Recording the Clinical Data Base

Patient: 54-year-old Caucasian male. Chief Complaint: Respiratory difficulties, fever, and lower extremity edema. History of Present Illness: The patient was diagnosed with chronic hepatitis during routine screening in 1999 due to hepatitis C (HCV) infection and alcohol abuse. Previous risk factors for HCV exposure included a blood transfusion (1977), tattoo, body piercing, and multiple sexual partners in the past. He was treated with interferon for a brief period of time, but the medication had to be stopped due to severe thrombocytopenia. He developed mild bilateral lower extremity edema and accumulated peritoneal fluid in 2008; these symptoms were controlled by diuretics. In 2012 the patient presented with a large volume of ascites and respiratory difficulties. A therapeutic paracentesis was performed. Cytological studies on the ascitic fluid showed atypical lymphoid cells with irregular nuclear contours, but immunohistochemical stains were inconclusive. A magnetic resonance imaging (MRI) scan of the chest, abdomen, and pelvis did not show any mass or lymphadenopathy. Three weeks later, the patient developed fever, acute renal failure, right pleural effusion, and peritoneal fluid re-accumulation, and was admitted to the hospital. Past Medical History: Same as above, otherwise non-contributory. Social History: Alcohol abuse. Family History: Non-contributory. Physical Exam: Temperature 100.2°F, pulse rate 85 beats/minute, blood pressure 112/62 mm Hg, respiratory rate 22/minute. No significant cervical, submandibular, and supraclavicular lymphadenopathy identified. Abdomen was distended. Principle Laboratory Findings: See [Table 1][1]. Additional Testing: Morphological studies of the peritoneal fluid revealed atypical lymphoid cells ([Image 1][2]). Results of immunohistochemical and flow cytometry studies are shown in [Table 2][3]. * HCV : hepatitis C virus HHV-8 : human herpes virus-8 HIV : human immunodeficiency virus PEL : primary effusion lymphoma EBV : Epstein-Barr virus EBER : Epstein-Barr virus-encoded RNA DLBCL : diffuse large B-cell lymphoma MRI : magnetic resonance imaging [1]: #T1 [2]: #F1 [3]: #T2

“Interesting belt — where did you get that?” “I see you are from Youngstown. The key question is, are you a Steelers fan or a Browns fan?” These are not the usual opening questions we teach for the medical interview. The answers are not included in the chief complaint, history of present illness, past history, social history, family history, review of systems, medications, or allergies. There is no hat or belt section in the physical exam. Differential diagnoses on sports, clothing, or food preferences are not a highly valued component of clinical reasoning. But often these opening comments and questions . . .

Patient: 52-year-old female. Chief Complaint: Fever with chills and rigor for 1 week. History of Present Illness: She was started on antimalarial treatment. She responded well and was afebrile 48 hours after initiation of therapy. She was also on regular medication for diabetes mellitus and hypothyroidism for the past 10 years. Past Medical History: Patient was admitted to the hospital with Falciparum malaria 1 month earlier and was treated for the same. She was afebrile for 3 weeks following discharge. Family History: Unremarkable. Medications: Unremarkable. Physical Examination: Mild pallor; temperature, 103°F; pulse, 100; blood pressure, 130/90; mild hepatosplenomegaly. Principal Laboratory Findings: Table 1 and Image 1 . 1. What are the most striking clinical and laboratory findings in this patient? 2. How do you explain these findings? 3. What is/are the causative agent(s) creating this patient’s condition? 4. What is the geographical distribution of the organism causing this illness? 5. What are the modalities used to diagnose this condition? 6. What is the explanation for the low peripheral yield of the organism causing this condition? 7. Which organisms, other than the 1 causing fever in this patient, can be seen in the blood/bone marrow? 1. Fever with anemia and leukopenia, rare gametocytes (1 in 100 oil immersion fields) of Plasmodium falciparum in the peripheral blood smear (detected after the peripheral blood smear was reviewed in the …

The history and physical examination of a patient remain the cornerstones of clinical medicine. Without an adequate history and physical examination to suggest possible differential diagnoses, the subsequent investigations of the patient may be endless (and fruitless). Although we rely heavily on the clinical examination, until recently there has been little formal evaluation of the information gained from these clinical encounters. A series entitled “The Rational Clinical Exam” in the Journal of the American Medical Association is now making a key contribution to our understanding by critiquing and summarizing the value of the evidence obtained during the initial patient-clinician encounter.1 In each encounter, we gather information that aids us in establishing a relationship with our patients, generating diagnoses, estimating prognoses, and initiating and monitoring our patients’ response to therapy. Generating diagnoses is an iterative process that includes information gathering and hypothesis generation. Data acquisition may begin with the chief complaint, history of present illness, past medical history, and findings from the physical examination. Information gathered at any stage in the clinical examination may be sufficient for hypothesis generation and a partial diagnosis that prompts action. With each new piece of information, the diagnoses that are considered, and their relative likelihoods, may change. Thus, we can consider components of the history and physical examination as individual diagnostic tests, from which sequential information is obtained that helps to rule in or rule out specific diagnoses. As with laboratory diagnostic tests, when considering relevant clinical skills as diagnostic tests, we must understand their properties of reliability and accuracy, and the appropriate use of likelihood ratios (LRs). To illustrate how the history and physical examination are used as diagnostic tests, we will follow a patient through an encounter with a general internist. Our clinical focus will be the diagnosis of cerebrovascular and peripheral vascular disease. At each step of the interaction, we will highlight the relevant clinical skills literature and the related diagnostic test properties, and demonstrate how application of this evidence increases the physician’s understanding of the patient’s problems, and guides subsequent management decisions.

Patient: 1-day-old Caucasian male neonate. History of Present Illness: The neonate was born to a 26-year-old gravida 1 female at 37 weeks gestational age via Caesarean section, secondary to failure to progress in labor. The infant was delivered without complications. Routine blood work on the infant revealed an unexpected red cell antibody. A direct antiglobulin test (DAT) and antibody screen were both noted to be positive. Past Medical History: The mother received routine prenatal care throughout her pregnancy. She has a past medical history of chronic hypertension, an anti-E antibody, a pan-reactive autoantibody to red cell antigens, and mild intermittent asthma. The anti-E was discovered upon prenatal screening in the mother, but was not identified in subsequent auto-absorbed specimens. No previous transfusions were documented. Social History: Non-contributory. Family History: Non-contributory. Physical Exam: The neonate’s APGAR scores were 8 at 1 minute and 9 at 5 minutes. An exam showed the neonate to be in no acute distress and with essentially normal physical findings. Principal Laboratory Findings: See Table 1, Table 2, Table 3, and Table 4. 1. What are the mother’s most striking laboratory findings? 2. The mother and neonate share the same antibody identification panel in Tables 3 and 4. Why? 3. What autoimmune conditions of pregnant women have been observed to produce transplacental antibodies resulting in neonatal disease? 4. What additional workup is necessary …

No abstract available. Manuscript truncated after 150 words. History of Present Illness A 58-year-old man complained of gradually increasing shortness of breath. He denied any cough. An outside chest x-ray is reported as showing mild bilateral interstitial changes. Past Medical History, Social History, and Family History • He has a history of rheumatoid arthritis and has complaints of mild joint stiffness and soreness. He has taken mycophenolate for several years which has made no difference in his symptoms. • He has never smoked and denies any occupational exposure. • There is no family history of lung disease. Physical Examination • Vital Signs: SpO2 95% on room air but declined to 88% with ambulation. • Chest: A few scattered inspiratory crackles noted. • Cardiovascular: Regular rhythm without murmur. • Extremities: No clubbing or edema. No evidence of synovitis or joint inflammation • Skin: Slightly raised, pink, scaly lesions on elbows and knees. Which of the following are indicated? 1. Dermatology consult 2. Pulmonary function testing 3. Connective ...

Progressive immunodeficiency in a patient with IgA deficiency.

Patient: 52-year-old Caucasian male. Chief Complaint: Swollen legs and abdominal distension. History of Present Illness: The patient has a past medical history that is significant for end-stage liver cirrhosis and blindness. Since 1967, he has had a history of heavy alcohol consumption; however, he quit 12 months prior. The patient had a PT of 27 seconds (INR=2.5) and liver disease associated with alcoholic liver cirrhosis. He was admitted for increased lower extremity edema due to noncompliance with medications. He had also been recently admitted for altered mental status and had been treated for hepatic encephalopathy. Past Medical History: Alcoholic cirrhosis, retinitis pigmentosa, panic disorder, and hepatorenal syndrome. He was admitted with lower-extremity edema and abdominal swelling. Family/Social History: He has a family history of blindness-retinosus pigmentosus (genetic brother), chronic obstructive pulmonary disease (COPD) (father), and hypertension (mother). Medications: Klonopin, Levaquin, Cephulac, Protonix, Deltasone, Inderal, Atarax, Lasix, and Spironolactone. Physical Examination: Temperature, 36°C; blood pressure, 118/68; pulse, 110; and weight, 74.8 Kg. He was alert and oriented and in no apparent distress. His pupils were equal and round. His oropharynx was clear with moist mucous membranes. The abdomen was firm and distended with normoactive bowel sounds. He had edema to the thigh with open ulceration on his feet with clear margins/base. Principal Laboratory Findings: Tables 1 , 2 , and 3 . 1. What are this patient’s most striking clinical and laboratory findings? 2. How do you explain these findings? 3. What is this patient’s most likely diagnosis? 4. What is the etiology of this patient’s condition? 5. What is the standard therapy for this patient’s disorder? 6. What is the diagnostic approach of hepatorenal syndrome seen in our patient? 7. What are the complications and prognosis for this disease? 1. Our patient presented with lower-extremity edema and abdominal swelling associated with a past medical history significant for …

41-year-old Hispanic woman. Chief Complaint: Pain in the neck, joints, and shoulders that started in August 2013. History of Present Illness: The patient has a history of psychiatric illness. Her primary care physician from an outside facility had prescribed alprazolam (Xanax) to treat her depression. The patient reported that in 2011 she experienced pain in the right side of her back and was diagnosed with sciatica. In addition, she was diagnosed with systemic lupus erythematosus (SLE) based on a positive finding for antinuclear antibodies (ANA) and double-stranded DNA (ds-DNA). She had not consulted a rheumatologist before this visit, nor had she received any medication for these conditions. Her recent history of symptoms included photosensitivity, painful aphthous ulcers, transient rashes, joint pain, myalgias, and bruising. The results of the most recent evaluation of her SLE serology revealed negative ANA and ds-DNA results. The current medications that the patient has been prescribed at Santa Clara Valley Medical Center include lamotrigine (Lamictal), sertraline (Zoloft), and gabapentin (Neurontin). In April 2014, the patient requested additional pain medication, such as hydrocodone/acetaminophen (Norco), during her physician visit. Consequently, as part of her pain management therapy agreement to ensure compliance,(1) she was subjected to a urine toxicology drug screening. At this time, her urine specimen, from an unwitnessed collection, tested positive for benzodiazepines using the Syva EMIT immunoassay (Siemens AG, Munich, Germany) at the cutoff of 200 ng/mL. However, results of a confirmatory test conducted via gas chromatography-mass spectrometry (GC/MS) did not identify any benzodiazepine metabolites in her urine but instead revealed the presence of a parent drug, alprazolam. Further, the same specimen tested positive for metronidazole. A visual inspection of the specimen revealed crystals on the bottom of the cup. In December 2013, this patient had tested positive for α-hydroxyalprazolam (an alprazolam metabolite; limit of detection, 10 ng/mL) and methamphetamine. At that time, she explained her positive urine-drug-test result by stating that "somebody had put something in my drink." Family history: Her father has been diagnosed with gout, knee osteoarthritis, and enlarged heart. Her brother has been diagnosed with clinical depression. Social history: Divorced; 3 children in the custody of their father; reported having smoked 0.5 packs of cigarettes per day for 20 years; denied any alcohol intake or illicit drug use.

Patient: 1-month-old male. Chief Complaint: Multiple positive sweat chloride tests in the absence of signs or symptoms suggestive of cystic fibrosis (CF). History of Present Illness: The patient was referred for sweat chloride testing after a positive newborn screen for immunoreactive trypsinogen (IRT). Immunoreactive trypsinogen is suggestive of CF when the value is within the top 5% of a period-specific floating cutoff value1 (Figure 1). The patient’s sweat chloride levels were elevated (>60 mmol/L). Preliminary screening for CF transmembrane conductance regulator (CFTR) mutations using a 40 mutation screen identified 1 mutation in intron 11 (1585 -1G>A, legacy name 1717 -1G>A). Subsequent full gene CFTR sequencing revealed a second CFTR mutation in intron 22. Past Medical History: The infant was full term, weighing 8 lbs 6 oz at birth, and experienced an uncomplicated delivery. The infant was discharged following a standard 2-day stay in the newborn nursery. Physical Exam: A temperature of 36.4°C (axillary), blood pressure of 120/80 mm Hg, heart rate of 148, and respirations of 40 per minute were measured for the patient. The patient’s O2 saturation was 100% on room air. The patient’s length was 61.2 cm (90th percentile), weight 6.27 kg (95th percentile), and head circumference was 39.7 cm (50th percentile). His weight-to-length ratio was at the 50th percentile. The patient appeared healthy with no labored respiration and no apparent digestive issues. Drug History: None Family History: No family history of chronic diseases. Principal Laboratory Findings: The patient underwent sweat chloride testing on sweat collected by pilocarpine iontophoresis from both arms (Table 1). These tests were repeated several weeks later yielding similar results (not shown). 1. What are this patient’s most striking laboratory and clinical findings (Table 1)? 2. How do you explain the patient’s most striking clinical and laboratory findings? 3. What conditions are typically associated …

History taking in patient suffering from pain is dealt like an art by emphasizing the multimodal experience of pain which is ignored in modern sophisticated investigations era. For clinical diagnosis, we need proper history, targeted clinical examination and support by investigation with or without diagnostic intervention. Ignoring history part in clinical assessment can lead to wrong diagnosis and unnecessary experience and expenses for patient. History part of patient evaluation can be divided into present pain as chief complaint, ruling out red flags or warning signals, past history, personnel history including sleep and bladder and bowel history, treatment history and family history. Present pain history can be divided into quantity assessment, quality assessment, mode of onset and location, duration and chronicity, provocative and relieving factors, special characters, timing of pain, relation to posture and associated features. Quantity and quality of pain can be assessed by different tools with different sensitivity and specificity. These tools give idea about the multimodal experience of pain which cannot be assessed by any physical examination and investigation. This helps us in diagnosing and planning for multimodal approach of pain management. We can conclude that proper history with adequate tools which is supported by physical examination and investigation with or without diagnostic intervention helps in diagnosing exact nature of pain.

206 Children Under 12 Presenting to the Emergency Department With Covid-19

33-Year-Old Woman With Postpartum Acute Shortness of Breath

Surgical history Introduction Age Occupation Presenting complaint (PC) • Symptom 1 duration • Symptom 2 duration • Symptom 3 duration History of presenting complaint (HPC) • Quality: what, where and how • Quantity: how much and impact on life • Time line: duration, onset, progression, offset • Associated features, risk factors and complications Past medical history (PMH) • Similar problems in the past • Medical history: MJTHREADS (MI, jaundice, TB, hypertension, rheumatoid, epilepsy, asthma/COPD, diabetes, surgery or strokes) • Anaesthetic history • General risk factors: stroke, ischaemic heart disease, angina, shortness of breath, COPD, renal failure, diabetes, change in bowel habit, DVT, PE • Women: last menstrual period (LMP), vaginal bleeding or discharge, pregnancies, deliveries Past surgical history (PSH) • Open surgery • Laparoscopy • Endoscopy/endovascular procedures • Ultrasound/CT/MRI imaging • Surgical fitness assessment: mobility, able to climb one flight of stairs, ability to lie flat, maximal exercise distance • Bleeding risk: bleeding disorders Drug history (DH) • Allergies • Regular medications • Medications taken since symptoms have started • Anticoagulant or antiplatelet agents: warfarin, heparin, aspirin, clopidogrel • Recreational drugs Social history (SH) • Smoking • Alcohol • Home + 3 others (work, social, personal) Family history (FH) • Relevant hereditary conditions • Exposure to any risk factors of acquired disease Systems review (SR) • Systems review if not already undertaken Summary of findings and confirmation that they are correct Any questions? Any concerns? Inform patient of future plans Proceed to examination Examination notes What is the purpose of the history? • The primary aim of the history is to establish a list of differential diagnoses based on the patient's history of presenting complaint and risk factors. • The second aim is to determine the patient's medical, social and functional background, which would guide further therapy and management.

History taking in clinical medicine — A forgotten art?