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Case Write Up Medicine-palliative Care

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  1 Name: Ang yi moi R/N: Date of Birth: Age: 74 years old Gender: female Ethnic Group: chinese Ward: palliative care unit Date of Admission: 1/4/19 Date of Discharge: -- 1.   Presenting complaint(s) My Patient 74 years old lady with underlying stage 4 bladder carcinoma presented to the emergency department (yellow zone ) with pain over the right leg, nausea and vomitting. 2.   History of presenting complaint(s) Regarding the pain over the right leg , was gradual onset and continous,throbbing pain,it was radiating to the right iliac fossa and backbone, associated with nausea ,exerbated my movement, relieved by taking medication such as fentanyl patch,score pain was 7.Patient also complain of more episode of nausea than vomitting.,there was generalized body pain , and malaise.Patient family complained that patient was always drowsy and tired,She did not defecate for 3 days but had flatus ,and had difficulty in passing urine for 2 days even with help of urinary cathether.Patient complained of having colicky abdominal pain over umbilicus region on and off when trying to defecate. Patient had reduced oral intake and poor appetite.Patient could not quantify her weight loss but family member say her clothes gone loose. 3.   Review of Systems Positive findings was loss of appetite for the past 4 days,there was nausea but no complaints of vomiting,there was drowsiness but no dizziness and headache, body ache,dehydrated,warm peripheries. There was no complaints of chest pain, shortness of breath,, no cough ,flu and sore throat. Review of all the other systems are unremarkable 4.   Past Medical History Patient has comorbid such as dyslipidemia and hypertension and is on medication. On february 2017-presented with painless hematuria, loose about 4-5 kg in 2 months. On 19 june 2017--done cystocopy at hospital fatimah, attempted stent but failed,Histopathological (HPE: astypical cells) On july2017- diagnosed to have Right uretric tumour , nephroureterectomy and trnasurectal resection of bladder tumour (TURBT) done.(HP: high infiltration carcionoma) ON 12 january 2018- done TURBT, and (HPE:pappilary transitional cell carcinoma with no muscle invasion) .  2 On 9 APRIL 2018,CT TAP, done, noticed irregular bladder wall thickening with enhancing lesion suggestive of tumour metastasis. Case discussed with oncologist in HKL planned for CECT biposy,results was postive. On 21 june 2018. 29 june 2018-TURBT done for recurrent bladder carcinoma extended to bladder neck. 18 september 2018- radical cystectomy done. Chemotheraphy was not done due to age factor and other risk factor.only radiation was done at hospital selayang. 2019-refered to palliative care unit IPOH hospital. 5.   Past Surgical History Apart from metioned above, no other surgery was done. 6.   Drug History Felodipine 5 mg Simvastain 20 mg Fentanyl patch 12 mg Ensure 38000p + 100 cc water 3 times hourly 7.   Allergies There is no known food or drug allergies. 8.   F amily History Patient has 5 children, 3 daughters and 2 sons.Patient father had hypertension.There was no significant family history of any type of cancer is patient family. *caretaker 9.   Social History Patient is a housewife married with 3 children.Patient had her menopause at the age of 50. Patient is non-smoker and do not consume alcohol. Patient husband had passed away in year 2017 due to road traffic accident.Patient stays with her younger daughter in first garden , ipoh.Patient has her own room and attached toilet . Her eldest daughter and youngest daughter and son is in ipoh,they normally take turn to take care of her. Patient has all her children support, she loves her children alot and claims they take care her alot. husband wife Daughter Stays in ipoh Son Stays in kl Son Stays in singapore Daughter Stays in ipoh Daughter Stays in ipoh  3 Patient is very depressed that she has cancer and wont be able to live longer.Patient is still not aware that she has what type of cancer and still has hope to live painless.Patient daughters ( decision maker)-understands progression of her disease and accepts the truth that her mother does not have much time to live. They want to give the best to their mother and let her have a peacefull and painless death. They have not prepared about their mother after death such as funeral, they are still discusing. Summary: Patient 74 years old lady with underlying stage 4 bladder carcinoma admitted to palliative care unit with somatic and neuropathy pain for optimization of pain control. 10.   Physical Examination General Examination Patient is alert, conscious, cooperative, not in tachypnea state and respiratory distress. She is lying down supported by 1 pillow.with branula inserted on the dorsum of her right hand. Vital Signs Temperature 37.3 ⁰ C Pulse Rate 80 bp/m Respiratory Rate 20 b/m Blood Pressure 120/90 SPO2 at room atmosphere 97% Examination of hands: Patient’s hands are of normal temperature. There is pallor of the palmar creases and nail beds.Patient had warm peripheries. Patient has blusih discolouration patchs over her left dorsum of hand due to iv line. Otherwise there is no other abnormalities such as finger clubbing, koilonychias, palmar erythema, muscle wasting, asterixis or Dupuytren’s contracture noted. Capillary refill test is normal (< 2 secs). The pulse is of good volume and rhythm. Examination of the arms reveals no spider naevi and no engorged vein. Examination of face: Examination of the eyes shows conjunctival pallor; otherwise no jaundice noted. Examination of the mouth reveals poor hydration status with no glossitis and no angular stomatitis. There was poor oral hygiene and dental carries. Examination of neck: There are no neck swelling or palpable cervical, supraclavicular or infraclavicular lymph nodes noted. Examination of legs: There is no pedal oedema and no bruises noted.  4 There was swelling at her right knee develop within 3 days , there was no redness noted, Impresion: bursitis or septic arthirits Examination of back: There is no bony tenderness or deformity noted. Systemic Examination Respiratory system: On inspection there was no scar marks , no abnormal deformity or no engorged vein seen. Upon percusion, it was resonance. Lungs field was clear..Air entry equal for both lungs Gastrointestinal Tract: On inspection, the abdomen is moving with respiration and appears symmetrical with no abdominal distension. Thee was a well healed vertical scare seen over the lower quadrant measuring about 9 cm , there was a weel healed horizontal scar seen over suprapubic region moz probably a surgical intervention was done, and a weel healed 6 cm horizontal scar at the right iliac fossa with no prominent veins, no visible mass, no visible pulsation and no peristalsis noted. The umbilicus is centrally located and not everted. Hernial orifices are intact. On palpation, the abdomen is soft and tender with no guarding or rigidity. There is no palpable mass, no hepatomegaly, no splenomegaly and the kidneys are not ballotable. On percussion, the abdomen is resonant with no ascites noted. On auscultation, normal bowel sounds heard. There is no hepatic or renal bruit noted. . Cardiovascular System: The jugular venous pressure (JVP) is not raised. On auscultation, S1 and S2 are heard with no added sound such as murmur or third heart sound. Central nervous system examination: Cranial nerves were intact. Speech for coherent , mental status : patient is well orientated ti time and place The power of muscle was 3 ,the tone was normal, superfical and deep reflexes was intact, there was muscle atrophy seen on the right and left leg, muscle bulk of the right thigh is lesser then left thigh, plantar reflex was negative.Kernigs sign and brudzinki ’s sign was negative.   Cerebellum examination such as Romberg’s sign was not be done du e to patient unable to stand . Examination of all other systems reveals no abnormalities. 11.Summary Miss Maradiah ,47 yeard old lady c complained of fever for 4 days ,headache and generalized body pain,upon examination there was petechial rashes found on her face,hand ,trunk.legs and poor hydration status .
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