Hello, Miss Gibson. My name is Dr Friedlander. I'm one of the doctors on
this ward. I need to do your admission now, if that's all right?
Yes, that's OK. Great. First, I'm going to ask you some
questions about your medical history then I'll do a physical examination. Are
you comfortable at the moment? Yeah, I'm OK.
Can I get your personal details first? Can you tell me your full name please?
It's Kayley Gibson. My middle name's Suzanne. Right. Sorry.
Can you spell your first name for me, please? Sure. It's not a very common name.
it's K,A,Y,L,E,Y. Thank you. What's your date of birth? 16th
of September, 1982. OK, thanks. Can you tell me what brought you into
hospital today? Yeah. I was just at home having lunch with my family.
We always have Sunday lunch together and I've got this awful pain all of a sudden
and it was so bad it took my breath away. Uh-huh. So, the pain came on suddenly .. Can
you show me where the pain was? Here on my right side, at the top of my
stomach. Have you still got the pain? No. It's gone away but it was really bad and
I was a bit worried about it. Yes, I see. Have you had the pain before? Yes, I have.
I seem to be getting the pain on and off after I eat, especially after fatty food.
All right. I'll take a look in a minute but I'd like to ask you some questions
about your general health first. Is that OK? Yes, that's OK.
Health issues which required hospitalisation before? Well I came into
hospital a month or so ago with the same pain. Other than that I had my appendix
out when I was a kid. I think I was 9 or 10.
Oh..and I broke my leg badly and had to have it fixed that was 2.. no 3 years
ago. It was a work accident. OK. Are you working at the moment? No. I
took a leave of absence to go back to uni. I'm doing my Masters. I was working
in hotel management before. Right.. do you take any regular medication? No. The only
thing I take is an antihistamine for hay fever in spring. I did get some antacids
mixture from the chemist for this pain. Does that count?
Yes. It could be important. I need to know about any medication whether it's a
prescription medication or an over-the-counter medication. The
information will help me make a diagnosis. Would you mind telling me
about any other drugs? What about recreational drugs, for
example? No, not really.
Um.. I smoke a few spliffs occasionally but but that's it.
Thanks for telling me that. I really appreciate your honesty and regular cigarettes? Are
you a smoker? Not anymore...can't afford to smoke now I'm back at
uni. I gave up...oh.. must have been at least 4 months ago. Right. How would
you describe your alcohol intake? I don't know... normal, I guess. Would you be
able to tell me if you drink every day? Sure. No I tend to have a few drinks
with my friends on the weekend. Sometimes I overdo it but not often.
So you wouldn't say that you're a binge drinker? No. I'm a social drinker most of
the time. You know... 4 or 5 drinks max and only on a Saturday and maybe
Sunday. I see. OK, thanks. That's very helpful. Do you have any
allergies? Only penicillin. I've avoided penicillin since I had a reaction when I
was younger. OK. What happens if you have penicillin?What
sort of reaction do you have? It's not life-threatening but it's not very nice
either. I get a really itchy rash over my whole body. Right. I'd like to ask you
about your family history, if I may? Their medical history, you mean?
Yes. Is there any history of major illnesses like kidney or heart disease
or diabetes? No, nothing like that. Well, my dad has high cholesterol but he takes
medication to lower it so I don't think it's a problem. My sister has some mental
health issues. She suffers from bipolar disorder but it's well managed and she
seems OK at the moment. OK. Thanks for sharing that information. I'd
like to do a full examination now, if that's all right with you?
Sure. No problem.