Hi sir,
 
sorry didnt mail u last night as my net was not working. Here are the details of my long case. Patient has come with a cardiovascular complaint but abdominal examination revealed hepatosplenomegaly. I want to take this case for my log book as I do not have an abdomen case, can I write the history given but write abdomen examination as my main system, patient has leukemia. Secondly, I could not really appreciate the surface of the liver and spleen find it very difficult to feel it. Thirdly, I think there is a murmur heard in pulmonary area during systole but I am not very sure about it as the murmur is not very loud. Few more friends tried to examine and thought it may be a murmur too but were not very sure either. Lastly, I could not copy the investigation done from the file as the file was not there yesterday, will copy it today sir. Thank you.
 
DOA    : 7th May 2006                                     DOE    : 9th May 2006

 

Chief complaint:

Known leaukemic with ischaemic heart disease, hypertensive and diabetic came to hospital with chief complaint of chest pain for 2 days.

 

HOPI:

1)       chest pain

-it was insidious in onset, intermitten in nature happened when she was sewing

 with the sewing machine

            -heaviness felt on the retrosternal area and pricking pain felt radiating to the left

             Shoulder, left arm and the back

            -the pain lasted for 30 minutes, relieved by ointment and rest

            -after 2 to 3 hours pain started again, she got 4 episodes of pain in a day

            -it is associated with sweating, grade 3 breathlessness

            -breathlessness is relieved by rest

            -there is no history of nausea, vomiting, epigastric pain or syncopal attack

            -patient gave history of similar episode last year and she was hospitalised for 8

             days

            -2 bypass surgery were done, in the year 2002 and 2003 respectively

            -patient is a non smoker and does not consume alcohol

 

Past History

-leukaemic, IHD, hypertensive and diabetic for 5 years on regular medication

-patient claimed has allergy to some drugs but does not know name of the drug

 

Family History

-mother is a diabetic on oral hypoglycaemic medication since 1 year

 

Menstrual History

-attended menarche at the age of 15

-last  menstrual period is on 1st May 2006

-last child birth is year 1991

 

Personal History

-follow diabetic diet

-good appetite

-good sleep

-no weight loss

-non smoker and does not consume alcohol

-bowel habit: thrice a day, brown colour stool

-bladder habit: twice in the day and once at night, urine is straw yellow in colour

 

 

Social History

-staying in single storey house with daughter and her family

-there are 5 members in the house

-there is no over crowding

-patient receives RM300/month from her children for monthly allowance

-she can perform daily activities on her own

 

General Examination (positive findings)

-conscious and co-operative

-moderate built and well nourished

-mild pallor

-bilateral pitting pedal oedema

-all peripheral pulses felt

-pulse rate: 68beats/min, low volume, regular rhythm, no vessel wall thickening

-respiratory rate: 26times/minute

-blood pressure: 120/70mmHg on the left arm

 

Abdominal examination

-abdomen is distended, flanks are full

-umbilicus is central and inverted

-stretch marks seen on lower abdomen

-liver palpable 13cm below the right costal margin at mid clavicular line

-consistency is firm, surface is smooth, non tender on palpation, border is sharp

-upper border of liver is at right 5th intercostal space

-spleen is palpable 12cm below the left costal margin at mid clavicular line

 

CVS

-apex beat seen and palpable in left 5th intercostals space 2cm lateral to mid clavicular line

-S1 and S2 heard in all areas

-?systolic murmur heard in pulmonary area


Thanks my impression is Leukemia-? on treatment ? which type CML?AML?CLL(you need to find that out along with what treatment she's recieving for it-- I might present this case in the lecture class when I take the Leukemia lecture class--or ask you to present it and then start the class--no don't start worrying about it--).Yes I agree the spleen and liver is barely palpable in this patient so one can't really talk abou its surface consistency etc. She also has Ischemic heart disease, risk factors diabetes, hypertension. The murmer is due to the hyperdynamic circulation giving rise to increased blood flow in the pulmonary artery (flow murmer). 
Do you notice how our text book teaching only talks about Leukemia separately but when you encounter a real patient you have to think of so many things at the same time--cvs, hemat--really real world medicine is all mixed up and that may be the reason some of you harbor mixed feelings about our trying to teach you real medicine for this term. Most of us would rather prefer to get into the warm and predictable shelter of memorising text books and notes in a linear sequence (but is it enjoyable, this kind of text book learning without patients?)  Rakesh