Tuesday, April 19, 2011

Diagnose This Patient

S/B MO oncall
Malay Ladies
26 Years old

Background Hx
1. Uncontrolled imagination
-diagnosed 2 years ago when start working at new place
 Last FU for mild fever and cough last year

ECHO done on 2009
-Best view in 4chamber
-Good EF
-Dilated LA
-Normal LV
-No clot wthin 4 chamber
-No effusion

Medication Hx
Not on any medications

Social Hx
Stays with friends
Travels overseas annually

T 37.0
PR 85
BP 89/60
SPO2 97

ECG - Sinus

c/o tachy an hour ago while on the phone talking to one of her medical personnel
followed by palpitation (unstable)
Unable to finish one sentence/Slurred speech
C/O butterfly in my stomach (nervousness)

No LOC, PIC, Nausea/ Vomiting/Sweating

Otherwise no other complaints


Discharge with  treatment ---> refer to Serdang
Even a 1000 cups of coffee with a friend it is too little (n_n)v


  1. @3pm
    Pt was triaged to Black zone acc. by SN Haslina (knp aku jugak) via stretcher (8 tayar).
    On arrival, pt's g/c alert and semiconscious (masih berangan)
    GCS 16/15 (terlebih suda)
    C/o severe palpitations, shivering and nervousness.

    S/B Dr Adzrul Ariff (refer to one in WTF 4***) and ordered:
    -large bore iv branula G14 inserted at JV wahahaha
    -ivd 24Pints over 1H (eh slh regime kew, em takpelah kire halal la)
    -Bloods ix sent to lab Toronto Hosp, entah bile nk siap kan...jauh bebenor.
    -CXR (pt request tutup pe yg patut, takut terlebih sexy)
    -ECG done: SN bace sinus rhythm..MO bace ntah apelah jeng3...assys.....oppss

    awaiting blood results (dh setahun 5jam 29minit dan 55 saat dah)

    blood results completed on 20/4/2012 at 3:15pm
    rv by Dr Adzrul (smbil membtulkan rambut yg tak kusut) and planned:

    "baik refer serdang dr awal, dh ade Specialist (MK) yg nk tgok la.." hampeh

    Discharge summary:
    IMP: TRO Missingitis secondary to nervousness prior to work overload

    SN Leen Lot
    Black Zone

  2. S/B Cardiac Consultant at Research Clinic

    Pre Screening Visit (PSY Trial)

    Subject met all inclusion criteria/no exclusion criteria met.

    Subject consented to ICF English Version 1.0

    No complaints
    No Chest Pain or Bleeding
    No N, V, H, M, headaches, coughs, fever
    Takes all medication (basically PCM)

    Physical Examination
    looks well
    100/65 pulse 81
    Chest: Clear
    No bruises
    No Carotid bruit
    No pallor

    Chronic Missingitis

    Management Plan
    FBC,CBC,RP,HepB (semua test yang ada and required in protocol)
    Continue obs under my consultation(FU ikut protocol)
    get appt from Serdang. Referal Letter done.
    referal letter to her bigboss to get her vacation to Hawaii (part of treatment)

  3. tak pasal2 patient nih dah jadi subject trial =P