Elderly Woman Asking for Explanation of Diverticular Disease Diagnosis — Free SCA Practice Case
Elderly woman asking for explanation of diverticular disease diagnosis
Station Timer
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
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Margaret Gable
Age
75 years
Consultation Type
VideoAge
75
Situation
Telephone or Video Consultation.
Reason for Encounter
"Patient wants to discuss a recent hospital letter and find out what 'diverticular disease' means."
Medical Records
- ●PMH: Hypertension, Osteoarthritis (knees).
- ●Medications: Amlodipine 5mg OD, Paracetamol 1g QDS PRN.
- ●Allergies: NKDA.
Recent Notes
- ●Consultant Gastroenterologist Letter (Attached to record): "Mrs. Gable attended clinic following a recent CT colonography for altered bowel habit and left-sided abdominal ache. The scan showed no evidence of malignancy. There is extensive diverticulosis in the sigmoid colon. I have reassured her and discharged her back to your care for the ongoing management of diverticular disease."
Patient Script
For the friend playing the patient role
Character Overview: You are Margaret. You are a pleasant but anxious older woman. You received a copy of the hospital letter, and the medical jargon has panicked you. You are secretly terrified that this is a precursor to bowel cancer, or that you will end up needing a colostomy bag like your friend did.
Opening Sentence: "Hello Doctor. Thank you for calling. I got this letter from the hospital specialist saying I have 'extensive diverticular disease'. He was very rushed in the clinic and just said I was being discharged. I'm really quite worried about what this actually means."
History if Asked (Data Gathering Phase)
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Current Symptoms: "I get this dull, crampy ache in my lower left tummy, usually worse in the evenings. I also get quite bloated, and my bowels are a bit all over the place—sometimes I'm constipated for days, and then I'll have a rush of loose motions."
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Relief: "Passing wind or going to the toilet usually makes the tummy ache feel a bit better."
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Red Flags (Ruling out complications/cancer): "No, I haven't seen any blood in the toilet. I haven't lost any weight, and I haven't had any fevers or sweats. The hospital said the scan didn't show cancer, but I don't know if this disease turns into cancer later."
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Diet & Beliefs (The Nutritional Trap): "My diet is quite plain. White bread, tea, biscuits, maybe some chicken. I read in a magazine years ago that if you have bowel pockets, you must never eat seeds or nuts because they get trapped and cause infections. So I avoid them completely."
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The "Hidden" Fear: "My friend Edna had a bowel problem, and she ended up with a stoma bag on her tummy. Is that what's going to happen to me?"
ICE — Ideas, Concerns, Expectations
The patient does not volunteer these unprompted. These responses surface only if the candidate directly explores her perspective.
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Ideas: "I'm not really sure what causes it — maybe something I ate over the years? I've always had a plain diet, so I don't understand how this happened. The letter said 'extensive' which sounds like it's everywhere. I just don't know if this is something that's been building up for a long time or if it's come on suddenly."
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Concerns: "Honestly, I keep thinking about Edna — she had something wrong with her bowel and ended up with one of those bags. I'm terrified that's where I'm heading. And the letter said 'no malignancy' but I don't fully understand — does that definitely mean no cancer? Could it still turn into cancer later? That's what keeps going round in my head."
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Expectations: "I just want someone to sit down and explain what this actually is in plain English — the consultant was so rushed I came away more confused than when I went in. I want to know if there's anything I can do to stop it getting worse, and I want to know I'm not going to end up like Edna."
If Asked — Medical History and Medications
The patient confirms details from her medical record if asked directly. She is not medically sophisticated but knows the basics of what she takes and why.
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Hypertension / Amlodipine: "Yes, I take a little tablet every morning for my blood pressure — I think it's called amlodipine. I've been on it for a few years now. I don't get any bother from it. My blood pressure has been fine as far as I know."
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Osteoarthritis / Paracetamol: "My knees have been playing up for years — the doctor said it's wear and tear. I take paracetamol most days for the pain, two tablets usually four times a day when it's bad. It takes the edge off but doesn't get rid of it completely. I don't take anything else for it."
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Allergies: "No, I've never had any allergies to medicines as far as I know."
Social History and Lifestyle Impact
Margaret volunteers this naturally if the conversation touches on how the symptoms affect her day-to-day life. She does not deliver it as a monologue — it comes out in the flow of discussion.
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Daily life context: Margaret is a retired school dinner lady. She lives alone in a terraced house since her husband Derek passed away four years ago. Her daughter Karen lives about twenty minutes away and pops in twice a week. Margaret is generally independent — she does her own shopping, attends a weekly knitting group at the church hall, and walks to the local post office most mornings.
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Lifestyle impact of the condition: "It's the unpredictability that gets me, Doctor. Some days I'm so bloated and uncomfortable I don't want to go out at all. I missed my knitting group twice last month because I was worried I'd need the toilet urgently and wouldn't make it there in time. And when Karen takes me to the supermarket, I spend half the trip looking for where the toilets are instead of actually shopping. I used to walk to the post office every morning but now I don't always risk it — I just feel like I can't trust my bowels anymore."
If Asked — Associated Symptoms
These responses are only given if the candidate asks directly about the specific symptom. The patient does not volunteer them.
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If asked about nausea or vomiting: "No, I don't feel sick. I've not been sick at all."
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If asked about urinary symptoms: "Now you mention it, I do seem to need the toilet for a wee a bit more often than I used to, but I put that down to my age. No pain or burning though."
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If asked about appetite: "My appetite is still fine — I still enjoy my meals. I haven't gone off my food or anything like that."
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If asked about rectal mucus or discharge: "No, nothing like that. It's just the usual when I go."
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If asked about back pain: "Well, my back aches sometimes but I think that's just my age and my arthritis. It's not connected to the tummy trouble as far as I can tell."
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If asked about pain on passing urine or blood in urine: "No, nothing like that at all."
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If asked about recent antibiotic use: "No, I haven't needed any antibiotics recently."
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If asked about smoking: "No, I gave that up years ago — must be thirty years now. I only ever smoked about five a day."
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If asked about alcohol: "I have a small sherry at Christmas, Doctor, that's about it!"
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If asked about exercise: "Just my walking, really. I try to keep moving for my knees but I can't do anything too strenuous at my age."
Responses to Management (The Negotiation Phase)
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If the Doctor explains what 'diverticula' are: Reaction: "So they are like little pouches pushing out of the bowel? Will they ever go away, or am I stuck with them?"
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If the Doctor tells you to eat more fibre/bran: Reaction: Hesitant. "I tried eating lots of bran a few years ago and it just made me so terribly windy and bloated. I couldn't leave the house! Do I really have to eat it?" (Needs advice on gradual increase and fluid intake).
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If the Doctor advises you to avoid nuts and seeds: Reaction: "Oh, so the magazine was right! I will make sure I never touch a strawberry or a tomato again." (Note: This is outdated advice. If the doctor says this, it is a clinical failure).
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If the Doctor prescribes painkillers: Reaction: "I already take paracetamol for my knees, can I just use that? Or should I take ibuprofen?" (Doctor must warn against NSAIDs like ibuprofen).
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Diverticulosis vs Diverticular Disease vs Diverticulitis — Knowing the Difference
- ●Diverticulosis refers to the presence of diverticula (small mucosal outpouchings through weak points in the bowel wall) without symptoms. It is extremely common — present in over 50% of people over 70 — and in isolation requires no treatment.
- ●Symptomatic diverticular disease describes diverticula that produce chronic symptoms (left lower quadrant cramping, bloating, altered bowel habit) without acute inflammation. This is Margaret's diagnosis.
- ●Acute diverticulitis occurs when a diverticulum becomes inflamed or microperforation occurs, producing constant severe left-sided pain, fever, and systemic upset. This is a distinct clinical emergency requiring urgent assessment.
- ●Distinguishing these three states determines the management pathway: lifestyle modification for diverticular disease; urgent hospital assessment for acute diverticulitis.
The Seed and Nut Myth — Correcting Outdated Guidance
- ●For decades, patients were instructed to avoid nuts, seeds, popcorn, and fruit skins on the premise that they could become lodged in a diverticulum and trigger inflammation. This advice is now explicitly contradicted by NICE CKS and BSG guidance.
- ●Current evidence does not support any dietary restriction of seeds, nuts, or high-residue foods in diverticular disease. These foods are in fact beneficial sources of fibre and should be actively encouraged.
- ●This is a high-yield point for the SCA: the patient script deliberately tests whether candidates will repeat this outdated advice. Stating it constitutes a clinical failure.
Dietary Management — Fibre, Fluid, and Practical Delivery
- ●A high-fibre diet (target 30g/day) is the primary intervention for symptomatic diverticular disease. It reduces intraluminal pressure, softens stool, and improves regularity.
- ●Fibre must be increased gradually over several weeks. An abrupt increase causes significant bloating and flatulence — the experience that led Margaret to abandon fibre previously — and undermines adherence. Frame this explicitly when advising the patient.
- ●Practical fibre sources to suggest: wholemeal bread, oats, vegetables, fruit (including skin), pulses, and legumes.
- ●Adequate hydration is essential alongside fibre — recommend at least 1.5–2 litres of fluid daily. Fibre without fluid worsens constipation.
- ●If dietary fibre is poorly tolerated or insufficient, a bulk-forming laxative (ispaghula husk, e.g. Fybogel) is the appropriate first-line supplement per NICE CKS.
Pharmacological Management — Safe Choices and Contraindications
- ●Paracetamol is the recommended analgesic for crampy diverticular pain.
- ●NSAIDs (ibuprofen, naproxen, diclofenac) must be avoided: they significantly increase the risk of diverticular perforation and haemorrhage. This is a patient safety point — when Margaret raises ibuprofen, the candidate must warn against it clearly.
- ●Opioids (codeine, morphine) should also be avoided: they reduce gut motility, worsen constipation, and increase intraluminal pressure, exacerbating the underlying pathology.
- ●Antispasmodics — mebeverine 135mg three times daily before meals, or hyoscine butylbromide — are recommended by NICE CKS for the crampy, colicky pain of diverticular disease and are frequently omitted by candidates. Consider offering these to address Margaret's symptomatic burden.
Medication Review — Amlodipine and Constipation
- ●Calcium channel blockers, including amlodipine, are a recognised cause of constipation through their effect on smooth muscle. In a patient whose predominant complaint includes constipation, this medication should be flagged for review.
- ●This is not a reason to stop amlodipine without specialist input (hypertension control remains the priority), but it is a relevant polypharmacy consideration that well-prepared candidates will identify.
- ●Margaret also takes paracetamol QDS PRN for osteoarthritis. If paracetamol is recommended for diverticular pain, she must be counselled on the maximum daily dose of 4g to avoid inadvertent overdose.
Prognosis — Cancer Risk and Structural Permanence
- ●Diverticular disease is not associated with an increased risk of colorectal cancer. This must be stated explicitly and clearly — not implied, not hedged.
- ●The CT colonography has already excluded malignancy. The word "extensive" in the letter describes the distribution of diverticula in the sigmoid colon, not severity or cancer risk.
- ●Diverticula are permanent structural changes — the pouches do not resolve. However, symptoms can be effectively managed with dietary and lifestyle measures in the majority of patients.
Red Flags and Indications for Acute Assessment
- ●Advise the patient to seek emergency assessment (A&E or 999) if they develop:
- ●Severe, constant (rather than crampy) left-sided or generalised abdominal pain
- ●High fever, rigors, or chills
- ●Significant fresh rectal bleeding (diverticular haemorrhage can be painless and voluminous)
- ●Inability to tolerate oral intake with vomiting
- ●These features suggest acute diverticulitis, perforation, or diverticular bleed — each requiring urgent secondary care assessment.
Associated Symptoms — Urinary Symptoms in Sigmoid Diverticular Disease
- ●Increased urinary frequency without dysuria, as Margaret reports, should prompt consideration of a colovesical fistula — a recognised complication of sigmoid diverticular disease where a fistula forms between the sigmoid colon and the bladder.
- ●The classic presentation of a colovesical fistula is pneumaturia (air in the urine) or faecaluria (faeces in the urine). Margaret reports neither, but this association should be in the candidate's differential when urinary symptoms accompany sigmoid diverticular disease.
- ●In the absence of these features, urinary frequency in a 75-year-old woman is more likely attributable to age-related bladder changes, but the association is worth noting for examination purposes.
Safety Netting and Follow-up
- ●Arrange follow-up in 4–6 weeks to review symptomatic response to dietary modification and any medication initiated.
- ●Encourage Margaret to contact the practice before that review if symptoms worsen or she has further concerns — particularly in the early weeks while dietary changes are being established.
- ●Document the consultation clearly, noting the educational content provided, the corrections made to outdated dietary advice, and the safety-netting given.
Mapped to the RCGP curriculum topic: Gastroenterology.
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