1. PR Bleeding
Stem: You are asked to see a pt. referred by her GP with the following letter-
~Mrs. Julia Marrie, DOB- 18/06/1947 Unit No. 234567 XXXXXXX
Kindly see this 73 year old lady who complains of about 3-month history of intermittent PR bleeding. She has no other symptoms. She has past medical history of MI & AF. The blood report (FBC) has been sent. Please give your expert opinion about diagnosis & further management. Thank you.
—Please take a history from the patient.
(Structural approach for taking history)
- Demographics: Name, Age/DOB
- Ask open Qs : e.g. Your GP has written describing you have problem about bleeding. Can you tell me about that?
- Ask about bleeding:
—Frequency: how many times do you see the bleeding? e.g. everyday, twice or thrice a week, once a week; or with every passing stool etc.
—Amount: How much will be the amount of blood?
—Colour: What is the colour of the blood- fresh with red, dark red, black, pitch black etc.
—Where do you see the blood? like over the pan, on toilet paper, coating the stool or mixed etc.
- Ask about associated features:
—Is there any pain or irritation at the lower passage?
—Ask about tenesmus
—Is there any abdominal pain/bloating/colic?
— Is the mucus/slime present in the stool?
—Have you noticed any change in your bowel habits? like in frequency or consistency?
—Has your appetite decreased recently?
—Wt. Loss: Have you lost some weight in past few weeks or months?
- Past Medical & Drug History:
—history of taking anti-coagulants e.g. Warfarin etc
- Social history & Family history:
—Smoking/Alcohol: Do you smoke? How many/much in a day? & What about drinking alcohol? How much amount do you take in a week?
—Living situation: Do you live with your husband/wife & your children?
—Exercise: How much exercise do you do everyday?
—Ask about any similar problem in the family- ( brothers/sisters/father/mother).
- Repeat to the patient what she/he has told so far & ask if she/he wants to add anything. Explain her/him that she/he can tell in the next visit if anything comes in the mind, & it will be better if she can write it on a paper.
Thank the patient & summarize the history to the examiner.
- Questions asked by the examiner:
—What is the most probable diagnosis? (The diagnosis in the 73 year lady on Warfarin, with a 2-month history of intermittent PR bleeding is the most likely to be Haemorrhoidal bleeding).
—What is the differential diagnosis?
(D/D: Carcinoma, Diverticular disease, Adenomatous polyps, Angiodysplasia, Ischaemic colitis, Inflammatory bowel disease etc.)
- Other Example:
~ 58 year lady with 6 months history of PR bleeding, blood mixed with stool, associated dull abdominal pain; no other type b symptoms- weight lost, appetite change etc,; strong family history (brother has colorectal ca)
- Investigation: Blood test, Colonoscopy with biopsy