How to run this case
One run: 28 minutes
- Read the door note 1 min
- Encounter with the patient 15 min
- Oral presentation 2 min
- SOAP note 10 min
Three roles
- Candidate reads the door note, runs the encounter, then presents the case and writes the note.
- Patient plays Ms. Novak from the script and reads each exam finding when the candidate performs that maneuver. No medical knowledge is needed, and no sensitive exam is ever performed.
- Examiner and timer keeps time, calls 5 minutes and 1 minute left, and ticks the checklist as items happen. With two people, the patient does this too.
The candidate sees only the door note. Everything else is for the partner: print the packet or open this page on a second device, and agree on times before you start. The times here are suggestions, so use your program's if you know them.
Working alone, ask each question out loud before you read its answer in the script, and announce each maneuver before you read its finding. You lose the practice of drawing answers out of a person, but you keep the order, the timing and the note. Afterward, score yourself with the checklist, then read the model presentation, the annotated note and the debrief.
The clinical content follows the 2025 edition of the World Society of Emergency Surgery (WSES) Jerusalem guidelines for acute appendicitis and the American College of Radiology (ACR) Appropriateness Criteria for right lower quadrant pain and for acute pelvic pain in the reproductive age group.1,2,3 The case is original and fictional.
Door note
Door note for the candidate
Claire Novak, 27-year-old woman. Urgent care clinic. Chief complaint: abdominal pain.
- Temp
- 37.9 °C (100.2 °F)
- Heart rate
- 98/min
- BP
- 122/76 mm Hg
- Resp
- 16/min
- SpO2
- 99% on room air
You have 15 minutes.
- Take a focused history.
- Perform a focused physical exam. State any sensitive exam you would perform, and the examiner will give you the findings.
- Explain your assessment and plan to the patient.
- Afterward, give a 60 to 90 second oral presentation and write a SOAP note.
This is all the candidate sees before the encounter. Use the minute to read it twice and plan. For abdominal pain in a woman who could be pregnant, write down the causes you cannot miss: ectopic pregnancy, appendicitis, ovarian torsion and pelvic infection first, then bowel obstruction, perforation and a kidney stone or kidney infection where the story fits.
Then decide what you will ask and do early. The menstrual and sexual history is easy to leave until the end and then forget, and one test belongs near the start of this encounter, not the end. Plan how you will explain your thinking to the patient in plain words.
Candidate: stop here. Everything below is for the patient and the examiner, including the answers. Come back to it after you have run the case.
Patient script
For the person playing Ms. Novak. Read it through once before the encounter, answer only what the candidate asks, and stay in character until the examiner calls time.
Show the patient script
Patient script for the partner
You are Claire Novak, a 27-year-old middle school science teacher. You hurt, and you lie still because moving makes it worse. You are also busy and hoping this is something you can treat at home. Answer in plain words. If a question is vague, give a short answer and wait.
Opening statement
My stomach has been hurting since last night, and now it's really sore down on the right side.
If the candidate asks an open question such as "Tell me more," add: "The car ride over here was awful. Every bump hurt." Say nothing else unless asked.
The history, only if asked
- Onset
- Last night around 10, while I was grading papers. It built up slowly over an hour or so. It didn't come on all at once.
- Location
- At first it was around my belly button. Around 3 this morning it woke me up, and since then it's been down here. (Point to the right lower abdomen.)
- Character
- Dull at first. Now it's sharp and constant.
- Severity
- About 6 out of 10 lying still. Every bump in the car was an 8.
- What makes it worse
- Walking, bumps, coughing. I'm trying not to move.
- What makes it better
- Lying still with my knees bent. I took 400 mg of ibuprofen at midnight, and it barely helped. Nothing since.
- Radiation
- It stays in one place. It doesn't go to my back, my groin or my shoulder.
- Timing
- Constant since it moved. It hasn't come and gone in waves.
Other symptoms, only if asked
- Appetite, nausea or vomiting
- I haven't wanted to eat anything since it started. I felt sick and threw up once this morning, after the pain moved.
- Bowels
- No diarrhea. My last bowel movement was yesterday morning, and it was normal. No blood and nothing black.
- Fever or chills
- I had chills this morning and felt hot. I didn't take my temperature.
- Urination
- No burning, I'm not going more often, and I haven't seen blood. No pain in my back or side.
- Vaginal bleeding or discharge
- No bleeding, and no unusual discharge.
- Pain with sex
- No.
- Lightheaded, fainting or shoulder pain
- No.
- Sick contacts or food
- My boyfriend and I ate the same leftover pasta for dinner, and he's fine. Nobody I know is sick.
- Last food or drink
- Dinner last night at about 7. A few sips of water this morning.
Background, only if asked
- Last menstrual period
- It started about 18 days ago. It was shorter and lighter than usual, only 2 days. Usually it's 4 or 5.
- Sexual activity and contraception
- One partner, my boyfriend, for 2 years. I'm on the pill. I missed two pills last month when I was traveling. (If asked whether you could be pregnant:) I'm on the pill, so I can't be, right?
- Pregnancies and gynecologic history
- I've never been pregnant. No ovarian cysts or other problems that I know of. No infections that I know of. My last Pap test and STI tests, a year ago, were normal.
- Medical history and surgery
- I'm healthy. I've never had surgery.
- Medicines
- A combined birth control pill every day, except the two I missed. The ibuprofen last night.
- Allergies
- Penicillin. I broke out in hives when I was a kid.
- Family history
- My mom had her gallbladder out. Nobody has bowel disease that I know of.
- Smoking, alcohol and drugs
- I don't smoke. A glass of wine on weekends. No drugs.
- Home and getting here
- I drove myself. My boyfriend works an hour away. My sister lives 10 minutes from here.
Your question for the candidate
When the candidate starts explaining the plan, ask: "Can I just take something for the pain and see my own doctor tomorrow? I have parent-teacher conferences tonight, and I can't afford a big ER bill."
If the candidate explains clearly why you need to go to the emergency department today, agree, and say your sister can drive you. If the candidate lets you go home or wait, say "Okay, thanks" and nothing more; the examiner will note it.
Physical exam findings
For the patient or the examiner. Read a finding only when the candidate performs the maneuver or clearly names it. Anything not listed is normal. The pelvic exam is never performed in this station: read its finding only when the candidate says it is needed, and give a urine result only when the candidate asks for that test.
Show the exam findings
Exam findings read each one only when it is examined
- General
- Lying still on the table with her knees slightly bent. Winces when she shifts or the table is bumped. Skin warm. Speaks comfortably in full sentences.
- Heart and lungs
- Regular rhythm at 98/min, no murmur. Lungs clear.
- Abdomen, inspection and auscultation
- Flat, no distention or scars. Bowel sounds present but hypoactive.
- Abdomen, palpation
- Soft. Tender in the right lower quadrant, most at McBurney point, with voluntary guarding there. Nontender in the other quadrants. No mass, no rigidity. Liver and spleen not enlarged.
- Rebound tenderness
- Rebound tenderness in the right lower quadrant.
- Pain with cough or heel tap
- Coughing or a heel tap causes sharp right lower quadrant pain.
- Rovsing sign
- Pressing on the left lower quadrant causes pain in the right lower quadrant.
- Psoas and obturator signs
- Both negative.
- Costovertebral angles
- No tenderness on either side.
- Pelvic exam (stated, with a chaperone)
- External genitalia normal. No blood in the vault; scant white discharge. No cervical motion tenderness. Uterus normal size and nontender. Mild right adnexal tenderness, no adnexal mass. Left adnexa nontender.
Tests, only if the candidate asks
- Urine pregnancy test (hCG)
- Negative.
- Urinalysis (dipstick)
- Specific gravity 1.025, ketones 1+. Negative for blood, leukocyte esterase and nitrite.
- Blood tests or imaging
- Not available at this clinic.
Examiner checklist
Score each item done or not done, one point each. The examiner ticks items as they happen, not from memory at the end. A history item counts if the candidate asked it in any wording; an exam item counts only if the candidate performed or clearly named the maneuver.
Two items are marked critical: they are the actions that keep this patient safe. For practice, call a run a pass when the candidate scores at least 26 of 37 and completes every critical action. Programs set their own standards, so use yours when you know it. After scoring, the examiner names two things done well and two to work on.
Examiner checklist tick each item the candidate does
History
- Onset, and whether it came on gradually or suddenly
- Where the pain started and where it is now
- Character and severity
- What makes it worse (movement, bumps, coughing) and better
- Radiation, including to the back, groin or shoulder
- Appetite, nausea and vomiting, and whether pain or vomiting came first
- Bowel habits: diarrhea, constipation, blood
- Urinary symptoms and flank pain
- Fever or chills
- Last menstrual period, and whether it was normal
- Sexual activity, contraception and missed pills
- Vaginal bleeding or discharge, and past pelvic infections
- Past surgery, including whether she still has her appendix
- Medicines and allergies, including the penicillin allergy
- When she last ate or drank
Exam
- Gets a urine pregnancy test promptly, if available without delaying transfer, and communicates the result or pending status to the ED Critical
- Reviews the vital signs, noting the temperature and heart rate
- Inspects and listens to the abdomen before palpating
- Palpates all four quadrants, starting away from the pain
- Checks for peritoneal signs: rebound, guarding, or pain with cough or heel tap
- Checks Rovsing, psoas or obturator sign
- Checks for costovertebral angle tenderness
- States that a pelvic exam is needed, with a chaperone, and asks for the findings
- Listens to the heart and lungs
- Asks for a urinalysis
Communication
- Introduces self, confirms the patient's name, cleans hands
- Opens with an open-ended question
- Explains why the menstrual and sexual questions matter before asking them
- Warns before pressing on the painful area
- Summarizes the history back to the patient
- Uses plain language, without jargon
Closure and counseling
- Explains that appendicitis is the main concern and needs imaging and a surgeon's evaluation today
- Sends her to the emergency department today for imaging and surgical evaluation Critical
- Answers the request to wait until tomorrow, with the reason
- Arranges a ride so she does not drive herself
- Advises nothing to eat or drink until she is evaluated
- Checks understanding and asks for questions
Score: ______ of 37 Critical actions: ______ of 2 Practice pass: 26 or more, and every critical action
Model oral presentation
Model presentation about 70 seconds aloud
Ms. Novak is a healthy 27-year-old woman on combined oral contraceptives, with two missed pills last month, who presents with abdominal pain that began around the umbilicus last night and moved to the right lower quadrant overnight.
The pain built gradually and is now sharp, constant and 6 out of 10, worse with walking, bumps and coughing. She has anorexia, vomited once after the pain moved and had chills. She denies diarrhea, urinary symptoms, flank pain, vaginal bleeding and discharge. Her last period, 18 days ago, was lighter than usual.
Temperature is 37.9 and heart rate 98. She lies still, with McBurney point tenderness, guarding, rebound and a positive Rovsing sign. Pelvic exam shows mild right adnexal tenderness without a mass or cervical motion tenderness. Urine pregnancy test is negative.
My leading diagnosis is acute appendicitis, with an Alvarado score of at least 7 before labs. Ovarian torsion, pelvic infection and ectopic pregnancy are less likely. I am sending her to the emergency department now for imaging and surgical evaluation, nothing by mouth, with her sister driving.
A good presentation follows the order of the note and leaves out what does not change the assessment. Open with one sentence that carries the key features: the age, the pregnancy risk, the time course and the migration of the pain. Someone who hears only that sentence should already be thinking of appendicitis and of the pregnancy test.
Give the history in the order that supports your reasoning: the classic sequence of periumbilical pain and anorexia, then pain that moves to the right lower quadrant, then vomiting, followed by the negatives that argue against each dangerous alternative. Report the exam as specific findings, and give the pregnancy test result before your assessment, not after it.
End with a ranked assessment and a plan that says what you did, not what you might do. Practice it against a timer until you can finish in under 90 seconds without notes.
Keep two vocabularies. Anorexia, Rovsing sign and adnexal tenderness belong in the presentation to the examiner; "no appetite," "pressing on the left side hurt on the right" and "this could be your appendix" belong in the room with the patient. If the examiner asks a question afterward, answer with the finding first and the reasoning second.
Annotated model SOAP note
A note the candidate could write in 10 minutes, with what each part is doing beside it. It uses common abbreviations; follow your program's rules.
Model SOAP note with what each part is doing
Chief complaint and history
CC: "My stomach has been hurting since last night."
HPI: 27F with abdominal pain that began last night around 2200 as a dull periumbilical ache, gradual in onset, and migrated to the RLQ by about 0300. Now sharp, constant, 6/10, 8/10 with bumps; worse with walking and coughing, better lying still. No radiation. Anorexia since onset; 1 episode of emesis this morning after the pain moved. Subjective fever and chills. Ibuprofen 400 mg at midnight with little relief.
What graders look for. The sequence is the diagnosis here: periumbilical pain and anorexia, then pain that settles in the right lower quadrant, then vomiting. Graders look for onset, migration, character, aggravating factors and which came first, the pain or the vomiting.
Common miss. Writing "RLQ pain x 1 day" without the migration, the anorexia or the order of pain and vomiting.
Pertinent negatives and gynecologic history
No diarrhea, hematochezia or melena; last BM yesterday, normal. No dysuria, frequency, hematuria or flank pain. No vaginal bleeding or discharge, no dyspareunia. No lightheadedness, syncope or shoulder pain. Partner ate the same meal and is well.
Gyn: LMP 18 days ago, 2 days and lighter than her usual 4 to 5. G0. Combined OCP, missed 2 pills last month. One male partner for 2 years. No known STI or PID; normal Pap and STI testing 1 yr ago. No known ovarian cysts.
What graders look for. Each negative answers a dangerous alternative: urinary symptoms and flank pain for a stone or pyelonephritis, discharge and dyspareunia for pelvic infection, fainting and shoulder pain for hemorrhage. The missed pills and the light period are why the pregnancy test is not optional.
Common miss. "LMP 18 days ago" with no note that it was atypical, or no mention of the missed pills.
Background
PMH: none. PSH: none (appendix in situ).
Meds: combined OCP daily; ibuprofen 400 mg x 1 at midnight. Allergies: penicillin (hives in childhood).
FH: mother s/p cholecystectomy; no IBD. SH: teacher; no tobacco or drugs; wine on weekends. Last oral intake: dinner at about 1900 last night, sips of water this morning.
What graders look for. A surgical patient's background: no prior surgery, the allergy that will shape antibiotic choice, and the time of the last meal, which the surgeon and anesthesia team will ask for.
Common miss. Leaving out the penicillin allergy or the last oral intake.
Objective
Vitals: T 37.9 °C, HR 98, BP 122/76, RR 16, SpO2 99% RA.
General: lying still, knees flexed, winces with movement. CV: RRR, no murmur. Lungs: clear. Abd: flat, hypoactive bowel sounds; soft; RLQ tenderness maximal at McBurney point with voluntary guarding; rebound tenderness RLQ; pain with cough; Rovsing positive; psoas and obturator negative; no mass, no rigidity. No CVA tenderness. Pelvic (chaperoned): no blood in vault, scant white discharge, no CMT, uterus normal size and nontender, mild R adnexal tenderness, no adnexal mass.
Urine hCG: negative. UA: SG 1.025, ketones 1+, otherwise negative.
What graders look for. Specific findings in a defensible order: where the tenderness is greatest, which peritoneal signs are present, and the findings that argue against the alternatives, such as no cervical motion tenderness, no mass and no flank tenderness.
Common miss. "Abd: tender RLQ" with no peritoneal signs, or no pregnancy test result in the note.
Assessment
27F on OCPs with missed pills, with periumbilical pain that migrated to the RLQ, anorexia, emesis after pain onset, low-grade fever, and RLQ tenderness with guarding, rebound and Rovsing sign. Urine hCG negative.
1. Acute appendicitis: leading diagnosis. Alvarado score at least 7 of 10 without a CBC (migration 1, anorexia 1, vomiting 1, RLQ tenderness 2, rebound 1, temperature 1).
2. Ovarian torsion: less likely; gradual onset, migrating pain, no adnexal mass. Mild R adnexal tenderness keeps it on the list. Pelvic US with Doppler helps but does not rule it out; urgent gynecology consult if suspicion persists.
3. PID or tubo-ovarian abscess: less likely; no discharge or CMT, one long-term partner, normal STI testing 1 yr ago. Not excluded: adnexal tenderness is a CDC minimum criterion. Keep on the list pending ED assessment; STI testing, and empiric treatment if criteria are met and no other cause is found.
4. Ectopic pregnancy: very unlikely with a negative urine hCG. If suspicion persists, quantitative serum hCG with pelvic US and clinical follow-up.
5. Ureteral stone or pyelonephritis: unlikely; no flank pain, CVA tenderness, urinary symptoms or hematuria.
6. Gastroenteritis: unlikely; pain came before vomiting, no diarrhea, partner who ate the same food is well.
What graders look for. Open with a summary sentence, then a ranked differential with the evidence for and against each diagnosis. If you give a score, show its parts and say what is missing: two laboratory items, worth three points, need a CBC with differential, so the score here is a floor, not a total. Count the rebound point only if rebound was elicited; pain with cough alone does not earn it.4
Common miss. Writing "Alvarado 7, appendicitis confirmed." A clinical score helps stratify risk; WSES guidance suggests against using the Alvarado score alone to confirm appendicitis in adults.5
Plan
1. To the ED now for surgical evaluation and imaging (likely CT abdomen and pelvis with IV contrast, plus pelvic ultrasound with Doppler if an adnexal cause remains a concern). Plan: call the ED and send this note and the urine results with her.
2. Hemodynamically stable; sister to drive her now. Patient not to drive. Call 911 if the pain suddenly worsens, she feels faint, or the ride falls through.
3. NPO until surgical evaluation.
4. Penicillin allergy (childhood hives) flagged for the ED.
5. Analgesia: offer here if available and safe, without delaying transfer; otherwise the ED will treat her pain.
6. Counseled: likely appendicitis, which needs imaging and a surgeon today; pregnancy test negative; pain medicine will not hide the diagnosis. Patient agrees to go today.
What graders look for. Disposition first, with how she is getting there, then every action taken and what she was told. Label anything not yet done as planned. Graders check that the plan fits the assessment: suspected appendicitis cannot end in "follow up with PCP tomorrow."
Common miss. Prescribing an antibiotic or pain medicine and sending her home to see how it goes. Treat the pain, here if analgesia is available and safe and does not delay transfer, or in the ED; analgesia does not increase diagnostic errors.6
Debrief: ranking the differential
The differential, ranked
-
Acute appendicitis Most likely; needs urgent ED and surgical evaluation
For: Periumbilical pain that moved to the right lower quadrant; anorexia; vomiting after the pain began; low-grade fever; McBurney point tenderness with guarding, rebound and Rovsing sign.
Against: Nothing that excludes it. Negative psoas and obturator signs do not rule it out.
-
Ectopic pregnancy Dangerous; address it first
For: Missed pills; a shorter, lighter last period.
Against: Negative urine pregnancy test; no vaginal bleeding, fainting or shoulder pain; stable vital signs.
-
Ovarian torsion Dangerous; address it
For: Right-sided pain with vomiting; mild right adnexal tenderness.
Against: Gradual onset, pain that migrated, no adnexal mass. Imaging helps but does not rule it out.
-
PID or tubo-ovarian abscess Less likely
For: Fever, lower abdominal pain, adnexal tenderness.
Against: No discharge, no cervical motion tenderness, one long-term partner, normal STI testing a year ago. Not excluded: adnexal tenderness is a minimum criterion.
-
Ureteral stone or pyelonephritis Less likely
For: Right-sided pain with vomiting.
Against: Constant rather than colicky; no flank pain, CVA tenderness, urinary symptoms or blood on the dipstick.
-
Gastroenteritis Unlikely
For: Vomiting.
Against: Pain came first and localized; no diarrhea; her partner ate the same food and is well.
Rank an abdominal pain differential on two scales at once: how likely each diagnosis is, and how much harm a miss would do. Here appendicitis tops the first list, and ectopic pregnancy, though less likely, tops the second until a pregnancy test is back. Ms. Novak's story carries most of the predictors Alvarado identified: migration of the pain, anorexia, nausea or vomiting, right lower quadrant tenderness, rebound and an elevated temperature. Before any blood test she scores 7 of 10, and the two laboratory items, a raised white count and a left shift, can only add to that.4
What does a score of 7 do? The 2020 WSES guidelines recommended clinical scores to exclude appendicitis and to identify patients at intermediate risk, suggested against using the Alvarado score alone to confirm appendicitis in adults, and suggested timely imaging for patients at intermediate risk.5 The 2025 edition again pairs validated risk scores with imaging to improve diagnostic accuracy and reduce negative appendectomies.1 In practice a high score raises the urgency; it does not replace imaging and a surgeon. For adults with right lower quadrant pain, the ACR rates CT with IV contrast as the primary imaging study, and in pregnancy, ultrasound and MRI without contrast are preferred.2
The gynecologic causes need their own answer. For acute pelvic pain in the reproductive years, the ACR organizes imaging around the pregnancy test result and rates transabdominal and transvaginal pelvic ultrasound with Doppler as usually appropriate.3 Her mild right adnexal tenderness can come from an inflamed appendix lying nearby, but it is also why torsion and pelvic infection stay on the list. Pelvic ultrasound with Doppler helps assess torsion, but normal blood flow does not exclude it, so persistent suspicion calls for urgent gynecologic consultation.7 Adnexal tenderness alone meets a CDC minimum criterion for PID, so the ED should keep PID in view, test for sexually transmitted infections and treat empirically if the criteria are met and no other cause is found.8 A negative urine pregnancy test makes ectopic pregnancy very unlikely. If suspicion persists, a quantitative serum hCG belongs with pelvic ultrasound and clinical follow-up, not read as a single result in isolation.
The red flags in this case: pain that migrated and localized, peritoneal signs, fever, anorexia and a possible pregnancy until the test is back. Together they take this patient out of any clinic workup and into the emergency department today.
Debrief: why the emergency department, today
Common mistakes on this case
- Skipping the pregnancy test because she is on the pill.
- Never asking about her last period, missed pills or vaginal bleeding.
- Pressing on the painful quadrant first, or never checking for rebound or guarding.
- Calling it gastroenteritis because she vomited, without asking whether the pain or the vomiting came first.
- Treating an Alvarado score of 7 as a diagnosis, or a negative pregnancy test as the end of the gynecologic workup.
- Sending her home with an antibiotic or pain medicine to see her doctor tomorrow.
- Letting her drive herself.
- Never answering her question about tonight and the cost.
Suspected appendicitis needs two things this clinic cannot provide: cross-sectional imaging and a surgeon. Even when the result is treatment with antibiotics alone, which the 2025 WSES guidelines describe as safe and effective for selected patients with uncomplicated appendicitis, that choice follows imaging and a surgical evaluation.1 An antibiotic prescription from urgent care is not that strategy.
Why not tomorrow? The 2025 WSES guidelines state that appendectomy for uncomplicated appendicitis may be safely delayed within 24 hours.1 That statement describes a patient already admitted, diagnosed and under a surgeon's care. They do not support sending an undiagnosed patient with peritoneal signs home overnight.
Do the pregnancy test early, because pregnancy changes both the differential and the imaging. Contraception lowers the chance of pregnancy but does not remove it, and she missed two pills and had a lighter period. Test every patient who could be pregnant, whatever she says about contraception. If the test is available here, run it promptly without delaying transfer, and send the result, or the fact that it is pending, to the ED so it is known before imaging is chosen.2,3
Her vital signs are stable, so a private car is reasonable, but she should not drive herself in this much pain, and she should not eat or drink until a surgeon has seen her. Then say it plainly: "The way your pain started and moved, and what I found on exam, point to appendicitis. You need a scan and a surgeon today, and the emergency department is where you get both. Your pregnancy test is negative." Answer the conferences and the cost directly, and check that she agrees.
