Gerry Attrix
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You are the FY1 on the acute medical ward at your local hospital. Gerry Attrix is a 41 year old gentleman who has been admitted to the ward with abdominal pain and diarrhoea. This is the second time that this kind of thing has happened. He has not had any previous medical problems.
Please take a history from Gerry, perform the relevant examination and identify the cause of his symptoms. Ensure that you assess the severity of his presenting complaint and consider an appropriate management plan for discussion.
You are Gerry Attrix, a 41 year old phlebotomist at the local hospital. It has been quite a distressing few days, culminating in you having to be admitted to hospital for your symptoms. You feel it’s all the more embarrassing that you’ve been treated by work colleagues!
HPC: You first noticed your symptoms one week ago, when you developed diarrhoea. At first it was clear and smelly, however soon you noticed blood staining the pan and the stool. There was not a lot of blood: about a teacup-full. Every time you opened your bowels, this was accompanied by a crampy tummy pain which shot to both your flanks. The pain was worst around 3 days ago, but now it has largely settled. What is most distressing is that you are opening your bowels more and more often. Normally you go only once every couple of days, but things have been getting out of control! You’ve even been getting up in the middle of the night to run to the toilet. You haven’t had any accidents, thankfully, but it is still extremely disruptive. You’ve obviously needed to take the week off work due to this. Yesterday you opened your bowels 20 times! It’s not just toilet symptoms that you’ve been experiencing. You’ve felt exhausted for about a month. Originally you had put this down to the short-staffing situation at work, however the tiredness has just got worse and worse, despite making extra effort to get more sleep. You haven’t had any problems with vomiting. You have also not experienced any chest pain or urine problems. You have, however, noticed that your phlebotomy uniform has been getting baggier – you’ve had to order a new one! You’re not sure if this is down to you losing weight – you haven’t been trying to do so – or if it’s your boss buying uniforms on the cheap again! You also haven’t noticed any rashes, bruising or vision changes.
ICE: You have no idea what is going on. Originally you had traced back your eating habits, since you felt it could be food poisoning. But you haven’t eaten anything out of the ordinary, and none of the other staff have been sick after eating the hospital food! Your aunt has a wheat intolerance, and your partner felt you could have inherited this: but you had this checked out at the GP last year and he told you that was negative. Going forward, you’re obviously quite concerned as to how you’re coping with this illness. Your job is your life and being unable to do is really upsets you. You also feel like you’re letting the already short-staffed side down when you can’t come to work. Furthermore the embarrassment of this illness is definitely affecting your dignity: you’re quite proud of the way you look and running to the toilet has completely ruined your pride and how you hold yourself. You just feel rubbish.
PMH: You haven’t had any medical problems in the past. This kind of episode has happened once before, six months ago. You were about to go into hospital for the illness, but it went away by itself. There was no blood on that occasion, it was simply diarrhoea and tiredness.
DH: You don’t take any regular medication. You take multivitamins in the morning as your mum used to always bang on about how they prevent any illness!
FH: Your aunt has wheat intolerance, and your mum has rheumatoid arthritis. Your dad had type 1 diabetes.
SH: You live with your partner in the city, and your job is your life. You go to occasional work nights out, and had one due last night. That you couldn’t make this party was the last straw: you just had to do something about this. You don’t smoke and you don’t drink alcohol.
The student should take a thorough history of Gerry’s condition, and should be able to elicit the impact that it has had on his life. A good history will assess the severity of this patient’s flare of symptoms.
An abdominal examination would be appropriate.
Differential Diagnosis: My differential diagnosis would include an abdominal cause: primarily inflammatory bowel disease, such as Crohn’s Disease or Ulcerative Colitis. This patient does not describe symptoms which would indicate widespread involvement of the GI tract, such as mouth ulceration, therefore I would be more suspicious of a colitis-type picture. Further differentials of such abdominal symptoms may include coeliac disease and gastroenteritis, whilst it would be important to rule out malignancy.
Discussion questions:
- What are the types of inflammatory bowel disease? What are the main differences between them?
- What appropriate investigations would you consider for this patient?
- How would you assess the severity of the flare of a patient with inflammatory bowel disease?
- What are the management options for IBD? Is there any difference between the management of ulcerative colitis and Crohn’s disease?
- Which healthcare professionals could be involved in Gerry’s care?
- Please name some of the extra-gastrointestinal manifestations of IBD.
