea at a time, and you can repeat a simple plan back.

Opening line (verbatim)

• “My belly hurts. It hurts here. Sharon said come.”

The story

• Point low down on your belly when you say it hurts.
• “Hurts for days.” “I feel sick.” “I don't like the medicine, it tastes horrible.” (The lactulose.)
• If asked simply: last poo “Sunday” (five days ago); “hard”; “hurts to go”; “I sit for ages”; no blood; “I feel full”; you pass wind.
• If asked simply: you eat chips, toast, biscuits; you drink coke; you walk to the shop; no fever; no vomiting; “had this lots of times”; once “went to hospital with it”, a long time ago, with “a big belly” and “a tube”; it hurt and you were frightened.
• If asked about the tablets: the olanzapine “makes me sleepy”; “nobody asked about it for ages”. No fits.
• “I don't like needles.” About blood tests.
• You have a phone; Sharon is your key worker; she comes at nine and at five and does the tablets in a box; your sister visits monthly; you like football and trains; the day centre three days a week. Your friend Dean “has the same tablets”.
• If asked simply whether you understand: “hard poo needs medicine to make it soft” — “Yes, soft.” You can repeat: “medicine, water, come back Tuesday.”
• If asked whether you can phone Sharon so the doctor can explain the plan: “Yes, Sharon knows.”

Ideas, concerns and expectations

• Idea: “The bad belly again.”
• Concern: Hospital; needles.
• Expectation: “Make it stop.” “No needles.”

Impact

• Day centre: you missed it yesterday because of the belly.
• Home: Sharon does the tablets; you do your own breakfast, toast.
• Money: Sharon helps. Driving: you do not drive.

Red flags

• Present: Five days without a stool, a distended abdomen with nausea, an antipsychotic unreviewed for three years, a previous admission for the same thing, an overdue health check, a weight of 104 kg and an HbA1c of 46 two years ago.
• Absent: No vomiting, no fever, no blood, no overflow soiling, no urinary retention; he passes wind.
• Absent: No seizures; no new behaviour change.

Hidden facts and their triggers

• That the olanzapine makes him sleepy and nobody has asked about it — released only if asked simply about the tablets
• The hospital admission with a tube and how frightening it was — released only if asked simply whether he has had this before or been to hospital
• What he eats and drinks — released only if asked simply what he had for breakfast, lunch and tea, and what he drinks
• The needle fear — released only when bloods are mentioned, or if asked what worries him
• That he can ring Sharon and she can come — released only if the doctor asks, after asking him first

Behaviour

• Minute 1: point; short sentences; look at the door if the doctor talks for long.
• Minute 3: “I don't like the medicine.”
• Minute 5: “I don't like needles.”
• If the doctor speaks simply and checks you have understood by asking you to say it back, asks about the belly in simple questions, explains and gives a medicine you will take (sachets you mix in a drink, more at first and then every day), tells you what to drink and eat in plain words, says the sleepy tablet needs looking at by the specialist but does not stop it, books your health check with more time, easy-read papers, numbing cream for the blood test and Sharon there if you want, asks if they can ring Sharon about the plan, tells you simply when to come back or ring, and books a week's time: smile. “Soft-poo medicine, drink water, come back Tuesday, Sharon comes.”
• If the doctor talks in long sentences and prints a prescription: “yes” to everything. Leave.
• If the doctor talks about you rather than to you (asks to ring Sharon before asking you anything): “I can talk.”
• If the doctor says needles without the cream: “No needles.” Fold your arms.

Examination findings, if the candidate states what they would examine and why

• If the candidate explains simply and asks: abdomen soft but swollen; a firm lump low down on the left that is stool; no guarding; bowel sounds present; temperature 36.8.
• If a rectal examination is proposed: explained simply, you may say “no, not today”; if it is done with consent: hard stool in the rectum. Weight 104 kg.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Asking long closed questions, so that he says “yes” to everything and the history is never taken (statement R4)
• Re-issuing the lactulose he will not take, with the olanzapine never considered as a cause (statement C2)
• Ringing Sharon before asking him anything, so that he says “I can talk” (statement R6)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis should have been stated, in his words: hard poo stuck inside, made worse by the sleepy tablet and the chips. The examiner is listening for: the sachets explained as a picture and the lactulose stopped; what to drink and eat; the sleepy tablet sent for review but not stopped; the health check booked with more time, easy-read papers, numbing cream and Sharon; the safety-net in three simple triggers; the review date; Kevin's permission for the call to Sharon; and Kevin saying the plan back.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. For faecal impaction in adults, offer a macrogol in escalating doses for disimpaction, then a maintenance laxative; if a macrogol is not tolerated or declined, a stimulant laxative is an alternative; review within a week and continue maintenance to prevent recurrence. NICE CKS — Constipation, management: faecal loading or impaction in adults, current online version, checked 10 Oct 2026
2. Constipation is a recognised cause of avoidable harm and death in people with a learning disability; antipsychotic medication, immobility, poor diet and reduced fluid intake compound it; constipation should be asked about and treated actively at every contact, including the annual health check. NHS England — LeDeR: learning from lives and deaths of people with a learning disability and autistic people; constipation resources, 2022 report and 2023 resources, checked 10 Oct 2026
3. Psychotropic medicines prescribed to people with a learning disability for behaviour, in the absence of a diagnosed mental illness, should be reviewed regularly by the prescriber with a view to reduction or withdrawal; they are not stopped abruptly, and the review is planned with the person and their supporters. NHS England — STOMP: stopping over-medication of people with a learning disability, autism or both, 2016, ongoing, checked 10 Oct 2026
4. Antipsychotic medication prescribed to manage behaviour that challenges in a person with a learning disability should be reviewed after three to four weeks and stopped if there is no benefit at six weeks; where it continues, review at least every six months with weight, glucose and lipid monitoring. NICE — NG11 Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges, section 1.8, medication, May 2015, checked 10 Oct 2026
5. Everyone aged 14 and over on the GP learning-disability register is offered an annual health check with a health action plan; reasonable adjustments (longer appointments, easy-read information, a supporter present, topical anaesthetic for blood tests) are a duty under the Equality Act 2010. NHS England — Annual health checks for people with a learning disability, 2023 guidance, checked 10 Oct 2026
6. A person is presumed to have capacity unless shown otherwise; capacity is decision-specific; a person with a learning disability must be given the information in a way they can understand and the help they need to decide, and an unwise decision is not of itself evidence of a lack of capacity. GOV.UK (Ministry of Justice) — Mental Capacity Act 2005: Code of Practice, chapters 2 and 3, the principles; helping people to make their own decisions, 2007, checked 10 Oct 2026
7. Red flags in constipation that need urgent assessment include vomiting, abdominal distension with absolute constipation, rectal bleeding, unexplained weight loss, a palpable mass and new symptoms over 60; overflow soiling and urinary retention are features of impaction. NICE CKS — Constipation, diagnosis: assessment and red flags, current online version, checked 10 Oct 2026
8. For faecal loading with hard stool, a high dose of an oral macrogol (up to eight sachets a day, dissolved in water and taken within six hours, for up to three days) is first line; add a stimulant laxative if the response is inadequate after a few days. Once cleared, continue a daily maintenance macrogol, encourage fluids, fibre and activity, and advise that the laxative is reduced slowly rather than stopped at once. NICE CKS — Constipation, management: faecal loading or impaction; lifestyle advice, current online version, checked 10 Oct 2026
9. A person is unable to make a decision only if they cannot understand the information relevant to it, retain it, use or weigh it, or communicate the decision. The information must be given in a way appropriate to the person, using simple language or visual aids, and being able to retain it only for a short time does not by itself mean the person lacks capacity. All practicable steps to help the person decide must be taken first. UK Parliament — Mental Capacity Act 2005, section 1, the principles; section 3, inability to make decisions, 2005, sections 1 and 3, checked 10 Oct 2026
10. Anyone taking an antipsychotic needs physical monitoring: weight weekly for six weeks, then at twelve weeks, one year and annually; waist circumference, pulse and blood pressure, fasting glucose or HbA1c and lipids at twelve weeks, one year and then annually. The GP monitors physical health once the person is stable and sends the results to the prescriber; an overdue review is a reason to act, not to wait. NICE — CG178 Psychosis and schizophrenia in adults: prevention and management, section 1.3, how to use oral antipsychotic medication; section 1.5, monitoring physical health in primary care, CG178, 2014, checked 10 Oct 2026
11. An HbA1c of 42 to 47 mmol/mol identifies a person at high risk of type 2 diabetes. Offer an intensive lifestyle programme (weight, diet and physical activity, such as the NHS Diabetes Prevention Programme) and repeat the HbA1c at least annually; a programme has to be adapted so that a person with a learning disability can take part. An HbA1c of 48 mmol/mol or more needs a repeat test to confirm diabetes in someone without symptoms. NICE — PH38 Type 2 diabetes: prevention in people at high risk, recommendations on risk identification, HbA1c thresholds and intensive lifestyle-change programmes, PH38, 2012, last updated September 2017, checked 10 Oct 2026
12. Constipation and sedation are common side-effects of olanzapine; weight gain, raised glucose and raised lipids are recognised and need monitoring. The BNF cautions its use where there is paralytic ileus and in people with a history of seizures, and lists the person's existing anti-seizure treatment as relevant to the choice; any change is made by the prescriber with the person and their supporters, not abruptly. BNF (NICE) — Olanzapine, cautions; side-effects; monitoring requirements, current online version, checked 10 Oct 2026
13. The curriculum expects the GP to make reasonable adjustments so that a person with a learning disability can take part in their own consultation, to avoid diagnostic overshadowing (attributing new physical symptoms to the disability), to deliver the annual health check and health action plan, to review psychotropic medicines under STOMP, and to assess and support decision-making under the Mental Capacity Act. RCGP — GP curriculum: Learning disability, what the GP is expected to do: reasonable adjustments, health checks, medication review, capacity, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

13 statements, 734 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-16