Fever

Name: Joseph Rucinski

Age: 48 Years Old

Date of Birth: 5th February 1976

Location: Accident and Emergency Department

Occupation: Accountant

“I have been experiencing a persistent fever over the past few days, and now I am experiencing new symptoms as well. I thought I should get this checked out”

Fever

• Onset: 4 days ago

• Temperature measured at home was about 38.7 degrees

• Fever comes down at times, with no particular pattern

• Each episode of fever varies, cannot put a finger to how long they last

Headache

• Site: On the right side of my head.

• Onset: Started last night.

• Character:  Dull ache.

• Radiation: Localised.

• Associated Symptoms: Nausea, vomited once last night, had a fit this morning at work. Fit stopped after 1 minute. No injuries sustained during fit. 

• Time: Has not gone away since it started.

• Exacerbating and Alleviating Factors: Cannot think of anything that has made things worse or better.

• Severity: Pain rated 6/10.

• Precipitating Factors : Cannot think of anything that may have triggered these symptoms

• Recent illness: Bad sinus which started a week ago and has not been getting any better.

• Recent head trauma: None

• Recent travel: None

• Ideas: “I think my sinusitis is causing all these problems.”

• Expectations: “Can I have some antibiotics? I read online that antibiotics may help if sinus problems persist – not sure if that’s true?”

• Concerns: “I just hope it’s nothing sinister, not too worried otherwise.”

• Bowel habits: Normal

• Urinary habits: Normal

• Appetite: Decreased ever since all these symptoms started

• Sleep: Poor ever since these symptoms started

• Weight: Lost about 3kg in the last 3 months. I lost weight as I have been training for an upcoming marathon. 

• ENT: Ear feels a little stuffy, I think it’s probably due to my sinus problems.

• Cardiology: Heart feels like it is racing a little. No chest pain

• Ophthalmology: No changes to vision.

• Previous hospital admissions: None

• Previous surgeries: None

• Medical conditions:

  • Asthma

• Medications:

  • Blue inhaler for asthma relief

  • Brown inhaler for asthma prevention

• Over the counters:

  • Vitamin C supplements

• Allergies:

  • Penicillin (gets an itchy rash)

Mother has type 2 diabetes. The rest of my family is well.

• Smoking: 3 cigarettes a day for the past 20 years. 

• Alcohol: Only on weekends. Amount varies but typically about three pints of beer on each day of the weekend. 

• Recreational drugs: Never

• Ill contacts: No one around me were ill recently

• Pets: None at home

• Home: Lives alone in a 2nd floor apartment flat.

• Active Daily Living: Good mobility and able to perform daily functions normally.