Thursday, March 13, 2008

Case untuk hari ini

Name: Tengku Abdul Kadir Tengku Zainal Abidin
Age : 24 years old
Sex : Male
Marital Status : Single
Residense : Sayeeda Zainab
Occupation : Student
Special habit : Drink a lot of tea and coffee,

Complaint of:
Shortness of breath at night and cough

History of present illness:
The patient complained of coughing for a week of duration and shortness of breath usually at night. Also having sense of fatigue waking up in the morning. His sleep is not disturbed from any condition.

The condition is exacerbated after meal and before sleep when the patient lying down. All the other systems is not affected. The general condition is normal. The patient is concious, well oriented, average intelligent and good mood and memory. The bloog pressure is normal 120/80. Temperature 37 C. The pulse rate is regular, 60 beats per minute, normal and equal in volume, and do not have any special character.

For Local Examination on the chest, the breath is normal, the shape is normal, TVF is equal, no adventitios sound, no ronchi or crepitation,

Past History:
The patient had complained about dyspnea and chest pain before and was diagnosed to have gastritis.

Family History :
Nobody of his family having the same conditioned except his little brother was previously noticed to have bronchial asthma.

Ok, so tu la case untuk malam ini, investigation apa-apa tak buat lagi, cuma kalau nak investigate mungkin kena lakukan,

1. Spirometry
2. Peak Expiratory flow test
3. chest X-Ray
4. Test of sputum for any infection.

Emmm apa ya differential diagnosis untuk case di atas, bronchial asthma kah? Bronchitis kah? COPD kah? Atau fibrosis. Wah teruk-teruknyer diagnosis anda. Apapun doa-doakanlah penulis blog ini sihat-sihat je ya. Belum tahu ingin pergi jumpa doktor atau tidak dan sebenarnya saya sendiri secara jujur makin malas hendak bertemu doktor-doktor di sini. Entah kenapa, Apapun doktor Khalid dalam round sebelum ini pernah berkata, “The doctor is the worst patient, they dont follow the instruction and change everything” mungkin Ok lah, mahu beradu dahulu. Hingga jumpa lagi. Jazakumullah Khairan Kathira...

3 comments:

HAMDAN said...

salam,bro.gua rasa bro kene check kat hospital la.doctor nnti mungkin suh bro buat plain chest x ray.based on the x-ray finding,dia akan sebut la apa yang dia patut sebut.

Anonymous said...

kalo nk ikutkan berlambak diff dx,paling2 kena pon pulm edema coz lying down dia orthopnic..btw.ada pnd tk.snoring when sleep..sleep apnea??.mustahil la pulm embolism..ada sputum tk?apa pon..syafakillah..int med interesting!!

Dr Kadir said...

interesting.... ya'ni :) alhamdulillah dah makin ok skrg without any medication