(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 : 24th August 2017
Date of
examination : 29th 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.
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
Acute gastroenteristis
Colitis
Acute
cholecystitis
Liver
abscess
Appendicular
Lump
Pyelonephritis
Cystitis
Lower
zone pneumonia
*** 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.***
