Case write up disorder

Bila meja penuh dengan kertas.. itu tandanya case write up sedang dalam progression.......

handwriting?? bila tengok balik tulisan sendiri-asyik mengutuk diri sendiri je... kalau huruf BESAR boleh la tahan kemas... bila tulisan kecik2.... mula lah macam2 bentuk.. hehehehe.....

let's prepared ourselves.. internet-unifi dah mula active balik... lepas makan ubat, should be kena tidur lah kan.. sabar adnin... semua ini ada hikmahnya...

chief complaint(C/C) :SYMPTOM

running nose for 2 week(duration)

Hx of presenting illness(HOPI):

• occur at close space area or only on exertion, sudden onset,episodic, worsen during evening.
• aggravating by dust, direct fan, air-cond, cold condition, when prostration or drinking ice. relieving by blow breath, avoid cold drink, away from direct fan and air-conditioner. 
• associated with nasal congestion (? sinusitis ? allergen), sometime bounding of the heart present without chest pain or any other symptom 
• (based on cerita- apa yg patient complain-itu adalah SYMPTOM)

review of system (ROS):

general : ( ask about)

weight loss? appetite?thirst?lethargy/weakness?Fever? sleep? itchiness?

respiratory: (ask about)

cough?haemoptysis? sputum colour?dyspnoea? wheezing? decrease effort tolerance?

CVS : (ask about)

palpitation(if mention xperlu la nak ulang lagi)orthopnea?PND? dyspnea?exertional dyspnoea?chest pain? ankle oedema?

GIT: (ask about)

etc.........

MSS:

CNS:

O&G:

 

Skin:

Urinary :

sexual/genital:

psychiatry:

 

-DETAIL lah............ kena tny sebab afraid patient xmention atau tak ingat mereka alaminya... just bg mereka FULL image of their condition-severity dll...

kalau tiada.... just mention

On review of system.. there is no other special or significant symptom related to patient condition..

then, baru masuk

Past medical hx (PMH):

- cari penyakit yang ada kaitan dengan symptom yang patient beri...-

find idea- asthma? heart disease?

Differential diagnosis??

surgical Hx:

Family Hx:

------------------------------------------------------------------------------

mother: 66, alive and well.

father :71,Diabetes since 2011,Hypertension -relapse case on 2011 -all are control under medication prescript by doctor at hospital raja permaisuri bainun, ipoh. under follow up and treatment. 

other family member are well and healthy- insya-allah.... heheehehe  =)

all are not smoker or not alcohol drinker.

social & occupational Hx:

single, student, stay with few friends in double storey house at bayu perdana,klang,

not smoking, do not take any alcohol

Drug Hx;

NKDA-no known drug allergy

physical examination: SIGN

general examination:

B/P: ??

Pulse rate : 92, regular rhythm, good volume and afebrile 

respiratory rate :13/ min

temperature :??

body weight : heehe... 50kg

height : 152cm

nails and hands: no abnormality

eyes: rabunlah...

mouth and tongue: jom gosok gigi.... nanti doktor gigi nk dtg sekolah.... =P

neck:

respiratory system examination

inspection

palpitation-vocal fremitus/ vocal resonant guna stethoscope '99' or "one,one,one"-ask examiner to hear it- more clearly sebenarnya guna stethoscope...

percussion-resonant?hyper-resonant-pneumothorax?dull-consolidation?stony-dull-pleural effusion? 

CVs examination

abdominal examination

limb examination

Neurological examination

Provisional diagnosis:

Differential Diagnosis

Medical summary:

patient 24 y/o come to haospital due to symptom of running nose ect