What you should cover

This history is typical of dyspepsia. Self management before presenting to a doctor is common. Distinguishing between epigastric pain, heartburn, and acid reflux is unlikely to change management, but atypical or increasingly severe symptoms require consideration of other diagnoses such as angina, biliary colic, or pancreatitis.

Consider:

• Red flags in the history and examination (box)—these should be documented

• Possibility of pregnancy, which can affect symptoms and management

• Medical history: specifically pernicious anaemia, Barrett’s oesophagitis, intestinal dysplasia, or previous peptic ulcer surgery, as these conditions are associated with increased risk of malignancy and would lower the threshold for referral

• Family …