Demographic Details

History Taking
Presenting complaint
Mrs MAB, a 79 year old Malay female, complained of having fever for 2 days and
abdominal pain and loose stool for 2 days.

History of Presenting Illness:

Patient had sudden, medium grade fever in the afternoon. The fever was
consistent and continuous throughout the day. She claimed to take no
medication to relieve fever.

Patient had abdominal pain for two days. The pain was sudden and diffuse but
become localised in the left lower abdomen region. The nature of pain was said
to be pricking and twisting-like and no radiation of pain is reported. The pain
episode is intermittent but consistent in severity throughout the day. Any change
in position exacerbates the pain and the pain is relieved by defecation and by
passing flatus. The patient gives a pain score of 7 in a scale of 10.

The patient had loose stool after almost each episode of abdominal pain. The
first episode started suddenly in the morning. It was watery, dark-brown in colour
and in moderate amount. No blood or mucus was seen in the stool. She had 7
episodes of loose stool on day 1 and 5 episodes in day 2.

Systemic review

The patient denies of having headache, nausea, vomiting, cough, sore throat,
running nose, heartburn, night sweat, chills, bloating of stomach, loss of weight,
loss of appetite, dysuria and haematuria. She complained of feeling general
body ache and tired due to increased frequency of toilet usage. There is no
palpitation or lethargy.

Past Medical History

Patient was diagnosed with high blood pressure for 10 years. She is having
follow-up every month and under medication (amlodipine and perindopril). She is
compliant to her medication.
She has been hospitalised before in 2004 for left lung infection.
This is the first admission for her current problem.
She has no food or medication allergy and currently, not taking any
supplements.
Surgical history

There is no history of any surgery.

Family History

Patient’s mother passed away due to complication of diabetes mellitus at the age
of 57. There is no other significant family history.

Social History

Patient is non-smoker and non-alcoholic. She does not exercise regularly.

Patient only consume meat and rice as her diet. Patient is married with seven
children and financially stable. Patient is currently staying in the house with her
husband.

She has no travel history and none of her family members is having diarrhoea.
However, she ate at a roadside food stall with her friends 2 days before she got
fever and loose stool. One of her friends is admitted due to the same
presentation.

Physical Examination

General Examination:

Inspection

Upon general examination, the patient was lying comfortably in supine position
on her bed. She was alert, communicative and responsive. She is not in
respiratory distress. She appears to be pink in colour and well nourished.

Vital Signs:

Blood pressure 100/60 mmHg

Pulse Rate 106 beats per minute,
regular rhythm, good volume, normal character,
no radio-radial delay
Respiratory rate 24 breaths per minute
Temperature 37.0 ᵒC
SpO2 95% under room air
Height 165cm
Weight 83kg
BMI 30.74Kg/m2
Pain Score Abdominal pain : 7/10
Upper Limbs

The hands appear warm, moist and red. No scars or joint deformity is noted.
Capillary refill is within 2 second and skin turgor is less than 3 seconds. There is
no clubbing (positive Schamroth’s sign), or peripheral cyanosis. No remarkable
findings on nail.

Head and Neck

Upon inspection of the eye, no pallor is seen over the conjunctiva and no
yellowish discolouration seen in the sclera. Upon examination of the lips, lips are
moist. Oral hygiene is good. The throat is not injected and no bluish
discolouration (central cyanosis) noted in the tongue.

No enlarged lymph node observed at the neck.

Lower Limbs

No signs of edema in lower limbs. The lower limbs were devoid of any obvious
deformity and bruising. There are no other significant findings.

Cardiovascular Examination:

No significant finding in cardiovascular examination. Apex beat was not palpable.

Normal S1 and S2 cardiac sound is heard in all four regions without any
additional sound or murmurs. Carotid bruit is also not heard.

Respiratory Examination

No significant finding in respiration examination. Upon auscultation, both air

entry and breath sound is equal and symmetrical bilaterally. There are no added
sounds heard.

Abdominal Examination:

Inspection:

Upon inspection of the abdomen, the abdomen was normal and had an inverted
umbilicus. There were no surgical scars or abnormalities seen.

Palpation:

Abdomen is sluggish, tender at left iliac fossa and guarding was noted. No
masses felt on light and deep palpation.

Percussion:
Tympanic percussion is elicited over all region of abdomen except at right
hypochondriac region (dull upon percussion). There is no shifting dullness and
liver dullness is preserved.

Auscultation:

Normal bowel sounds were heard.

Provisional diagnosis:

Acute bacterial gastroenteritis

Patient experienced a mild fever and non-bloody,watery and medium amount

diarrhoea two days after eating food at a roadside food stall, and one of her
friends has a similar presentation with her. She might consume contaminated
food that irritated her stomach.
Differential diagnosis:

1) Acute viral gastroenteritis

The patient had sudden abdominal pain with mild fever and non-bloody, watery
diarrhoea for two days. Viral gastroenteritis is normally self-limiting. However,
further observation need to be done in order to rule out this diagnosis as the
patient is an elderly woman. If the fever spikes up and diarrhoea turns bloody,
then there is possibility of here having viral gastroenteritis.
2) Diverticulitis

Patient complains of having belly pain in the lower left side which became worse
when moving. This is the most common symptom in diverticulitis. She also
experiences fever and diarrhoea. However, the patient deniesy of having
bloating or vomiting. And top of that, her friend, who consume similar food with
her 4 days ago, having the same symptom and the abdominal pain she is having
is consistent in severity. To rule out this cause, complete blood count and CT
scan (to find if any diverticulum has burst) should be done. If CBC shows reduce
RBC number (possibly because bleeding in the colon) and increase in WBC (due
to infection), there might be possibility for the patient to be diagnosed with
diverticulitis.
3) Acute gastritis
Initially, patient had diffused abdominal pain and upon physical examination,
guarding of the abdomen was observed. She also had taken food from road side
food stall, which might be contaminated. To rule out this cause, FBC (for
anaemia) and nonendoscopy-based H.pylori tests need to be done.

4) Colon cancer
 Patient is an elderly patient and symptoms of colon cancer are nonspecific.
Although patient present with no palpable abdominal mass, she has abdominal
tenderness and change in bowel habit. Thus, malignancy should be ruled out.

Investigations:

Investigation Justifications
Full Blood Count To assess for anemia and leukocytosis possibly due
to either infection or inflammation
Fecal occult blood test To find any blood in stool
Stool culture for ova and cyst To access the presence of any infection
Renal Profile To assess renal function as nephrotic syndrome can
lead to pleural effusion
Liver Function Test To detect the presence of any liver diseases or
cirrhosis, evaluate liver function and exclude from
differential diagnosis
CT scan To rule out diverticulitis

Management:

1) Encourage oral hydration

2) I/O chart (to access kidney function)
3) Paracetamol 1g for fever
4) IV Augmentin 6 to 8 hourly (for bactericidal action)
Reflection

This three weeks of clinical attachment had given me an insight on what should I
expect in my future days and how should I cope with work burden. I realised that
medicine is an ever-evolving field and I, as a medical student need to update and
equipped myself with enough knowledge to help my patients and colleague.

During these three weeks, I realised that history taking can become simple or
difficult; depend on the way I present myself to the patient and the way I
communicate with them. Some patients forthcoming with their complains and tell me
everything without the need to ask. However, there are other patients whom forget
some part of their complaint details, or just reluctant to give details about their
admissions. A lot of patience and understanding needed to break their shell and
obtain the needed information. Since I am used to take history from simulated
patients back in the university, and those simulated patients know what I am going to
ask them and what kind of answers I am expecting, thus, it was an easy feat to
compile their problem and reach a diagnosis. However, in a real hospital setting, I
come to know the methods needed to approach a patient to extract information.

Furthermore, communication aspect plays an important role to establish good

rapport with patients. Although I normally communicate in English with simulated
patients in university, but in hospital settings, I need to use Malay language in a way
that the patients understanding is on par with mine. This is not exactly easy as I am
used to ask questions in English. During history taking in hospital settings, some
words just won’t come to my mind or sometimes I won’t understand what the patient
is trying to say. In those times, I have to be confident and try my best to rephrase the
content of the conversation until I get what they mean. By doing this, not only my
communication skill would get better, but the patient themselves can feel my
sincerity and willingness to understand their problem and might provide with more
information.

I also realised that as a doctor, I am not only going to deal with patients, but also
other hospital personnel like nurses and other doctors in a team. Although some
nurses do not treat us with respect, but most of them are friendly, forgiving and even
volunteer to teach us. Dealing with hot-headed nurses teach me that we can’t expect
everyone to be good to us, and some time I will just have to accept the reality and
make sure I do not make the same mistakes that I despise in others. I also need to
show professionalism, so that others would not belittle me and I, myself, will feel
comfortable and confident enough to communicate with others.

Bedside teaching and clinical case discussion session teach me several important
values and the aspects that I could not get in normal traditional teaching method.
These sessions give me an opportunity to find out what patients normally present
with, and what kind of information is needed to reach a conclusive diagnosis. Back in
universities, we were taught all kinds of disease, according to system, but this clinical
attachment enables us to integrate all l those knowledge to find out the patient’s
problem.

This clinical attachment has helped me in many ways to improve my interpersonal

skills as well as clinical skills. From being not confident in doing physical examination
on a patient, I become more mature and willing to try and do make more mistakes,
so that I can learn now and devoid making any mistakes in future. This clinical
attachment makes me realise that I still have much more to learn and to improve to
become a competent doctor in future.