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Name
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Carol Howard
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DOB
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15/08/1967 (40 years)
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Occupation
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Office Worker
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History
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Upper abdominal pain, mostly in the RUQ. Started 8 hours ago, initially would come and go in waves, but now is constant for 6 hours (8/10). Had similar pain that comes and goes after eating (particularly after fatty food, thought it was indigestion). Nothing helps the pain. Feeling nauseous but no vomiting. No change in bowel habit. No jaundice.
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Past Medical History
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Type 2 Diabetes
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Drug History
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NKDA. Metformin
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Family History
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Father died from MI at 65
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Social History
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BMI 32, 20 units alcohol weekly, non-smoker
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Introduction & consent
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Name, age, occupation
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Asks open question
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Establishes site of pain
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Establishes onset & duration of pain e.g. sudden, gradual
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Establishes time course of pain e.g. intermittent, progressive or continuous
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Establishes character of pain
e.g. colicky (renal stones), burning (peptic ulcer or reflux disease), sharp (rupture of viscus) or dull | |
Asks if pain radiates
e.g. loin to groin (renal stones), shoulder tip (gallbladder), back (abdominal aortic aneurysm or ruptured duodenal ulcer) groin or testicles (hernia) | |
Asks how severe pain is
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Alleviating factors (diet, opening bowels)
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Exacerbating factors (swallowing, fatty food (gallstones), spicy food/hot drinks (peptic ulcer))
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Checks for associated symptoms: nausea/vomiting, bowel habits, dysphagia, dyspepsia, bloating/swelling, flatulence, fever
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Screens for hepatic/gallstone symptoms: jaundice, ankle swelling, dark stools, pale urine
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Enquires about relationship with periods, menorrhagia, irregular periods, vaginal discharge/bleeding, dyspareunia
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Checks if patient pregnancy is possible (contraceptive use, last period and unprotected sexual intercourse)
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Identifies any red flags: rectal bleeding (fresh/melaena), vaginal bleeding, haemetemsis, haematuria, weight loss, loss of appetite
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Asks for any recent illness or any family members/contacts with similar symptoms
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Past medical and surgical history (specifically abdominal pain, bowel disorders)
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Family history (specifically asking for colon cancer, inflammatory bowel disease)
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Drug history and allergies
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Smoking, alcohol and illicit drug use
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Checks impact of symptoms on occupation
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Ideas
"Was there anything you thought it might be?" | |
Concerns
"What about it is worrying you in particular?" | |
Expectations
"Is there anything in particular you were hoping we would to today?" | |
Communication skills (empathy and avoids jargon)
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Summarises back to patient
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Gives reasonable differential diagnosis (Cholecystitis, Biliary Colic, Ectopic Pregnancy)
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