Informed Consent OSCE - Appendicectomy Consent

Case Overview

• Age/Sex: 21-year-old male
• Occupation: University student, semi-professional footballer
• Setting: Emergency department / surgical admissions unit
• Chief complaint: "Procedure consent discussion"

Patient Script

Who I Am

I'm a 21-year-old uni student and football player — otherwise fit and active.

What Brings Me In

The emergency doctor told me I likely need my appendix taken out and they want me to talk to a doctor about the operation and sign consent.

My Story

About 24 hours ago I started with a dull pain around my belly button. Over the next 12–18 hours the pain got worse and moved to the lower right side of my tummy. I felt nauseous and vomited once last night, and I haven't felt like eating since the pain started. I had a bit of a fever on and off — I felt hot and had chills early this morning. I took some ibuprofen which helped the pain a bit for a few hours but it came back.

I played football two days ago and felt fine then; I did twist my right hip a little but I didn't think much of it. I also had a spicy kebab last night — I thought maybe that upset my stomach — but now the pain is localised on the right lower side and it's tender when you press there.

My Medical Background

• Past medical history: none significant
• Surgical history: none
• Medications: occasional ibuprofen for aches, protein supplements after training
• Allergies: none known
• Social history: lives with teammates, non-smoker, drinks socially, trains 4–5 times/week
• Sexual history: single partner, no recent STIs
• Family history: father fit, mother with mild asthma

What I Think & Worry About

• I want to get fixed quickly so I can go back to training and uni.
• I'm worried about complications from the operation and getting a big scar that might affect my football.
• I'm a bit anxious about being put to sleep for the operation.

If You Ask Me About Other Symptoms...

• Appetite: I have no appetite since it started.
• Bowel movements: I had a normal bowel movement yesterday, no diarrhoea since symptoms began.
• Urine: peed normally today, no burning but I did notice it was a bit darker (probably dehydrated).
• Fever: I felt feverish overnight; took ibuprofen which reduced it.
• Chest: no cough or breathlessness.
• Testicular pain: none.
• Skin: I had an insect bite on my arm last week — just a small mark.

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Clinical Summary

Examination

• General: alert, anxious but cooperative
• Temperature: 38.2°C
• Heart rate: 100 beats/min
• Blood pressure: 118/72 mmHg
• Respiratory rate: 16/min
• O2 saturation: 98% on air
• Abdomen: localized tenderness in the right iliac fossa (McBurney's point), voluntary guarding, mild rebound tenderness, positive Rovsing's sign, decreased bowel sounds
• Genital exam: testes normal, no tenderness

Investigations

• White cell count: 14.5 x10^9/L (neutrophils 12.0 x10^9/L) (leukocytosis with neutrophilia)
• C-reactive protein (CRP): 65 mg/L (elevated)
• Urinalysis: trace leukocytes, no nitrites (likely dehydration/contamination - possible red herring)
• Abdominal ultrasound: non-compressible tubular structure in right iliac fossa measuring 10–11 mm with increased periappendiceal echogenicity (suggestive of appendicitis)
• (If CT performed) CT abdomen/pelvis with contrast: dilated appendix 11 mm with periappendiceal fat stranding; no abscess or perforation identified (confirms acute uncomplicated appendicitis)

Diagnosis

• Primary: Acute appendicitis — supported by history of periumbilical pain migrating to right lower quadrant, localized tenderness at McBurney's point, fever, leukocytosis/neutrophilia, raised CRP, and imaging showing an enlarged non-compressible appendix.

• Differentials:

  • Mesenteric adenitis — more likely in children/viral illness; less likely with focal guarding and imaging findings.
  • Acute gastroenteritis — usually more diarrhoea/vomiting and diffuse pain; exam and imaging favour appendicitis.
  • Ureteric colic/UTI — can cause flank/loin pain and haematuria; urinalysis shows only trace leukocytes and no haematuria; imaging localizes the appendix.
  • Right-sided diverticulitis / Meckel's diverticulitis — less likely given age and imaging consistent with appendix.

Management

• Obtain formal informed consent for appendicectomy (discuss indication, procedure, risks, benefits, and alternatives):
  • Explain nature of procedure: usually laparoscopic appendicectomy; conversion to open possible.
  • Benefits: removal of inflamed appendix to prevent perforation and sepsis.
  • Common risks: wound infection, postoperative pain, nausea, temporary ileus.
  • Important/rare risks: bleeding, injury to bowel/bladder/adjacent structures, anaesthetic complications, hernia at port sites, need for further surgery.
  • Alternatives: conservative antibiotics alone (discussed if appropriate) but explain increased risk of recurrence and that surgery is standard of care for most cases.
• Preoperative measures: nil by mouth (fasting), IV fluids as needed, analgesia (avoid masking progressive signs), single-dose IV antibiotics pre-incision (e.g., cefuroxime + metronidazole or local protocol), antiemetic as needed.
• Operative plan: laparoscopic appendicectomy under general anaesthesia; discuss likely timing (urgent, within hours) and allow opportunity for patient questions.
• Documentation: note the consent discussion, risks discussed, patient understanding, and signature on consent form; ensure operation site is noted and patient identity checked.
• Postoperative plan: pain control, mobilization, wound care, review of histology if performed, clear instructions about return to sport (typically graded return depending on surgical approach and recovery).

Key Learning Points

• Typical appendicitis presents with periumbilical pain migrating to the right lower quadrant, anorexia, nausea/vomiting, fever, localized peritonism, and inflammatory markers — imaging confirms diagnosis.
• Informed consent requires explaining the procedure, benefits, risks (common and serious), and alternatives, and documenting that the patient understands and has had the opportunity to ask questions.
• Preoperative care includes appropriate fasting, IV fluids, analgesia, and single-dose prophylactic antibiotics; laparoscopic appendicectomy is the standard approach for uncomplicated appendicitis.