GENERAL OUTLINE
SAMPLE MEDICINE CLERKSHIP HISTORY AND PHYSICAL EXAMINATION WRITE UP
John Doe
AB1234
January 1, 2000
INFORMANT: Patient and wife, both knowledgeable about history of present illness, fairly
knowledgeable about past medical history and medications.
PATIENT PROFILE:
Mr. Doe is a 56-year-old married White male with no previous Duke hospitalizations but multiple
admissions at community hospitals for similar presentations. He is followed by Dr. Jane Smith in
Nowhere, NC (phone # (919) 555-1212, fax# (919) 555-1111).
CHIEF COMPLAINT: “I can’t get rid of this stomach pain.”
HISTORY OF THE PRESENT ILLNESS:
The patient reports that he has had multiple hospitalizations for similar episodes of abdominal pain
but was doing fairly well over the last month until about a week ago, when he started developing
sharp mid-abdominal pain. The pain is severe; he rates it at a 9/10, sometimes as bad as 10/10, and
radiates to his back. He notes that he develops some nausea and vomiting associated with the pain.
He admits to becoming sweaty at times when he has the abdominal pain. He cannot recall exactly
what he was doing at the time the pain first started coming back, although he does acknowledge that
eating makes the pain worse. When asked, he denies any bloody vomit or blood in his stools. He is
not sure about whether or not he has had dark, tarry stools. He has not had any constipation or
diarrhea. He denies any episodes of feeling faint. He has not had any chest pain or shortness of
breath. The abdominal pain is similar to episodes he has experienced in the past but has not gotten
better with the usual remedies. Because of his and his wife’s concern that there might be something
“seriously wrong” with him, he presented to Duke for evaluation and management of severe
abdominal pain, nausea and vomiting.
PAST MEDICAL HISTORY:
(Obtained from patient and his wife; records requested but not available from outside hospital):
Hypertension – diagnosed in 1984, on medications
Type II diabetes mellitus – diagnosed in 1984, on medications
The patient does not recall his most recent hemoglobin A1c.
He is not aware of when his last foot exam was; wife thinks it was about 2 years ago.
He had an ophthalmologic evaluation in October and was diagnosed with retinopathy.
He denies problems with neuropathy or nephropathy.
History of peptic ulcer disease with upper GI bleed in 1984 requiring hospitalization and transfusion
The patient’s wife recalls he received 2 units of packed red blood cells; no surgery.
History of pancreatitis
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Gout
Status post cholecystectomy at Local Hospital in Nowhere, NC
Status post motor vehicle accident in 1988 – seen in the ER and discharged
CURRENT MEDICATIONS:
Hydrochlorothiazide 25 mg PO daily (for hypertension)
Metformin 500 mg PO BID (for diabetes)
Aspirin 325 mg PO daily (“the doctor told me to take it for my heart”)
Colchicine 0.6 mg PO as needed for gout flares
Saw Palmetto unknown dosage (herbal remedy for prostate)
Denies other herbal remedies
Denies other medications other than occasional acetaminophen
ALLERGIES/SENSITIVITIES:
The patient avoids NSAIDs due to his history of peptic ulcer disease
Penicillin (unknown reaction; was told in childhood that he was allergic to penicillin)
SOCIAL HISTORY:
The patient lives in East Nowhere, North Carolina, with his wife of 8 years. He has two children from
his first marriage; they are grown and live nearby. He completed high school and works with a
construction company. He has health insurance and is able to afford his medications. He smokes
about 1 pack of cigarettes daily and admits to smoking for 40 years (40 pack-years). He says he
drinks 2-3 beers daily and admits to sometimes drinking in the morning. He denies using any illegal
drugs.
HEALTH MAINTENANCE:
The patient received the influenza vaccine in November.
The patient is not aware of ever receiving a Pneumovax.
The patient says his PSA has been checked and is in the normal range.
His wife says he has turned in stool cards yearly and has never been asked to come in for a
colonoscopy for colon cancer screening.
FAMILY HISTORY:
Father died at age 65 from a heart attack. He had alcoholism.
Mother (age 80) has diabetes and kidney disease.
Brother (age 58) has had two heart attacks.
Sister (age 53) has diabetes and had a “ministroke” last year.
The patient denies any family history of cancer.
REVIEW OF SYSTEMS:
General: + weight loss (5 lbs over 1 week) with decreased appetite. Denies fever, fatigue, sweating
except with some episodes of abdominal pain as per HPI. No night sweats.
Skin, Hair, Nails: Denies any new rashes, lesions, or changes.
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HEENT:
Eyes – + blurry vision, recent diagnosis with retinopathy, wears glasses.
Ears – Denies any changes or tinnitus.
Nose/Throat/Mouth (including teeth); Denies any complaints. Last saw a dentist 3 years ago for
fillings.
Respiratory: Denies shortness of breath. Has morning cough with white “phlegm.”
Cardiovascular: Denies shortness of breath, PND, orthopnea. Gets up 4 times nightly to urinate. No
edema. Denies chest pain, palpitations. Has some dyspnea on exertion (can walk ½ mile but needs
to rest to catch his breath). No syncope. Denies history of heart murmur.
Breasts: Denies concerns.
Gastrointestinal: Denies dysphagia. + abdominal pain with nausea/vomiting as per HPI; no
hematemesis or coffeegrounds. Denies jaundice. No diarrhea or constipation.
Genito-Urinary: + polyuria; no dysuria or hematuria. + frequency and dribbling.
Menstrual: not applicable.
Sexual: Denies change in libido; + difficulty achieving erection.
Musculoskeletal: History of gout; currently no active gout. + General aches and pains, chronic.
Neurologic: Denies weakness, tremor, changes in sensation or gait.
Endocrine: + Polyuria. Hasn’t checked blood sugars at home recently. No changes in skin color, no
sweating or flusing.
Hematopoietic: Denies easy bruising or bleeding.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 100/60 Pulse 87 left arm lying; 104/62 right arm lying;
Blood pressure 96/58 Pulse 95 left arm sitting
Temperature 37.6 (oral). Respirations 16. Height 70”. Weight 190 lbs.
GENERAL APPEARANCE: Well-developed, well nourished slightly overweight White male with a
ruddy complexion, appears mildly uncomfortable but in no acute distress.
SKIN: Scattered cherry angiomas no rashes or lesions.
HAIR: Male pattern baldness
HEENT:
Head: Normocephalic, atraumatic.
Eyes: Anicteric sclerae; PERRL, EOMI.
Fundoscopic: Sharp discs, cotton-wool spots, AV nicking.
Ears: Cerumen L, R TM clear.
Nose/Sinuses: Deferred.
Mouth/Pharynx: OP clear; moist mucosa.
NECK: Trachea midline; no thyromegaly. JVP not elevated. No carotid bruits. No cervical LAD.
CHEST: Symmetric. No dullness to percussion. Equal expansion, no crackles; prolonged expiratory
phase with some wheezing.
HEART: Quiet precordium, PMI displaced laterally. Distant S1S2 RRR no m/r/g appreciated.
ARTERIAL VASCULATURE: 2+ carotid pulses no bruits. 2+ radial pulses B. Femoral pulses 2+
without bruits. 1+ dorsalis pedis pulses.
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BREASTS: Symmetric, no abnormalities.
LYMPH NODES: No lymphadenopathy (cervical, supraclavicular, axillary, inguinal)
ABDOMEN: Mildly obese. Normal percussion. Normal bowel sounds. + tenderness to palpation
mid-epigastric without rebound or guarding. No hepatosplenomegaly. No bruits.
GENITALIA/RECTUM: No masses or abnormalities of external genitalia. Rectal exam reveals small
external hemorrhoids, normal sphincter tone, smooth, enlarged prostate without tenderness. Guaiac
positive brown stool in vault.
EXTREMITIES: No cyanosis or edema; mild clubbing. No deformity.
MUSCULOSKELETAL: Normal tone and bulk. Crepitation at both knees; no effusion. No active
synovitis.
NERVOUS SYSTEM:
Mental Status: Alert and oriented to person, place and date. Normal affect. Cognition not
formally tested.
Cranial Nerves II-XII tested; visual impairment (20/200 with glasses) otherwise no deficits.
Sensory: Decreased sensation to pin prick bilateral lower extremities.
Motor: Normal posture. 5/5 strength in upper and lower extremities. No tremor.
Reflexes: 2+ biceps, patellar; absent ankle-jerk; downgoing toes bilaterally.
Cerebellar: FTN normal; slightly broad-based gait, Romberg negative.
LABS/DATA:
Hgb 11.6 (low) Hct 39 (low) Plt 155 WBC 5.6
Na 144 K 3.4 Cl 106 HCO3 28 (high) BUN 18 Cr 1.4 Glu 288 (high)
Amylase 186 (high)
Lipase 632 (high)
AST 126 (high) ALT 75 (high) ALKP 126 Bili 0.4
PT 13.2 (INR 1.1) PTT 28.4
CK 198 MB 4 Troponin T 0.02
Abdominal XRay: Nonobstructive bowel gas pattern
Chest XRay: Hyperinflated lungs, no acute airspace disease
EKG: Normal sinus rhythm, nonspecific T-wave changes in anterior leads, no priors to compare.
INITIAL FORMULATION (ASSESSMENT/PLAN):
This is a 56 year old man with a history of peptic ulcer disease, pancreatitis, and cardiac risk factors
who presents with sharp epigastric abdominal pain, nausea and vomiting that appear to be most
consistent with an episode of acute pancreatitis. Other important diagnostic considerations include
peptic ulcer disease (of which he has a history and which could present in a manner similar to or even
cause an episode of pancreatitis), coronary event (he has a history of diabetes and may not
experience chest pain with ischemia), aortic dissection (with sharp chest pain radiating to the back).
Preliminary work-up is reassuring that he is not experiencing an acute ST-elevation myocardial
infarction, and the weeklong history of pain without elevated troponin is also reassuring. Aortic
dissection must be considered, as there are multiple episodes in the literature in which failing to
consider aortic dissection results in fatal delays to diagnosis, though the cardiovascular and pulse
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examination do not reveal asymmetries or bruits. Laboratory data obtained on presentation point to
acute pancreatitis as at least partly responsible for this patient’s complaints, which are similar to his
previous episodes of pancreatitis and are supported by the elevated amylase and lipase along with
epigastric pain and nausea/vomiting associated with food.
1. Pancreatitis: The patient has acute pancreatitis by symptoms, exam, and lab data. Possible
etiologies for his pancreatitis include alcohol (including the possibility that he drank more
heavily around Christmas and exacerbated his pancreatitis), drugs (he is taking
hydrochlorothiazide, which has been associated with pancreatitis), hypertriglyceridemia
(particularly with his history of diabetes mellitus), and peptic ulcer disease (which he has a
history of). The patient has had a cholecystectomy, so gallstones are much less likely. Rare
causes of pancreatitis exist and will be investigated if the more usual causes fail to provide an
explanation.
In order to further evaluate this patient’s pancreatitis, we will order a lipid profile to assess
triglycerides and will further elucidate his history of present illness with more specific detail
given to alcohol consumption and postprandial symptomatology. In general, CT scans are not
necessarily recommended in cases of uncomplicated acute pancreatitis; however, in this
patient with the question of aortic dissection and multiple vascular risk factors, we have
ordered a CT of the chest and abdomen to assess for dissection. Also, since the patient is
diabetic and may have alternative presentation of coronary events, we will place him on
telemetry and complete three sets of cardiac enzymes to rule out myocardial infarction.
Ranson’s criteria are classically used for the determination of severity in pancreatitis; this
patient’s LDH is 300 and his Ranson score at present is 2, indicating favorable prognosis.
Over the next 48 hours he will be monitored clinically and for worsening anemia, worsening
renal function, worsening oxygenation, base deficit and evidence of fluid sequestration to
ensure continued favorable prognosis.
Treatment will be conservative at this time: NPO; if nausea/vomiting become a problem, will
place an NG tube. Gentle fluid replacement. Monitor I/Os and follow abdominal examination.
Once pain has improved and n/v resolve, may start cautiously with a clear liquid diet. In some
patients with acute pancreatitis, data exist for the prophylactic use of antibiotics to prevent
pancreatic necrosis. This patient does not appear acutely ill and is afebrile; if the abdominal
CT demonstrates any evidence for necrosis, would consider antibiotic prophylaxis. Pain
control with narcotics may be necessary until symptoms start to improve; consider using a
patient-controlled analgesia (PCA) system.
In the longer term, the patient will need to be counseled and educated regarding the role of
alcohol in the development of acute pancreatitis, and he should be encouraged to quit drinking
alcohol.
2. Diabetes mellitus: The patient has a history of diabetes mellitus and is on oral agents. He has
retinopathy and, by physical examination, neuropathy that is likely attributable to diabetes. By
labs obtained on admission, his renal function is not completely normal; it is not clear whether
this is related to diabetes or possibly volume depletion from decreased PO intake. Will check
hemoglobin A1c to determine level of control of diabetes. Given creatinine 1.4 and unclear
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etiology or direction of renal function at this time, along with contrast CT scan to be performed,
will hold metformin due to risk of lactic acidosis in renal insufficiency and with IV contrast dye.
Will follow up on hemoglobin A1c and creatinine and determine whether or not resuming
metformin 48 hours after CT scan is appropriate or whether alternative treatments need to be
considered. Meanwhile, will start to check Accu-checks and will write for sliding scale Regular
insulin to be administered during mealtimes with a goal of keeping blood sugar < 200.
Regarding blood pressure medications, the choice of HCTZ in this patient is suboptimal
and could be causing problems in terms of gout and pancreatits. Given the history of diabetes
and the possibility of nephropathy, a more optimal blood pressure regimen would include the
use of an ACE inhibitor. Given his relatively low blood pressure and the mildly elevated
creatinine, will currently hold antihypertensive medications but will consider adding an ACE
inhibitor once other issues are resolved.
3. Cardiovascular: The patient has a number of cardiac risk factors including family history,
smoking, diabetes mellitus and hypertension. Therefore, even though his presentation is not
typical for a coronary event, he will be placed on telemetry and ruled out for myocardial
infarction. Given his abdominal symptoms and nausea and the lack of convincing changes on
EKG, if he is experiencing an acute coronary syndrome, it is most likely to be posterior-inferior
ischemia or infarction. Regarding risk stratification, will obtain a fasting lipid profile in the
morning; given his risk factors, his goal LDL is less than 100. Goal blood pressure is < 130/80.
We will obtain a CT of the chest and abdomen to assess for the unlikely possibility of aortic
dissection.
4. Gout: The patient has a history of gout; according to him, he has had joints tapped and doctors
have told him he has gout. His alcohol use likely contributes to his gout, as does his
prescription for hydrochlorothiazide, which is also associated with the development of
pancreatitis. At this time, there is no evidence for acute gout flare. We will discontinue HCTZ
given its possible association with pancreatitis and gout and will monitor the patient for any
acute arthritis. He will receive counseling regarding the recommendation to quit drinking
alcohol.
5. Renal insufficiency: As described above, creatinine is elevated and reflects some degree of
renal insufficiency. Will check urine for sodium and creatinine in order to calculate a FeNa,
which may help determine whether the cause is pre-renal, intrinsic renal or post-renal (e.g.,
obstruction). The patient has possible contributions from each including decreased PO intake
for pre-renal, diabetes for renal, and symptoms of prostatism indicating the possibility of
obstruction. Pending FeNa, may need to pursue ultrasound to assess for hydronephrosis. Will
monitor I/O, Cr, and gently hydrate. Given risk of hypotension causing worsening renal
function, will hold HCTZ and, if Cr improves, will consider starting an ACE inhibitor for renal
protection in diabetes mellitus.
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6. Pulmonary: Given the extensive smoking history, pulmonary examination, symptoms and CXR,
suspect the patient has COPD. He should be worked up in the outpatient setting with
pulmonary function tests, which will be set up for him at the time of discharge from the hospital.
7. Alcohol abuse: The patient has some features that are concerning for an alcohol use disorder
and should receive counseling regarding resources available to him for quitting, particularly
since alcohol use may exacerbate his medical conditions and may have caused his
pancreatitis. Will continue to educate him while he is here and will work to seek outpatient
resources to him should he decide he would like to quit alcohol. He has no past history of DTs
or seizures but will monitor blood pressure, pulse, temperature carefully to assess for
possibility of w/d syndrome.
Signed: M. D. Student, MS2; July 25, 2005 3:57 p.m.
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