Station 65
Sophie Johnson
Age: 10 years old female
Full Case
Patient’s Data
Patient’s name: Sophie Johnson
Age: 10-year-old female
Past medical history
- No known medical conditions
Drug and Allergy History
- Not currently on any regular medications
- No known drug allergy
Recent Notes/Consultation
Seen 3 months ago by Dr Temitope Alao (Clinical practitioner access role)
Presenting complaint: Patient was seen with mum. She reports intermittent abdominal pain on/off for 2-3 months duration. No change in bowel habits or PR bleeding. No vomiting or diarrhoea, No weight loss
Examination: Abdomen soft, and non-tender. No masses
Plan: Bloods including TFTs, LFTs, FBC, U+E’s, Ferritin, Coeliac screen and stool for calprotectin. Review in 2 weeks.
Investigation Outcome:
Blood and stool calprotectin results were reviewed and found to be within normal limits. Results were filed by Dr Temitope Alao.
Recent A&E Attendance (4 days ago):
Accident and Emergency Letter
To: GP Practice,
Re: Sophie Johnson (Age:10 years old female)
Dear Colleague,
Sophie Johnson, a 10-year-old female, was seen in the Emergency Department today for episodic abdominal pain. She reported recurrent episodes of cramping abdominal pain over the last 6 months which suddenly got worse a day ago and hence presentation to emergency department. There are no associated vomiting, diarrhoea, or fever. On review, she was otherwise well, with no signs of acute illness.
Investigations:
Urinalysis: Normal
Blood Tests (Including, thyroid function test, FBC, U+ E’s, LFTs, Ferritin, Folate, CRP ) : Normal
Bed side ultrasound of abdomen: Normal
Based on her clinical presentation and the normal findings of the investigations, we suspect abdominal migraine as the most likely diagnosis.
Recommendations:
If the symptoms reoccur, we recommend that Sophie follow up with her GP for further evaluation and management. Should her symptoms change in nature or become more severe, or if any other concerning symptoms arise, we advise immediate re-assessment.
Kind regards,
Dr Chika Cubana, MBBS FRCEM
ST6 Emergency Medicine Specialist Registrar
Patient’s mum – Emily Johnson has booked routine telephone consultation to discuss ongoing concerns.
Patient's Story (Role player’s brief)
Patient’s Story
You are Emily Johnson, the mother of Sophie Johnson, a 10-year-old girl. You’ve arranged this telephone consultation to discuss Sophie’s ongoing tummy pain, which has been happening for the past six months.
If asked to explain further:
Sophie experiences episodes of tummy (abdominal) pain every 2 to 3 weeks. Each episode typically lasts a few hours to a full day.
The pain is located in the centre of her tummy and feels cramping or aching.
She sometimes feels slightly nauseous during these episodes, but she has never vomited.
You’ve noticed that these episodes tend to occur after Sophie eats dark chocolate, which she loves.
Sophie is otherwise well, happy at home, and doing well at school. She hasn’t missed school because of the pain.
Social History: Sophie lives at home with you, your husband, and her two older sisters, who are also well.
Family History: You (her mother) have a history of migraine headaches.
Ideas: An A&E doctor recently mentioned abdominal migraine as a possible cause, and you’re wondering if that could be the diagnosis.
Concerns: You’re concerned about Sophie being in pain and want to know if she needs treatment.
Expectations: You would like to confirm whether this is abdominal migraine and understand how best to manage it moving forward.
Questions for the Doctor:
Will she go on to develop migraine headaches in the future?
Could this be irritable bowel syndrome (IBS)?
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask about the onset of symptoms
- Ask about the nature of the abdominal pain, including location, duration, and whether anything relieves or worsens it (e.g. stress, certain foods such as chocolate)
- Ask about associated symptoms such as nausea, vomiting, change in bowel habits (diarrhoea or constipation), or PR bleeding
- Ask about the presence or absence of headaches
- Ask if the patient has started her periods (menarche) to rule out menstrual-related causes such as dysmenorrhoea
- Ask about any weight loss, changes in appetite, or concerns around growth (to assess the nutritional impact of symptoms, for example food avoidance due to pain, and malignancy)
- Ask about family history of migraines
- Ask how these symptoms have affected the child’s day-to-day life, including school attendance and activities
- Take a social history, including who lives at home
- Give diagnosis of possible abdominal migraine given that all other investigations were reported as normal.
Example of explanation to patient
Mrs Johnson, thank you for bringing Sophie’s symptoms to our attention again.
You mentioned that the A&E doctor recently mentioned abdominal migraine as a possible cause, and based on Sophie’s symptoms, the normal results from her tests, and her recent examination, I do agree that this seems like the most likely explanation.
Before we go any further, have you come across this condition before, or had a chance to look into it at all?
(pause and respond appropriately based on her answer)
Abdominal migraine is a condition we sometimes see in children. Although we usually think of migraines as headaches, in this case the pain is felt in the tummy instead. It comes in episodes, often every few weeks, and can be triggered by things like stress, lack of sleep, or certain foods. In Sophie’s case, it sounds like dark chocolate might be one of them.
There are things we can start doing to help manage it. One thing that can really help is keeping a symptom diary, noting when the pain happens, what she’s eaten beforehand, how long it lasts, and whether anything helps. This can help us spot patterns and identify clear triggers. Is this something you are happy to do?
During an episode, giving simple painkillers like paracetamol or ibuprofen is perfectly reasonable
If the episodes start to happen more often, or if they start to affect her school attendance, or if you feel it’s really starting to impact her day-to-day life, then we can look at referring her to a child specialist (paediatrician). They may explore other options such as medications to prevent an episode.
And just to touch on something else you asked. Yes, children with abdominal migraine can sometimes go on to develop typical migraine headaches in their teenage years, especially if there’s a family history, like in your case. But not all children do, and many grow out of it altogether.
I know you were wondering about IBS . This doesn’t sound like IBS, as IBS usually comes with changes in bowel habits like diarrhoea or constipation, and Sophie hasn’t had those symptoms.
Does that all make sense so far?
Management
Management
- There is no need for a face-to-face meeting to assess this child, as the child has already been evaluated for this condition twice, with the most recent assessment occurring just four days ago.
- Advise keeping a symptom diary to help identify potential triggers, monitor the frequency and pattern of episodes, and guide future management.
- Advise avoiding dark chocolate, as this appears to be a possible trigger for her symptoms.
- Recommend paracetamol or ibuprofen during acute episodes to manage pain.
- If episodes become more frequent, start to interfere with school attendance, or significantly affect her day-to-day life, consider referral to a paediatrician for further evaluation and possible preventative treatments.
- Advise the mother to seek urgent medical advice if patient (Sophie) develops new symptoms such as constant or worsening pain, fever, vomiting, weight loss, or if the nature of the pain changes.
- Offer a follow-up review in 4–6 weeks to assess progress, discuss the symptom diary, and adjust the plan if needed.
- Inform the mother that abdominal migraines can sometimes be a sign that a child may be more likely to develop regular migraines later in life, especially with a family history. However, not every child with abdominal migraines will develop them, and some children may grow out of it as they get older.
- Reassure the mother that this is unlikely to be irritable bowel syndrome (IBS), as IBS usually involves ongoing bowel symptoms such as diarrhoea or constipation, which Sophie does not have
Learning point from this station:
Abdominal migraine is a recognised functional gastrointestinal disorder in children, characterised by episodic abdominal pain in the absence of identifiable structural or biochemical abnormalities. It typically presents with generalised abdominal pain, often accompanied by nausea and vomiting but with no headache during the episode. It is more common in children with a personal or family history of migraine. Some children may go on to develop typical migraines later in life, while others experience them separately.
Management of abdominal migraine is broadly similar to that of typical migraine headaches, focusing on trigger avoidance, lifestyle adjustments, and pain relief during episodes. Referral to paediatrics may be considered in more severe or disruptive cases. It is also important to explore the impact on school and wellbeing, and to address parental anxiety through clear explanation and follow-up planning.