What`s up, Doc?

Introduction to Medical English

By: Mutiara Budi Azhar

Faculty of Medicine Sriwijaya University Palembang - Indonesia

What s u!" #oc$

Contents
Introduction 2 The Parts of the Body
1. The Human Body 3 2. The Human Face 4 3. Organs and Structures 5

Specialties 7 Clerking a Patient

1. Part one 2. Part t"o 3. Part three : Taking a Medica History ! : The com# ete Physica $%amination 12 : &etters o' (e'erra 1)

Common Illnesses and Lay Terms 19 Medical n!ironment

1" Instruments and Materials Things a doctor might ha*e #$ +se'u instruments #1 #" %&'ects in a patient(s room #1 )" *ifferent rooms ## +" Special clinical tests and procedures ##

Case ,istories #) -ppendi.

1" ,o/ to /rite an -pplication &etter o' (e'erence #0 &etter o' ,## ication #7 -urricu um .itae #1 #" List of -&&re!iations #9 )" 2eights and Measures )$ +" Some facts a&out the British ,ealth System )1 3" Literature ))

Introduction

There are the di''icu ties o' dai y i'e on a "ard/ such as the ack o' sentences you can use in a con*ersation "ith a #atient "hen $ng ish is not your mother tongue. 0diomatic e%#ressions and technica terms/ the "ay o' taking medica histories according to the British scheme and the con*ersation "ith #atients are the main to#ics o' the course. This scri#t ser*es as a re'erence 1ook and shou d #ro*ide you "ith the 1asic in'ormation. ,#art 'rom that there "i 1e ro e2# ays and handouts in some o' the meetings. The conce#t o' the course is 1ased u#on your i*e y #artici#ation you3d rather not stay seated 4 1ored to death 4 "hi e an e*en more 1oring ecturer e%# ains his amia1 e 1ut 5again6 1oring theories. 7ou shou d take this o##ortunity and rea y learn something "ithin a grou# o' students reaching at the same target: 'ind out a1out the mysteries o' $ng ish as a medica anguage and 1ecome com#etent 'or your c erkshi# 1y training your communication ski s. 8e are ooking 'or"ard to the term9

%rgans and structures

1rain/ ence#ha on u##er 1rain/ cere1rum cere1e um 1rain stem/ ence#ha ic trunk menin% 5# r. meninges6 s#ina marro"/ s#ina cord 1ase o' sku / crania 1ase ' uid/ i;uor tongue #a ate 5hard<so't6 throat/ #haryn% *oice 1o%/ aryn% *oca igaments cords "ind#i#e/ trachea 1ronchi ung/ #u mo 5 o1e o' ung6 thyroid 5g and6 thymus 5g and6 heart/ cor atrium 5o' heart6 cham1er o' the heart/ *entric e atrio*entricu ar *a *e semi unar cus#<*a *e aorta 5ascending/ aortic arch/ desc.6 gu et/ eso#hagus midri''/ dia#hragm stomach/ a1domen/ 1e y/ tummy duodenum #ancreas sma 1o"e <intestine arge 1o"e <intestine 1 ind gut/ a##endi% anus s# een i*er ga 1 adder kidney/ ren ureter 5urinary6 1 adder urethra *agina/ 5sheath: sarung/ 3=ondom36 "om1/ uterus 5'a o#ian6 tu1e/ sa #in%/ tu1a uterina o*ary/ o*arium #enis/ 5mem1er6 scrotum testic e/ orchis #rostate 5g and6

Specialties
>

SP CI-LIT4
anaesthetics anatomy 1acterio ogy 1iochemistry cardio ogy dermato ogy em1ryo ogy endocrino ogy e#idemio ogy gastroentero ogy geriatrics gyneco ogy<o1stetrics9 haemato ogy histo ogy immuno ogy micro1io ogy neuro ogy onco ogy o#htha mo ogy ortho#aedics otorhino aryngo ogy #aediatrics #arasito ogy #atho ogy #harmaco ogy #harmacy<#harmaceutics #hysics #hysio ogy #sychiatry radio ogy rheumato ogy surgery uro ogy *iro ogy

SP CI-LIST
anaesthesist anatomist 1acterio ogist 1iochemist cardio ogist dermato ogist em1ryo ogist endocrino ogist e#idemio ogist gastroentero ogist geriatrician gyneco ogist<o1stetrician haemato ogist histo ogist immuno ogist micro1io ogist neuro ogist onco ogist o#htha mo ogist ortho#aedic surgeon otorhino aryngo ogist #aediatrician #arasito ogist #atho ogist #harmaco ogist #harmacist #hysicist #hysio ogist #sychiatrist radio ogist rheumato ogist surgeon uro ogist *iro ogist

-*5 CTI6
anaesthetic anatomica 1acterio ogica 1iochemica cardio ogica dermato ogica em1ryo ogica endocrino ogica e#idemio ogica gastroentero ogica geriatric gyneco ogica < o1stetric haemato ogica histo ogica immuno ogica micro1io ogica neuro ogica onco ogica o#htha mo ogica ortho#aedic otorhino aryngo ogica #aediatric #arasito ogica #atho ogica #harmaco ogica #harmaceutica #hysica #hysio ogica #sychiatric radio ogica rheumato ogica surgica uro ogica *iro ogica

7 pay attention8

, o' these s#ecia ists dea "ith illnesses 9 ailments 9 diseases 9 disorders 9 complaints 9 maladies 9 trou&les 9 sicknesses 9 sufferings

Clerking a Patient
,dmitting a #atient to hos#ita inc udes t"o ma?or ste#s: on the one and the doctor has to take the #atient3s medical history/ "here he is gi*en the o##ortunity to re#ort his com# aints and to ans"er the doctor3s ;uestions. On the other hand a 5com# ete6 physical e.amination shou d 1e done in order to detect certain #hysica sym#toms and to 'ind a diagnosis.

Part one: Taking a Medical ,istory

A typical medical history usually follows a defined scheme. Of course one should know that scheme well, but obviously gathering the relevant data from an English speaking patient !not to mention the typical "laswegian or the #orkshire dalesman$ can be a problem in itself. %n general &ritish people tend to be more polite than people on the 'continent(. )he language is full of phrases that might appear strange or even e*aggerated to a foreigner. As a physician !to be$ you are obliged to have the patient+s trust and the use of an ade,uate style of language is important to reach that aim. -o this lesson includes some useful common phrases of conversation. Introducing oneself9Specific ;reetings @ood morning/ Mr. Brad'ord/ my name is ,nne @o ding. 0 am a medica student 5 you may say: Astudent doctorB6 doing a c erkshi# on this "ard. 0 heard a1out the #ro1 ems you ha*e "ith your heart. 8ou d you mind i' 0 e%amined your chest againC He o/ Mrs. (uther'ord/ my name is (o1ert 8eiss. 0 am a Senior medica student. The doctor "i 1e here short y/ may 0 ask you a 'e" ;uestions mean"hi eC @ood morning Mr. He" ing/ itDs nice to see you. P ease come in and ha*e a seat. 8hat has 1rought you a ong todayC 8hat seems to 1e your #ro1 emC -ou d you descri1e it 'or me/ # easeC @ood a'ternoon/ Mrs. Eohnson. 0 see 'rom your chart that you came to us com# aining o' #ain in the stomach. 0s there anything e se you "ant to te me 1e'ore "e ook at your stomach more c ose yC He o/ Mr. Mc&eod. 8e met ast "eek/ didn3t "eC 8e / 0 ha*e 1een going o*er some o' the resu ts o' your tests "ith a co eague o' mine and "e are # eased "ith your #rogress. @ood morning/ you are -hristo#her/ aren3t youC 0 heard a ot o' nice things a1out you. But your Mum to d me you ha*e a tummy ache. 0s that rightC Fo"/ -hris/ 0 "ant you to te me a a1out it. He o/ Mr. Smith. -ou d you # ease ro u# your s ee*e and et me take our 1 ood #ressureC He o again/ Mr. 8right/ 0 ha*e come to take a 1 ood sam# e. -ou d you # ease ro u# your s ee*eC 0t might 1e a 1it uncom'orta1 e. 0t is ike a shar# scratch.

;athering Information I. Personal Data: Time of assessment (!) o .ame !surname/0hristian name$ o Age !1O&$ o -e* o Occupation o 2arital -tatus II. C/O (= complaining of = Chief Complaint) o )ry to find a short phrase describing the patient+s problem. 1o not give a diagnosis3 III" HPC <7 ,istory of the presenting complaint= o o o o o o o o o 8hen did the #ro1 em 1eginC Ho" ong has it 1een 1othering youC *>?-TI%@ Ho" did it startC 5gradua y<sudden y6 M%* %A %@S T Ho" o'ten does it come onC A? B> @C4 Ha*e you e*er had anything ike this 1e'oreC 8hat 1rings it onC Goes anything make it 1etter<"orseC Goes it occur in certain #ositionsC ? LI 6I@;9-;;?-6-TI@; A-CT%?S Goes anything go a ong "ith itC $.g. ,re you 'ee ing sick/ are you s"eatingC
-SS%CI-T * S4MPT%MS

o 8here does it hurtC o 0s it a constant #ain< does it come and goC o Goes it inter'ere "ith your dai y acti*itiesC P-I@ 8hat is the #ain ikeC 0s it ... 2 ...1itingC 2 ...sta11ingC 2 ...#in ikeC 2 ...shar#C 2 ...#inchingC 2 ...cram#ingC 2 ...thro11ingC 2 ...1 isteringC 2 ...1urningC 2 ...soreC 2 ..."renchingC 2 ...stingingC 2 ...num1C 2 ...gna"ingC 2 ...du C

2 ...e%cruciatingC mnemonic CpainD S ite % nset C haracter ? adiation - ssociations 5nausea/ s"eating6 T iming o' #ain<duration %acer1ating<a e*iating 'actors S e*erity 5e.g. sca e 'rom 121I6 IV. P o o o o o o o V. H (= Past me!ical histor") ,#art 'rom your #resent com# aint ho" is your genera hea thC 8hat #re*ious i nesses ha*e you hadC Go you remem1er any chi dhood diseasesC Ha*e you e*er 1een serious y i C Ha*e you e*er 1een hos#ita iJed<had an o#erationC 8hat a1out 1roken 1onesC Go you su''er 'rom any chronic diseaseC

e! (= e!ications) o ,re you taking any medicines< ta1 etsC o ,re you on the #i C o Go you need s ee#ing ta1 etsC

VI. #ll (= #llergies) o Ha*e any medicines e*er u#set youC o ,re you a ergic to #enici in/ contrast agents/ 'oods or anything e seC o Ha*e you 1een immuniJed against tetanus<#o io<in' uenJa< he#atitis ,/ B<#ertussis<di#htheriaC VII. $H% &H (= $amil" histor"% social histor") o Goes anyone in your immediate 'ami y su''er 'rom a chronic diseaseC o ,re your #arents 5other mem1ers o' the 'ami y6 a i*e and "e C o Ask for the circumstances of the patient4s accommodation, education, 5ob, leisure interests. o Ask whether he is married/has children. 6III" -lcoholE to&accoE recreational drugs o Go you smokeC o Ho" o'ten do you drink a coho C o Go you take any kind o' drugsC

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Part t/o: The Complete Physical .amination

E*amining a patient re,uires some attention and practice. -o again, following a certain scheme frees the physician4s mind and enables him to concentrate on his five senses. %n addition to some useful ,uestions given below there are e*amples of sentences one might need to instruct the patient during the e*amination. %t is vital that the instructions you give are simple and clear. 1o not use technical terms the patient probably won4t understand. %f you wish to do a thorough physical e*amination it is usual to say6 A8ou d you mind taking o'' your c othes e%ce#t your #ants 5men6< e%ce#t your #anties and 1ra 5"omen6C &ie on the couch and co*er yourse ' "ith a 1 anket.B AP ease get undressed/ 1ut kee# on your under"ear.B

;eneral Sur!ey &efore beginning a physical e*amination you make a survey of the patient4s general health. #ou should evaluate the following6 gait/ #osture/ a##earance/ hygiene!/ menta state. *ita signs/ inc uding: 2 height 2 "eight 2 #u se 2 tem#erature 2 res#iratory rate 2 BP , #ossi1 e "ay to #roceed during an e%amination is according to the scheme IPP- 7 Ins#ection/ Pa #ation/ Percussion/ -uscu tation Cardio!ascular System '(estions Go you ha*e any #ain in the chest/ es#ecia y a'ter e%ertionC ,re you 1reath ess at any time 5on e%ertion< at rest< in 1ed6C Go your ank es s"e u#C Go you 'reeJe o'ten and ;uick yC Ho" 'ar can you "a k 1e'ore the #ain in your eg sto#s you going 5intermittent c audication6C Ha*e you recent y ost consciousnessC Instr(ction 0 "ou d ike to isten to your heart. P ease ie do"n on your 1ack. Fo" ro o*er to your e't side. Try to take short ra#id 1reaths. &ean 'or"ard "ith your hands on your knees and ho d your 1reath 'or a 'e" seconds. 11

?espiratory System '(estion ,re you short o' 1reathC Ha*e you noticed any "heeJing "hen you 1reatheC Go you cough u# any s#utum<#h egm<s#itC 8hat co our is itHC Ha*e you coughed u# any c ots o' 1 oodC Instr(ction -ou d you # ease undress to your "aistC 03d ike to e%am your chest and ungs. 0 "ou d ike to isten to the sounds in your chestK sorry i' the stethosco#e is a 1it co d. Fo" 1reathe through your mouth. Take a dee# 1reath/ ho d your 1reath 'or a 'e" seconds and et out the air again. ar9@ose9Throat <incl" ,ead9@eck= '(estions Ha*e you noticed any s"o en g ands or um#s in your throatC Go you su''er 'rom chronic headachesC ,re they steady/ one2sidedC Instr(ctions 0Dm going 1ehind you to 'ee your neck. -ou d you # ease o#en your mouthC Try not to s;uint "hen 0 shine the torch into your eye. 8hen 0 #ress on your cheek 1one # ease/ te me i' it hurts. 0 "ant to check your ears 5nose6 no"K # ease ean 'or"ard "ith your 'ace to the side. ;astrointestinal System '(estions Go you ha*e any #ain in your a1domenC Ha*e you ost your a##etiteC Go you ha*e any di''icu ty in s"a o"ingC Gid you 'ee sick recent yC Ha*e you ost<#ut on "eightC Go you ha*e regu ar 1o"e mo*ementsC Ho" o'ten do you o#en your 1o"e s<go to the toi etC ,re they hard<so'tC Ha*e you noticed any 1 ood in your stoo sC Instr(ctions P ease ie do"n on your 1ack and rest 1oth arms a ong side your 1ody. Fo" 0 "ant to ta# on your 1e y. 8hen 0 #ush here and et oose sudden y/ does it hurtC

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P ease re a% and try to et your 1e y go so't.

;enitourinary System '(estions Go you ha*e any trou1 e #assing "aterC Go you ha*e any trou1 e "ith your "ater"orksC 0s there any #ain or 1urning "hen you urinateC Go you e*er eak urineC Go you su''er 'rom incontinenceC Ho" o'ten do you ha*e to s#end a #enny during the nightC 7emale 8hen did you start your ast menstrua #eriodC Goes it come regu arC Ho" o'tenC Ho" hea*y is the ' o"C Ho" many days "ou d you 1 eedC Ha*e you e%#erienced #ain'u #eriodsC ,re you in the change o' i'eC ,re you on the #i C Go you ha*e any #ain on intercourseC 2ale Ha*e you noticed any sores or s"e ings on your #enisC Go you ha*e any discharge 'rom your #enisC ,ny s"e ings or #ain in the scrotumC Ho" o'ten do you ha*e intercourseC Go you use condomsC Go you 1e ong to a high risk grou# 'or ,0GSC Instr(ctions @eurological System C@S L%C '(estions -ou d you # ease 'ro"nC -an you "hist e 'or me/ # easeC 5La "ays ook on the 1right sideL6 -ou d you o#en your mouth and sho" me<stick out your tongueC Instr(ctions 7ou shou d ?ust try to re a%/ 0 am going to test your re' e%es/ no". This hammer ooks more dangerous than it actua y is: so/ do not 1e a'raidK 0 "on3t hurt you. 8hen you have finished the e*amination, you should not leave your patient unsure about what to do ne*t. A7ou can get dressed no" and then come out to me. 5you might add6 Go not hurry/ take your time.B

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Part t/o: Letters of referral

0ommunication is an important part of a physician4s daily routine. %t is obvious that several different specialists might have to be consulted before a suitable treatment can be guaranteed. 9sually it is the ": !"eneral :ractitioner$ who has the closest contact with the patient and who refers him to the specialists. )hus written communication providing sufficient information is indispensable with. I. )*ample of a +P,s letter referring a patient to hospital
*r -&dul -FiF E Bangau )! Pa em1ang/ 3I13! -onsu tant Physician (S Mohamad Hussein E M. , i Pa em1ang Gear Gr (e: Mina ,1idin<M< 2>2321H)2<E Gi#onegoro 1)/ Pa em1ang This man has c<o 1ackache on and o'' 'or t"o years. (ecent y he has a so com# ained o' *ague discom'ort in the e't side o' his a1domen. This is not re ated to 'ood intake. Micturition and 1o"e norma . O<$ imitation o' the mo*ements o' his s#ine. ,1domen F,G. Perha#s the a1domen #ain originates in the s#ina co umn and 0 shou d a##reciate your o#inion o' him. 7ours sincere y/ *r -gung Per/ira 2> Eu y 2II>

II. )*ample of a letter from a Cons(ltant to a +P

*r Taufik ,idayat E -i#to )2 Pa em1ang 3I1:) 11 ,ugust 2II! Gr S ,1di ah E Musi 5> Pa em1ang 3I3!> Gear Gr ,1di ah Pau a Huta1arat <F< )2>21H):<E =omering 53/ Pa em1ang 3>13)

1:

Thank you 'or re'erring this #atient "ho gi*es an interesting history o' 're;uent urinary in'ections occurring a1out e*ery : months since marriage > years ago. Ho"e*er/ there is no c ear2cut re ation to intercourse nor is there any other #reci#itating 'actor. $ach attack seems to res#ond ra#id y to treatment and there is nothing to suggest #ermanent rena damage. There is an interesting 'ami y history "ith her mother and sister ha*ing simi ar sym#toms. Her mother is on ong2term #ro#hy a%is and she has re a#ses i' she e*er sto#s taking the ta1 ets. 0 cou d not 'ind any signi'icant signs on genera and recta e%amination a#art 'rom s ight tenderness o*er the sigmoid co on. 0 ha*e ordered 0.P and other re e*ant in*estigations to e%c ude any under ying cause. Shou d nothing 1e 'ound/ it might 1e ad*isa1 e to treat her in the same "ay as her mother "ith ong2term chemo#ro#hy a%is. 7ours sincere y *r Taufik ,idayat -onsu tant Physician

+sua y those etters o' re'erra inc ude the 'o o"ing in'ormation: 16 PatientDs name/ age/ se%/ address. 26 Presenting sym#toms 5reminding the #hysician o' the re e*ant data6. 36 ,ny 'urther in'ormation 'rom taking the history. :6 Findings 'rom #hysica e%amination. 56 Tests re;uired. >6 Pro*isiona <'irm diagnosis. )6 Treatment re;uired 5e.g.: none<medica < hos#ita iJation<surgica < #sychiatric6. !6 Prognosis. H6 8hat in'ormation one has gi*en the #atient. 1I6 =ee# contact o#en and 'uture arrangements.

Clerking a Patient Common Illnesses <G Lay Terms=

#ou should keep in mind that the patient might need a sick certificate to show his employer.

Childhood *iseases
Doctor-s Terms .arice a Joster *irus (u1e a (u1eo a e#idemic #arotitis .a" Terms chicken #o% @erman meas es Meas es 5campak6 mum#s 5gendongan6 15

scar et 'e*er #ertussis #o iomye itis

2 "hoo#ing cough #o io<in'anti e #ara ysis

Common Illnesses and other conditions

Doctor-s term arteriosc erosis arthrosis asthma adi#osity de#ression dia1etes icterus hemo#hi ia he#atitis hy#ertension cancer rheumatism a ergic rhinitis tinnitus #e#tic u cer .a" Term o1esity 2 sugar 5ye o"6 ?aundice 2 2 high 1 ood #ressure 2 hay'e*er 2 ringing in the ears 2

Doctor-s term hardening o' the arteries ?oint disease 2 coryJa in' uenJa acute<surgica a1domen a1domina #ain nausea *omiting migraine tonsi itis myocardia in'arct #u monary em1o ism a#o# e%y 5gast.6 hemorrhage shock 5#sy.: trauma6 .a" Terms a#o# ecti'orm dea'ness aortic aneurysm con*u sions gastroenteritis g aucoma con?uncti*itis tetanus co d 'u 2 1e y ache sickness thro"ing u#

1>

headache sore throat heart attack 2 5a#o# ectic6 stroke 5gast.6 1 eeding 2

sudden dea'ness 2 'its 5to thro" a 'it6 2 2 #ink eye ock?a"

Doctor-s term 'emora neck 'racture a##endicitis *aricose *eins 5incarcerated6 hernia i eus cho e ithiasis goiter 1urn in?ury<"ound head trauma/ sku in?ury

.a" Terms 2 2 2 2 intestina o1struction ga stone 5disease6 thyroid 2 2

Medical n!ironment
Instruments and Materials
Things a Doctor ight Ha/e

"hite coat # a;ue<name tag 1ee#er<1 ee# stethosco#e 5mem1rane<tu1ing<ear#hones6 tongue de#ressor tourni;uet torch 5+=6<' ash ight 5+S,6

1)

re' e% hammer<tendon hammer scissors sca #e shar#<du 1 ade 5steri e6 g o*es ta#e measure cannu a<i.*.2 ine<i.*.2access adhesi*e # aster<ta#e s"a1

0sef(l Instr(ments s#hygmomanometer 1 ood #ressure cu'' o#htha mosco#e otosco#e thermometer tuning 'ork 5steri e6 go"n 'ace mask dis#osa1 e ca# #a#er to"e s<tissues syringe cannu a<need e stretcher ointment #incers<5#air o'6 t"eeJers< 'orce#s

%&'ects in a patient(s room

1edsheet 1 anket #i o" rai s handgri#<tra#eJe 1e #ush 5+=6<signa cord 5+S,6 ight s"itch 1edside ta1 e tray 1ed#an emesis 1asin< *omit 1o"

1!

crutch # aster o' #aris e astic 1andage

*ifferent ?ooms
consu ting room "aiting room theatre , N $ 5accident N emergency6 de i*ery room sick room nurses3 room "ard a1oratory 5in'm .: a16 corridor dining ha <canteen

Special clinical tests and procedures

7or further details please consider English te*tbooks. Blood Fu 1 ood count 5FB-6< -om# ete 1 ood count 5-B-6 8hite 1 ood count 58B-6 +rea and e ectro ytes 5+N$6 - otting screen ,rteria 1 ood gasses 5,B@6 B ood cu tures 5B-6 &i*er 'unction tests 5&FT6 ?adiology -hest O2ray 5-O(6 ,1domina O2ray -T2scan M(0 lectrocardiogram < C;= Procedures *eni#uncture um1ar #uncture #aracentesis 5e.g. o' ascitic ' uid6 + trasound scanning

1H

angiogra#hy gastric a*age Gi atation and curettage 5GN-6

Case ,istories

Case ,istory I: - Patient /ith -&dominal Pain

The #atient "as a 33 year o d sa esman/ "ho came to the emergency room 1ecause o' A1e yacheB. He had 1een in good hea th unti the #re*ious e*ening/ "hen he "ent to a #arty. There he had se*era 1ott es o' 1eer. He sam# ed the chi i and ate custard. ,1out

2I

an hour a'ter the mea o' chi i he sudden y 'e t an e%cruciating a1domina #ain/ accom#anied 1y nausea. The #ain a##eared to arise 'rom the area under his 1e y 1utton. He 1roke out in a s"eat and had to ie do"n. ,'ter a1out 5 min the #ain "as com# ete y gone and he 'e t 'ine again. He e*en engaged in a match o' *o ey1a ater that e*ening. 8hen # aying in the 'ront ro" c ose to the net he ?um#ed and stretched 'or the 1a . 0mmediate y therea'ter/ the a1domina #ain recurred. Since then he had 1een rest essK his #ain ne*er et u# com# ete y. 0n the ast 2h he had not had any desire 'or 'oodK he had 1een nauseated > times and *omited : times. $ach attack "as accom#anied 1y "orsening o' his shar# a1domina #ains. The #ain "as no" ocated in the e't a1domen and under the um1i icus. 0t "orsened a'ter coughing or sneeJing. The #atient3s ast 1o"e mo*ement had 1een 2 days ago. Physical e.amination The #atient a##eared to 1e in acute distress on account o' his a1domina discom'ort. He "as dia#horetic/ the ora tem#erature "as 1IIPF 53!P-6/ the #u se "as 1I: 1eats<min/ and the 1 ood #ressure "as 1II<)I mmHg. The #atient rested motion ess on his stretcher. He had his knees #u ed u# and a##arent y tried to a*oid any mo*ements. The a1domina e%amination sho"ed tenderness to gent e #a #ation in the e't u##er ;uadrant/ the e#igastrium/ and the area o' the um1i icus. This "as accom#anied 1y guarding in these res#ecti*e areas. Pa #ation o' McBurney3s #oint "as unremarka1 e. There "as no re1ound tenderness in any a1domina area. The 1o"e sounds "ere diminished or e*en a1sent. There "as no costo*erte1ra ang e tenderness and the recta e%amination "as norma . Buestions 8hat diagnostic #ossi1i ities "ou d you consider at this #oint and "hat "ou d you do to "ork them u#C

Case ,istory II: - policeman /ith chest pain

, :) year2o d #o iceman "as taken to the emergency room 1ecause o' su1sterna chest #ains. The attack 1egan :5 min 1e'ore admission/ "hi e he "as on the #hone. The #ain radiated to his 1ack and did not 1udge unti admission. 0t "as accom#anied 1y shortness o' 1reath/ diJJiness/ and nauseaK he *omited once. The #atient3s "i'e re#orted that he had had a simi ar attack 2 hours 1e'ore "hi e i'ting a case o' 1eer. Furthermore/ on the morning o' this day the #atient had had a 'ainting s#e / 'o o"ed 1y #a #itations and rest essness. The #atient had a #ast medica history o' high 1 ood #ressure. Fami y history: his 'ather died sudden y at 51 years o' age. Physical e.amination 0n the emergency room the #atient "as in acute distress 'rom se*ere chest #ain. He moaned and groaned continua y and "as #ro'use y dia#horetic and cyanotic. The tem#erature "as H)PF 53>/!P-6. The #atient "as an o1ese ma e 51:! 1s<532336 Q 5>)kg<1/55m6 ooking much o der than his stated age. Guring his e%am he tem#orari y ost consciousness. The BP "as )I<:I mmHg/ the #u se rate "as 13:<min and irregu ar.

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The #hysica e%am o' heart/ skin/ ung/ a1domen and e%tremities "as unremarka1 e. -ardiac auscu tation "as a so unremarka1 e. La& $-@ "as norma . Buestion 8hat #ossi1 e diagnoses do you think o' and "hat "ou d you do to con'irm them at this #ointC

Case ,istory III: - *ying -dolescent

&ucy "as 'i'teen years o d and one o' 'our chi dren. Her mother "as a registered nurse and her 'ather a machine o#erator in a oca 'actory. She "as admitted to the hos#ita "ith a t"o2day history o' nausea/ *omiting/ and #ersistent a1domina #ain. , gastrointestina O2ray series and a gastrosco#y con'irmed an o1struction in the initia #ortion o' the sma intestine. $%# oratory surgery re*ea ed a arge tumor "hich a##eared to arise in the #ancreas and had #enetrated the intestine. The tumor had a so s#read to regiona ym#h nodes/ the i*er/ and one kidney. Patho ogica e%amination o' s#ecimens remo*ed at surgery con'irmed the diagnosis o' carcinoma o' the #ancreas. 8ithin t"o "eeks a'ter surgery/ an intensi*e si%2"eek course o' chemothera#y "ith three drugs "as undertaken. ,'ter this course/ there "as a marked regression o' the tumor in the #ancreas. , other tumor had disa##eared entire y. , second si%2"eek cyc e o' treatment "as initiated/ 1ut 1y the end o' this course/ O2ray and #hysica e%amination re*ea ed that the tumor "as again gro"ing ra#id y and metastases "ere a##earing. Throughout the ear y #eriod o' treatment/ the #atient "as *ery interested in ho" treatment "as going. She "as a so *ery coo#erati*e through a series o' di''icu t #rocedures. She o'ten e%#ressed to the nurses a concern a1out the im#act o' her i ness on her #arents and si1 ings. Ho"e*er/ she "as a so usua y *ery reser*ed in interchanges "ith hos#ita sta'' mem1ers/ and she ne*er initiated discussions o' her condition. 0n addition/ the #atientDs mother "as *ery #rotecti*e o' the chi d and/ as the hea th #ro'essiona in the 'ami y/ assumed the decision2making ro e. ,t a times/ the 'ami y/ #articu ar y the mother and the #atient/ a##eared to 1e *ery c ose2knit and o*ing. ,'ter 'ai ure o' the 'irst regimen o' chemothera#y/ a di''erent anticancer drug thera#y "as attem#ted. Ho"e*er/ t"o "eeks ater the #atient "as admitted to the hos#ita "ith acute gastrointestina 1 eeding. $ndosco#ic e%amination re*ea ed 1 eeding in three sites in the initia #ortion o' the sma intestine/ suggesting that the tumor "as eroding 1 ood *esse s. O*er the ne%t three days the gastric 1 eeding continued/ and the #atient occasiona y *omited arge c ots o' 1 ood. The #atientDs 1 ood *o ume "as ke#t sta1 e 1y dai y administration o' red ce s. @enera iJed a1domina #ain "as contro ed "ith a moderate dose o' intra*enous mor#hine. The #hysician *isited the room each day to discuss the #atientDs condition "ith the 'ami y. These discussions "ere he d at the 1edside and "ere 'ocused on day2to2day changes in her condition.

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The #atient remained a"ake and a ert during this #eriod/ 1ut she "as a "ays *ery ;uiet. She did not ask "hether she might soon die/ and the issue "as not raised "ith her. On a cou# e o' occasions/ the mother e%#ressed a concern outside the room a1out conducting discussions o' her dai y condition in the #atientDs #resence. But in #ri*ate con*ersations "ith the nurse #ractitioner/ the chi d said that she "as a"are that she might not 1ecome "e enough to return home/ a though she "ou d ike to do so. She e%#ressed 'urther concern a1out her #arents. She a so said she 1e ie*ed @od "ou d make her "e again. One "eek a'ter hos#ita iJation the #atientDs #rognosis "as discussed #ri*ate y "ith her mother. The mother in;uired a1out the a*ai a1i ity o' other chemothera#eutic agents. She "as to d that no other drugs "ith esta1 ished dosages or e''ecti*eness "ere a*ai a1 e 'or the treatment o' #ancreatic cancer/ a though some e%#erimenta agents might 1e tried. 0t "as em#hasiJed that the chance 'or regression o' the tumor "as s ight/ and at 1est i'e cou d 1e #ro onged on y 1rie' y. ,t any rate/ chemothera#y cou d not 1e administered unti the 1 eeding a1ated and the #hysician said that it "ou d #ro1a1 y not 1e #ossi1 e to sto# the 1 eeding. He suggested that it might 1e a##ro#riate not to send the #atient to the intensi*e care unit shou d her condition "orsenK doing so might su1?ect her to need ess discom'ort. He a so raised the #ossi1i ity o' discontinuing the 1 ood trans'usions. The mother "as un#re#ared to acce#t either suggestion/ asked that the trans'usions 1e continued at their #resent rate/ and he d out the ho#e that additiona chemothera#y might 1e #ossi1 e. Fina y/ the ;uestion raised a1out in*o *ing the #atient in the decision2 making #rocess. But the mother a so 'irm y resisted this #ossi1i ity/ indicating that she did not "ish to intensi'y the an%iety and su''ering o' her daughter. Buestion Point out the #hysicianDs di emmata and try to e*a uate the o#tions he has.

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-ppendi.
2eights and Measures
,eights 1 inch 12 inches Q 1 foot 3 'eet Q 1 yard > 'eet 5 't ) inches 5A'i*e se*enB6 5 't 3 R inches : 't 1 inch Temperature Celci(s IP 2IP 3IP )7H )1H )9H +$H 1IIP 2/5 cm 3I cm HI cm 5a1out 1 meter6 1!I cm 1)I cm 1>I cm 12: cm 5chi d6 $ahrenheit 32P >!P !>P 91E0H 1$$E+H 1$#E#H 1$+H 212P

, use'u hint 5C96: To con*ert degrees Fahrenheit 5PF6 to degrees -e sius 5P-6 su1stract 32 and mu ti# y the remainder 1y 5<H. 2eights 1 ounce 1> ounces Q 1 pound <7l& 3 i1ra36 1: 1s Q 1 stone To trans'er kg to l&s mu ti# y 1y 2/29 1 kg Q 2/2 1s :53/5H grams 5 :5I g6 >/3 kg 2!.3grams

2:

-&&re!iations of time 3<2: 3<) 3<52 3<12

3 hours 3 days 3 "eeks 3 months

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