i should be more concise

salam.  because of too tired, class from morning till evening today.  i slept at 9.30pm and woke up at 2am. end up i cannot sleep after that because of thinking about the things that i cannot figure out after clerking my patient. she has infective endocarditis. she was diagnosed after taking 3 blood culture taking at different site and after 30 minutes of each.

just imagine. a patient come to you. she is pregnant. coming to hospital because she was referred from maternal health centre due to low haemoglobin level which was 7.6 g/dl.
5days prior to admission she also had loss of consciousness for 30minutes and after regain consciousness  she did not directly seek for medical attention.

the problem is she was referred because of  low haemoglobin level. she did not reveled her LOC as the main complaint at the hospital. . as you know, infective endocarditis, patient will come with history of fever. however when the first time im clerking my patient, she had history of fever. at the first trimester of pregnancy and she just told you that it happened at time of having symptoms of pregnancy...  patient was not concerned about the fever. for her that fever is not the chief complaint for her.  she also had history of cardiac problem a the age of 15 years and completed medication treatment for 1 year. however, she do not know the diagnosis and the treatment she had.

just imagine. if she come to general practitioner in private clinic... then complaint of fever... just treated with paracetamol. and just imagine again... in private clinic they dont have enough time to check you from A to Z. which it private clinic. they just check certain systems only base on your complaint like general examination and respiratory system they might auscultate your lungs but not doing full examination for your cardiovascular system. they got a lot of patients waiting outside.

alhamdulillah, this patient admitted to the ward. i ward doctor have plenty of time to review you 24 hours. all systems were examined. and this patient found out that she had pansystolic murmur.

but i am so sad, because i just got to know that her problem earlier at th age of 15 years old. she had fever  for a week then resolved... then fever come again for  a week and resolved again. i just got the point when im clerking for the second time by using straight forward question. initially you just asked any fever before? that question is not enough because patient might think that the proble is not concern her enough. so you need to justify her,that time whether she frequently developed fever ?
make the things clear, so that she can recall the symptoms that she had.

another thing that make me sad because of myself. for the first time i do CVS examination on her. i am only heard pansytolic murmur . and when i checked her hand i only found she had clubbing.

but i met her for another time and do cvs examination again. it was found that she had janeway lesions but i miss it because it just a little point at the palm... and she said that , there is more lesions like that before and it disappeared after the treatment. and another thing i didnot look properly is that se had corrigan;s sign. and after ausculatate her heart for the second time it not just a pansystolic murmur at the mitral area but she also had end diastolic murmur at aortic area. and she also had collaapsing pulse. oh god. i just realized that i miss all those important signs because i that time, when the first time i came to her. i clerking her for half and hour and do CVS examination by just auscultate the heart and not doing proper from general, checking for the collapsing pulse, JVP and all tose menuver after detectiong the murmur, timing for murmur wheter it is the systolic or diastolic. and yes the reason is i want to finish my examination earlier as i need to cover another 2 patients within 2 hour that night. and i miss all those important signs.

so the thing is. after this i will make sure asking patient properly, giving direct questions to rule out all my differential diagnosis and not just asking open ended questions just why you come here and end up my conversation, anyting you want to tell?any symptoms tht you had? bcause patient sometimes not concerned with the symptoms they had and sometimes they did not realized it.

yes i need to buck up!! especially in the way of taking good history and finding relevant positive and negative signs in patient. read more and learn more. from patient i learn more.