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Name
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Mark Fletcher
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DOB
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06/01/1995 (23 years)
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Occupation
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Dental Student
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History
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Woke this morning with generalised abdominal pain 6/10 in severity. Pain progressively became more severe (8/10) and now located in RIF. Was in bed when the pain came on. Pain is made worse by movement, and better slightly by lying completely still with knees up towards chest. Has been vomiting from about an hour after the pain started (approximately 5 times), no blood or bile in the vomit. Two episodes of diarrhoea, no blood in stool. No contact with anyone who has been ill. No recent travel.
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Past Medical History
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Asthma
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Drug History
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NKDA. Salbutamol inhaler (uses less than once a week)
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Family History
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Father has ulcerative colitis
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Social History
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Non-smoker. Does not drink alcohol.
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Introduction & consent
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Name, age, occupation
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Asks open question
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Establishes site of pain
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Establishes onset & duration of pain e.g. sudden, gradual
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Establishes time course of pain e.g. intermittent, progressive or continuous
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Establishes character of pain
e.g. colicky (renal stones), burning (peptic ulcer or reflux disease), sharp (rupture of viscus) or dull | |
Asks if pain radiates
e.g. loin to groin (renal stones), shoulder tip (gallbladder), back (abdominal aortic aneurysm or ruptured duodenal ulcer) groin or testicles (hernia) | |
Asks how severe pain is
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Alleviating factors (diet, opening bowels)
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Exacerbating factors (swallowing, fatty food (gallstones), spicy food/hot drinks (peptic ulcer))
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Checks for associated symptoms: nausea/vomiting, bowel habits, dysphagia, dyspepsia, bloating/swelling, flatulence, fever
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Screens for IBD symptoms: red eye, joint pain, skin lesions, oral ulcers, bloody diarrhoea
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Identifies any red flags: rectal bleeding (fresh/melaena), vaginal bleeding, haemetemsis, haematuria, weight loss, loss of appetite
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Asks for any recent illness or any family members/contacts with similar symptoms
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Past medical and surgical history (specifically abdominal pain, bowel disorders)
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Family history (specifically asking for colon cancer, inflammatory bowel disease)
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Drug history and allergies
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Smoking, alcohol and illicit drug use
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Checks impact of symptoms on occupation
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Ideas
"Was there anything you thought it might be?" | |
Concerns
"What about it is worrying you in particular?" | |
Expectations
"Is there anything in particular you were hoping we would to today?" | |
Communication skills (empathy and avoids jargon)
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Summarises back to patient
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Gives reasonable differential diagnosis (Appendicitis, Gastroenteritis, Testicular torsion)
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