Bowel Obstruction


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a Medical Student on the Surgical assessment unit

Patient: 75 year old patient presents with vomiting and abdominal pain

Task:
– Take a focused history from the patient
– After 6 minutes you will be asked a series of questions by the examiner.
– Answer any questions that the patient may have

You’re a 75 year old patient who’s had abdominal pain for the past 2 days, it has been getting worse and nothing really seems to make it better. If asked, the pain had previously been coming and going in waves ‘colicky’ but is now constant.

If specifically asked you have not opened your bowels for the past 7 days, or passed any wind (flatus) either.

Your abdomen is more distended and you feel nauseated. If asked, you have no appetite.

If asked, you’ve noticed some weight loss as your clothes are a lot looser although you have not weighed yourself, so you do not know how much weight you have lost.

In general, you have been more tired recently but you have put this down to old age.

PMH
– Hypertension
– Asthma

DH
– Amlodipine
– Blue inhaler when needed
– Simvastatin

SH
– You do not smoke at the moment. If asked you have smoked 15 a day for 20 years
– You are retired
– You live at home with your wife

FH
– Father died of a heart attack

ICEF
– You do not like all this fuss, you really just want to go home after the pain stops.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school, year or grade
Clarifies who they are talking to
Asks patient for preferred name


History Abdominal pain
Severe central abdominal pain
Started 2 days ago
Previous colicky abdominal pain now constant
No radiation
Explore exacerbating / relieving factors


Associated features
Weight loss
Abdominal distension
Bowels not opened for 2 days, no flatus either
Anaemia symptoms – increased SOB, increased lethargy, facial pallor


PMH Past medical history
Hypertension
Asthma
No previous operations


DH Drug History
Amlodipine, Blue inhaler when needed, Simvastatin
NKDA (No Known Drug Allergy)


SH + FH Social and family history
Social and family history appropriately asked about


ICEF ICEF
Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions


Question What are the most important examinations to perform given the history?
Abdominal examination
PR examination


Question What are your differentials?
Bowel obstruction
Diverticular disease
Constipation
Appendicitis
Volvulus
Other appropriate answer


Question What investigations would you like to do?
FBC
U&E
LFTs
CRP
Amylase
G&S
AXR
CXR
Urine Dip
Blood gas / Lactate


Question
Please interpret the following blood results

Microcytic anemia


Question
Please interpret the following investigation and state your findings

Abdominal radiograph (X-ray)
Distended loops of large bowel
Transition point in descending colon


Question What are the most common causes of large bowel obstruction?
Neoplasia
Strictures (benign / malignant)
Volvulus
Fecal impaction
Pseudo-obstruction


Question What is the most likely cause of this patients bowel obstruction?
Bowel Cancer


Question What is your immediate management plan given the above information
NBM
IV fluid replacement
Analgesia
Catheter - for fluid balance
VTE Prophylaxis



Score