today's patient Mon Week 6 of Gastro block...

morning in liver clinic: Hep C medication follow up, responds to treatment(liver enzyme level does not mean the virus is cleared; viral load is cleared patient may still have elevated liver enzymes), Hep B (Pt from china with an interpreter with her own opinion in interpretation, which is bad...), haemochromotosis (Pt with active Hep C had increased Iron, 100% satuaration, increased ferritin whose mother has recently been diagnosed with haemochromotosis too)

12:30pm: Claire's session on FBE, U/E, asthma, DVT/PE, COPD, smoking cessation and medication adherence. ( realised need to learn FBE and DDx, anaemia and consolidate the DDx for U/E. Need to know those topics back to front, practice the questions Clarie asked today:
-COPD: what is the role of pulmonary rehab? What is the role of surgery in COPD? What is your understanding of nutrition in Pt with COPD? What is the role of immunisation?
-Asthma: Please instruct/assess the patient in terms of using inhalers
-DDx for primary hypothyroidism: hashimoto disease, medication (amiodarone, Tx of thyrotoxicosis, lithium), thyroiditis, (then iodine deficiency, etc). Mx: Hx(fHx, medication, infection, Sx), Test(thyroid antibody)
-hyperthyroidism
*DDx for with low TSH and High FT4 and 3: graves' disease, toxic multinodular goitre, Hashimoto's thyroiditis, thyroiditis, Meds (thyroxine, amiodarone)
*Mx: ultrasound of the neck, looking for malignancy, THEN iodine uptake scan


Afternoon saw 2 cardio patients:
1. 78 y/0 gentlement presented with syncope yesterday and atril flutter on ECG on a background of T2DM, previous heart attack, HTN and hyperlipidaemia.
On inspection, he's an obese, pale looking gentlement lying in bed with mild tachypnoea (22 /min), having normal saline infusion. Obs: BP 150/90, afebrile, Sat 90%RA, PR 60/min.
Apex beat could not be appreciated due to obesity. Soft S1S2 with a very soft ejection systole murmur. No peripheral oedema but absent peripheral pulses. Loss of sensation on both legs up to the knee, with multiple lesions/ulcers and fungal infections?.
A brief Hx was taken. The Pt loss consciousness on the way to the toilet and could not recall the symptoms before the syncope. The patient has had silent inferior myocardio infarction ? years ago.
Meds: insulin, mixtard, atrovstatin (lipertor), clavicil,
The interview was stopped because the Pt would like to rest. May go back and talk to him tmr.

2. 34 y/0 5 wk postpartum lady presented with syncope on a back ground of potential 14 yrs Hx of palpitations and rapid heart beats and 3 yrs Hx of anxiety and panic attacks.

Last Thu, after feeling rapid heart beats, dizziness she loss consiousness for about 1 min. The similar event occured again and her husband noticed her faces turned pale before she passed out.
At the age of 20, she noticed these tachycardic episodes occured, various in frequency. 3 yrs ago, she as diagnosed with anxiety and panic attack associated with hot flush and palpitatoins, relieved by breathing technique. However, the rapid heart beats episodes seem to be consistant and not relived by the breathing technique.
There's no particular trigger for the tachycardia. The Pt reported that the beats were so fast that she couldn't tell whether it's regular or irregular and she couldn't tap out the beats. There is an increased in no. of tachycardia events during her second pregnancy. She drinks 2-3 cups of coffee a day and does not notice any association b/w the episodes and coffee. There's no recent infection, no family Hx of similar problems nor any significant health issues, no previous Hx of heart, thyroid problems and anaemia. She has never smoked and drank occasionally. She is currently on Halter moniter.
ECG: SVT with abrency? VT? to be confirmed......

4:00 CPC: lump in the nect and salivary tumour
most common salivary tumour is mucoepidermal carcinoma....

5:00 metabolic bone disease: bisphosphonate, PTH for oesteoporosis. oesteomalacia and Rickett's, Paget's disease (use bisphosphonate to slow down the bone turnover).