DEPARTMENT OF MEDICINE

INTRODUCTION TO MEDICAL PRACTICE (IMP)

EXAMPLE OF CASE NOTES

HISTORY-TAKING AND PHYSICAL EXAMINATION

The imaginary case history which follows is meant as a guide for students learning
clinical examination. The history illustrates the way in which the patient’s symptoms
may be recorded in a chronological order so that the pattern of illness can be readily
appreciated by others. Note that answers to direct questions about the system
principally involved (in this case gastrointestinal) are included under HPC (History of
presenting complaint) and not in the review of system.

Under ROS (Review of Other Symptoms) answers to some important questions about the
symptoms in the other systems are recorded. It should be realized that this is not a list
of all the possible questions which could be asked. With experience one learns how to
closely-question patients in order to elicit symptoms which they do not mention
spontaneously. The number of questions in this example is a reasonable minimum.

It would be possible to under the record of Physical Examination record many more
normal facts about the patient than are given here. The objectives should be to record
all abnormal physical signs plus important normal ones. Once again, experience will
show what is necessary and the details given (as for ROS) represent the minimum
required.

August, 2018
Esmerelda COBRINS Age: 54 Years Domestic Helper

Address: 7 Rise Road, Kingston 10; Religion: Christianity; Denomination: Pentecostal

Admitted from the Accident and Emergency to Ward 7 on January 7, 2014 as an

emergency

Presenting Complaints (PC)

1. Abdominal pains x 5/7

2. Vomiting blood x 1/7

History of presenting complaints (HPC)

Well until 3 years ago when she began to notice occasional epigastric pain.
The pain, usually severe and of gradual onset, was “sticking” in character,
did not radiate, tended to come on before meals and would sometimes wake
her at night, often lasting up to 3 hours. She found that it was relieved by
food, milk and “white medicine” which she bought at a pharmacy. She could
not recall any aggravating factors. After six weeks, during which the pain
was experienced daily, she became symptom-free.

18 months ago, she had a recurrence of the same pain. It troubled her for
three weeks and then disappeared spontaneously.

5 days ago, the epigastric pain returned. It was more severe than before (5
on a scale of 1-10, with 10 being the most severe) and occurred 3 to 4 times
each day.

2 days ago, she felt “dizzy” on getting out of bed, but she did not faint. The
dizziness was relieved by lying flat in bed. She then noticed that she passed
tarry black stools when she “opened her bowels” on two occasions.

3 hours before admission, she suddenly vomited about 2 cups of bright red
blood. She felt “sweaty” and faint, and was brought to hospital by her son.

Until 5 days ago, her health had been generally good. Her appetite was
normal, she had no dysphagia and her weight was steady. She had no other

August, 2018 2
 episodes of vomiting and no jaundice. Her stools were previously normal in
colour with no blood or slime. She has never noticed black stools until 2
days ago.

PMH (Past Medical History)

No Diabetes or Hypertension. No cardiac disease, Rheumatic Fever,
Asthma, Sickle Cell Disease, liver or renal disease or pneumonia.
No drug allergies.
Hospitalization: UHWI (see below)
Surgeries: 7 years ago: Operation on right foot for hallux valgus (UHWI)
No other operations, hospital admission or serious illnesses

DH (Drug History)
“White medicine” for epigastric pain (? Magnesium trisilicate mixture)
No over-the-counter medications
No prescription medications
No Herbal medicines
Never takes aspirin or other analgesics

FH (Family History)
Mother: age - 85 years, well for her age but partially blind from cataracts.
Father: died 35 years ago (at age 57), after falling off a ladder.
Siblings: 2 brothers]
1 sister ] All alive and well

Children: 3 sons, ages 24, 29, 31

1 daughter, age 26
The eldest son had a lung operation 2 months ago
All others are alive and well.
No Family history of Has a Family History of
- Diabetes - Obesity – Mother height 5’2”

August, 2018 3
 - Hypertension Weight over 90 kg
- Sickle Cell Disease - Brothers and Sister are fat
- Peptic Ulcer Disease (PUD)

SH (Social History)
Married and works as a part-time domestic helper
Husband, aged 57, works in a small factory re-treading truck tyres
Second son, unmarried, lives at home. Patient lives with husband and
children in a concrete 2 bedroom house with indoor plumbing and piped
water in the house. Husband and family are supportive but worried about
her illness. Patient worried about keeping her job.
Has never been abroad.
Smokes 10 cigarettes daily for the last 15 years.
No ganja or other illicit drugs.
Does not drink alcohol.
Exercises 2 times per week for 30 minutes by walking.
Does not feel badly about her illness.
Breakfast – skips this
Lunch – has 1 bowel of cornmeal porridge sweetened with condensed milk
Dinner – has 2 servings of chicken – fried, 1 bowl of rice and peas, has a
slice of tomato and a glass of lemonade.

ROS (Review of Systems)

CVS : No dyspnoea on exertion
No orthopnoea or paroxysmal nocturnal dyspnoea
No palpitations or chest pain
No ankle swelling

RS : No cough, sputum or wheezing

No haemoptysis

August, 2018 4
 GI See H.P.C. (The review of systems captures only the symptoms not
evaluated in the HPC)

GU : No dysuria, stones or haematuria

No incontinence
No loin pain
No polyuria or polydipsia
Micturition D/N (Day/Night) = 4/0
No urgency or hesitancy
Good urinary stream

CNS : No headaches, fits or loss of consciousness

No numbness or tingling in limbs
No tinnitus
No diplopia; eyesight normal
Climbs steps normally and combs hair without difficulty

ENDO: Birth weight 7.5 kg

Weight at primary school – normal
Weight at age 18 50 kg
Weight at age 21 72 kg
Weight at age 40 84 kg
Weight at age 50 86 kg

GYNAE : LMP 5 years ago

No post-menopausal bleeding
No PV discharge

SUMMARY: 58-year-old domestic helper of a Kingston address presenting with a 3-

year history of intermittent epigastric pain and a 2-day history of
passing black tarry stools which was associated with dizziness and a

August, 2018 5
 3-hour history of vomiting bright red blood. She denies a PMH of liver
disease. She denies alcohol, aspirin or NSAID usage, but she has
smoked 10 cigarettes daily for 15 years. No family history of PUD.

O/E : Ill-looking, middle-aged woman, lying flat in bed in no obvious distress.

Temperature 37.2o C. Height 1.57 m. Weight 86 kg. BMI 34.6 /m2
Weight circumference 31 inches (78.7 cm).
Mucus membranes pale. No cyanosis nor jaundice.
Nails normal, but pale.
Teeth: poor condition with several loose and decayed.
Tongue: normal, papillae preserved.
No significant lymphadenopathy.
No peripheral oedema.
Breasts normal. Skin normal but sweaty
Thyroid not palpable
Hair going gray.

RS : Respiratory rate (RR) 20 breaths per minute.

Character : thoracoabdominal
Chest shape normal : no kyposcoliosis
Trachea central
Expansion normal
Tactile vocal fremitus normal
Percussion note resonant throughout
Vocal resonance equal on both sides
Breath sounds vesicular. No crepitations or wheezes. No added sounds

CVS : Pulse 100/minute, regular, low volume, symmetrical, non-collapsing

No radio-femoral delay. Radio-radial synchronicity present
Dorsalis pedis pulses not palpable; feet cold. All other pulses palpable
JVP is not visible

August, 2018 6
 B/P 100/60 mmHg right arm, supine (phase V), oedema o

Felt faint on sitting up, so BP not taken in the sitting position

No LPH or thrills or P2 palpated
Apex beat in 5th left intercostal space, mid-clavicular line
Cardiac impulse normal
Heart sounds 1 & 2 heard and normal. Heart sounds 3 & 4 not present. No
murmurs or added sounds
No bruits auscultated over the carotid arteries

Abdomen : Scaphoid
Soft, non-tender, no visible peristalsis.
Liver - soft on deep palpitation
- edge just palpable
- non-tender
- span 11 cm
Spleen not palpable
Kidneys not ballotable
No palpable masses. Shifting dullness not present. Fluid thrill not
present
Bowel sounds normal
DRE: No skin tags. No anal fissures. Anal tone normal. No masses felt.
No rectal shelf felt. Stools – tarry, black, foul smelling

CNS : Alert and oriented in time, place and person

Higher mental function: All Normal
1. Registration: naming of 3 objects
2. Recall: recalling the three objects
3. Attention and concentration: serial sevens, “world” spelt
backwards
4. Short-term memory

August, 2018 7
 Long-term Memory
5. Reasoning
i) Judgement: “What would you do if you saw a house on
fire?”
ii) Abstractional abilities: “One one coco full basket”
Speech normal
Kernig’s negative. Neck supple.
Cranial nerves :1: Smell normal
11: Fundi : Disc margins: Well defined.
Colour normal.
Normal cup-to-disc ratio
No A-V nipping
No silver wiring or copper
wiring.
No haemorrhages
No exudates

: Pupils - equal, size 3mm,

- react briskly to direct and
consensual light
Visual Acuity –

Left Right

Without glasses 20/70 20/40

With glasses 20/20 20/20

Visual fields – normal

III,IV,VI Eye movements full
No diplopia
No nystagmus
Accommodation normal

August, 2018 8
 V: Corneal reflexes present, no motor or sensory
deficits; Jaw Jerk negative

VII: No facial asymmetry

VIII: No deafness
Air conduction better than bone conduction
No lateralization (Weber and Rinne)
IX, X: Gag reflex normal.
Palate moves centrally
XI: Sternomastoids and trapezius normal
XII: Tongue protrudes centrally, no wasting or
fasciculations.

Motor : No muscle wasting, bulk normal

No fasciculations or abnormal movements
Tone normal

Power: Grade V in all limbs

(L) (R)
Reflexes: BJ ++ ++
TJ ++ ++
SJ ++ ++
Abdomen __ __
KJ ++ ++
AJ ++ ++
Babinski -ve -ve
Co-ordination and Gait normal
Romberg negative
Sensory : Light touch normal, pain normal
Vibration and position senses normal in feet.

August, 2018 9
Musculoskeletal
The patient has normal gait and ambulates independently.
No muscle wasting, bulk normal, grade V power in all limbs, normal hand grip
All joints are without warmth, erythema, scars, bony swelling, soft tissue swelling,
effusion, tenderness or deformity. There is no audible or palpable crepitus. All joints
demonstrate normal range of motion actively and passively.

Urine : No protein
No sugar
Microscopy not done

Glucose monitor readings (GMRs) when relevant

SUMMARY : 54 year old woman with a 3 year history of epigastric pain

and recent onset of melena and haematemesis as well as
past history of smoking cigarettes, found on examination
to have a fast, low volume but regular pulse with
hypotension and faintness on attempting to sit up, a soft
non-tender abdomen and melaena on PR examination.

DIAGNOSIS : Upper gastrointestinal bleeding likely due to Peptic Ulcer

Disease (PUD) - probably duodenal
Exclude gastric neoplasm (unlikely in view of duration of
symptoms, normal appetite and weight)

PROBLEMS 1. Haematemesis and melena with -

hypotension,tachycardia, cold extremities

2. Smoking

INVESTIGATIONS : 1. Hb and blood film

August, 2018 10
 2. PT, PTT, Platelets
3. U&E’S
4. LFT’S
5. Group and cross match. Reserve 6 units packed red
blood cells
6. Upper Gastro-intestinal Endoscopy when stable

MANAGEMENT 1. I.V. Line with CVP, Nasogastric tube, IV Pantoprazole

80 mg bolus then 8mg/hr x 72 hrs
2. Transfuse with normal saline until packed red cells
available
3. Inform Surgical Resident
4. Nil by mouth
5. Complete bed rest
6. 2-hourly observations of blood pressure and pulse.
7. 4- to 6-hourly cbcs
8. When acute problems are over, discuss dangers of
smoking and peptic ulcer disease.

8/1/14: PROBLEM: UPPER GI BLEED

S: (Symptoms): No further haematemesis or melena
No epigastric pain
Feels much better
Not faint now

O: (Observation): (Please write FULL examination

findings as per first examination)
Pulse 72/minute
BP 115/75 mmHg lying
110/80 mmHg sitting

August, 2018 11
 CVP = + 6 cms
Chest : NAD (No abnormalities detected)
CVS: NAD
Abdomen: NAD
Investigations: Initial Hb = 7.2 g/dL
PT = 12/12 secs
Platelets normal on film
Transfused 3 units of blood

A: (Assessment): Bleeding probably stopped

No indication for emergency surgery

P: (Plan): Transfuse 1 more unit packed red cells

Switch to normal saline
Keep IV line open.
IV Pantoprazole
Can begin light diet at breakfast
Seen by Consultant

9/1/14: PROBLEM: UPPER GI BLEED

S. ‘Not bad, doc.”
O. Pulse 76/minute
BP 120/80 supine and sitting (include
rest of full examination)
Investigations: Hb after 4 units blood = 11.2 g/dL
A. Bleeding site probably duodenal ulcer.
(If confirmed, and H. pylori positive, for
Pantoprazole and H.pylori eradication
therapy)

August, 2018 12
 Endoscopy not possible as no bulbs
available
P. Book BARIUM MEAL and then surgical
consultation.
Repeat Hb.
Check - Liver function tests.
- Urea and electrolytes
- Chest x-ray
- ECG
15/1/14: PROBLEM: UPPER GI BLEED
S. Asymptomatic. Eating well.
O. BP 120/80 supine and erect. (Include rest of full
examination).
Investigations: Liver function tests normal
A. Upper GI Bleed, now ceased
Duodenal ulcer: Confirmed on barium meal.

P. Discharge home on Lansoprazole 30 mg od

for 6 weeks and H.pylori eradication therapy
To be seen in Gastroenterology Clinic in 1/12.
Patient advised to stop smoking.

Discharge summary
A previously well 54 year old lady presented on
7/1/14 with a 5-day history of abdominal pain, a 1-
day history of vomiting blood. She had no
constitutional symptoms and was found to be
haemodynamically stable on assessment with severe
anaemia. She was treated with transfusion of
packed red cells plus crystalloid infusion with
resolution of instability. Intravenous proton pump

August, 2018 13
 inhibitors were administered, with resolution of
acute bleed. Upper GI endocscopy was not
performed but she is scheduled to have a barium
meal as part of her investigations.
Discharge diagnosis- peptic ulcer disease (likely
duodenal ulcer).
TTH (To-take-home, meds)- Pantoprazole 20 mg
once daily
Plan- GI clinic for continued investigations.

August, 2018 14