History Taking · Intermediate · Gastroenterology

Left-Sided Abdominal Pain with Fever

Practise this PLAB 2 history taking station on Diverticulitis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the acute medical unit. Mrs Orla Power, a 67-year-old woman, has presented with severe left lower abdominal pain and fever that started two days ago. She has also noticed a change in her bowel habit. Please take a focused history and discuss your initial assessment and management plan.

Background notes: PMH: Hypertension, Diverticular disease previously asymptomatic (noted on colonoscopy 5 yrs ago), Hypothyroidism, Appendectomy (age 23)

What this station tests

  • Recognising the classic diverticulitis presentation: left lower quadrant pain, fever, altered bowel habit in a patient with known diverticulosis
  • Screening for complications: perforation (peritonism), abscess (persistent fever, mass), obstruction (vomiting, absolute constipation), fistula (pneumaturia)
  • Distinguishing complicated from uncomplicated diverticulitis: this determines whether outpatient antibiotics or admission with imaging is needed
  • Addressing the cancer anxiety driven by family history: explaining why diverticulitis is not cancer while acknowledging the father's bowel cancer
  • Follow-up colonoscopy: standard practice after first episode to exclude underlying malignancy once inflammation settles

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Acute left lower quadrant pain with fever in an older patient is diverticulitis until proven otherwise. The candidate must assess severity, exclude complications (perforation, abscess, obstruction), and consider alternative diagnoses. Mrs Power is 67, presenting with 2 days of severe left lower abdominal pain and fever (38.2). She has known asymptomatic diverticular disease from a colonoscopy 5 years ago. Open with: 'Mrs Power, I can see you are in a lot of pain. Tell me when this started and what happened.'

Core approach

The pain started suddenly 2 days ago after a spicy meal, is sharp and colicky in the left iliac fossa, constant with waves of worsening, aggravated by movement and eating. She has fever (38.2), nausea, reduced appetite, and a change in bowel habit (looser stool, mucus, incomplete emptying). No rectal bleeding. No vomiting. These features, left lower quadrant pain, fever, altered bowel habit in a patient with known diverticulosis, are classic for acute diverticulitis.

Screen for complications. Perforation: is there rigidity or generalised peritonism? Severe diffuse pain, inability to move, or board-like rigidity would suggest perforation requiring urgent surgical review. Abscess: persistent fever despite treatment, palpable mass, or worsening despite antibiotics. Obstruction: vomiting, absolute constipation, distension. Fistula: pneumaturia or faecaluria (colovesical fistula). None of these appear present, suggesting uncomplicated diverticulitis.

Her family history is the emotional subtext: her father died of bowel cancer. She is terrified this might be cancer. Ask about red flag cancer symptoms: weight loss (none), change in bowel habit preceding this acute episode (none), rectal bleeding (none). Her colonoscopy 5 years ago showed diverticulosis but no malignancy.

PMH: hypertension, hypothyroidism, appendicectomy (she may worry this is 'another appendicitis,' though she knows logically the appendix is gone). Medications: check for NSAIDs and anticoagulants which increase perforation and bleeding risk.

Closing and safety netting

Explain the diagnosis: 'Mrs Power, based on your symptoms, the location of the pain, the fever, and your known diverticular disease, this is most likely an episode of diverticulitis, where one of the small pouches in your bowel has become inflamed and possibly infected.' Address the cancer concern directly: 'This is not cancer. Your colonoscopy 5 years ago was clear.'

Management depends on severity. Uncomplicated: oral antibiotics (co-amoxiclav or ciprofloxacin plus metronidazole), clear fluids initially progressing to soft diet, paracetamol for pain, review in 48 hours. If she is systemically unwell (high fever, unable to tolerate oral intake, severe pain), admission for IV antibiotics and imaging is needed. CT abdomen with contrast is the gold standard for confirming diagnosis and detecting complications.

Safety net: 'If the pain becomes generalised across your abdomen, you develop a high fever, start vomiting, or notice blood in your stool, come to A&E immediately.' Follow-up colonoscopy in 6 weeks once inflammation settles (to exclude underlying malignancy, standard practice after first episode of diverticulitis). Dietary advice: high-fibre diet once settled to reduce recurrence.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for diverticulitis. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Classic presentation identified. Complication screening: peritonism, abscess signs, obstruction, fistula. Red flag cancer symptoms excluded. Known diverticulosis history incorporated. Medication review (NSAIDs, anticoagulants).

Costs marks: Not screening for complications. Not checking for peritonism. Not asking about cancer red flags. Not reviewing medications.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct management based on severity assessment: antibiotics, diet advice, pain management. CT as gold standard imaging. Follow-up colonoscopy in 6 weeks. Clear safety netting for perforation and deterioration. High-fibre diet for recurrence prevention.

Costs marks: No antibiotics. No imaging plan. Not arranging follow-up colonoscopy. No safety netting. No dietary advice.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing cancer anxiety directly (father's bowel cancer). Explaining diverticulitis clearly as a different condition. Reassuring based on previous clear colonoscopy. Acknowledging her pain and distress.

Costs marks: Not addressing cancer fear. Being dismissive of her anxiety. Not explaining what diverticulitis is. Ignoring her distress.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not screening for complications. Uncomplicated and complicated diverticulitis have completely different management pathways. Candidates who diagnose diverticulitis without checking for perforation, abscess, or obstruction cannot determine the correct management.
  2. Not arranging follow-up colonoscopy. After a first episode of diverticulitis, colonoscopy is recommended once inflammation settles (typically 6 weeks) to exclude underlying malignancy. This is standard practice and commonly tested.
  3. Attributing the pain to the spicy meal. She ate a curry before the symptoms started, but spicy food does not cause diverticulitis. It may have been coincidental or exacerbated existing inflammation. Candidates who accept the dietary explanation miss the actual pathology.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the diverticulitis history in this PLAB 2 station?

Acute left lower quadrant pain with fever in an older patient is diverticulitis until proven otherwise. The candidate must assess severity, exclude complications (perforation, abscess, obstruction), and consider alternative diagnoses. Mrs Power is 67, presenting with 2 days of severe left lower abdominal pain and fever (38.2).

What are examiners marking in this diverticulitis station?

Marks are won for: Classic presentation identified. Complication screening: peritonism, abscess signs, obstruction, fistula. Red flag cancer symptoms excluded. Known diverticulosis history incorporated. Marks are lost for: Not screening for complications. Not checking for peritonism. Not asking about cancer red flags. Not reviewing medications.

What is the most common mistake candidates make in this diverticulitis station?

Not screening for complications. Uncomplicated and complicated diverticulitis have completely different management pathways. Candidates who diagnose diverticulitis without checking for perforation, abscess, or obstruction cannot determine the correct management.

How do I prepare for this station if I have not managed diverticulitis in clinical practice?

This station rewards process over personal experience. The skill being assessed: Screening for complications: perforation (peritonism), abscess (persistent fever, mass), obstruction (vomiting, absolute constipation), fistula (pneumaturia). The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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