Angry Patient OSCE - Delayed Diagnosis Anger

Case Overview

• Age/Sex: 29-year-old female
• Occupation: Office administrator
• Setting: Surgical outpatient clinic / GP follow-up / complaint meeting
• Chief complaint: "I want to complain — nobody took me seriously and I nearly died because of the delay."

Patient Script

Who I Am

I'm 29, I work in an office doing admin, and I have been under a lot of stress at work lately.

What Brings Me In

I want to complain about the care I got — I went to my GP twice and they told me it was wind, and then I nearly had my appendix burst because no one listened.

My Story

About three weeks ago I started with a dull pain around my tummy that I thought was maybe a trapped wind after lunch. Over the next 10 days it got worse — it moved to the lower right and I had fever, nausea and worse pain. I saw my GP twice in that time; the first time they said it was probably constipation, the second time they said it might be a tummy bug and told me to rest and take paracetamol. On Friday last week the pain became unbearable and I had a high fever, so I went to the hospital. I was told I had a perforated appendix and I needed emergency surgery. They took me into theatre and I had a laparoscopic appendectomy. They said there was pus and it had burst.

I was in hospital for three days and then discharged home. Since coming home five days ago I still have a fever sometimes and the wound on my lower right is red and oozing a little. I still have quite bad pain when I move. I feel angry and shaken — I think if the GP had done more or referred me sooner this wouldn't have happened.

I also had a cough for a couple of days last week (I thought it was an allergy), and I got the COVID booster two weeks ago — that's probably irrelevant but the doctors kept bringing it up. I used to get migraines when I was a teenager.

My Medical Background

• Past medical history: mild migraines as a teen; otherwise fit and well
• Medications: combined oral contraceptive pill; takes paracetamol and ibuprofen for pain
• Allergies: penicillin (rash as a child) — not sure exactly what that means now
• Social: works long hours in an office; drinks alcohol socially (1–2 glasses at weekends); does not smoke; occasional recreational cannabis years ago (not now)
• Family history: mother has depression; father healthy

What I Think & Worry About

• I think my GP didn't take me seriously and that delay caused my appendix to burst.
• I'm worried about infection, getting sepsis or another complication, and that I could have died.
• I expect a proper explanation, an apology, and someone to take responsibility; I want to know what will be done to stop this happening to someone else.

If You Ask Me About Other Symptoms...

• Pain: "It's a constant ache across the lower right of my tummy; worse when I move — I rate it about 7/10 today."
• Fever: "I still feel hot sometimes and had a temperature at home last night (about 38 C)."
• Wound: "One of the small cuts from the keyhole surgery is red and a bit sticky with yellow stuff."
• Nausea/vomiting: "I felt sick before the operation but I haven't been vomiting since."
• Vaginal bleeding/periods: "My last period was about two weeks ago and normal — I'm on the pill."
• Bowel/urine: "No diarrhoea, no blood in stool, no burning pee." (red herring: had some constipation earlier)
• Breathlessness/chest pain: "I get a bit short of breath if I'm panicky but no chest pain." (possible distraction)
• Mental state: "I'm really angry, I can't stop replaying it in my head; I'm scared and I want answers."

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Clinical Summary

Examination

• General: alert but visibly upset and agitated; speaking loudly at times
• Vitals: temperature 38.2°C; pulse 110 bpm (regular); blood pressure 128/82 mmHg; respiratory rate 18/min; SpO2 98% on room air
• Abdomen: small laparoscopic port sites visible on lower abdomen; right lower quadrant tenderness with localized guarding; mild erythema and tenderness around the right lateral port site with small amount of seropurulent discharge
• Cardiovascular/Respiratory: normal heart sounds, clear lungs on auscultation
• Neuro: alert, oriented, no focal deficit

Investigations

• Full blood count: WBC 14.5 x10^9/L (elevated) (suggests ongoing inflammation/infection)
• CRP: 120 mg/L (elevated) (supports significant inflammatory response)
• Urea & electrolytes: within normal limits (no renal impairment)
• LFTs: within normal limits
• Wound swab: pending (culture for organisms and sensitivities)
• Abdominal ultrasound: small fluid collection in the right iliac fossa ~3 cm (possible residual collection/abscess)
• If ordered: CT abdomen with contrast: small loculated collection adjacent to appendiceal stump (interpretation: possible post-op abscess)

Diagnosis

• Primary: Patient presenting with significant anger and desire to lodge a complaint regarding perceived delayed diagnosis of appendicitis leading to perforation and post-operative wound infection/possible residual collection.

  • Evidence: history of two GP visits over 10 days with non-referral, subsequent ED presentation with perforated appendix, and current wound infection/collection; strong expression of anger and desire to complain.

• Differentials (reasons):

  • Acute distress/anger related to pain and ongoing infection rather than systemic grievance (pain-driven irritability)
  • Somatic symptom amplification / anxiety exacerbating perception of care failure
  • Formal medico-legal motivation (seeking compensation) — consider but do not assume
  • Underlying mood disorder (e.g., depression) contributing to anger — family history of depression noted

Management

• Immediate clinical care:

  • Senior review by surgical team to assess need for drainage (interventional radiology or return to theatre) and to manage wound infection
  • Start/adjust appropriate antibiotics guided by local guidelines and allergy history (avoid penicillin if suspected true allergy; use alternative such as a cephalosporin only after allergy assessment) and tailor once cultures available
  • Analgesia plan: regular multimodal analgesia (paracetamol ± NSAID unless contraindicated) and opioid as needed for severe pain
  • Arrange repeat imaging (CT abdomen) if not already done to assess for abscess requiring drainage

• Communication and complaint handling / de-escalation:

  • Acknowledge and validate the patient’s feelings: explicitly recognise her fear and anger about the delay
  • Offer a clear, factual explanation of what is currently known (what happened, what treatment was done, what the current plans are) and what is not yet known (pending tests)
  • Apologise for her distress and for any failures in care she perceives, without admitting legal liability; offer to arrange a formal meeting with the GP practice and hospital patient liaison or complaints officer
  • Offer printed information and a named contact (e.g., patient liaison officer) and arrange a follow-up appointment to review investigations and treatment response
  • Document the discussion carefully in the medical record
  • If behaviour becomes aggressive or threatening: ensure staff safety, call for security, use trained staff for de-escalation, and involve senior staff

• Longer-term/process:

  • Offer referral to clinical governance/patient liaison to review timeline of care and offer an explanation/meeting
  • Consider offering psychological support if ongoing distress (e.g., liaison psychiatry, counselling)
  • Ensure appropriate outpatient surgical follow-up and wound care instructions

Key Learning Points

• Acknowledge emotions first: in patients who are angry about perceived delayed diagnosis, validate feelings, apologise for distress, and provide a clear factual explanation and plan.

• Balance clinical and communication priorities: address any ongoing clinical issues (e.g., infection, abscess) promptly while arranging appropriate channels for complaint resolution and documentation.

• Safety and escalation: de-escalate verbally, document thoroughly, involve senior clinicians and patient liaison services, and ensure staff safety if the patient becomes threatening.