Chief complain:
28-year-old male complaint of fever( to 40˚) for a week.
Present illness:
The patient developed fever (up to 40˚) with cold sweating for a week. He denied
vomiting, nausea and cough. He remembered he had diarrhea 2 times that week. He had no
dizziness and headaches. He denied stiffness head and light-headedness. He felt tiredness
and weakness. His appetite was bad. He stated 4 ~ 5 kg weight loss over a week. He was so
thirsty ever through drinking a lot of water. He stated loss of sleeping. The patient complaint of
swelling and pain on left hand fingers and left leg knees joint. He denied skin rash. The fever
was persistent. He saw LMD in 9/28. The physician offered him antipyretic medicines. After the
administration of the medicine, the symptoms and signs were relieved. However, the fever
relapsed and the knees joint and the left hand fingers swelling again in the next day. He was a
drug abuser. He took amphetamine and heroin at least half a year. He denied extraction of
teeth recently. He was brought to our ward for further evaluation.
Dr Buttrey’s rewrite:
Chief complaint:
28-year-old male complaining of fever for a week.
Present illness:
The patient has had a fever (up to 40˚) with diaphoresis for a week. He denied vomiting,
nausea, or cough. He remembered he had diarrhea 2 times during the week, [with the stool
looking like what?]. He had no dizziness, light-headedness, stiff neck [?], or headache, but he
felt tired and weak and slept poorly. His appetite was poor [with decreased intake?] and he lost
4-5 kg in that week. He felt very thirsty and drank lot of water. [Any increase in urine volume?]
He complained of swelling and pain in the fingers of the left hand [Which joints?] and the left
leg knee joint. He denied skin rash. The fever was persistent. He saw an LMD in 2 days PTA
and was given antipyretics, which gave temporary relief. [Did the LMD suggest a diagnosis?
Were any antibiotics given?] However, the fever relapsed and the arthralgias and hand
swelling recurred the next day. The patient had used amphetamines and heroin [Route of
administration?] for at least 6 months. He denied recent dental work.
Missing data: Nature of the diarrhea, amount of food intake (With a poor appetite, we assume
decreased intake, but that’s not always the case.), exact joints involved in the hands, urine
volume. Did the patient note whether the joints hot and red? Did he inject the heroin and/or
amphetamines IV? Any previous history of similar problems? Any known history of a heart
murmur or valvular abnormalities? Any friends or family with a fever around the same time?
Comments
Content:
As I read through this history, a number of different diagnoses came to mind, which
explains some of the questions noted in the PI. Initially, I wondered about a GI
infection, although those symptoms were minimal. However, we should always
describe anything coming out of the body, in this case, the diarrhea. The absence of
HA or stiff neck lessened the possibility of meningitis. The weight loss and thirst
made me think of diabetes, which is why I asked about polyuria. They both may have
been because of dehydration, secondary to poor intake and fever, but a specific denial
of polyuria would be helpful. The arthralgias raised the possibility of an autoimmune
inflammatory disease, but it’s important to describe them fully. The swelling suggests
frank arthritis, but we need to mention redness and heat as well. (Remember: rubor,
calor, dolor, tumor, Latin for redness, heat, pain, and swelling. [You can remember it
in Chinese!] Anytime inflammation is a possibility, ask the patient about the presence
or absence of all 4 signs. Record their response in the history, which we will then
compare with what we find and record in the PE) As soon as you mentioned the drug
abuse, I remembered seeing the patient and knew he had infective endocarditis. Your
comment on dental work also suggests this diagnosis. Good! The route of the drug
administration is of course extremely important. It’s the IV drug abusers who are at
risk of endocarditis. Sniffing or oral use of drugs doesn’t carry the same risk. If he
injects the heroin, where does he do so? The differential dx of the L hand swelling
includes cellulitis, septic arthritis, or possibly an inflammatory disease. If you know
he has endocarditis, a clearer description of the joints is vital because he may have a
septic arthritis. Pyogenic infection may destroy the joint if left untreated and may
require drainage. Finally, include some comment on whether he was known to have
valvular abnormalities or other heart disease previously. IV drug abusers certainly
often develop endocarditis on normal valves, but abnormal valves may increase the
risk.
English:
28-year-old male complaint of fever: “complaining of.” His complaint was fever, but he
complained of fever.
cold sweating: We don’t say this very often in English. Use the medical term “diaphoresis.” The
point of “cold sweating” is that he wasn’t sweating because of exercise. But that’s not how we
express the concept.
He denied vomiting, nausea and cough: Usually in a negative statement, we use “or” rather
than “and” as the conjunction.