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Mrs.Jane Doe
Registration 12345
432 Maple Avenue
Babylon，California Tel （123） 456-7899
August 31，1982 2：00 P.M.
CC （Chief Complaint）： This 45-year-old married mother has had episodic right upper quadrant“knife-like”pain for the past 2 days.
HPI （History of Present Illness）： Mrs.Doe was in her usual good state of health until 2 days ago （August 29） when having just finished a pork-chop dinner，she had severe “knife-like” pain in the right upper quadrant of her abdomen，radiating to her epigastrium.She concurrently felt “sick to her stomach”（without vomiting），sweaty，and faint （without loss of consciousness）.She immediately lay down on her bed and felt better after a minute.The severe pain grew rapidly less，as did the nausea，but she had a “dull ache” in her right upper quadrant for several hours.She took no medication.Position did not affect the pain.She felt well enough after an hour to clean up the dinner table and slept well that night.She has had two subsequent“attacks”，the first at lunch yesterday （August 30） following hamburger and French fries.The most recent episode was at breakfast today after two slices of bacon.
She's had no fever，chills，vomiting，or diarrhea.She denies past history of similar episodes.She has no current or past history of jaundice，white stools，dark urine，or change in bowel habits.She is unaware of a history of anemia （other than mild “low blood” associated with her first pregnancy）.She has not had tarry or black stools，hematemesis，burning abdominal pain or other “indigestion”，kidney stones，polyuria or hematuria，hepatitis，or foreign travel.She has had no cough，shortness of breath，or pleurisy.She has no calf pain.She regularly examines her breasts and has noted no masses.There is a history of breast cancer in her mother.She has no known heart disease.She denies trauma to her chest，back，or legs.Her menses have been normal.She takes no regular medications and specifically denies the use of antacids，aspirin，clofibrate （Atromid），or alcohol.She currently feels quite well.
PMH （Past Medical History）：
Childhood illness：Mumps and chickenpox as child.No measles，rheumatic fever，scarlet fever.
Adult illness：None significant.Hospitalized only for childbirth （Soma Hospital，Babylon-1961 and 1963）
Trauma：Fractured left clavicle as child.No sequelae.
Surgery：Tonsillectomy as child of 6 （Soma Hospital）.Episiotomy with each childbirth.
Allergies：Penicillin-urticarial rash without wheezing，stridor，（last dose 1976，at which time reaction occurred）.
Medications：None at present.Has taken occasional aspirin for headache in past.
Travel：Never outside California.
Habits：Has never smoked tobacco or cannabis.Occasionally dinner wine （none in past 2 weeks）.No illicit drugs.Regular diet，3 meals a day.
Immunizations：Does not remember childhood shots other than oral polio vaccine in early 1950s.Last tetanus shot 7 years ago.
Family History：No family history of renal disease，liver disease，hypertension，anemia，tuberculosis.
Social History：Mrs.Doe was born and raised in Babylon，where she married her current husband after her graduation from high school in 1955.She worked as a secretary in his construction firm until their first child was born in 1961.She remained at home to raise her two sons，both of whom are college students （majoring in art and mathematics，respectively），and has recently returned to night school to gain college credits herself.She describes her life as full and her marriage as happy.Activities include housekeeping，gardening，and reading “romantic novels”.Her husband's medical coverage extends to her，and she is not worried about money.She does admit to some unhappiness at not having gone to college as a young woman，but “is making up for it now”.She is worried that her pain may represent an illness that will interfere with her studies，and she has “a test coming up next week”.She is also fearful of cancer，as her mother has metastatic cancer of the breast，which is painful and emotionally draining on Mrs.Doe，who visits her in a nursing home every day.
Review of System：
General：See HPI.No weight changes.
Head：Occasional“stress”headache.No dizziness.“Faintness” with her recent attacks as described in HPI.
Eyes：last tested 1 year ago at 20/20.No blurring，double vision，pain，discharge.
Ears：No decreased hearing，tinnitus，pain.Otitis media once as child （right ear）.
Nose：No epistaxis，sinusitis.
Throat and mouth：Teeth in good repair.Infrequent sore throats.
Chest：See HPI.No wheezing，hemoptysis，sputum.Chest X-ray normal on screening exam 1 year ago.Negative TB skin test 1 year ago.
Heart：No pain，palpitations，orthopnea，cyanosis，edema.No history hypertension.
GI （Gastrointestinal）：see HPI.
GU （genitourinary）：See HPI.No dysuria，frequency，urgency，incontinence.No history venereal disease or urinary tract infection.
Menstrual：Menarche age 13.Periods light flow for 3 days every 28 days and regular，with slight cramping on 1st day of flow.Last period normal，ended August 19，C2P2A0.
Neuromuscular：Faintness as in HPI，without syncope.No vertigo，dysesthesias（multiple sclerosis pain），seizures.No history emotional disease.
Physical Examination：
August 31，1982
2：30 P.M.
General：Mrs.Doe is a slightly obese pleasant 45-year-old white woman who is somewhat anxious but in no acute distress.
Weight：132lbs，Height：5'6”
Vital Signs：T 99℉ orally，P85 regular，R12
BP R sitting：140/90
L arm sitting：148/92
L arm standing：155/95
Skin：Warm and dry.No petechiae，purpura，excoriations （an abraded area where the skin is torn or worn off）.Anicteric.Hair and nails normal.No cutaneous lesions or rashes.
Nodes：No cervical，supraclavicular，epitrochlear lymphadenopathy.1 cm×1cm，soft，non-tender，mobile node R axilla.Scattered shotty inguinal nodes bilaterally.
Head：Normocephalic，without trauma.No scars，tenderness，bruits.
Eyes：Conjunctivae normal.Slight scleral icterus bilaterally.Lids without lesions.Pupils equal，round，and react to light and accommodation.Vision equally normal （reads newspaper）.Visual fields full to confrontation.Extraocular motions full，without strabismus or nystagmus.Fundus shows normal discs and vasculature.No arteriovenous nicking，silver-wiring，hemorrhage，or exudate.
Ears：External ears normal.Tympanic membranes normal bilaterally.Weber midline.Air conduction greater than bone bilaterally.
Nose：Nasal mucosa normal，without inflammation，obstruction，or polyps.
Mouth：Lips，buccal mucosa without lesions.Tongue well papillate，pink，midline.Teeth in good repair.Uvula midline.Oropharynx without inflammation or lesions.
Neck：Supple.Trachea midline.Thyroid not enlarged and without nodules.Jugular veins flat.Venous pulses normal.Carotid 4+ without bruits，normal pulse contour bilaterally.
Chest and lungs：Chest wall contour normal，with symmetrical full expansion，No rib tenderness to palpation.Tactile fremitus normal.Diaphragmatic excursion 5cm bilaterally.No percussion dullness.Lungs are clear to auscultation save for an isolated musical wheeze on forced expiration at the right base posteriorly.There is no egophony over this area.No rubs heard.
Heart：No visible lifts，PMI palpable 8 cm from the L sternal border in the 6th intercostal space.No palpable thrills，lifts，heaves.Rhythm regular，rate 80.S1 normal，S2 physiologically split.There is no S3 but a soft S4 at the apex.There is a 2/6 systolic ejection murmur at the L sternal border，without radiation.No rubs，no diastolic murmurs.
Breast：R breast slightly larger than L.No retractions，visible dimpling or skin changes.Nipples normal，everted.2cm×2cm cystic，mobile，non-tender mass without skin fixation in upper outer R breast.No nipple discharges.
Abdomen：Slightly protuberant.No scars or visible masses.Venous pattern normal.Bowel sounds normal.No hepatic or splenic rubs.No bruits.Liver is 15 cm to percussion and is 3cm below the right costal margin.Liver edge is smooth and tender to with positive Murphy's sign.No epigastric tenderness.Spleen and kidneys not palpable.No shifting dullness or fluid wave.No hernia.
Pelvic and rectal：External genitalia normal，including Bartholin's and Skeine's glands.Vaginal vault without lesions or discharge.Cervix parous，without lesions or discharge.Pap smear taken.
Bimanual：Fundus normal，in size & position.No tenderness.Ovaries and ligament felt and are without masses or tenderness.
Rectovaginal：Confirms bimanual.
Rectum：No anal lesions.Sphincter tone normal.No masses.Stool is clay -colored and for occult blood.
Extremities：Pulses fill and symmetrical，without bruits.Skin and hair are normal on extremities.
Pulse：
No clubbing，cyanosis，or edema.No swelling，redness，tenderness，limitation of movement of joints.No visible varicosities.No calf tenderness or cords.Muscle mass normal bilaterally.
Back：Slight cervical kyphosis.No spinal tenderness，CVA tenderness or sacral edema.
Full range of motion spine.
Neurologic：
Mental status：Alert，oriented.Memory，judgment，mood normal.
Cranial nerves：
Ⅰ-Not tested.
Ⅱ-Pupils react to light.Reads Newspapers
Ⅲ，Ⅳ，Ⅵ-NO strabismus.EOM normal.
Ⅵ-Corneal reflex intact.
Ⅶ-Face symmetrical.
Ⅷ-Hearing normal.
Ⅸ，Ⅹ-Uvula elevates symmetrically.
Ⅺ -Trapezius，sternomastoid normal.
Ⅻ-Tongue protrudes midline.
Cerebellar：Gait，finger-nose，and heel-shin normal.
Station and gait：Romberg negative； Heel-toe walk normal.
Motor：Muscle mass normal.Good strength in arm and legs.
Deep tendon reflexes：2 + = NI.
No pathological reflexes.
Sensory：Normal to touch，pinpricks，vibration.
Laboratory Findings：
Hemogram：Hgb （hemoglobin）14.2，Hct （hematocrit） 46%，WBC 8500，Polyps 65，Bands 5，Monos （monocyte） 10，Lymphs （lymphocyte） 19，Eos （eosinophil） 1，Baso （basophil） 0.Peripheral smear：Normocytic，normochromic RBCs.No fragments，targets，nucleated RBC.WBC morphology normal.Platelets abundant on smear.
Urine：Clear，dark yellow.SG1.015.Dipstix neg.heme，protein，glucose，ketones.3 + for bilirubin，pH = 6.Micro：0-1 WBC，0 RBC，no organisms per high-power field.No crystals，casts.
Serologics：
Electrolytes：Na：140，K= 4.2，Cl：100，Ca：10，P= 3.4，albumin= 4.0，Glob-3.5，SGOT：123，SGPT= 85，Alkaline Phosphatase= 210，Bilirubin total= 4.0，Bilirubin direct= 3.5，Serum amylase= 236，GI= 123，Cr= 1.0，BUN= 10
Chest X-ray：Bones normal，without blastic or lytic lesions.Heart shows slight straightening L heart border.Parenchyma clear except for slight linear atelectasis R base posteriorly （R lower lobe，basal seg）.No evident effusion.
KUB：Bones normal.Psoas shadows seen.Nephrograms show normal size kidneys.Bowel gas normal.No evident ascites.Speckled calcification medial RUQ in area gallbladder.
ECG：Rate= 80，rhythm= sinus，PR= 0.15，QRS= 0.10，QT= 0.32，Axis= + 30.P waves normal.QRS normal.No T wave flattening or ST segment abnormalities.No LVH by voltage.Impression= normal ECG.
Impressions：
1.RUQ pain
a.R/O cholecystitis with cholelithiasis.This is supported by the historical relationship of RUQ sharp pains associated with fatty foods，scleral icterus，hepatomegaly，and + Murphy's sign，clay-colored stools，and laboratory finding of bilirubinuria，abnormal liver function studies with an obstructive pattern，hyperamylasemia，and calcification on KUB that might represent gallstones.The RLL atelectasis on chest film is not inconsistent with an intra-abdominal process.
b.R/O carcinomatosis of the liver.With her family history of breast cancer the breast mass and node on physical examination，this diagnosis must be considered.The episodicity of her pain，the lack of nodularity of the liver，and the absence of evident disease elsewhere makes this less likely.
c.R/O pulmonary embolism.Though unlikely，the RLL wheeze on P.E.and atelectasis on chest film could represent the site of lodgment of pulmonary embolism from the legs （for which there is no local evidence of phlebitis） or peripelvic （She has had 2 children） areas.The liver disease in this circumstance would represent congestive hepatopathy from transient right failure of pulmonary embolism.
d.R/O myocardial infarction or ischemia.This is very improbable with her history，but should be considered in light of her recent stress in classes and the association of her pain with eating.Her hypertension，though mild，could predispose her.In this circumstance，her liver disease would be transient congestive hepatopathy.
Although other diagnosis is possible （infective pneumonia，pancreatitis，peptic ulcer，infective or toxic hepatitis），there is little to support them in the history or physical examination.
1.RUQ pain
Plan：I will hospitalize her today and obtain an ECHO of her gall bladder and biliary tree.Should this prove nondiagnostic，I would proceed to prepare her for an oral cholecystogram.
I will ask the surgeon to see her today，should another attack occasion the need for emergency surgical intervention.
Serial physical examination，urine bilirubin testing，and serum liver function tests will allow monitoring of her process.
2.Right breast mass and axillary node with PH cancer of the breast
Although the cystic lesion of the breast probably does not represent a malignancy' her FH and deep concern are troublesome.
Plan：Mammography and probably biopsy of the mass are in order.These be done on this hospitalization.
3.Hypertension
Although this might be due to anxiety，the presence of the S 4 and the strengthening of left heart border on chest film suggest a fixed hypertension rather than labile one.
Plan：I will monitor her pressure in hospital.Should they remain elevated，salt restricted weight loss and probably diuretic therapy will be instituted.
4.Allergy to penicillin
Her urticaria response could presage anaphylaxis.
Plan：I will instruct the nurses to flag her chart as allergy to penicillin.On discharge，Mrs.Doe should obtain medic-alert to the effect that she is allergic to this drug.
5.Systolic heart murmur
This is probably a flow murmur.
Plan：Observe.
（signature）
I.H.Galen，M.D.