1. health and fitness
2. disease

0200-0202 ‫القائمة األكادمية‬
Sample Clinical Reports for 5th year
Medical Rotations
Peer reviewed and collected from
different Authors
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reports. These aim to Facilitate and guide you while writing your reports.
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SAMPLE CLINICAL NOTE 1 - Medicine
Personal Details
Name: Adult female
Age: xx years old
Nationality:
Admitted on:.
Seen on:
Chief complaint
Right upper quadrant abdominal pain lasting for x days
History of presenting complaint
Patient came to the causality complaining of right upper quadrant abdominal pain for the
past x days. The pain was dull in character. It was of sudden onset, did not radiate, and was
constant. It did not stop her from being able to perform her daily activities. She says she tried to
alleviate the pain by taking panadol, but it only helped a little. It was associated with nausea and
vomiting and loss of appetite. The vomiting was clear fluid with no blood (no hematemesis).She
also said that she would get breathless after walking short distances but had no palpitations or
chest pain. There were no changes in bowel habits or stool color as well as no other source of
bleeding. She went to a Mishref clinic on the second day, which referred her to Mubarak
Hospital.
Past Medical History
-
She had a similar episode in ……. She was diagnosed with anemia and given packed red
blood cells and one injection (she did not know what it was).
-
She has no history of operations
-
Diabetes
o Diagnosed last month at a Mishref clinic. She was then prescribed Glucophage.
-
Hypertension
o She was diagnosed … years ago in………... It was discovered incidentally when
she went to the doctor there for a headache. She goes to check up once a month at
the clinic in Mishref.
o She takes Tenoretic (atenolol and chlorthalidone)
-
She has no history of respiratory diseases, cardiac diseases or dyslipidemias.
-
Dental – she has had removed several teeth removed
Drug History
-
Glucophage (metformin) – 500 mg, once daily
-
Tenoretic (atenolol and chlorthalidone)
-
She has no allergies
-
She does not take any herbal remedies
-
In-patient
o Vitamin B12 injection, once daily for 5 days
o Folic acid, once daily
Family History
-
Mother – deceased. She was a diabetic and had a foot amputated.
-
Father – deceased. He died at the age of 75 from a myocardial infarction.
-
10 siblings (4 boys and 6 girls) – all are hypertensive
Social History
-
Married, her husband is an electrician in Sri Lanka
-
She has 2 children, one boy (35 years old) and one girl (32 years) both healthy.
-
Occupation – she is a domestic worker. She has been working in the same house for 20
years.
-
She usually goes to Sri Lanka every 3-4 years. Her last visit was 4 years ago and she
wasn’t ill there except for the discovery of her hypertension.
-
Non-smoker (never smoked)
-
Does not consume alcohol
-
Diet – she eats everything but does not eat meat, however she eats poultry and fish.
General Health
-
Well-being – she feels better
-
Appetite – better but not completely back to normal
-
Sleep – disturbed because of hospital environment
-
No significant weight changes
Systemic Review
-
Cardiovascular – (see above)
-
Respiratory
o No cough
o No wheeze
-
Gastrointestinal tract – (see above)
-
Urinary Tract
o No changes in urine color or amount
o No pain on urination
-
Reproductive system
o Last menstrual period – 5 years ago (menopause)
-
Nervous system
o has prescription glasses but has not checked her eyesight recently
o No tingling in extremities
o No weakness
o No hearing problems
-
Musculoskeletal
o Complains of pain along lateral side of dorsal side of right foot from when she fell
after tripping over an open sewer in the street.
-
Endocrine
o No heat or cold intolerance
o No excessive thirst
-
No bleeding or bruising
Physical Examination
-
General appearance
o Patient is lying in her bed, conscious and looks comfortable.
o Patient has a cannula in her right arm.
-
General exam
o Hands – warm, no palmar erythema, no clubbing, fine tremor
o Eyes – slight jaundice, pale conjunctiva
o Mouth – no cyanosis of membranes, no ulcers, normal tongue (not red or
enlarged).
o Neck – no palpable masses
o Lymph nodes in neck (submental, submandibular, tonsilar, superficial and deep
cervical) impalpable.
-
Vital signs
o Heart rate = 78 beats/min
o Blood pressure = 130/75
o Respiratory rate = 24 breaths/min
o Temperature = 37oC
-
Cardiovascular
o Radial pulse – regular rhythm, good volume. Symmetrical in both arms.
o Carotid pulse – good volume on both sides with no bruit
o Pulses –
Right

Radial
++
++

Dorsalispedis
++
++

Posterior tibial
++
++

Popliteal
++
++
Left
o Legs – no edema, no tenderness, no erythema
o JVP – normal
o Palpation: apex beat could not be felt even when asking patient to turn over onto
her left side. There were no palpable thrills or parasternal heave
o Auscultation: S1 and S2 heard clearly with a systolic murmur.
-
Respiratory system
o On inspection, her chest was moving symmetrically, no chest wall deformities, no
scars
o On palpation, her trachea was central, she had normal chest expansion with both
sides moving symmetrically both on the anterior and posterior aspect of the chest.
o On percussion, chest was resonant over both lung fields and tactile vocal fremitus
was resonant
o On auscultation – equal air entry on both sides, vesicular breath sounds. No added
sounds. Vocal resonance is normal on both sides.
-
Abdominal exam
o Inspection – no masses, no pulsations. She has white striae over the lower aspect
of her abdomen.
o Palpation – abdomen was soft, but there was tenderness on the right upper
quadrant. There is no organomegaly.
o Auscultation – no bruits over renal arteries and liver. Bowel sounds are present.
-
Nervous system
o GCS = 15/15
o Patient oriented to place and person. When asked about time, she said it was night
(although it was afternoon). I am not sure if it was due to difficulties in
communication or not.
o No dysarthria or dysphasia.
o Gait – tandem gait is normal. No instability.
o Cranial nerves – all intact bilaterally

Optic (II) & Occulomotor (III) – pupils are equal, round & reactive, no visual field
defects.

Occulomotor (III), Trochlear (IV) and Abducens (VI) – extraocular movements normal,
no nystagmus

Trigeminal (V) – sensation equal on both sides over the distribution of the 3 branches V1,
V2, and V3. She could open her jaw against resistance.

Facial nerve (VII) – on inspection: no facial droop or asymmetry. Patient could wrinkle
her forehead, show her teeth, puff out her cheeks and resist eye opening.

Vestibulocochlear (VIII) – hearing is equal on both sides.

Glossopharyngeal (IX) and vagus (X) – No uvula deviation. Gag reflex not tested.

Accessory (XI) – sternocleidomastoid bulk normal and can push against resistance,
trapezius muscle is of normal bulk and can push against resistance

Hypoglossal (XII) – No fasciculations on inspection. The tongue does not deviate when
protruded, she can move it left and right with no problems.
o Coordination – no dysdiadochokinesis, performed cerebellar tests (finger-nosefinger, rapid alternating movement). Heel-to-shin test was normal.
o Tone – normal in upper and lower limbs bilaterally
o Power


Upper limb -
Right



Wrist
Elbow flexion/extension
Shoulder adduction/abduction


Foot dorsiflexion/plantarflexion
Knee extension/flexion
Left
5/5
5/5
5/5
5/5
5/5
5/5
5/5
5/5
5/5
5/5
Lower limb
o Sensory

Light touch & pain – intact bilaterally on both upper and lower limbs

Vibration – intact bilaterally on both upper and lower limbs

Position sense – intact bilaterally on both upper and lower limbs
o Reflexes


-
Upper limb –



Right
Brachioradialis
Biceps
Triceps
Left
++
++
++
++
++
++


Ankle reflex
Knee jerk
++
++
++
++
Lower limb
Diabetic foot exam
o No sign of skin infection, ulcers, edema
o No deformities, for example, Charcot’s foot or claw foot
o Skin temperature is normal (warm to the touch) on bothfeet.
Investigations –
LAB RESULTS HAVE BEEN OMMITTED for the sake of this handout– but
should be mentioned in details




CBC and blood film
o Report note: 11/10/2010
WBCs – “No abnormal cells seen”
RBCs – “Normocytic normochromic. Anisocytosis. Macrocytes seen.”
Platelets – “increased”
o Report note: 13/10/2010
WBCs – “No abnormal cells, mild leucopenia”


RBCs – “Macrocytes seen”
Platelets – “normal”
-
RFTs, AML, TBIL, ALT
Coagulation profile
Urine
HbA1c
-
Iron profile – Fe (serum Fe, transferring, transferring saturation)
o Done on 12/10/2010 (AFTER transfusion of 2 units of packed RBCs)
-
ECG – normal rate (68) and rhythm (sinus).
-
Chest x-ray – normal
Follow-up 13/10/2010
-
Patient’s abdominal pain has gone, no tenderness on examination
-
She was given one unit of packed RBCs the night before
-
She complains of a headache along the front part of her head which started the previous
night. She was given panadol for it but it still had no effect.
-
Patient complains that she was unable to sleep last night, she didn’t feel sleepy.
-
Hematology consult was received. They suggested follow up CBCs and to keep going
with the same medications.
Working Diagnosis and Management
The patient, known to be diabetic and hypertensive, presented with right upper
quadrant pain for three days. The pain was dull, constant, did not radiate or interfere with her
ability to perform her daily activities. It was slightly improved by taking panadol. It was
associated with vomiting of several times, nausea and loss of appetite. The vomit was of clear
fluid and did not have any blood in it. She had exertional dyspnea preceding the pain but had
no palpitations. There was no bleeding per rectum or per vagina.
The working diagnosis is macrocytic anemia as was derived from her investigations,
most probably megaloblastic. Her complete blood count (CBC) revealed that she was severely
anemic with a hemoglobin level of 32 g/L. The mean corpuscular volume (MCV) was 110fL,
making it a macrocytic anemia (>95 fL). She also has and a decreased reticulocyte count which
can happen with B12 or folate deficiency. The blood film reported anisocytosis (variation in red
blood cell (RBC) size) and is represented by an increased RDW (red cell distribution) in the CBC.
Macrocytic anemia can be divided into megaloblastic and non-megaloblastic by bone marrow
examination; however, it is not usually done during the course of investigating macrocytic
anemia. The initial investigations are to measure the serum B12 and red cell folate because
their deficiencies are the most likely causes of macrocytic anemia. In megaloblastic anemia,
there is intramedullary hemolysis which causes an increase in lactate dehydrogenase (LDH) and
bilirubin. Increase in LDH levels suggest ineffective erythropoiesis. The increase in bilirubin
contributed to the patients mild jaundice. Erythrocyte sedimentation rates (ESR) can be high
due to her anemia. Serum ferritin levels are usually increased in macrocytic anemia. Her
urinalysis came back normal. Her chest x-ray was clear and her ECG was of normal rate and
rhythm.
The smear also revealed slight leucopenia with no abnormalities in the white blood cells
(WBCs) but an increased number of platelets. From the increased platelets, it was suspected
that she may have iron deficiency with her macrocytic anemia. However, her iron studies were
done after she had received 2 units of packed red bloods cells when she was first admitted. It
revealed increased serum iron and transferrin saturation.
Her very low hemoglobin levels required a transfusion of packed RBCs. She was started
on vitamin B12 injections and folic acid pills for the following 5 days. She will then be given a
B12 shot every month.
THIS SHOULD BE FOLLOWED BY THE SUMMARY IN THE BOX
SAMPLE CLINICAL NOTE 2 – Medicine- Pulmonology
Personal Details
Name:
Age:
Nationality:
Occupation:
Status:
Adult female
xx
Presenting Complaint
1. SOB
2. Productive cough
3. Chest pain
(x days)
(x days)
(x days)
History of Presenting Complaint
The patient presented to the casualty on 20/09/2010 complaining of shortness of breath (SOB).
She is known to have asthma and needed to control her SOB in order to travel to London where
she is planning to undergo hip replacement surgery next month.
The SOB began 10 days ago with the onset of an upper respiratory tract infection. It was episodic
in nature and each episode lasted around 10 minutes. The patient could not estimate how far
apart the episodes were. It occurred at rest and was aggravated by exertion and by lying flat and
relieved by sitting upright and breathing from the mouth.
The SOB was accompanied by orthopnea and paroxysmal nocturnal dyspnoea (PND) along with
a productive cough that progressively increased in severity; it was worse in the morning. The
sputum was copious (around 1-2 cups per day). It was initially white in colour, however, a few
days previously, it had become yellowish green; there was no blood in the sputum.
The patient suffered from chest pain that she described as stabbing and heavy in character in the
sternum, back and sides, and it sometimes radiated to the left shoulder and arm. The chest pain
was aggravated by cough and taking a deep breath and was not associated with sweating or
aggravated by exertion.
Additionally, the patient complained of fever (undocumented), palpitations and nightsweats. She
did not suffer from loss of appetite, weight loss, dysuria, haemoptysis, or lower limb oedema.
She was last well on the 09/09/2010. On 10/09/2010 she sought medical attention for her URTI
and was started on a course of antibiotics (she does not remember the name or dose) along with
some steroids and increasing the frequency of her usual nebulizer. However, she did not feel any
better after completing the courses.
She has been admitted several times this year for the same problem. Her last admission was on
July.
Past Medical History
????:
2 Caesarian sections, diagnosed with osteoporosis, sinus tachycardia (controlled)
1997:
Diagnosed with asthma, hypertension (controlled), and dyslipidaemia
2004:
Hysterectomy
2006:
Left hip joint replacement at Al-Razi hospital
2008:
Repeat left hip joint replacement therapy in London, endoscopy
2010:
Diagnosed with diabetes mellitus (DM) (uncontrolled) no nephropathy, or
retinopathy however there are signs of neuropathy.
Family History
Father:
DM, died at the age of 65 from gastrointestinal cancer
Mother:
Asthma, DM, hypertension (HTN)
Siblings:
Asthma, DM, HTN
Children:
Asthma, DM, HTN
Drug History
Allergic to penicillin and rocephin.
Hydrocortisone
200mg
Atrovent
(ipratropium inhalation)
1cc
Ventolin
(albuterol)
0.5cc
Pulmicort
(corticosteroid)
0.5cc
Isoptin
(Vermapamil/ca channel blocker)
240mg
Losec
(omeprazole)
20mg
Lipitor
(atorvastatin/HMG CoA reductase inhibitor)20mg
Singulair
(Leukotriene inhibitor)
10mg
Calcium + Vit D
600mg
Avelox
(moxifloxacin/fluoroquinilone antibiotic) 400mg
Neurontin
(gabapentin/anti-epileptic)
300mg
Disflatyl s
(imethicone)
(unknown)
Diovan
(Hydrochlorothiazide)
80mg
(3x/day)
(4 hourly)
(6 hourly)
(12 hourly)
(2x/day)
(2x/day)
(2x/day)
(3x/day)
Social History
Residence:
She lives in a house in Al-Rawda with her family. Her bedroom is on the 2nd floor
and she uses the elevator to avoid exertion.
Travel:
Last was to Dubai in June
Pets:
None
Alcohol:
Never
Tobacco:
Never
Life style:
Sedentary
Allergies:
Dust, strong perfume
General Health
Weight:
94kg
Height:
170cm
BMI:
32.5 (obese)
Appetite:
Normal
Bowel movements:
Alternating diarrhoea and constipation (predominantly diarrhoea)
Micturition:
Steady stream, normal colour, no nocturia or oliguria
Mood:
Worried
Sleep:
Disturbed by SOB and cough several times per night
Systemic Review
GI:
Positive for dyspepsia and nausea. No abdominal pain.
Endocrine:
Unremarkable.
Musculoskeletal:
Positive for generalized bone ache. No joint pain/swelling or deformities.
Neurological:
Positive for decreased visual acuity and paraesthesia in the extremities. No
headache, dizziness, vertigo, balance or hearing deficits.
** Respiratory, cardiovascular and renal were already discussed above.
Physical Examination
The patient was sitting upright in bed and was oriented in time, place and person. She
was on a nasal cannula and appeared to be in respiratory distress. She could not complete
a sentence in one breath.
Vital Signs
Temperature:
36.9oC
Blood pressure:
130/60mmHg
Respiratory rate:
28 breaths/minute
Pulse rate:
64 beats/minute
Sa02:
99% (on 5 litres of oxygen)
General Examination
Hands:
No clubbing, peripheral cyanosis, nicotine stains, palmar erythema,
flapping tremor, koilonychia or leukonychia
Eyes:
Positive for conjunctival pallor. No sclera icterus or congestion of vessels
or suffusion
Mouth:
No central cyanosis, good oral hygiene
Lower Limbs:
Mild pitting oedema up to mid-shin level
Respiratory Examination
Inspection:
Symmetrical breathing, no scars on the chest, no chest deformities (e.g
pectus carinatum/excavatum or barrel chest), no paradoxical breathing
Trachea:
Centrally located
Chest expansion:
Normal and equal on both sides
Vocal Fremitus:
Could not be assessed
Percussion:
Resonant
Auscultation:
Vesicular breathing over both lungs with bilateral global wheeze heard
during expiration.
Cardiovascular Examination
Radial pulse:
Normal volume, regular, symmetrical, not collapsing
Apex beat:
Palpable in the 5th intercostals space within the midclavicular line
Peripheral pulses
Site
Right
Left
Dorsalis Pedis ++
++
Posterior tibial ++
++
Percussion:
Unremarkable
JVP:
Not performed
Auscultation:
Normal S1 and S2 with no added sounds
Abdominal Examination
Inspection:
Distended abdomen with hysterectomy scar and hernia
Palpation:
Not performed
Auscultation:
Normal Bowel sounds
Digital rectal exam:
Not performed
** Neurological, musculoskeletal and some components of the cardiovascular
and abdominal exam were not performed as the patient was in distress and refused.
Investigations LAB RESULTS HAVE BEEN OMMITTED for the sake of this handout– but
should be mentioned in details
ABG (20/09/2010)
CBC (20/09/2010)
Comment:
Slightly low haemoglobin, leukocytosis, hyperglycaemia and low
creatinine.
WBC Differential
Comment:
Predominantly neutrophilic
Blood Culture
Negative growth over 5 days
Sputum Culture
Showed some epithelial cells along with increased pus cells.
Growth of haemophilus.
ECG
Normal axis and slightly high rate.
Chest X-ray (20/09/2010)
Normal except for increased vascular markings more prominent on the right lung field.
Pulmonary Function Test (26/09/2010)
FEV1:
49%
FVC:
52%
FEV1:FVC:
80%
Comment:
Decreased FEV1 and FVC values with normal ratio indicate a restrictive pattern.
Differential Diagnosis
Pneumonia, congestive heart failure, pulmonary infarction, COPD, vocal cord dysfunction
Diagnosis and Management Plan
The patient was admitted as a case of acute severe asthma. She was given IV MgSO4, and was
put on supplemental 02. The dosage and frequency of her bronchodilators was increased. Blood
and sputum cultures were assessed in order to determine a causative organism and determine its
sensitivity if applicable. If the culture results were positive then we should put her on the
appropriate treatment until the symptoms have subsided. Also, a short course of oral
corticosteroids is beneficial. After this short course she can be put on inhaled corticosteroids
along with her usual dose of bronchodilators.
As for the hyperglycaemia, further evaluation is needed and she might need to be given oral
hypoglycaemics.
THIS SHOULD BE FOLLOWED BY THE SUMMARY IN THE BOX
SAMPLE CLINICAL NOTE 3 – Medicine- Pulmonology
Name: Adult female
Age:xx years
Nationality:
Date of admission:
Date seen:
Chief Complaint
Shortness of breath of few hours duration and fatigue for x days.
History of presenting complaint
Patient, who is known to be diabetic, came to the casualty complaining of shortness of
breath and severe fatigue. She described the shortness of breath as gasping for air which
developed suddenly on Wednesday night while sitting at home.The fatigue gradually worsened
over the course of 5 days but she was able to go about her day as usual. Associated with her
symptoms were nausea and vomitingwhich developed at the same time as her shortness of
breath. The patient stated that she vomited around 10 to 12 times on Wednesday night; she
describes it as being mostly watery material with some phlegm.She does not have orthopnea,
paroxysmal nocturnal dyspnea, palpitations, chest pain or pain on walking (claudication). She
does not have a cough or a wheeze and there was no hemoptysis. She had no fever, abdominal
pain or changes in stool consistency or color or changes in urine habit.When she developed the
shortness of breath, she was driven to the hospital by her son and friend. On the way over, she
said that she had the windows down in the car so she can breathe better.Previous to
developing her symptoms, she had stopped taking her insulin for 5 days because of a painful
sprained right forearm after a fall which required a cast, making her unable to inject herself
with insulin.
Past Medical History
-
-
-
Diabetes
o The patient developed gestational diabetes during her last pregnancy, it went
away after delivery but then returned a month later. She was definitely
diagnosed around 4 years ago when she started having polydipsia and polyuria.
She has been on insulin ever since and takes it once daily after waking up. She
goes to the Salmiya Clinic for follow up once a month which is when she checks
her glucose levels.She used to check her blood glucose at home, but not
anymore. She is not on any special diabetic diet.
Last week – fell down while washing her legs in the bathroom, bruised her right arm
which required a cast done at Al-Razi hospital. She removed the cast herself 2 days later
because it was uncomfortable.
Hospital admissions:
o Appendectomy at Al-Sabah Hospital – does not remember when
-
o She had a total of 4 caesarean sections for her 4 kids – all full term, no
complications, except she developed gestational diabetes with her last
pregnancy
o 2 miscarriages – was not told why
Not hypertensive, no cardiac diseases, no respiratory diseases, no dyslipidemia
No similar episodes have happened to her before
Drugs/Allergies
-
Insulin for her diabetes
No known allergies
Currently on (administered at the hospital):
o Tazocin (piperacillin) – I.V.
o Celebrex (celecoxib) – 200g oral
o Lantus (long-acting insulin) – subcutaneous
o Thiamine – oral
o Losec (omeprazole) – oral
o Dalacin (clindamycin) – I.V. (added after ultrasound was performed with
suggesting result of an abscess)
Family History
-
-
Mom – passed away after going to a hospital complaining of abdominal pain and was
found to have internal hemorrhage. She was a diabetic and had a foot amputated. She
was also hypertensive.
Dad – deceased, had hemiplegia
o Patient does not know exact details about her father’s medical conditions.
Siblings – 3 brothers and 2 sisters who are all diabetic and hypertensive. One of her
brothers who in his 30s, has a heart problem (does not know exactly what it is)
She has 4 sons who areall healthy except for one who has hemolytic anemia (she did not
know what type)
No one had the same symptoms as she did
Social History
-
-
The patient is divorced, lives in Hawalliin an apartment on the first floor with her
children and maid. She takes the elevator. She lived in the Emirates for 12 years, and
could not estimate when she returned to Kuwait. The patient does not work
(unemployed).
She smokes shisha but says she has cut down recently. She does not consume alcohol.
The Patient states that she takes up walking 2 times a weekwhenever it is possible.
General Health
-
Well-being – tired, pain due to her forearm is making her anxious
Appetite – better
Sleep – interrupted due to pain in her arm
-
No significant weight changes
o Weight = 70 kg and height = 159cm. Her BMI = 27.68
Systemic Review
-
-
-
-
-
-
Cardiovascular – with history of presenting complaint (see above)
Respiratory– (see above)
Gastrointestinal tract – (see above)
Urinary Tract
o No changes in urine color
o No pain on urination
Reproductive system
o Last menstrual period – last week
o Period comes regularly (every month) with a normal flow and lasts for 4 days
Nervous system
o Last night, had headaches and dizziness
o Got prescription glasses last week
o Tingling in both legs
o No weakness
o No hearing problems
Musculoskeletal
o Painful and swollen right forearm after falling on it
o No joint pain (arthralgia)
o No sudden falls
Endocrine
o No heat or cold intolerance
o No excessive thirst
No bleeding or bruising
Circular area of skin loss (ulceration) on elbow near edge of where cast used to be on
her right forearm
Physical Exam
-
General appearance
o Patient is lying in her bed, conscious and alert but tired. She is in pain with her
right arm resting on a pillow.
o Patient has an I.V. in her left hand.
-
General exam
o Hands – warm, no palmar erythema, no clubbing, cannot establish cyanosis due
to nail polish
o Right forearm – swollen, tender, warm. Area of skin loss (ulcer) on the extensor
surface of elbow with a yellowish-white discoloration where the end of her cast
used to be.
o Eyes – no jaundice, conjunctiva are not pale
o Mouth – no cyanosis of membranes
o Over left arm injection site there was an area of lipodystrophy
-
Vital signs
o
o
o
o
o
-




-
Heart rate = 96 beats/min
Blood pressure = 120/75
Respiratory rate = 20 breaths/min
Temperature = 37oC
Blood sugar = 12.3mmol/L
Cardiovascular
o Radial pulse – regular rhythm, good volume but of a fast rate. Could not assess
symmetry due to pain and swelling of right forearm.
o Carotid pulse – normal. No bruit.
o Pulses –
Right
Left
Radial
could not assess due to swollen arm
++
Dorsalispedis
++
++
Posterior tibial
++
++
Popliteal
could not be felt
could not be felt
o Legs – no edema, no tenderness, no erythema
o JVP – normal
o Palpation: apex beat in 5th intercostal space in midclavicular line and there were
no palpable thrills or parasternal heave
o Auscultation: S1 and S2 heard clearly, no added sounds, no murmurs
Respiratory system
o On inspection, her chest was moving symmetrically and she did not use any
accessory muscles to breathe.
o On palpation, her trachea was central, she had normal chest expansion with
both sides moving symmetrically both on the anterior and posterior aspect of
the chest.
o On percussion, chest was resonant over both lung fields and tactile vocal
fremitus was resonant
o On auscultation – equal air entry on both sides, vesicular breath sounds. No
added sounds. Vocal resonance is normal on both sides.
-
Abdominal exam
o Abdomen is soft and non-tender over all 9 regions. There was no organomegaly
or swelling. There was no guarding.
o Auscultation – no bruits over renal arteries and liver. Bowel sounds are present.
-
Nervous system

o GCS = 15/15
o Patient oriented to place, person and time.
o No speech problems like dysarthria or dysphasia
o Cranial nerves – all intact bilaterally
Optic (II) &occulomotor (III) – pupils are equal, round & reactive, no visual field defects.
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Occulomotor (III), Trochlear (IV) and Abducens (VI) – extraocular movements normal, no
nystagmus
Trigeminal (V) – sensation equal on both sides over the distribution of the 3 branches V 1,
V2, and V3. She could open her jaw against resistance. Corneal reflex not tested.
Facial nerve (VII) – on inspection: no facial droop or asymmetry. Patient could wrinkle
her forehead, show her teeth, and resist eye opening.
Vestibulocochlear (VIII) – hearing is equal on both sides.
Glossopharyngeal (IX) and vagus (X) – gag reflex not tested. Uvula does not deviate.
Accessory (XI) – sternocleidomastoid bulk normal and can push against resistance,
trapezius muscle is of normal bulk and can push against resistance
Hypoglossal (XII) – tongue does not deviate when protruded, she can move it left and
right with no problems.
o Coordination – no dysdiadochokinesis, performed cerebellar tests (finger-nosefinger, rapid alternating movement) even though right forearm is swollen and
painful. Heel-to-shin test was normal.
o Power
Upper limb Right
Left
 Wrist
could not assess
5/5
 Elbow flexion/extension
could not assess
5/5
 Shoulder adduction/abduction
5/5
5/5
Lower limb
Right
Left
 Foot dorsiflexion/plantarflexion
5/5
5/5
 Knee extension/flexion
5/5
5/5
o Sensory
Light touch & pain – intact bilaterally across dermatomeson both upper and lower limbs
Vibration – intact bilaterally on both upper and lower limbs
Position sense – intact bilaterally on both upper and lower limbs
o Reflexes (right arm was swollen and painful, therefore not tested for reflexes)
Upper limb –
right
left
 Brachioradialis
arm swollen and painful
++
 Biceps
arm swollen and painful
++
 Triceps
++
++
Lower limb
 Ankle reflex
++
++
 Knee jerk
unable to elicit
unable to
elicit
Diabetic foot exam
o No sign of skin infection, ulcers, edema
o No deformities, for example, charcot’s foot or claw foot
o Skin temperature is normal and equal on both sides
Investigations: LAB RESULTS HAVE BEEN OMMITTED for the sake of this
handout– but should be mentioned in details
-
-
CBC
Arterial Blood Gas (ABG) (- = nonormal reference ranges on lab result)
Clinical chemistry
o RFT and CK, cardiac profile ( - = no normal value with lab report)
o Full profile – FPG, LFT, Lipid
o Thyroid profile
Urine
o Culture – No growth
o Testing (no normal values were available with the report)
-
ECG – sinus tachycardia (heart rate = 137 beats/min) with normal axis, no ischemic
changes
-
Venous Duplex of right arm veins report:
o Subclavian, axillary, brachial, radial, and ulnar veins – normal, no evidence of
venous thrombosis
o Diffuse interstitial edema of right forearm
-
X-rayfilm of right forearm – not informative.
-
Superficial ultrasound of right forearm: suggests abscess formation
o “there is massive subcutaneous edema seen at the ventral surface of the
forearm as it is severe enough to involve the underlying superficial fascia”
o “all the flexor muscles with their tendons at the region of forearm are seen
totally & markedly edematous & engorged with such severe inflammatory
process with significant thickening of the intervening fascial septa as well as
there are area few sockets of fluid collections seen in between such flexor
muscles which contain dynamically mobile thick internal echoes, mostly
consistent with an abscess infiltration. The most significant socket abscess is
seen at the level of pronator quadrates muscle.”
o “Such a picture is of severe inflammatory process with non-organized abscess
formation which needs MRI or CT scan” for further evaluation.
-
An MRI was ordered for her right forearm and the results are still pending
Follow-up on Wednesday 6th October 2010
-
Patient had a fasciotomy on her right forearmthe previous night(5/10/2010), right arm
is bandaged. She complain of oozing from the bandage. She also vomited after eating
solid food, so she was started on a liquid diet.
-
Vitals
o blood glucose level = 14 mmol/L
o Temperature = 37.2oC
THIS SHOULD BE FOLLOWED BY THE Working Diagnosis and
Management and the SUMMARY IN THE BOX
SAMPLE CLINICAL NOTE 4 – Medicine
Personal Details
Name:
Young male
Age:
17
Nationality:
Kuwaiti
Occupation:
Student
Status:
Single
Presenting Complaint
Pain in the left knee and lower back (1 day duration)
History of Presenting Complaint
The patient was last well on 03/10/2010. He presented to the medical casualty on
04/10/2010 complaining of severe, continuous pain in the left knee and lower back of 1 day
duration. The lower back pain woke him up from his sleep and was followed by the left knee
pain an hour later. The pain was localized to these two areas and did not radiate. The patient
could not describe the character of the pain, however, he rated it as an 8 on a scale from 1-10. It
was not relieved or aggravated by anything.
The pain was not associated with stiffness, swelling, warmth, bruising or rash. There was
no shortness of breath, palpitations, haematuria, fever, lethargy, nightsweats or weightloss,
however the patient did complain of anorexia coinciding with the onset of the pain.
The patient gave no history of recent drug ingestion or being ill recently.
Past Medical History
He has had repeated hospital admission for similar attacks, the last being a year ago.
During his admission last year he has received a blood transfusion of unknown amount. He has
had no surgeries in the past. The patient does not suffer from any other chronic conditions such
as bronchial asthma, diabetes, hypertension or dyslipidaemia.
Family History
Father:
HTN
Brother:
SCD
Drug History
Allergic to tramal
Folic acid
(unknown dose)
Panadrex
(paracetamol)
(as needed)
Social History
Residence:
Lives on the 2nd floor in a house with his family, has no problems walking up and
down the stairs
Travel:
None recently
Pets:
None
Alcohol:
Never
Tobacco:
Never
General Health
Appetite:
Decreased
Weight:
Hasn’t been measured recently and he hasn’t noticed any changes
Bowel movements:
Normal
Micturition:
Steady stream, normal colour, no nocturia or oliguria
Sleep:
Disturbed by pain
Systemic Review
Endocrine:
Unremarkable.
Neurological:
Unremarkable.
Renal:
Unremarkable
Respiratory:
Unremarkable
Cardiovascular:
Unremarkable
Gastrointestinal:
Positive for vomiting.
**Musculoskeletal and haematological systems were covered above.
Physical Examination
The patient was lying down in bed and was oriented in time, place and person. He
was on a nasal cannula and appeared comfortable.
Vital Signs
Temperature:
37.4oC
Blood pressure:
100/60mmHg
Respiratory rate:
16 breaths/minute
Pulse rate:
120beats/minute
Sa02:
98% (on 2 litres of oxygen)
General Examination
Hands:
No clubbing, peripheral cyanosis, nicotine stains, palmar erythema,
flapping tremor, koilonychia or leukonychia
Eyes:
Positive for jaundice, no pallor
Mouth:
No central cyanosis, good oral hygiene
Lower Limbs:
No oedema
Respiratory Examination
Inspection:
Symmetrical breathing, no scars on the chest, no chest deformities (e.g
pectus carinatum/excavatum or barrel chest),
Trachea:
Centrally located
Chest expansion:
Normal and equal on both sides
Vocal fremitus:
Resonant
Percussion:
Resonant
Auscultation:
Good quality normal vesicular breathing over both lung fields
Cardiovascular Examination
Inspection:
Normal, no scars
Palpation:
No heaves or bruits
Radial pulse:
Normal volume, regular, symmetrical, not collapsing
Apex beat:
Palpable in the 5th intercostal space within the midclavicular line
Peripheral pulses
Site
Right
Left
Dorsalis Pedis ++
++
Posterior tibial ++
++
Femoral
++
++
Brachial
++
++
Radial
++
++
Percussion:
Unremarkable
JVP:
Normal
Auscultation:
Normal S1 and S2 with no added sounds
Abdominal Examination
Inspection:
Distended abdomen, no scars
Palpation:
Mild tenderness on deep palpation in the right iliac fossa. Enlarged
Spleen (5 fingers)
Auscultation:
Normal Bowel sounds
Digital rectal exam:
Not performed
Lymph Node Examination
Unremarkable
Musculoskeletal Examination
Unremarkable.
Neurological Examination
Unremarkable
Investigations
Haematology (04/10/2010)
Test
Result
Normal value
RBC
4.37 x 1012.L-1
4 .5– 6.2 x 1012.L-1
Hb
10.9 g.dl-1
13.0 – 17.7 g.dl-1
Haematocrit
0.330 l/l
0.36-0.45 l/l
MCV
76 fl
76-96fl
MCH
25pg
27-32pg
RDW
21.7
Retics %
6.06
Retics #
0.2644
<5%
WBC Differential
Neutrophils %
67.1
60%
Lymphoctes %
25.6
30%
Monocytes %
1.6
5%
Eosinophils %
1.9
3%
Basophils %
0.4
1%
Clinical Biochemistry (04/10/2010)
Comment:
and AST.
Slightly high glucose, low BUN and creatinine, increased total and direct bilirubin
Chest X-ray (04/10/2010)
Unremarkable
Urine Analysis (05/10/2010)
Unremarkable
Bleeding Profile (05/10/2010)
Comment: Prolonged PT
Differential Diagnosis
Vasoocclusive crisis of SCD, septic arthritis
Diagnosis + Management Plan
The patient is suffering from a vasoocclusive crisis of sickle cell disease. Management includes
aggressive rehydration, analgesia, oxygen therapy and antibiotics. He has received IV fluids, is
on 2 litres of oxygen and he is taking intramuscular analgesics almost every 4 hours.
THIS SHOULD BE FOLLOWED BY THE Working Diagnosis and
Management and the SUMMARY IN THE BOX