AYAT2 CANTIK UNTUK CASE PRESENTATION

1) CHIEF COMPLAINT
MADAM RAJA , A 60 YEAR OLD MALAY LADY who has no known past
illness , came in / presented / admitted / was referred with a chief complain

2) HOPI

of _______ of ________ duration

With a background history of _________
With no co morbidities / with no known co-morbid
Patient has had diabetes mellitus over the past 6 years
A previously healthy 30 year old malay gentleman
Presented to the emergency department at this hospital with ____
She was apparently well until ___ prior to admission
The patient had been in her usual health until approximately
She was completely healthy when she started /began
He/she had been in good health
He rated the pain as 10/10 in terms of severity / on a scale of 0 to 10 , with

10 indicating the most severe pain

The patient reported
His car collided with ____.she sustained injury to her ______
During this period of time , he saw numerous doctors : however his condition

continue to deteroriate
Her hemoglobin level rose to ____
He was brought to the hospital emergency department at this hospital by an

ambulance , arriving 50 minutes after the onset of chest pain

He was advised to follow up with primary care physician but he did not.
2 days earlier / prior to / before admission / before this current

presentation
On arrival at the hospital ,
The remainder of the tests were normal , as were the result of fasting blood

sugar bla bla bla

He did not record his temperature , but felt as though he had a fever / by

palpating her forehead

Patient does not report any recent trauma , or history of similar symptoms
The pain gradually increased without improvement after pcm

She took her daughter to a clinic

The pain was worse in the morning and was not improved on
PCM provided slight relief
On evaluation by his PCM doctor ,
No documented fever
The pain developed suddenly / abruptly in his right chest while he was
playing badminton.minutes later the pain bcame more severe that it had
stopped her from playing , which he rated as 10 on the scale of 0 -10 with 10

indicating the most severe pain.

He took pcm , the pain gradually improved but the nausea persisted
19 years previously / 18 years back
It abated / resolved spontaneously after 10 minutes
Later that day
When she became aware of / noticed
A pruritic rash initially developed on her left groin , then it gradually

spread to involve face , chin , with sparing of other parts of the body
She received a course of antibiotics for a presumed respiratory tract

infection , and her symptoms resolved/improved

She was unable to identify any specific exposures that might have provoked
her symptoms these symptoms , although she noted that the symptoms

tended to worsen at night

She noted unintentional weight loss of ___
She was previously until 2 am on the night of admission , when she awoke
with .

3) PAST

MEDICAL ILLNESS
He had been remarkably healthy
He has not been instructed in diabetic foot care
Although he was told by his doctor that his past blood pressure readings

were up a little he was not aware of the need to keep BP lower than
His past medical history was significant for
He had had leukemia 3 years ago , but had been successfully treated by

____
She is able to walk about half a block before stopping to catch her breath.
She had a remote history of tuberculosis , but didnt recall the details of

the treatment
She has hypothyroidism for which she takes _____
He was admitted to this hospital multiple times for ______
The past medical history was notable for _____ ( list of illness ) which
necessitated _____ ( procedure / treatment given )

 He had received diagnosis of ____ but declined to be treated

her medications on admission included cetrizine as needed for pruritus

4) PAST SURGICAL HISTORY

In the past he had undergone ___________ for ________
5) FAMILY HISTORY
She has a strong family history of ____ in her _________ ( family
members)
His parents had died of old age / leukemia
Her paternal uncle had brain tumor when his 30s

6) DIETARY HISTORY
His dietary history reveals excessive carbohydrate/ protein /fat intake in

the form of _______________

His normal dinner / breakfast / lunch consists of ____ slices /cups /
He prefers _____
He consumes normal adult diet which normally consist / which would be
His usual meals for the day would be nasi-lemak for breakfast, followed by
roti-canai for mid-morning snack, rice with 23 pieces of chicken /meat /
fish for lunch, a multiple variety of kuih-muih for tea-time and again rice for

dinner
7) MEDICATION HISTORY
He is currently taking / On _______ for ________ x dose x duration
He has tolerated this medication and adheres to the doctor prescription /

daily schedules
He takes ______ 10 mg daily for ______
He has been started by the doctor on ____
He stopped / discontinued this medication when / as / due to
Her medications include _______
Her current medications are unknown
He has not used / taken / consumed any over the counter medications or
herbal supplements for the past / never used
The patient did not recall being told about his diagnosis

8) SOCIAL HISTORY
The patient reportedly drank 9 glass of wine daily
It was not known whether there was history of illicit drug use
He is of Indonesian / African descent n immigrated to Malaysia 20 years

back
He drank alcohol in moderation

The patient was born in Korea , and has immigrated to

He does not smoke , drinks alcohol or use illicit drugs
He has no history of exposure to sick contacts , recent travels
She is widowed and lived with her children in >>>>>
He drank alcohol occasionally but never smoke or used illicit drugs
He is married with 3 kids , currently works as professor and live in Kajang.he
has maintained a monogamous sexual relationship with his wife with no

previous hx of sexual promiscuity

He drink on occasion
He had been laid off by from her job due to
She has smoked approximately 1 pack of ciggates per day for the past 15

years and reported minimal alcohol intake

She is single mother of two children all of whom are healthy
He was divorced with 3 kids and now living alone in
She had smoked 20 sticks per day for 10 years and had quit smoking 10

years prior to this presentation

She is not employed
She has never smoked tobacco or used illicit drug.she does not drink alcohol.
9) SYSTEMS REVIEW
10) PROGRESSION
From then until now , she has been well managed by ______
He was discharged on ____ ( name of meds )
At the time of diagnosis , his blood glucose level was ____
During the next 5 years , her blood sugar level
Despite being on medical rx , his condition became worse ,,,.
She began experiencing _____
She returned to the clinic 3 days later as
Her symptoms has progressed gradually over the preceding 10 months
Despite aggressive treatment, her clinical state deteroriates.
The fever abated on _____ / spontaneously abated
The fever went down on paracetamol
He had experienced chest pain of similar character but less intense over the

preceding 3 mo
It lasted for 5 minutes at a time / for each episode
The O2 saturation 90 % while he was breathing ambient air
The pain was so severe that it had awakened the patient from sleep
It resolved /aborted spontaneously
The remainder of the history is unremarkable
A _______ ( name of procedure ) was performed to ___ ( indication )

He saw a doctor, a diagnosis of fungal infection was made , and fluconazole

was administered with no / without improvement of the symptom.

Patient reported reduced level of pain from 10 to 4
She was able to ambulate without assistance
She was discharged home on ____ with instructions to follow up with her

PCM physicians in ____

She was discharged home on _ and was scheduled for follow up with the

physician
He was in distress because of the
Subjective fevers
He did not follow up with her doctor thereafter
Three years earlier, she was treated with and then the diarrhea resolved.

11) Physical examination:

There were fine crackles at the base of the lung bilaterally.
Other lab results are still pending
Lung fields on both sides are clear to auscultation
There is pitting edema in both legs , to the level of mid-calf
Symmetric calf circuference
12)