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Name
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Elna Magruder
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DOB
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01/12/1989 (25 years)
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Occupation
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Hairdresser
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History
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I suddenly began vomiting blood
yesterday so thought I should get it checked up. If asked directly it was
after drinking the night before and I was retching a lot before. Other then
this I deny all other symptoms. I am vague and argumentative and frequently
attempt to annoy the candidate
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Past Medical History
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Nil
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Drug History
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Nil
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Family History
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Father had lung cancer at 80 years.
Mother had breast cancer at 70 years. Maternal uncle has prostate cancer at
60 years
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Social History
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15 cigarettes per day. Massive binges
on the weekend. Uses cannabis and cocaine
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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
|
1
|
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
|
|
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 (Mallory-weiss tear, gastritis, peptic ulcer, oesophageal varices)
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0
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1
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