Semester 5

Name- Ms F.T
Gender- female
Age- 3 years
DOA- 8/1/18

Chief complaint
Ms F.T a 3 year old child presented with high fever, cough and runny nose lasting for 2 days.

HOPI
The child had a high grade fever of 39 C, together with a productive cough(white phlegm) and a runny nose for the last 2 days. What does this suggest?

Though panadol was given it didnt help as she vomited the medication. she has poor oral intake and presented with a weight loss of 0.2kg in one week. Her bowel movement and urination were normal. What is the significance of the vomiting?

she complained of throat pain but has no symptoms of abdominal pain, nausea, vomiting,headache and breathing difficulties. What does the throat pain indicate?

birth
she was a full term baby and the weight was 3.1kg, Had neonatal jaundice at birth but was not admitted to the hospital. What does this tell you about the jaundice?

The mother had no complications during the pregnancy and delivary. Her immunization is upto date as well.
all her family members are health and there is no significant past medical history.

physical examination
BP- 108/59
HR-137 bpm
TEMP-39.1C
RR-36 breath per min
What do these vital signs indicate?

examination of the throat
injected throat and tonsils were enlarged but with no exudate
auscultation- equal air entry, no added breath sounds

What is a possible diagnosis?

How will you summarise this clinical information?

2

A 63 years old Malay Male presented with intermittent fever for 5 days and generalised jaundice over the lower limbs. He was referred from a nearby Klinik Kesihatan to Hospital Sultan Nora Ismail,Batu Pahat. He also presented with yellowish sclera. He had no nausea and vomiting. He has no cough, flu and body ache. His bowel movements are normal but he had pale stools. His urine appears concentrated. He was lethargy and appetite was noted to be reduced. There is no weight loss. There is no diarrhea, vomiting, cough and flu. He has no previous admissions to hospital. Upon physical examination, the vital signs are normal. The upper sclera appears yellowish. Liver span was 11 cm and liver is not enlarged. There is shifting dullness appreciated in this patient. The possible diagnosis will be Hepatitis B infection.

Comments:

  1. "Generalised jaundice" cannot be only over the lower limbs
  2. If he was referred to this hospital, it will be good to say what he was referred for
  3. "He also presented with yellow sclera" is redundant when you have already said that he has jaundice
  4. What is the significance of "pale stools" in the presence of jaundice?
  5. Urine was "concentrated" or was it "high coloured"?
  6. The summary makes no mention about the CVS, RS and CNS
  7. An elderly man with a febrile illness of short duration associated with jaundice and pale stools cannot be diagnosed as Hepatitis B infection right away.

3

MS male 49 years old was sent to Sultan Nora Ismail hospital by his spouse on 14th January. He experienced chest pain that radiated to his left arm and up his jaw, at rest. Pain subsided a little after 5 to 10 minutes, also at rest and after taking GTN. He did not remember sweating, he did not vomit, he had no shortness of breath. 2 days ago he experienced the same kind of pain but was relieved using one drop of GTN. Mr MS is obese, was aware and concious, has arcus cornealis, no xanthelasma. upon examination, he has clear s1 and s2 heart sounds with no added sounds and no parasternal heave. he has a fix diet, 2 meals a day as he skips dinner. he does not exercise or do heavy work. Back in 2017, an angiogram revealed an atherosclerosis. His medications are aspirin, GTN, ranitidine and maxolon. provisional diagnosis is unstable angina. Differential diagnosis is gastric pain.

Comments

  1. Is the information that he did not sweat and did not vomit important?
  2. What is the significance of the fact that he did not have breathlessness after the chest pain?
  3. What is the interpretation of the chest pain he had 2 days ago?
  4. In this patient, why are vital signs not given?
  5. What is the interpretation based on the physical examination?
  6. How does an angiogram reveal "atherosclerosis"?
  7. If the provisional diagnosis is unstable angina, what relevant points in the history should have been mentioned (even if it is negative)?
  8. What causes "gastric pain"? Why is this being considered as a differential diagnosis?

4

7 years old girl was admitted yesterday with coughing and dyspnea for 2 days. Before admission, she had a blood test and a chest X-ray done at a health clinic and her white blood cell was high. Besides, she had post tussive vomiting 3 times yesterday with whitish phlegm. She also had fever at 38.4 degree Celsius yesterday evening but her temperature is normalized now. She has no sore thoat, no diarrhea and no runny nose. She has good oral tolerance. She has no asthma and no known allergy. From her family history, her elder brother has asthma but he's not in any treatment. None of her family members has similar symptoms as her. She has tachycardia at 149 beats per minute and tachypnea at 36 breaths per minute. On auscultation, there is some wheezing sounds at the right lobe of her lung during expiration. Possible diagnosis: Pneumonia

Comments

  1. A 2 day history of coughing and dyspnoea will suggest a respiratory problem. What could be the cause?
  2. What does the high WBC count indicate?
  3. How do you think the temperature returned to normal? Without antibiotics or without antibiotics?
  4. What does "she has good oral tolerance" mean?
  5. How important is it to put the family history in this summary?
  6. The abnormal finding on auscultation is wheeze. What does wheeze indicate?
  7. You have made a diagnosis of pneumonia. What are the points in favour of pneumonia in this child?

5

NBR, an 11 month old female has complaints of a runny nose and a productive cough with whitish sputum for 3 days. Her mother noted that NBR has had similar episodes with these symptoms over the last few months, but she brought her to the Klinik Kesihatan those times. She was admitted one day ago after an episode of tachypnoea. She occasionally has post-tussive vomiting, usually after heavy bouts of coughing in the morning. She has been less active than usual and her food intake has decreased. She has also been having less stool, less frequently than normal.
NBR has not been admitted before. Previously when she had similar episodes her mother brought her to the clinic, where she was prescribed paracetamol syrup as well as salbutamol. NBR also had neonatal jaundice which was treated with phototherapy.
Apart from the medication mentioned above, the mother is also giving her an unspecified antibiotic, allegedly on doctor's orders.Her father has had asthma since he was a child. NBR's birth was a term pregnancy, SVD. Her vital signs were as follows:

Respiratory rate: 35 breaths/min
Pulse: 118 beats per minute
Breath sounds: Expiratory wheeze audible bilaterally
Temperature: 36.5 celsius

Provisional diagnosis: Asthma . Differentials: Common cold, allergic rhinitis

Comments:

  1. Will a 11-month old child actually "complain of a runny nose and a productive cough with whitish sputum"?
  2. What does a "runny nose and cough" signify?
  3. Why is the child "less active than usual"?
  4. Why is the child having "less stool, less frequently than normal"?
  5. What finding in the lungs will trigger the prescription of salbutamol?
  6. Why do you think the child was prescribed an antibiotic?
  7. What does the "expiratory wheeze audible bilaterrally" suggest to you?
  8. Why is the provisional diagnosis "Asthma"?

6

A 53 years old gentleman, with a history of smoking 30 pack-years and drinking alcohol for about 3 times a month, admitted last night for sudden onset of non-radiating burning chest pain which was localized on the middle of chest with a pain score of 6 out of 10. His appetite has been reduced. He also complains of bloated feeling on his upper abdominal region which relieves upon drinking water. He had similar episodes previously whenever he skipped meals. He is taking NSAIDS medications for a long period of time. He has a past medical history of hypertension for 10 years. There was no significant findings in physical examination. The possible diagnosis is gastritis.

Comments:

  1. What diagnosis should be considered when a 53 year old old man with hypertension and a history of smoking tobacco presents with chest pain?
  2. Is the "sudden onset of burning chest pain" a point in favour of gastritis or a point against it?
  3. What are the points in the history that suggest his pain may be related to the stomach?
  4. What physical finding will you expect in a patient with "gastritis"?
  5. How is "gastritis" different from "peptic ulcer disease"?
  6. What important information is missing in this summary? [Remember: this summary is about a middle aged man with hypertension who presented with chest pain.]
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