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Name
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Douglass Hopf
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DOB
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08/06/1964 (51 years)
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Occupation
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Stockbroker
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History
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I suddenly began vomiting blood
yesterday so thought I should get it checked up. It was only a little amount
of blood so it probably isn't serious. I cannot remember how much and it
might have happened before but I'm not exactly sure. If asked directly,
co-worker mentioned that my eyes are looking yellow and I have noticed some
red spider-like rash on my chest. I have not had any pain, dark stools or
pain/difficulty whilst eating. I have lost my appetite a little and have lost
2kg in weight over the last few weeks. After admitting alcohol abuse, is
willing to admit if asked that you are worried you've messed up your liver.
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Past Medical History
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Anxiety and depression since my wife
passed away 3 years ago. Not been the same since
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Drug History
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Occasional paracetamol for morning
headaches
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Family History
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Unknown. Lived in a group home before
running away.
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Social History
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Non-smoker. Denies drinking
excessively, admits to a little during the day to keep going. If asked
directly, admits to several bottles of wine a day.
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Introduces self
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0
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1
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Confirms name & age of patient
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0
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1
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Explains reason for consultation
& builds rapport
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0
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1
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Gains consent
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0
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1
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Asks open question
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0
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1
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Establishes if true haematemesis or
potentially haemoptysis
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0
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1
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Assesses volume
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0
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1
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Confirms type (coffee grounds, dark
clots, fresh blood, mixed with vomitus)
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0
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1
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Establishes onset and number of
events
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0
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1
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Asks if there were any triggering
events
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0
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1
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Specifically screens for
retching/alcohol use prior to episode for Mallory-Weiss tear
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0
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1
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Specifically screens for NSAID
overuse (peptic ulcer)
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0
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1
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Screens for associated melaena,
abdominal/chest pain
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0
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1
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2
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Assesses for shock (faintness, shortness
of breath, palpitations)
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0
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1
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Looks for associated dysphagia,
odynophagia and vomiting
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0
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1
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2
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Looks for associated liver disease
(right upper quadrant pain, jaundice)
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0
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1
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Screens red flags of dysphagia, loss
of appetite and weight loss
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0
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1
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2
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Asks for past episodes of
haematemesis
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0
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1
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Elicits past medical history
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0
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1
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Specifically screens for
gastro-oesophageal reflux disease, peptic ulcer, liver disease and varices,
clotting disorders
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0
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1
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2
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Elicits family history (specifically
asking for upper gastrointestinal cancers)
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0
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1
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Elicits drug history (including use
of NSAIDs, Warfarin, Steroids and others)
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0
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1
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Checks for allergies
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0
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1
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Checks if patient smokes or drinks
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0
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1
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Checks occupation of patient
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0
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1
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Explores and responds to ideas
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0
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1
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Explores and responds to concerns
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0
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1
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Explores and responds to expectations
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0
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1
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Shows empathy
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0
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1
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Avoids jargon
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0
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1
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Summarises back to patient
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0
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1
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Thanks patient
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0
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1
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Patient global score
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0
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1
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2
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Gives reasonable differential
diagnosis (Oesophageal varices secondary to alcohol abuse, gastritis, peptic
ulcer, mallory-weiss tear)
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0
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1
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