1

nIS1Ck AND nSICAL- LkAMLL CI 1nL WkI1L-U

Lxperlence ls Lhe moLher of sclence. 8CvL88
ID: Mrs. Sanaz lranl, 8eglsLrauon#12343, 432 Maple Avenue, 8abylon, Callfornla,
1el# (123)-436-7899, Azar 31, 1389, 2:00 .M.

CnILI CCMLAIN1
1hls 43-year-old marrled moLher of Lwo has had eplsodlc rlghL upper quadranL 'knlfe-
llke' paln for Lhe pasL 2 days.

nIS1Ck CI kLSLN1 ILLNLSS
Mrs. lranl was ln her usual good sLaLe of healLh unul 2 days ago (Azar 29) when,
havlng [usL flnlshed a pork chop dlnner, she had severe knlfellke" paln ln Lhe rlghL
upper quadranL of her abdomen, radlaLlng Lo her eplgasLrlum. She concurrenLly felL
slck Lo her sLomach" (wlLhouL vomlLlng). sweaLy," and falnL (wlLhouL loss of
consclousness). She lmmedlaLely lay down on her bed and felL beLLer afLer a
mlnuLe." 1he severe paln grew rapldly less, as dld Lhe nausea, buL she had a dull
ache" ln her rlghL upper quadranL for several hours. She Look no medlcaLlon. oslLlon
dld noL affecL Lhe paln. She felL well enough afLer an hour Lo clean up Lhe dlnner
Lable, and slepL well LhaL nlghL. She has had Lwo subsequenL almosL ldenLlcal
auacks", Lhe rsL aL lunch yesLerday (Azar 30) followlng a hamburger and french
frles. 1he mosL recenL eplsode was aL breakfasL Loday afLer Lwo sllces of bacon.
She's had no fever, chllls, vomlLlng, or dlarrhea. She denles pasL hlsLory of slmllar
eplsodes. She has no currenL or pasL hlsLory of [aundlce, whlLe sLools, dark urlne, or
change ln bowel hablLs. She ls unaware of a hlsLory of anemla (oLher Lhan a mlld low
blood" assoclaLed wlLh her flrsL pregnancy). She has noL had Larry or black sLools,
hemaLemesls, burnlng abdomlnal paln or oLher lndlgesLlon", kldney sLones, polyurla
or hemaLurla, hepaLlLls, or forelgn Lravel. She has had no cough, shorLness of breaLh,
or pleurlsy. She has no calf paln. She regularly examlnes her breasLs and noLed no
masses. 1here ls a hlsLory of breasL cancer ln her moLher. She has no known hearL
dlsease. She denles Lrauma Lo her chesL, back, or legs. Per menses have been
normal. She Lakes no regular medlcaLlons and speclflcally denles Lhe use of anLaclds,
asplrln, cloflbraLe (ALromld), or alcohol.
She currenLly feels qulLe well.
2

AS1 MLDICAL nIS1Ck
cbllJbooJ llloess. Mumps and chlckenpox as chlld. no measles, rheumaLlc fever,
scarleL fever.
AJolt llloess. none slgnlcanL. PosplLallzed only for chlldblrLh (Pafez PosplLal, 1363
and 1369).
1toomo. lracLured lefL clavlcle as chlld. no sequelae.
5otqety. 1onslllecLomy as chlld of 6 (khallll PosplLal). LplsloLomy wlLh each chlldblrLh.
Alletqles. enlclllln-urucarlal rash wlLhouL wheezlng, sLrldor, (lasL dose 1976, aL
whlch Llme reacLlon occurred).
MeJlcotloos. none aL presenL. Pas Laken occaslonal asplrln for headache ln pasL.
1tovel. never ouLslde Callfornla.
noblts. Pas never smoked Lobacco or cannabls. Cccaslonal dlnner wlne (none ln pasL
2 weeks). no llllclL drugs. 8egular dleL, 3 meals a day.
lmmoolzotloos. lranls noL remember chlldhood shoLs oLher Lhan oral pollo vacclne ln
early 11330s. lasL LeLanus shoL 7 years ago.

IAMIL nIS1Ck
M.CrandmoLher M.CrandfaLher .CrandmoLher .CrandfaLher
(dled? Cause, age77) (dlabeLes, allve age92) (dled? Cause, age60) (dled? Cause, age76)



M. AunL MoLher laLher
(A&W, age60) (breasL cancer, (A&W, age 72)
Allve age63)


SlsLer aLlenL Pusband
(A&W, age40) (?, age43) (sLomach ulcer,
Allve age46)


Son Son
(A&W, age24) (asLhma, allve age20)

no famlly hlsLory of renal dlsease, llver dlsease, hyperLenslon, anemla, Luberculosls.
3

SCCIAL nIS1Ck
Mrs. lranl was born and ralsed ln 8abylon, where she marrled her currenL husband
aer her graduauon from hlgh school ln 1362. She remalned aL home Lo ralse her
Lwo sons, boLh of whom are college sLudenLs (ma[orlng ln arL and maLhemaLlcs,
respecLlvely), and has recenLly reLurned Lo nlghL school Lo galn college credlLs
herself.
She descrlbes her llfe as full and her marrlage as happy. AcLlvlLles lnclude
housekeeplng, gardenlng, and readlng romanLlc novels." Per husband's medlcal
coverage exLends Lo her, and she ls noL worrled abouL money. She lranls admlL Lo
some unhapplness aL noL havlng gone Lo college as a young woman, buL ls maklng
up for lL now." She ls worrled LhaL her paln may represenL an lllness LhaL wlll
lnLerfere wlLh her sLudles, and she has a LesL comlng up nexL week" she ls also
fearful of cancer, as her moLher has meLasLaLlc cancer of Lhe breasL, whlch ls palnful
and emoLlonally dralnlng on Mrs. lranl, who vlslLs her ln a nurslng home every day.

kLVILW CI SS1LMS
Ceoetol. See Pl. no welghL change.
neoJ. Cccaslonal sLress" headache. no dlzzlness. lalnLness" wlLh her recenL
aLLacks as descrlbed ln Pl.
yes. LasL LesLed 1 year ago aL 20/20. no blurrlng, double vlslon, paln, dlscharge.
ots. no decreased hearlng, LlnnlLus, paln. CLlLls medla once as a chlld (8 ear).
Nose. no eplsLaxls, slnuslLls.
1btoot ooJ mootb. LeeLh ln good repalr. lnfrequenL sore LhroaLs.
cbest. See Pl. no wheezlng, hemopLysls, spuLum. ChesL x-ray normal on screenlng
exam 1 year ago. negauve 18 skln LesL 1 year age.
neott. no paln, palplLaLlons, orLhopnea, cyanosls, edema. no hlsLory hyperLenslon.
Cl. See Pl.
Cu. See Pl. no dysurla, frequency, urgency, lnconLlnence. no hlsLory venereal
dlsease or urlnary LracL lnfecLlon.
Meosttool. Menarche age 13. erlods llghL ow for 3 days every 28 days and regular,
wlLh sllghL cramplng on 1
sL
day of ow. LasL perlod normal, ended Azar 19, C22A0.
Neotomoscolot. lalnLness as ln Pl, wlLhouL syncope. no verLlgo, dysesLheslas,
selzures. no hlsLory emoLlonal dlsease.


4

PnY5lc4L x4MlN41lON
Azar 31, 1389, 2:30 .M.
Ceoetol. Mrs. lranl ls a sllghLly obese, pleasanL, 43-year-old whlLe woman who ls
somewhaL anxlous buL ln no acuLe dlsLress.
vltol 5lqos. 8 8 arm Slmng: 140/90 83 regular 8 12
L arm Slmng: 148/92
1 99 l orally
L arm sLandlng: 133/93
PelghL: 3'6" WelghL: 132 lb
5klo. warm and dry. no peLechlae, purpura, excorlaLlons. AnlcLerlc. Palr and nalls
normal. no cuLaneous leslons or rashes.
NoJes. no cervlcal, supraclavlcular, eplLrochlear lymphadenopaLhy: 11 cm, so,
nonLender, moblle node 8 axllla. ScaLLered shoLLy lngulnal nodes bllaLerally.
neoJ. normocephallc, wlLhouL Lrauma. no scars, Lenderness, brulLs.
yes. Con[uncLlvae normal. SllghL scleral lcLerus bllaLerally. Llds wlLhouL leslons.
uplls equal, round, and reacL Lo llghL and accommodaLlon. vlslon grossly normal
(reads newspaper). vlsual flelds full Lo confronLaLlon. LxLraocular moLlons full,
wlLhouL sLrablsmus or nysLagmus. lundus shows normal dlscs and vasculaLure. no
arLerlovenous nlcklng, sllver-wlrlng, hemorrhage, or exudaLes.
ots. LxLernal ears normal. 1ympanlc membranes normal bllaLerally. Weber mldllne.
Alr conducLlon greaLer Lhan bone bllaLerally.
Nose. nasal mucosa normal wlLhouL lnflammaLlon, obsLrucLlon, or polyps.
Mootb. Llps, buccal muscosa wlLhouL leslons. 1ongue well paplllaLed, plnk, mldllne.
1eeLh ln good repalr. uvula mldllne. Cropharynx wlLhouL lnflammaLlon or leslons.
Neck. Supple. 1rachea mldllne. 1hyrold noL enlarged and wlLhouL nodules. !ugular
velns aL. venous pulses normal. Carouds 4+ wlLhouL brulLs, normal pulse conLour
bllaLerally.
cbest ooJ looqs: ChesL wall conLour normal, wlLh symmeLrlcal full expanslon. no rlb
Lenderness Lo palpaLlon. 1acLlle fremlLus normal. ulaphragmauc excurslon 3 cm
8llotetolly. no percusslon dullness. Lungs are clear Lo ausculLaLlon save for an
lsolaLed muslcal wheeze on forced explraLlon aL Lhe rlghL base posLerlorly. 1here ls
no egophony over Lhls area. no rubs heard.
3

neott. no vlslble lls, Ml palpable 8 cm from Lhe L sLerna border ln Lhe 6
Lh

lnLercosLals space, Lapplng ln quallLy. no palpable Lhrllls, llfLs, heaves. 8hyLhm
regular, raLe 80. S1 normal. S2 physlologlcally spllL. 1here ls no S3, buL a so S4 aL Lhe
apex. 1here ls a 2/6 sysLollc e[ecuon murmur aL Lhe L sLerna border, wlLhouL
radlaLlon. no rubs, no dlasLollc murmurs.

8teosts. 8 breasL sllghLly larger Lhan L. no reLracLlon, vlslble dlmpllng or skln changes.
nlpples normal, everLed. 22 cm cysuc, moblle, nonLender mass wlLhouL skln flxaLlon
ln upper ouLer quadranL 8 breasL. no nlpple dlscharge.

AbJomeo. SllghLly proLuberanL. no scars or vlslble masses. venous paLLern normal.
8owel sounds normal. no hepaLlc or splenlc rubs. no brulLs. Llver ls 13 cm Lo
percusslon, and ls 3 cm below Lhe rlghL cosLal margln. Llver edge ls smooLh and
Lender Lo palpaLlon, wlLh poslLlve Murphy's slgn. no eplgasLrlc Lenderness. Spleen
and kldneys noL palpable. no shlfLlng dullness or fluld wave. no hernla.

lelvlc ooJ tectol. LxLernal genlLalla normal, lncludlng 8arLholln's and Skelne's glands.
vaglnal vaulL wlLhouL leslons or dlscharge.
Cervlx parous, wlLhouL leslons or dlscharge. ap smear Laken.
8lmooool. lundus normal ln slze & poslLlon. no Lenderness. Cvarles and broad
llgamenL felL and are wlLhouL masses or Lenderness.
kectovoqlool. Conflrms blmanual
kectom. no anal leslons. SphlncLer Lube normal. no ampulllary masses. SLool ls clay
colored and negaLlve for occulL blood.
xttemltles. ulses full and symmeLrlcal, wlLhouL brulLs. Skln and halr normal on
exLremlLles.

6

ulses:

CaroLld
Supra-
clavlcular
8adlal 8rachlal AorLa lemoral u 1

4+

3+ 4+ 4+ 0 4+ 4+ 4+
8

4+=nL

L

4+

3+ 4+ 4+ 0 4+ 4+ 4+

no clubblng, cyanosls, or edema. no swelllng, redness, Lenderness, llmlLaLlon of
movemenL of [olnLs. no vlslble varlcoslLles. no calf Lenderness or cords. Muscle mass
normal bllaLerally.
8ock. SllghL cervlcal kyphosls. no splnal Lenderness, CvA Lenderness, or sacral
edema.
lull range of moLlon splne.
neurologlc:
Meotol stotos. AlerL, orlenLed. Memory, [udgmenL, mood normal.

ctoolol oetves. l-noL LesLed.
ll-uplls reacL Lo llghL. 8eads newspaper.
lll, l, vl- no sLrablsmus, LCM normal.
v- Corneal reflex lnLacL.
vll- lace symmeLrlcal.
lx, x- uvula elevaLes symmeLrlcally. Cag normal bllaLerally.
xl- 1rapezlus, sLernomasLold normal.
xll- 1ongue proLrudes mldllne.

cetebellot. CalL, flnger-nose, and heel-shln normal.
5totloo ooJ qolt. 8omberg negaLlve. Peel-Loe walk normal.
Motot. Muscle mass normal. Cood sLrengLh ln arms, legs.
ueep Lendon reexes: 2+ = nl
no paLhologlc reflexes.
5eosoty. normal Lo Louch, plnprlck, vlbraLlon.

7

LA8C8A1C8? llnulnC

Pemogram: Pgb 14.2, PcL 43, W8C 8300, olys 63, 8ands 3, Monos 10, Lymphs 19,
Los 1, 8aso 0.
erlpheral smear: normocyLlc, normochromlc 88Cs. no fragmenLs, LargeLs,
nucleaLed 88C. W8C morphology normal. laLeleLs abundanL on smear.
urlne: Clear, dark yellow. SC 1013. ulpsux neg. heme, proLeln, glucose, keLones. 3+
for blllrubln. pP= 6.mlcro: 0-1 W8C, 0 88C, no organlsms per hlgh-power fleld.
no crysLals, casLs.

Serologles:
LlecLrolyLes: na=140, k=4.2, Cl=100, CC
2
=28, Ca=10, =3.4, Albumln=4.0, Clob=3.3,
SCC1=123, SC1=83, Alk 'Lase=210. 8lll: LoLal=4.0, dlrecL=3.3. Amylase serum=236,
Cl=123, Cr=1.0, 8un=10.

8adlologles:
ChesL x-ray: 8ones normal, wlLhouL blasLlc or lyLlc leslons. PearL shows sllghL
sLralghLenlng L hearL border. arenchyma clear excepL for sllghL llnear aLelecLasls 8
base posLerlorly (8 lower lobe, basal seg.). no evldenL effuslon.
ku8: 8ones normal. soas shadows seen. nephrograms show normal-slze kldneys.
8owel gas normal. no evldenL asclLes. Speckled calclflcaLlon medlal 8uC ln area
gallbladder.

LCC: 8aLe=80, rhyLhm=slnus, 8=0.13, C8S=0.10, C1=.32, axls=+30. waves normal.
C8S normal. no 1 wave flaLLenlng or S1 segmenL abnormallLles. no LvP by volLage.
lmpresslon-normal LCC.

8

lM8LSSlCnS
1. 8uC paln
a. robable cholecysLlLls wlLh cholellLhlasls. 1hls ls supporLed by Lhe
hlsLorlcal relaLlonshlp of 8uC sharp palns assoclaLed wlLh faLLy foods,
sclera lcLerus, hepaLomegaly, and + murphy's slgn, clay-colored sLools,
and laboraLory flndlngs of blllrublnurla, abnormal llver funcLlon sLudles
wlLh an obsLrucLlve paLLern, hyperamylasemla, and calclflcaLlons on
ku8 LhaL mlghL represenL gallsLones. 1he 8LL aLelecLasls on chesL fllm ls
noL lnconslsLenL wlLh an lnLra-abdomlnal process.
(1) 8/C carclnomaLosls of Lhe llver. WlLh her famlly hlsLory of breasL
cancer and Lhe breasL mass and axlllary node on physlcal examlnaLlon,
Lhls dlagnosls musL be consldered. 1he eplsodlclLy of her paln, Lhe lack
of nodularlLy of Lhe llver, and Lhe absence of evldenL dlsease elsewhere
makes Lhls less llkely.
(2) 8/C pulmonary embollsm. 1hough unllkely, Lhe 8LL wheeze on .L.
and aLelecLasls on chesL fllm could represenL Lhe slLe of lodgmenL of
pulmonary embollsm from Lhe legs (for whlch Lhere ls no local evldence
of phleblus) or perlpelvlc (she has had 2 chlldren) areas. 1he llver
dlsease ln Lhls clrcumsLance would represenL congesLlve hepaLopaLhy
from LranslenL 8 hearL fallure of pulmonary embollsm.
(3) 8/C myocardlal lnfarcLlon or lschemla. 1hls ls very lmprobable wlLh
her hlsLory, buL should be consldered ln llghL of her recenL sLress ln
classes and Lhe assoclaLlon of her paln wlLh eaLlng. Per hyperLenslon,
Lhough mlld, could predlspose her. ln Lhls clrcumsLance, her llver
dlsease would be LranslenL congesLlve hepaLopaLhy.

2. 8 breasL mass and axlllary node wlLh lP cancer of Lhe breasL
AlLhough Lhe cysLlc leslon of Lhe breasL probably lranls noL represenL a
mallgnancy, her lP and deep concern are Lroublesome.
3. PyperLenslon
9

AlLhough Lhls mlghL be due Lo anxleLy, Lhe presence of Lhe S4 and Lhe
sLralghLenlng of Lhe L hearL border on chesL fllm suggesLs a flxed hyperLenslon
raLher Lhan a lablle one.
4. Allergy Lo penlclllln
Per urLlcarlal response could presage anaphylaxls
3. SysLollc hearL murmur
1hls ls probably a flow murmur.

AlLhough oLher dlagnoses are posslble (lnfecLlve pneumonla, pancreaLlLls,
lnfecLlve or Loxlc hepaLlLls), Lhere ls llLLle Lo supporL Lhem ln Lhe hlsLory or physlcal
examlnaLlon.
LAn
1- 8uC aln
lloo. l wlll hosplLallze her Loday and obLaln an LCPC of her gallbladder and
blllary Lree, as Lhe mosL lmmedlaLely avallable and leasL lnvaslve of sLudles.
l wlll ask Lhe surgeon Lo see her Loday, should anoLher aLLack requlre
emergency surglcal lnLervenLlon.
Serlal physlcal examlnaLlon, urlne, blllrubln LesLlng, and serum llver funcLlon
LesLs wlll allow monlLorlng of her progress.
2- 8 breasL mass and axlllary node wlLh lP cancer of Lhe breasL
lloo. Mammography and probably blopsy of Lhe mass are ln order.
1hese can be done on Lhls hosplLallzaLlon.
3- PyperLenslon
lloo. l wlll monlLor her pressures ln hosplLal. Should Lhey remaln elevaLed, salL
resLrlcLlon, welghL loss, and probably dlureLlc Lherapy wlll be lnsLlLuLed.
4- Allergy Lo penlclllln
10

lloo. l wlll lnsLrucL Lhe nurses Lo flag her charL as allerglc Lo penlclllln. Cn
dlscharge, Mrs. lranl should obLaln a Medlc-AlerL Lo Lhe effecL LhaL she ls
allerglc Lo Lhls drug.
3- SysLollc hearL murmur
lloo. Cbserve
I.n.CAlN Mu
l.P.CALLn, M.u.
1he hlsLory and physlcal examlnaLlon deLalled above are a full and formal, wrlLLen P
and . CLher slLuaLlons (emergency vlslLs, pregnancles, readmlsslons Lo hosplLal, eLc.)
wlll demand less broad deLall, or oLher emphases. Pow long" a wrlLLen hlsLory and
physlcal needs Lo be" (a frequenL quesLlon asked by sLudenLs) depends on a
[udlclous balance of Lhe paLlenL's need and Lhe cllnlclan's Llme avallable. ln all cases,
Lhe wrlLLen hlsLory and physlcal examlnaLlon needs Lo be as long as ls necessary Lo
convey perLlnenL daLa clearly and compleLely. Moreover, as ln oLher flelds of sclence,
Lhe cllnlclan need noL say (or wrlLe) everyLhlng he knows-buL he should know
everyLhlng he says.
S1AnuA8u C8uL8S
GLNLkAL
1. lollow a sysLemaLlc sequence (see below) Lo ensure compleLeness.
2. WrlLe leglbly. A mlslnLerpreLed word or drug may harm your paLlenL.
3. 8e sure Lo revlew your orders frequenLly and Lo speclflcally cancel Lhe old
order before a new one ls enLered.
4. Conslder prn orders as generally undeslrable buL occaslonally necessary. 8e
cerLaln Lo revlew prn orders regularly (every oLher day).
3. uo noL order Lhlngs LhaL your paLlenLs do noL need (e.g., sleeplng pllls should
noL be rouLlne).
6. 8ecord daLe, Llme, and leglbly slgn all orders. lf an order ls lmmedlaLe or
lmporLanL, dlscuss lL wlLh Lhe responslble nurse.


11

An C8uL8 lC8 C8uL8S
1. AdmlLLlng dlagnosls.
2. aLlenL's condlLlon (crlLlcal, poor, falr, good).
3. known allergles, lf any.
4. AcLlvlLy permlLLed (e.g., bed resL, or baLhroom prlvlleges, up ad llb.).
3. uleL (e.g., 2 gm sodlum, low poLasslum).
6. Ceneral orders
a. WelghLs (how ofLen)
b. llulds (lnpuL and ouLpuL).
c. 1urnlng (lf bedrldden).
d. recauLlons (e.g., selzures, confused, myocardlal lnfarcLlon).
7. vlLal slgns: frequency, and speclflcs for whlch you wanL Lo be called (e.g.,
noLlfy Mu lf Lemp. greaLer Lhan 102 l").
8. MedlcaLlons and lv flulds
a. Speclc Lo dlagnosls (1) lv soluuon and raLe. (2) Anubloucs. (3) Cardlac
drugs, eLc.
b. Ceneral: urugs for fever, bowels, sedaLlon, eLc.
9. Speclmens and LesLs: e.g., lease obLaln spuLum for Mu and for culLure" or
uraw glucose ln mornlng before breakfasL."
Slgn -------------------------------------------
rlnL name ----------------------------------