Documente Academic
Documente Profesional
Documente Cultură
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.
28/0211
28/02/11
Presenting Complaints: PC
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.
2
28/02/11
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.
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
3
28/02/11
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
4
28/02/11
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
5
28/02/11
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
6
28/02/11
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
7
28/02/11
8
28/02/11
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.
2. Smoking
9
28/02/11
10
28/02/11
consultation.
Repeat Hb.
Check - Liver function tests.
- Urea and electrolytes
- Chest x-ray
- ECG
11
28/02/11
12