Student Instructions
You are a junior doctor working in general practice.
Mr James O'Leary is a young man who has come to see you in clinic today with his mum as he has been having diarrhoea, he looks rather embarrassed to have her in the room with him.
Please take a history from the patient and formulate a differential diagnosis and management plan.
After 7 minutes the examiner will stop you to ask you some questions.
Patient Instructions
Name: Mr James O’Leary
Age: 18 years old
Job: In school
PC
You have come to the GP practise with your mother as you have been having diarrhoea for the past few weeks. You are very embarrassed talking about this, but your mother has said you have to see the doctor, so she has brought you in today.
It started while you are on holiday with your friends in Ibiza three weeks ago to celebrate your graduation from school. You were in Ibiza for one week and the diarrhoea started two days before your return to the UK. You are passing stool up to six times a day for the first few days but now are passing stool three times a day. There was bright red blood mixed with the stool as well as thick clear mucus. You also notice you frequently get crampy lower abdominal pain often before you pass stool. You have to go to the toilet immediately if you feel you need to pass stool and only if the doctor directly questions you, do you report that you have been incontinent on two occasions - once in Ibiza and once last week. You have not been out much since returning from Ibiza as you are worried that you might suddenly need the toilet and have an accident.
This initially scared you, but you really didn't want to cause a fuss with all of your friends around, so you didn't seek help abroad. You had not eaten anything different to the rest of your mates so you just thought that perhaps all the alcohol you were drinking was taking its toll on your body and this episode would pause when you got back to the UK, but it doesn't. You have not felt nauseous feverish or been vomiting at all. You have not lost any weight and your appetite is not greatly changed. You have not had any mouth ulcers or problems with your eyes and deny any skin lesions on any part of your body.
PMH
You have had lower back pain for the past six months which you assume is due to a football related injury though you cannot recall any injury specifically. You play foot football for your school. You are seeing a physiotherapist for this. The pain is worse in the mornings and usually goes away by lunchtime and when you are up and about moving a little more. A hot water bottle or heat pack on the back also tends to make the pain much less although paracetamol doesn't do anything.
DH
NKDA
You occasionally take some ibuprofen when the back pain is bad.
SH
You do not smoke and only drink when you are with your friends. Although you only drink in moderation usually whilst in Ibiza you did drink much larger quantities of alcohol than usual. You can't recall how much but you are pretty sure it was over the recommended limit. (You find this very difficult to admit with your mother in the room so if asked about alcohol you will try to avoid telling the doctor the amount you drank in Ibiza unless questioned directly.) you do not take any other recreational drugs. You live at home with your parents but will be moving away to University in a few months to study law.
FH
Your grandfather died of colon cancer at the age of 87 years old.
ICE
You are worried about how this is affecting your life and want some medication to make the symptoms go away. You really do not want to be stuck indoors or have this hold you back from making new friends at University during freshers week.
Questions
What is the likely diagnosis?
Ulcerative colitis
What are your differential diagnoses?
Crohn’s Disease
Infectious colitis
What investigations would you do?
Routine blood tests: FBC, U&E, LFTs, CRP, blood cultures.
Stool microscopy and culture to rule out an infective cause.
Urine microscopy, sensitivities and cultures with dipstick test to rule out concomitant urinary tract infection.
What would you do next?
Referral to gastroenterology outpatient clinic as well as for sigmoidoscopy/colonoscopy and biopsy for histological diagnosis.