Some of my case reports created during my rotations in different specialties, most of them are reviewed by the doctors
1-surgery
first case report in surgery about abdominal mass, the purple color is the doctor's comment
Fatemah,33 years-old female Saudi pt, divorced ,jobless ,admitted through ER
complaining of abdominal mass & back pain for 1 month.
Patient seems unreliable, source
of a part of the history is her mother. (You can say informer is … if the patient is not the
source of the history)
HPI
Since 1 month ago, Fatemah's mother has
noticed her daughter feeling moderate , gradual, local , lower back pain which
increases during working at home and decreases by rest , (Fatemah cannot
describe the character of pain) , this pain attracted mother's attention to a
painless hypogastric mass which is getting bigger by the time with slightly (mild, moderate or marked loss of weight) decrease
in weight and appetite(dose not know the exact weight) (
a clue can be extracted by asking whether her clothes are getting wider or so)
,the mass never disappears , and no
other masses in her body, the mother did not care about it because her daughter
was not complaining, 1 week prior to
admission , the mother felt worry about the mass that (became)
it becomes bigger and visible ,then they came to
ER bcz (do not use such
abbreviations, remember this is scientific
writing) of this complain (complaint) ,ultrasound and routine investigation was (were) done for her in ER then admitted to surgery word (ward), no abdominal pain , no vomiting ,no diarrhea
,no constipation , no change in stool color ,no dysuria , no hematuria , no
urine retention ,menarche was at age of 13 and the menstruation is regular ,comes monthly ,lasts for 6 days, last
period was 1 week ago, no vaginal discharge ,no breast pain or swelling , she
was married for three years but no children (does not know the cause).
PMH
She has epilepsy since puberty ,diagnosed
in KKH and she is on carpamizapine ,400 mg/day
history of hospitalization in KFH 1 year ago for 1 week due to RT lumber (lumbar) pain (dose not know the diagnosis, the investigation
nor the medication)they referred her to KKH but she did not come because she
got better ,
history of hospitalization , for 17 days,due to LT forarm burning (burn) by
hot water in the bathroom (these are known as
scalds),
history of using alternative
medicine for loss of appetite in unknown man who gave her some pieces of paper
and told her to put it in a cup of water and drink one cup per day ,no
affection , and the appetite returned by itself, no history of (not
known Diabetic or hypertensive or…) DM, HTN ,anemia (Pt might not be aware of this disease despite its
presence, it is not as recognizable as DM and HTN), CHD, bronchial
asthma, no history of
allergy ,no history of surgery, no history of blood transfusion, she (is fully
vaccinated) took all her vaccines .
FH
Her brother is dead by cancer in his
neck when he was 17 years old, diagnosed
in KKH (did you ask to know the diagnosis? Do you
think this mass might be related to this abdominal mass?), and referred
to Riyadh (does not know in which organ the tumor was) Her father is dead by an accident 20
years ago, and he was free of chronic diseases, no history of DM, HTN,CHD.
OB/GYN /mentioned in HPI
SH
Fatemah got married 10 years ago then got
divorced after 3 years, now she is living in tabuk with her family in their own apartment ,not
smoker, her diet is normal (you can say balanced
diet according to your judgement), no much fat ,no much coffee, no
much soft drink.
ROS
No fever ,no sweating, no fatigue, no
remarkable symptoms . (thses should be mentioned in
the HPI because it could tell about the nature of the tumor i.e. inflammatory)
On general physical examination,
Fatemah ,young lady, lying flat on the bed
comfortably, alert ,conscious ,looking well ,thin, not in pain ,no distress,
connecting to IV canula for medication hands/symmetric ,no muscle wasting ,no deformity,no palmer (palmar)
erythema no staining, no abnormal
pigmentation, no leukonychia ,no koilonychias, no dupuytren's contracture.
Arm and forarm/ burn trace (marks)
in her left forarm .
Vital signs
Puls/
80 (write in full, 80 beats/min.)
RR/20 (write in
full, 20 breaths/min.)
BP/110/82 (mmhg.)
TEMP/26,9 (what
is the unit, C˚ or ˚F)
Face/ no asymmetry, no pigmentation, no special
feature , no jaundice ,no pallor, no central cyanosis .
Mouth/ good hygiene
Lymph node>>neck, axillary ,inguinal/no enlargement, no tenderness (what about other groups of lymph nodes? i.e cervical. Do
you think it is related to the tumor?)
Leg/no deformity ,no edema . (This should come after examination of the system that is
mainly involved).
On abdominal examination
Inspection/burn trace in RT lumber (lumbar)
region extended to the back, mass in lower abdomen , normal hair distribution,
umbilicus is central and inverted , no deformity, no scars ,no dilated veins, symmetrical
movement with respiration, no muscle defect, no cough impulse .
Palpation
&percussion /
superficial>> no tenderness (temperature and
superficially palpable mass) ,,,,deep >>no tenderness no deep masses
, liver>>no tenderness (is it enlarged or not?)
,liver span is 10 cm , spleen>> not palpable ,no tenderness
,kidney>>no tenderness, no enlargement
Auscultation/ no change in bowel sound (mention the frequency and the character of the sound i.e,
5 sounds/min. or say normal), no renal bruit, normal aortic sound (???).
On mass examination
Inspection/mass in hypogastric region
extended to about 2 cm above the umbilicus 5.5x7.5 inches , spherical in shape
(if spherical mention only one diamension usually
the diameter, according to your dimensions this is oval), no change in skin color or texture ,no scars
,no ulcers, no sinuses (these have already been
mentioned in observation of the abdomen
in general) , no expansile cough impulse no change in surrounding
structure .
Palpation/normal temperature , no tenderness, hard (this is the
feeling of a bone!! I think you wanted to say firm), regular surface, irreducible,
uncompressible (reducibility and compressibility
are tested for superficial lumps usually and might be difficult to be tested
for an intra-abdominal mass) not
fluctuated (fluctuation is again used for
superficial lumps of moderate size, and is difficult to test for in an
intra-abdominal mass. How did you test for
fluctuation in this huge mass??) , no fluid thrill, edge is unclear and
con not detect lower border (or can not go below
the mass) ,immobile ,no pulsation, no translucence (there is a lot of tissues above the mass making
transillumination difficult. Usually not used for intra-abdominal masses.)
Have you looked for a
palpable thrill??.
Percussion/
dullness.
Auscultation/no bruit ,no bowel sound (you have already mentioned that bowel sounds were normal !!!!).
Comments:
1- History was good
although not indicating the nature of the swelling (inflammatory, gynecological
etc).
2- Systemic enquiry was
not mentioned, respiratory and central nervous symptoms were not sought.
3- You should make
examination of the abdominal mass a part of abdominal examination and not a
separate entity, for example by observation abdomen is distended with full
flanks and there is visible mass seen extending form lower abdomen to above the
umbilicus …. Then; by superficial palpation there is a palpable mass……. You
describe the mass fully and then move to comment on the spleen, liver and any
other masses.
4- Examination for
ascites is important, you forget to do it.
5- Abdominal examination
is not complete until you do rectal examination.
6- Per vaginal
examination is also essential in this case.
7- Please be ware of the
language (check words and phrases in red color), do not also use abbreviations
unless otherwise indicated.
8- Please check
corrections in blue color.
9- Examination of lower
limbs for edema.
10- What is your
differential diagnosis? Try to make a list of possible causes.
Another surgical case report about hypothyrodism
Alia3,46 Y.O female Saudi PT, originally
from Jordan but she has Saudi nationality ,widow, mother of 5 children, smoker
,jobless, lives in Tabuk for more than 25
years
CC/ Alia3,46 Y.O female Saudi PT ,widow ,jobless, admitted to the KKH
surgical ward through OPD complaining of swelling in the neck
for more than one year.
HPI/one year ago ,Alia3 came to ER in KKH complaining
of cough(cough was due to flu ) and
chest x-ray was done for her ,the doctor discovered a small mass in her
neck which she was not aware of ,then
the doctor referred her to a surgery clinic but she did not go because she did
not care about it that it was asymptomatic and invisible ,after that the mass
has been getting bigger and visible in the anterior aspect of the neck
,disturbing her swallowing, make mild strangulation feeling in her neck. This
mass is painless , never disappeared and no other masses in her body ,
associated with coldness but no need for more clothes or blankets, fatigue ,
weakness , tendency to sleep ,bone and muscle pain which disturb her daily practices,
loss of appetite and weight loss !! (Cannot detect exact WT) , she also
noticed her voice changed , her hair and
skin became more dry, constipation and
hard stool, nausea ,dyspepsia . No diarrhea, no vomiting, no abdominal
distention. No fainting, no confusion, no nervousness, no fever or sweating, no
dyspnea, no bradycardia or tachycardia , no arthralgia or joint swelling or
redness , no rashes or itching. for the last 6 months the menstruation has been
irregular, comes twice a months and sometime after 2 months, last period was 2
months ago and it was so heavier than normal. Although all these malign
symptoms ,she did not seek any medical advice because she is always depressed ,hates the hospital and medication
and also she has a trouble with communication, but she decided to come to the
hospital by her friends force that they make her afraid of a dangerous disease.
ROS/general/ in HPI
CVS: nil
of note
Resp/ nil
of note
Git/in
HPI
Urinary/
polyurea, urine incontinence, dysurea , others
are normal
Cns/ in
HPI
Rheumatology/in
HPI
Dermatology/in
HPI
Hematology/
nil of note
PMH/history of hemorrhoid for more than 2 years
and she is not on medication (she refuses any medication or surgeries)
History
of UTI and she was treated well
No
history of DM, HTN, CHD
No
history of hospitalization, previous surgery or trauma
No
history of blood transfusion
No
history of allergy
No
history of exposure to radiations.
OB/GYN/
menarche on the age of 14, the menstruation was regular coming monthly
and lasting for 7 days, she has 5 children and no history of abortion or
cesarean section.
FH/her father is alive with DM, HTN, CHD, (she does
not know about any details of her father diseases) and her mother is in a good
health, no history of tumor.
SH/ Alia3 is smoker for a long time, number of
cigarettes is variable according her mode, her diet is unhealthy, she eats much
fat and drinks 3 to 4 can of soft drink every day,
Alia3
lives in a apartment with her family, low socioeconomic status, her life is
stressful that she is widow for 2 years and she always worried about her sons'
and daughters' future.
On general examination:
Alia3, middle aged pt, sitting on the bed
comfortably, alert ,conscious ,looking well ,well body built, not in pain ,no
distress, an IV cannula is inserted for medication, no IV fluid, oxygen or
monitor , hands/symmetric
,normal temperature, no wetness, no dryness, no muscle wasting ,no deformity,
no palmer erythema, no staining, no abnormal pigmentation, no peripheral
cyanosis, no koilonychias, no leukonychia ,no clubbing, no dupuytren's
contracture, no fine tremor or flapping tremor Face/ no
asymmetry, no pigmentation, no special feature ,no pallor, no jaundice, no
central cyanosis ,no proptosis, no lid lag , no lid retraction, no periorbital
edema. Mouth/ good
hygiene, no dehydration, no tremor, no swelling. Lymph
node>> neck, axillary, inguinal/no enlargement, no tenderness, Leg/no deformity, no edema.
Vital signs
Puls/ 60 bpm, regular, average volume, not
collapsing in nature, BV wall is not felt, symmetrical in both side.
RR/20 bearths/minute
BP/110/60 mmhg
TEMP/36, 3 C˚
HEENT/we did not take how to do it
CHEST/ we did not take how to do it
CVS/ we did not take how to do it
On abdominal examination
Inspection/ normal hair distribution,
umbilicus is central and inverted , no deformity, no scars ,no dilated veins,
symmetrical movement with respiration, no muscle defect, no cough impulse .
Palpation
&percussion /
superficial>> no tenderness, no superficial mass ,,,,deep >>no
tenderness no deep masses , liver>>no tenderness ,not palpable ,liver
span is 10 cm , spleen>> not palpable ,no tenderness ,kidney>>no
tenderness, no enlargement, back>> no tender kidney, no sacral edema, no
ascites supraclavicular lymph node>>no
enlargement, PR examination and external genetalia>>not done
Auscultation/ no change in bowel sound, no
renal bruit, no aortic bruit.
NEURO/ we did not take how to do it
MSK/ not done
ENDOCRINE/ we did not take how to do it
On neck examination
Inspection/ visible huge nodular
mass in the anterior aspect of the neck involve thyroid isthmus &
both lobes, take whole anterior triangles and not extended below the clavicle,
RT nodule is more prominent, width 16cm, length 7cm. The mass is
elevated with swallowing but not moved with tongue protrusion, no scar, no
discoloration, no rash over the mass
Palpation/
palpable mass in the anterior aspect of the neck ,normal temperature, no
tenderness, nodular smooth surface, firm, move upward with swallowing, clear
edge, not reducible or compressible, no fluctuation or fluid thrill, not
pulsating, no translucence, she felt shocked during palpation
Percussion/ no dullness in retrosternal area.
Auscultation/no bruit over the mass.
2- pediatric
interesting case in hematology with many details
2- pediatric
interesting case in hematology with many details
................................................................................................................................................
Case about diabetes witch is very important topic in pediatric
Elaf 10 year old saudi
girl originally from Tabuk and lives in Tabuk
History is obtained
from both the patient and her mother.
CC/ she is a known
case of diabetes for 1 year on insulin. Admitted through ER complaining of
abdominal pain, high blood sugar measurement for few hours prior to admission.
HPI/ Elaaf was doing
well till 3 days ago when she had her evening insulin dose and had the usual
dinner, she started to feel fatigue and abrupt onset of mild dull epigastric abdominal
pain with no reliving or aggravating factor, associated with nausea, when she
started to have this complaints, her sister measured her blood sugar and it was
400 mg/dl, and they immediately brought her to the ER. No vomiting or change in
bowel habits, no lower abdominal discomfort, no dysuria or hematuria, no cough,
SOB, or chest pain, no fever or sweating, no convulsion, or loss of
consciousness, no history of weight change or loss of appetite .
Since diagnosis, she
has been complaining of polydypsia, polyphagia and polyuria with painful urination, incontinence and dysuria.
These urinary symptoms got worse with
the present complaint, there is also occasion dizziness after exercise and they
are not sure about any history of hypoglycemia, no history of chest pain, SOB,
or cough.
No vision or hearing
problem, no evidence of impaired sensation or poor wound healing.
PMH/she was diagnosed
to have diabetes 1 year ago in KKH when she complained of Polyuria and polydipsia and it was 500
mg/dl. Since that time, she has been on injectable insulin and the recent dose
is 9 units a.m and 9 units p.m. History of repetitive ER visits for the same
complaint. no history of ICU admission.
for 5 months, she had
have repetitive attacks of convulsions and loss of consciousness. She was
investigated in KKH and diagnosed to have epilepsy ,They prescribed syrup
medications she used it for 5 months then stopped it without her doctor's advice.
She is not following
diabetes clinic due to transportation issue.
No history of allergy,
no history of trauma or blood transfusion, no history of surgeries.
She was fully
immunized at the proper times with no complications.
Developmental history/
she developed normal mile stone, she has an excellent school performance, she differentiates
between right and wrong, she can tell a story.
Nutritional history/
she was exclusively breast-fed. weaning at the age of 6 months and she was
eating from the usual family meal fed for 2 years. Now, she is eating well, low
sugar and fat diet.
Perinatal Hx/
antenatal/ she was booked, no complication, hospitalization or medications
except vitamins and iron.
Natal/ full term normal
vaginal delivery, birth weight was proper but she is uncertain about the exact
weight, no birth complications or injury.
Post natal/no history of any
complication, resuscitation or NICU
admission.
No history of abortion
or stillbirth.
Family history/
Social history/ she is
a student in elementary school, she is repetitively absent due to the same
problem, she is interactive with her classmate, her mother is not educated, not
working and she is the only one taking care of her children, no housemaid.
her father is a
governmental employee, has enough outcome, he is smoking but usually outdoor. She
has 7 siblings, one of them is having chronic illness which make the mother
very distracted and busy. Difficult access to the hospital due to
transportation issue. No history of animal contact or recent travelling.
Examination/ General
Appearance: Elaf was looking well, alert, lying on the bed comfortably, not in
pain or respiratory distress, average body built (Attached growth chart), no
deformity or dysmorphic features. No skin lesion, petechea, pallor, jaundice,
cyanosis or edema. No lymphadenopathy, Iv cannula was inserted to the left hand
not connected to IV line.
VS
HR- 100 bpm, regular,
synchronized, normal peripheral pulse
RR- 20 breaths/m T- 37 ͦ C axillary BP-
not don, not easy accessible.
Growth
parameters (Attached)
Abdomen/ soft, lax, no
tenderness or organomegally, normal bowel sound.
MSK: all extremities
are freely symmetrically moving, no joint swelling ,redness or tenderness.
chest: symmetrical
chest, moves freely with respiration
normal breath sound.
Cardiac: symmetrical
chest, no obvious pulsation ,normal heart sound no added sounds or murmur .
neurological:
conscious, alert, intact cranial nerve, no signs of weakness or atrophy,
normal
muscle tone and power.
..............................................................................................................................................................
ID/ Yasmin, 2 months
Saudi girl, from Tabuk.
History was provided by the
mother(she is the only one taking care of her child).
CC/cough and abnormal
breath sound for 4 days prior to admission.
HPI/ Yasmin was well till
4 days ago when she developed wet gradually progressive cough, aggravated
during feeding. Post tussive vomiting with yellowish sputum, no blood. Mild
wheezing started along with the cough and mouth breathing. She went to private
clinic where they did CXR and diagnosed her as chest infection and gave her O2
once, no medication was given. Next day, she noted worsening of the symptoms
and came to the ER. No fever, No wt loss or sleep disturbance. No cyanosis,
runny nose, SOB, sweating on feeding or edema. No history of recent travelling
or ill contact
ROS/ General and
cardiopulmonary: mentioned in HPI.
GIT and urinary: repetitive abdominal
distension since birth, normal bowel habits and normal urination………
Blood: no anemia, bleeding disorder
or bruises……
MSK: no skin rash, no signs of
inflammation e.g redness, swelling…..
CNS: no irritability, dizziness or
abnormal movement…..
PMH/ not known to have any
medical or surgical problem, no known allergy, no history of hospitalization or
repetitive ER visits
Medication: oral drops PRN for
abdominal distention since she was 2 week- old.
Immunization: took birth
immunization, 2 months' vaccines are not
given yet.
Perinatal Hx/ the mother has no
complication during pregnancy except Iron deficiency anemia, she took 8 Iron
injections at 8th month of gestation, otherwise the baby was healthy
and developed normally. Delivery was normal vaginal with no fetal
complications, birth wt was 3.5 kg, no hospitalization, resuscitation or NICU
admission.
Developmental Hx/ she is moving freely,
elevate her head on prone position on plane of the body, follow moving objects,
smile to her mom.
Feeding Hx/ she was on breast
feeding for first 2 weeks and then shifted to modified infant formula with Iron
(Nan) 4 times a day, 30 ml, plus herbals once a day. The mother is the one who
prepares the bottles and following the instructions on the can.
FH/ the parents are not
related, has 3 siblings age range from 3-7 years, all are healthy. No family
history of chronic diseases.
SH/parents are well
educated, good socioeconomic state easy access to the hospital, no smoking, no
recent travelling, no animal contact.
DDx/ bronchiolitis,
bronchiopneumonia, hyperactive airway disease, GERD
