History Taking · Intermediate · Gastroenterology

Persistent Gastrointestinal Symptoms

Practise this PLAB 2 history taking station on Crohn's Disease. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in general practice. Mr Graham Collins, a 34-year-old man, has attended with a six-month history of persistent diarrhoea. He has constitutional symptoms (weight loss, fatigue), abdominal pain, and recent blood in stool. He is concerned about malignancy and wants to know what is causing his symptoms. Please take a focused history to differentiate between IBS, IBD, coeliac disease, and other causes, and formulate appropriate investigation plan.

Background notes: PMH: Nil significant

What this station tests

  • Recognising red flag features in chronic diarrhoea: blood, weight loss, fever, and nocturnal symptoms that mandate investigation and exclude IBS without testing
  • Distinguishing Crohn's from UC through symptom location: periumbilical and lower abdominal pain favours Crohn's, left-sided and rectal symptoms favour UC
  • Screening for extra-intestinal manifestations: joint pain, oral ulcers, skin lesions, and eye symptoms as supporting evidence for IBD
  • Faecal calprotectin as the key non-invasive discriminating test: elevated calprotectin distinguishes inflammatory from functional bowel disease
  • Addressing cancer anxiety proportionately: acknowledging the concern while explaining why IBD is more likely at 34

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Chronic diarrhoea with red flag features requires the candidate to distinguish inflammatory bowel disease from other organic causes while addressing the patient's cancer anxiety. The key is recognising which features mandate urgent investigation versus reassurance. Mr Collins is 34, presenting with 6 months of persistent diarrhoea, weight loss, blood in stool, and abdominal pain. He is worried about cancer. Open with: 'Mr Collins, tell me about these symptoms and how they have been affecting you.' Let the full picture emerge before narrowing your differential.

Core approach

The clinical picture has multiple red flags. Diarrhoea for 6 months (chronic), 4 to 6 times daily, loose and watery. Blood in stool for 2 months (visible). Weight loss of 8kg in 4 months (significant, approximately 10% body weight). Crampy periumbilical and lower abdominal pain, worse after eating, partly relieved by defecation. Occasional low-grade fever. Fatigue. Reduced appetite. Some knee aching. No nocturnal diarrhoea mentioned but ask specifically: nocturnal symptoms strongly suggest organic disease over functional.

These features, chronic bloody diarrhoea, weight loss, periumbilical pain, young adult, low-grade fever, and possible joint involvement, strongly suggest Crohn's disease. The periumbilical location favours Crohn's over ulcerative colitis (which typically presents with left-sided or rectal symptoms). Joint pain could be an extra-intestinal manifestation. Ask about oral ulcers, skin lesions (erythema nodosum), and eye symptoms (iritis) to screen for other extra-intestinal features.

Exclude competing differentials through targeted questions. Coeliac disease: does he have a family history (his sister-in-law is coeliac)? Any relationship to gluten? Infection: any travel, any food poisoning? Cancer: at 34 with no family history, colorectal cancer is unlikely but blood in stool still requires investigation. IBS: the red flags (weight loss, blood, fever) exclude a diagnosis of IBS without investigation.

ICE: He thinks it might be IBS or stress but is deeply worried about cancer. The blood in his stool frightens him. He wants to know what investigations are needed and whether it is serious.

Closing and safety netting

Explain the working differential: 'Mr Collins, the combination of persistent diarrhoea with blood, weight loss, and abdominal pain over 6 months needs urgent investigation. The most likely diagnosis is inflammatory bowel disease, a condition where the gut becomes inflamed. At your age and with no family history of bowel cancer, cancer is much less likely, but we still need to investigate properly.'

Investigations: urgent bloods (FBC for anaemia, CRP for inflammation, coeliac screen), faecal calprotectin (the key non-invasive test that distinguishes inflammatory from functional bowel disease), stool cultures (exclude infection), and referral for colonoscopy (definitive investigation). If calprotectin is significantly elevated, this strongly supports IBD and expedites the colonoscopy.

Reassure about cancer proportionately but do not dismiss: 'The colonoscopy will give us a definitive answer and rule out any other cause.' Safety net: 'If you develop severe abdominal pain, high fever, significant bleeding, or cannot keep fluids down, go to A&E.' Arrange urgent gastroenterology referral.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for crohn's disease. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Red flag identification: blood, weight loss (quantified), fever, duration. Symptom localisation favouring Crohn's. Extra-intestinal screening (joints, skin, mouth, eyes). Nocturnal symptoms asked. Coeliac and infective differentials considered. Family history checked.

Costs marks: Not identifying red flags. Not quantifying weight loss. Not asking about nocturnal symptoms. Not screening for extra-intestinal features. Not considering coeliac disease.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Appropriate investigation pathway: bloods (FBC, CRP, coeliac), faecal calprotectin, stool cultures, colonoscopy referral. Urgent gastroenterology referral. Accurate safety netting for complications. Proportionate cancer risk communication.

Costs marks: Diagnosing IBS without investigation. Not requesting calprotectin. Not referring for colonoscopy. No safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing cancer anxiety directly and proportionately. Explaining IBD in plain language. Acknowledging the impact on his family life (two young children). Providing a clear investigation timeline so he knows what to expect.

Costs marks: Dismissing cancer concern. Being vague about investigations. Not acknowledging functional impact. Using jargon ('calprotectin', 'colonoscopy') without explanation.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Diagnosing IBS without investigating the red flags. Bloody diarrhoea with weight loss and fever cannot be IBS. Candidates who say 'this is probably IBS' without arranging investigation demonstrate dangerous diagnostic complacency.
  2. Not requesting faecal calprotectin. This is the single most useful non-invasive test for distinguishing IBD from IBS. Candidates who go straight to colonoscopy referral without calprotectin miss the opportunity to demonstrate knowledge of the investigation pathway.
  3. Not screening for extra-intestinal manifestations. The knee pain could be IBD-related arthropathy. Candidates who treat the joint pain as coincidental miss supporting diagnostic evidence.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this crohn's disease station?

Chronic diarrhoea with red flag features requires the candidate to distinguish inflammatory bowel disease from other organic causes while addressing the patient's cancer anxiety. The key is recognising which features mandate urgent investigation versus reassurance. Mr Collins is 34, presenting with 6 months of persistent diarrhoea, weight loss, blood in stool, and abdominal pain.

What does a strong performance look like to the examiner in this station?

Strong performances show: Red flag identification: blood, weight loss (quantified), fever, duration. Symptom localisation favouring Crohn's. Extra-intestinal screening (joints, skin, mouth, eyes). Weak performances: Not identifying red flags. Not quantifying weight loss. Not asking about nocturnal symptoms. Not screening for extra-intestinal features.

What is the biggest pitfall in this crohn's disease station?

Diagnosing IBS without investigating the red flags. Bloody diarrhoea with weight loss and fever cannot be IBS. Candidates who say 'this is probably IBS' without arranging investigation demonstrate dangerous diagnostic complacency.

How should I prepare for crohn's disease if I have never seen it in practice?

Structure beats experience here. Focus on distinguishing Crohn's from UC through symptom location: periumbilical and lower abdominal pain favours Crohn's, left-sided and rectal symptoms favour UC. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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