History taking: Per rectum bleeding: OSCE checklist

Pre-history taking

TASK YES NO
Preparation: wash hands, identify patient
Introduce yourself, gain consent
Environment; ensure privacy, no noise, appropriately positioned
History taking

History of presenting complaint

 Obtain description of blood seen – fresh/altered, quantities
 Colour of stool; tarry (malaena), mucus, blood mixed through it
 Obtain description of stool consistency (soft or liquid, hard, pellets)
 Onset, frequency, exacerbating factors
 Associated local pain, tenesmus
 Abdominal pain: use SOCRATES template
 Normal frequency of bowel motion
 Any recent change in bowel habit
 Any weight loss, fever
Past medical and surgical history
 Constipation, diarrhoea, IBS, IBD
 Any other illnesses; previous malignancies
 Any previous surgery – especially gynaecological or abdominal
Medications and allergies
 Current medications
 Allergies
Family history
 Any members of the family with similar complaint
 Any illnesses which run in the family
Social history
 Who the patient lives with
 Occupation
 Smoking and alcohol
 Recent foreign travel
 Change in diet

Post-history taking

Thank the patient

Present your findings
Offer differentials
Suggest initial investigations