DEPARTMENT OF MEDICINE

INTRODUCTION TO MEDICAL PRACTICE

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.

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Esmerelda COBRINS Age: 54 Years Domestic Helper

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

Admitted from Accident and Emergency to Ward 7 on January 7, 1990 as an emergency.

Presenting Complaints: PC

PC : 1. Abdominal pains x 5/7

2. Vomiting blood x 1/7

H.P.C. 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) 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.

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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 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.

P.H. : 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

D.H. : White medicine for epigastric pain (? Magnesium trisilicate mixture)

No other medications
Never takes aspirin or other analgesics

F.H. : Mother: age 85 years, well for her age but partially blind from cataracts.
Father: died 35 years ago (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 - Diabetes

- Hypertension
- Sickle Cell Disease
- Peptic Ulcer Disease (PUD)
S.H. : Married. Works as a part-time domestic helper.
Husband – age 57, works in a small factory re-treading truck tyres

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Second son – unmarried – lives at home. 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 about 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.

ROS
or
S/E 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

G.I. : See H.P.C.

G.U. : No dysuria, stones or haematuria

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

CNS : No headaches, fits or loss of consciousness

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No numbness or tingling in limbs

No tinnitus
No diplopia; eyesight normal
Climbs steps normally and combs hair without difficulty

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 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 cardiopulmonary distress.
Temperature 37.2o C.
Mucus membranes pale. No cyanosis or jaundice.
Nails normal but pale.
Teeth: poor condition; several loose and rotten.
Tongue: normal, papillae preserved.
No significant lymphadenopathy.
No peripheral oedema.
Breasts normal. Skin normal but sweaty
Thyroid not palpable
Hair going gray.
R.S. : Respiratory rate (RR) 20 per minute
Chest shape normal : no kyposcoliosis
Trachea central
Expansion normal

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Tactile vocal fremitus normal

Percussion note resonant
Vocal resonance equal on both sides
Breath sounds vesicular. No crepitations or wheezes. No added sounds

CVS : Pulse 100/minute, regular, low volume, symmetrical

No radiofemoral delay. Radioradial synchronicity present
Dorsalis pedis pulses not palpable; feet cold. All other pulses palpable
JVP is not visible
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
B/P 100/60 mmHg right arm, supine (phase V)
Felt faint on sitting up, so BP not taken in the sitting position

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 palpable
No palpable masses. Shifting dullness not present. Fluid thrill not present
Bowel sounds normal
PR: 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

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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
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.
Physiological cup normal
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 – can read fine prints

normally
Visual fields– normal
III,IV,V Eye movements full
No diplopia
No nystagmus
Accommodation normal

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VI: Corneal reflexes present, no motor and sensory

deficits

VII: No facial asymmetry

VIII: No deafness
Air conduction better than bone conduction
No lateralisation
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
Sensory : Light touch normal, pain normal
Vibration and position senses normal in feet.
Romberg’s negative
Gait normal

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Coordination normal
Musculo-skeletal : Joints: full range of movements. No crepitations.
Surgical scar on right foot over position of absent distal end of first
metatarsal.

Urine : No protein
No sugar
Microscopy not done

SUMMARY : 54 year old woman with a 3 year history of epigastric pain and
recent onset of melena and haematemesis with a past history of
smoking cigarettes, who on examination is found to have a fast,
low volume but regular pulse with hypotension and faintness on
attempting to sit up, a soft non-tender abdomen but with melaena
stools on PR examination.

DIAGNOSIS : Peptic Ulcer Disease 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

2. PT, PTT, Platelets
3. U+E’S
4. LFT’S
5. Group and cross match. Reserve 6 units of whole blood

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6. Upper Gastro-intestinal Endoscopy when condition stable

Management : 1. I.V. Line with CVP, IV Lansoprazole

2. Transfuse with normal saline until whole blood available
3. Inform Surgical Resident
4. Nil by mouth
5. Complete bed rest
6. 2-hourly observations of blood pressure and pulse.
7. When acute problems are over, discuss dangers of smoking and
peptic ulcer disease.

8/1/90: PROBLEM: UPPER GI BLEED

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

O: (Observation): Pulse 72/minute

BP 115/75 mmHg lying
110/80 mmHg sitting
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
Has had 3 units of blood

A: (Assessment): Bleeding probably stopped

No indication for emergency surgery

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P: (Plan): Transfuse 1 more unit whole blood, then

change to normal saline
Keep IV line open.
IV Lansoprazole, Mist. Mag. Trisilicate 15
mls 2 hourly po
Can begin light diet at breakfast
Seen by Consultant

9/1/90: PROBLEM: UPPER GI BLEED

S. ‘Not bad, doc.”
O. Pulse 76/minute
BP 120/80 supine and sitting
Chest)
CVS ) NAD
Abd. )

Investigations: Hb after 4 units blood = 11.2 g/dl

A. Bleeding site probably duodenal ulcer.
If confirmed, will need to give Lansoprazole
and H.pylori eradication therapy
Endoscopy not possible : no bulbs available.

P. Book BARIUM MEAL and then surgical

consultation.
Repeat Hb.
Check - Liver function tests.
- Urea and electrolytes
- Chest x-ray
- ECG

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15/1/90: PROBLEM: UPPER GI BLEED

S. Asymptomatic. Eating well.

O. BP 120/80 supine and erect.
Chest, CVS, Abd. - NAD
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.

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