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Name
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Lindy Barlett
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DOB
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02/12/1991 (23 years)
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Occupation
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Cartoonist
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History
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I have had blood mixed in with my
stool for 2 weeks. It is around 2-3 tablespoons of murky blood with bits of
mucous in it each time I pass stool. It has got worse from the last time it
occurred 2 months ago, where it was less blood but still around 2-3 weeks. My
stool has also been runnier but has some lumps. I have also found myself
going more frequently, up to 3 times a day whereas I used to go once a day at
most. I cannot think of any triggers or any particular foods which worsen or
improve my symptoms. It's a little uncomfortable but not too painful. I have
lost around 4kg in weight. I deny any nausea or vomiting. I have not been in
contact with anyone unwell or travelled abroad. just feel unwell with a
slight fever and stomach upset. No other symptoms including no joint pain,
rashes or eye symptoms. I know that this is cancer and I should've got it
checked earlier because I looked up my symptoms online.
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Past Medical History
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Nil
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Drug History
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Nil. No recent antibiotic use or use
of laxatives. No known allergies.
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Family History
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Mother has psoriasis. Nil else
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Social History
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Smoking 20 cigarettes per day. No
alcohol or recreational drug use. No recent travel
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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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Clarifies that it is not haematuria
or vaginal bleeding (if female)
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0
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1
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Clarifies whether blood is mixed in
with stool, around the stool, dripping from the anus or on tissue paper
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0
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1
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Establishes duration and trigger (if
present)
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0
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1
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Establishes character: fresh,
dark/melaena, liquid/clots, mucus, smell
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0
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1
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Establishes amount and frequency
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0
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1
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Establishes time course (worsening,
continuous, intermittent)
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0
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1
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Asks for alleviating or exacerbating
factors (specifically dietary, constipation, anal intercourse, foreign
bodies)
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0
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1
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2
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Asks for associated pain, itching,
tenesmus, lumps/piles, prolapse, change in bowel habit, abdominal pain
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0
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1
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2
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Asks for IBD symptoms: red eye, joint
pain, skin lesions, oral ulcers, bloody diarrhoea
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0
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1
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Establishes if symptoms of anaemia
are present: lethargy, palpitations, shortness of breath
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0
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1
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Identifies any red flags:
haematemsis, weight loss, loss of appetite
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0
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1
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Asks for any recent illness, bleeding
from elsewhere or any family members/contacts with similar symptoms
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0
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1
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Elicits past medical and surgical
history (specifically previous rectal bleeding or disorders, bowel disorders)
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0
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1
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Asks for any recent foreign travel
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0
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1
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Elicits family history (specifically
asking for colon cancer, polyps, angiodysplasia, inflammatory bowel disease)
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0
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1
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Elicits drug history (specifically
NSAIDs, warfarin or other blood thinners)
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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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Asks if any history of illicit drug
use
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0
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1
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Checks impact of symptoms on
occupation
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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 (Inflammatory bowel disease, Infective gastroenteritis, Polyps)
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0
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1
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