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Name
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Shanita Hecker
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DOB
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01/12/1989 (25 years)
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Occupation
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Auctioneer
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History
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I am quite worried that I have
cancer! I vomited up some blood this morning at work and it was so scary. If
directly asked, admits it looks similar to coffee grounds and around 20ml.
There was no specific trigger or retching beforehand. If asked directly, I
have had some associated burning chest pain and dark stools but deny
difficulty or pain whilst eating, if anything food makes it slightly better.
I also deny weight loss or loss of appetite. If asked directly, I suffer from
headaches frequently for which I take aspirin or ibuprofen.
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Past Medical History
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Eczema and hayfever
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Drug History
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If asked directly, ibuprofen or
aspirin for headaches
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Family History
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Father had heart attack at 45 years.
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Social History
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15 cigarettes per day. Drinks
occasionally. High stress job which I need as money is tight. Very concerned
about losing job and will insist on going back to work
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Introduces self
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0
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1
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Confirms name & age 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 if true haematemesis or
potentially haemoptysis
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0
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1
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Assesses volume
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0
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1
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Confirms type (coffee grounds, dark
clots, fresh blood, mixed with vomitus)
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0
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1
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Establishes onset and number of
events
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0
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1
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Asks if there were any triggering
events
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0
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1
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Specifically screens for
retching/alcohol use prior to episode for Mallory-Weiss tear
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0
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1
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Specifically screens for NSAID
overuse (peptic ulcer)
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0
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1
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Screens for associated melaena,
abdominal/chest pain
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0
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1
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2
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Assesses for shock (faintness,
shortness of breath, palpitations)
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0
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1
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Looks for associated dysphagia,
odynophagia and vomiting
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0
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1
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2
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Looks for associated liver disease
(right upper quadrant pain, jaundice)
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0
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1
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Screens red flags of dysphagia, loss
of appetite and weight loss
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0
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1
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2
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Asks for past episodes of
haematemesis
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0
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1
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Elicits past medical history
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0
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1
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Specifically screens for
gastro-oesophageal reflux disease, peptic ulcer, liver disease and varices,
clotting disorders
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0
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1
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2
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Elicits family history (specifically
asking for upper gastrointestinal cancers)
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0
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1
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Elicits drug history (including use
of NSAIDs, Warfarin, Steroids and others)
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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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Checks occupation of patient
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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 (Peptic ulcer, Irritation of oesophagus or stomach, Gastritis,
Tumours)
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0
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1
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