Six Weeks of Loose Stools and Weight Loss Who Thinks It Is Stress — Free SCA Practice Case

Character Overview: You are Hollie Drummond, a 25 year old trainee solicitor. Six weeks ago you started your two year training contract in the property team of a commercial law firm in Leeds. The hours are long, there are client meetings most days, and the firm decides at the end of the two years which trainees it keeps. You share a flat with your friend Tamsin. Your parents and younger brother live in Nottingham.

In the week you started the job your bowels changed. You now go four or five times a day, the stools are loose, and you have to rush. You have lost about half a stone without trying. You are sure it is stress, because the timing fits so neatly and because your mum has had a "nervous tummy" for years and says you have inherited her stomach. You are calling from a glass meeting pod at the office on your lunch break. You are bright, upbeat and a little brisk, want a quick fix and play things down, but are more worn out and embarrassed than you let on.

You do not volunteer the weight loss, the night time trips to the toilet, the mouth ulcers or the near accident on the train unless the doctor asks about those areas.

Opening Sentence: "Hi, thanks for calling me back. So, since I started my new job my stomach's been all over the place and I'm back and forth to the loo all day. I'm pretty sure it's just stress, so I was hoping you could give me something for IBS."

History if Asked (Data Gathering Phase)

• ●How often and what it is like: "Four times a day usually, sometimes five. It's loose, sort of like porridge, and on bad days it's like water. I used to go once a day, regular as clockwork." It began the week she started at the firm, every day, with no normal day since.
• ●Rushing to the toilet (if asked about urgency or accidents): "When it comes, it comes. I always need to know where the nearest loo is." If asked whether she has ever not made it in time, her voice drops: "Last Tuesday on the train in, I honestly thought I wasn't going to make it. I got off two stops early and ran into a café. I made it, just. I haven't told anyone that."
• ●Night time (if asked whether it wakes her): "Most nights, yes. I'm up once, sometimes twice, in the night. Before all this I'd sleep straight through."
• ●Tummy pain (if asked): "Crampy, around my belly button and down on the right a bit, usually an hour or so after I've eaten. Going to the loo helps a little."
• ●Blood, slime, dark or greasy stools (if asked): "No, never any blood, and I do look. No slime, not black, just brown and loose. Nothing greasy or floating. It flushes away fine."
• ●Weight (if asked): "I've lost about half a stone. I'm normally about nine stone eleven and I was nine stone four on Tamsin's scales at the weekend." She has not been trying: "I'm eating normally. My mum said I looked thin when I went home and that threw me a bit." Appetite fine, no diets.
• ●What she has tried (if asked about medicines or remedies): "I bought loperamide from the supermarket. I take two before a big client meeting, so two or three days a week for the last three weeks. It helps for the meeting, but it all comes back the next day." No laxatives or painkillers.

Ideas, Concerns, Expectations

Gating note: Hollie 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 was hoping for.

• ●Ideas: She is convinced it is stress and that she has her mum's stomach. "It's the job, it has to be. It started the same week. And my mum's had IBS for years."
• ●Concerns: Work. She is six weeks into a contract and cannot be the trainee who is always off or always running out of meetings. "I can't be the one who's always off sick. They decide who they keep at the end and everyone's watching the new trainees." If the doctor explores further, a quieter worry comes out: "The weight thing's been bugging me a bit, if I'm honest. I didn't think stress did that so quickly."
• ●Expectations: She wants a tablet to get her through the working day, like her mum's peppermint capsules or something stronger, and would rather not have many appointments.

If Asked: Medical History and Medications

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

• ●Past health: Always well, bowels totally normal before this. Coil fitted two years ago, periods light, nothing changed, cannot be pregnant.
• ●Other medicines and allergies: Only the loperamide. No antibiotics for years. No allergies.
• ●Family history: Mum has IBS and Dad has high blood pressure. Her younger brother is fine. Nobody has had bowel cancer, inflammatory bowel disease, coeliac disease or serious bowel problems.

Social History and Lifestyle Impact

Gating note: Hollie shares this naturally when talking about work and how she is managing, bit by bit and not as a speech.

• ●Work: A big completion deadline at the end of the month.
• ●Lifestyle impact: "I plan my whole day around where the toilets are. I sit at the end of the table in meetings so I can slip out. I've stopped going to the gym, and I'm shattered by the afternoon."
• ●Alcohol, caffeine and smoking: Three medium glasses of wine on Thursdays and a couple at the weekend. Three or four flat whites a day. Never smoked, no drugs.
• ●Travel and contacts: No travel abroad for about ten months. Nobody at home or work has had a stomach bug.
• ●Diet: Meal deal at her desk for lunch, proper tea at night. No food makes it worse, including milk or bread.

If Asked: Associated Symptoms

Gating note: Hollie answers briefly, in a sentence or two.

• ●If asked about mouth ulcers or a sore mouth: "Oh, yes, loads this last month. Two or three at a time, inside my lips and under my tongue. They clear up in about a week and then new ones come. I put that down to late nights and too much coffee." No single ulcer has lasted more than a few weeks.
• ●If asked about tiredness: "I'm wiped out. I thought that was the hours."
• ●If asked about the back passage: "It's a bit sore from wiping so much. No lumps or anything coming out."
• ●If asked about mood: "I'm stressed with work, obviously, but I'm not low."
• ●All of the following are negative: fever, shivers or night sweats, joint pain or swelling, sore or red eyes, rashes or tender lumps on the legs, nausea or vomiting, a swollen tummy (only "a bit gurgly"), dizziness or fainting, any change in how much she drinks or passes urine, and a racing heart, shakiness or feeling hot (her heart only races after too much coffee).

Responses to Management (The Negotiation Phase)

• ●If the Doctor says it does not sound like stress or IBS and needs looking into:
  • ●Reaction: Taken aback and a little defensive. "Really? But it started literally the week I started work. Isn't that a bit of a coincidence?" If the doctor explains which parts do not fit stress, she goes quieter: "I suppose the waking up at night is weird. And the weight. I'd just put it all down to being run off my feet." If the doctor simply offers an IBS tablet she is pleased: "Perfect, that's exactly what I was after."
• ●If the Doctor asks her to stop or avoid the loperamide:
  • ●Reaction: Alarmed. "But what do I do before a client meeting? That's the only thing that gets me through." Once the risk is explained: "Okay, I didn't know that. I thought they were just harmless supermarket tablets." She agrees if she has a practical plan for meetings.
• ●If the Doctor arranges tests or an examination:
  • ●Reaction: Practical. Blood tests: "Can I get them done early, before work? What are they looking for?" Advised to keep eating gluten: "I wasn't planning to change what I eat, but why does that matter?" Stool test: "Oh God. Do I have to bring it in? I can't exactly carry it round the office." Examination: "Could it be this week, early morning?" If it may include the back passage: "Could it be a female doctor, or someone else in the room?" If asked to press on her own tummy she declines: "I'm in a glass meeting pod. Can I come in?"
• ●If the Doctor says she needs a hospital bowel specialist, a camera test or A&E today:
  • ●Reaction: Worried about work. Specialist: "How soon? I've literally just started this job. Is it that serious?" Camera: "Am I awake for that?" A&E: "Today? I feel alright. Is that really necessary?"
• ●If the Doctor says what it could be:
  • ●Reaction: She asks directly once a plan is made: "So if it's not stress, what do you actually think it is?" If inflammation of the bowel is named, she is frightened: "Isn't that the one where people end up with a bag? Would I be ill on and off for the rest of my life?" She settles with an honest, hopeful answer and a clear next step. If gluten is mentioned: "So I'd have to give up sandwiches?" She is reassured that nothing changes until it is confirmed.
• ●If the Doctor gives safety netting, work advice and a plan for results:
  • ●Reaction: To "get back in touch if it gets worse": "Worse how, though? I'm already going four times a day." To specific warning signs: "Okay, blood or a temperature, ring the same day. Can you send me that in a text?" To a fit note: "Would work have to know what it's for? I don't want to be the trainee with the bowel problem." She is open to it if told what it would say. On results: "Will you ring me, or do I have to chase?"