gastrointestinal symptoms: nausea, abdominal pain or vomiting, a consideration for gastro-oesophageal reflux disease (GORD). The absence of a history of a cold or rhinorrhoea lessened the likelihood of the aetiology being viral in nature (Hathorn, 2018; Patel et al., 2019 and CKS, 2018). There was no report of any weight loss, another “red flag” consideration.
She reported that paracetamol had not helped her pain, that she was tired and lacking in energy and was finding it challenging to care for her 2-year old son, whom she described as very energetic. Lucy expressed a hope she would be prescribed an antibiotic.
Recent past medical / surgical history is a crucial element of comprehensive history taking (Young and Duggan, 2010 and Innes et al., 2018). Scrutiny of this provides background, and an overview of general health status and any predisposing factors, underlying disease or long-term conditions, the presence of which may impact subsequent management decisions. (Patel et al., 2019). This was elicited with the use of the mnemonic JAMTHREADSCa (Cupples, 2011). Of note was a past history of gestational diabetes and hypertension during Lucy’s last pregnancy. There was no family history of significance.
Medication review revealed no current use of prescribed, herbal or over the counter drugs aside from paracetamol. Lucy reported no known allergies or sensitivities and was up to date with all immunisations.
Lucy was married with a 2-year-old son and not currently employed. She never smoked, did not disclose any use of illicit drugs and had the very occasional glass of wine.