Clinical History Example – Using the Four Frames Approach



hello my name is Evan hotel I won the GP registrar's here so I'm just going to find out a little bit about the problem that you've come in would that be all right oh yes I make some notes and basically this will just help me write it up on to the computer later on so just in your own words tell me what's brought you in today and well I've been getting some diarrhea raining yeah for the loss of Wow two three weeks mm-hmm okay so before two or three weeks no problems really um so before that no no I mean I know I just been going normally which is once every couple of days or something yeah no no problems normally okay so just have a little bit more about the diarrhea what it's like and um so like what my Poonam okay I'm tasks it's quite right it's funnier Jeff Lewis really normal I don't think there's any change in my colour or anything um and I probably but but I'm just going a lot more often okay so check do you have any blood in it at all oh um gosh yes I'm surprised haven't said that already isn't worrying me and yet that I've had em for a couple of couple of days mm-hmm that is it difficult to flush away at all no no no it's not to have got to flush away yeah and do you ever see any food that's not digested properly in it hmm not no that wouldn't be something no yeah so you said diarrhea but how many times a day does it actually happen um well I would say somewhere between well at the moment probably somewhere like yesterday was probably about eight times eight times oh yeah um I don't think it's been like that every day for the last three weeks but up to eight times a day time yeah just get up at night to go to yeah yeah yeah never had to do that if you're losing sleep over it oh yeah yeah and you have any tummy pain at all yes um yeah that's quite a sort of crampy and mainly just before I go to the toilet there can be other times but then does that pain go away once you've been to the toilet um yeah a little bit yeah I would say so a little bit mm-hmm does anything make the pain worse at all um just eating I do not like I can really think of any pointed your tummy exactly where is it it is it's just around the middle of really yeah and how do you describe that pain am i thought it's off so cramping I'm he is what he said isn't it yeah and how bad is it um can was excruciating and one was very little pain where would he put it it was they stopped I've had worse I'm sorry about for yeah yeah so it's not agonized but it certainly is there yeah okay and you've told me about when it comes on and what makes it a little bit better and worse as well which is good I'm just gonna ask the rest of the questions just about the whole gut itself give any gets go to chewing your food at all oh no no no mouth ulcers or anything like that um any difficulty swallowing your food at all do you ever get indigestion yeah not really ah sometimes maybe honor my gonna weekend so good times okay but but not usually okay so this was only about three weeks ago that you've had lots okay and prior to that what what was your bad habit like that awesome really it's over maybe once a day once every two days once a day once every two days but certainly no diarrhea oh yeah normal forms so it's quite harder yeah yeah but no blood not a lack at all yeah okay that's great thank you very much for that so just want to ask you some questions about the other systems of the body so do you get any headaches fits faints blackouts anything like that and yeah I get a kitchen get headache mm-hmm yeah everyone gets headaches oh no and I've done for a few years a few years yeah now they're not getting worse at all anything like that okay that's good that's good any problems with breathing and shortness of breath off anything that like any chest pain yeah do a fetal heart having extra beads and swelling of the ankles or any difficulty breathing at night yeah nothing that laughs at all okay you've told me quite a bit about you tell me so any muscle aches and pains at all I sometimes get like hims a weakness you my arm with that day all right so you get weakness but how long's that weakness last ball oh okay any skin problems at all I've had it sort of a little bit of a rash it comes and goes yes do you know what that's due to no no okay but no joint problems no no joke any process of waterworks at all at night and contemporary periods I am yeah well I'm on the pill actually the the I don't know what it's called but the one I take it for three weeks and then I have a week off yeah so I get that I get my period in that weekly regular and they haven't changed at all no no I don't really not that so yes so just a final check on your symptoms so Tommy there's a little bit of blood in the diarrhea yeah okay and this is that every time you have the diarrhea oh it's only been in the last couple of days as it's worried maybe and it's I would know I'm not every time for not coughing at blood nothing like that okay no lumps and bumps anyway I'm aware of no and what about weight loss and changing that potoski I think I probably have lost ways actually over the last few weeks and my trousers definitely feel a bit looser you don't know how much weight you've done I don't really weigh myself so no I don't I mean yeah it's not very very short bit okay so it is a little bit of weight loss is anyway okay so that's fine now let's move on to your past medical history any operations in the past of you and yeah I did when I was out sort of in my teens probably I think I was about 15 um I had M my appendix removed in your teens okay but nothing since then no no the operation since that okay if you said that you take a little bit of pass each mole for your headaches okay and are you doing any of the medicines at all and just wives pale yeah no no nothing nothing else and nothing else at all okay and nothing else over-the-counter no just paracetamol you haven't had any recreational drugs at all no okay okay and are you allergic to anything oh and yes I'm allergic to and my mock Sicilian so that penicillin yeah so allergic to penicillin mm-hmm okay what happens really a person oh that's what I guess went you know talk about a rash again yeah oh I see so that Serrano better yeah yeah okay so rash with penicillin so do you avoid person yeah yeah absolutely I've only had it once yeah well as far as I'm aware happening anyone I checked that you've had only the appendix operation but no the serious illnesses no oh I am about no not serious now okay okay that's fine thank you so just want to move on to your social history if you don't mind but classy are you working at the moment yeah yeah I'm a teaching a system alright you enjoy it yeah I do yeah they fight the kids can be a little bit of a nightmare sometimes but you know on the whole so how's this condition impacting on your world it's oh well I haven't really know if to go in to be honest good because if it's infection I don't want to pass it on to their children so actually I haven't been going in the last the last sort of couple of weeks too worried about the fact that yeah so if it's an infection yes you're supposed to be clear aren't you for like to 48 hours 48 hours years I don't really know what to do but yeah it's a gone past you and do smoke at all um no no I never smoked oh I have yeah I spoke to college yeah yeah how many did uses me about 10 a day but yeah how many years was that for uh my speech for about five three years three years okay that's your smoking and what about alcohol do a drink alcohol at all not much really my joke weekends hmm so what would the typical intake being a week living in a week in the week probably nothing a man but then the weekend zone one night I tend to go up my tend to go out with my friends or on a partner and so I might get through a bottle of wine maybe a couple of shots or something I'm writing a whole bottle I like that hey yeah yeah I think so probably over the course the evening and then on the other night we might just have a couple of glasses of you know share a bottle of wine I mean that sounds as if it's more than about about 20 units roughly right no because a bottle of wine would be about eight nine units yeah and then you've got the other half bottle and a few shots oh that's about 20 unit which is excessive I have to say and the fact that you have more than what we call six units which is just over half a bottle in a single session at can cause that dis benefits to your health is where can harm your health in the future I need to talk about that would that be all right yeah yeah I mean obviously I don't want your chip you know that's why I'm here good things sure sure we'll concentrate on that the main problem so whose was you at home um yes I live with my partner Sam okay no predict problems there at all no no can't get about three years it is it any family history of note no not I'm aware of anyway no gut conditions in the family my aunt my aunt maybe my aunt had something to do with her tummy but I don't know what it was really it wasn't cancer mm-hmm so just moving towards the end I just want you to explore your ideas concerns and expectations really so what do you think's going on with this problem but I think it could be an infection mm-hmm an infection yeah and you told me about one of your concerns about passing it on to people working specially the children I guess but any other concerns listen to me yes my sister by M Fran sister mm-hmm has got bow hunting she's only thirsty oh dear and so it's just the bleeding really more than anything that's worried me and so I wondered about that really that familiar glad you told me that rule we'll try and reassure you and let's see what what what turns out in your Hey what do you think we need to do today to help you well I wondered if I might need some tests I mean I'm really hoping because I did have a little look on the internet and I'm really hoping it's not going to be one of the you know the cameras a cogent Oscar Basel yes and yeah I took hoping I did I stop that a short Jojo okay um I think I've got everything that is it anything else that you ought to tell me actually I've just remembered a lot to ask you about travel have you had any travel in the last few months or weeks even know being away anywhere okay and you can't distinctly say that this is due to a particular funda you've had and nobody else has had this problem in your family no you just wanted to check yeah okay so is it anything else like you want to tell me about it um no I did go traveling about three years ago to Africa all right three years ago yeah yeah okay we went to the South Africa and end up into sim Bob way but were you well there there yeah I was very happy okay okay and you have any questions for me um no how likely is it that I'm gonna come back well I think initially would probably run some blood tests and do the stool sample back and make sure there's no infection that I probably need to get a gut specialist to have a look at you it hasn't got better in a matter of weeks but and then we'll take it from there yeah but let me just summarize what's been happening there so you've had this problem for about two or three weeks yeah it is distinct diarrhea around up to eight times a day sometimes overnight as well you have to get up to go you're cramping abdominal pain at tummy pain and you've got some blood in the motions as well there's no real past medical history apart from a little bit of migraine you said and the appendix you don't smoke at all now alcohol you know we may need to talk about it later on a little bit too much there I think but you're worried about this because one of your somebody you know had bowel cancer and you're a bit concerned about an endoscopy as well but would it be alright if we ran the blood test today and did the sample and then I want to get yeah go on then maybe I can see you again next week but yeah I was talking what okay right there was thank you very much thank you

31 comments

  1. I would also ask if the patient has had recent exposure to sick people of the same symptoms (i.e. children at work or her partner if they share a home) and intake of possible dubious/new food items that might cause this.

  2. what I understood (and correct me)
    he divides the paper into 4 frames :
    1- asks about the complain and its present history
    2- the rest of the body systems symptoms and their present history
    3-past history, therapeutic history
    4-personal history, family history

  3. About half way through, with the presentation of the rash, it sounds like it could be crohns to me. I’m not a doctor at all though so I don’t know. Let’s hear the past medical history!

  4. It is good but. Some important information shouldn't be miss like nausea,vomiting,halitosis,palpitation and mouth dryness

  5. He interrupts the actor a lot and the way he spoke about her alcohol use came off quite accusatory. Good thing this is just an actor and not a real patient, as they'd likely backtrack or try and cover up other parts of their history that they thought might come off badly to the practitioner. 🙁

  6. This video shows a very detailed and step by step patient consultation which is very informative and a good learning experience. The doctor greets the patient warmly and allows the patient to settle in. Once she’s comfortable, he then starts asks the relevant questions for getting an idea of the patient’s problem. The patient seems to be very open and supportive in this session as the doctor is very polite and comfortable to be with. The doctor tries his best to ask as many questions as he can to get to know everything that the patient is experiencing. He ensures he covers as many aspects of the body and the problem so he doesn’t miss anything at all.

  7. Did you ask about fevers? Age of the patient? Age appropriate screening colonoscopy? Critical questions, my friend

  8. Really helpful ..thanks …
    But two to three weeks long time little bit ..
    It is better to ask her what occured right now to come ??
    Why didnt you come before that ?!

  9. Doc, I think I'm tripping. The curtains and drawers are distorting. Help. Bugger the blood-filled liquid pooh.

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