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Name
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Lee Sabatino
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DOB
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12/12/1948 (66 years)
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Occupation
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Television presenter
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History
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I am embarrassed to admit that I have
come because I've noticed fresh blood mixed in with my stool. It began a few
weeks ago and hasn't really changed in amount. It occurs every time I go and
I find myself getting increasingly worried. I have not noticed any change in
my bowel habits. I am still going 2-3 times per week. If asked directly, I
may have lost 5kg in the last few weeks but haven't been dieting or anything
else. I have had no other symptoms (no appetite loss, nausea/vomiting,
incomplete emptying, pain). Apart from this I have been feeling more tired for
a number of weeks but deny palpitations or breathlessness. I also deny any
rashes, joint pain or eye symptoms. I have never experienced this before. I
have not had any recent illness nor contact with anyone ill nor have I been
abroad recently.
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Past Medical History
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No history of polyps or bleeding
disorders. I do not participate in the bowel cancer screening programme. Have
high blood pressure.
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Drug History
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I take paracetamol for the occasional
headache and some medication to lower my blood pressure
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Family History
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No family history of bowel disorders
including cancer. Mother had endometrial cancer at 60 years which was treated
successfully. Father has prostate cancer at 90 years.
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Social History
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I smoke and drink on the weekends but
not in excess
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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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Clarifies that it is not haematuria
or vaginal bleeding (if female)
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0
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1
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Clarifies whether blood is mixed in
with stool, around the stool, dripping from the anus or on tissue paper
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0
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1
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Establishes duration and trigger (if
present)
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0
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1
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Establishes character: fresh,
dark/melaena, liquid/clots, mucus, smell
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0
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1
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Establishes amount and frequency
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0
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1
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Establishes time course (worsening,
continuous, intermittent)
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0
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1
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Asks for alleviating or exacerbating
factors (specifically dietary, constipation, anal intercourse, foreign
bodies)
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0
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1
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2
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Asks for associated pain, itching,
tenesmus, lumps/piles, prolapse, change in bowel habit, abdominal pain
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0
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1
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2
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Asks for IBD symptoms: red eye, joint
pain, skin lesions, oral ulcers, bloody diarrhoea
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0
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1
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Establishes if symptoms of anaemia
are present: lethargy, palpitations, shortness of breath
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0
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1
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Identifies any red flags:
haematemsis, weight loss, loss of appetite
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0
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1
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Asks for any recent illness, bleeding
from elsewhere or any family members/contacts with similar symptoms
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0
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1
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Asks if they participate in bowel
screening programme (above 60 years in England)
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0
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1
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Elicits past medical and surgical
history (specifically previous rectal bleeding or disorders, bowel disorders)
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0
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1
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Asks for any recent foreign travel
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0
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1
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Elicits family history (specifically
asking for colon cancer, polyps, angiodysplasia, inflammatory bowel disease)
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0
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1
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Elicits drug history (specifically
NSAIDs, warfarin or other blood thinners)
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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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Asks if any history of illicit drug
use
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0
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1
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Checks impact of symptoms on
occupation
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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 (Bowel cancer, Polyps, Inflammatory Bowel Disease)
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0
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1
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