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IBS Hx OSCE

Apr 06, 202510 min read

Irritable Bowel Syndrome (IBS) - OSCE Scenario

Table of Contents

Information for Student/Candidate

Patient Brief Record / Scenario

  • Patient Name: Khalid
  • Age: 33 years old
  • Presentation: Complaining of generalized abdominal pain.
  • Examination Finding: Abdominal examination is normal.

Task: What is expected from the candidate

  1. Take a relevant history.
  2. Discuss the management plan with the patient.

Simulated Patient (SP) Instructions / Scenario

Patient Details

  • Your Name: Khalid
  • Age: 33 years old
  • Occupation: Teacher
  • Family: Married with 2 children (4-year-old daughter, 2-year-old son).

Opening Scenario & Information Disclosure

  • Opening Statement: “Doctor, I keep on having this pain in my tummy” (Point towards your abdomen).
  • Initial Information (Give in response to first query): The pain started 8 months ago. It is generalized (all over your tummy).
  • Reveal the following information ONLY if specifically asked:
    • Pain Frequency/Pattern: Pain occurs on 6-8 days per month; it comes and goes.
    • Associated Bowel Habits: Associated with alternating bowel habits:
      • Diarrhea: When present, 3-4 loose stools per day, often after meals.
      • Constipation: When present, pass a hard stool every 3rd day.
    • Triggers/Aggravating Factors: Pain is increased by stressors at home and at work, and by drinking milk.
    • Negative Symptoms (Deny if asked):
      • No loss of appetite.
      • No weight loss.
      • No per rectal bleeding.
      • No nausea or vomiting.
      • No fever.
      • No history of GIT infection before symptoms started.
      • No history of physical or sexual abuse as a child.
      • No symptoms of depression (low mood, loss of interest, sleep disturbance, excessive tiredness, etc.).
      • (Say NO to any other complaints not included in this scenario).
    • Reason for Seeking Help Now: You have coped without medication so far, but now need advice and help as it’s disturbing your performance at work.
    • Past History: Not significant.
    • Medication: Taking none.
    • Family History: No history of colon cancer or other GI problems in the family. Not significant.
    • Social History Details: Non-smoker, don’t take alcohol. Get a little tense coping with work at school and home. No conflict at home or work.

Patient’s Perspective (Ideas, Concerns, Expectations - ICE)

  • Idea: You don’t have any specific idea about the cause.
  • Concern: You don’t have any specific concern about the pain itself (e.g., not worried about cancer).
  • Expectation: You expect good treatment for the pain because it is disturbing your performance at work.

Important Notes for the Simulated Patient

  • Say no to any other complaints not included in this scenario if asked by the student.

Dress and Behavior

  • Wear casual dress.
  • Act a little anxious.

Candidate Expectations & Key Areas to Cover

General OSCE Skills / Doctor-Patient Interaction

  • Introduction & Rapport: Introduce self clearly, confirm patient identity, build rapport (good posture, appropriate body language of encouragement, respectful tone).
  • Communication Techniques:
    • Use a mix of open-ended and closed questions appropriately and in sequence.
    • Listen attentively, allow patient time to respond, avoid interruptions as far as possible.
    • Use facilitation techniques (verbal/non-verbal encouragement, silence, nodding).
    • Use concise, easily understood language; avoid or explain medical jargon.
    • Periodically summarize (“Internal Summary”) to check understanding and invite corrections.
  • Patient-Centered Approach:
    • Demonstrate interest, concern, and respect throughout. Show empathy. Maintain good eye contact.
    • Actively elicit the patient’s Ideas, Concerns, and Expectations (ICE) and effect on function.
    • Encourage the patient to talk and express their views.
    • Promote informed, shared decision-making regarding the management plan.
  • Structure & Timing:
    • Maintain a logical flow throughout the consultation.
    • Attend to timing.

History Taking

HOPI

Presenting Complaint (Abdominal Pain & Bowel Habit Analysis)

  • Pain Details:
    • Onset (* 8 months ago*).
    • Location (* Generalized/all over*).
    • Frequency (* 6-8 days/month*).
    • Duration (How long does each episode last?).
    • Character (What does it feel like?).
    • Severity (Pain scale 1-10?).
    • Radiation (Does it travel anywhere?).
    • Aggravating factors (* Stress, milk*).
    • Relieving factors (Ask specifically: “Is it relieved by defecation/passing stool?”).
  • Bowel Habit Details:
    • Clarify the pattern of altered bowel habits (* Alternating diarrhea and constipation*).
    • Diarrhea details: Frequency (* 3-4/day*), consistency (loose), timing (* After meals*), presence of mucus (Ask: clear/white?).
    • Constipation details: Frequency (* Every 3rd day*), consistency (* Hard*), straining, feeling of incomplete evacuation.
    • Stool description (Form/appearance - relate to Bristol Stool Chart if possible).

Rome IV Criteria Exploration

  • Assess for Rome IV criteria for IBS: Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with two or more of the following:
    1. Related to defecation (usually improved).
    2. Associated with a change in frequency of stool.
    3. Associated with a change in form (appearance) of stool.
  • Confirm criteria met for the last 3 months with symptom onset at least 6 months prior to diagnosis. (* Symptoms started 8 months ago*).

Associated IBS Symptoms (Including Extra-intestinal)

  • Gastrointestinal: Bloating/distension, dyspepsia, heartburn, nausea, vomiting (* Denies N/V*), clear or white mucorrhea (non-inflammatory).
  • Extra-intestinal: Impaired sexual function (dyspareunia, poor libido), urinary frequency/urgency, dysmenorrhea (if applicable), fibromyalgia symptoms.

Red Flag Symptom Exclusion

  • Actively ask about and rule out “alarm” features:
    • Rectal bleeding (* Denies*).
    • Weight loss (* Denies*).
    • Loss of appetite / Anorexia (* Denies*).
    • Iron deficiency anemia (ask about fatigue, pallor symptoms).
    • Abdominal masses (though exam is normal).
    • Onset at older age (>50 years).
    • Nocturnal symptoms (pain waking from sleep, nighttime diarrhea).
    • Persistent/Chronic severe diarrhea or painless diarrhea.
    • Steatorrhea (fatty stools).
    • Dysphagia (difficulty swallowing).
    • Recurrent fever (* Denies*).

Other Relevant History Points

  • Gluten intolerance symptoms.
  • History of preceding gastrointestinal infection (* Denies*).
  • History of physical or sexual abuse (* Denies*).

Past Hx

Past Medical & Surgical History

  • Any previous GI investigations or diagnoses.
  • Other medical conditions.
  • Previous surgeries. (* Not significant*).

Medication History

  • Current medications (prescription, OTC, supplements). (* Nil*).
  • Allergies.

Family History

  • Specifically ask about: IBS, Inflammatory Bowel Disease (IBD - Crohn’s, Ulcerative Colitis), Celiac disease, Colorectal cancer. (* Not significant, denies family history of colon cancer/other GI problems*).

Social History

  • Occupation (* Teacher*).
  • Marital status / Family structure (* Married, 2 children*).
  • Smoking status (* Non-smoker*).
  • Alcohol intake (* Doesn’t drink*).
  • Dietary habits (typical meals, caffeine intake, artificial sweeteners, fatty foods).
  • Exercise level.
  • Stressors (* A little tense with work/home coping, but no conflict*).

Psychological History

  • Assess for anxiety, depression, stress levels.
  • Ask about mood, interest/pleasure (anhedonia), sleep, energy levels. (* Denies specific depression symptoms, admits to being ‘a little tense’*).

Travel History

  • Ask about recent travel, especially to areas with parasitic infestation risk.

Patient’s Perspective (ICE) & Functional Impact - Elicitation

  • Actively ask:
    • “What ideas do you have about what might be causing this?” (* No idea*)
    • “Is there anything specific that worries you about these symptoms?” (* No concern*)
    • “What were you hoping we could do for you today?” (* Expects good treatment as it affects work*)
  • Explore the impact of symptoms on daily life, work performance, social activities. (* Disturbing performance at work*).

Clinical ExaminationY

(Note: Scenario states exam is normal, but candidate should know what to look for)

  • Vital Signs (V/S): BP, HR, RR, Temp.
  • General Appearance: Assess for distress, nutritional status, pallor. Calculate BMI.
  • Abdominal Examination:
    • Inspection: Distension, scars.
    • Auscultation: Bowel sounds (normal, hyper/hypoactive).
    • Palpation: Tenderness (location, severity), masses, hepatosplenomegaly. (Scenario: Normal)
  • Rectal Examination: (Mention necessity if indicated, e.g., by altered bowel habit, though may not be performed in OSCE). Look for fissures, fistulas, assess tone, check for masses/stool/blood.

Investigations

(Mention investigations that could be considered, primarily if red flags are present or diagnosis is uncertain, but emphasize IBS is often a clinical diagnosis)*

  • Generally, investigations are used to rule out other conditions, especially if red flags exist.
  • Possible tests (explain why they might be done):
    • Blood Tests:
      • Complete Blood Count (CBC) - Check for anemia (red flag).
      • ESR and CRP - Inflammatory markers (low in IBS, elevated in IBD).
      • Thyroid Stimulating Hormone (TSH) - Rule out thyroid dysfunction affecting bowel habits.
      • Tissue Transglutaminase (tTG) antibodies / IgA levels - Screen for Celiac disease.
      • Electrolytes (if severe diarrhea).
    • Stool Tests:
      • Stool for ova and parasites (if travel history or relevant exposure).
      • Fecal calprotectin (to differentiate IBS from IBD - usually normal/low in IBS).
    • Other:
      • Urea breath test (for H. pylori if dyspepsia prominent).
      • Consider colonoscopy if red flags present or age >45/50 for CRC screening.

Management Plan

Diagnosis Explanation & Education

  • Share the likely diagnosis of Irritable Bowel Syndrome (IBS) based on the history (symptom pattern, duration, absence of red flags) and normal examination.
  • Explain what IBS is: A common functional gut disorder characterized by abdominal discomfort/pain associated with altered bowel habits, in the absence of structural or biochemical abnormalities. Emphasize it’s not a dangerous or life-threatening condition like cancer or IBD.
  • Explain the brain-gut axis connection and the role of factors like stress, diet, and gut sensitivity.
  • Acknowledge the impact on quality of life and work (SP’s expectation).
  • Check the patient’s understanding of the diagnosis and address any remaining concerns.
  • Reassure the patient that while chronic, symptoms can often be managed and may fluctuate or even decrease over time.

Non-Pharmacological Management (Diet, Lifestyle, Psychological)

  • Dietary Advice:
    • Advise eating regular meals and taking time to eat.
    • Suggest keeping a food and symptom diary to identify personal trigger foods (mentioned milk).
    • General advice: Adequate fluid intake, consider increasing soluble fiber (e.g., oats, ispaghula) gradually for constipation/general regulation, but caution insoluble fiber (e.g., bran) can worsen pain/bloating for some.
    • Advise trial avoidance of common triggers: caffeine, alcohol, artificial sweeteners (sorbitol), fatty/spicy foods, and known personal triggers (like milk - suggest lactose-free alternatives or trial exclusion).
    • Consider a trial of a low FODMAP diet under guidance (if initial measures fail).
  • Lifestyle Advice:
    • Encourage regular physical exercise.
    • Stress management techniques (relaxation exercises, mindfulness, yoga) given the stress trigger (mentioned work/home stress).
  • Psychological Therapies:
    • Mention options like Cognitive Behavioral Therapy (CBT), hypnotherapy, or relaxation techniques if stress/anxiety is a major component or symptoms are refractory.

Pharmacological Management (Symptom-Targeted)

  • Explain that medication targets specific symptoms.
  • For Pain/Bloating:
    • Antispasmodics: Recommend trying an antispasmodic like Mebeverine 135mg taken 2-3 times daily, 20 minutes before meals. (Adjust dose based on local formulation/guidelines, source mentioned 125mg twice daily).
    • Peppermint oil capsules (enteric-coated) can also be effective.
  • For Constipation Predominance:
    • Start with fiber supplements (soluble fiber like psyllium/ispaghula).
    • If needed, add an osmotic laxative like Lactulose (e.g., 15-30 mL or 10-20g orally once daily, titrate) or Polyethylene Glycol (PEG) (e.g., 17g in water daily).
  • For Diarrhea Predominance:
    • Loperamide (e.g., 2-4 mg initially, then 2 mg after each loose stool as needed, maximum 16 mg/day). Advise using it strategically (e.g., before anticipated triggers) rather than regularly long-term if possible.
  • Other Options (Consider if needed, often specialist input):
    • Low-dose Tricyclic Antidepressants (TCAs) like Amitriptyline (e.g., start 10-25 mg at night) can help with pain and regulate bowel habits (can cause constipation).
    • Selective Serotonin Reuptake Inhibitors (SSRIs) may be used, particularly if co-existing anxiety/depression.

Follow-up

  • Emphasize the importance of follow-up to monitor symptoms, assess effectiveness of interventions, adjust treatment, and provide ongoing support.
  • Arrange a review appointment (e.g., in 4-6 weeks).
  • Advise the patient to return sooner if symptoms worsen significantly or if any red flag symptoms develop.

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