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- Chief complaint : Patient presented with breast lump for 1 month duration
- HOPI :-
1st : Tell more about presenting complaint, HOPI (describe lump, when
noticed, how noticed, etc) & progress of the lump
2nd : Risk factors!!!*** (mention all positive and negative relevant risk
factors)
3rd : Management that had been done to the patient
- Past medical hx
- Family hx :-
1st degree relatives are parents, siblings and children-50% share DNA
What malignancy are we concern about in patient with breast lump? (FIND!)
- Social hx :-
Criteria of alcoholic (back to pasychiatry)-cuz dayah mentioned the word
alcoholic
- P/E :-
Please show me how you examine for signs of metastasis (distant metastasis)
Spine tenderness (palpate all the way from cervical to sacral)
Percuss lungs for pleural effusion (stony dullness)
Abdomen felt for hepatomegaly and ascites
- DDX (give points for and points against) :-
a) Breast cancer
b) Fibroadenoma
c) Breast abscess
d) Etc, etc
- Investigations :-
Triple assessment
i. History & PE
ii. Imaging
iii. Biopsy (trucut biopsy)
o Risk factors, risk factors and RISK FACTORS! (drop dead serious)
o Definition of wide local excision? : removal of lump with rim of normal tissue
o If you did biopsy and the result came out as invasive ductal carcinoma (IDC), what to
do next?
Proceed with CT TAP for STAGING
o Option of treatment for her?
Depends on staging of the disease
If no distant metastasis what to do?
How to divide your mx? (medical and surgical)
Medical : if positive receptor status, start on hormonal therapy such as
SERM (Tamoxifen), aromatase inhibitor, etc (read about the
medications!)
Surgical : READ! From CPG :
***ADDITIONAL INFO :
SUPERFICIAL SET
- C/C
Mr A, with underlying lung cancer stage 4 since 2 years ago presented with
shortness of breath on the day of admission.
- Dr Arifs comments
1. For HOPI :-
1st : start with presenting complaint (tell more about the SOB, started
when, what was he doing during that time, etc mcm biasa rule out
semua differentials for SOB. Dont just focus on the lung cancer!)
Then baru cerita about the diagnosis of the lung cancer
a. How many times admitted?
b. What chemo was he started on? How many cycles already
received?
c. Last follow up?
d. How many more session to go?
e. Risk factors?
f. How long has the patient been on morphine? How long has
been constipated? (because patient dpt current SOB time dia
tgh defecate)
Recently, the patient presented with lump at the back of left shoulder
which his doctor said possible to be bone metastasis then tell more
about the lump (ni ayat dr)
2. O/e : conclusion of the lung finding? (reduced air entry on left lung, reduced
left lung expansion, dullness on percussion, and reduced vocal resonance)
left lung collapse
- From the c/c which is SOB, try to rule out the differentials (other causes of deterioration in
lung cancer) :-
i. Infection (pneumonia)
ii. Recurrent lung cancer
iii. Pleural effusion
iv. Pulmonary embolism
****Thalassemia needs a booster of Hep B every now and then (depends on antibody
level-dr need to do serology)READ ABOUT THIS!
Development :-
3 y/o : for language igt coloursss
Cth ayat : regarding developemental history, he is appropriate to his age
whereby for gross motor he is able to ______, fine motor able to _______,
speech _______ and social _________
Past medical hx :-
His 1st hospitalisation was during point of diagnosis
Any hospitalisation due to febrile illness? (or hospitalised for recurrent febrile
illness?) They are prone to get sepsis and die!
Currently patient is on Esjade (compliance and monitoring!!) patient is
compliant and monitored by mother
Any adverse or allergic reaction during blood transfusion?
Family hx :- any genetic counselling given?
Impact of illness :- currently patient is coping well with the disease
Summary :-
MA, a 3 year old boy with underlying transfusion-dependent thalassemia
diagnosed since 1 year old whereby he presented with _______. Patient is
currently asymptomatic of thalassemia but has underlying iron overload with
symptoms of _________.
o If youre the managing doctor and see patient for the 1st presentation, what work up to
do? :-
FBC (TRO other ddx) :-
a. Hb (microcytic hypochromic anemia)
b. WCC (low/markedly high hyperleukocytosis in leukemia)
c. Platelets (look at other cell lines ; WCC & platelets)
d. RDW
e. Reticulocytes count
f. Mentzer index (read!)
Peripheral blood film :-
a. Presence of blast cells
b. Hemolysed RBCs
c. Features of microcytic hypochromic RBCs
d. Target cells/nucleated RBCs
Iron work up :-
a. Serum iron (if low, rule out IDA)
b. Ferritin level
c. Transferring
d. TIBC
Hb electrophoresis :-
a. Low HbA
b. High HbF
c. High HbA2 (kot?)
Prior to transfusion (if patient needs transfusion) :-
a. Viral screening (Hep B & C, VDRL)
b. Group cross match
HLA phenotyping (to look at minor blood antigens) mesti kena bagi blood
yg match. Kalau tak, pt produce antibody & susahlah for future transfusion.
o How would you manage the patient then :-
Gradually transfuse the patient for few days until I reach Hb of 12 g/dL
Prescribe with medications like folic acid, vitamins
If febrile, give antipyretic or may need antibiotic
C/C : patient came with neck stiffness due to underlying conflicts (ni kena ckp
kalau tak examiner direct kan kita ke soalan medicine!)
Patients symptoms
Panicky :-
- Onset?
- Triggering factors?
- Symptoms (all panic symptoms) feels like having heart attack
Neck pain (SOCRATES)
No past history of medical problem
Was he ever investigated during first presentation? If yes, what? And results?
Any medications given to him in ED or OPD? Did the medication relieved his pain?
***3 types of impairment to include in HOPI!! :-
a. Social (interaction with people)
b. Work (patient cant work)
c. Psychological (has anxiety and depression?)
Mention the medications he is on currently for the anxiety (compliant to medications
and follow up?)
Family history (if relevant can put in HOPI) :-
Mom and dads age, any medical problem?
Patient not talking to mother for 3 years
Mom has underlying anxiety
GAD is more of duration (tak kisah sgt yg free-floating anxiety and the anxiety cant
be pinned to one specific issue tu. Prof said if more than 6 months terus je ckp GAD)
- C/C : brought to ED due to aggressive behaviour for 2 days prior to admission (if has
underlying psychiatric disorder put with underlying psychiatric disease dont
mention straightaway the diagnosis the patient had) dont hv to mention with
no known medical illness
- Patient had auditory hallucination, persecutory delusion (people are going after him)
for 4 months duration
- Mother said was temperamental since childhood
- Had history of drug use 5 years ago. Stopped 6 months ago. No withdrawal symptom
In past psychiatric hx : baru cerita how many admissions patient had and what
was the initial presentation.
For PTSD case you must show that the patient had :-
a. MUST GET THE TRIGGERING FACTOR! assault, trauma, saw a
situation that is traumatic (last time ada your senior dpt case PTSD patient
tu ada symptom depression with history kena slash dgn parang. Tp your
senior directed to MDD je. Penat kami bagi hint psl trauma tu. So make
sure you know the triggering factor)
b. Signs and symptoms (anxiety, depression, flashbacks)
c. Having dreams about the traumatic event
d. Avoid situation (avoidance)
e. Worry about the same thing