Station 78

Priya Patel

Age: 56 years old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis

  • Ask about the onset of symptoms
  • Ask about the number of episodes of diarrhoea and vomiting
  • Ask if there is any blood in the stools or vomit
  • Ask if there is any fever, abdominal pain, mucus or pus in the stool.
  • Ask about current fluid intake   
  • Ask if she is passing urine normally, or if there has been any change in how often she passes urine during the day (to assess for dehydration, as adults typically pass urine 4 to 7 times per day)
  • Ask about symptoms of dehydration—such as dry mouth/tongue, weakness, or dizziness
  • Ask if she has been in contact with anyone with gastroenteritis
  • Ask about her occupation—if she works in food handling, this may require stool testing and exclusion from work
  • Ask about recent travel abroad
  • Ask about recent use of antibiotics (to rule out C. difficile)
  • Ask if she is on any other medications besides the COCP, and whether the diarrhoea or vomiting has affected her ability to take the pill
  • Give a likely diagnosis of viral gastroenteritis

Example of explanation to patient​

Thanks for explaining everything so clearly, Sabrina. From what you’ve described, this sounds very much like a stomach bug caused by a virus, what we call viral gastroenteritis. It is common and, usually settles within a few days, and doesn’t typically require antibiotics.

You mentioned you wondered if it might be related to the meal you had at the restaurant. That’s understandable, but based on the timing, it’s less likely to be food poisoning. Food poisoning usually causes symptoms within 2 to 6 hours of eating contaminated food, whereas your symptoms started the following day. Also, your boyfriend, who ate at the same place, hasn’t become unwell, which makes a viral cause more likely.

I know you’re eager to get back to work, and that’s completely understandable. In most cases, the body clears this on its own with rest and fluids. Antibiotics won’t help in this situation and may even make things worse by upsetting the tummy. Similarly, we don’t routinely recommend anti-diarrhoea medications because they can slow down how quickly the body clears the infection.

That said, if you’re otherwise well and your stools have no blood or mucus and you don’t have a high fever, you could consider using an over-the-counter medication like loperamide to help settle the diarrhoea temporarily, especially if you feel you need it to manage essential activities. But just to be clear, this should be avoided if your symptoms worsen or show signs of bacterial infection.

I will advise staying off work until 48 hours after your last episode of diarrhoea or vomiting, as that’s the period during which you could still spread the infection to others, even if you’re feeling better.

You’re doing the right thing by keeping hydrated. Try to sip fluids regularly. I will also send you a link explaining how your contraceptive pill may be affected by diarrhoea, so you know when to use extra protection, just in case.

Management

Management

  • Reassure the patient that this is likely a case of self-limiting viral gastroenteritis
  • Advise to maintain adequate hydration by increasing fluid intake
  • Explain that antibiotics and antidiarrhoeal (antimotility) medications are not recommended in this context, as the illness is usually self-limiting and resolves on its own. 
  • Inform the patient that if she feels she needs rapid symptom relief to help her return to essential activities, she may choose to purchase loperamide (an antimotility agent) over the counter
  • Advise that loperamide or other antidiarrhoeal agent should not be used if she has blood, mucus, or pus in the stools, or if she develops a high fever, as these may suggest a more serious infection such as dysentery, which requires medical assessment
  • Advise that she should not return to work or attend any social or institutional settings until at least 48 hours after the last episode of diarrhoea or vomiting
  • Emphasise hygiene measures to prevent spread, thorough handwashing, cleaning the toilet with disinfectant, and using a disposable cloth or one kept specifically for toilet cleaning
  • Advise that due to diarrhoea and vomiting, the effectiveness of her combined oral contraceptive pill (COCP) may be reduced. She should use extra protection (e.g., condoms) until 7 days after symptoms stop.
  • Explain that if she was ill (vomiting or diarrhoea) for more than 24 hours while taking the last 7 pills before her pill-free break, she should skip the break and start the next pack straight away
  • Offer to send her a leaflet or link to official guidance on COCP use during diarrhoea/vomiting.
  • Advise that she can self-certify for up to 7 days; after that, a sick note will be needed if she is still unwell
  • Provide safety netting: advise to seek medical attention if symptoms are not settling by day 7, are worsening, or if she notices any red flags—such as blood in stools, abdominal pain, signs of dehydration (e.g., dizziness, dark urine, reduced urine output)

Learning point from this station: ​

When patients present with gastrointestinal symptoms after eating at a restaurant, differentiating between viral gastroenteritis and food poisoning can be challenging. However, the timing of symptom onset is a key distinguishing factor. Food poisoning symptoms typically begin within few hours (2–6 hours) of consuming contaminated food, whereas viral gastroenteritis symptoms usually appear 24–48 hours after exposure.

Most cases of acute diarrhoea are usually self-limiting, and investigations such as stool culture are not routinely required. However, stool testing should be considered if:

  • Diarrhoea persists beyond 7 days
  • There is suspected food poisoning
  • The patient has had recent antibiotic or PPI use, or recent hospital admission (to exclude Clostridium difficile)
  • There is bloody, mucous, or painful diarrhoea, which may suggest dysentery or STEC (e.g. E. coli O157)
  • The person is at increased risk of transmission (e.g. food handlers, nursery/school children under 6, or healthcare/social care workers)
  • There has been recent travel abroad outside of Western Europe, North America, Australia, or New Zealand
  • There has been contact with an affected person or outbreak, particularly in households, care homes, or community settings

Notification to the local Health Protection Team (HPT) is required if a notifiable disease is suspected (e.g. food poisoning, Shigella, enteric fever, or cholera), even before lab confirmation. This helps control spread and allows for public health intervention.

Additionally, it is important to practice holistically. In this case, the patient is on the combined oral contraceptive pill, and diarrhoea and vomiting can reduce its effectiveness. Clinicians should take the opportunity to provide contraceptive safety advice, including the need for additional protection and how to manage pill-taking around gastrointestinal illness. 

Further reading