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My patient Mrs norsiha binti ahmad 50 year old woman was admitted 2 days ago due to chest pain that occured on the day of admission. It was tightening in nature, didn't radiate anywhere, associated with excessive sweating at nights, exacerbated on exertion severity was on 6 out of 10 otherwise not associated with shortness of breath, cough, vomiting, fever, headache or seizure. However, she has had previous hospitalisation due to Generalised abdominal pain few years ago, that was associated with fever and vomiting, and was referred for cholecystectomy but the operation got cancelled as she was diagnosed with influenza that time, otherwise no history of Jaundice was mentioned. Patient has no diabetes mellitus or hypertension or asthma. Past surgical history, is her cholecystectomy done a day ago. Family history, there are no malignancy cases, patient's parents had hypertension. Personal or social history, she doesn't smoke nor drink but she's a passive smoker, she's married with 3 kids, is housewife

Reading Document
Thanks. I can help you turn this into a clean clerking summary / case presentation.

Case Summary (formatted)

Patient: Mrs Norsiha binti Ahmad, 50-year-old woman
Date of admission: 2 days ago
Presenting complaint: Chest pain on day of admission

History of Presenting Illness

  • Chest pain started on day of admission
  • Character: tightening
  • Radiation: none
  • Severity: 6/10
  • Aggravating factor: exertion
  • Associated symptom: excessive night sweating
  • No associated shortness of breath, cough, vomiting, fever, headache, or seizure

Relevant Past Medical/Surgical History

  • No known diabetes mellitus, hypertension, or asthma
  • Previous hospitalization (few years ago) for generalized abdominal pain with fever and vomiting
  • Was referred for cholecystectomy at that time, but surgery was cancelled due to influenza
  • No history of jaundice mentioned
  • Cholecystectomy performed yesterday

Family History

  • No family history of malignancy
  • Both parents had hypertension

Social History

  • Non-smoker
  • Non-alcohol user
  • Passive smoker exposure
  • Married, housewife, 3 children

Clinical Impression (from history only)

This chest pain has possible cardiac features (tightening, exertional worsening, diaphoresis), so acute coronary syndrome should be excluded urgently if not already done.

Suggested immediate inpatient workup (if pending)

  1. Serial ECGs
  2. Serial high-sensitivity troponins
  3. Vitals and continuous cardiac monitoring
  4. Basic labs: FBC, renal profile, electrolytes, glucose, lipid profile
  5. Chest X-ray
  6. Risk stratification (eg, HEART/TIMI as locally used)
If you want, I can next convert this into:
  • a full SOAP note, or
  • a formal long case presentation, or
  • an assessment + differential diagnosis + management plan for ward round documentation.

Should I add any negative symptoms for her history of presenting illness

Yes. For chest pain, adding key negatives strengthens the HOPI and helps rule out dangerous differentials.
Use these targeted negatives:
  • No radiation to arm, jaw, back, or epigastrium
  • No pleuritic component (not worse with deep breathing/cough)
  • No positional component (not relieved by leaning forward, not worse lying flat)
  • No reproducible chest wall tenderness
  • No palpitations or syncope/presyncope
  • No dyspnea, orthopnea, or PND
  • No cough, sputum, hemoptysis, or fever
  • No nausea/vomiting (if truly absent during this episode)
  • No leg swelling/calf pain, recent immobilization/long travel (PE risk)
  • No tearing pain radiating to back (aortic dissection feature)
You can document it like this:
“Chest pain was non-radiating, non-pleuritic, non-positional, and not reproducible on palpation. There was no palpitations, syncope, dyspnea, orthopnea, PND, cough, hemoptysis, fever, leg swelling, or calf pain.”
If you want, I can rewrite your full HOPI in one polished paragraph ready for case write-up.
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