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CASE HISTORY/MEDICAL DOCUMENTATION

Составители: старшие преподаватели кафедры иностранных языков Санкт-


Петербургской Государственной Педиатрической Медицинской Академии
И.Л.Гальфанович, М.Ю.Дайнеко, Н.А.Мордвинова.
Рецензент: доцент кафедры романской филологии факультета иностранных
языков РГПУ им. А.И.Герцена, кандидат педагогических наук В.Д.Макаричева.
Ответственный редактор: заведующая кафедрой иностранных языков Санкт-
Петербургской Государственной Педиатрической Медицинской Академии,
кандидат филологических наук доцент И.И.Могилёва.
Учебное пособие “Case History/Medical Documentation” предназначено
для работы по подготовке студентов разных медицинских специальностей в
рамках элективного курса, посвящённого паспортизации пациента.
Данное пособие имеет чёткую направленность на формирование навыков
самостоятельной работы аудиторного и внеаудиторного планов и способствует
выработке у студентов навыков классификации, анализа и синтеза, логически
осмысленного чтения, выделения ключевых моментов в описании клинических
случаев.
Учебное пособие состоит из 10 мини-модулей, содержащих задания по
различным частям основного документа пациента – карте больного.
Упражнения представляют собой вариативный материал – от элементарного
заполнения бланков до креативной работы по самостоятельному созданию
истории заболевания на основе информации по клинической картине.
Структура пособия подразумевает последовательность комплексности, что
позволяет использовать его при работе со студентами с разноуровневой
подготовкой по программе школьного курса.

Dear medical student!


You are starting a medical career. You are going to become a doctor. There is a
great variety of areas of medicine you can later choose. But whatever branch of
medicine you will take, you will have to deal with medical documentation, fill in lots
of special forms. The wide open world you live in will make you need to take part in
international scientific or doctors’ conferences and meetings, to discuss current
medical problems with foreign doctors or patients asking for your help. Three English
languages of medicine will be necessary for you to do it, they are: the language
medical professionals speak to each other, the language of their talks with patients
and the language of medical documents. Medical documentation is written with
abbreviations, letters and shortened word forms which every doctor understands. This
book will help you to master the basics of the three medical English languages, the
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language of English medical documentation in particular, and to translate to and from


these languages.

I.Basic Parts of Case History


Fill in the Case History of Mr./Mrs./Ms./Miss N according to the plan given
below (use the special boxes (A, B, C) for details) (some gaps can be left without any
information):
1) Hospital
Register № _____
Department _____
Doctor _____
Admitted to the hospital on _____
Hospitalization days number _____
Discharged from the hospital on _____
Transferred to _____
Died on _____
A)
2nd February
Specialized Sanatorium, Sherwood
24
John Smith, MD
Department of Cardiology
2 weeks
B)
Tropical Dermato-Venereology Department
Professor Nick Swan
2 weeks
23rd August
25NS
C)
Doctor Anna Cornex
Trauma
TD6-01/02/2011
Car injury on 1st February
The injured unconscious person has been brought from Perlax Street

2) Identification of a patient
Name _____
Surname _____
Sex _____
Age _____
Citizenship _____
Place of employment _____
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Profession _____
Diagnosis on admission _____
Chief complaints _____
History of present illness _____
Past History _____
Family History ______
A)
Female
Tram driver
Lobar pneumonia
Irish
No cases of pneumonia
Persistent dry cough, pains in the chest, fever
Jane
State Tram Company
Half a year ago – series of colds
3 weeks of non-stopping cough
35
Stompson
B)
Peru
Frequent cases of gum and nose bleeding among family members
P.Lumumba University student
Acute form of gangrenous stomatitis
Ulceration of the mucous membrane of the cheek, profuse salivation
Male
20
Tumbu-Hadgeru
The disease developed gradually after some hot days of bad hygiene and
started from a burning sensation in the mouth
C)
Male
Closed skull injury is suspected
Not known
There is considerable displacement of bone fragments
No information
The patient has some open fractures
Urgent case, no history
Approximately 35 years old
The patient is severely wounded
The patient has multiple soft tissue bruises

3) System Review and Physical Examination


Laboratory tests/instrumental invesstigations _____
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Clinical diagnosis _____


Complications _____
Surgery notes _____
Surgeon _____
Anaesthetist and anaesthetic used _____
Postoperative treatment _____
Doctor’s recommendations _____
A)
Blood test – high level of leucocytes
No liquid found in the pleural cavity
No sequalae
Clinically confirmed lobar pneumonia
Adequate airway should be maintained
B)
To rinse the mouth with a warm solution of sodium bicarbonate
Clinically confirmed gangrenous stomatitis
There is a facial asymmetry on account of swollen soft tissue
Reddened and edematous mucosa
Treat the oral cavity with antiseptics
C)
Operation under general anesthesia
Artificial respiration is being performed
The patient is unconscious
Pupils are dilated, no reaction to light
The patient has depressed respiration
Overdosage should be avoided

II.Taking Medical History


Choose the most suitable phrases for the situations below using the specialized
Questionnaire and List of Commands (add your own variants if it is necessary):
1) You are questioning a patient on the state of his health. Find out:
A) the passport data, age, occupation, place of residence, marital status;
B) his complaints;
C) the onset of the disease.
2) You are taking the past history of your patient. You must know:
A) the diseases the patient had in his childhood;
B) if the patient was ill with TB (VD, AIDS);
C) if the patient has been operated on before;
D) if the patient consulted a doctor on his disease;
E) if a similar disease runs in the family.
3) You are questioning a patient on the signs and symptoms of the present illness.
Try to find out:
A) the character of the onset of the pains (symptoms);
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B) localization and character of the pain (symptom);


C) duration of the disease;
D) progress of the disease;
E) the factors aggravating the condition.
4) You are examining a patient with heart trouble. What do you say if:
A) you are listening to his heart;
B) you are listening to his lungs;
C) you are going to palpate (auscultate) him;
D) you are going to take his temperature;
E) you are going to measure his blood pressure.
5) You are examining a patient with an ulcer disease. Question him:
A) on the location of the pain;
B) on the character of the pain;
C) on the last fit of pains;
D) give your instructions to the patient how to prepare for the X-ray
examination (roentgenoscopy) of the stomach.
Questionnaire
- What do you do?
- What’s your problem?
- Where do you feel the pain?
- Do the pains subside after applying a hot-water bottle?
- How long have you been ill?
- Have you ever been seriously ill?
- Do you have any belching? Is it of a sour or bitter taste?
- How old are you?
- What’s your job?
- Do you have any pains on an empty stomach?
- What diseases have you had in the past?
- When do the pains come on? Do they appear after meals?
- What’s your address, please?
- Have you been exposed to any industrial hazards at your place of work? Which
ones?
- How long after meals do the pains begin?
- At what age did you begin working?
- Are you allergic to any drugs?
- Are there any night pains?
- What relieves the pains?
- Is your appetite good?
- Is there any burning sensation in the stomach? When do you feel it?
- Does nausea trouble you? How often? When?
- When did you vomit?
- When did the first symptoms appear?
- What’s your occupation?
- How many times a day do you have stools?
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- Do you take laxatives? Are you given an enema?


- Do you have constipation or diarrhea?
- Has anybody in your family had tuberculosis (cancer, heart diseases, bronchial
asthma, epilepsy, alcoholism)?
- What has brought you here?
- Do you have any pain in the heart region?
- Do you have a heart trouble?
- Have you ever been in hospital, if yes, for what reasons?
- Do you have a pain in the joints?
- Have you ever suffered from some heart trouble like this before?
- When and in what hospital were you treated?
- Did the disease recur from time to time?
- Have you consulted any doctor about this disease?
- Have you had your ECG made?
- Have you noticed any swelling?
- Have you ever been treated in a surgical department?
- When did this swelling appear?
- Do you always feel short of breath or does the breathlessness come from time
to time, or at a certain time?
- What drugs relieve a fit of pain?
- Are you married or single?
- What diseases did you have in your childhood?

List of Commands
- Show where the pain is the most acute.
- Lie down flat on your back.
- Show me your tongue.
- Watch my finger.
- Let me look into your throat.
- Bend your body forward.
- Say ah.
- Undress, please.
- Strip to the waist.
- Turn your head and breathe.
- Breathe deeply.
- Breathe normally.
- Take a deep breath in and keep it.
- Dress up, please.
- Slip off your coat, please.

III.Medical Examination
Choose the proper set of questions (from part B) for the following points (from
part A):
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Part A:
1) Identification
2) CC (Chief Complaints)
3) HPI (History of Present Illness)
4) PH (Past History)
5) FH (Family History)
6) √ (Diagnosis)
Part B (I):
1) - What is the problem?
- I have difficulty in breathing, especially at night. You know, it constantly keeps
me awake. I quite often have episodes of wheezing. The shortness of breath comes
more and more frequently.
2) - Are you married?
- Yes.
- Have you got any children?
- No.
- Are your parents alive?
- Yes. They are healthy.
- And what about your grandparents?
- They died of heart failure when they were elderly.
- Your uncles and aunts?
- In good health.
- Have you ever heard your relatives talk about asthma in your family?
- No, never.
3) – Your diagnosis is bronchial asthma. It is a very serious disease. I advise you a
change of climate, first of all.
4) – Who are you?
- Ann Brag.
- How old are you?
- 26 years old.
- What’s your address, please?
- 32, Forest Street, Eastpoint, Missouri.
5) – What diseases did you have in your childhood?
- Measles, mumps, chicken-pox.
- Any surgery?
- No, doctor.
- Will you tell me more details about your present illness?
- Yes, of course, I started having wheezing when I was 5. My parents told me that
I had had shortness of breath after attacks of children diseases.
6) – When do you think the disease began? How long has it been troubling you?
- I was taken ill when I was 5 years old. Our family doctor advised my parents to
take me to the sea for a change of air.
- How did you feel there?
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- Fine. I had no trouble while staying at the sea. But when we returned home my
breathing ailment recurred. I don’t feel well in cold and rainy weather.
- What treatment did your physician prescribe you?
- Inhalations. But my condition became worse, more severe. You know, tobacco
smoke irritates me badly. My husband is a heavy smoker.
- Oh, my dear, you need only pure fresh air. He should know this.
Part B (II):
1) - Are you married?
- Yes.
- Do you have any children?
- Yes, two boys and a girl.
- Do you have any close relatives living?
- Yes, my parents and a brother are alive and healthy.
2) – What’s your name?
- __________ (fill in the gap)
- How old are you?
- __________ (fill in the gap)
- Where do you live?
- __________ (fill in the gap)
- What’s your occupation?
- __________ (fill in the gap)
3) – What diseases have you had?
- Whooping cough, mumps, measles.
- Have you ever had pneumonia or kidney trouble?
- I often caught colds in winter and had pneumonia, that’s all I remember.
- Any harmful habits?
- I neither smoke nor drink.
4) – What’s your trouble?
- I have persistent coughing and pains in the chest.
5) – I suspect you have pneumonia as a complication after influenza. But to confirm
the diagnosis you have to have your tests of blood, urine and X-ray examination
made.
6) – When did you notice the first signs of the disease?
- I had influenza a week ago, but I followed the doctor’s recommendations and
recovered rather quickly.
- When did you feel chest pain for the first time?
- Two days later.
- Can you relieve it by any drug?
- No.
- Do you cough up any phlegm?
- Yes, a little.
Part B (III):
1) - Are you married?
- Yes, but we are childless.
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- Do you have parents? Are they well?


- My mother died of diabetes, my father of heart trouble.
- Have you any sisters or brothers?
- No, I have no relatives.
2) – Have you ever been sick?
- In childhood I had some children diseases but I don’t remember which of them.
- Have you ever been operated on?
- Five years ago I had urethral resection made.
- Any bad after-effects of the surgery?
- No, not any.
- Did you seek medical attention to clear the cause of your trouble?
- Yes, my family doctor advised me some drugs and to have a good rest, but with
no effect.
3) – What’s your opinion, are these epileptic attacks?
- No, I’m sure you have been suffering from heart trouble for a rather long time.
Your seizures have been connected with cardiac standstill. It is difficult to manage. I
think of installing a pacemaker, with your coming for check-ups yearly.
4) – What problem do you have?
- I have been having a feeling of heaviness in my chest for more than a year.
- Any pain?
- Not any, Doctor, but three or four times when I was gardening, I had recurrent
episodes of convulsions, brief seizures.
- Do you have headaches?
- No, not often.
- Do you feel worried or nervous?
5) – What’s your name?
- I’m Mrs. Gross.
- How old are you?
- I’m 50, doctor.
- Your address?
- 38, Rockland Road.
- What do you do for living?
- I’m a housewife, I have a large family.
6) – A feeling of heaviness in the chest, convulsions, tiredness, seizures, loss of
consciousness.

IV.Abbreviations Used in Clinical Notes


Match the notes given in the Case History on the left with their meanings on
the right:
A)
F 29 yrs pulse
Overactive thyroid 10 yrs ago alive and well
Stomach trouble weight
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Depressed 1 yr. Librium. Sleepy. years


Wt 2010 – 9 st regular
2011 – 8 st 1 lb central nervous system
Bowels – constipated brother
Periods – reg; 1 child (5yrs) stone (6,34 kg)
Family: 1S+1B, AW normal
O/E – rather staring eyes cardiovascular system
Thyroid palpable, enlarged 3-4 cm on examination
No tremor blood pressure
CVS: P – 72 reg female
Ht – not enlarged sister
Ht sounds – N centimeters
BP – 120/80 heart
CNS: Reflexes not exaggerated pound (453,6 grams)

B)
normal
diagnosis
Mr.Johnson, 35 on examination
с/o ankle swelling Social History
SH married with 1 daughter regular
25 cigs/day no information
50 units alcohol/week heart
PH n/i died
FH father d. 42 MI minutes
mother a&w complains of
OE obese alive and well
P – 110/min reg Past History
BP – 100/60 cigarettes
Ht sounds - N chest X-ray
CXR enlarged Ht Family History
Ds.: MI blood pressure
myocardial infarction
pulse

C)
normal delivery
birth weight
M born nocte 3 a.m. ear-nose-throat
DOB – 11/11/2011 full term pregnancies 6, abortions 5
ND heart sounds
SH unfavourable gastro-intestinal system
Para.6+5 grams
BWt – 3050g male
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HS&HR – norm ante-meridiem


ENT: standard measures of treatment heart rate
GIS: normal stool Social History
at night
date of birth

V.Medical Kits
Compose a suitable medical emergency kit for:
A) home;
B) car;
C) travel.
(Some items may be used for different kits)
(Add some individually required remedies!)

Sterile gauze dressing Cotton applicators Thermometer Aspirin Iodine


Petroleum jelly Distilled water Rubbing alcohol Cough syrup Cups Splint
Honey Activated charcoal Paracetamol Salt Baking soda Hemostyptic
pencil Painkillers Pair of scissors Medical gloves Eye drops Adhesive
plaster Mustard plaster Brilliant green solution Manganese crystals
Disposable syringes Pump oxygenator Blood pressure measurement apparatus
Enema syringe Purgative medicine Antiemetic medicine Hematogen
Vitamin C Bandage Earplugs Cloth tourniquet Validol Nasal drops

VI.Reading Medicine Labels


Match A and B to understand the information medicine labels contain:
1)
A B
KORPEX  How to take a dose
Relieves coughs, fever, headaches  Name of the product
Aspirin, coriniol, hexaperon  Possible side effects
Wonder Drugs, USA  Total dose that may be taken a
2 tablets every 3 hours day
KORPEX tablets can be chewed or  Active ingredients
swallowed  The amount of each dose
No more than 10 tablets daily over a 1-
 Symptoms the product relieves
week period
 Limitation
Not advisable for pregnant women
May cause drowsiness  Company producing the product
 Frequency with which it may be
taken
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2)
A B
Apply 1-2 times daily, continuing for 2-3
weeks after lesions have healed
Occasional local irritation and
hypersensitivity reactions include mild  Side-effects
burning sensation, erythema, and itching,  Name of the product
rare blistering; treatment should be  Dose
discontinued if these are severe  Company producing the medicine
Fungal skin infections  Cautions
SULKANAZOLE NITRATE  Indications
Extraderm, Hungary
Contact with eyes and mucous membranes
should be avoided
3)
A B
Anti-viral throat spray as a part of complex
therapy  Name of the product
ANAFERON KID SPRAY  Active ingredients
No registed cases of overdosage  Company producing the medicine
Is not used for infants under 1 month  Indications for usage
The recommended scheme requires 3-5  Recommendations on limitation
times a day usage  Description of the product
Interferon gamma antibodies
 Possible reactions in the case of
White colour can (contains colourless
overdosage
liquid with pleasant smell) with a special
 How often to use the spray
spray tube
“MateriaMedCompany”, Moscow, Russia

Think up a medicine label of a drug used for the treatment of:


A) Heart failure;
B) Diarrhea;
C) Headaches.

VII.Practising Medicine – Case History


Dear future doctors!
As quite soon you are going to practise medicine in our clinic (the probability that
some of you have already had such an experience is quite high), we would like to
stress some extremely important points to you… With the modern trend toward
objective and laboratory methods of diagnosis (don’t suppose we consider them to be
unreliable ones), you mustn’t decrease attention to the patient’s story of his troubles
and problems. A careful history always leads to making a correct diagnosis. It gives
the information which aids the doctor in choosing the type of recommended therapy
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or surgery. The physician who is able to gain the patient’s confidence will find the
problem of physical examination greatly simplified. This is particularly true of
children…We hope you’ll manage to cope with the most important document in
medical practice – Case History or Case Report, or Medical Record, or Clinical
History. To make the task more complicated we suggest filling in the form with the
data taken from the dialogues given further. A short block of useful information after
each recorded conversation should be thoroughly translated in written form:

Surname First names


Age Sex Marital status
Occupation
Present complaints
O|E
General condition
ENT
RS
CVS
GIS
GUS
CNS
Immediate past history
Points of note
Investigations
Diagnosis

Dialogue 1
- Doctor, help my boy! He throws up the food he takes. In the morning he had
convulsions and nearly passed out. I’m so afraid he won’t live the day out,
unless you help him, Doctor.
- Has he a fever?
- I don’t think he has. Jimmy’s body is rather cold.
- Well, we’ll see… It must be something he has eaten. He may have eaten some
food that was spoiled and disagreed with him. What food did he take for supper
yesterday and breakfast today?
- He had a tin of sardines for breakfast. Our little boy likes them without any
bread. You know, my husband and I didn’t taste them.
- Has he ever had any trouble with his bowels? Constipation or loose bowel
movement, for instance?
- He has never complained of it. His bowels seem to be all right.
- Well, I suppose it’s better to do him a stomach washing.
Over to you (1)
The commonest cause of vomiting is faulty feeding, i.e. the child who is very
hungry swallows too rapidly and a lot of air is swallowed with the meal. There are
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many other reasons why a baby may vomit, such as infection. This may involve the
gastrointestinal system or may involve any other part of the body, e.g. earache, and
throat infection when the child vomits with a bout of coughing. Some children are
more prone to vomiting than others. Another serious cause of vomiting is obstructive
lesion in the gastrointestinal tract, which could be serious indeed.

Dialogue 2
- Doctor, the little girl, Rosa Stevens in Room A, first floor, has convulsions.
- Don’t be in fear. She has convulsions because of a high fever and three day’s
constipation. Make her take these tablets every two hours, nurse.
- Shall we send her home today? Her mother is waiting for the answer. She is on
the anxious seat, poor thing.
- Please, tell her that the girl should stay here over night and perhaps we’ll
decide the problem tomorrow. Don’t you think so? If not, give me a piece of
your mind, what you’re thinking about it.
- Yes, of course, I completely agree with you. She is too young, only 2, to be
treated at home. To be on the safe side it’s better to have the girl here.
Over to you (2)
Constipation is a relative term. A baby may not pass stool for two days but at the
end of this period he may pass a soft stool. If he passes hard stool then you can label
it as constipation. The commonest cause of constipation is inadequate food, roughage
or carbohydrate. If an older infant has constipation his food intake should be
increased, i.e. early supplementation with vegetable soups, mashed vegetables etc.
should be started. In older children increased roughage and water is required, vs. raw
vegetables and fruit.

Dialogue 3
- Doctor, help my Bobby, please!
- What’s the matter with him?
- When I came home I found my little boy crying bitter tears. I couldn’t stop him
crying. I saw at once that there was something wrong with his left ear.
- Why did you think so?
- He tried to pick his left ear with his finger and when I wanted to have a look at
his ear, he pushed my hand away.
- Didn’t you ask him why he was crying?
- Certainly I did ask him but he wouldn’t tell me. There were other kids playing
and I saw them trying to insert some small objects in each other’s ears.
- Well, they often do it out of mischief and get into trouble… Never try to
remove any object out of the ear. It’s easy to push it deeper and more trouble
may occur. Nurse, get everything ready. I’ll examine the boy’s ear.
Over to you (3)
Solid objects, such as beans, peas, buttons, or small seeds are often introduced into
the ears by children. Such things as seeds absorb moisture and swell, making their
removal difficult. Do not use pins or pieces of wire to try to dislodge those, as there is
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great danger of seriously injuring the ears. Insects, such as flies or bugs, frequently
crawl into the ear. They can be killed and the buzzing stopped by dropping a little
olive oil or mineral oil into the ear. In every case, the object should be removed by a
physician.

Dialogue 4
- How old was the child you admitted a couple of days ago?
- She was a 2-month-old girl, colleague.
- What problem made her mother bring the baby to the clinic?
- She had been noted to become jaundiced, and when I examined her I found the
baby was anemic too.
- Were lab values significant?
- Oh, yes. The values of hemoglobin and cholesterol were remarkable.
- Didn’t you notice any lymph nodes enlargement?
- No, I didn’t.
- What was the course of the disease?
- Jaundice was progressively getting worse.
- What pathologic signs and symptoms accompanied it?
- The liver was slightly enlarged and the spleen was one finger below the left
costal margin.
- What should be done first, you think?
- Bone marrow aspiration to exclude acute leukemia.
- And won’t you do blood culture? She may have an underlying infection to
explain anemia.
- To begin with I think that blood should be transfused because of the low
hemoglobin. You see, I don’t like the way she is doing. We constantly keep an
eye on her.
- Well, it would be better to discuss the problem with the visiting pediatrician,
Professor Figner. Today he is making the round… Look, he is coming here.
Over to you (4)
A new-born baby is born with a large amount of red blood cells in the body. Since
the requirement of oxygen in the uterus is more and the child has to depend on the
mother’s circulation for oxygen, a large number of red blood cells in the fetus are
required to carry oxygen. Once the baby is born, this large amount of red blood cells
is not required. They undergo destruction. The pigment thus released is normally
transformed in the liver and is excreted, but since there is a large amount and also the
liver of the baby is immature and hence not able to cope with the total pigment,
jaundice is produced. The other causes of jaundice can be infectious and certain
congenital conditions which may be operative during pregnancy.

Dialogue 5
- On admission to our hospital my patient, a 5-year-old boy, had a bad headache,
malaise, and backache, a sore throat, marked loss of appetite, a rash on the face
and trunk, and a temperature of 38ºC.
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- What kind of rash was it?


- It was a vesicular rash. The rash appeared more numerous on the second day
after the admission and completely involved the entire body surface.
- What else did you notice?
- I noticed that the rash evolved through the typical stages of chickenpox. The
skin lesions of chickenpox in various stages were present over the scalp, face,
trunk, with lesions over the limbs. The patient appeared quite ill, his pulse was
100 beats per minute, but there was no cyanosis.
- Did he complain of anything?
- Yes, he did. He complained of cough and chest pain.
- Did you examine his lungs and his heart?
- Certainly. There were moist rales with coarse breath sounds in both lungs;
chest X-ray findings were those of pneumonia.
- And what else aggravated his condition?
- His chest pain. He complained of left anterior chest pain. The heart sounds
were strong and no rub or gallop rhythm was present.
- What diagnosis do you suggest?
- I believed first it was chickenpox with pneumonia, but he again complained of
steady left anterior chest pain. I examined his heart most thoroughly and
noticed that a pericardial rub was evident. So he had pericarditis too.
Over to you (5)
A single skin lesion can be regular or irregular in shape. When there are many
(multiple) lesions, especially macules or papules, the result is a rash (or spots), for
example the rash of an infectious disease such as rubella. A rash is said to erupt or
break out.

VIII.Practising Medicine: Case Report


Compose a Case Report relying on the data given about the disease. Some
information should be added:
1) Cause: Unknown.
Symptoms: Weak pulse, pale face, periodical heart pains, death anxiety,
breathlessness. The patient absolutely cannot lie down.
Diagnosis: Heart failure.
Treatment: The patient must be propped up to allow him to breathe or he may
be allowed to sit straight up. A cup of coffee or tea may do some good, and will
surely do no harm. The patient should be covered to keep him warm. Reassure
the patient and give him cardiacs.

2) Cause: Not clear.


Symptoms: The onset is sudden. The pain in the right iliac region and all over
the abdomen is acute. The patient feels constant nausea and has profuse
vomiting. The temperature is elevated.
Diagnosis: An acute attack of appendicitis.
17

Treatment: Urgent surgical intervention is necessary. Local anesthesia is


indicated. Opening the abdominal cavity with an oblique incision in the right
iliac region is to be applied.

3) Cause: A fish bone in the pharynx because of too rapid eating.


Symptoms: The patient feels stinging pain, especially when swallowing.
Diagnosis: A foreign body in the pharynx.
Treatment: An attempt to remove the bone with finger was successfully
followed by the extraction of the bone with forceps.

IX.Medical Record
Read the dialogue between Doctor Johnson and a medical student through.
Then read and translate the first case below. Using the sections of the medical record
Dr. Johnson is reading in the dialogue as a model, fill in the similar sections for Case
1. Continue making up medical records with the same sections for the other cases
described.
The diagnoses of these cases are given after the 7 th Case. You are not qualified
enough yet to find the correct diagnosis to each case. However, you could try, think
and guess, relying on some medical knowledge you do have. Prepare to give your
reasons why you have chosen the particular diagnosis. Your lecturer will give you the
correct diagnosis of the doctors.

Dr.Johnson: So, what is the history of your new case? Let me see it!
Medical Student: Here you are!
Dr.Johnson (reads):
Patient: Paul Brown.
Age: 58.
Sex: Male.
Occupation: Engineer.
Family status: Married.
Family history: Wife and four children living and well; father living and well;
mother died: the result of a street accident; two sisters and а brother living and well.
Past history: Measles, scarlet fever and pneumonia in childhood; two ribs
fractured: the result of a war wound; neither drinks nor smokes.
Present complaints: A severe pain in the abdomen (the right iliac region);
nausea and vomiting; temperature 39ºC.
Duration: 2 days.
Diagnosis: Acute appendicitis.
Dr.Johnson: In most cases, appendicitis is not difficult to diagnose, but sometimes the
picture is that of acute intestinal process, e.g. enterocolitis. It is particularly easy to
overlook it in children, in whom its course is a violent one and often produces general
phenomena with negligible local ones. Children cannot point out the location of pain
18

and often complain of it in the epigastrium or all over the abdomen. Tell me, please,
what does his physical examination reveal?
Medical Student: The physical examination of my patient reveals pain and limited
muscular tension in the right iliac region. The clinical picture is the one of acute
appendicitis.
Dr.Johnson: I agree with you that his symptoms are those of acute appendicitis.

VOCABULARY OF MEDICAL TERMS TO THE CASE REPORTS:


productive cough влажный кашель
sputum=phlegm мокрота
on exertion=on effort при напряжении
cyanotic blush цианотический румянец
heart sound сердечный тон
clapping sound хлопающий тон сердца
dull sound притупленный, глухой тон
presystolic murmur пресистолический шум
pleural fremitus =rub шум трения плевры
exposure to cold пребывание на холоде
expose to cold подвергать воздействию холода
pulse of an average fullness пульс среднего наполнения
regular shape правильная форма
it is somewhat retarded она несколько отстает
harsh breathing (respiration) жесткое дыхание
amphoric breathing амфорическое дыхание
tympanitic resonance тимпанический звук
loss of resonance притупление перкуторного звука
infiltrate darkening инфильтративное затемнение
erythrocyte sedimentation rate (ESR) СОЭ (скорость оседания эритроцитов)
shift to the left сдвиг влево
vocal fremitus голосовое дрожание
forced position вынужденное положение
injected veins набухшие вены
the border is moved down граница опущена
mobility подвижность
disseminated rales рассеянные хрипы
moist rales влажные хрипы
sonorous coarse rales звучные крупные хрипы
medium bubbling rales средне-пузырчатые хрипы
single rales единичные хрипы
median line средняя линия
from the medioclavicular line out снаружи от средне-ключичной линии
fall into layers распадаться на слои
accent акцент
accentuated акцентуированный
19

interscapular space межлопаточное пространство


dyspnea одышка
compressing pain сжимающая боль
edema отек
hypochondrium подреберье
vascular wall сосудистая стенка
outside the pulse wave вне пульсовой волны
spread heart beat разлитой сердечный толчок

CASE 1
The doctor was called in as the patient, Eric Someson, complained of high
temperature, pains in the right side on deep respiration, dry cough. The onset was
sudden, the day before while working he felt malaise, chill, a slight cough appeared.
In the evening the temperature was 38ºC, today in the morning it was 38,4ºC. He had
never had anything like this illness before. He had suffered from measles, quinsies,
now and again an upper respiratory infection. The patient is 38, male, works as a
driver. He believes his illness is due to his exposure to cold.
Objective findings: there is feverish blush on his face, his position is active.
The pulse rate is 90 per minute, rhythmic, of an average fullness and tension. His
heart borders and sounds are normal. The shape of his chest is regular, the right side
of it is somewhat retarded in breathing, respiration rate is 18 per minute. On
percussion a dull sound (loss of resonance) was revealed in the right subscapular
area. There is slightly harsh breathing and pleural rub in the same area.

CASE 2
Mike Green was brought to the in-patient department as an emergency case
with complaints of fever, the temperature being up to 38,5-39ºC, pains in the left side
of the chest, especially bad on respiration, cough with a small amount of
mucopurulent sputum without any smell. The patient had been ill for a week. The
onset had been sudden, the temperature rising to 38ºC, with cough and pains in the
left side. He had been on a business trip at the time, and because of this he hadn’t
consulted a doctor. Having returned home he called in the doctor who insisted on
hospitalization.
The patient is 41, male, works as an engineer at a plant. He believes the cause
of his illness to be his exposure to cold. He had hardly any complaints in the past,
only once in a while he had an upper respiratory infection or quinsy.
Objective findings: the patient’s general condition is bad, there is feverish
blush, dyspnea, superficial breathing, respiration rate is 24 per minute. The pulse rate
is 120 per minute, it is small, soft. Blood pressure is 100 over 60 mm. The heart
borders are normal, the first sound is slightly dull. The chest on the left is retarded on
respiration. On the left at the back the lung border cannot be determined, on the right
the lung border is normal. There is a pleural friction rub along the lower side. The
vocal fremitus and bronchophony are increased.
20

CASE 3
Evan Wilson, aged 50, male, was brought to the in-patient department as a case
of emergency. He complained of a pain in the right side of his chest which set in
abruptly and of short breath. He had been ill with an upper respiratory infection for
some days when an acute pain in his side and breathlessness developed on a bad
attack of coughing. The temperature is normal. The patient used to suffer from
bronchitis in the past, he smokes.
Objective findings: the patient’s general condition is of an average severity, he
takes a forced sitting position, respiration rate is 28 per minute, he is pale, his lips are
cyanotic, the veins on his neck are injected, the right side of his chest doesn’t take
part in the respiration. The breathing is absent over the right side of the chest, over
the left side dry rales are heard. Pulse rate is 90 per minute.

CASE 4
The patient, Peter Smith, aged 38, male, has been staying in the in-patient
department for 3 weeks. At present he complains of subfebrile temperature, cough
with a large amount of sputum (200 gr per day), having a foul smell (if kept it falls
into layers), mild pains in the right side of his chest. He had felt ill for a month
before, when subfebrile temperature, dry cough and cold in the head appeared. The
patient continued working for a week, but then his temperature rose up to 38-39ºC
and he was hospitalized. A week ago expectoration of a large amount of purulent
sputum developed, his temperature dropped and became subfebrile, his condition
somewhat improved.
The patient works as a shopmaster at a factory, he is often exposed to draughts
at his shop and frequently catches cold, he had pneumonia twice. He smokes, drinks
alcohol regularly, almost daily. He believes his illness is due to his having been
exposed to severe cold when drunk.
Objective findings: general condition of the patient is rather severe. The
position is active, but he tends to lie on the right side as cough worries him less in this
position. The patient is grayish-pale, his pulse is frequent, pulse rate is 90 per minute,
heart borders are within the normal limits, the first heart sound is somewhat
weakened, the second one is accentuated on the pulmonary artery.

CASE 5
Jane Melton is 55, female, she was admitted to the in-patient department with
the complaints of subfebrile temperature, persistent cough with a small amount of
mucopurulent sputum without any smell, a bad general weakness, sweating, a feeling
of heaviness and pains in the right side of her chest, especially on deep respiration.
She fell ill two weeks ago when cold in the head and malaise appeared. Her
temperature was normal, so she continued working. A week later her cough increased,
a small amount of sputum appeared, the temperature began to rise. Then the patient
was given a sick leave and treated by an expectorating mixture, mustard plasters,
aspirin. As her condition didn’t improve, the doctor referred her to the hospital.
21

Objective findings: the patient’s general condition is not bad, there is no


dyspnea. Her pulse is rhythmic, of an average fullness and tension, pulse rate is 86
per minute. Heart borders and sounds are within the normal limits. The chest mobility
is normal, there is no retardation in breathing. On percussion the lung borders were
found to be normal, on the right there was noticed limited mobility of the lung border
along the back surface, loss of resonance in the right intrascapular space, one could
hear harsh breathing and fine bubbling moist rales, sonorous ones.

CASE 6
Catherine Reice, aged 30, female, complains of breathlessness, productive
cough with expectoration of a small amount of sputum, occasionally bloody. When a
child, she used to suffer from quinsies. She had tonsillectomy at 12. Dyspnea first
developed two years ago. Breathlessness increased and expectoration of bloody
sputum appeared a few days ago on physical exertion.
Objective findings: she has cyanotic blush on her cheeks, her pulse rate is 120
per minute, small, rhythmic. In the cardiac region the heart beat is displaced to the
right, which is confirmed by palpation. The heart borders are dilated upwards and to
the right, the first sound is clapping, the second sound accent is on the pulmonary
artery, there is a presystolic murmur at the apex.

CASE 7
Alan Gray, 67, male, complains of compressing pains in the cardiac area,
radiating to the left shoulder, arm, to the region of the 4 th-5th finger. The pains are
associated with physical exertion and excitement. In addition the patient complains of
dyspnea, edema of his feet developing towards night, feeling of heaviness in the right
hypochondrium. He has been suffering from pains in the heart area for 10 years, with
nitroglycerin relieving them. The pains occurred seldom at first and he was treated as
an out-patient. He considers his last setback to be associated with overwork due to an
urgent problem at his shop. He works as a senior master at a factory. In the past he
had rare colds, smoked much. He drinks alcohol regularly.
Objective findings: he has acrocyanosis, the pulse rate is 106 per minute,
rhythmic, of an average fullness, hard. The vascular wall may be palpated outside the
pulse wave. The spread heart beat is auscultated in the 5th intercostal space, 2-3 cm
from the mediaclavicular line out, on the left. His heart borders are extended to the
left, 2 cm from the left mediaclavicular line. The first heart sound is weakened and
dull, the second one is accentuated on the aorta. Systolic murmur is heard at the heart
apex. Blood pressure is 160 over 70 mm Hg. In the lungs single, moist rales, with
somewhat harsh breathing at the background, are heard in the posterobasal parts. The
abdomen is soft, tender, the liver edge is palpated 2-3 cm under the ribs, it is round,
soft, tender.

DIAGNOSES
The cases above describe:
right pneumothorax associated with an acute attack of chronic bronchitis;
22

coronary vascular angina pectoris(stenocardia) with mitral and circulatory


insufficiency and cadiosclerosis;
right focal pneumonia of the lower lobe;
lung abcess;
croupous pneumonia;
dry pleurisy associated with pneumonia;
mitral stenosis associated with the left ventricular circulatory failure.

X.Problem Solving
Each of the numbered items in this section is followed by possible answers. Try to
select the one lettered answer or completion that is best in each case, discuss it with
your partner(s) and comment on your choice trying to prove your decision:
1) An 8-year-old boy with acute lymphoblastic leukemia has had three relapses
over the past 2 years. The only available treatment is experimental
chemotherapy. Without treatment, the child is unlikely to survive for more than
6 weeks; with treatment his prognosis is unknown. The parents do not want
further treatment for their son and wish to take him home; the child also says
he wants to go home. Which of the following is the most appropriate course of
action?
A) Discharge the child against medical advice;
B) Discharge the child routinely;
C) Petition the court for an order for treatment;
D) Report of the parents to the child protective services for medical neglect.
2) A nurse is hospitalized for appendectomy at the medical center where she is
employed. One week after discharge, the assistant hospital administrator asks
the surgeon who performed the procedure about the final diagnosis. Which of
the following is the most appropriate response on the part of the surgeon?
A) Answer, because it will expedite handling of insurance issues at the medical
center;
B) Answer, because as an employee of the medical center the administrator has
access to information about patients;
C) Answer, because of the possibility of spreading misinformation about the
patient;
D) Decline to answer, because the administrator is not a medical doctor;
E) Decline to answer, because the information is confidential.
3) An asymptomatic 3-year-old boy is brought to the physician for a routine
examination. Small, inguinal lymph nodes are palpable; no other abnormalities
are noted. Which of the following is the most appropriate next step?
A) Schedule a routine follow-up examination;
B) Urine culture for bacteria;
C) Tape test for pinworms;
D) Monospot test;
E) Complete blood test.
23

4) A 10-month-old girl, who happily allowed herself to be held when her


grandmother visited 2 months ago, now cries when her mother tries to put her
in her grandmother’s arms. The most likely explanation is that the child has
A) Been maltreated by the grandmother;
B) Begun to develop problem with socialization;
C) Normal stranger anxiety;
D) A sense of poor relationship between the mother and the grandmother;
E) Separation anxiety disorder.
5) An 8-year-old boy needs to be coaxed to go to school and often, while there,
complains of severe headaches or stomach pain. Sometimes his mother has to
take him home because of his symptoms. At night, he tries to sleep with his
parents. When they insist he sleeps in his room, he says there are monsters in
his closet. This history is most consistent with
A) Childhood schizophrenia;
B) Normal concerns of latency-age children;
C) Separation anxiety disorder;
D) Socialized conduct disorder;
E) Symbiotic psychosis.
6) A 70-year-old widower has ecchymosys, perifollicular petechiae, and swelling
of the gingival. His diet consists primarily of cola and hot dogs. The most
likely diagnosis is
A) Beriberi;
B) Kwashiorkor;
C) Pellagra;
D) Rickets;
E) Scurvy.
7) A 12-year-old girl has incurable muscular dystrophy and has been in a
persistent vegetable state for 5 years. Her parents are actually eager to take her
to Switzerland to end her life as assisted dying is legal there. Opponents of
euthanasia, or ‘mercy killing’, argue that legalization would lead to abuse and
call for doctors who participate to be struck off. Those people who are against
euthanasia suppose that Public Health Care Service has to organize better
palliative care and more hospices for the terminally ill to allow such patients to
die with dignity. Which of the following is true to the situation?
A) It’s not correct to continue the critically ill girl’s suffering;
B) You would agree to assist in the death of such a child to end the useless
existence;
C) You are against the parents’ position;
D) You are constantly trying to find some experimental drug to help to improve
the girl’s condition.

Credit Clinical History Filling


24

Complete sections according to the case notes given below using complete and
abbreviated forms of notes:

SURNAME

NAME

AGE

SEX

MARITAL STATUS

OCCUPATION

PRESENT COMPLAINT

ON EXAMINATION
GENERAL CONDITION
ENT
RS
CVS
GIS
GUS
CNS

PAST HISTORY

FAMILY HISTORY

LABORATORY FINDINGS

DIAGNOSIS

TREATMENT

CLINICAL HISTORY 1
A 5 month-old male infant John McConnwale was brought to the Emergency
Department by his parents with persistent, worsening shortness of breath and
wheezing associated with excitement and physical exertion. The boy was lethargic,
anorexic. He had a history of poor sleep and crying for two days. No fever, diarrhea,
vomiting, foreign-body ingestion were noted. No asthma, recent illness or antibiotic
ingestion, home treatment, recent infectious exposure or immunizations were
25

recorded. There was evidence of dehydration, with limited tearing and decreased
urine output. Oral intake was limited.
A chest Computed Tomography showed large, thin-walled cysts occupying
most of the left hemithorax. A small portion of collapsed lung was present in the left
upper thorax. The largest cyst was approximately 8 cm. There was a significant mass
with mediastinal shift to the right. The right lung was essentially clear. There was no
evidence of pneumothorax. The impression was of congenital cystic malformation of
the lung.

CLINICAL HISTORY 2
A 21-year old Caroline Montley, student of Law University had 5 episodes of
wheezing attacks during her childhood associated with mumps, chicken-pox, and
common colds. After a move to the California coast at the age of 13, she had no
asthmatic symptoms up to the present case. She is in distress, with labored breathing.
The patient has a sensation of chest constriction. She produces coarse dry rales in the
bronchial tubes. She thinks that continual wheezing and mild dyspnea are connected
with relatively cold and damp months, at times with the periods of emotional upset,
and after exposure to tobacco smoke. The symptoms are not aggravated by exposure
to animal or house dust. The physical examination reveals increased resonance to
percussion. Chest X-ray films show marked abnormalities.

CLINICAL HISTORY 3
A 2-year-old boy Jacob Witch was brought to the local General Practitioner by
his mother. After the medical examination he was immediately referred to the city
hospital. Five days before the admission he began to vomit and became irritable. He
had a bad weakness, sweating and malaise.
On the admission a brain Computed Tomography was performed which
revealed a large midline mass; the lesion was heterogeneous, cystic, partly solid with
calcifications. Magnetic resonance imaging demonstrated a 5x4.9x4.7cm mass,
extending into the left angle. The patient was operated upon and a total resection of
the mass was performed.

CLINICAL HISTORY 4
A 34-year old school teacher of Geography Julia Mettew came to one of the
clinics complaining of bad headaches and generalized malaise which lasted out. The
temperature was 38,4º, the pulse rate 120, and the respiration 27 per minute. The
throat was acutely inflamed and edematous and both tonsils were covered with an
exudate. The patient was hospitalized and on the tenth day when the throat appeared
normal and her ward doctor thought that the temperature should decrease too, it
continued to be elevated and the woman complained that she could not swallow at all.
A few hours later she refused to take the food. Local examination at this time
revealed a swelling on the anterior surface of the neck above and in the region of the
thyroid gland. The patient’s complaint that she could not swallow was confirmed by
having her drink water under the observation: each time that she attempted to
26

swallow it, the water came through her nose. A diagnosis of abscess of the
prevertebral fascial space was made and the operation was performed. An incision,
three and a half inches in length, was made. An aspirating needle was inserted into
the mass and thick creamy pus was evacuated. The recovery was uneventful and the
patient was discharged ten days later.

CLINICAL HISTORY 5
A 16 month old female Cristina Horthex was admitted to the Pediatric
Intensive Care Unit with fever, hypoxia, altered mental status, breathlessness, and
seizures. Magnetic resonance imaging (MRI) of the brain showed a single
intraventricular mass which could be isolated easily because of dense cells
concentration. The mass measured 4x4x4 cm. There was additional, but mild right
lateral ventricular dilatation. These characteristics were most suggestive of a
meningioma.
The patient subsequently had surgical resection of the mass with MRI
Navigation Guidance. The mass had a thick capsule and a rubber like core. The tumor
was removed without intraoperative complications. The patient was discharged home
4 days later and had done well since that time with no neurological disorders.
The child's parents underwent extensive genetic counseling and were
encouraged to undergo mutation analysis as both are in their early twenties.

CLINICAL HISTORY 6
A pregnant woman Monica Lux, aged 19, had two spontaneous early abortions.
On clinical grounds delivery was expected in the middle of February. The present
pregnancy ran a normal course. On December 8, when the pregnancy was estimated
to have lasted approximately 32 weeks, the patient was hospitalized for probable
fetus growth retardation and mild vaginal blood loss. In spite of treatment and a salt-
free diet the blood pressure rose up to 170 over 110 and the patient had constant sense
of nausea. On December 12, 06.15.am, the patient had a few contractions, the base
line of the fetal heart rate was 155 to 160 beats per minute. On December 13,
11.35.am, the fetal heart sounds could no longer be heard and a female dead fetus,
weighing 1600 grams, 31 cm longer was delivered. There were no congenital
abnormalities. The placental weight was 230 grams. There was noticed an important
ischemic necrosis with vascular necrosis.

CLINICAL HISTORY 7
The patient is a 6-year old girl, Bernarda Crix, with past medical history
significant for biliary cirrhosis. The patient, at one year of age, underwent a liver
transplantation. This time she is admitted with an enlarging left neck nodal mass.
On admission significant laboratory findings include:
Hemoglobin-12.2g/dL;
Increased white blood cell count with:
Neutrophiles-49%,
Lymphocytes-31%,
27

Monocytes-9%,
Eosinophils-10%,
Basophils-1%.;
Renal function tests, electrolytes, glucose-within normal limits.
The examination reveals two partially affected practically equal in size lymph
nodes matted together (4.5 x 2.5 x 1.5 cm).

CLINICAL HISTORY 8
A 45-year-old electrician Kent Renou fell 3 meters on January 5 and was
unconscious for 15 minutes. He was found by his neighbours and wife and admitted
to the hospital where after regaining consciousness, he complained of pain in both
shoulders and neck and of numbness of the second and third fingers of the right hand.
He was noted to have limitation of neck motion. A cervical spine roentgenogram,
taken at the time of his admission, included only five upper vertebrae. A complete
roentgenographic series of the cervical spine taken the next day was normal. He was
treated by physiotherapy and discharged several days later.
His complaints persisted and two months later a consultation revealed a tilt of
his head to the right, limitation and diffuse tenderness of the posterior neck muscles.
The right triceps reflex was absent with hypoesthesia to pin prick over the second and
third fingers of the right hand. A lateral cervical X-ray film demonstrated a first-
degree delayed traumatic dislocation of the cervical spine. An anterior cervical disk-
ectomy and reduction of the cervical vertebrae were performed. The patient did well
and was asymptomatic ten months later with roentgenographic evidence.

CLINICAL HISTORY 9
A 3-year-old girl Marisha Pishka with a history of mild motor delay was
presented with a change in mental status, gait difficulties, nausea and vomiting. The
patient was in her usual state of health until 9 months prior to presentation, when she
was found to have abnormalities of the left eye. Over the next several months, she
developed gait difficulties and behavioral changes. On the day of admission, she
developed confusion, severe gait difficulties, nausea and profuse vomiting. On
physical examination, she had increased deep tendon reflexes of her right Achilles
tendon. She subsequently became unresponsive. She was intubated and given
mannitol and steroids. An external ventricular drain was placed. Neuroimaging
showed a minimally heterogeneous tumor measuring 8×8×9 cm involving the left
parietal region and, partly filling the left lateral ventricle. Gross total resection of the
tumor was confirmed by post-operative imaging. Staging evaluation revealed no
metastasis. The patient was discharged one week later.

CLINICAL HISTORY 10
The patient Robert Bush was born at 38 weeks via C-section. The pregnancy
was complicated by gestational diabetes in the mother who was treated. She also had
elevated liver function tests (LFTs) during pregnancy; otherwise, no additional
28

problems were noted. He was 7 pounds 14 ounces. The patient was diagnosed with
neonatal jaundice, treated with phototherapy and discharged three days after birth.
This baby boy with postnatal onset microcephaly had speech impairment and
global developmental delay that were noted at 12 months of age. He also had feeding
problems which included gagging, choking and frequent drooling. The mother also
noted that the child has been sleeping more in recent weeks. According to the mother,
the infrequent episodes are typified by the boy stopping suddenly, staring and
becoming unresponsive. The child's history is negative for convulsions, meningitis,
encephalitis or severe head trauma associated with loss of consciousness. There is no
family history of developmental delay or neurological problems. The boy is
characterized by frequent smiling and laughter, hyperactivity. He has a strikingly pale
hair and unusually pale blue eyes. Involuntary hand movements, wide-based gait, and
dystonically upgoing toes are noticed. The patient's physical examination is positive.
An EEG was performed and showed a normal awake-and-asleep pattern; however, a
subtle slow background frequency for age was noted. An MRI was positive. A blood
sample from the patient was sent for DNA molecular testing.