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
NKDA
Not on any medications
Social Hx
Single
Stays with friends
Working
Travels overseas annually
Vitals:
T 37.0
PR 85
BP 89/60
SPO2 97
ECG - Sinus
HOPI:
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
Shivering/Giddiness
C/O butterfly in my stomach (nervousness)
No LOC, PIC, Nausea/ Vomiting/Sweating
Otherwise no other complaints
Problem:__________________
Plan:
Discharge with treatment ---> refer to Serdang
@3pm
ReplyDeletePt 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)
NKMI
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
S/B Cardiac Consultant at Research Clinic
ReplyDeletePre Screening Visit (PSY Trial)
Subject met all inclusion criteria/no exclusion criteria met.
Subject consented to ICF English Version 1.0
Hx
Well
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
Heart:DRNM
No bruises
No Carotid bruit
No pallor
Diagnosis
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)
tak pasal2 patient nih dah jadi subject trial =P
ReplyDelete