Philip Gorman

Age: 68 years old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis   

  • Ask how long the symptoms have been going on
  • Ask about the amount and pace of weight loss (quantify if possible)
  • Ask about abdominal pain
  • Ask if the stools have been loose or if there has been any change in bowel habit
  • Ask about nausea/vomiting 
  • Ask if there are any masses (lumps or bumps) felt in the abdomen
  • Ask about anaemia-related symptoms: dizziness, light-headedness, fainting, shortness of breath
  • Ask if any recent vital signs have been checked (BP, pulse, etc.)
  • Ask if Philip has been more tired than usual (suggestive of anaemia or general decline)
  • Ask about appetite and whether it has changed
  • Ask about any family history of bowel cancer or bowel disease
  • Ask if there’s any history of smoking
  • Ask about Philip’s general health before these symptoms started (to assess baseline function and fitness)
  • Make a working diagnosis of possible bowel cancer

Example of explanation to patient​

Andy, thank you for sharing everything so clearly — it’s clear how much you care about Philip and want to do what’s best for him. 

From what you’ve told me, the recent weight loss, the blood in the stools, the left-sided tummy pain, and the fact that his bowel movements are a mix of loose and normal, these are symptoms that we take seriously and we do have a few possible explanations.

One of the things we need to consider is bowel cancer like you mentioned, especially given the family history and the nurse’s concern. But we also keep in mind other possibilities, such as bowel infections (infectious gastroenteritis), which can cause diarrhoea and blood, or sometimes other bowel conditions. It’s important we try to understand what’s going on, but do this in a way that causes as little stress for Philip as possible.

I completely understand your concerns about putting Philip through anything distressing. He has a severe learning disability, he’s non-verbal, and you’ve mentioned he’s not open to being examined or having much done, that makes things more complicated, and we have to handle this gently.

Philip is normally physically fit, and so if there’s something going on that we can identify and manage in a way that keeps him comfortable, that may be in his best interests. We’d never rush into anything without thinking it through carefully.

One simple, non-invasive step we can take is a FIT test, which involves collecting a small stool sample, something the carers might be able to help with. This helps us assess whether the bleeding might be coming from deeper in the bowel, which could mean something more serious is going on. Even though we’ve already seen visible blood, this test can still help guide what we do next. In addition, we will also do a stool culture, to rule out an infection in the bowel that might be causing the loose stools or blood.  

If the results come back reassuring, we might be able to monitor him without needing more tests. If they come back concerning, then we’d carefully consider the next steps.

Now, I appreciate that even if it is positive, more tests like a scan or camera test could be distressing for Philip. That’s where we have to pause and think very carefully. We’d hold a best interest meeting with you as his LPA, the care team, and possibly others like a learning disability specialist nurse. We would look at:

  • Whether the test is truly necessary
  • What benefit it would bring Philip
  • Whether it can be done safely, with the least amount of distress

Sometimes things can be done under light sedation or even a short general anaesthetic, but we’d only consider that if absolutely necessary, and only if everyone agrees it’s in his best interests.

On the other hand, if the team, including you, feel that further investigations or treatment would cause more harm or distress than benefit, then we may decide to focus purely on keeping Philip comfortable and managing any symptoms as they arise.

I want to reassure you that we will always act in Philip’s best interests, and that includes listening to you, since you know him best. We will never force anything on him. We’ll take things step by step, and I will support you through that process.

Would you be comfortable with us starting with the FIT test and stool culture as a first step, and then coming together for a proper discussion if it comes back positive?

Management

  • Offer a care home visit for a face-to-face assessment to see if Philip will allow a clinical review in person.
  • Offer FIT test and Stool culture – explain that carers can collect a stool sample from Philip’s pad or commode when he next opens his bowels.
  • Explain to the LPA/NOK that if the FIT test comes back positive, further referral (2-week wait) and  investigations (e.g., CT colonography or colonoscopy) may be needed, but this would first be discussed in a best interest meeting involving: The LPA, Care home staff/nurse, the GP (Yourself)  and a learning disability nurse. 
  • In the best interests meeting, the team would consider: Philip’s baseline health and quality of life, whether the test is clinically necessary, whether it can be done safely, with the least possible distress and what benefit further investigation or treatment would bring. 
  • Explain that light sedation or short general anaesthesia may be options for certain investigations, but these would ONLY be used if absolutely necessary, and only if everyone involved agrees it’s in his best interests. 
  • Reassure that if the team, including the LPA, feel that further tests or treatment would cause more harm or distress than benefit, the plan may instead focus on comfort care and symptom management.
  • Emphasise that all decisions will be guided by Philip’s best interests, and that no procedures will be forced; the process will be taken step by step, with the LPA fully involved and supported.
  • If a 2WW referral is made, advise to recontact the surgery if there is no hospital contact within 2 weeks.
  • If investigations are declined or deferred, offer symptom management, such as analgesia for abdominal pain. 
  • Advise the LPA to inform the care home that if patient’s condition worsens, he appears unwell, or if they have any concerns about his health, they should contact the GP surgery promptly.

Learning point from this station: ​

This station highlights the complexity of managing red flag bowel symptoms in a patient with severe learning disability and no capacity to consent. All decisions must be made following the Mental Capacity Act (2005), with a focus on acting in the patient’s best interests, using the least restrictive options, and involving the LPA and care team in decision-making.

In patients presenting with symptoms such as rectal bleeding, weight loss, abdominal pain, and a change in bowel habit, colorectal cancer must be considered. When the patient cannot tolerate invasive testing, initial non-invasive investigations like FIT (faecal immunochemical testing) and stool culture may be appropriate as first steps.

A key update in clinical guidance is that FIT testing is now recommended even in patients who present with rectal bleeding. This is because FIT does not detect fresh blood (such as from haemorrhoids or fissures) but instead detects degraded haemoglobin — a breakdown product that indicates bleeding from higher up in the bowel, which may be due to cancer or polyps. FIT is therefore a valuable risk assessment tool to guide referral and investigation decisions in primary care.

Importantly, faecal calprotectin should not be used when colorectal cancer is suspected. Calprotectin can be elevated in both inflammatory bowel disease and bowel cancer, as both involve inflammation. Using calprotectin inappropriately can delay a potentially serious diagnosis by creating false reassurance or diagnostic confusion. Calprotectin is more appropriate when cancer is not suspected, and the concern is to differentiate between IBD and functional bowel disorders.

If FIT is positive or clinical concern remains high, further testing may be needed. However, in patients who lack capacity and may be distressed by hospital procedures, this should trigger a formal best interests meeting, involving the LPA, carers, GP, and possibly a learning disability nurse. The decision to proceed with further testing, such as CT colonography or colonoscopy with sedation, must be based on whether the test is:

  • Truly necessary
  • Likely to benefit the patient
  • Tolerable and safe to carry out

If the burden outweighs the benefit, a plan of symptom management and supportive care may be more appropriate.

This case reinforces the importance of:

  • Careful clinical triage and ethical reasoning
  • Appropriate use of FIT over calprotectin in suspected cancer
  • Early involvement of the wider MDT and family
  • Providing clear safety netting and arranging follow-up