Print
PDF
Name
|
Flavia Stocking
|
DOB
|
05/12/1977 (37 years)
|
Occupation
|
Insurance consultant
|
History
|
I noticed increasing amounts of fresh
blood whenever I am wiping my bum associated with some pain. It started
around a month ago and I have tried to ignore it. I cannot think of what
could have caused it. There is no history of trauma. I deny any history of
anal sex and I have never inserted anything into my anus. I deny any other
symptoms including any change in bowel habits, pain or weight loss. I have no
history of prolonged standing or sitting. No other symptoms including no
joint pain, rashes or eye symptoms.
|
Past Medical History
|
Diabetes which is well controlled
with medication
|
Drug History
|
Metformin
|
Family History
|
Mother has Type 2 diabetes
|
Social History
|
Smoking 20 cigarettes per day. No
alcohol or recreational drug use. No recent travel
|
Introduces self
|
0
|
1
|
|
Confirms name & age of patient
|
0
|
1
|
|
Explains reason for consultation
& builds rapport
|
0
|
1
|
|
Gains consent
|
0
|
1
|
|
Asks open question
|
0
|
1
|
|
Clarifies that it is not haematuria
or vaginal bleeding (if female)
|
0
|
1
|
|
Clarifies whether blood is mixed in
with stool, around the stool, dripping from the anus or on tissue paper
|
0
|
1
|
|
Establishes duration and trigger (if
present)
|
0
|
1
|
|
Establishes character: fresh,
dark/melaena, liquid/clots, mucus, smell
|
0
|
1
|
|
Establishes amount and frequency
|
0
|
1
|
|
Establishes time course (worsening,
continuous, intermittent)
|
0
|
1
|
|
Asks for alleviating or exacerbating
factors (specifically dietary, constipation, prolonged standing or sitting,
anal intercourse, foreign bodies)
|
0
|
1
|
2
|
Asks for associated pain, itching,
tenesmus, lumps/piles, prolapse, change in bowel habit, abdominal pain
|
0
|
1
|
2
|
Asks for IBD symptoms: red eye, joint
pain, skin lesions, oral ulcers, bloody diarrhoea
|
0
|
1
|
|
Establishes if symptoms of anaemia
are present: lethargy, palpitations, shortness of breath
|
0
|
1
|
|
Identifies any red flags:
haematemsis, weight loss, loss of appetite
|
0
|
1
|
|
Asks for any recent illness, bleeding
from elsewhere or any family members/contacts with similar symptoms
|
0
|
1
|
|
Asks if they participate in bowel
screening programme (above 60 years in England)
|
0
|
1
|
|
Elicits past medical and surgical
history (specifically previous rectal bleeding or disorders, bowel disorders)
|
0
|
1
|
|
Asks for any recent foreign travel
|
0
|
1
|
|
Elicits family history (specifically
asking for colon cancer, polyps, angiodysplasia, inflammatory bowel disease)
|
0
|
1
|
|
Elicits drug history (specifically
NSAIDs, warfarin or other blood thinners)
|
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
|
|
Checks impact of symptoms on
occupation
|
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 (Haemorrhoids, Anal fissures)
|
0
|
1
|