‘Bright Red Blood in stool’
Example Question
Open Question
What brings you
in today?
Tell me more about the blood?
Amount?
Would you say the blood is on
the tissue or mixed with the
stool?
How long has this been a
problem?
Is it every time?
Has your bowel habit
changed? Have you had any
constipation?
Do you get any pain in the
bottom? Does it stop you
going?
On the tissue
Mixed in with the
stool
Chronic
Acute
Constipation
Intense anal
pain
Anal
Fissure
Diarrhoea +/vomiting
No Pain
Haemorrhoids
No
Pain
Do you get any pain in the
tummy?
Any weight loss?
Alternating
Weight loss
Cramping
Weight loss
Severe
abdo pain
Unlikely
Gastroenteritis
Have you ever noticed any
mucous in your stool?
When you go does it feel
like you don’t completely
empty or you feel the urge
and nothing comes out?
None
Mucous
IBD
UC>Crohn’s
Tenesmus
Distal cancer
After this:
 After these questions you should have a good idea of the history of
presenting complaint and asked a few high marking question.
 Try and do a real quick summary but if you’re worried about time skip
this and do one at the end
 PMH
o Ask about surgeries?
o Ask about regular GP visits? --> clotting problems/blood
thinners/chronic constipation
o ALLERGIES
 ICE
o As them have they ever had anything like this before
 FH
o Bowel cancer
o IBD or IBS
 SH
o Smoking
o Alcohol
o Suspect food
o Stress
 Systems review
o Use which ever questions work for you
o Include melena – they might wipe more and have caused
haemorrhoids!!
o ask lumps and bumps
o Ask about fever
o Ask about nausea and vomiting
Vingette 1
 Daniel(le) Smith
 DOB: 7/1/62 (age 53)
 PC: Pain when going to the toilet
 HPC:
o Pain has been there for week but it has now unbearable
o It really affects her life as she can’t sit for long
o She hasn’t manage to open her bowels today as it was too painful
o It has started to make her sick with the pain
o S: At her anal opening
o Q: sharp and intense
o I:6/10 normally and 10/10 when trying to go
o T: Last week but worse in last few days
o A: Nothing makes it better. Worse on going.
o S: Blood on tissue
o Not much blood just a couple of drops
o Normally goes every other day but has been constipated over the
last month. Thinks it is due to a change in diet so she can look good
for her son’s wedding.
o Faeces has been small hard balls
o No weight loss/tenesmus/mucous/abdo pain.
o Otherwise fit and well





PMH:
o Sees the GP for HRT – went through the menopause at 51
o No surgeries
o NKDA
ICE
o Thinks it might be a problem with her bowels
o She is concerned she will be unable to go to the toilet
o Expects her GP to give her some laxatives so she can go
SH
o Lives at home alone
o Works as a social worker
o Smokes 5 per day
o Drinks 2-3 glasses of wine over the weekend
o No stress as her divorce was amicable
FH
o None relevant
Systems review
o Nil of note
Mark Scheme
Point Required
Washes hands
Greets Patient
Checks Patient Id with wrist band
Asked how the patient would like to be
called
Starts with open question
Allows patient to talk for up to 2
minutes
Correctly assess pain
Retrieves information of blood on
defecation and follows the cue
 Amount of blood
 Asks whether any blood in stool
Asks about change in bowel habit
Asks red flags: tenesmus/weight loss
Asks past medical history
Asks allergies
Asks ICE
Shows empathy to patient
Assess smoking history
Asks if she has cut down
Asks about alcohol
Asks a comprehensive systems review
including meleana
Thanks patient and washes hands
Was it done
Comments: (include good questions asked)
So this would be a anal fissure (tear) history. A young patient with constipation,
in women you need to assess whether they are sure it is coming from the anus
and not the vagina.
You could ask about trauma to the area. Fissures are common in people who
have experimented with anal sex. Don’t push this point as it can alienate the
patient and examiner, just ask about trauma they will know to mention it if it is a
cue.
Vingette 2
 Leonie Sinclair
 DOB: 20/4/42 (age 73)
 PC: Blood on going for a number 2
 HPC:
o Has noticed blood on doing a number 2 for about 3 months.
o The blood was on the tissue but in the last few times it has also
been in the pan.
o The blood is bright red and watery
o Occasionally there has been a bit of blood on the underwear.
o There has been no pain
o Otherwise feeling good
o Has been constipated since she had painkillers for her back pain
o She normally goes every day but since before Christmas she is
lucky if she goes twice a week.
o When she does go she has found it difficult to pass and has been
waiting on the toilet for about 20 minutes.
o She increased her fibre intake but it didn’t make much of a
difference.
o She’d like to know if ducloease would work.
o No weight loss/tenesmus/mucous/abdo pain.




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PMH:
o Has hypertension and high cholesterol
o Has had a bit of problem with back – has been taking solphadol to
help with the pain.
o C-section when 25
o Allergy to penicillin – headaches
ICE
o Knows it a mass but not sure what type
o Concerned as lost partner to bowel cancer
o Expects GP to have ‘a good look’
SH
o Lives at home alone
o Worked in a shop before retirement
o Never smoked
o Drinks a G&T at Christmas
FH
o Father died of lung cancer
o Mother died from pneumonia
Systems review
o Nil of note
o Occasionally feels dizzy after going to the toilet
Mark Scheme
Point Required
Washes hands
Greets Patient
Checks Patient Id with wrist band
Asked how the patient would like to be
called
Starts with open question
Allows patient to talk for up to 2
minutes
Assesses amount of blood
Follows cue about back pain
Asks about change in bowel habit
Asks red flags:
 Tenesmus
 weight loss
 meleana
Asks past medical history
Asks allergies
Asks ICE
Shows empathy to patient
Assess smoking history
Asks if she has cut down
Asks about alcohol
Asks a comprehensive systems review
Thanks patient and washes hands
Was it done
Comments: (include good questions asked)
Haemarrhoids can present similarly to anal carcinoma. If patient complains of
fullness in anal canal think carcinoma. Have a high index of suspiscion for asking
red flag questions
Vignette 3
 Charlie Christmas
 DOB: 6/5/38 (age 77)
 PC: Problems going to the toilet
 HPC:
o Over the last 4 months, hasn’t had a normal poo.
o Sometimes constipation and then the next time diarrhoea
o Sometimes with the diarrhoea doesn’t make it to the toilet in time.
o No pain although does occasionally feel bloated
o Normally bowels used to open every evening but they have slowly
become very irregular and varied in consistency.
o If asked about blood: bright red blood is found mixed in with stool.
It was occasional at first but now it is more often. Only seen when
constipated.
o If asked about weight loss: had to tighten clothing recently but is
pleased about it as hasn’t been trying to loose weight.
o If asked about tenesmus: recently has felt like the bowels haven’t
been being completely emptied and has sat longer on the toilet to
be sure.
o No mucous in the stool
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



PMH:
o Has hypertension and high cholesterol treated with simvastatin
and verapamil – doesn’t regularly attend check ups as doesn’t like
doctors
o No surgeries
o Allergy to strawberries
ICE
o Thinks it could be old age
o Concerned as father and brother died of bowel cancer
o Expects GP to send him to UHCW
SH
o Lives at home with wife
o Worked in a engineering before retirement
o Smokes 20 a day having cut down from 40
o Drinks a brandy before bed every night
FH
o Father (87) and brother (76) died of bowel cancer
o Mother died in her sleep at 89
Systems review
o Recently has a feeling of nausea
Mark Scheme
Point Required
Washes hands
Greets Patient
Checks Patient Id with wrist band
Asked how the patient would like to be
called
Starts with open question
Allows patient to talk for up to 2
minutes
Assesses amount of blood
Follows red flag cues
Asks red flags:
 Tenesmus
 weight loss (tried to quantify)
 meleana
Asks about change in bowel habit
Asks past medical history
Asks allergies
Asks ICE
Shows empathy to patient
Assess smoking history
Asks if she has cut down
Asks about alcohol
Asks a comprehensive systems review
Thanks patient and washes hands
Was it done
Comments: (include good questions asked)
If you ask all the red flags cancer should be pretty obvious in an osce. Learning
how to word some of the red flag questions so patients understand is key.
Vignette 4
 Maggie/Mark Royce
 DOB: 6/3/91 (age 24)
 PC: Terrible diarrheoa
 HPC:
o Over the last 3 months, has had multiple episodes of diarrhoea a
day. If asked to quantify: up to 6
o Has felt like he isn’t getting enough time to absorb food and has
noticed he has lost a significant amount of weight.
o It has been particularly bad in the last week in the lead up to
exams.
o He has been feeling very tired.
o Before this was very fit and healthy
o If asked about blood: bright red blood is found in the stool and the
worry of this has prompted today’s visit.
o Poo can be very mucosy
o Has had a few episodes of colicky abdominal pain which have
been followed by a bad bout of diarrhoea
o No tenesmus





PMH:
o
o
o
ICE
o
o
o
SH
o
o
o
o
FH
o
o
Normally fit and well
Appendix removed at 14
NKDA
Thinks it could be an infection- was in Kenya a few months ago
Concerned as it has been going on along time
Expects GP to ask for a sample
Lives at home with mum and dad
Doing an internship at a bank
Heard smoking might help chronic diarrhoea so smokes 5 a day
Drinks 5-6 pints a night on Friday and Saturday.
Mum and dad are alive - mum has IBD
Grandmother had a similar problem but she died at 50 from a
heart attack.
Systems review
o Been a little dizzy
o Has been getting more short of breath
Mark Scheme
Point Required
Washes hands
Greets Patient
Checks Patient Id with wrist band
Asked how the patient would like to be
called
Starts with open question
Allows patient to talk for up to 2
minutes
Assesses diarrhoea
 Amount
 Timing
 Triggers
 Recent travel/food
 Pain
 Blood
Follows red flag cues
Assess for anaemia
Asks about normal bowel
Asks past medical history
Asks allergies
Asks ICE
Shows empathy to patient
Assess smoking history
Asks if she has cut down
Asks about alcohol
Asks a comprehensive systems review
Thanks patient and washes hands
Was it done
Comments: (include good questions asked)
Diarrhoea is a common osce history. Make sure to ask about other GI red flags
and also check for travel and suspect food.