Today was my Case Presentation Day with Dr. Che Rosle at 9.00am and I was fairly anxious. I wasn't feeling very confident to present this case because I just clerked the pakcik yesterday, I felt like I haven't prepared much. I wasn't really sure if I'll manage to present the Case correctly or not.
1) At 8.00am, I went to the Ward to see the pakcik, to see how he progressed. I looked for him in his usual bed, in the Respiratory Wing. He wasn't there. I panicked.
Is he dead? :O He was still fine yesterday!
I checked the Discharge File and looked for his name. His name was still here. But where is he?
I asked the Staff Nurse and she pointed to a bed in the Acute Observational Cubicle. I saw the pakcik wearing an Oxygen Mask around his face, and his wife was sitting next to him.
I greeted him and asked about what had happened. He told me that at 4.00am today, he felt breathless and couldn't breathe. His son called the nurses and they gave him Oxygen. He mentioned that he felt like he was almost dying and that I am close to not being able to see him today. He told me that there was pain at the puncture site.
The pakcik coughed and the sputum streaked with blood. There was a H.O Doctor writing his progression on the case file. She auscultated the pakcik's lungs and told me that there were significant findings heard. She asked me to hear it myself.
I thought I could hear crepitations at his lower part of his right lung. Pneumothorax, perhaps.
When he coughed badly, his wife patted him gently on the back, comforting him. I glimpsed at him and saw tears pooling inside his eyes. His wife wiped away the tears and I slowly walked away.
2) My Case Presentation was a little bit messy. I left out a few important histories and my Chief Complaint (CC) was incorrect.
My initial CC:
Mr.Z, a 63-year-old male was admitted to the hospital due to persistent cough for five months duration.
The correct CC:
Mr.Z, a 63-year-old male was referred from Hospital Muadzam to do CT-Guided Biopsy.
I really thought that chief complaint must be a Symptom, so I chose the Cough. According to Dr. Che Rosle, the CC should be the reason why the patient came to the hospital. So, in my case, the patient came to the hospital because he was scheduled to do the Biopsy. In the HOPI, only then I should mention about the Cough.
If the patient came to the hospital for the purpose of the exam, you must say that 'This patient was admitted due to exam purposes'.
I got 6 marks over 10, the lowest among my three friends. They all got 7. Of course I was sad, but my friend Sally reminded me that I should be grateful for it.
Yeah. I definitely should. Based on my insufficient information and the wrong CC, I knew that I could get a lower mark than that but Dr. gave me 6. It was more than enough. Thank you Dr. Che Rosle.
This served as a lesson for me. I should learn how to recognize a Chief Complaint. I need to brush up on my History Taking skills.
3) Tonight my friends and I went to the Ward to clerk patients. I checked on the pakcik and I was glad to see him in the Respi Wing. He looked better than this morning. My friends and I chatted with the pakcik for a while before we saw other patients.
There were new cases admitted tonight - Two dengue patients with white mosquito nets hung over their bed. A young, married Indian male and a 17-year-old teenager who live in Semambu and Kem Batu 10 respectively.
They both have fever and headache. Other presentations were dengue rash, pain behind the eyeballs, exhaustion, joint pain (arthralgia) and muscle pain (myalgia).
We went back at 10.00pm, I dropped off my friend at the Terminal Bus station and I drived straight home.
Monday is Malaysia Day. So I'll be back in the Ward on Tuesday morning.
Happy Holidays, everybody!! :D