Medical School for Everyone: Grand Rounds Cases

Imagine that you are working in an internal medicine clinic. A 55-year-old woman comes to the clinic with a chief complaint of “I never feel good.” A patient’s chief complaint is a quote, in the patient’s own words, of what his or her main concern is. Why did this person come to see the doctor? It’s a very important bit of information, because it focuses the evaluation on what the patient is worried about.

Imagine that you are in an outpatient clinic—general internal medicine. The patient is a 33-year-old man with a chief complaint of “I can’t get rid of this fever.” He had been in excellent health until two months ago. Since then, he has run fevers almost every day, usually in the range of 101 to 102 degrees Fahrenheit. He has also developed a cough that is getting increasingly worse and uncomfortable ulcers or sores in his mouth.

Imagine that a 36-year-old woman, Louisa, comes to our outpatient clinic with a chief complaint, in her words, of: “I’m tired of being in pain all the time.” Louisa says that her main problem is abdominal pain, usually in the lower part of her belly, that sometimes gets better and worse but is essentially always there. It began four or ¿ve years ago and has gotten progressively worse.

Jayden, a 10-year-old boy, is brought to the emergency department with a chief complaint of “Just look at me.” The remainder of the HPI was taken both from the child and his parents and older sibling, all of whom have accompanied him to the visit.

Gordon, a patient in the emergency department, comes in with the chief complaint of “I’ve got another one of these sinus headaches.” The patient is a 42-year-old male, who is actually well known in the emergency department. He says that he gets sinus headaches all the time. This one began earlier in the day, with a severe headache starting kind of over his right eye, though it has now spread to both sides of his forehead. He says that when he gets these, he almost can’t think straight, and his nose gets all stuffed up.

Julie, a 52-year-old woman, comes to our general medicine outpatient clinic with a chief complaint of “I can’t play tennis anymore.” Julie says that she used to be a very active athlete, but about 10 years ago, she started having mostly right-sided hip and knee pains. She was diagnosed with osteoarthritis.

The person in front of you collapses to the floor. You have no time for a chief complaint or history. There is a woman lying on the floor in front of you, and she looks to be about 50 years old. She is pale, and she’s taking what are called agonal respirations: just the barest gasps that occur when a person is near death. Within moments, even these respiratory efforts stop. What do you do?

A 15-year-old patient, Trevor, is brought to our office by his father. When asked, he has no chief complaint, or at least he’s not willing to say one. His father says that Trevor is failing school and is maybe falling asleep in class.

In our general medicine clinic, a 42-year-old woman named Tina says that for the last few months, she gets these “attacks” where all of a sudden she gets dizzy. She can’t stand up straight, and sometimes she hears a buzzing or high-pitched sort of noise. She says that she sort of staggers around and has to eat a candy bar. Once she has some sugar, in about a half of an hour, she starts to feel better.

In the general internal medicine clinic, a 46-year-old woman named Charlene comes in for a scheduled checkup. When asked what’s on her mind, she says, “I feel ¿ne.” Charlene is either 1) perfectly healthy or 2) has something wrong with her that she hasn’t noticed yet, or at least hasn’t told us about yet.

A 19-year-old man is brought to the emergency department. His name is Christopher, and his chief complaint is: “Doc, I can’t walk.” He says that for the past two days, his legs have been hurting very badly, and it’s getting worse. The pain is mostly in his calves. As long as he doesn’t try to move much, it’s okay, but if he stands or stretches out his legs or feet, the pain becomes much worse.

Leslie, a new patient to the general adult medicine clinic, is a 45-year-old woman with a chief complaint of “I’m tired of the itching.” She has brought a voluminous stack of prior medical records that is loaded with lab reports and letters from specialists.

A 7-month-old boy named Marcus has been brought by his parents to the pediatric clinic. In their words, “He looks weak.” They say that Marcus is a happy baby, but he has never been as active as his sister. Lately, though, he seems more fussy at times and isn’t interested in sitting up or playing much. In addition, Marcus was anemic last month.

Sandra is a 35-year-old woman who we have not met before. Her chief complaint, as listed on the intake form, is “constipation.” According to her, it’s been going on for about a year, maybe longer, but it’s just getting worse and worse. She has brought some of her medicines with her so that you could see what she’s tried.

Joe is 55 years old, and he comes to our general medicine clinic with his wife. His chief complaint is: “I fall asleep all the time.” Joe says he’s not sure how it happens; he just kind of nods off, and someone has to wake him up.

On a snowy winter night in Boston, a four-month-old African American girl named Samantha is brought to the emergency department, and the chief complaint, as written on a form by the parents, is: “She’s shaking; is something wrong?”

A 39-year-old woman, Sally, comes into the emergency department with a chief complaint of “I can’t stop vomiting.” Sally says that she has had episodic vomiting and some abdominal pain on and off for a few months, but it’s gotten much worse this week, with frequent vomiting every time she tries to eat or drink.

In the emergency department, an older man is being pushed in a wheelchair. He’s with his daughter, who gives us the chief complaint: “I think my Daddy is having a stroke.” Our patient’s name is Ramesh, and they’re hooking him up to monitors while we get some basic history.

We’re working at the student health center of a big university today, seeing college students and faculty. Our patient is a 22-year- old Hispanic woman named Elena whose chief complaint is “I feel terrible.”

Our first patient in the pediatric clinic is James, who is coming in for his routine two-year-old checkup. His parents express the chief complaint: “We don’t think he talks right.”

Appendicitis refers to acute inflammation of the appendix, and it’s the most common abdominal surgical emergency. About 250,000 appendectomies are done in the United States each year—though the incidence is much lower in the developing world. About 1 in 14 people will experience appendicitis during their lifetimes and will get their appendix removed. Almost all patients with appendicitis have pain. One recent report showed that a history of increased pain while driving to the hospital over bumpy roads correlates well with an appendicitis diagnosis.

What happens to a human body when it’s pushed to the edge of survival? Imagine that you are in your car on your way to the emergency department for your next shift. A man on a motorcycle passes you, darting into and out of oncoming traffic. He’s probably going 60 miles an hour on a two-lane street. Up ahead of you now, you see his back wheel clip the edge of a car. The motorcycle spins out of control and slams into a concrete utility pole. What do you do?

Our patient in the general medicine outpatient clinic is Margo, a 49-year-old woman who has come in with her husband with a chief complaint of “I’ve got this cough again.” Margo says that she gets a cough frequently, a bad cough that lingers for weeks, and she keeps seeing doctors, and it gets better, and then it comes back. She thinks this time it’s her allergies, because it’s the fall, and she always gets this cough in the fall.

In the general medicine clinic, our patient is a 90-year-old gentleman named Isaac. He is brought in by his son. You’ve known Isaac for many years, though he’s a snowbird who you see for routine care only about six months out of the year. It’s April, and he’s come back to town from his usual winter stay in Boca Raton, Florida.