• Concise (ED/ward clerking): Vomiting — 10 episodes, onset 1 day prior to admission (1 day PTA).
• Full sentence (history write-up): The patient presented with a chief complaint of vomiting, occurring approximately 10 times, with onset one day prior to admission.
• SOAP/structured note style: CC: Vomiting (×10 episodes) — 1 day PTA.

• Use "PTA" (prior to admission) as a standard abbreviation.
• State the symptom, frequency/severity, and duration — exactly what you have here.
• Keep it brief — the detail goes in the History of Present Illness (HPI), not the CC.

History of Present Illness (HPI) — Vomiting

Written Narrative Form (for clerking note):

The patient presented with a 10-day history of vomiting, occurring approximately 5 episodes per day. The vomitus was clear in colour and contained undigested food, with the patient reporting that she vomits out everything she consumes. Onset was 10 days prior to admission. There are no relieving factors. Associated symptoms include headache and abdominal pain. Vomiting is exacerbated by any oral intake. The patient rates the severity of her discomfort at 7/10.

Past Medical History (PMH)

Written Narrative Form:

The patient is a known case of Diabetes Mellitus (DM) for the past 4 years. She also has a history of breast cancer (BRCA), diagnosed in 2020.

Combined HPI + PMH (Full Clerking So Far):

The patient presented with a 10-day history of vomiting, occurring approximately 5 episodes per day. The vomitus was clear in colour and contained undigested food, with the patient reporting that she vomits out everything she consumes. There are no relieving factors. Associated symptoms include headache and abdominal pain. Vomiting is exacerbated by any oral intake. The patient rates the severity at 7/10.

She is a known case of Diabetes Mellitus for 4 years and was diagnosed with breast cancer in 2020.

• Surgical history — Did she have mastectomy, lumpectomy for BRCA?
• Current medications — Is she on insulin/OHAs for DM? On chemotherapy or hormonal therapy for BRCA?
• Family history, Social history, Systemic review

Past Medical History (PMH)

Past Surgical History (PSH)

Written Narrative Form:

The patient is a known case of Diabetes Mellitus (DM) for the past 4 years. She was diagnosed with breast cancer (BRCA) in 2020 and subsequently underwent a mastectomy the same year.

Full Clerking So Far:

Chief Complaint: Vomiting ×5 episodes/day, 10 days prior to admission.

HPI: The patient presented with a 10-day history of vomiting, occurring approximately 5 episodes per day. The vomitus was clear in colour and contained undigested food, with the patient reporting that she vomits out everything she consumes. There are no relieving factors. Associated symptoms include headache and abdominal pain. Vomiting is exacerbated by any oral intake. The patient rates the severity at 7/10.

PMH: Known case of Diabetes Mellitus for 4 years. Diagnosed with breast cancer in 2020.

PSH: Underwent mastectomy in 2020 for breast cancer.

Current Treatment / Medication History

Written Narrative Form:

The patient is currently undergoing chemotherapy, administered once every 6 months. She is also on cancer-related medications (specific drugs not documented at this time).

⚠️ Clinical Note: The patient's vomiting is highly likely to be chemotherapy-induced nausea and vomiting (CINV), which is a well-known side effect of chemotherapy. This should be considered in the differential diagnosis.

Full Clerking So Far:

Chief Complaint: Vomiting ×5 episodes/day, 10 days prior to admission.

HPI: The patient presented with a 10-day history of vomiting, occurring approximately 5 episodes per day. The vomitus was clear in colour and contained undigested food particles, with the patient reporting that she vomits out everything she consumes. There are no relieving factors. Associated symptoms include headache and abdominal pain. Vomiting is exacerbated by any oral intake. The patient rates the severity at 7/10.

PMH: Known case of Diabetes Mellitus for 4 years. Diagnosed with breast cancer (BRCA) in 2020.

PSH: Underwent mastectomy in 2020 for breast cancer.

Current Treatment: Currently undergoing chemotherapy (once every 6 months) and is on cancer-related medications.

• Name of chemotherapy regimen (e.g., AC, CMF, Taxane-based)
• Any anti-emetics prescribed alongside chemo?
• DM medications — insulin or oral hypoglycaemics?

Systemic Review — Likely Positives

🔴 Gastrointestinal

🔴 Neurological

🔴 General/Constitutional

🔴 Endocrine

🔴 Cardiovascular

🔴 Respiratory

🔴 Musculoskeletal

⚠️ Key Red Flags to Specifically Ask About:

1. Headache + vomiting → Rule out brain metastases (BRCA can spread to CNS)
2. Bone pain → Rule out bone metastases
3. Fever + mouth ulcers → Rule out neutropenic sepsis (chemotherapy)
4. Hypoglycaemia symptoms → Patient on DM meds but not eating due to vomiting — high risk

Physical Examination — Expected Findings

📋 General Inspection

🩺 Vital Signs

👁️ HEENT

🫀 Cardiovascular

🫁 Respiratory

🏥 Abdomen

🧠 Neurological

🦴 Musculoskeletal

🩹 Skin

⚠️ Most Critical Findings to Look For:

1. Signs of dehydration — top priority given 10 days of vomiting
2. Neurological signs — headache + vomiting → rule out brain mets
3. Fever + pallor → neutropenic sepsis
4. Hepatomegaly / lymphadenopathy → metastatic disease

Past Surgical History (PSH)

Written Narrative Form:

The patient underwent a left mastectomy in 2020 due to left breast cancer (BRCA). She also had a hysterectomy in 2013 for uterine fibroids.

Updated Full Clerking:

Chief Complaint: Vomiting ×5 episodes/day, 10 days prior to admission.

HPI: The patient presented with a 10-day history of vomiting, occurring approximately 5 episodes per day. The vomitus was clear in colour and contained undigested food particles, with the patient reporting that she vomits out everything she consumes. There are no relieving factors. Associated symptoms include headache and abdominal pain. Vomiting is exacerbated by any oral intake. The patient rates severity at 7/10.

PMH: Known case of Diabetes Mellitus for 4 years. Diagnosed with left breast cancer (BRCA) in 2020.

PSH:

• Left mastectomy (2020) — left breast cancer
• Hysterectomy (2013) — uterine fibroids

Current Treatment: Currently undergoing chemotherapy (once every 6 months) and is on cancer-related medications.

📝 Physical Exam Update:

On inspection of the chest — left mastectomy scar expected on the left chest wall. Abdomen — hysterectomy scar (midline or Pfannenstiel) expected on the lower abdomen.

Medication History

Written Narrative Form:

The patient is currently on medications for Diabetes Mellitus (OHA and/or insulin), chemotherapy (administered once every 6 months), and cancer-related medications (likely hormonal or targeted therapy for breast cancer). Specific drug names were not documented at this time.

⚠️ Clinical Relevance of Her Medications:

📋 Questions to Clarify:

• Is she on insulin or tablets for DM?
• Was she prescribed anti-emetics alongside chemotherapy?
• Any new medications started recently?

Full Clerking So Far:

CC: Vomiting ×5 episodes/day, 10 days PTA.

HPI: 10-day history of vomiting, 5 episodes/day. Vomitus clear, containing undigested food. No relieving factors. Associated headache and abdominal pain. Exacerbated by oral intake. Severity 7/10.

PMH: DM (4 years), Left breast cancer (2020).

PSH: Left mastectomy (2020) — BRCA; Hysterectomy (2013) — fibroids.

Medications: DM medications, chemotherapy (once every 6 months), cancer-related medications. Specific drugs not documented.

Hysterectomy & Menstruation

✅ Will NOT get periods if:

Since her hysterectomy was for fibroids, it was most likely a total hysterectomy — so no periods after 2013. ✅

⚠️ Important Distinction — Ovaries:

📋 Relevance to This Patient's Clerking:

Under Gynaecological/Obstetric History (GynObs):

"Patient underwent hysterectomy in 2013 for uterine fibroids. She has had no menstrual periods since 2013. Menopausal status to be clarified based on whether oophorectomy was performed concurrently."

Also Note:

Since she is on breast cancer treatment (likely Tamoxifen or an aromatase inhibitor), these drugs also suppress oestrogen — further confirming she would have no menstrual activity regardless.

GENERAL EXAMINATION

Vital Signs

General Inspection

Hydration Status

SPECIFIC EXAMINATION

1. 🏥 Abdominal Examination

• Abdomen flat/scaphoid
• Pfannenstiel or midline scar noted at lower abdomen — consistent with hysterectomy (2013)
• No visible distension
• No visible peristalsis

• Epigastric tenderness on light palpation
• Generalised mild tenderness
• No guarding, no rigidity
• No palpable mass
• Hepatomegaly — may be present if liver metastases

• Tympanic throughout
• No shifting dullness (no ascites)

• Reduced bowel sounds — ileus from electrolyte imbalance
• No succussion splash

2. 🫁 Respiratory Examination

• Left mastectomy scar visible on left chest wall
• Chest moves symmetrically

• Trachea central
• Reduced expansion on left (if pleural effusion)

• Dull on left base — pleural effusion (BRCA metastases)

• Reduced air entry at left base
• No added sounds on right

3. 🧠 Neurological Examination

4. 🦴 Musculoskeletal / Lymph Node Examination

5. 💉 Cardiovascular Examination

⚠️ Most Important Findings to Highlight:

1. Dehydration signs — dry mucosa, reduced skin turgor, tachycardia, low BP
2. Left mastectomy scar + hysterectomy scar — confirms surgical history
3. Alopecia — confirms chemotherapy
4. Neurological signs — rule out brain metastases (headache + vomiting)
5. Epigastric tenderness — GI involvement

Specific Examination — Breast Examination

This is documented under Specific/Local Examination because it is directly relevant to her known diagnosis of breast cancer.

🔵 Breast Examination (Right Breast)

• Right breast — no visible skin changes
• No peau d'orange (skin dimpling)
• No nipple retraction/discharge
• Left breast absent — consistent with left mastectomy scar

• Palpable mass at right upper outer quadrant (UOQ)
• Size: 2 cm × 2 cm
• Shape: Round/irregular (to be described)
• Surface: Smooth or irregular (to be described)
• Consistency: Hard/firm (suspicious for malignancy)
• Margins: Well/poorly defined (to be described)
• Mobility: Fixed or mobile (fixed = sinister)
• Tenderness: Tender or non-tender
• Skin involvement: Present or absent
• Nipple involvement: Present or absent

• Right axillary lymph nodes — palpable/enlarged (suspicious for metastatic spread)
• Right supraclavicular lymph nodes — palpable/enlarged
• Right infraclavicular lymph nodes — check

⚠️ Clinical Significance:

📋 Where This Fits in the Clerking:

EXAMINATION
│
├── General Examination
│     ├── Vital signs
│     ├── General inspection (pallor, cachexia, alopecia)
│     └── Hydration status
│
└── Specific/Local Examination
      ├── Abdominal Examination
      ├── Respiratory Examination
      ├── Breast Examination  ← RIGHT HERE
      │     └── 2×2 cm mass, right UOQ
      ├── Neurological Examination
      └── Lymph Node Examination

📝 Written Form:

On specific breast examination, the left breast was absent with a well-healed mastectomy scar noted. On palpation of the right breast, a 2 × 2 cm mass was palpable at the upper outer quadrant, with firm consistency and [mobile/fixed] margins. No nipple discharge or skin changes were noted. Right axillary lymph nodes were palpable, raising concern for contralateral breast malignancy or metastatic spread.

Specific Examination — Right Breast

Inspection:

• Left breast absent — well-healed left mastectomy scar noted
• Right breast — no skin changes, no peau d'orange, no erythema
• No nipple retraction or discharge
• No visible mass or asymmetry

Palpation — Right Breast Mass:

Lymph Node Examination:

📝 Written Narrative Form:

On inspection, the left breast was absent with a well-healed mastectomy scar. The right breast showed no skin changes, peau d'orange, nipple retraction or discharge. On palpation, a 2 × 2 cm, round, smooth, firm, well-defined and mobile mass was noted at the right upper outer quadrant. The mass was non-tender with no skin or nipple involvement. Right axillary and right supraclavicular lymph nodes were palpable, raising concern for regional lymph node involvement.

⚠️ Clinical Interpretation:

🔴 TNM Staging Clue (Right Breast):

Palpable supraclavicular lymph node = N3 = Stage IIIC minimum — this is a red flag requiring urgent investigation.

CASE SUMMARY

A middle-aged woman with a known history of Diabetes Mellitus (4 years) and left breast cancer (BRCA, 2020) — for which she underwent left mastectomy (2020) and is currently on chemotherapy (once every 6 months) and cancer medications — presented with a 10-day history of vomiting, 5 episodes/day. Vomitus was clear, containing undigested food. Associated symptoms include headache and abdominal pain, severity 7/10, exacerbated by oral intake. She also has a past surgical history of hysterectomy (2013) for uterine fibroids.

On examination, she appeared ill, cachexic, pale and dehydrated, with alopecia. Vital signs revealed tachycardia and hypotension consistent with dehydration. Breast examination revealed a 2×2 cm, round, smooth, firm, well-defined, mobile, non-tender mass at the right upper outer quadrant (UOQ) with no skin or nipple involvement. Right axillary and right supraclavicular lymph nodes were palpable.

PROVISIONAL DIAGNOSIS

1. Chemotherapy-Induced Nausea and Vomiting (CINV) — Most likely cause of vomiting given active chemotherapy use

2. Right breast malignancy — suspected contralateral breast cancer (new primary or metastatic) — 2×2 cm firm right UOQ mass + palpable right axillary and supraclavicular lymph nodes = highly suspicious

DIFFERENTIAL DIAGNOSES (DDx)

For Vomiting:

For Right Breast Mass:

INVESTIGATIONS (Ix) & EXPECTED RESULTS

🩸 Bloods

🩻 Imaging

🔬 Histopathology

DEFINITIVE DIAGNOSIS

1. Contralateral (Right) Breast Cancer — new primary invasive breast carcinoma, right upper outer quadrant, with right axillary (N1) and supraclavicular (N3) lymph node involvement → Minimum Stage IIIC

2. Chemotherapy-Induced Nausea and Vomiting (CINV) — secondary to ongoing chemotherapy for left breast cancer

3. Dehydration — secondary to prolonged vomiting (10 days)

4. Diabetes Mellitus — pre-existing, likely poorly controlled given reduced oral intake

OUTLINE OF TREATMENT

🚨 Immediate (Acute Management):

🏥 Definitive (Cancer Management):

📋 Monitoring:

Key take-home: This patient has two concurrent major issues — acute CINV with dehydration requiring immediate supportive care, and a highly suspicious right breast mass with lymph node involvement requiring urgent oncological workup. The palpable supraclavicular lymph node is a particularly sinister sign indicating at minimum Stage IIIC disease.