Name: Jessica Alba

DOB: DD/MM/YYYY

Age: 46

• Nobody has taken your pains seriously so far, you want to leave the consultation with a solution, you have become very emotional regarding your symptoms

• I: You think you have something seriously wrong with you
• C: You are worried that the episodes could become more frequent and that paracetamol will stop helping eventually.
• E: You want to leave this consultation with medication for your pain

• You have asked to see your GP as you have been experiencing tummy pain that has been occurring quite often recently

Positive symptoms:

• Pain:
  
  • Pain is present average once a month, experienced last week after daughter's birthday party
  • Strongest on right hand side, below the ribs
  • Sharp in nature
  • Radiates through to back on occasion
  • Pain builds to 7/10 severity over 30 minutes approx. -- pain remains for 5/6 hours
  • Regularly take paracetamol
  • Big/heavy meals seems to be associated with pain
  • First experienced pain 6 months ago after dinner party with colleagues
  • Experienced heartburn last week; this current pain is different to heartburn
  • Pain can be severe enough -- cause difficulty in breathing

Negative symptoms:

• No recent changes in bowel habits eg: consistency, colour, frequency
• No red flag symptoms e.g. jaundice, fever, weight loss, per rectal bleeding
• No other gastrointestinal or systemic symptoms e.g. dysphagia, nausea & vomiting, bloating, tiredness, palpitations, urinary symptoms

• Sexually active with husband
• No chance of pregnancy -- using the pill (have not done a pregnancy test)
• Last menstrual period 6 days ago
• 1 child -- elective C-section
• No vaginal discharge
• No vaginal bleeding

• No other past medical history
• Have been advised to lose weight -- by GP
• BMI 31

• Combined oral contraceptive pill for 10+ years
• No other medications
• No known drug allergies

• Mother had surgery for tummy pain -- cannot recall the reason

• Smoke 5 cigarettes/day for 5 years
• Socially drink alcohol
• No recreational drug use
• Work as a restaurant chef
• Variable diet, often eat heavy meals at workplace
• Live at home with husband and 15 y/o daughter
• No recent travel