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You are an F1 on an A&E rotation. Your first patient of the day is Mr Umnenemma, you from the triage you seen has presented with diarrhoea and rectal bleeding. From his observations you see he is pyrexial (37.9), and tachycardic.

Please take a history from Mr Umnenemma, and perform an appropriate examination. You will then be asked to discuss the case with the examiner.

You are Barry Umnenemma. You are 59 year old building contractor. Your health isn’t something that really worries you, you rarely see the doctor and think youre a pretty fit guy. This problem has really got you a bit concerned, you’re trying to be light hearted about it and brush it off, but deep down you’re genuinely a bit scared – what if its cancer? For a normally happy-go-lucky guy this has really rattled you.

HPC You’ve been feeling under the weather for the past 3 days, with what you thought was a stomach bug. But then this morning when you went to the loo, you noticed a lot of blood coming out of your bum. It really scared you! It looked like something from a horror movie. It wasn’t particularly painful, you just felt like you needed the loo, again, but when you went instead of poo coming out, it was this bright red blood. If asked directly – it wasn’t black or sticky, or mixed in with the stool. You didn’t notice any mucous either. This has never happened before, and you really hope it doesn’t again! For the last few days you haven’t been feeling very well. You’ve had the shits, sorry doc, you’ve had diarrhoea and some pain in your stomach. You’ve probably been opening your bowels about 5 or 6 times a day. Its been much looser as well. It was gradually getting worse, and yesterday you felt hot and cold as if you had a fever. You haven’t been eating much, which is really unusual as you can probably tell doc, haha. You didn’t want to eat because you then had to go to the loo, but you were also just feeling really sickly, although you weren’t actually sick. The pain started around the same time as the diarrhoea did, and has gradually just got worse. Its more on the left side, low down. It hasn’t spread anywhere else. Its worse after you eat, when you have to go to the loo. You’ve taken some Paracetamol which has taken the edge off a bit. You’ve got a pretty high pain threshold so it hasn’t really bothered you much, unlike that bleeding did. If asked directly – you haven’t been away on holiday recently, or left the country and you haven’t eaten anything unusual or dodgy.

ICE At first you just thought it was a stomach bug, and were waiting for it to just settle down on its own. But then with all this bleeding, you’re not really sure what to think anymore. If you’re honest, doc, it has got you very worried. Is there any chance it could be cancer? You think you need to have a scan or something to see what’s going on.

PMH Normally a very fit guy! You know you’re a bit overweight, but your job keeps you pretty active and you often go walking with the dog anyway. Never had anything like this before, or any problems with your bowels. You’ve had your appendix out as a teenager, and had a broken collar bone before but apart from that, nothing really.

SH Live with your wife and two daughters. You work as a building contractor, and have done for the past twenty years. Your whole family is normally fit and well. You do smoke, not in the house – only at work, and probably have about 10 a day. A long time ago you used to smoke a lot heavier, but really cut down when your first daughter was born 17 years ago.

FH Your dad died last year from a heart attack, he was 82 though and had problems with it for the last couple of years, so it wasn’t unexpected really. Your mum is fit and well, although her memory has started to go now she’s lost dad. Your sister has had a lot of problems with her bowels over the years, and she has to see a specialist for it. If prompted - you think she’s said its called Crohn’s, but she lives the other side of the country so you don’t see her much.

Drugs and allergies Apart from the Paracetamol, you haven’t had anything. Nothing regular from your doctor. You’re allergic to morphine, it made you really spaced out and sick whenever you’ve had it.

The student should take a fluent history of this gentleman’s presenting complaint. They should perform an abdominal examination, and should mention that they would like to perform a PR examination.

Diverticulitis should be included in their differentials. Bowel cancer or IBD are not unreasonable to mention, especially given the FH, but would often have a more chronic presentation.

Topic for discussion might include: • Initial investigation and management of this gentleman • Definitions of diverticulosis/diverticular disease/diverticulitis • Risk factors for diverticular disease, and those present in the patient • Whether you should do a colonoscopy in this gentleman • Red flags for bowel cancer, and those present in this patient • Complications of diverticulitis • Common causes of PR bleeding, and what helps distinguish between them