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Name
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Jacob Johnson
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DOB
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05/12/1971 (44 years)
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Occupation
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Tax inspector
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History
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I look and feel quite low. My
co-worker mentioned that my eyes look yellow and asked if I have been getting
much sleep as I often arrive to work late. I am a lawyer but have not been
working much as I have been fighting a huge legal battle over the last few
years because my wife passed away following medical negligence. I cannot
discuss it any further due to confidentiality. If asked directly, I am vague
about the amount of alcohol I drink. If pressed, I admit drinking a bottle of
red wine throughout the day and a few beers with my dinner. On the weekends I
drink significantly more. I have got angry at my brother who has questioned
me about my drinking but I recognise that I may be drinking too much. I have
not noticed any changes to my urine or stool nor any other symptoms. If asked
about my sexual history in a insensitive manner, I get very mad.
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Past Medical History
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None
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Drug History
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None. Allergy to penicillin which
causes widespread rash
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Family History
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Both parents died young in a road
traffic accident.
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Social History
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Non-smoker. Excessive alcohol
consumption but only admit if asked directly. No recent travel history. Not
sexually active
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Introduces yourself
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0
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1
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Confirms name, age & occupation
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 duration and trigger (if
present)
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0
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1
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Establishes evolution (onset to now)
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0
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1
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Establishes time course (worsening,
continuous, intermittent in Gilbert's syndrome)
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0
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1
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Identifies red flags: painless
jaundice, weight loss, loss of appetite
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0
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1
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Asks for any recent illness, fever or
any family members/contacts with similar symptoms
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0
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1
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Asks for gallstone/obstructive
symptoms: abdominal pain, pale stool, dark urine, pruritus, steatorrhoea
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0
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1
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Asks for liver symptoms: abdominal or
ankle swelling, easy bruising, confusion, sleep-night reversal
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0
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1
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Asks for associated features: joint
pain, lethargy, skin hyperpigmentation
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0
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1
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Identifies risk factors for viral
hepatitis (intravenous drug user particularly needle sharing, blood
transfusions outside the UK, tattoos, piercing, needle stick injuries)
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0
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1
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Takes brief sexual history
signposting before doing this
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0
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1
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Elicits past medical history
(specifically asking for previous jaundice, diabetes, haemolytic anaemia,
inflammatory bowel disease, heart failure, autoimmune disorders)
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0
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1
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Elicits family history (specifically
asking for viral hepatitis, autoimmune hepatitis, liver cancer)
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0
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1
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Elicits drug history (specifically
hepatitis B and C immunisation, antibiotics, tuberculosis medication,
antiepileptics, herbal medication)
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0
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1
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Asks for any foreign travel and
consumption of raw food
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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
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0
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1
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Takes thorough alcohol history
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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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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 (Alcoholic liver disease, Pancreatic Cancer, Haemochromatosis,
Autoimmune Hepatitis)
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0
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1
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