Change in Bowel Habit

  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an F1 in general practice

Patient: A 60 year old patient has attended clinic with a change in bowel habit

– 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

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You’re a 60 year old patient who’s attended your GP surgery with a change in bowel habit. You’ve only come because you told your partner and they keep nagging you to see the GP. You think this is all a waste of the doctor’s time as they have much sicker patients to see.

You’ve noticed over the past 3 months that your stools are a lot looser and you’ve been having to use the toilet more frequently. When you are on the toilet you feel like you cannot quite get everything out. If asked, you’ve noticed some blood intermittently mixed in with the stools, although it is not there all the time.

If directly asked you’ve noticed some weight loss of about 3kg over the past 2 months although you’ve not been trying to loose weight. You are more tired than usual too.

No rashes, joint pain or eye symptoms

– Hypertension
– No previous operations

– Amlodipine
– Ramipril

– You smoke about a pack of cigarettes a day and have done so for the past 20 years
– Drink about a bottle of red wine a week

– Your dad had problems with his bowels for many years but you do not know anymore about that because he refused to talk about it

Category Question
Introduction Candidate appropriately introduced themselves with:
Full name
Clarifies who they are talking to
Asks patient for preferred name

Loose stools
Onset of symptoms
Elicits how bowel habit has changed
Establishes toilet frequency of around 4 times per day
No recent change in lifestyle / diet
Elicits that blood is mixed in with stool

Colorectal cancer red flags
Change in bowel habit
PR bleeding
Weight loss
Abdominal pain
Mucus present in stool
Loss of appetite

Associated features
No back pain
IBD symptoms - No rashes, joint pain or eye symptoms
Anemia symptoms – no lethargy, palpitations, shortness of breath
Not recently been unwell

PMH Past Medical History
No previous operations

DH Drug History
Amlodipine, Ramipril

SH Social History
Smoking history
Alcohol history

FH Family History
Established father had bowel problems
Candidate specifically asks about two of the following: colon cancer, polyps, inflammatory bowel disease)

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

Question Given the history you have taken; what examination/s would you like to do?
Abdominal examination
PR examination

Question What are your differentials for this patient?
Colorectal cancer
Diverticular disease
Inflammatory bowel disease
Irritable bowel syndrome
Hemorrhoid disease
Colorectal polyps

Question Given you are in general practice, what is your further management?
Referral for colonoscopy / Colorectal Surgery / Gastroenterology
Urgent / 2 week wait

Question What are the key investigations for this patient?
Bloods - FBC / U&E
Faecal occult blood
Stool Culture
CT scan