History Notecard by Jennifer Tyson on Case Victoria Lewis

Use this worksheet to organize your thoughts before developing a differential diagnosis list.

1. Indicate key symptoms (Sx) you have identified from the history.

Start with the patient’s reason(s) for the encounter and add additional symptoms obtained from further questioning.

Symptom (Sx)Reason for EncounterAdditional Symptoms from QuestioningChief ComplaintAbdominal painAdditional SymptomsNausea, vomiting, feverFatigue, weight loss

2. Characterize the attributes of each symptom using “OLDCARTS”. Capture the details in the appropriate column and row.

Symptom (Sx)OnsetLocationDurationCharacteristicsAggravating FactorsRelieving FactorsTimingSeverityAbdominal pain2 weeks agoEpigastricPersistentDull, cramping painEating fatty foodsRest, antacidsIntermittent, worse after meals6/10Nausea1 week agoGeneralizedIntermittentQueasy feelingEating, strong smellsGinger tea, restAfter meals5/10Vomiting1 week agoGeneralizedIntermittentProjectile vomitingEatingHydration, restAfter meals7/10Fever3 days agoGeneralizedPersistentLow-grade feverActivityAntipyretics, restContinuous4/10Fatigue2 weeks agoGeneralizedPersistentFeeling of exhaustionActivityRest, sleepContinuous6/10Weight loss2 weeks agoGeneralizedPersistentUnintentional weight lossN/AN/AContinuousN/A

3. Review your findings and consider possible diagnoses that may correlate with these symptoms.

Based on the symptoms and their characteristics, possible diagnoses include:

• Gastroenteritis: Inflammation of the stomach and intestines causing abdominal pain, nausea, vomiting, and fever.
• Cholecystitis: Inflammation of the gallbladder, often associated with eating fatty foods, causing abdominal pain, nausea, vomiting, and fever.
• Peptic Ulcer Disease: Sores in the lining of the stomach or duodenum, causing persistent abdominal pain, nausea, and weight loss.
• Gastroesophageal Reflux Disease (GERD): Chronic digestive disorder causing epigastric pain, nausea, and vomiting.
• Pancreatitis: Inflammation of the pancreas, causing severe abdominal pain, nausea, vomiting, and fever.

This worksheet should help organize the symptoms and guide the development of a differential diagnosis list for further investigation and management.