Run the List When Illness Scripts Fail: A Mystery Case
Sep 30, 2025
Dr. Mitchell Charap, a seasoned internal medicine clinician and former residency program director at NYU Langone, delves into a perplexing clinical case. He highlights the pitfalls of relying solely on illness scripts for diagnosis, especially when symptoms can be misleading. The discussion includes a patient experiencing unusual chest and shoulder pain, leading to the surprising discovery of pulmonary emboli through meticulous diagnostics. Charap emphasizes the importance of physical exams and adapting clinical reasoning, especially in younger patients.
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Illness Scripts Are Context-Dependent
- Illness scripts guide diagnosis but vary by context, age, and socioeconomic factors. Rigid reliance on canonical scripts can mislead when a case deviates from typical presentations.
Healthy Young Man With Sudden Pleuritic Pain
- A 43-year-old healthy man developed sudden severe right-sided chest and shoulder pain after intense exercise. He initially treated it with NSAIDs and continued to have pleuritic pain that worsened when lying on his right side.
Always Do A Focused Physical Exam
- Perform a thorough physical exam even in clinic settings because it changes management. Finding dullness to percussion and decreased breath sounds at the right base prompted further imaging rather than assuming musculoskeletal pain.