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Comprehensive Case Write-ups

Name

Course

Institution

Instructor

Date
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Comprehensive Case Write-ups

Comprehensive case write-ups are important because they capture the history and

physical information. The write-ups are important because they are used as reference

documents offering detailed information regarding patients' exam findings and history at

admission. Additionally, write-ups are important because they represent an outlined plan

addressing all the issues leading to patient hospitalization. The medical team addressing the

healthcare situation of the patient in question are guided by the medical history on what has

to be done next. Similarly, the patient can be referred to other professionals for

comprehensive and specialized care where the medical history becomes important in

informing them on what exactly has to be done.

The information captured in the write-up is presented logically, ensuring all data

related to the patient's condition is captured. Thus, write-ups are used to communicate patient

data to all providers who are working in offering patient care. It is important to note that

write-ups give the interns and students a chance to display their knowledge in accumulating

examination-based and historical information. However, the write-ups should not be viewed

as instruments of torturing interns and medical students. Any unrelated or unnecessary

information should not be captured.

So much time should not be used during writing down the information and

submission to ensure the information is not obsolete (Koonce et al., 2021). The medical

teams are usually determined to operate in ways in which they have to get the full

information concerning the patient to understand how they can intervene moving forward.

The article focuses on a comprehensive case write-up covering the chief complaint, pertinent

history, system review, physical examination, diagnosis, and interventions.

Chief Complaint
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The patient is an 84-year-old woman admitted to the facility previously with a

prolonged history of hypertension; the chief complaint presented involves substernal chest

pains that have lasted for 14 hours. She describes the pain as toothache-like. 

Pertinent History

Ms. Sophia is an 84-year-old woman and a retiree from the nursing profession. She

has a prolonged medical history of hypertension successfully controlled using diuretic

therapy. Her first admission to the facility was in 1997 when she presented chest pain

complaints characterized by occasional midsternal. An electrocardiogram was taken,

displaying a first-degree heart ventricular blockage. 

A chest x-ray was also done, showing mild pulmonary conditions. There were no

cardiac enzyme and electrocardiographic abnormalities, consequently ruling out any chances

of myocardial infarction. Ms. Sophia was put under a digoxin, enalapril, and Lasix regime.

After a short moment, she responded well and was discharged. 

The main medical history captured is about postmenopausal states and hypertension.

However, she denied any risk factors connected to other coronary artery diseases. The factors

include heart disease, history within the family, diabetes, hypercholesterolemia, or cigarette

smoking. The patient also reported that she has been experiencing dyspnea due to exertion,

especially when she walks a distance of 2 blocks. She has two stable pillow orthopnea and

mild chronic edema around her ankle and reported that it became more severe with prolonged

standing. However, Ms. Sophia denied any recent chest pains, syncope, or paroxysmal

nocturnal dyspnea.

Ms. Sophia has been faring well until 9 p.m. on the previous night before admission.

She started experiencing aching pain near her breastbone area as she was seated on her couch

watching television. The patient describes this pain as "intense" and "toothache-like." The
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pain neither radiated nor increased with exertion. The patient denies any palpitations, nausea,

loss of consciousness, dizziness, diaphoresis, or vomiting. 

Ms. Sophia takes a full tablespoon of antacid, but the pain does not subside. However,

she eventually managed to fall asleep. She did not feel any pain when she woke up the

following morning. Nevertheless, she stood and walked towards the bathroom; similar pain

that she had been experiencing the previous night returned with a lot of severity.

When the pain became so much, she called her 25-year-old granddaughter, who

immediately gave her aspirin and rushed her to the hospital, bringing her into the emergency

room. An electrocardiogram was conducted, and the results showed the patient had sinus

tachycardia. The score was 110 with considerable elevations in V-4 to V-6, AVIL, and

regular ventricular paroxysmal contractions. The patient was immediately given thrombolytic

therapy alongside cardiac medicines and a consequent transfer into the intensive care unit.

Current Prescription Drugs

Enalapril 20mg daily in the morning and evening

Kcl 20 mg to be taken once per day

Digoxin 0.125 mg taken once per day.

Tylenol tablets, two tablets in the morning and evening

Lasix 40 mg taken once per day

Past Health State

General description: relatively good health state.

Infectious illnesses: no infectious disease such as rheumatic fever history and only the normal

childhood illnesses were reported.

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Immunizations: annual flu vaccine and pneumovax in 1998.

Blood transfusion: 3 units were transfused in 1980 due to GI hemorrhage, and the transfusion

process was complex due to hepatitis B infection.

i. Injuries, hospital admissions, and operations.

ii. Gastrointestinal hemorrhage in 1980

iii. Severe chest pains in 1997 connected to the present condition.

iv. Mammogram in 1996

v. Flexible sigmoidoscopy in 1999.

Review of the System

1. Constitutional: generally good energy levels with a stable weight of 158 lbs, and a

height of 5 ft 7 inches.

2. HEENT analysis

 No headaches reported

 Eyes: no pain in the eyes or diplopia; however, she wears reading glasses and reports

that her vision is worsening.

 Ears: she is wearing hearing aid since she lost her earring many years back.

 Nose: No obstructions or epistaxis.

 No reported tonsillectomy or tonsillitis history.

 Loss of teeth due to aging and is currently wearing full set dentures

3. Respiratory system

The patient has no history of wheezing, hemoptysis, pleurisy, pulmonary emboli, asthma,

coughing, tuberculosis exposure, tuberculosis, or pneumonia.

4. Cardiac
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Kindly find the information in the history of present illness.

5. Vascular

The patient has an existing chronic venous skin stasis. However, there is no history of

gangrene, aneurysm, claudication, or deep vein thrombosis.

6. Gastrointestinal; Gingival Index (G.I.)

Admission into the facility in 1982 after 48 hours of hematemesis and melena. The

endoscopy results showed that there is evidence of a series of negative upper G.I. The gas

prices is presumably due to ibuprofen intake. Administration of 4 units packed cells due to

hematocrit which was 24% during hospitalization.

Multiple diverticuli as reviewed by colonoscopy. Since admission, her stool's hema test is

negative and the stool appears brown during the clinic checkup. Ms. Sophia was discovered

to have elevated liver enzymes and mild jaundice several months following her

hospitalization. Further investigations revealed that the patient had contracted hepatitis B

during blood transfusions. Nevertheless, there was not any signs of chronic hepatitis.

7. Genitourinary (G.U). Reported dysuria 3 days before admission. History of numerous

cystitis episodes with a recent E Coli 3/1/90, whose regime included Bactrim. The patient has

no sexually transmitted disease history, hematuria, or fever. Regular intervals and durations

of menstrual cycles with menopause onset at 54 years. She has had 6 pregnancies with 2

miscarriages and 4 normal births.

8. Neuromuscular: Osteoarthritis on the two hips, shoulder, and knees for over two decades.

The patient managed these conditions using Ibuprofen until 1982 and has been taking

acetaminophen since GI bleeding with relatively good intermittent arthritis pain relief. Ms.

Sophia does not have any history of syncope, seizures, memory changes, or stroke.
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9. Emotional: The patient denies any history of anxiety or depression.

10. Hematological: No history of clotting or blood disorders.

11. Rheumatic: No history of lupus, rheumatic arthritis, or gout.

12. Endocrine: No history of thyroid or diabetes diseases.

13. Dermatological: No pruitis or newly appearing rashes.

Personal history

a. Ms. Sophia has been a single mother who is currently living with her

granddaughter.

b. Career: she was working in the nursing field tilled until her retirement at the

age of 65 years.

c. Lifestyle: does not take alcohol or smoke cigarettes. Similarly, she is not on

any special diet.

d. She was brought up in South Carolina until 1933 when she moved to New

York. She has not lived or worked outside the US.

e. Present residence: she resides in a one-bedroom apartment on the second floor

with an elevator. Her house chores are done by home help who comes daily

for 3 hours.

f. She does not have any financial constraints because she gets Medicare and

Social security besides the support given by her children.

g. Psychosocial: she is active and generally alert regardless of the arthritis

symptoms. She understands the present time because she knows she has a

heart attack and is extremely anxious about it.

Family History
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She grew as an orphan who was adopted by a relative. Ms. Sophia's mother died at 36 due to

kidney failure while her father got an accident at 41 years. She separated with her husband

who later died due to pneumonia and seizures. She did not have any sister but had one brother

who died at birth. She has two sons and two daughters aged 58, 63, 54, and 46. All of them

are in good health. Ms. Sophia has 14 grandchildren, seven great-grandchildren, and five

great-great-grandchildren. There is no medical family history of cancer, diabetes, or

hypertension.

Physical examination

1. Vital symptoms: Pulse rate of 96 with regular extra beat, a blood pressure of 180/100,

respiratory rate of 24, and the body temperature of 38.2.

2. General observations: elderly, slightly obese, and well-developed black woman who is

seated on the bed with slight breathing difficulties and chest pain complaints which are

resolving.

3. HEENT:

Ears- tympanic landmark membranes are visible, and the patient has very poor bilateral

hearing.

Mouth: No exudates, no injection at Pharynx, and the patient has complete lower and upper

set of dense dentures. She displays normal gag reflex and uvula moves to the midline.

Eyes: Full extraocular motions with clear conjunctiva and gross visual confrontations. No

proper fundi visualization possibly due to cataracts. Reactive and round equal pupils which

are sensitive to light.

Nose: No septum deviation, no obstruction, and no discharge.

4. Neck: No palpable thyroid, no muscles, and there is 8 cm jugular venous pressure.

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5. Nodes: There is no adenopathy.

6. Chest: The patient's breast do not have any discharge masses, but are symmetric, atrophic,

and non-tender. Respiration facilitates diagram movement and there is no percussive

dullness, rubs, wheezes, or rhonchi.

7. Spine: No cost of vertebral tenderness and there is mild kyphosis. The spine is also non-

tender and mobile.

8. Extremities: Smooth and warm skin with an exemption of chronic venous stasis in the two

legs. Non-pitting, very tender to palpation and edema on the knees. No cyanosis or clubbing.

9. Pelvic: Examinations were deferred until the patient stabilizes.

10. Heart: No thrills or heaves, Normal narrow split on S1 and S 2, and regular extra beats.

S4 has positive gallop, and PMI is at the 6th ICS. The left side of sternal border has a grade

ii/vi systolic ejection murmur which can be hard without radiation. The purses are

considerable for sharp carotid upstrokes (Deng et al., 2019).

11. Rectal: Prominent external hemorrhoids. The stool is brown and test negative for blood,

and they are no masses.

12. Abdomen: No bruits, flat, soft, and with bowel sounds. Spleen, liver, and kidney are not

felt. However, no masses and no tenderness for palpation. The liver span is by percussion 10

cm.

13. Neurobiological: Fully oriented alert and awake. Intact cranial nerves iii to xii exempting

the reduced hearing.

Sensory: Grossly normal to pin, prick ,and touch.

Reflexes: No Babinski symptoms, and they are symmetrical throughout.

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Motor: She can move to all extremities, but strength was not tested.

Cerebellar: No dysmetria or tremor.

Formulation

The 84-year-old female patient presents congestive heart failure history, and the risk factors

for coronary artery disease, postmenopausal state, and hypertension. She complains of

substandard chest pains and upon examination, it was discovered that she has sinus

tachycardia, without JVD (Henning & Krawiec, 2021). However, there are pedal edema, and

bibasilar rales. Results suggests possibility of congestive heart failure to some extent

(Wolters et al., 2018). EKG changes also present indicating acute anterolateral myocardial

infarction. The laboratory results show elevated troponin and CPK (Henning & Krawiec,

2021)..

Diagnosis

1. Hypertension

2. Acute anterolateral myocardial infarction with ventricular dysfunction on the mild left,

complicating the issue.

3. Dysuria due to presence of Pyuria and 3 + bacteria.

Treatment Plan and interventions

1. Continue heparin, beta blockers, aspirin, nitrates, and nasal oxygen. Following physical

examinations laboratory results and EKGs.

2. Continue blood pressure monitoring and ACE inhibitor therapy.

3. Obtaining echocardiogram for further assessment of the murmurs heard from cardiac

examination and previous my heart functioning.

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4. Pyuria and Dysuria - There is probability of recurring cystitis, because the patient is

afebrile without any costovertebral tenderness. The patient will begin Bactrim treatment due

to presumed urinary tract infection and later do a urine culture test.

Conclusion summary

The write-up starts with a chief concern, a statement covering the main reasons for

patients' admission. It has a confrontation of sounding and is less pejorative. History of

present illness is also important because it provides sufficient information that helps health

providers to understand the events and symptoms resulting from admissions.

The section covers all details that led to the patients coming into the emergency

department, including the events that took place upon arrival at the facility. Some of the

crucial issues covered under this section include onset, characteristics, location, alleviating

factors, duration, significance, treatment, and related symptoms. The health status of a patient

baseline is also described in this section, ensuring that impairment resulting from the current

issue is apparent.

The past medical history is also crucial because it covers all present and past illnesses

that the patient has had with objective data support. The details that appear in the history of

the present illness are stated in this section. A sentence showing where they add is used to

direct anyone going through the write-up to go back to that section. There is no need for

detailed descriptions and in-depth reporting. For example, one does not have to list all the

medicines used and the duration. Instead, one can use the abbreviations of the condition. It is

important to have data supporting every diagnosis.

It is equally important to note down all the surgical operations with the rough date of

when they were done, including every major trauma. Similarly, a write-up should contain all

medications the patient is currently using, including traditional therapies and over-the-counter
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medications. This covers frequency, dosage, and adherence to the prescription. After noting

down the medication, it is important to specify any allergic reaction that followed every

medicine. The other part is a family history that focuses on illnesses occurring in patients'

immediate families. Significant diseases include cancer, heritable diseases, or vascular

diseases amidst the first-degree relatives.

Social history is also covered in a write-up because it is a key determinant of a

patient's health status. If the patient takes any alcohol, it is important to specify the duration,

quantity, type, and frequency. Cigarette smoking should also be noted, determining the

packets smoked daily and the duration for which the patient has been smoking. If the patients

have quit smoking, it is important to note when they quit. Any other drug used should be

specified alongside its duration and frequency. Marriage and relationships should be

captured, and any form of intimate partner violence noted.

Additionally, sexual history such as sexually transmitted infections and other

activities should be noted. Work is also important because it shows the type of work the

patient has been doing, their duration, and the environmental exposures. It is important to

capture military history, especially for those working in VA hospitals. Obstetrical history is

also crucial because it covers several live births, pregnancies, and complications.

A review of systems is an area that cannot be overlooked because it helps to answer

questions that are crucial to the negatives and positives linked to the chief complaints.

Responses to extensive reviews analyzing systems are written under the ROS section.

However, there are always questions that help discover the cause of chief complaints.

Lastly, physical examination is very important because although it begins with a

single sentence, it describes patients' appearance and covers vital signs. They include lymph

nodes, cardiovascular, HEET, abdomen, lungs, and rectal. The neurologic section covers
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cranial nerves, reflexes, mental state, observed ambulation, sensory, and coordination. The

medical team dealing with the patient's case will be determined to operate in a way that is

based on the information given to ensure that the medication is facilitated in the best ways

forward for the sake of recovery.

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References

Deng, L., Zhang, Y., Chen, Z., Zhao, Z., Zhang, K., & Wu, J. (2019). Regional upstroke

tracking for transit time detection to improve the ultrasound-based local PWV

estimation in carotid arteries. IEEE Transactions on Ultrasonics, Ferroelectrics, and

Frequency Control, 67(4), 691-702. https//doi.org/ 10.1109/TUFFC.2019.2951922

Henning, A., & Krawiec, C. (2021). Sinus tachycardia. In StatPearls [Internet]. StatPearls

Publishing.

Koonce, T., Moore, Z., & Dallaghan, G. B. (2021). Medical Students Learning to Take a

Complete Military History. Family Medicine, 53(9), 800-802. https//doi.org/

10.22454/FamMed.2021.201979

Wolters, F. J., Segufa, R. A., Darweesh, S. K., Bos, D., Ikram, M. A., Sabayan, B. &

Sedaghat, S. (2018). Coronary heart disease, heart failure, and the risk of dementia: a

systematic review and meta-analysis. Alzheimer's & Dementia, 14(11), 1493-1504.

https://doi.org/10.1016/j.jalz.2018.01.007