Frank Further

40 year old teacher

 

PC:      abdominal pain

HPC:    woke up at 3 am with sharp, stabbing pain in right iliac fossa

            coming in waves, associated with nausea

            radiating to right groin and loin

            dysuria and pain when opening bowels

            passed watery diarrhoea x1

            started shivering just now

            took Tramadol 2 hours ago

PMH:   pancreatitis 1997 (due to alcohol excess, now cut down intake)

            Hep B 1995 (was jaundiced for 3 weeks)

            Syphilis 1980 (fully treated)

            patchy alopecia (mainly occipital but also left parietal)

            cholelithiasis since 1999 (usually asymptomatic)

DHx:    Aspirin 75 mg od

            Paracetamol for "aches and pains"

            beta-blocker

            party drugs (none recently)

            NKDA

FHx:     father: unknown

            mother: SLE (systemic lupus erythromatosus

            brother: schizophrenia

            grandmother: blind and deaf

SHx:    lives with boyfriend

            multiple sexual partners (male and female)

            smoker (about 4 cigarettes per day)

            social drinker