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Name
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Taylor Parker
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DOB
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04/06/1961 (54 years)
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Occupation
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Security guard
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History
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I talk very little and am annoyed
that I am not talking to a doctor. My wife noticed that I have become
increasingly yellow over the last week, although she's unsure of exactly when
and where it started. If asked directly, I have had 9 kilograms of weight
loss over the last 2 months. I have also noticed my stool has been closer to
the colour of clay and my urine much darker than it was previously. I have a
really poor appetite and occasionally I feel quite sick. I have not had any
pain. I do not suffer from any other symptoms
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Past Medical History
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Asthma. Never been admitted and well
controlled.
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Drug History
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Atorvastatin, one tablet at night.
Allergy to simvastatin
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Family History
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None
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Social History
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Current smoker of 30 cigarettes per
day over 10 years. Drink alcohol frequently but not excessively with a few
beers every other day. No recent travel. Sexually active with wife, 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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Asks for associated features: joint
pain, lethargy, skin hyperpigmentation
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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 (Pancreatic Cancer, Alcoholic Liver Disease, Hepatitis B)
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0
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1
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