Krystal's Diarrhoea

Name	Krystal Worthey
DOB	04/02/1977 (38 years)
Occupation	Crematorium worker
History	I felt unwell 2 days ago with a fever and then I suddenly got very watery diarrhoea. I have to go around 7 times a day. It is like a chocolate milkshake in consistency. There isn't any mucus or blood in it. I have not had diarrhoea or constipation for many years now. I have slight abdominal pain but it isn't too bad. I have been feeling a little dizzy and faint but am otherwise okay. I cannot think of anything I ate that could be the cause although one of my friends also has similar symptoms. I have also been vomiting a lot so have not been able to keep anything down but no weight loss. No other symptoms.
Past Medical History	If specifically asked, one day admission one week ago for chest infection
Drug History	If specifically asked, antibiotics for recent chest infection. Allergic to penicillin.
Family History	Nil
Social History	Travelled to India one month ago. Non-smoker, non-drinker and no use of recreational drugs

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
Elicits what the patient means by diarrhoea	0	1
Asks for the onset of diarrhoea	0	1
Elicits the consistency of the diarrhoea (How watery? Pellets? Greasy and hard to flush away?)	0	1
Checks colour of the diarrhoea is and asks if it smells offensive	0	1
Checks for mucus, blood or melaena in the diarrhoea	0	1
Elicits if the diarrhoea has been constant or intermittent	0	1
Elicits rough volume of stool and frequency	0	1
Checks for previous history of diarrhoea or constipation	0	1
Identifies, if present, any triggers or exacerbating factors (diet: unpasteurised dairy/uncooked meat, gluten, contact with ill person, animals)	0	1	2
Elicits any alleviating factors	0	1
Asks patient if they have ulcers, nausea, vomiting (if so, explores)	0	1
Checks if patient has had abdominal pain (reduced by defaecating?) or bloating	0	1
Asks if patient has had a change in bowel habits or increased flatulence	0	1
Checks if patient has anal pain, tenesmus or incontinence	0	1
Asks constitutional symptoms (fever, tiredness, loss of appetite, weight loss)	0	1
Asks if patient has had joint or eye pain or any rashes	0	1
Checks if patient has had recent antibiotics or hospital care	0	1
Checks for changes in periods or abnormal menstrual bleeding	0	1
Elicits past medical and surgical history	0	1
Asks if there is a family history of bowel problems including colon cancer, inflammatory bowel disease and coeliac's)	0	1
Elicits a drug history including laxative use and over the counter medication	0	1
Recent hospital admission or use of antibiotics	0	1
Checks for allergies	0	1
Elicits a social history including travel abroad (if so contact with abnormal food/animals, (if appropriate) drunk non-bottled water?), recent changes to diet	0	1
Checks if patient smokes or drinks	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 (Viral gastroenteritis, bacterial gastroenteritis including c difficile, inflammatory bowel disease, irritable bowel syndrome)	0	1

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