(Circle the appropriate answers.)
HISTORY OF PRESENT ILLNESS
This (0-109)-year-old (Asian, Black, Caucasian, Aleutian, Venusian) (male, female, other) presents with a (1, 7, 100)-(second, minute, day, year, century) history of (pain, swelling, itching, enlargement) of the (arm, chest, scrotum, uvula, pineal gland). (She/He/It) rates it as (11, 12, 20) out of 10. It is aggravated by (breathing, thinking, hang gliding, vigorous dancing, ennui) and alleviated by (acetaminophen, chocolate, high-dose morphine).
PAST MEDICAL HISTORY
Diabetes, hypertension, pineal insufficiency, Kluver-Bucy syndrome, rectal prolapse, Chagas disease, visceral larval migrans, ichthyosis, all of the above
PAST SURGICAL HISTORY
- Transplant of the (heart, kidney, pancreas, amygdala, pineal gland)
- ORIF of (humerus, femur, rear axle)
- Hemorrhoidectomy, cholecystectomy, pancreatectomy, cerumen removal, all of the above
(Penicillin, sulfa, every known drug in existence except Demerol)
- Insulin, metformin, Gila monster venom
- Alpha blocker, calcium blocker, beta blocker, blocker blocker
- Amoxicillin, “gorillacillin,” maggot extract, “mickeymycin”
- SSRI, MAOI, TRIAD, ECT, DOA
- (Thyroid, adrenal, pineal) gland extract
Adopted, old age, some kind of cancer
- Alcohol: (teetotaler, tippler, boozer, lush, no alcohol—only beer)—multiply by 10
- Smoking: (never; three packs a day; not tobacco; old stogies I have found, short but not too big around)
- Drugs: (Is this confidential?, Freon, whatever I can get my hands on)
- Employment: (meter maid, sewer maintenance worker, JCAHO auditor, forensic proctologist, hospitologist)
REVIEW OF SYMPTOMS
- (Chest pain, more chest pain, even more chest pain), (rectal, urinary, salivary) incontinence, (ears itch with urination, nose runs with defecation, small bugs crawling out of my skin), (short of breath, short of patience)
- Stool is (sticky, floating, malodorous, frequent, shaped like the Statue of Liberty)
- Double vision, tunnel vision, television, hyperacusis, hearing loss, could you repeat that?, halitosis, dysgeusia, dysphonia, “datphonia”
- Abdominal (pain, cramping, crunches)
- BP (0, 90, 140, 230, 290)/(0, 3, 90, 160)
- Pulse (absent, irregularly irregularly irregular, tachycardic, tacky dresser) rate (0, 3, 84, 112, 190, 280)
- Temperature (32.2, 36.8, 25 minutes at 450—baste often)
- Normocephalic/atraumatic, bullet-headed, pointy-headed, hatchet in skull
- Eyes (PERRLA, anisocoria, bloodshot, pinpoint dude)
- Fundus exam (never can see them, cotton wool spots, cotton candy)
- Ears (present, “hyperceruminic,” absent)
- Mouth (macroglossia, foot in mouth, black hairy tongue, halitotic, skin of the teeth, wooden teeth)
- Neck (supple without adenopathy, thick, multiple hickies, red)
- Lungs (clear to auscultation and percussion—OK, I never really percussed; Velcro rales; egophonic; wheezy)
- Heart (systolic, 5/6, even a medical student can hear) murmur (no, pericardial, aye there’s the) rub
- Abdomen (scaphoid, pendulous, six-pack); bowel sounds (absent—was that you?)
- Umbilicus (surgically absent, Sister Mary Joseph nodule, high lint content)
- Extremities (extreme, all six present, night-clubbing)
- Reflexes (cremaster positive, anal wink intact)
- Mentation (alert and oriented x3, catatonic, dogatonic)
- Psychiatric (appropriate, psychotic, truly weird, bipolar, tripolar)
- Skin (present, hideous thing growing on the patient’s face)
Results of (CBC, ionized calcium, “citrulated ceruloplasmin,” complement levels, insult levels, saliva electrophoresis, urinary zinc level, melatonin level, and protein Q) all markedly abnormal.
(CAT scan, PET scan, DOG scan, plain film, complex film, KUB, IVP, XYZ, molybdenum scan, Afghaniscan)—all suggest need for further imaging.
ASSESSMENT AND PLAN
- “Hyperlabemia:” Likely iatrogenic etiology, or not. Correct with supplemental lab results.
- Pain: Source unclear but probably malingering. Treat with excessive narcotics, thereby causing problems 3 and 4 (see below).
- Bowel obstruction: Discontinue narcotics. Place (NG tube, rectal tube, boob tube, multiple consults).
- Altered mental status: Baseline worsened by narcotics. Give benzodiazepines, antipsychotics, antihistamine, more narcotics; then intubate.
- Discharge planning: The patient is a rock and will be on service forever.
- Abnormal imaging: Perform further scans.
- Code status: (Full code, no code, Morse code)
- Pineal: Gland abnormal—consult the pineal gland service TH
Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.