MRCS-B: History taking

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)

  1. Demographics: Name, Age/DOB
  2. Ask open Qs : e.g. Your GP has written describing you have problem about bleeding. Can you tell me about that?
  3. 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.
  4. 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?
  5. Past Medical & Drug History:
    —history of taking anti-coagulants e.g. Warfarin etc
  6. 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).
  7. 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.
  8. 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.)
  9. 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)
  10. Investigation: Blood test, Colonoscopy with biopsy