Case 40: Annie Nguyen

INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history from Annie. Then outline to the facilitator what examination and investigations you would normally do in your clinical practice and indicate the most likely diagnosis.

While waiting to see the doctor she completed a new patient questionnaire in which she gave the following information:

• Past medical history

• Glandular fever Year 12 of high school

• Medication

• Nil

• Allergies

• Nil known

• Immunisations

• Fully immunised

• Family history

• Nil relevant

• Social history

• Lives on campus in hall of residence

• Non-smoker

• Alcohol—three standard drinks per week.

INSTRUCTIONS FOR THE PATIENT, ANNIE NGUYEN

You are 19 years old and in your first year at university. You have not been to this GP before. You have been nauseated for the past three days but have not vomited. You had diarrhoea for the first two days but this has now settled. You do not feel like eating. You experienced colicky abdominal pain just before each episode of diarrhoea.

Your last menstrual period was one week ago. You have no other symptoms. You are not currently sexually active.

You have filled out the new patient questionnaire as follows:

• Past medical history

• Glandular fever Year 12 of high school

• Medication

• Nil

• Allergies

• Nil known

• Immunisations

• Fully immunised

• Family history

• Nil relevant

• Social history

• Lives on campus in hall of residence

• Non-smoker

• Alcohol—three standard drinks per week.

SUGGESTED APPROACH TO THE CASE

Establish rapport

Open-ended questions to explore Annie’s ideas, concerns and expectations.

Specific questions

Gastrointestinal

• — Anorexia

• — Nausea and vomiting

• — Haematemesis

• — Suspect food prior to onset of symptoms

• — Abdominal pain

• — Diarrhoea/constipation

• — Blood or melaena pr

Associated features, such as headache

Systems review—fever, energy level

Genitourinary

• — Frequency, haematuria, discharge

• — Menstrual cycle, LMP, risk of pregnancy

Infectious contacts—are any other students or staff at hall of residence unwell? Potential public health issues may need consideration if history suggests others with similar symptoms

History of recent travel

Substances—medication prescribed elsewhere, OTC, alcohol, drugs of abuse

Request permission to examine.

Examination

Pulse

Temperature

Hydration

Jaundice

Abdominal examination—for tenderness, masses or organomegaly

Urine specimen dipstick.

Most likely ...