POST LONG EXAM FOR INTERNAL MEDICINE 2018

6:55:00 PM

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POST END POSTING EXAM - LONG CASE 

Fuhhh, I just told you guys that I don't want stroke patient this morning right? Turn out I went to see my patient and suddenly my patient that I got is a stroke patient. WOW. What a case... I almost broke into tears and I became very nervous. Thank God, Liyana was there helping me out to prepare for the case. She did all the research while I try to memorise and smoothing my CNS physical examination flows.

Nina was there too and helping me out with the physical examination. I'm blessed to have friends like them. My subgroup-mates also  very supportive and wish me luck with the patient.

I went to Mahsuri ward at 2.00 pm and starting to clerk the patient. Then I receive a message from Dr. Ong that I need to clerk Bed 15 instead Bed 2. I asked her for confirmation, and she said Bed 15 for me. Mann..

I called my friend and I told her our case had been swapped - giving her hints that she need to read about CNS examination and ischaemic stroke 2ry to cardioembolism instead CVS case. 

The CNS CASE

The patient was a 65 year old malay gentleman but seems old from his age. He has underlying Chronic Rheumatoid Heart Disease, Chronic Kidney Disease and Gouty Arthritis.
He came due to left upper and lower limb muscle weakness.

My case - The CVS patient

My patient was well cooperate and very friendly. 1 hour was not enough for me to clerk and did my examination (suprisingly!). 1 hour given to me was always enough before this, I wonder if changing my style by first listening to all the patient had to say is better than while listening I should jotted down everything and arrange it all together. Hmm. The latter seems better for me. 

My patient was a 43 year old, malay gentleman working as hawker and live in Melor, Kota Bharu. He is a smoker with history of 21 pack years for more than 30 years. He stopped smoking last month.
Patient is a known case of hypertension and also hypercholesterolnemia. He was diagnose with hypertension since 2 years ago and not compliance to medication. His hypercholesterolnemia was diagnosed last month and claimed compliance to medication.
His main complaint was chest discomfort, breathlessness and lethargy. Then nothing. Aiyoo. There was  5 days history admission to CCU  recently (last month) due to almost similar presentation but worsen than the current one. He was not aware of the diagnosis. But listening to his description about the symptoms is more likely like acute myocardial infarction or acute heart failure.
Upon physical examination, Apex beat was not displace (5th intercostal space, mid-clavicular line), there was thrills present at left sternal edge. Pansystolic murmur was heard best heard by diaphragm at mitral area and radiated to axilla - bloody hell it was mitral regurgitation! And I was so pleased with myself that I can finally differentiate the type of murmur. Bibasal crepitation was heard and there was no sacral and pedal edema. 

My differential diagnosis were Acute Coronory Syndrome and also Heart Failure. Dr. Ong asked me about the investigation I would done and management for Acute Coronary Syndrome Disease. She gave me good mark, Alhamdullilah !

Investigation I would carry out :

1) FBC - looking for any infections from total white count and looking for anemia from Hb level.
2) Coagulation Test
3) Renal profiles
4) Liver Function Test
5) Cardiac Biomarkers - Troponin & CKMB
6) ECG - ST elevation in Myocardial Infarction
7) Chest X-Ray - to look for any cardiomegaly or other underlying disease
8) Echocardiogram - To see the LVEF status, cardiac wall, cardiac contractility and to confirm mitral regurgitation

Management:

1) Airway
2) Breathing
3) Circulation
4) Give oxygen if patient still breathlessness
5) Primary PCI
6) Anti-fibrinolytic such as streptokinase or ateplase
7) Anti hypertensive drug - Frusemide
8) Educate patient

💕 READ HOW TO DIFFERENTIATE MURMURS 💕

HERE

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