Sample History: Fever and Abdominal pain

(Italicized words and parenthesized words and  sentences are for readers purpose only not to be read when presenting a case. The letters In Blue are points of special interest to be discussed later.

All the patients may not have the same symptoms at presentation and the same risk factors, so history taking should always be INDIVIDUALISED than generalised to a standard sets of check list.It is always RECOMMENDED to ask the patient their problems and the question associated with the problem as per the need.

Interpersonal variations are always exists in the way the history is taken and written. Pattern, format and style of history taking and presenting are subject to change as per institutional protocol and region.Please kindly follow the system that is acceptable in your context.)

A case of Fever with Abdominal Pain

Patient Particulars

Name : Mr Shrestha

Age :  25 years

Sex: Male

Religion: Hindu

Occupation : Serviceman

Marital Status : Single

Address: Bhaktapur

Date of admission : 24^th August 2017

Date of examination : 29^th August 2017

Mode of admission: Emergency Room

(Mr Shrestha,a  25yrs gentleman, unmarried, hindu, serviceman from Bhaktapur presented to XYZ hospital emergency 5 days back with )

Chief complaints

Fever x 5 days

Abdominal Pain x 2 days

History of Present illness

According to the patient, he was in his usual state of health 5 days back, then he gradually developed fever which was insidious in onset, initially low grade on and off  and gradually progressed to high grade and was continuous. Fever was associated with chills but no rigors. Patient gives history of sweating but no rashes. Patient gives history of generalised weakness, body ache and severe frontal headache. The temperature is not documented in the home. Patient gives history of fever subsiding early in the morning and after intake of paracetamol.

Patient also gives history of pain in the central abdomen, which is insidious in onset, continuous, dull aching, non radiating. The pain is aggravated with intake of fatty meal. Patient also gives history of nausea but no history of vomiting, belching or bloating. Patient gives history of inability to pass stool for last 2 days however is passing the flatus. No history of diarrhea, blood in stool or abdominal distension.

No history of yellowish discoloration of skin or eyes. No change in color of stool or urine.

No history of weight loss, no anorexia and easy fatigualbility. (Generalised symptoms)

No history of burning micturition, urgency, frequency or blood in urine. (No Other foci of Fever )

No chest pain, shortness of breathe, cough, sputum and palpitation.

No abnormal body movement, excessive drowsiness or confusion. No intolerance to light and stiffness of the neck. (No other foci of fever)

No joint pain, pus draining sites or recent history of trauma.

No history of recent travel to any new places.

History of past illness

No similar illness in the past.. No history of chronic illness like DM, HTN or Tuberculosis. No history of prior hospitalization and blood transfusion in the past. No history of tattooing in the body. No surgical interventions.

Personal history

Patient is a non smoker and consumes alcohol occasionally. Patient does not give history of use of oral and injectable drugs for recreational purposes.

He is non vegetarian and has normal bowel and bladder habit.

Sleep pattern is normal.

Family history

He has 8 members in the family.

No similar illness in the family and friends.

No chronic illness like DM, HTN, TB or any cancers in the family.

Socioeconomic history

He belongs to well sustained middle class family. They have adequate provision of clean drinking water and toilet facilities.

Drug and allergy history

No known history of allergy to any drug, food or other substance. He has not been taking any medication for long period of time.

Summary

25 years gentleman with complains of high grade continuous fever for 5 days has chills, sweating and severe frontal headache. Patient also gives history of dull aching continuous central abdominal pain with nausea and constipation. No jaundice, no anorexia and weight loss. Bowel and bladder habit is normal.

Provisional Diagnoses based upon history

Enteric Fever

Differential diagnosis

Acute Hepatitis
Acute gastroenteristis

Colitis

Acute cholecystitis

Liver abscess

Appendicular Lump

Pyelonephritis  

Cystitis

Lower zone pneumonia

Learn how to describe abdominal examination after you finish writing your history.

*** Disclaimer : This is a hypothetical case and is not a real life scenario. However, the condition is so common and prevalent, it is a coincidence if it matches with the life of any. This case is solely for educational purpose with no intentions meant otherwise.***