Abdominal Pain OSCE - Irritable Bowel Syndrome

Case Overview

• Age/Sex: 20-year-old female
• Occupation: University student (undergraduate)
• Setting: Student health clinic during exam period
• Chief complaint: "Abdominal pain"

Patient Script

Who I Am

I'm a 20-year-old uni student studying biology, here because things have been off with my tummy while I'm preparing for finals.

What Brings Me In

My stomach has been hurting on and off for months, and it's been worse this week with my exams — I wanted someone to check it out and tell me if it's serious.

My Story

I've had intermittent tummy pain for about 6 months, but it's been worse over the last 3 weeks while I'm studying for exams. The pain is usually a crampy ache in my lower belly, sometimes on both sides. It often gets a bit better after I go to the loo. My bowel habits have changed — sometimes I get looser stools for a day or two and sometimes I get a bit constipated; it tends to vary. I don't have blood in my stool. I haven't lost weight — I actually feel a bit stressed and haven't been eating as normally. No fever. I get headaches and take ibuprofen occasionally. I had a course of antibiotics for a throat infection about 2 months ago but that was short and after that I was fine for a while. I went on a trip to Spain about 4 months ago for a week but nothing else unusual then. My periods are a bit painful (like normal cramps) but I haven't noticed the tummy pain being clearly linked to my period.

My Medical Background

• Past medical history: No major illnesses; occasional tension headaches
• Medications: Combined oral contraceptive pill (for contraception), ibuprofen PRN for headaches
• Allergies: None known
• Social: Non-smoker, drinks alcohol occasionally (2–3 drinks on weekends), lives in student halls, sexually active with one partner and uses condoms sometimes
• Family: Aunt had "bowel problems" but no formal diagnosis I know of; mother has mild anxiety

What I Think & Worry About

• I think it might be stress from exams making my stomach worse.
• I'm worried it could be something serious like an infection or something wrong with my bowel.
• I'm also anxious it could affect my ability to get through exams.

If You Ask Me About Other Symptoms...

• Appetite: "My appetite is okay, maybe a bit less when I'm stressed."
• Weight: "I haven't lost weight — if anything I'm a little heavier than last year."
• Fever/night sweats: "No fevers or night sweats."
• Blood in stool: "No — I've not seen blood."
• Nausea/vomiting: "Sometimes I feel a bit nauseous when it's really bad, but I haven't vomited."
• Urinary symptoms: "No burning or frequency; I had a urine dip once at the campus clinic and it was fine."
• Menstrual pain/sexual health: "Periods are a bit painful as usual; no unusual vaginal discharge."
• Travel/exposure: "I went to Spain 4 months ago but was fine afterwards."
• Recent antibiotics: "I had antibiotics 2 months ago for tonsillitis but felt back to normal after a few days."

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Clinical Summary

Examination

• General: Well-appearing, anxious-appearing university student
• Vitals: Temperature 36.6°C, HR 78 bpm, BP 110/70 mmHg, RR 14/min, SpO2 99% on room air
• BMI: 22 kg/m2
• Abdominal exam: Soft, mild diffuse lower abdominal tenderness (more in the suprapubic and lower left quadrant), no rebound tenderness, no guarding, no palpable masses
• Bowel sounds: Present, non-tender percussion, no hepatosplenomegaly
• Pelvic/rectal: External genitalia normal, no obvious pelvic tenderness on limited exam; rectal exam deferred (or normal if performed)

Investigations

• Pregnancy test (urine β-hCG): <5 IU/L (negative)
• FBC: Hb 13.1 g/dL, MCV 90 fL, WCC 6.5 x10^9/L (all within reference ranges) (no anemia or leukocytosis)
• CRP: 1.2 mg/L (normal) (no systemic inflammation)
• ESR: 6 mm/hr (normal)
• TSH: 2.1 mU/L (normal)
• Celiac serology (tTG IgA): negative (within reference range)
• Faecal calprotectin: 30 µg/g (normal, suggestive against active inflammatory bowel disease)
• Stool culture & ova/parasites: negative (no enteric pathogen identified)

Diagnosis

Primary diagnosis:

• Irritable Bowel Syndrome (probable IBS - mixed subtype), supported by:
  • Chronic intermittent abdominal pain for ~6 months, exacerbated by stress
  • Pain improves with defecation and associated with change in stool form and frequency (alternating loose stools and constipation)
  • Absence of alarm features (no weight loss, no rectal bleeding, no nocturnal symptoms, normal inflammatory markers and faecal calprotectin)

Differential diagnoses (with reasoning):

• Inflammatory bowel disease — less likely given normal CRP/ESR, normal faecal calprotectin, and no alarm features
• Coeliac disease — unlikely given negative tTG IgA and lack of malabsorption/anemia
• Post-infectious IBS — possible historical trigger given past antibiotic use or travel but current stool studies negative
• Lactose intolerance — could cause similar symptoms but tends to be more clearly linked to dairy ingestion; consider testing or trial
• Functional dyspepsia/gynaecological pathology (e.g., endometriosis) — less likely given pain pattern and absence of cyclical worsening linked to menses, but consider if symptoms change

Management

• Reassure the patient that findings are most consistent with IBS and that serious disease is unlikely given normal exam and investigations
• Explain typical trigger relationship between stress and gut symptoms; validate impact on exams and daily life
• Lifestyle/dietary measures:
  • Encourage regular meal patterns, adequate hydration, and moderate exercise
  • Consider trial of low-FODMAP dietary advice or referral to a dietitian experienced in IBS
  • Advise fiber modification: soluble fiber (e.g., psyllium) may help if constipation predominant; avoid abrupt increase in fiber
• Symptom-targeted pharmacotherapy as needed:
  • Antispasmodic (e.g., hyoscine) for crampy pain PRN
  • Loperamide for predominant diarrhoea episodes or osmotic laxative for constipation-predominant episodes (tailor to symptoms)
• Address psychosocial contributors:
  • Discuss stress-management strategies; consider guided relaxation, CBT referral if symptoms severe or refractory
• Safety-netting and follow-up:
  • Advise return if alarm features develop: weight loss, rectal bleeding, persistent fever, nocturnal symptoms, progressive anemia, or marked change in symptoms
  • Arrange follow-up in 4–6 weeks to assess response to initial measures
  • Consider gastroenterology referral and endoscopic evaluation if symptoms persist or if alarm features arise

Key Learning Points

• IBS is a functional bowel disorder diagnosed clinically: recurrent abdominal pain related to defecation and associated with a change in stool frequency/form, with exclusion of alarm features and organic disease.

• Use simple investigations (FBC, CRP, faecal calprotectin, pregnancy test, celiac serology as indicated) to exclude inflammatory or organic pathology before labeling IBS.

• Management focuses on symptom-directed therapy, dietary and lifestyle modification, and addressing psychosocial triggers; reassure and provide safety-netting for alarm features.