Timothy, a male aged 21 years with abdominal
pain, was admitted to the surgical unit from the
emergency department in one hospital. He was
living in student accommodation and had been
revising for his university examinations, which
were due to take place in two months’ time. He
had experienced several episodes of nausea and
vomiting, and had pain in his right iliac fossa
It is essential that healthcare professionals
ascertain the patient’s medical history to aid
accurate diagnosis and prompt treatment.
Griffith et al (2003) stated the patients should
be encouraged to explain their symptoms and
express their emotions. Timothy’s medical history
was taken to provide information about his
abdominal pain. Initial information gathered was
demographic in nature, for example that he was
a 21-year-old male student residing in university
accommodation.
The patient’s main health problem was
abdominal pain in his right iliac fossa radiating to
the umbilical area. It is essential that the clinician
asks questions about the various characteristics
of the patient’s pain. History taking needs to
include details of the location and radiation, type,
onset, duration and severity of the pain, and
whether it is associated with any other symptoms
(Coleman 2005). It is important to identify where
radiating to the umbilical area. Timothy had
not eaten for 48 hours. His skin was dry, he was
dehydrated and had low-grade pyrexia. The
patient’s clinical history and a physical examination
were undertaken.