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Name
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Leah Scott
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DOB
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03/12/1961 (54 years)
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Occupation
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Speech therapist
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History
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I have had this awful dull pain on my
right side, just underneath my ribs which just won't go. It is possibly
moving towards the middle and shoulder. It began suddenly around 6 hours ago
and has been getting worse. Nothing helps with the pain or makes it worse.
Additionally, I have had this awful fever and have completely turned yellow!
I have no idea what is causing this pain, but apart from the yellowness and
fever it seems similar to an episode I had a few months ago, but that went
away after 4 hours and I left the emergency department. I have not passed
urine or stool to know if the colour has changed. I get increasingly angry if
I feel things aren't quickly going forward. I have no other symptoms. I have
not eaten or drunk anything since the pain started
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Past Medical History
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Have 3 children all born normally.
Otherwise never been to hospital
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Drug History
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None. No known allergies
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Family History
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Mother has Type 2 diabetes
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Social History
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Non-smoker. Do not drink alcohol. No
recent travel. Sexually active with husband, no other sexual partners
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Introduces yourself
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0
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1
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Confirms name, age & occupation
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 duration and trigger (if
present)
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0
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1
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Establishes evolution (onset to now)
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0
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1
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Establishes time course (worsening,
continuous, intermittent in Gilbert's syndrome)
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0
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1
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Identifies red flags: painless
jaundice, weight loss, loss of appetite
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0
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1
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Asks for any recent illness, fever or
any family members/contacts with similar symptoms
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0
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1
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Asks for gallstone/obstructive
symptoms: abdominal pain, pale stool, dark urine, pruritus, steatorrhoea
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0
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1
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Asks for liver symptoms: abdominal or
ankle swelling, easy bruising, confusion, sleep-night reversal
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0
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1
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Identifies risk factors for viral
hepatitis (intravenous drug user particularly needle sharing, blood
transfusions outside the UK, tattoos, piercing, needle stick injuries)
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0
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1
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Takes brief sexual history
signposting before doing this
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0
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1
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If female asks if pregnant (HELLP,
obstetric cholestasis)
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0
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1
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Elicits past medical history
(specifically asking for previous jaundice, diabetes, haemolytic anaemia,
inflammatory bowel disease, heart failure, autoimmune disorders)
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0
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1
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Elicits family history (specifically
asking for viral hepatitis, autoimmune hepatitis, liver cancer)
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0
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1
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Elicits drug history (specifically
hepatitis B and C immunisation, antibiotics, tuberculosis medication,
antiepileptics, herbal medication)
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0
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1
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Asks for any foreign travel and
consumption of raw food
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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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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 (Ascending Cholangitis, Hepatitis B, Pancreatitis)
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0
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1
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