Cases/Gastroenterology

2 Months of Diarrhoea and Weight Loss — Free SCA Practice Case

Young man with 2 months of diarrhoea and weight loss

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Jacob Miller

Age

19 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I've had diarrhoea for about two months now and I've lost quite a bit of weight without trying. I'm getting worried something's wrong."

Medical Records

●PMH: Nil significant.
●Medications: None.
●Allergies: NKDA.
●Recent contact: No recent consultations. No recent blood tests on file.

Patient Script

For the friend playing the patient role

Character Overview: You are Jacob, a 19-year-old university student in his first year. You are health-aware and a bit anxious — two months of diarrhoea and losing weight without trying has started to frighten you. You are articulate and cooperative. You are not fixated on a particular diagnosis; you want to know what is wrong and to be taken seriously.

Opening Sentence: "Hi Doctor. For about two months I've had loose, frequent stools — going several times a day — and I've lost about half a stone without trying. I feel a bit run down. I'm starting to worry, so I wanted to get it checked."

History if Asked (Data Gathering Phase)

●The diarrhoea: "Loose, sometimes watery, three or four times a day. It's been pretty constant for a couple of months, not really settling."
●Weight loss: "About half a stone over the two months. I haven't been dieting or trying to lose it — my clothes are looser."
●Blood or mucus: "No blood that I've seen. Maybe a bit of mucus sometimes."
●Night-time symptoms (only if asked): "Yeah, actually — it sometimes wakes me at night to go, which is new for me."
●Diet: "Normal student diet — bread, pasta, cereal, the usual. I've not cut anything out."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Jacob is not sure what is causing it — he has wondered about a lingering stomach bug or stress from starting university, but the weight loss has made him think it might be "something more." "I thought maybe it was a bug or stress from uni, but losing weight like this has made me think it's something more serious."
●Concerns: His main fear, when explored, is bowel cancer — a friend's parent was recently diagnosed and it has stuck with him — and, more immediately, that something is seriously wrong. "I know I'm young, but a friend's mum just got bowel cancer and now I can't stop worrying it could be that."
●Expectations: He wants tests to find out what is going on and a clear plan. "I want to get to the bottom of it — some tests, and to know what happens next."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Past health: "I'm normally fit and well. No bowel problems before this."
●Family history: "My aunt has coeliac disease, I think. No one's had bowel cancer young, and no Crohn's or colitis that I know of."
●Medications: "Nothing regular. No recent antibiotics."
●Travel/infection: "No foreign travel recently. No one else at home has been ill."
●Allergies: "None."

Social History and Lifestyle Impact

Jacob is a first-year university student living in halls.

●University: "First year, living in halls. It's been a big change but I'm enjoying it."
●Diet: "Typical student food, lots of bread and pasta. I've not changed my diet or cut out gluten or anything."
●Smoking/alcohol/drugs: "I don't smoke, drink a bit at weekends, no drugs."
●Impact: "It's affecting my studies — I'm tired, and I'm always needing the loo, which is embarrassing and disruptive."

If Asked — Associated Symptoms and Red-Flag Screen

The patient answers these only when directly asked.

●If asked about nocturnal diarrhoea: "Yes — it does wake me at night sometimes, which it never used to." (Organic red flag.)
●If asked about rectal bleeding: "No visible blood, no."
●If asked about abdominal pain: "Some crampy tummy pain, especially before I go."
●If asked about mouth ulcers, joint pains, eye problems, skin rashes (extra-intestinal IBD): "I have had a few mouth ulcers lately, now you mention it. No joint or eye problems."
●If asked about fever or night sweats: "No fevers, no night sweats."
●If asked about fatigue: "Yes, I've been really tired and run down."
●If asked about appetite: "Appetite's a bit down, but I'm still eating."
●If asked about relationship of symptoms to gluten/specific foods: "I've not noticed a particular food trigger, but I've not tried cutting anything out."
●If asked about dehydration now (dizziness, not passing urine): "No, I'm drinking and passing urine normally, not dizzy."

Responses to Management (The Negotiation Phase)

●If the Doctor arranges coeliac blood tests and advises continuing to eat gluten: "So I should keep eating bread and pasta before the test? I'd have thought cutting it out would help." (The tested point is explaining that gluten must be continued for coeliac serology to be accurate.)
●If the Doctor arranges a stool test for inflammation (faecal calprotectin): "A stool test? What's that looking for?" (The tested point is explaining faecal calprotectin as a marker that helps distinguish inflammatory bowel disease from a non-inflammatory cause.)
●If the Doctor explains it needs proper investigation but is not an emergency today: "So it's not an emergency, but it's not nothing either? How worried should I be?" (The tested point is calibrating urgency honestly — neither dismissive nor alarmist.)
●If the Doctor addresses the cancer fear: "Could it be bowel cancer, even at my age?"
●If the Doctor safety-nets: "What would mean I need to be seen urgently before the results come back?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Chronic Diarrhoea with Weight Loss Is Organic Until Proven Otherwise

●Diarrhoea persisting beyond about 4 weeks is chronic and warrants investigation. Unintentional weight loss and nocturnal diarrhoea are organic red flags that argue strongly against a functional diagnosis such as irritable bowel syndrome.
●In a young adult, the leading diagnoses are coeliac disease and inflammatory bowel disease.

Coeliac Disease — Test Correctly

●Test with anti-tissue-transglutaminase (tTG) IgA antibodies with total IgA (to detect IgA deficiency, which causes false negatives).
●The patient must continue eating gluten (in more than one meal a day for several weeks) before serology and any biopsy — starting a gluten-free diet first invalidates testing.
●A positive result requires specialist referral for confirmatory duodenal biopsy before a lifelong gluten-free diet is started. A family history of coeliac disease raises the prior probability.

Inflammatory Bowel Disease and Faecal Calprotectin

●Faecal calprotectin is a marker of intestinal inflammation used to help distinguish inflammatory bowel disease from non-inflammatory causes (e.g. IBS) in patients without alarm features requiring immediate referral.
●Supportive features of IBD include weight loss, nocturnal symptoms, mucus, fatigue, anaemia, raised inflammatory markers, and extra-intestinal manifestations (mouth ulcers, arthralgia, eye and skin involvement).

Baseline Blood Tests

●Check FBC (anaemia, thrombocytosis), CRP/ESR (inflammation), ferritin, U&E, LFTs, and thyroid function to identify anaemia, inflammation, and nutritional/metabolic contributors.

Distinguishing Organic from Functional Disease

●Features favouring organic disease: weight loss, nocturnal diarrhoea, rectal bleeding, anaemia, raised inflammatory markers, short history, and onset at the extremes of age.
●Functional bowel disease (IBS) is a diagnosis made in the absence of these red flags — which are present here.

Calibrating Urgency and Referral

●A stable patient does not need emergency admission, but chronic diarrhoea with weight loss should be expedited, not left to "wait and see."
●Refer to gastroenterology for suspected IBD (raised calprotectin, supportive features) and via the coeliac pathway for positive serology; escalate urgency if the patient is systemically unwell or deteriorating.

Examination Still Matters

●Even when investigations are arranged, examine the abdomen, document weight/nutritional status, and consider assessment for perianal disease (relevant to Crohn's) — which requires an in-person appointment.

Safety-Netting

●Advise urgent review for significant rectal bleeding, severe abdominal pain, high fever, dehydration, or rapid deterioration, and ensure results are reviewed and acted upon.

Common Candidate Mistakes in This Case

●Dismissing it as stress/IBS: ignoring the weight loss and nocturnal symptoms that mark this as organic.
●Invalidating the coeliac test: advising gluten avoidance, or not warning against it, before serology and biopsy.
●Omitting faecal calprotectin: missing the key test that directs the IBD pathway.
●Poor urgency calibration: either over-reassuring and "watching," or over-escalating a stable patient to emergency care.
●Starting a gluten-free diet on serology alone: not referring for confirmatory biopsy first.

Free MRCGP SCA practice case for GP registrars covering 2 Months of Diarrhoea and Weight Loss — Gastroenterology. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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