Bleeding Per rectum
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Stem (Candidate Instructions)
You are a surgical trainee in the outpatient clinic.
Your next patient is John Smith, a 60-year-old man who has been referred by his GP with bleeding per rectum and unintentional weight loss.Take a focused history from the patient
You do not need to perform an examination
At the end, summarise your findings and outline your initial concerns to the examiner
You have 6 minutes.Role Player (Patient Script)
60-year-old male
3-month history of intermittent rectal bleeding
Blood is dark red, mixed with stool, sometimes on paper
Associated change in bowel habit → looser stools, increased frequency
Unintentional weight loss (~6–8 kg over 3 months)
Occasional abdominal discomfort, no severe pain
No PR bleeding previously
If asked:
No melaena
No haematemesis
Some fatigue
No known haemorrhoids
No inflammatory bowel disease history
PMH: Hypertension
Drugs: Amlodipine
FH: Father had bowel cancer at 70
SH: Ex-smoker, moderate alcohol16-Mark Scheme (Examiner Checklist)
- Introduction & Communication (2 marks)
Introduces self, confirms patient identity, gains consent
Open questioning style, allows patient to describe symptoms - Presenting Complaint Exploration (4 marks)
Bleeding history:
Onset and duration
Colour (fresh vs dark), relation to stool
Quantity/frequency
Mixed vs separate from stool
Red flag features:
Change in bowel habit
Weight loss
Tenesmus or urgency - Associated Symptoms (3 marks)
Abdominal pain or discomfort
Symptoms of anaemia (fatigue, dizziness)
Melaena / upper GI symptoms
Mucus in stool / features suggestive of IBD - Bowel History (2 marks)
Baseline bowel habit vs current
Stool consistency (loose, hard, alternating)
Frequency and urgency - Past Medical & Drug History (2 marks)
GI conditions (polyps, IBD, haemorrhoids)
Medication review (anticoagulants, antiplatelets, NSAIDs) - Family History (1 mark)
Colorectal cancer or polyps - Social History (1 mark)
Smoking and alcohol
Functional impact / performance status - Ideas, Concerns, Expectations (ICE) (1 mark)
Elicits patient concern (e.g., cancer worry)
Examiner questions
DifferentialsMalignancy
HemorrhoidsManagement
Blood, examination.
High suspicion of colorectal malignancy
Needs urgent investigation (e.g., 2-week wait referral, colonoscopy) - Introduction & Communication (2 marks)
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