Abdominal pain history: CBL Block 1 Case 2
Name: Ben Brown
Date of birth: 19/01/1985
Age: 29
History of presenting complaint
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Diarrhoea
o First noticed looser stools approximately 5-6 weeks ago
o Symptoms got worse a couple of weeks ago: since then, opening
his bowels 3-4 times in the day and 1-2 times during the night
o Has opened his bowels ~ 5 times in the last 24 hours
o Usual bowel habit: opening his bowels once every two days
Most stools in the last week were bloody with mucus. Prior to that he had
not noticed any blood
No blood in the pan or on wiping
No faecal incontinence
Has not noticed any fatty white stool
From time to time feels like he hasn’t completely emptied his bowels
Sometimes he needs to go to the toilet urgently
‘Crampy’ stomach pain
o Intermittent
o Around his navel and on the left side of his lower abdomen
No vomiting
Hasn’t noticed a fever/feeling hot
Has been feeling very tired recently
Has had a loss of appetite, but hasn’t noted any weight loss
Drinking and passing urine regularly. Not thirsty. No episodes of collapse
or dizziness
No foreign travel
Hasn’t come into contact with anyone with similar symptoms
No obvious food source for the symptoms
Has had a kind of rash on both his shins
o Thought they might be bites but cannot remember being bitten
o They are larger than any bite he has had in the past
o They are painful, but not itchy
Past medical history
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Usually fit and well
Fractured clavicle age 18
No history of anxiety/depression/other psychiatric disorders
Medication
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No medication prescribed
No recent abx
Over the counter: has been taking Imodium for his diarrhoea for the last
week
No known allergies
Family medical history
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Both parents alive and well
No family history of bowel disease
Social history
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Lives with wife and son (aged 8 months) in a one-bedroom flat
Primary school teacher
o The school he works at has just been placed under special
measures, so he has been under a lot of stress
Doesn’t smoke
Drinks one can of lager a night
His wife is very concerned – she made the appointment for him and has
accompanied him to the GP surgery.
Systems Review
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CVS: no palpitations, no sweating/clamminess.
CNS: no headaches, no jitteriness, no fits/faints/falls.
MSK: no joint pain or swelling, no back pain.
No ocular pain, no problems with vision, no photophobia, no redness
noted in the eyes.
ICE
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Ideas: thinks the diarrhoea is due to stress.
Concerns: he is concerned that the problem has got worse and wonders if
he has a ‘bad infection’.
Expectations: he is expecting to be reassured and have some tests.
GI RED FLAGS!
1) Unintentional weight loss
2) Change in appetite
3) Change in bowel habit
4) Tenismus (feeling they haven’t finished going)
5) Blood in stool
6) TRAVEL
Also must ask about diarrhoea AND constipation