soo..this were the things i managed to recall (either correctly or wrongly!) - i just made up the scenario here, so that it'll be easier for me to imagine and recall. and please excuse the medical jargons and the way i write the report (im writing it exactly like how a Msian houseman doctor would- oh btw i translated them into layman terms for you readers to understand :).
clerking a case in SURGERY: 56 yo man with abdominal swelling
56/Malay/Man ( patient's demographics : must put these first)
-has a background history of :
1). intravenous drug abuser for the past 20 years (claimed last injected heroine 1 year ago)
2). a chronic alcoholic
3). Hepatitis B,C & Retroviral disease status is unknown
admitted to the A&E with PC of abdominal swelling x 5/7 (translation: presenting complaint of abdominal swelling for 5 days)
further on HPC (history of presenting complaint):
-abdominal swelling started 5 days ago, gradual onset
-claims no abdominal pain/discomfort
-able to BO (bowel open i.e pass motion) and PU (per urine i.e pass urine) normally. no constipation, able to pass flatus(wind)
-claims that the abdominal swelling was accompanied by yellowish discoloration of the eyes (= jaundice) x 3/52 (translation: 3 weeks)
-also claimed of passing black tarry stool since 5 days prior, but no vomiting out blood
-also claimed of having low grade fever x 3/7 (translation: 3 days)
- collateral history shows evidence of altered behaviour and consciousness for the past 3 days, patient was mostly drowsy and 'talking rubbish'
-patient admitted of previous episode of vomiting blood and passing malaenic stools in 2009 - he was hospitalised and told of having oesophageal varices via OGDS --> variceal banding was consequently done. no further episodes of hematemesis or melena afterwards.
(translation: malaenic stools: black tarry stool due to bleeding in the alimentary tract; oespohageal varices: engorged & tortuos blood vessels; OGDS: oesophago gastro duodenoscopy i.e passing a tube in from the mouth down to the stomach and some part of the gut)
-denied of easy bruising, vomiting or other stigmata of chronic liver disease
-since last hospitalisation in 2009, he claimed of being given Propanolol 60mg bd but is non compliant to the medication
Past medical history: diagnosed with diabetes 5 years ago, on Metformin 500mg bd
Past surgical history: oesophageal varices banding and ligation done in 2009
Drug and allergies: Metformin 500 mg bd, no known drug allergies.
Family history: parents alive n well, 4 siblings with no known medical illness, no significant family history of liver diseases or other illnesses
Social history: a pensioner who is married, lives with wife and 5 children in a terrace house in Gelugor. an active smoker with history of cigarette smoking for 20 pack years. a chronic alcoholic for the past 40 years - normally drinks 4 bottles of beer on a daily basis. he claims of having good home support and no financial constraints.
systemic review: non contributary (systemic review: a quick series of questions asking about all 'organs'/systems in the human body to screen for other problems)
summary: 56 yo Malay Man who is an ex IVDU, chronic alcoholic and diabetic - presented with 5 days history of abdominal distention accompanied by jaundice, fever, altered consciousness/behaviour and episodes of passing malaenic stools.
impression: decompensated liver disease as evident by ascites, jaundice and hepatic encephalopathy.
(actually takleh wat impression lg before physical examination is conducted, but in this case just assume that i have carried out the physical examination as needed - and found evidence of stigmata of liver disease, ascites and fresh malaena on per rectal examination)
Fuh...amcam, ok tak my clerking?? huhuu..im really rusty ok, dah 2 bulan tinggal buku sume..hadoi..mmg kene brush up cpt ni! ok2 now i better get to my medical books. lupe la plak camne nak wat per rectal examination! huhuuu
hari ni tak tayang juadah iftar, sbb hari ni i masak bodo2 je - spagetti bolognaise (upon request from my sister plak this time). hari tu dah penah tayang gmbr spageti bolognaise, so malas nak snap n tayang lagi skali kat sini. tapi i nak tayang satu mende ni:
jeng3x..kopok lekor nipis - my all time favorite! wuhuu..dah berminggu mengidamkan mende nihh..sejak puasa ni tak menyempat2 nak gi pasar malam every saturday. i ni mmg hantu kopok lekor..bole makan benda ni je, takyah mkn benda lain dah! sebbaik tak kempunan eden..huhu..
malam ni malam yg ke 27 berpuasa..org Melayu panggil ape tuh - malam tujuh likur? entah ape fungsinye mlm 7 likur ni pun tak tau la..takde pun dlm sunnah nabi kan. slalu malam tujuh likur ni org dok nyala pelita sekeliling umah...buat pa tah? huhu..patutnye malam ganjil ni kene perbanyakkan ibadah ye tak, kot2 malam lailatul Qadr ke..dpt gak pahala extra kan. mlm ni my dad tetibe plak terasa nak pasang lampu lip-lap die kat sekeliling garage, maka jadi la rupenye mcm ni:
ni lampu lip-lap letrik je. takde main sumbu2 pelita segala. time kecik2 dulu ade la gak my dad nyalakan lampu pelita siap dgn sumbu minyak tanah nye sekeliling umah. i pun tlg nyalakan sama. tp dah besar2 ni takde masa dah ha. sume pakai letrik je. tunggu ade cucu nanti kot baru nak ralit pasang pelita minyak tanah.. heheee ;))