Cases/Infectious Disease and Travel Health

Diarrhoea After A Hospital Stay — Free SCA Practice Case

Older woman with diarrhoea after a hospital stay

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

Sheila Dawson

Age

72 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The community nurse visited today for post-discharge bloods and advised the patient to speak to the GP about her diarrhoea.

Reason for Encounter

"Doctor, I've had diarrhoea for about five days now. The nurse who came to take my blood today said I should talk to you about it."

Medical Records

●PMH: Hypertension. Type 2 diabetes.
●Medications: Amlodipine 10 mg OD, ramipril 5 mg OD, metformin 1 g BD.
●Allergies: NKDA.
●Hospital discharge summary (1 week ago): Admitted with community-acquired pneumonia; treated with IV antibiotics and fluids, discharged on oral co-amoxiclav 625 mg TDS to complete a 5-day course. Developed acute kidney injury (AKI stage 2) on admission (creatinine 210 µmol/L, eGFR 40, K⁺ 5.4); metformin and ramipril were withheld in hospital. Hospital-at-Home to repeat renal bloods one week post-discharge; GP asked to review results and restart metformin/ramipril once renal function recovers.

Patient Script

For the friend playing the patient role

Character Overview: You are Sheila, a 72-year-old retired seamstress. You are stoical and a little embarrassed about "bothering" the doctor. You are convinced the diarrhoea is from an expired chicken wrap you ate the day you got home. You restarted your own tablets at home because no one explained why they had been stopped and you felt better. You are cooperative and will accept advice.

Opening Sentence: "Hello, Doctor. I've had this diarrhoea for five or six days now. The nurse came to do my blood today and said I ought to ring you about it. I think it was an out-of-date chicken wrap I had the day I got home from hospital, to be honest."

History if Asked (Data Gathering Phase)

●The diarrhoea: "Loose and watery, about four or five times a day. It started the day after I got home from hospital. There's no blood or mucus that I've seen. I get crampy tummy pains with it."
●The chicken wrap: "I had a chicken wrap the day I got home — turned out it was past its date, I only noticed after. The diarrhoea started the next day, so I've blamed that."
●Hospital stay: "I was in for a chest infection — pneumonia. They gave me antibiotics through a drip, then sent me home with more tablets to finish."
●Tablets (only if asked): "The hospital stopped my metformin and my ramipril while I was in, but didn't say why. Once I felt better at home, I started taking them again myself — I assumed that was fine."
●Fluids: "I'm managing to drink, though I'm a bit off my food."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Sheila is sure it is food poisoning from the chicken wrap and has not connected it to her recent hospital stay or antibiotics. "In my mind it's that chicken wrap, plain and simple. I hadn't linked it to the hospital or the antibiotics at all."
●Concerns: She is worried about being caught short and has stopped going out; she is also fed up and drained. When it is raised, she is a little alarmed at the idea of an infection from the antibiotics. "I've stopped going out — I daren't be far from a toilet. And now you mention an infection from the antibiotics, that does worry me."
●Expectations: She wants an explanation and something to settle it — she is hoping she can take the loperamide she has at home. "I'd like to know what's going on, and can I take the loperamide I've got in the cupboard to stop it?"

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Antibiotic course: "I finished the antibiotic tablets they sent me home with."
●Medications restarted: "I restarted the metformin and ramipril myself, yes, once I felt better."
●Other medicines: "Just those and the amlodipine, which I kept taking throughout."
●Contacts unwell / travel: "No one else at home is ill. No travel — I've been in hospital and then at home."
●Previous bowel problems: "No, my bowels are normally fine."

Social History and Lifestyle Impact

Sheila is a retired seamstress. She lives with her husband.

●Home: "I live with my husband. He's well, no diarrhoea."
●Diet/fluids: "Off my food a bit, but drinking tea and water."
●Smoking/alcohol: "Never smoked, don't drink."
●Impact: "I've stopped seeing friends and going to my group — I'm worried about needing the loo urgently. It's getting me down."

If Asked — Red-Flag and Dehydration Screen

The patient answers these only when directly asked.

●If asked about blood or mucus in the stool: "No blood, no mucus."
●If asked about fever: "No fever that I've noticed."
●If asked about dizziness, light-headedness, palpitations: "No, I don't feel faint or dizzy, my heart feels steady."
●If asked about passing urine / reduced output: "I'm still passing water, maybe a bit less than usual."
●If asked about ability to keep fluids down: "Yes, I can keep fluids down — it's the diarrhoea, not vomiting."
●If asked about severe abdominal pain or distension: "Just crampy pains, nothing severe, no swelling."
●If asked about weight loss / cancer red flags: "No weight loss, no lumps that I know of."

Responses to Management (The Negotiation Phase)

●If the Doctor explains C. difficile is a likely cause rather than the chicken wrap: "The antibiotics caused it? But surely it was the out-of-date wrap?" (The tested point is explaining that, given recent hospital admission and broad-spectrum antibiotics, C. difficile is an important differential, without dismissing the food-poisoning idea.)
●If the Doctor advises against loperamide: "Why can't I take the loperamide? I just want it to stop." (The tested point is explaining why anti-motility agents are avoided when C. difficile is suspected.)
●If the Doctor advises stopping metformin and ramipril: "Stop them again? And what about the amlodipine — should I stop that too?" (The tested point is applying sick-day rules for the AKI-risk drugs while continuing amlodipine unless she becomes dehydrated.)
●If the Doctor asks her to provide a stool sample: "A sample? How do I do that, and where do I take it?"
●If the Doctor gives infection-control advice: "Do I need to keep away from my husband and friends?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Post-Antibiotic, Post-Hospital Diarrhoea — Think C. difficile

●New diarrhoea after recent hospital admission and broad-spectrum antibiotics (e.g. co-amoxiclav), particularly in older adults, should raise Clostridioides difficile infection as a key differential.
●C. difficile typically causes watery diarrhoea with abdominal cramping; it can progress to colitis, dehydration, and sepsis if not recognised.

Managing Diagnostic Uncertainty

●A plausible alternative (an expired chicken wrap) can distract from the more important diagnosis. Food poisoning usually causes symptoms within hours to a couple of days, but the clinical context (hospital, antibiotics, age) makes C. difficile the priority to exclude. Hold both possibilities while investigating.

Stool Testing

●Send a stool sample for C. difficile toxin (and culture) to confirm or exclude the diagnosis and guide treatment.

Avoid Anti-Motility Agents

●Loperamide and other anti-motility agents are avoided when C. difficile is suspected, because slowing gut transit can retain toxins and worsen colitis.

Sick-Day Rules

●During acute dehydrating illness, temporarily stop drugs that increase AKI risk or accumulate — including metformin (lactic acidosis/renal risk) and ACE inhibitors/ARBs (e.g. ramipril), especially with a recent AKI.
●Calcium-channel blockers (amlodipine) can usually be continued, unless the patient becomes dehydrated or hypotensive. Recheck renal function before restarting withheld nephrotoxic-risk drugs.

Rehydration and Infection Control

●Encourage regular fluids and oral rehydration salts. Advise hand hygiene, cleaning of toilet and surfaces, not preparing food for others, and staying away from public/group settings until at least 48 hours after diarrhoea stops.

Treatment of Confirmed C. difficile and Safety-Netting

●Confirmed C. difficile is treated with oral vancomycin (first-line) guided by microbiology, with review of the causative antibiotic.
●Safety-net for inability to keep fluids down, faintness, reduced urine output, blood in stool, or severe abdominal pain (severe colitis/sepsis), and arrange follow-up on the stool and renal results.

Common Candidate Mistakes in This Case

●Blaming the chicken wrap: attributing the diarrhoea to food poisoning and missing C. difficile.
●Permitting loperamide: advising an anti-motility agent where C. difficile is suspected.
●Mismanaging sick-day rules: leaving metformin/ramipril running in a dehydrating illness with recent AKI, or stopping amlodipine unnecessarily.
●No stool sample: failing to arrange the test that confirms the diagnosis.
●Weak infection control/safety-netting: omitting hygiene advice or specific dehydration/colitis red flags.

Free MRCGP SCA practice case for GP registrars covering Diarrhoea After A Hospital Stay — Infectious Disease and Travel Health. 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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