History Taking · Foundation · Surgery

Severe Epigastric Pain Radiating Posteriorly

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

Clinical scenario

You are an FY2 doctor in the emergency department. Mr Rupert Leach, a 56-year-old man, has presented with severe epigastric pain radiating to his back. He appears extremely unwell. Please take a focused history, assess severity using Glasgow criteria, and discuss your initial management plan.

Background notes: PMH: Gallstones (known, asymptomatic), Hypertension, High triglycerides, Alcohol use (moderate-heavy, 20+ units/wk)

What this station tests

  • Classic pancreatitis pattern: epigastric pain boring to back, worse lying flat, better leaning forward
  • Identifying the cause: gallstones and alcohol account for 80%, both present in this patient
  • Aggressive IV fluid resuscitation: pancreatitis causes massive third-space losses
  • Severity assessment: Glasgow criteria, CRP at 48 hours, lactate, and clinical signs of organ dysfunction
  • Cholecystectomy during same admission for gallstone pancreatitis: NICE recommendation to prevent recurrence

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

Epigastric pain boring through to the back is acute pancreatitis until proven otherwise. The candidate must initiate resuscitation, identify the cause (gallstones or alcohol), and assess severity. Mr Leach is 56, presenting with severe epigastric pain since 4am, radiating to his back, with vomiting. He has known gallstones and drinks 20+ units weekly. Open with: 'Mr Leach, I can see you are in extreme pain. I am going to get you pain relief while I assess you.'

Core approach

The presentation is classic. Severe epigastric pain (10/10), boring through to the back (between shoulder blades), constant, worse lying flat, slightly better leaning forward. Vomited 6 times. He is sweating and appears systemically unwell. This pattern is almost pathognomonic for acute pancreatitis.

Identify the cause. He has two major risk factors: known gallstones (gallstone pancreatitis is the commonest cause in the UK) and heavy alcohol use (20+ units weekly, moderate-heavy). Ask about recent alcohol intake (he had a heavy session last night) and any previous biliary colic episodes. The mnemonic 'I GET SMASHED' covers the causes, but gallstones and alcohol account for 80%.

Assess severity early. Glasgow/Imrie score or modified Glasgow criteria assess predicted severity within 48 hours. Initial markers of severe pancreatitis: tachycardia, hypotension, fever, oliguria, raised CRP (>150 at 48 hours), raised lactate. Check for Cullen's sign (periumbilical bruising) and Grey-Turner's sign (flank bruising): late and sinister signs of haemorrhagic pancreatitis.

Closing and safety netting

Immediate management: IV fluids (aggressive fluid resuscitation, pancreatitis causes massive third-space losses), IV analgesia (morphine or fentanyl PCA, not pethidine which was previously preferred but has no proven advantage), anti-emetic, nil by mouth initially, catheter for urine output monitoring. Bloods: amylase or lipase (lipase more specific), FBC, U&E, LFTs (check for obstructive pattern suggesting gallstone cause), calcium, glucose, CRP, lactate, ABG.

If gallstone pancreatitis: MRCP or USS to assess common bile duct, ERCP if stone is impacted in CBD. Cholecystectomy during same admission once recovered (or within 2 weeks per NICE). Address his alcohol: now is not the time for a motivational interview, but document the intake for later intervention.

Safety net: he is admitted. Explain: 'Your pancreas is inflamed and we need to rest it with fluids and pain relief. Most people recover within a week.' Complications to monitor: organ failure, necrosis, pseudocyst.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for acute pancreatitis. 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 pattern identified. Causes assessed (gallstones, alcohol). Severity markers checked. Examination findings documented (Cullen's, Grey-Turner's). Alcohol history quantified.

Costs marks: Not identifying the pattern. Missing gallstone history. Not assessing severity. Not quantifying alcohol.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Aggressive IV fluids. Appropriate analgesia. Amylase/lipase requested. LFTs for obstructive pattern. Cholecystectomy planned if gallstone cause. Nil by mouth. Catheter for output monitoring.

Costs marks: Inadequate fluid resuscitation. No amylase/lipase. No cholecystectomy plan. No output monitoring.

Domain 3: Interpersonal Skills (Adapted to emergency)

Scores well: Analgesia prioritised. Brief, clear explanation of what pancreatitis is. Reassurance about recovery timeline. Not lecturing about alcohol during acute illness.

Costs marks: Delayed analgesia. Lecturing about alcohol while acutely unwell. Not explaining the diagnosis.

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 requesting amylase or lipase. These are the diagnostic blood tests. Candidates who investigate with standard bloods without specifically requesting amylase or lipase cannot confirm the diagnosis.
  2. Not identifying both causes. He has gallstones AND heavy alcohol use. Both may be contributing. Candidates who attribute it to one without considering the other provide an incomplete assessment.
  3. Not arranging cholecystectomy for gallstone pancreatitis. If gallstones are the cause, cholecystectomy during the same admission (or within 2 weeks) prevents recurrence. This is a NICE recommendation commonly tested.

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 acute pancreatitis station?

Epigastric pain boring through to the back is acute pancreatitis until proven otherwise. The candidate must initiate resuscitation, identify the cause (gallstones or alcohol), and assess severity. Mr Leach is 56, presenting with severe epigastric pain since 4am, radiating to his back, with vomiting.

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

Strong performances show: Classic pattern identified. Causes assessed (gallstones, alcohol). Severity markers checked. Examination findings documented (Cullen's, Grey-Turner's). Alcohol history quantified. Weak performances: Not identifying the pattern. Missing gallstone history. Not assessing severity. Not quantifying alcohol.

What is the biggest pitfall in this acute pancreatitis station?

Not requesting amylase or lipase. These are the diagnostic blood tests. Candidates who investigate with standard bloods without specifically requesting amylase or lipase cannot confirm the diagnosis.

How should I prepare for acute pancreatitis if I have never seen it in practice?

Structure beats experience here. Focus on identifying the cause: gallstones and alcohol account for 80%, both present in this patient. 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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