Luciana's Jaundice

Name	Luciana Rivera
DOB	16/06/1984 (31 years)
Occupation	Publisher
History	I am very talkative. I have been feeling under the weather, with some fever and I have noticed that I have gone yellow all over. I thought it could be because I drink but thought I should get it checked up. If asked directly and assured about confidentiality, I admit that during my business trip to Africa 5 weeks ago I slept with a few women. I paid for the sex and it was unprotected. I deny any other symptoms. I deny any intravenous drug use, transfusions abroad or tattoos.
Past Medical History	If asked directly, admits to several sexually transmitted infections that have been treated. No other conditions
Drug History	None. Allergy to penicillin which causes anaphylaxis
Family History	My father had inflammatory bowel disease and type 2 diabetes. My mother is well
Social History	Smoke around 5 cigarettes per day for 10 years. I have at the most two cans of regular strength beer every few days when I am watching football. Occasionally I may drink more when I am at the pub on the weekend

Introduces yourself	0	1
Confirms name, age & occupation of patient	0	1
Explains reason for consultation & builds rapport	0	1
Gains consent	0	1
Asks open question	0	1
Establishes duration and trigger (if present)	0	1
Establishes evolution (onset to now)	0	1
Establishes time course (worsening, continuous, intermittent in Gilbert's syndrome)	0	1
Identifies red flags: painless jaundice, weight loss, loss of appetite	0	1
Asks for any recent illness, fever or any family members/contacts with similar symptoms	0	1
Asks for gallstone/obstructive symptoms: abdominal pain, pale stool, dark urine, pruritus, steatorrhoea	0	1
Asks for liver symptoms: abdominal or ankle swelling, easy bruising, confusion, sleep-night reversal	0	1
Asks for associated features: joint pain, lethargy, skin hyperpigmentation	0	1
Identifies risk factors for viral hepatitis (intravenous drug user particularly needle sharing, blood transfusions outside the UK, tattoos, piercing, needle stick injuries)	0	1
Takes brief sexual history signposting before doing this	0	1
Elicits past medical history (specifically asking for previous jaundice, diabetes, haemolytic anaemia, inflammatory bowel disease, heart failure, autoimmune disorders)	0	1
Elicits family history (specifically asking for viral hepatitis, autoimmune hepatitis, liver cancer)	0	1
Elicits drug history (specifically hepatitis B and C immunisation, antibiotics, tuberculosis medication, antiepileptics, herbal medication)	0	1
Asks for any foreign travel and consumption of raw food	0	1
Checks for allergies	0	1
Checks if patient smokes or drinks	0	1
Asks if any history of illicit drug use	0	1
Explores and responds to ideas	0	1
Explores and responds to concerns	0	1
Explores and responds to expectations	0	1
Shows empathy	0	1
Avoids jargon	0	1
Summarises back to patient	0	1
Thanks patient	0	1
Patient global score	0	1	2
Gives reasonable differential diagnosis (Hepatitis B, Hepatitis C, Hepatitis A, Alcoholic Liver Disease)	0	1

Share this

Related Posts