Tom Bosis
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This is Tom Bosis, a 37yr old man, who recently presented to A&E with abdominal pain. He has a history of Crohn’s disease and his medications include:
• Azathioprine 120mg OD • AdCal D3 2 tablets BD • Alendronic acid 70mg once weekly
Please take a focussed history of his presenting complaint at the time of admission, and perform a relevant examination.
You are Tom Bosis. You are 37yrs old and came to A&E with worsening abdo pain several weeks ago. You had an operation in that admission, but the student will ask you for details of what happened when you were admitted. You have a stoma, but this was fitted DURING the last admission and was not present when you were first admitted. Do not mention it unless asked directly.
HPC: The pain has been going on for 2 days. It started gradually but by the next day it was quite sever. You’re used to getting abdo pain with your Crohn’s disease but you are feeling really unwell now. The pain is around the middle, and is like someone is stabbing you. You aren’t able to point to where exactly the pain is. It is worse on moving, but doesn’t spread anywhere else. When moving it is 9/10, but if you lie still it is 6-7/10. Eating makes the pain worse.
You haven’t opened your bowels for 2 days, and the last time you did it was very loose. If asked directly, you have passed gas either for over a day now. There was no blood or mucus. There are no urinary symptoms, and you are passing small amounts of dark urine. You are feeling very nauseous and have been sick several times. You haven’t eaten anything for over a day and are managing small sips of water only. The vomit is mostly just clear fluid now, there is no blood. You feel clammy, and are just exhausted. You haven’t noticed if your stomach looks particularly swollen.
ICE: You think this is probably a bad flare of your Crohn’s although you haven’t had a lot of diarrhoea which you usually do. Someone in your Crohn’s support group developed a fistula and you are worried about that as you really don’t want to end up with a bag.
PMH: You have had Crohn’s for the last 15yrs. Over the last few years you have had quite of lot of hospital admissions because of it - most recently a few months ago to drain an abscess that had developed. You had your meds changed after that, and it seems to have helped. Other than that you are ‘fit and well’ although honestly you don’t feel like that much. Apart from the abscess drainage, you’ve had no other surgeries.
SH: You live with your partner Jack and your four parrots. You don’t smoke or drink and try really hard to eat a good diet, although you struggle because of the Crohn’s sometimes. You are independent and have a good support network through various charities and support groups. Drugs and allergies: You take medication to protect your bones, and azathioprine for the Crohn’s.
FH: There is a family history of autoimmune conditions, particularly thyroid problems and rheumatoid arthritis on your Mum’s side of the family. As far as you know you’re the first one with Crohn’s.
The challenge here is to think of differentials that are unrelated to the Crohn’s disease. The good candidate will ensure they ask about urinary symptoms, reflux or gallbladder symptoms. However, they will also get a good idea of the severity of the patients chronic disease. A poor candidate may focus exclusively on this presenting complaint, or focus entirely on the Crohn’s.
An abdominal examination is the most suitable examination. Students would struggle to justify another examination. On examination there will be a (healthy) ileostomy bag, and scars from previous laparoscopic surgery. The examination is otherwise normal.
A good differential may sound like:
“My top differential would be an intestinal stricture, due to the history of Crohns with recent surgery. The pain and vomiting associated with total constipation would support this. However I would also consider a recurrence of the abscess and appendicitis”
Other questions to consider asking include:
• How would you investigate this patient? • How would you manage this patient? • How can you tell if a stoma is healthy? • Tell me about the different type of stoma • This patient has bowel obstruction. What are the risk factors for bowel obstruction in the patient? • What are the different types of bowel obstruction, and how may the present differently? • What post-operative complications might occur in this patient?
