Simulation case | A 21 year old with abdominal pain and lethargy

James Hobson   Published 10th February 2023

Handover from ambulance

Selina Begum - a 21yr old female university student brought in by ambulance due to acute-onset abdominal pain and vomiting. She is lethargic. Selina has been feeling under the weather recently, which she thinks was just a common cold. She is otherwise well.

On further questioning:

  • The pain is all over her abdomen. Tender to touch. Constant 5/10. Goes to 7/10 if you press on it. It has gotten worse over the last 24 hours
  • Selina is feeling nauseous and has vomited three times. There was no blood in the vomit
  • She's been feeling very tired and irritable in the last few hours
  • No past medical history or current medications
  • No known drug allergies

HR 102, BP 105/76, RR 24, SpO2 95% OA, Temp 37.2C, Lethargic/Confused



Selina is talking. Her airway is patent and self-maintaining.


None required.


None required.



RR: 24, SpO2: 95%

Chest expansion – normal and equal

Percussion - normal resonance

Auscultation - good air entry bilaterally with no added sounds


None required.


None required.



HR 100, BP 98/74, Temp 36.5C

Pulse is fast, regular, but feels weak

CRT 4 seconds

HS I + II + 0

No peripheral oedema

If asked about urine output – you’ve not been all day – but the previous couple of days had actually been going to the toilet a lot

Dry mucous membranes


Insert at least one wide-bore cannula – 14G (Orange) or 16G (Grey)

Bloods – ask to justify:

  • FBC – anaemia, ?sepsis
  • U&Es – renal function and electrolyte depletion
  • LFTs – liver function for medications and other causes of acute abdomen
  • CRP – ?infection
  • Glucose – ?DKA/HHS
  • Amylase/lipase - ?pancreatitis
  • Serum ketones - ?ketogenesis
  • Serum osmolality
  • HbA1c

Urinalysis for glucose and ketones

VBG - no hypoxia, so no need for arterial sample

12-lead ECG

Consider 'sepsis six' screen


Patient is hypovolaemic

  • Start IV fluid resuscitation
  • 500ml bolus over 15 mins of normal saline or Hartmann’s

If raised glucose and ketones - ?DKA

  • Continue fluids with 1L over next hour. Add 40 mmol/L potassium chloride
  • Fixed-rate IV insulin infusion – 0.1 units/kg/hour

Until investigations come back, students should consider sepsis as a possible cause and begin treatment with empiric antibiotics. These can be stopped once sepsis is ruled out.

ECG for Selina Begum

  • Rate ~120bpm
  • P waves precede QRS = sinus rhythm
  • Rhythm is regular
  • All waves/intervals are normal

This ECG shows sinus tachycardia.

Blood results for Selina Begum

Glucose, HbA1c ketones and serum osmolality are elevated - this fits with the picture of diabetic ketoacidosis

The patient has an electrolyte abnormality, likely related to dehydration, and raised amylase, which can happen due to acidosis

VBG results for Selina Begum

Metabolic acidosis

Cannot comment on respiratory compensation due to venous sample

Urinalysis results for Selina Begum

Ketones present (moderate)

Glucose present (1000 mg/dL)



Alert but tired/irritable

GCS 14/15 – E3 V5 M6


If students perform neurological exam – Selina is weak and lethargic, no cranial nerve findings


Bedside CBG if not already performed in C – 23.3 mmol/L

Bedside ketones – 4.7 mmol/L


IV NaCl with K+ and FRIII as above



No skin findings

Abdomen is very tender to palpation with mild guarding. No distention. Normal bowel sounds

Calves SNT

No peripheral oedema

Selina doesn’t think she could be pregnant

She hasn’t taken any drugs or alcohol


Consider PR exam - NAD

Consider abdominal imaging to rule out acute abdomen (bedside USS would be most appropriate, or arrange CTAP) - NAD

Urine pregnancy test - negative

Consider toxicology screen - NAD


Provide analgesia in accordance with pain ladder

Post-ABCDE Actions

Can you confirm a diagnosis?

What will you do now?

  1. Re-assess the patient regularly (Now SpO2 96%, BP 108/80, HR 97, CBG 20.1 mmol/L, Serum ketones 3.9 mmol/L)
  2. Glucose, ketones, HCO3-, K+ and pH to be monitored hourly
  3. Verify diagnosis with senior in ED
  4. Arrange for inpatient admission via MAU

Handover using SBAR technique

  1. “Hello my name is X, I am calling from ED resus at Leicester Royal Infirmary. I have a patient, Selina Begum, who is being treated for DKA.
  2. The patient is a 21 year old female admitted with a one day history of generalised abdominal pain, vomiting and lethargy following a recent viral illness. She has no past medical history.
  3. On admission, she was lethargic, hypotensive and tachycardic – with signs of severe dehydration. She has metabolic acidosis. CBG is 23.3, serum ketones are 4.7 and potassium is 3.8. I have given her IV fluids with potassium replacement and started a fixed-rate insulin infusion. In the last hour, glucose and ketones have started to come down.
  4. Can I please arrange transfer to MAU for continued treatment and monitoring.”