Name
Luisa Schack
DOB
07/09/1993 (21 years)
Occupation
Dressmaker
History
I have had small volumes of loose stool over the last few weeks. I really feel an urge to go and have been going sometimes 8 or 9 times in a day, particularly after I eat. There isn't any blood or mucus in it. A few weeks ago I had constipation so there's clearly something very wrong with me. I have also been so bloated and felt very gassy. I also had quite a lot of pain in my lower tummy but I cannot pinpoint it. I have also had some nausea and vomiting. I think breads and pasta makes it slightly worse. It is also worse right before my period. It hasn't got any worse, nor have I had weight loss or fever. No other symptoms
Past Medical History
Anxiety. No recent hospital admissions.
Drug History
Nil. No recent antibiotic use. No known allergies.
Family History
If asked mother had depression. Nil else
Social History
15 cigarettes per day. Drinks occasionally. No recent travel

Introduces self
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1
Confirms name & age of patient
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1
Explains reason for consultation & builds rapport
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1
Gains consent
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1
Asks open question
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1
Elicits what the patient means by diarrhoea
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1
Asks for the onset of diarrhoea
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1
Elicits the consistency of the diarrhoea (How watery? Pellets? Greasy and hard to flush away?)
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1
Checks colour of the diarrhoea is and asks if it smells offensive
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1
Checks for mucus, blood or melaena in the diarrhoea
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1
Elicits if the diarrhoea has been constant or intermittent
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1
Elicits rough volume of stool and frequency
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1
Checks for previous history of diarrhoea or constipation
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1
Identifies, if present, any triggers or exacerbating factors (diet: unpasteurised dairy/uncooked meat, gluten, contact with ill person, animals)
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2
Elicits any alleviating factors
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1
Asks patient if they have ulcers, nausea, vomiting (if so, explores)
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1
Checks if patient has had abdominal pain (reduced by defaecating?) or bloating
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1
Asks if patient has had a change in bowel habits or increased flatulence
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1
Checks if patient has anal pain, tenesmus or incontinence
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1
Asks constitutional symptoms (fever, tiredness, loss of appetite, weight loss)
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1
Asks if patient has had joint or eye pain or any rashes
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1
Checks if patient has had recent antibiotics or hospital care
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1
Checks for changes in periods or abnormal menstrual bleeding
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1
Elicits past medical and surgical history
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1
Asks if there is a family history of bowel problems including colon cancer, inflammatory bowel disease and coeliac)
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1
Elicits a drug history including laxative use and over the counter medication
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1
Recent hospital admission or use of antibiotics
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1
Checks for allergies
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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
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1
Checks if patient smokes or drinks
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1
Explores and responds to ideas
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1
Explores and responds to concerns
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1
Explores and responds to expectations
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1
Shows empathy
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1
Avoids jargon
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1
Summarises back to patient
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1
Thanks patient
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1
Patient global score
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1
2
Gives reasonable differential diagnosis (irritable bowel syndrome, coeliac's disease, gastroenteritis)
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1