Clinical History Example - Using the Four Frames Approach

Summary

The transcript captures a detailed consultation between a GP registrar and a patient, Vard Patel, who has been experiencing diarrhea, abdominal pain, and occasional blood in stools for the past two to three weeks. Vard describes the symptoms, including cramping and disrupted sleep due to frequent nighttime bathroom visits. The GP gathers relevant medical, social, and family history, addressing concerns about potential infections and bowel cancer. The patient is particularly concerned about the possibility of needing an invasive colonoscopy. The GP suggests blood tests and a stool sample to rule out infection, with follow-up to determine further steps.

Takeaways

• 😀 The patient, Vard Patel, presents with diarrhea lasting 2–3 weeks, with recent blood in the stool.
• 😀 Stool is described as loose and runny, occurring up to eight times per day, sometimes at night.
• 😀 Abdominal pain is crampy, mostly mid-abdomen, and partially relieved by bowel movements; pain severity is around 4/10.
• 😀 Patient reports mild weight loss over the last few weeks.
• 😀 No significant past medical history apart from appendectomy in teens and occasional migraines.
• 😀 Patient is on the oral contraceptive pill and takes occasional paracetamol; allergic to penicillin (rash).
• 😀 Social history includes living with a partner, working as a teaching assistant, past smoking, and moderate weekend alcohol consumption (~20 units/week).
• 😀 No recent travel or obvious dietary triggers, and no family history of bowel cancer, though there is a distant relative with a gut condition.
• 😀 Patient is concerned about infectivity at work and the possibility of bowel cancer, and hopes to avoid invasive procedures like colonoscopy.
• 😀 Plan includes running blood tests and stool sample to rule out infection, with referral to a gut specialist if symptoms persist, and follow-up next week.

Q & A

What was the main reason the patient sought medical attention?

The patient sought medical attention due to experiencing diarrhea for the last two to three weeks, with additional concerns about blood in the stool and frequent bowel movements.

How often has the patient been experiencing diarrhea?

The patient reported having diarrhea up to eight times a day, with some episodes occurring at night, which led to disrupted sleep.

What kind of abdominal pain did the patient describe?

The patient described experiencing crampy abdominal pain, mainly before going to the toilet, which eased slightly after bowel movements. The pain was rated around a 4 out of 10 on the pain scale.

Did the patient experience any other symptoms related to the digestive system?

The patient did not report any issues with chewing or swallowing food, indigestion, or undigested food in the stool. However, the patient did mention occasional headaches and a rash.

Was there any blood present in the stool, and if so, how often?

Yes, the patient reported seeing blood in the stool for the past couple of days, but not every time they had diarrhea.

What concerns did the patient express regarding their symptoms?

The patient was worried about the possibility of having bowel cancer, particularly because a friend's sister had been diagnosed with the condition at a young age. They also expressed concern about the potential need for a colonoscopy.

What medical history did the patient provide?

The patient mentioned having had their appendix removed when they were 15 years old, and they reported occasional headaches treated with paracetamol. The patient also has a known allergy to amoxicillin, which causes a rash.

What lifestyle factors could be relevant to the patient's symptoms?

The patient occasionally drinks alcohol on weekends, consuming around 20 units per week, which is considered excessive. They also smoked for three years during college but quit.

Did the patient mention any family history of health issues?

The patient mentioned that their aunt had some unspecified tummy issues, but they did not specify whether it was a serious condition or cancer.

What is the plan for managing the patient's condition?

The plan is to run blood tests and a stool sample to check for infections. If the symptoms do not improve within a few weeks, the patient may be referred to a gut specialist. The possibility of an endoscopy or colonoscopy was discussed, but the patient expressed concern about it.