Makindo Medical Notes

🩺 OSCE Station – Rectal Bleeding

Candidate Instructions 📋

You are the medical student in an outpatient clinic. A 62-year-old patient has been referred by their GP with rectal bleeding. Take a focused history, assess for red-flag symptoms, and outline your initial management plan. You do not need to perform a physical examination. You have 8 minutes.

Key Learning Points 🔑

• Rectal bleeding = alarm symptom 🚨, must exclude colorectal cancer.
• Most causes are benign (haemorrhoids, fissures), but don’t miss cancer, polyps, IBD, diverticulosis.
• Always ask about quantity, colour, association with stool, and systemic features.

History Framework 📝

• Onset & Duration: When did bleeding start? Single or recurrent episodes?
• Character: Bright red vs dark, mixed with stool or coating stool?
• Associated Bowel Symptoms: Change in bowel habit, diarrhoea, constipation, mucus, tenesmus.
• Systemic: Weight loss, night sweats, anorexia, fatigue, anaemia symptoms.
• Past History: Haemorrhoids, IBD, diverticulitis, bowel polyps, family history of colorectal cancer.
• Medications: Anticoagulants, NSAIDs.
• Lifestyle: Smoking, alcohol, diet (fibre, red meat).

Role-Player Prompts 👩‍⚕️

• Bleeding noticed for 6 weeks, bright red, coating the stool and on toilet paper.
• No pain on defecation, occasional mucus.
• Increasing constipation and feeling of incomplete emptying.
• Lost 4 kg unintentionally in the past 3 months, feels more tired.
• No previous bowel disease. Father had bowel cancer at age 70.
• Smokes 15/day, drinks 20 units/week.

Differential Diagnosis ⚖️

• Colorectal cancer 🚩
• Colorectal polyp
• Haemorrhoids
• Anal fissure
• Diverticular disease
• Inflammatory bowel disease (UC, Crohn’s)
• Angiodysplasia

Investigations 🔬

• Urgent 2-week wait colonoscopy if ≥40 with unexplained weight loss + abdominal pain, or ≥50 with unexplained rectal bleeding, or ≥60 with iron deficiency anaemia/change in bowel habit.
• Bloods: FBC (anaemia), U&E, LFTs, CRP, clotting.
• Stool tests: FIT (faecal immunochemical test) for triage if low risk.
• Flexible sigmoidoscopy – useful for distal lesions/haemorrhoids.
• Imaging: CT colonography if colonoscopy contraindicated.

Management 🚑

• Red-flag referral: Urgent 2-week wait colorectal clinic 🚨.
• Supportive: Treat iron deficiency anaemia with oral iron; advise on fluid and fibre intake if constipation present.
• Specific Causes:
  • Colorectal cancer → surgical + oncology MDT management.
  • Haemorrhoids → conservative (diet, fluids), banding, or surgical options if severe.
  • IBD → gastroenterology referral, medical therapy (mesalazine, steroids, biologics).
  • Diverticulitis → antibiotics, fluids, surgical review if complicated.

Examiner’s Marking Guide 📋

• Introduces self, takes consent, explores bleeding in detail.
• Asks about red flags: weight loss, anaemia, change in bowel habit, family history.
• Considers benign vs malignant causes, but does not miss cancer.
• Plans urgent referral appropriately.
• Explains clearly and sensitively to patient.

References 📚

• NICE CKS: Rectal Bleeding
• NICE NG12: Suspected cancer recognition & referral