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In Team Training
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Problem representation
A 34-year-old man presents with a four-month history of altered bowel habit.
Hypothesis generation
Before formulating a hypothesis of the likely causes, it is necessary to establish what Simon means by diarrhoea as, medically, this is defined as an increase in frequency of the passage of soft or watery stools relative to the usual bowel habit for that individual.
Once confirmed you can see that Simon has a long-standing history of the problem, thus ruling out acute causes of diarrhoea (defined as diarrhoea lasting fewer than 14 days) such as infection (viral, bacterial or parasitic).
Additionally, because of his age, it also means the conditions listed below are unlikely and can be discounted from your early thinking:
- Colorectal cancer (over 50s; very elderly)
- Faecal impaction (elderly)
- Hyperthyroidism (increases with age and more common in women)
- Lactose intolerance (infants).
Given his presenting symptoms, you should be considering:
Likely diagnosis
- Anxiety
- Coeliac disease
- Excess alcohol
- Inflammatory bowel disease
- Irritable bowel syndrome.
Possible diagnosis
- Diabetes
- Medicines
- Traveller’s diarrhoea.
Critical diagnosis
- Addison’s disease
- Colorectal carcinoma.
Continued information gathering
Knowing more about when his symptoms occur will be helpful in ruling in/out anxiety and excess alcohol as the cause, as incidence of diarrhoeal episodes should coincide with acute alcohol intake and bouts of anxiety. Simon says that, while he does drink, he rarely drinks to excess and has not experienced any hangovers over the past few months. He also says that he very rarely feels stressed and does not suffer from any sort of panic-type attacks. This seems to rule out these as the cause of his symptoms.
