Cases/Infectious Disease and Travel Health

Daughter Worried About Her Mother's Diarrhoea in A Care Home — Free SCA Practice Case

Daughter worried about her mother's diarrhoea in a care home

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•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

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Materials for Candidate

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Patient Profile

Full Name

Philomena Kavanagh

Age

84 years

Consultation Type

Telephone

Situation

Telephone Consultation.

Reason for Encounter

"Mum's had diarrhoea for nearly a week, ever since her antibiotics finished, and I don't think she's right today."

Medical Records

●PMH: Mild vascular dementia. Chronic kidney disease 3a. Constipation. Dyspepsia.
●Medications: Omeprazole 20 mg daily, lactulose, paracetamol, calcium with vitamin D. NKDA.
●Social: Nursing home 14 months. No advance care plan.

Recent Notes

●3 months ago: Creatinine 98 µmol/L, eGFR 49.
●2 weeks ago: Confusion, temperature 38.1. Urine E. coli, trimethoprim resistant. Cefalexin for 7 days.

Patient Script

For the friend playing the patient role

Character Overview: You are Bernadette Quigley, a 57 year old woman ringing about your mother, Philomena Kavanagh, who is 84 and lives at Hazelwood Court Nursing Home. You work three days a week on reception at a vet's practice and live 25 minutes' drive away with your husband Declan. Your grandchildren, Cathal who is 7 and Saoirse who is 4, adore their nana. Today is your day off. You visited this morning, were frightened by what you saw, and rang as soon as the surgery opened. You are practical and polite, you talk a little fast when worried, and your voice wobbles when you talk about hospital or losing her. You do not want to get the home into trouble, but you are privately cross that nobody has called a doctor.

Opening Sentence: "Hello, doctor, it's Bernadette Quigley. I'm ringing about my mum, Philomena Kavanagh, she's at Hazelwood Court. She's had diarrhoea for nearly a week now, since her antibiotics finished, and I went in this morning and she just isn't right."

History if Asked (Data Gathering Phase)

●The diarrhoea: "It started the day after she took her last antibiotic, so six days ago. It's proper water, about five times a day, two or three of them in the night. She can't always get to the toilet in time with her frame, and she's mortified." No blood, but the smell is dreadful. Before this she was constipated, going every other day or so.
●The antibiotic (if asked): "It was for a water infection two weeks ago. She had a temperature and was muddled and her urine smelled strong. It was a capsule twice a day for a week, something beginning with C. She finished it a week ago."
●Drinking and passing urine (if asked): "She's only taking sips, about three cups yesterday, and she wouldn't touch breakfast. She pushed the cup away this morning. The carer says she's only done two small wees today and they were dark."
●How she is compared with normal (if asked): "She was dozing when I got there at ten, and that isn't like her. She knew me, but she was vague and thought it was Sunday. Normally she's sharp as a tack in the mornings."
●Tummy and checks (if asked): "She gets cramps and groans just before she goes. The nurse took her temperature this morning and said 37.3. Nobody's told me her pulse or blood pressure."
●The home (if asked): "Nobody else is poorly, the nurse in charge says, it's only Mum. They moved her into the single room four days ago. It's got its own toilet and sink, a sign on the door, and the staff wear aprons and gloves. I don't think anyone's sent a sample anywhere. The nurse said they'd mention it at the doctor's round on Thursday. I don't think it can wait till Thursday."

Ideas, Concerns, Expectations

Gating note: Bernadette does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her or what she is hoping for, or where the response notes below say so.

●Ideas: She thinks her mum's tummy has reacted to the antibiotics, the way hers did once on holiday. It has gone on much longer, and she wonders if it is "a bug" going round. "I thought it was just the antibiotics upsetting her tummy. But it's gone on so long. Is it a bug?"
●Concerns: Her main fear is that her mum is drying up and going downhill. "She's so tiny. I'm frightened she's going to just fade away." She feels guilty, because she pushed the home to get her mum's urine tested. "It was me who kept on at them to send her water off. If I'd left it she wouldn't have had the tablets." She dreads hospital. Her mum was in for nine days after a fall fourteen months ago, became muddled and frightened, and came out much weaker. "Mum made me promise not to let them put her back in there." She also worries that her mum is shut in her room. "She keeps asking what she's done wrong."
●Expectations: She wants someone to see her mum today and to give her something to stop it. She would rather her mum stayed at the home if that is safe. She wants to know about Saturday. "It's her 85th birthday on Saturday. Twelve of us booked in the lounge at two, with a cake. Can we still do it?"

If Asked: Medical History and Medications

Gating note: Bernadette answers each of these plainly when the doctor asks about it.

●Memory, kidneys and hospital: "She's got mild vascular dementia. She knows all of us, she just loses the day and the date. Her kidneys aren't great. Fourteen months ago she fell, was in hospital nine days, thought the nurses were burglars, and came out weaker. She went into the home after that."
●Her tablets: "She has the omeprazole for her stomach, for years, I couldn't tell you why. Nobody's ever talked about stopping it. She has the sticky laxative twice a day, paracetamol if she's sore, and calcium tablets. No blood thinners, water tablets or anti inflammatories. No allergies."
●Laxative (if asked whether she is still having it): "Yes, the carer gave her the sticky stuff at breakfast today. Should they not?"
●Wishes (if asked what she would want if very ill): "She just says she wants to stay at Hazelwood and she doesn't want to go back into hospital. There's no form that I know of."
●Whether she knows Bernadette is ringing, and power of attorney (if asked): "Yes, I told her, she said 'good girl'. She's never minded me talking to the doctors about her. No, we never got round to power of attorney. I'm just down as next of kin."
●Making her own decisions (if asked): "Most days she decides everything for herself, what she wears, what she fancies for her tea. Today she was too sleepy and vague for me to tell."

Social History and Lifestyle Impact

●Her mum's life: Philomena worked thirty years on the counter at a Post Office and was widowed nine years ago. She walks with a frame and needs help washing and dressing. The carers call her their favourite.
●Bernadette's role: "I go in three times a week and every Sunday. We have a cuppa and I do her hair. This week I've been helping her with her drinks and giving her a cuddle, I haven't worn anything over my clothes."
●Impact on her mum: "She's stuck in her room, she can't go down to the lounge for her morning cuppa, and she asked me 'Have I been bad?' It broke my heart."

If Asked: Associated Symptoms

●Negatives: No vomiting. No blood or black stools. No swollen tummy that the nurse has mentioned. No shaking or chills. No urine infection symptoms. No dizziness, falls, cough, breathlessness or chest pain. No travel, and she eats the same food as everyone else.
●If the doctor asks her to check her mum's pulse, tummy or skin: "I wouldn't know what I was doing and I'm at home today. The nurse in charge is there, I can ring her and ask her to call you back."

Responses to Management (The Negotiation Phase)

●
If the doctor links the diarrhoea to the antibiotics or to a germ in the bowel:
- ●Reaction: Upset. "From the antibiotics? Oh no. It was me who made them send her water off." She softens if she hears that treating the urine infection was right and that this is a recognised risk that cannot be predicted for any one person. "Is it catching? Will it come back?"
●
If the doctor says she needs to be seen today, or suggests hospital:
- ●Reaction: Relieved at being seen. "Oh, thank God. Who's coming? What time?" Waiting for Thursday makes her firm: "That's too far off. Is that safe?" About hospital she is frightened. "She made me promise she wouldn't go back. But if she's got to go she's got to go. Can I go with her?" She accepts it if the doctor explains why and what will help with her dementia, and is honest that it may become the safest place.
●
If the doctor says Bernadette cannot decide for her mother, or hesitates to share details:
- ●Reaction: Surprised. "I thought as her daughter it'd be down to me. So who decides if she can't?" She settles when she hears Philomena will be asked first, and otherwise it will be in her best interests with Bernadette's views counted. If refused information she is hurt. "Mum's happy for me to talk to you. Surely I'm allowed to know what's going on?"
●
If the doctor discusses a stool sample, treatment or changing her medicines:
- ●Reaction: Practical and puzzled. "How do they get a sample, she can't do it on request? Is it a result today?" On an antibiotic: "Another one? Isn't that what caused this?" She accepts once she hears it works in the bowel. On stopping the lactulose: "Won't she get bunged up again?" On omeprazole: "Won't her stomach play up?" On rehydration salts: "She hates anything strange. Would the little yoghurt drinks do?"
●
If the doctor raises infection control, visiting or Saturday:
- ●Reaction: Anxious. "I've been giving her cuddles all week. Should I even be going in? And what about Saturday? Twelve of us, and the children." She is relieved by practical suggestions, such as a short visit in her mum's room or moving the party.
●
If the doctor gives vague safety netting, or talks about how serious it is:
- ●Reaction: Direct. "Worse how? What should the home look out for, and who do they ring?" And: "Is she going to be all right? Could she die from this? She's eighty four." She settles if the doctor is honest about what happens next. If asked what the home has said: "They've been lovely to her, but the nurse said wait until Thursday, and I don't think it can wait. Is that wrong of me?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Philomena is 84, lives in a nursing home, took a cephalosporin for a week, has taken omeprazole for years, and has had six days of watery diarrhoea starting the day after the last dose. Clostridioides difficile infection (CDI) is the diagnosis to exclude. Her daughter is the only voice on the line, so the central judgement is "how unwell is she, and who needs to see her today?", not "what is it?".
●Model plan: recognise probable CDI, arrange a liquid stool sample today, arrange a same day clinician assessment with observations and bloods, stop the lactulose, review omeprazole, avoid loperamide, set up oral rehydration salts with fluid and urine charts, give infection control advice, safety net with named triggers, and name who rings the home and when.
●Acceptable routes to assessment: a same day visit to the home, hospital assessment, or full nurse observations now with a clinician ringing back within hours (bloods within 24 hours and a same day visit for any abnormal observation). The wrong choice is telephone advice and a plan for Thursday's ward round.

Why C. difficile Is the Leading Diagnosis

●Antibiotics, especially cephalosporins, fluoroquinolones, co amoxiclav and clindamycin, are the strongest risk. Others are age over 65, frailty, care home residence and proton pump inhibitor use. She has four of these.
●UKHSA guidance says as a minimum every community patient aged 65 or over with diarrhoea should be tested. About 20% to 30% of antibiotic associated diarrhoea is C. difficile (NICE CKS).
●Keep norovirus and lactulose in mind as causes or contributors. Neither removes the need to test.

Assessing Severity When You Cannot Examine

●NICE NG199 grades severity. Mild: normal white cell count. Moderate: white cell count raised but below 15. Severe: white cell count above 15, creatinine more than 50% above baseline, temperature above 38.5 or signs of severe colitis. Life threatening: hypotension, ileus or toxic megacolon. Stool number is a less reliable guide.
●She has about five stools a day, a temperature of 37.3 and no recorded bloods. Baseline creatinine is 98, so a level above about 147 counts as severe.
●Drowsiness, little urine and sips of fluid in an 84 year old with kidney disease are warning signs of dehydration and acute kidney injury, and drowsiness may be the main sign of sepsis. A registered nurse is on every shift, so ask for temperature, pulse, blood pressure, respiratory rate, oxygen saturation, alertness and urine output. Request full blood count, urea and electrolytes with creatinine, and CRP.

Where Should She Be Managed?

●NG199 recommends hospital referral if people are severely unwell or deteriorating, urgently if life threatening, and consider referral where age, frailty or comorbidity create high risk. NICE CKS says people with severe CDI should be admitted. Whichever route is chosen, a severe result means admission.
●Her wishes matter. She wants to stay at Hazelwood and fears hospital after a delirium last year. If she goes, tell the receiving team about the dementia and let her daughter accompany her where possible. A past wish is something to weigh, not a promise: be honest that hospital may become the safest place.
●No advance care plan exists: suggest a conversation about her preferences once she recovers.

Capacity, Lasting Power of Attorney and Sharing Information

●Next of kin has no legal power to consent to or refuse treatment for another adult. Only an attorney under a registered health and welfare lasting power of attorney, or a court appointed deputy, can. Here there is none, so Bernadette's views, including her promise about hospital, are to be weighed and are not the decision.
●Every adult is presumed to have capacity (Mental Capacity Act 2005). Dementia does not by itself mean she lacks it, and capacity is judged for each decision at the time. Mild vascular dementia with new drowsiness may mean fluctuating capacity, so the clinician who sees her should assess it for any decision about hospital or treatment.
●If she lacks capacity, act in her best interests: her past and present wishes, her values, and the views of her daughter and the home.
●GMC confidentiality guidance (2017): listening to a relative is not a breach, and where a patient lacks capacity it is reasonable to assume she would want those closest to her kept informed. Share what is relevant to care, not the whole record. Philomena knows about the call, so sharing the plan is reasonable. If an attorney or deputy existed, you would have to share relevant information with them.

Stool Testing and Treatment

●Send a sample from a liquid stool today (Bristol type 5 to 7), with the antibiotic, omeprazole and care home residence on the request. A stool culture alongside is reasonable. If she is admitted, hand over the suspicion so a sample is sent on arrival.
●NG199 recommends an oral antibiotic for suspected or confirmed CDI, and in the community consider prompt microbiologist advice first. First line for a first episode of any severity is vancomycin 125 mg orally four times a day for 10 days. Second line if vancomycin is ineffective is fidaxomicin 200 mg twice a day for 10 days, which is also used for relapse within 12 weeks.
●Starting on suspicion is acceptable in a frail patient who is worsening. Waiting for the result is also acceptable if she is stable, provided a named clinician acts on it the same day (CKS). Improvement can take 1 to 2 weeks.
●Metronidazole is no longer first line.

Reviewing Medicines and Hydration

●Hold the lactulose until her bowel habit settles. Omeprazole was started in 2019 for dyspepsia with no ulcer, Barrett's oesophagus or gastroprotection need: stop it, step it down with a plan to stop, or continue only until a dated review, and warn about rebound dyspepsia. The cefalexin has finished. Record suspected CDI so later prescribers avoid high risk antibiotics.
●NG199 says do not offer antimotility medicines such as loperamide. That advice for mild diarrhoea in well adults does not apply once CDI is possible.
●For older adults at risk of dehydration, offer oral rehydration salts in small frequent amounts, such as 200 to 400 mL after each loose stool (CKS), alongside drinks she likes. Keep a fluid and urine chart and a Bristol stool chart. If she cannot drink or passes no urine over a stated number of hours she needs intravenous fluids, which means hospital.

Infection Control and Visiting

●Isolate in a single room with a self contained toilet or dedicated commode until no diarrhoea for at least 48 hours and her usual bowel habit returns. Staff wear gloves and aprons and wash hands with soap and water, because alcohol gel does not kill C. difficile spores. Clean with a sporicidal (chlorine based) product.
●If two or more residents or staff become unwell, the home tells the UKHSA health protection team.
●Visiting should be supported: hand washing with soap and water on entering and leaving, gloves and an apron for personal care, and visits in her own room. A party in the communal lounge is a different risk: postpone it or hold a small gathering in her room.

Safety Netting and Follow Up

●Call 999 or arrange emergency admission for: hard to rouse or much more drowsy or confused, collapse, a very fast pulse or low blood pressure, a swollen or severely painful tummy, repeated vomiting so she cannot keep fluids down, blood in the stool, or temperature above 38.5.
●Ring the practice the same day for: drinking less, very little urine or more diarrhoea.
●Name who acts on the result and who rings the home, with a stated time. Reassess if no improvement by about day 7 of treatment.

Common Mistakes in This Station

●Treating this as simple antibiotic associated diarrhoea with fluids advice and no stool test.
●Planning a sample and a call back with no clinician assessment, observations or bloods today for a drowsy 84 year old passing little urine.
●Missing that lactulose is still being given, or not reviewing omeprazole.
●Suggesting loperamide or prescribing metronidazole.
●Generic "keep her drinking" with no oral rehydration salts, charts or escalation point.
●Relying on alcohol gel, or lifting isolation as the diarrhoea eases.
●Telling the daughter to stay away or ignoring the party.
●Asking Bernadette to consent as an attorney, treating her promise as the decision, assuming dementia means no capacity, or refusing to speak to her on confidentiality grounds.
●Missing the guilt about the urine test, or promising she will never need hospital.
●Criticising the home for waiting.

Mapped to the RCGP curriculum topic: Infectious Disease and Travel Health.

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