Gen Med Station 3

 

Station 3

A nasty episode of diarrhoea

 

Candidate Instructions

Setting:

You are a junior doctor working on the wards. This patient has presented with altered bowel habits.


Name: Steven Smith


Tasks:

1. Take a history from the patient.

2. State which investigations you would like to the examiner.

3. Interpret the investigations provided.

4. Give your preferred diagnosis and management to the examiner.

You are not required to examine the patient.

Simulated Patient Instructions

Briefing

Diagnosis: IBD presenting with a diarrhoea
You are Steven Smith, a 22 year old male.
You have presented to A&E with a 3 week history of tummy pain and diarrhoea.

Opening statement

“I’ve been having crampy tummy pain for the past 6 weeks, I thought it might have been something I ate but it’s been getting worse and worse. Now I've started to have really bad diarrhoea so I thought I should come in.”

Presenting Complaint

Site - generalised abdominal pain
Onset - it came on slowly over the course of a week
Character - it’s crampy pain which comes and goes, there’s always background pain
Radiations - no radiation.
Associated symptoms -
  • I’ve been getting profuse diarrhoea which started at 3-4 times a day but is now 10-15 times a day.
  • If asked, there is now some blood and mucus present in the stool which you are worried about.
  • At home you have had occasional low-grade fevers.
    • Timing - it’s been getting gradually worse since it started
    Exacerbating/relieving factors - you’ve noticed it’s a little worse when you eat lots of fibre. Nothing seems to help.
    Severity - 5/10, up to 7/10 during a wave of cramps.

    Past Medical History

    Previous similar episodes - I’ve had similar episodes of cramps and diarrhoea like this over the last few years. They have always resolved and never been this bad. I’ve never sought medical help.
    Other medical conditions - You went to the doctor last year about red itchy eyes but they just gave you eye drops and it eventually went away. It was during an episode of diarrhoea but you didn’t mention this at the time.
    Previous surgeries - nil

    Drug History

    Prescribed - Nil
    Over the counter - Nil
    Allergies - Nil

    Family History

    Your mother has a problem with her bowels but you’ve never discussed the name of her condition, she is on long term medication for this.

    Social History

    Smoking - quit 3 weeks ago, 2 pack year history (note, smoking is protective in UC)
    Alcohol - Nil
    Job - Plumer
    Normally very fit and well

    Systems Review

    General/red flags - At home you took your temperature and it was occasionally over 38oC.
    Ophthal - You have itchy red eyes which started last week (implying episcleritis/uveitis).
    Weight - You’ve lost 3kg in the last few weeks.
    ENT - No oral ulcers
    GI - As per presenting complaint. NO vomit.
    GU - No change in urinary habits
    MSK - No joint involvement
    Derm - No skin changes (e.g. erythema nodosum)

    Ideas / Concerns / Expectation

    Ideas - “I think it might have been something I ate. ”
    Concerns - “I’m worried there’s a chance it is cancer, because of this weight loss”
    Expectations - “You want to take something to stop the diarrhoea.”

    Discussion / Questions

    Nil

    Patient Results

    Please interpret these results

    Name: Mr Steven Smith

    DoB: 02.02.1999

    Date of Study:

    Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org. From the case rID: 40900



    Blood results

    Hb CRP Amylase Culture
    98 g/L

       (reference 130-180)  
    31 mg/L

       (reference 0-10 mg/L)   
    50

       (reference 30-110 U/L)  
      Negative  


    Endoscopy report

    Endoscopy report
       Continuous mucosal inflammation from the rectum to the descending colon. Spontaneous bleeding of the mucosal membrane. Superficial ulceration of the bowel wall. Pseudopolyps are present. No skip lesions. Histology samples sent.   

    Start the Timer and Begin

    Intro

     

    Presenting complaint

     

    Obtains clear history of presenting complaint, establishing:

    Past Medical History

     

    Drug History

     

    Family History

     

    Social History

     

    Systems Reviews

     

    Ideas, Concerns, Expectations

     

    Examiner Instruction

     

    At this point please direct the candidate to give their initial investigations and review the investigations provided.

    Diagnosis & Interpretation

     

    Management

     

    Some extra details

    There are several other medications used for mild-moderate flares of IBD but as a general rule, severe flares require IV steroids to settle the immediate flare, this is the most important initial therapy. The factors that suggest that this is a severe flare are; temperatures, Hb <105, and CRP >30. The fact that this has been ongoing for months suggests IBD. A similar presentation for only a couple of weeks would likely be put down to infective colitis, time frame is key.

    Truelove-Witt criteria can be used to categorize the severity of UC.

    Crohn’s disease activity index can be used for Crohn's.

    Ultimately A biopsy result is required for the final diagnosis.

    Submit for Scoring

    Tags | GI | Gastroenterology | Diarrhoea | IBD | Crohn's disease | Ulcerative Colitis

    Station Written by: Dr Benjamin Armstrong

    Peer Reviewed by: Dr Rishil Patel

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