Cases/Gastroenterology

Recurrent Abdominal Pain and Rectal Bleeding Requesting Steroids — Free SCA Practice Case

Woman with recurrent abdominal pain and rectal bleeding requesting steroids

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

Sophie Daniels

Age

30 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I've had crampy tummy pain and bleeding when I go to the toilet on and off for months. I've read it's probably inflammatory bowel disease and I want to be started on steroids to get it under control."

Medical Records

●PMH: Nil significant.
●Medications: None.
●Allergies: NKDA.
●Recent contact: No recent consultations.

Patient Script

For the friend playing the patient role

Character Overview: You are Sophie, a 30-year-old teacher. You are articulate, proactive, and have researched your symptoms extensively online, concluding you have inflammatory bowel disease and that steroids are the treatment. You have come with a clear request and can be quite insistent. You are frustrated by months of symptoms and want fast relief. You are reasonable and will engage if the doctor takes you seriously and explains things, but you will push back on being told you cannot have steroids today.

Opening Sentence: "Hi Doctor. For months now I've been getting crampy tummy pains and there's blood when I open my bowels — sometimes mixed in, and I'm going more often and urgently. I've done a lot of reading and I'm pretty sure it's ulcerative colitis or Crohn's. I want to start on steroids to calm it down — that's what they use, isn't it?"

History if Asked (Data Gathering Phase)

●The bleeding: "Blood mixed in with the stool, and sometimes on its own, quite a few times over the last few months. It's not just on the paper — it's mixed in."
●Bowel pattern: "I'm going more often — maybe five or six times a day when it's bad — looser, with urgency, and sometimes mucus. I get cramping, especially before I go, and it eases a bit after."
●Pattern over time: "It comes in flares — a few weeks bad, then a bit better, then it flares again. It's been going on maybe four or five months."
●Weight and systemic: "I've lost a little weight, and I'm tired a lot. No fevers that I've noticed."
●Why steroids: "Everything I've read says steroids are what they give you for a flare of IBD. I just want to get on them and stop feeling like this."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Sophie is convinced she has inflammatory bowel disease and that steroids are the obvious, immediate treatment; she has effectively self-diagnosed and self-prescribed from her reading. "I've basically diagnosed myself — it all fits IBD, and steroids are the treatment, so that's what I've come for."
●Concerns: Underneath the confident request is real distress at months of debilitating, embarrassing symptoms and a fear that it will keep getting worse or is "damaging her insides." "Honestly, I'm worn down and a bit scared — it's taking over my life and I keep imagining it's doing permanent damage."
●Expectations: She expects to leave with a steroid prescription and will be frustrated if simply refused without explanation. "I came in expecting steroids today. If you just say no, I'll be really frustrated — I need something to change."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Past health: "Normally well, no bowel problems before this started."
●Family history: "My cousin has Crohn's disease, actually."
●Medications: "Nothing regular. I've tried over-the-counter stuff for the cramps, no real help."
●Infection/travel: "No recent travel, no obvious food poisoning."
●Allergies: "None."

Social History and Lifestyle Impact

Sophie is a primary school teacher. She lives with her partner.

●Work: "I teach, so I can't just nip to the loo whenever I need — the urgency is a nightmare at work. I've had a couple of accidents scares."
●Impact: "It's affecting everything — work, my relationship, going out. I plan my life around toilets now."
●Smoking/alcohol: "Non-smoker. The odd glass of wine."
●Mood: "It's getting me down, if I'm honest. I feel like it's ruling my life."

If Asked — Associated Symptoms and Red-Flag Screen

The patient answers these only when directly asked.

●If asked about the nature of the blood (mixed vs on surface/paper, colour): "Dark red, mixed through the stool, not just on the paper."
●If asked about nocturnal symptoms: "Yes — I get woken at night to open my bowels, which is new."
●If asked about urgency and incontinence: "Really urgent — I sometimes barely make it. That's the worst part at work."
●If asked about mucus: "Yes, there's often mucus with it."
●If asked about weight loss: "A little, maybe a few pounds. Not huge."
●If asked about mouth ulcers, joint pains, eye/skin problems (extra-intestinal): "I've had some achy joints and a couple of mouth ulcers, actually."
●If asked about fever: "No fevers that I've noticed."
●If asked about dehydration/severity now (dizziness, unable to keep fluids down, very frequent bloody stools today): "I'm coping today — going a lot but drinking fine, not dizzy. Some days are much worse."
●If asked about haemorrhoid-type symptoms (bright blood on wiping, lump, itch): "It's not really like piles — the blood's mixed in, not just bright on the paper, and there's no lump or itch."

Responses to Management (The Negotiation Phase)

●If the Doctor declines to start steroids empirically: "Why not? Everything I've read says steroids treat IBD. I don't understand why you won't just start them." (The tested point is explaining, without dismissing her, that steroids are not started for undiagnosed bowel disease — the diagnosis must be confirmed and treatment is specialist-led — while offering a concrete alternative plan.)
●If the Doctor explains investigation and referral first: "So more waiting? I've been suffering for months. How long is all this going to take?"
●If the Doctor arranges a stool test for inflammation (faecal calprotectin): "What's that test for? Will it prove it's IBD?"
●If the Doctor wants to examine her in person: "You need to examine me? Down there too? What for?"
●If the Doctor safety-nets: "What would mean I need to be seen urgently rather than waiting for the referral?"

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 / 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

Rectal Bleeding — Characterise It

●Blood mixed through the stool, with mucus, urgency, and a change in bowel habit, points to colonic/inflammatory pathology, whereas bright blood only on the paper or coating the stool, with a lump or itch, suggests an anorectal cause (haemorrhoids, fissure).
●Always consider the full differential: inflammatory bowel disease, infective colitis, haemorrhoids/fissure, and — applying NICE NG12 — colorectal cancer, which is not excluded by youth alone when there is a change in bowel habit with bleeding.

Recognising Inflammatory Bowel Disease

●Suggestive features: bloody diarrhoea, urgency, mucus, nocturnal defecation, crampy pain relieved by defecation, weight loss, fatigue, a flaring course, a family history of IBD, and extra-intestinal manifestations (arthralgia, mouth ulcers, eye and skin involvement).
●Nocturnal symptoms and rectal bleeding are organic red flags that argue against a functional diagnosis.

Faecal Calprotectin and Baseline Workup

●Faecal calprotectin supports a diagnosis of intestinal inflammation and helps distinguish IBD from functional disease.
●Stool microscopy and culture should be sent to exclude infective colitis before any immunosuppressive treatment.
●Baseline bloods: FBC, CRP/ESR, ferritin, U&E, LFTs for anaemia, inflammation, and disease activity.

Why Empirical Steroids Are Not Started in Primary Care

●Systemic corticosteroids are not started empirically for undiagnosed bowel disease: the diagnosis must be confirmed (endoscopy/biopsy), an infective cause excluded (steroids can be harmful in infection), and IBD treatment is specialist-initiated as part of a structured plan.
●Steroids carry significant short- and long-term side effects and are not a maintenance therapy. Declining the request is correct — but must be paired with a clear explanation and an alternative plan.

Referral and Urgency

●Refer suspected IBD to gastroenterology for endoscopic diagnosis, with urgency guided by severity.
●A severe acute flare (frequent bloody stools, systemic upset, tachycardia, dehydration, high inflammatory markers) is a medical emergency (acute severe colitis) needing same-day/acute assessment.

The Lower-GI Cancer Pathway (NICE NG12)

●Apply NG12 to rectal bleeding with a change in bowel habit; do not exclude colorectal pathology on age alone where the pattern warrants consideration.

Examination and Dignity

●The abdomen and perianal/rectal area require in-person examination (including rectal examination/proctoscopy as appropriate) — this cannot be done on video. Explain the need sensitively and preserve dignity.

Interim Support While Awaiting Diagnosis

●Acknowledge the patient's suffering and provide safe interim support (hydration, appropriate analgesia avoiding NSAIDs, dietary measures) and clear safety-netting — without inappropriate immunosuppression.

Common Candidate Mistakes in This Case

●Prescribing empirical steroids: starting immunosuppression for undiagnosed, potentially infective bowel disease.
●Flat refusal without alternative: declining steroids without explanation or a concrete plan, alienating the patient.
●Omitting faecal calprotectin/stool culture: failing to arrange the tests that support the diagnosis and exclude infection.
●Not examining or referring: managing suspected IBD remotely in primary care without examination or gastroenterology referral.
●Missing severity or the cancer pathway: not assessing for a severe acute flare, or excluding colorectal pathology on age alone.

Free MRCGP SCA practice case for GP registrars covering Recurrent Abdominal Pain and Rectal Bleeding Requesting Steroids — 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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