History Taking · Foundation · Surgery

Acute Abdominal Pain with Pulsatile Mass

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

Clinical scenario

You are an FY2 doctor in the emergency department. Mr Elliot Spencer, a 74-year-old gentleman, has presented with acute lower back pain and abdominal discomfort. He appears unwell and anxious. Please take a focused history and discuss your initial assessment and management plan.

Background notes: PMH: Hypertension, COPD (mild, ex-smoker), Chronic kidney disease Stage 3, Diabetes (type 2, controlled), Peripheral vascular disease

What this station tests

  • Immediate recognition of potential ruptured AAA: acute back/abdominal pain in elderly man with vascular risk factors
  • Permissive hypotension: do not over-resuscitate, target systolic 80-100 to avoid disrupting clot
  • Decision pathway: CT angiogram if stable, direct to theatre if unstable
  • Vascular surgery contact as immediate priority: this is a surgical emergency
  • Not delaying for unnecessary investigations: imaging should not delay surgical intervention in an unstable patient

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

A 74-year-old man with acute back and abdominal pain, vascular risk factors, and haemodynamic instability is a ruptured AAA until proven otherwise. The candidate must initiate resuscitation alongside rapid assessment. Mr Spencer is 74, presenting to A&E with acute lower back pain and abdominal discomfort. He appears unwell and anxious. Open with: 'Mr Spencer, I can see you are in significant pain and feeling unwell. I am going to start treating you immediately while I examine you.'

Core approach

This is a surgical emergency. Two large-bore IV cannulae. Bloods including crossmatch for 4 to 6 units. Fluid resuscitation with crystalloid. Do not over-resuscitate (permissive hypotension, target systolic around 80 to 100 to avoid disrupting any clot).

Rapid focused assessment. Pain: acute onset, severe, lower back and abdomen. He has significant vascular risk factors: hypertension, COPD (40 pack-year ex-smoker), CKD, diabetes, PVD. His brother died of sudden cardiac death at 68. Examine for pulsatile abdominal mass (do not palpate aggressively). Check peripheral pulses. Assess haemodynamic status.

Differential: ruptured AAA (most dangerous), renal colic, acute pancreatitis, mesenteric ischaemia, MI (atypical presentation). The combination of age, vascular risk factors, and acute back/abdominal pain makes AAA the priority diagnosis.

If haemodynamically stable: urgent CT angiogram to confirm. If unstable: direct to vascular surgery theatre without imaging.

Closing and safety netting

Contact vascular surgery immediately. 'I have a 74-year-old man with acute back and abdominal pain, significant vascular history, and I am concerned about aortic aneurysm.' CT angiogram if stable. Theatre if unstable. Group and save, crossmatch, clotting, and major haemorrhage protocol on standby.

Communicate with the patient briefly: 'Mr Spencer, I am concerned about a possible problem with the large blood vessel in your abdomen. We are arranging an urgent scan and I have contacted the surgical team. We are looking after you.' Keep communication brief and reassuring through action.

Safety: continuous monitoring, senior review, anaesthetic standby. Do not delay for unnecessary investigations.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for abdominal aortic aneurysm. 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 (Secondary (resuscitation priority))

Scores well: Rapid vascular risk factor identification. Haemodynamic status assessed. Pulsatile mass noted. Peripheral pulses checked. Differentials considered.

Costs marks: Prolonged history before resuscitation. Not checking haemodynamic status. Aggressive abdominal palpation.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Two large-bore cannulae. Crossmatch. Permissive hypotension. CT angiogram if stable, theatre if unstable. Vascular surgery contacted. Major haemorrhage protocol standby.

Costs marks: Over-resuscitation. Delayed vascular contact. No crossmatch. Unnecessary delay for imaging.

Domain 3: Interpersonal Skills (Adapted to emergency)

Scores well: Brief, calm reassurance through action. Honest about the concern. Not causing panic. Maintaining human connection during a life-threatening emergency.

Costs marks: Ignoring the patient entirely. Being alarmist. No communication about what is happening.

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. Over-resuscitating with fluids. Aggressive fluid resuscitation in a contained AAA rupture can raise blood pressure, disrupt the clot, and cause catastrophic haemorrhage. Permissive hypotension (systolic 80-100) is the correct approach.
  2. Waiting for CT before contacting vascular surgery. The surgical team should be contacted on clinical suspicion, before imaging. If the patient becomes unstable during the CT, the surgical team must already be aware.
  3. Palpating the abdomen aggressively. A pulsatile mass should be noted gently. Vigorous palpation of a suspected AAA can theoretically worsen the rupture.

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 do I approach the consultation in this abdominal aortic aneurysm station?

A 74-year-old man with acute back and abdominal pain, vascular risk factors, and haemodynamic instability is a ruptured AAA until proven otherwise. The candidate must initiate resuscitation alongside rapid assessment. Mr Spencer is 74, presenting to A&E with acute lower back pain and abdominal discomfort.

What does a strong performance look like to the examiner in this station?

Strong performances show: Rapid vascular risk factor identification. Haemodynamic status assessed. Pulsatile mass noted. Peripheral pulses checked. Differentials considered. Weak performances: Prolonged history before resuscitation. Not checking haemodynamic status. Aggressive abdominal palpation.

What is the biggest pitfall in this abdominal aortic aneurysm station?

Over-resuscitating with fluids. Aggressive fluid resuscitation in a contained AAA rupture can raise blood pressure, disrupt the clot, and cause catastrophic haemorrhage. Permissive hypotension (systolic 80-100) is the correct approach.

How should I prepare for abdominal aortic aneurysm if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Permissive hypotension: do not over-resuscitate, target systolic 80-100 to avoid disrupting clot. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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