CLINICAL EXAMINATION MELBOURNE 11TH AUGUST 2007 ( afternoon session PAEDIATRY 1! A fat"er of 1# $ont" %o& 'o$e to &o(r G) to*a&!

T"e& +(st 'a$e %a', fro$ "o-i*a&! Last .ee, t"e '"i-* "a* ,in* of f-( so t"e /arent %ro(0"t "i$ to see G)! At t"at ti$e1 t"e '"i-* -oo,e* /a-e so &o(r 'o--ea0(e arran0e* so$e %-oo* test for "i$! B-oo* test res(-t s"o.e* ane$ia $i'ro'&ti' "&/o'"ro$i' .it" -o. iron -e2e-! ( In t"e e3a$ settin0 1 res(-t .as 0i2en s"o.e* t"e H%1 MC41iron an* ferritin -e2e- .it" t"e nor$a- ran0e to 'o$/are Tas, 5 ta,e f(rt"er "istor& E3/-ain t"e %-oo* test res(-t to t"e fat"er1 an* $ana0e 6"en ta,in0 "31 t"e '"i-* .as %reastfe* %efore1 no. a-rea*& on so-i* %(t 2er& re-('tant to eat1 $ore ,een on *rin,in0 'o.7s $i-, an* *rin,s a -ot ( I 'ant re$e$%er "o. $('" !No "3 of %-oo* *isor*er in t"e fa$i-&1 no "3 of re'ent-& %-ee*in0 or %-oo* -oss! A "ea-t"& '"i-*1 2a'' is (/ to *ate1 no 'on'ern a%o(t 0ro.t" an* *e2e-o/$ent! No $a+or i--ness!6"en I as,e* if t"e %a%& is 0ainin0 .ei0"t1 fat"er to-* $e1 "e a't(a--& .ants to ,no. ."et"er "is %a%&7s 0ro.t" is o,1 so I as,e* a%o(t /re2io(s 0ro.t" '"art7s res(-t an* ."et"er "e %ro(0"t t"e %oo, .it" "i$1 fat"er 'an7t re$e$%er an* not "a2in0 t"e %oo, .it" "i$!I as,e* e3a$iner ."et"er I 'an "a2e 0ro.t" '"art1 t"en e3a$iner 0a2e $e t"e %o&7s .ei0"t an* "ei0"t an* t"e 0ro.t" '"art an* as,e* $e to s"o. "i$ first an* t"en e3/-ain to t"e fat"er!T"e 0ro.t" '"art is nor$a- (a%o(t 28t" 980t" /er'enti-e1 'ant see '-ear-& %e'a(se t"e -ines fa*in01 %(t a--o. to *ra. t"e -ine on t"e 0ro.t" '"art to $a,e it '-ear !After t"at1 I e3/-aine* t"at "is %a%& :s 0ro.t" is o,1 sti-- 0ainin0 .ei0"t1 ."en I .ante* to e3/-ain f(rt"er a%o(t 0ro.t" '"art1 e3a$iner sto//e* $e an* as,e* +(st te-- t"e fat"er1 it7s nor$a- or not! An* t"en1 I e3/-aine* t"e %-oo* test res(-t 1 ."at7s t"e reason "e "as iron *ef ane$ia! I to-* fat"er 'o.7s $i-, 'an $a,e "i$ 0ainin0 .ei0"t1 %(t 'o.7s $i-, a-so 'an 'a(se o%s'(re %-ee*in0 an* %-oo* -oss in "is *i0esti2e s&ste$1 e2ent"o(0" .e 'an7t see it in t"e stoo- .it" na,e* e&es! I a*2i'e fat"er to offer so-i* foo* first %efore 0i2in0 $i-,1 so t"e '"i-* .i-- eat1 -i$it t"e $i-, inta,e1 an* .o(-* %e %etter if 'an '"an0e to for$(-a $i-, ."i'" "as %een fortifie* .it" iron an* /res'ri%e* t"e '"i-* .it" iron s&r(/ an* s(00est t"e fat"er to (se stra. so it .i-- not stain t"e teet" ( a-$ost for0ot to 0i2e iron1 t"an,f(--& t"e fat"er as,e* $e ."et"er .e nee* to treat t"e ane$ia ;at"er as,e*1 any side effect of the treatment t"en I ans.ere* it 'an 'a(se 'onsti/ation so nee* to 0i2e $ore fi%re into "is *iet! ;at"er as,e* a0ain1 how long he will be back to normal. I sai* it *e/en*s on "o. &o( $ana0e .it" "i$! If "e ,ee/s *rin,in0 'o.7s $i-, a -ot an* re-('tant to eat 1 t"e i$/ro2e$ent .i-- %e s-o. %(t if t"e a*2i'e is fo--o.e*1 I e3/e't to see i$/ro2e$ent at -east 2 /oints in "is iron -e2eafter < .ee,s t3 ( I7$ not s(re a%o(t t"is an* *on7t ,no. ."& I sai* t"at1 /-ease '"e', it !

;at"er as,e* $e what the risk of anemia1 I e3/-aine* it .i-- 'a(se "i$ /rone to 0et infe'tion1 $a,e "i$ .ea, an* .i-- affe't "is 0ro.t" an* *e2e-o/$ent! I as,e* fat"er if "e "as an&$ore =s1 "e sai* no so I finis"e* t"is station ear-ier! 2! A %a%& 0ir- ( 'an7t re$e$%er t"e a0e "as *iarr"ea in t"e -ast 2< "o(rs1 %reastfee*! ;at"er no. %rin0 "er to see &o( in G) settin0 Tas, 5 f(rt"er "istor& As, /"&s! ;in*in0 fro$ e3a$iner Mana0e t"e 'ase On "31 t"e %a%& starte* to "a2e *iarr"ea in t"e -ast 2<"o(rs1 rea--& .ater& stoo-1 'an7t see a %it of fe'es1 on-& .ater& *iarr"ea1 no $('(s 1no %-oo*1 *oesn7t -oo, oi-&1 not s$e--& an* offensi2e1 >(ite often '"an0e t"e na//ies %e'a(se of t"e *iarr"ea ( I 'an7t re$e$%er "o. often 6"en as,e* a%o(t .et na//ies1 fat"er sai* "e7s not s(re %e'a(se it $i3e* .it" stoo- ( fair eno(0"1 I t"in, %(t "e sai* "is %a%& *oesn7t -oo, too *e"&*rate*! On f(rt"er >(estionin01 fat"er sai* %a%& s(',s -ess t"an %efore "o.e2er sti-- .ant to fee*! Ba%& *oesn7t 0o to '"i-* 'are1 is ta,en 'are %& t"e /arents at "o$e1 "as ot"er ,i* at "o$e1 .as (n.e--1 sort of f-( &ester*a&1 %(t no. o, an* 0o to '"i-* 'are! No one e-se si', at "o$e! 4a'! is (/ to *ate an* no 'on'ern a%o(t 0ro.t" an* *e2e-o/$ent! On /"&s! ;in*in01 *oesn7t -oo, too *e"&*rate*1 ."en as,e* a%o(t s,in t(r0or1 e3a$iner sai* %or*er-ine! 4ita-s as I 'an re$e$%er .ere >(ite nor$a-1 ot"er s&ste$s (nre$ar,a%-e! 6"en I as,e* if I 'an "a2e a -oo, at t"e na/& +(st to see ."at t"e stoo-s -oo, -i,e1 t"e e3a$iner sai* ( 'an *o ."ate2er ( .ant %e'a(se it7s (r G)1 %(t not te--in0 $e ."at7s t"e res(-t1 an* "onest-& I *i*n7t 'at'" ."at "e $eant1 so I *e'i*e* to 0o strai0"t to t"e fat"er I e3/-aine* ."at "is %a%& 0ir- "as an* it7s 2er& 'o$$on! T"e *iarr"ea .i-- sett-e *o.n .it"in fe. *a&s1 +(st $a,e s(re 0i2e t"e %a%& eno(0" f-(i*s1 'ontin(e %reastfee*in01 0i2e t"e 0astro-&te in %et.een! I te-- t"e fat"er "o. to $a,e t"e 0astro-&te or "e a-so 'an %(& it fro$ /"ar$a'&! I to-* t"e fat"er t"e .arnin0 si0ns ."en "a2e to 'o$e %a', to $e or 0o to E?1 ot"er.ise I .i-- re2ie. "is %a%& in @ "o(rs! ;at"er asked about antibiotic1 I sai* anti%ioti' *oesn7t .or, for t"is 'ase as t"e 'a(se is 2ir(s! I 0i2e t"e /a$/"-et a%o(t t"e 0astro an* a-so t"e .arnin0 si0ns ."en "a2e to 'o$e %a',!I as,e* "i$ ."et"er "e "as =s1 "e sai* no1 %(t "e re/eat a0ain so I 'an %rin0 "er "o$eA I sai* &es1 %(t re$in* "i$ a0ain I .ant to re2ie. t"e %a%& a0ain in @ "o(rs1 "o.e2er if "e noti'e* t"e %a%& *rin, -ess or (7re not a%-e to 0i2e "er f-(i* at a--1 -ess .et na//ies1 -oo,s *ro.s&1 t"en s"o(-* %rin0 "er %a', ear-ier !T"en1 t"e fat"er sai* "e "as no $ore =s! I finis"e* t"e station ear-ier1 %(t t"en I re$e$%er I *i*n7t ta-, a%o(t "&0iene an* a*2i'e fat"er to ,ee/ t"e %a%& a.a& fro$ "er %rot"er (nti- t"e *iarr"ea sett-es! I .as (/set1 %e'a(se +(st not re$e$%er ."en .as sti-- in t"e roo$1 In fa't I sti-- "as ti$e %(t not (se it effe'ti2e-&! On'e ( 0o o(t of t"e roo$1 ( 'an7t 0o %a', a0ain

B! A fat"er of B &ear o-* 0ir- 'o$es to &o(r G) settin0 %e'a(se "is *a(0"ter "as %een 'r&in0 an* 'o$/-ain a%o(t /ain e2er& ti$e ."en s"e /ass (rin for t"e -ast t.o *a&s! S"e "as "a* fe. si$i-ar e/iso*es %efore ."i'" "a* %een sett-e *o.n %& itse-f! T"ere is re**enin0 on "er 2(-2a an* s-i0"t &e--o.is" *is'"ar0e on "er (n*er.ear to*a&! MSU res(-ts 5 e/it"e-ia- 'e--s1 no -e('o'&te1 no nitrite1 "as sent t"e (rine for '(-t(re1 res(-t "asn7t %a', &et Tas, C As, f(rt"er '-arif&in0 =s Ta-, to t"e fat"er a%o(t t"e 'on*ition an* ans.er t"e fat"er7s =s Mana0e t"e 'ase I as,e* an& fe2erA ;at"er sai* no1 6"en s"e 'r&1 *oes s"e *ra. "er -e0s (/A No An& t($$& /ainA No1 A%o(t t"e *is'"ar0e1 is it offensi2eA No1 Is it %-oo* staine*A No An& ."itis" /-a>(e on t"e *is'"ar0eA No1 S$e--&A No ?oes s"e s'rat'" "er %otto$ a -ot es/e'ia--& at ni0"tA Not t"at .e a.are1 6"o -oo,s after "er (s(a--&A Me an* $& .ife An* of 'o(rse ( -o2e (r *a(0"ter1 *o &o(A Des I *o A%o(t /re2io(s si$i-ar e/iso*es1 *i* ( %rin0 "er see an& *o'torA No %e'a(se it7s 0one %& itse-f Sti-- on na/&A Des1 so$eti$es No ot"er 'on'ern a%o(t "er ot"er "ea-t"A No 4a'' is (/ to *ateA Des T"en1 I e3/-aine* it7s 2(-2o 2a0initis1 inf-a$$ation of "er /ri2ate area1 2er& 'o$$on *(rin0 t"is a0e %e'a(se t"e s,in aro(n* t"at area sti-- t"in 1 easi-& 0et irritate* an* inf-a$e*1 a-so %e'a(se t"at area ten*s to %e $oist! Not a serio(s 'on*ition in $ost 'ases1 as ( see s"e "a* it %efore an* t"e& sett-e* *o.n %& t"e$se-2es .it"o(t 'a(se "er an& /ro%-e$1 .i-- 0ro. o(t of it as s"e 0ets o-*er1 a*2i'e t"e fat"er to ,ee/ "er fro$ na//& as $an& "o(rs as /ossi%-e1 if s"e /ass (rin1 as, "er to *o it .it"er -e0s a/art1 '-ean it .it" .ater an* .i/e *r& .it" soft tiss(e fro$ front to %a',1 for t"e ras"1 'an (se na//& ras"1 a2ai-a%-e fro$ /"ar$a'&! I to-* t"e fat"er s"e $a& 0et it a0ain1 %(t *on7t .orr&1 +(st re/eat t"e a*2i'e1 I 0i2e t"e /a$/"-et a%o(t it1 *on7t /(t ta-, or *eo*orant on t"at area! ;at"er as,e* why she cries when passing urin is it because of infection! I sai* s"e 'ries %e'a(se ."en s"e /ass (rin1 t"e (rin .i-- 'o$e into 'onta't .it" t"at inf-a$e* s,in1 an* it7s /ainf(-! Un-i,e-& to %e infe'tion1 sin'e t"e (rin test *oesn7t s"o. an& si0ns of infe'tion1 an* an&.a& .e "a2e sent it for '(-t(re so +(st .ait for t"e res(-t E"aminer asked me what are the DD# ! I sai* UTI1 /in.or$ infe'tion1 'an*i*iasis1 '"i-* a%(se! B(t a-- of t"e$ are (n-i,e-& as I "a2e e3'-(*e* t"e$ fro$ t"e "istor& I as,e* t"e fat"er ."et"er "e sti-- "as an& =sA He sai* no! I finis"e* t"e station ear-ier! $%Y& 'Y( 1! A &o(n0 .o$an 'o$e to &o(r G) for "er /a/ s$ear res(-t ."i'" s"o.e* -o. 0ra*e a%nor$a-ities! S"e7s no. in sta%-e re-ations"i/! Her /re2io(s /a/ s$ear .as nor$a-! S"e .i-- as, &o( "o. s"e 0et t"at Tas, 5 as, f(rt"er re-e2ant =s E3/-ain t"e res(-t 1 ans.er "er =s an* $ana0e t"e 'ase

I as,e* if s"e a-.a&s "a2e /a/ s$ear e2er& 2 &earsA Des a-- t"e /re2io(s res(-ts .ere nor$a-A Des! I (n*erstan* t"at &o( are no. in sta%-e re-ations"i/ .it" (r /artner1 "o. a%o(t /re2io(s-&1 if ( *on7t $in*A I "a* se2era- /artner %efore t"is one An& /ro%-e$ -i,e /ain *(rin0 se3(a- inter'o(rse or %-ee*in0 after.ar*sA No1 An& .ei0"t -ose1 tire*ness1 *is'"ar0e or %-ee*in0 o(tsi*e t"e /erio*A No1 I to-* t"e /atient I *on7t "a2e 0oo* ne.s1 t"is ti$e (nfort(nate-& t"e res(-t is not nor$a-! It s"o.e* so$e '"an0es in t"e 'e--1 %(t t"e 0oo* t"in0 is it7s not a 'an'er an* 'an %e treate*! If -eft (ntreate* it 'an /ro0ress to 'an'er! )atient as,e* what the cause of this changes! )hy she has it now because it was normal before does she get it from her current partner! I ans.ere* it7s *(e to H)4 infe'tion1 a-$ost a-- se3(a--& a'ti2e .o$an "as %een infe'te* %& t"is 2ir(s %e'a(se it7s 2er& 'o$$on 2ir(s1 "o.e2er $ost of .o$an 'an 0et ri* of t"e 2ir(s %& t"eir i$$(ne s&ste$! So$eti$es in so$e 'ases t"e 2ir(s 'an re$ain in t"e %o*& an* ."en a'ti2ate* it 'a(ses '"an0es 1 &o( $a& 0et t"is 2ir(s fro$ /re2io(s /artners an* no. t"e 2ir(s %e'o$e a'ti2e 1 an* t"e /a/ s$ear is on-& a s'reenin0 test! *an I gi+e it to my partner! Do I need to use condom! &o(r /artner $a& 0et 0enita- .art if infe'te* .it" t"e 2ir(s1 not %a* i*ea to (se 'on*o$ an* /ra'ti'e safe se3A I7-- refer &o( to 0&nae'o-o0ist for f(rt"er in2esti0ation an* t3 ( I e3/-aine* a%o(t 'o-/os'o/&1 %io/s&1 -aser treat$ent1 -ar0e -oo/ e3'ision1 'one e3'ision an* te-- t"e /atient s"e $a& nee* $ore fre>(ent /a/ s$ear /ro%a%-& &ear-&1 %(t s/e'ia-ist 7-- a*2ise ( f(rt"er a%o(t t"at!S"e as,e* what will happen to my baby if I pregnant! As I7$ not s(re t"e effe't to t"e %a%&1 so I sai*1 .e-- it *e/en*s on t"e treat$ent t"at ( "a2e1 if it7s 'one e3'ision1 t"ere7s a ris, for $is'arria0e %e'a(se t"e 'er2i3 %e'o$es .ea, %(t (s(a--& after t"e treat$ent1 it7s fo--o.e* %& re/airin0 t"e 'er2i31 .e 0i2e sti'"es to $a,e it stron0! I as,e* if s"e "as an&$ore =s1 s"e sai* no1 t"en I 0i2e "er /a$/"-et a%o(t a%nor$a- /a/ s$ear test res(-t an* a-- t"e infor$ation t"at I te-- "er .i-- a-so %e in t"e /a$/"-et! I finis"e* ear-ier! 2 ! A 2< .ee,s 0estation .o$an 'o$es to &o(r G) '-ini'! S"e7-- 'o$e to &o( fro$ no. on for "er ANC '"e', (/ as s"e +(st $o2e* fro$ 'it& area to t"is 'o(ntr& si*e!S"e "as %oo,e* for "er *e-i2er& in a "os/ita- in t"e 'it& ."i'" #0 ,$ fro$ "er "o(se!T"is is "er se'on* /re0nan'&! S"e .ants to ,no. ."en s"e s"o(-* 0o to "os/itaTas, 5 as, f(rt"er =s Te-- "er ."en s"e s"o(-* 0o to "os/ita-1 an* ans.er "er =s T"is is $& first station1 T"e ro-e /-a&er .as not /re/are* at a--1 s"e see$e* 'onf(se* "o. to ans.er $& =s1 ,ee/s -oo,in0 to e3a$iner "o. s"e s"o(-* res/on* an* se2erati$es -oo,e* at t"e /a/er ."i'" .as on t"e f-oor for ans.er On =(estionin01 "er first /re0nan'& .as (n'o$/-i'ate*1 %(t "a* for'e/s *e-i2er& (not s(re a%o(t /ro-on0e* an* *iffi'(-t -a%o(r as ro-e /-a&er not 'onfi*ent in ans.erin0 t"is1 e2en for for'e/s s"e first sai* 2a0ina- *e-i2er&1 -oo,e* at t"e /a/er t"en sai* .it" for'e/s no 'o$/-i'ation after *e-i2er&1 %a%&7s no. "ea-t"&! ;or se'on* /re0nan'&1 "as re0(-ar ANC1 "er /re2io(s %-oo* test .ere a-- nor$a-1 USG s"o.e* nor$a-1 sin0-e

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%a%&1 nor$a- /-a'enta! No "3 of "i0" B) or *ia%eti' in "er /re2io(s /re0nan'& an* %efore /re0nan'&!S"e is R" (9 I to-* t"e /atient a-- t"e si0ns ."en s"e s"o(-* 0o to "os/ita-! I a*2i'e* "er sin'e s"e "as %oo,e* for "er *e-i2er&1 if s"e "as a 'o$/-i'ate* /re0nan'&1 t"en %etter for "er to a--o'ate to -o'ation near to "os/ita-1 e2ent"o(0" s"e "as a 'ar! S"e "as re-ati2e t"at -i2e '-ose t"ere1 so .i-- not a /ro%-e$ !If "er /re0nan'& r(ns s$oot"-& t"en o, for "er to sti-- sta& in "er "o(se %(t ."ene2er s"e "as t"at .arnin0 si0n 1%etter for "er to 'a-a$%(-an'e to %rin0 "er to "os/ita-1 S"e -i2es .it" "er "(s%an*! S"e as,e* how long will be my labour! ( after -oo,in0 to t"e /a/er a0ain E I to-* "er it7s not eas& to ans.er t"is =s1 as it .i-- *e/en*s on $an& fa'tors1 t"en I $entione* t"ose fa'tors1 "o.e2er I sai* (s(a--& it7-- %e >(i',er t"an t"e /re2io(s one! I sai* in first ti$e $ot"er1 .e e3/e't t"e *e-i2er& .it"in 1291@ "o(rs1 t"e ne3t one $i0"t ta,e .it"in 10912 "o(rs1 %(t a0ain 2er& s(%+e'ti2e! I arran0e* s.eet *rin, test for 2@ .ee,s an* a*2i'e "er to "a2e re0(-ar ANC '"e', (/! I finis"e* ear-ier! B! A &o(n0 .o$an in "er t.enties 'o$e to &o(r G) .orr& a%o(t not "a2in0 /erio* for 12 $ont"s Tas, 5 as, "3 As, for /"&si'a- fin*in0 an* In2esti0ations ( on-& 0i2en ."at &o( as,e* Te-- t"e /atient ."at *o &o( t"in,1 "o. &o( $ana0e t"e 'ase On H3 1 "as irre0(-ar /erio*s %efore an* 0ettin0 -ess an* -ess %(t no. "as sto//e* for 1 &ear1 0enera--& "ea-t"&1 no $e*i'a- i--ness1 not in stress1 not on e3'essi2e *iet1 "a//& .it" t"e %o*& .ei0"t an* s"a/e1 no '"an0es in .ei0"t1 not *oin0 e3'essi2e e3er'ise 1 (se* to se3(a--& a'ti2e1 %(t not no.1 not on an& 'ontra'e/tion1 no /referen'e for .eat"er1 no $i-,& *is'"ar0e fro$ ni//-e1 no a'ne1 no e3'essi2e "air 0ro.t" on fa'e an* (//er ar$s1 not on an& $e*i'ation1 /a/ s$ear 1 &ear a0o an* nor$a- 1 no a%*! )ain1 no *is'"ar0e1 no ot"er 'on'ern a/art fro$ not "a2in0 /erio*! At t"is /oint I *on7t ,no. an&$ore ."at to as,1 so I sai* to t"e /atient1 I ,no. it so(n*s si--& =s1 *o &o( fee- -i,e &o(7re /re0nantA T"e ro-e /-a&er .as 0i00-in0 an* ans.ere* $e no ( I ,no. it7s st(/i*1 t"e %a%& "as a-rea*& %orn if s"e7s /re0nantFF ;or fin*in01 e2er&t"in0 is nor$a-1 BMI nor$a-1 2ita- si0ns N1 no -an(0o "airs1 no t"&roi* en-ar0e$ent1 no 0a-a'torr"ea1 no "irs(tis$ an* a'ne! On I31 sti-- not satisfie*1 I sti-- as,e* for /re0nan'& test1 I sai* to e3a$iner1 I ,no. it7s 2er& (n-i,e-& %(t sti-- .ant to *o it! Res(-t ne0ati2e! ;SH1 LH1 are N1 testosterone not a2ai-a%-e1 TSH N1 Oestrio-o.1 )ro-a'tine <3 in'rease1 USG /e-2is1not a2ai-a%-e So I to-* t"e /atient t"e 'a(se is *(e to t"is "i0" -e2e- of /ro-a'tine "or$one! )atient as,e* why she has this high hormoneA I sai* $ost -i,e-& *(e to 0ro.t" in t"e $aster 0-an* in t"e %rain t"at ,ee/s /ro*('in0 t"is "or$one1 I .i-- arran0e 't s'an! Is it a cancer! I sai* (/ to t"is /oint1 I 'an7t sa&1 it $i0"t %e on-& a 0ro.t" t"at sti$(-ate t"e $aster 0-an* to /ro*('e t"is "or$one1 -et7s .ait for 't res(-t an* I .i-- refer ( to s/e'ia-ist ."en .e 0et t"e res(-t! Is it ok not ha+ing period for ,- months! ( ro-e/-a&er .as ni'e1 I *efinite-& for0ot it if s"e *i*n7t as, $e t"at =s1 I sai* it $a& 'a(se t"innin0 of t"e %ones1 $a,e it eas& to %rea, .it" $inor in+(r& or fa--1 .e 'a-- it osteo/orosis1 so I .i-- arran0e ot"er test %one *ensi$etr&1 an* refer ( to G&nae'o-o0ist as ( $a& nee* to "a2e "or$one t31 $ost-i,e-& OC) ( I7$ not s(re ."et"er G) 'an

/res'ri%e1 as I re$e$%er one of t"e 'a(se of "i0" /ro-a'tine is OC)1 so +(st refer to s/e'ia-ist E3a$iner as,e* $e any medication for high prolactine! I 'an7t re$e$%er t"e na$e at a-- at t"at ti$e1 so I sai* &es1 %(t 'an7t re$e$%er t"e na$e1 T"e e3a$iner to-* $e %ro$o'ri/tine! I t"in, I finis"e* t"e station ear-ier ME?ICINE AN? SURGERD 1! Do(r /atient t"at &o( ,no. .e--1 -ast ti$e "a* a %it *is'o$fort in "is '"est1 &o( 0a2e "i$ GTN -ast ti$e an* it reso-2e* so &o( arran0e* stress test! ?(rin0 t"e test1 "e "a* ti0"tness an* *is'o$fort in "is '"est an* a-so "is ECG s"o.e* st *e/ression in antero -atera- ( not s(re1 /-ease '"e',e* it .it" ot"er !His $e*i'a- re'or* .as 0i2en in t"e e3a$ s"o.e*1 s$o,es for $an& &ears1 "as trie* to '(t *o.n to B9< 'i0areetesG*a&1 *rin,s o''asiona--&1 B) ( 'an7t re$e$%er1 I t"in, it7s nor$a-AA '"o-estero- @1 no H3 of *ia%etes! Tas,5 te-- t"e /atients t"e res(-t an* &o(r $ana0e$ent s"ort an* -on0 ter$ $ana0e$ent In t"is 'ase1 %asi'a--& *o C4S ris, assess$ent1 I to-* t"e /atient "is ECG 'onsistent .it" 'oronar& arter& *isease an* e3/-aine* ."at it is an* to-* "i$ "e "as se2era- ris, fa'tors in'-(*in0 "is a0e an* 0en*er! If -eft (ntreate* "e $a& "a2e "eart atta', .e asked me Does he ha+e heart attack! I sai* no it7s *ifferent1 in "is 'ase "is "eart $(s'-e on-& -a', of o3&0en (is'"ae$ia In "eart atta',1 t"e "eart not 0ettin0 o3&0en an* $a& *ie ( infar't an* I to-* "i$ t"e s$o,in0 is t"e iss(e "ere1 I (n*erstan* &o( "a2e trie* to '(t it *o.n1 (nfort(nate-& it7s not eno(0"1 'a(se 'an $a,e t"e %-oo* 2esse-s s/as$ an* $a,e t"e narro.in0 .orse1 T"e ro-e /-a&er (I t"in, a *o'tor sai* "e7-- tr& to '(t *o.n! I +(st s$i-e1 an* sai* I ,no. it7s not eas& an* I a//re'iate &o(r effort1 "o.e2er t"is is for &o(r o.n "ea-t"1 .e 'an *is'(ss it $ore *etai- "o. to sto/ s$o,in01 I7-- $a,e anot"er a//oint$ent for &o( to ta-, a%o(t it if t"at7s o,! T"e ro-e /-a&er s$i-e an* sai* o, *o'tor if &o( t"in, t"at I rea--& "a2e to sto/!I t"en sai* I7-/res'ri%e "i$ .it" GTN an* as/irin ( I as,e* first an& /ro%-e$ .it" in*i0estion an* to-* "i$ ."at s"o(-* %e *one if t"e atta', "a//ens a0ain an* if it *oesn7t reso-2e .it"in 8910 $in(tes t"en 'a-- a$%(-an'e! .e asked me whether he will ha+e open surgery1 I sai*1 .e-- if -eft (ntreate* t"e narro.in0 'an 0et .orse ."i'" e2ent(a--& .i-re>(ire s(r0er&! He as,e* $e how about se" can I still ha+e it! I sai* se3 $i0"t tri00er t"e atta', as ."en ( *o se3 &o(r "eart .i-- /($/ an* .or, "ar*er1 %(t a0ain ."en &o( "a2e fee-in0 *is'o$fort in (r '"est1 ta,e t"e *r(0s1 If not reso-2e1 'a-a$%(-an'e! I ta-, a%o(t ot"er -ifest&-e $o*ifi'ations! He as,e* $e a%o(t ."at e3er'ise1 "o. a%o(t if "e 0ot /ain1 I to-* "i$ to *o it 0ra*(a--&1 *on7t o2er *o it1 if "a2e /ain "a2e to sto/1 %ris, .a-,in0 is 0oo* ! I as,e* "i$ ."et"er an& ot"er =s1 "e sai* no! I $a*e a//oint$ent to see "i$ a0ain !I 'a$e o(t ear-ier1 after t"at I re0rette* as I for0ot tota--& to $ention an0io0ra/"& an* for0ot a-so a%o(t t"e '"o-estero-1 e2en not s(re if I $entione* a%o(t *iet or not! If t"is is 'riti'a- error 1 I fai- t"is station1 e2ent"o(0" not *iffi'(-t one! I *on7t ,no. ."& I $a*e t"ese si--& $ista,es

2!

A @0 &ear o-* -a*& 'o$es to &o(r G) 'o$/-ainin0 a%o(t .ea,ness in "er ri0"t -e0 2 .ee,s!S"e is a *ia%eti' /atient1 .e-- 'ontro--e*1 on $etfor$in Tas, 5 f(rt"er "31 as, for fin*in0 an* $ana0e

On "31 s"e "as it in e/iso*es1 B e/iso*es in t"is 2 .ee,s1 a-so on "er ri0"t ar$ as .e--1 no n($%ness1 no /in nee*-es or tin0-in0 sensations1 on-& .ea,ness! No /ro%-e$ .it" t"e -eft si*e! No *iffi'(-t& on s.a--o.in01 no '"an0es in "er s/ee'"1 ne2er "as e/iso*e of s(**en %-(rrin0 e/iso*es %efore! No. fee- o,1 ne2er "a2e /ro%-e$ .it" '"est /ain1 no "3 of "i0" B)1 fat"er *ie* %e'a(se of "eart atta', at @0 so$et"in01 s$o,es 'i0arettes "ea2i-& sin'e &o(n01 I 'an7t re$e$%er a%o(t a-'o"o-1 *o e3er'ise re0(-ar-&1 "er -ast %-oo* s(0ar -e2e- .as nor$a-1 ."en I trie* to e3/-ore f(rt"er a%o(t "er *ia%eti'1 t"e /atient trie* to 0i2e $e si0na- t"at it7s o, .it" "er s(0ar! Not on an& ot"er $e*i'ations On fin*in01 BMI nor$a-1 2ita-s are N1 re0(-ar /(-se1 no "i0" B)1 'aroti* %r(it is "ear* on "er -eft 'aroti*1 H4) n1 "eart is '-ear1 ne(ro-o0i'a- e3a$ination ( tone1 /o.er1 ref-e3es1 sensation1 'rania- N is nor$a-! ?i/ sti', an* fin0er /ri', test for s(0ar N! I to-* t"e /atient it7s TIA1 e3/-aine* to "er ."at it is1 an* refer "er to "os/ita- for %-oo* test ( ;BC1 H%A1C1(Ie an* 'reatinine1 fastin0 s(0ar an* -i/i* /rofi-e1 'aroti* ?o//-er USG1 %rain 't s'an1 e'01 '3r an* te-- t"e /atient a%o(t -ife $o*ifi'ations an* if t"e 't is nor$a- t"en .i-- /res'ri%e "er .it" as/irin! 6"en I as,e* ."et"er s"e 'a$e "ere a-one an* nee* $e to or0aniJe ta3i as s"e %etter not *ri2e to "os/ita- "erse-f1 s"e sai* "er "(s%an* .i-- /i', "er (/ an* *ri2e "er to "os/ita- !I finis"e* ear-ier1 t"is is t"e $ost re-a3in0 station1 t"e ro-e /-a&er .as 2er& ni'e -a*&! I *on7t ,no. ."et"er s"e7s a-so a *o'tor or not! T"ere .ere 2 e3a$iners in t"is station! <! )"oto of t"e -e0 .as 0i2en 1 s"o.in0 (-'er on t"e -atera- si*e of t"e -e0 .it" so$e /i0$entation aro(n*! A t&/e 1 ?M /atient 'o$es to &o(r G) settin0 %e'a(se of t"e (-'er on "er ri0"t -e0 Tas, 5 as, H31 /"&si'a- fin*in0 an* $ana0e On "31 t"e (-'er "as %een t"ere for fe. $ont"s1 starte* .it" s$a-- .o(n* t"en %e'o$e %i00er an* %i00er1 /atient 'an7t re$e$%er "o. t"e .o(n* "a//ene*1 /ro%a%-& ."en *o 0ar*enin0 0et in+(re*! Not /ainf(-1 not it'"&! No /ain in t"e -e0 on .a-,in01 no n($%ness1 /in nee*-es on %ot" -e0s! On-& "as ?M an* .e-- 'ontro--e*! Ha* -e0 fra't(re %efore on t"at -e0 10 &ears a0o an* a-so ?4T %efore1 .as treate* .it" .arfarin for fe. $ont"s an* sto//e* a''or*in0 to *o'tor a*2ise*! Not s$o,in01 not on an& $e*i'ation 1 e3'e/t ins(-in ( I for0ot to as, /i-- S"e is a ta3i *ri2er1 $ost of t"e ti$e sit a -ot On e3! BMI is N 1 2ita-s are N1 -e0 e3a$ on-& s"o. s.e--in0 aro(n* t"e (-'er1 no ot"er s.e--in01 t"ere7re so$e 2ari'ose 2eins on t"e -atera- as/e't of t"at -e01 a-- /(-ses are /a-/a%-e1 ABI is N1 tren*e-en%(r0 test s"o.e* in'o$/eten'e 2eins %e-o. t"e ,nee No -&$/" no*es /a-/a%-e on in0(ina- area So e2ent"o(0" t"e (-'er on -atera- as/e't1 I sti-- $a*e a *ia0nosis as 4eno(s (-'er1 as a-- t"e /(-ses are /a-/a%-e an* a-so ABI is nor$a-! I e3/-aine* t"e /atient ."at it is1 "o. it "a//ene* an* it ta,es ti$e to "ea- ! I to-* t"e /atient to e-e2ate t"e -e0 as $an& "o(rs as /ossi%-e1 0i2e 'o$/ression sto',in0 to (se for t"e *a&1 *rin, a -ot of f-(i*1

'-ean t"e (-'er an* /(t t"e *ressin0 on! )atient sai*1 s"e a-rea*& "as *ressin0 for t"e (-'er 1 an* asked me whether I can gi+e her antibiotic 1I as,e* ."et"er t"ere7s /(s on t"e (-'er %e'a(se t"e /i't(re *oesn7t s"o. an& si0n of infe'tion an* a-so -&$/" no*e (9 1 s"e sai* it see$e* so! O,1 t"en I sai* I7-- ta,e s.a% fro$ t"e .o(n*1 if t"ere7s e2i*en'e of infe'tion I7-- 0i2e "er a$ti%ioti'1 %(t no. nee* to '"an0e t"e *ressin0 re0(-ar-& e2er& .ee, an* as,e* "er to %e 'aref(- ."en *o 0ar*enin01 0i2e "e -ea2e 'ertifi'ate for a .ee,1 an as,e* "er ."en 0oin0 %a', to .or,1 re$e$%er to e-e2ate t"e -e0s *(rin0 %rea,ti$e! I finis"e* t"is station ear-ier! B(t I for0ot to *o ne(ro-o0i'a- e3a$1 in fa't s"e is a *ia%eti' /atient1 it $i0"t %e t"e 'a(se s"e 0ot t"e in+(r&1 a-so for0ot to as, a%o(t /i--1 as it7s a ris, fa'tor for ?4T1 a-so for0ot to arran0e* for ?o//-er USG for "er -e0 an* %-oo* test to see "er *ia%eti' 'ontro- ! It7s so eas& to for0et in t"e roo$1 e2en t"o(0" Before I -eft t"e roo$1 I trie* to t"in, ."at e-se t"at I $i0"t $iss1 %(t +(st 'an7t re$e$%er! On-& re$e$%er ."en a-rea*& o(tsi*e t"e roo$ E( 8! )i't(re .as 0i2en s"o.in0 a .o$an .it" ra*i'a- $aste'to$& on t"e -eft %reast1 no. /resent .it" non /itin0 oe*e$a on "er -eft ar$! S"e "a* %reast 'an'er an* .as treate* .it" ra*i'a- $aste'to$& .it" a3i--a -&$/" no*es '-earan'e an* t"en 'ontin(e* to "a2e ra*iot"era/& on "er ne', an* a3i--a 1 no. /resent to ( .it" t"e s.e--in0 Tas, 5 te-- t"e /atient ."at 'o(-* %e t"e 'a(se of "er s.e--in0 Arran0e in2esti0ation if ne'essar& Mana0e an* a*2i'e t"e /atient ( referra- to s/e'ia-ist is ins(ffi'ient ( In t"is 'ase1 t"e ro-e /-a&er .as a *o'tor as s"e as,e* $e $an& =s1 a't(a--& s"e trie* to "e-/ $e %& *oin0 so1 (nfort(nate-& it $a*e $ore o%2io(s t"at I 'o(-*n7t *o t"e 'ase .e-I to-* t"e /atient $ost -i,e-& t"e s.e--in0 *(e to o%str('tion in t"e -&$/" *raina0e as a si*e effe't of "er treat$ent %efore! It7s (n-i,e-& to %e o%str('tion in "er *ee/ 2eins as t"e s.e--in0 *oes not 0o in ."en I /ress on it! S"e as,e* $e Do u need to arrange some test for me! I sai* I .i-- arran0e *o//-er USG +(st to r(-e o(t ?4T 1 S"e as,e* $e what else doctor any other tests I sai* CT of t"e '"est to see if t"ere 'an'er 'e--s 'o$in0 %a',! S"e as,e* $e a0ain any other test ! I .as at t"e 'orner1 sin'e I 'an7t t"in, an&1 so I sai* /ro%a%-& Li2er f(n'tion test an* CT a%* to see t"e -i2er! At t"at sta0e1 t"e e3a$iner to-* $e ?o//-er USG nor$a-1 $eans not ?4T an* as,e* $e ."et"er it7s ne'essar& to *o CT a%*1 if t"e /atient *oesn7t "a2e s&$/to$s! )atient as,e* $e a0ain1 so what can you do for this swelling ! I sai* e-e2ate &o(r affe'te* ar$ 1 /(t 'o$/ression %an*a0e on it to re*('e t"e s.e--in0! S"e as,e* $e do I need to put the compression all the time! I sai* not a-- t"e ti$e1 ( nee* to ta,e it off so$eti$e so it .i-- not 'a(se too $('" 'o$/ression1 /ro%a%-& a//-& t"e 'o$/ression %an*a0e B9< 3 ti$es a *a& ( I .as rea--& %-an,1 to %e "onest1 ."at in $& $in*1 t"at7s ."at I sai*1 I *on7t ,no. an&$ore it7s ri0"t or not S"e t"en as,e* $e a0ain )hat could be happen with this swelling! Is there any side effects or complications that might happen due to this swelling! A0ain1 I on-& 'an sa&1 .e-t"e si*e effe'ts t"at $ost -i,e-& to "a//en is /ress(re effe'ts to s(rro(n*in0 str('t(re as t"ere7re %-oo* 2esse-s an* ner2es t"at r(n a-on0 t"e ar$1 if it 'a(se too $('"

/ress(re on t"ose str('t(res it 'an 'a(se '"an0es in t"e s,in 'o-o(r1 /ain 1 .ea,ness1 /in nee*-es1 n($%ness or tin0-in0 sensation! S"e as,e* $e a0ain1 any thing else that can happen apart from the colour changes! I rea--& *on7t ,no. ."at s"e $eant1 I ,no. s"e trie* to 0i2e $e a "int! So I +(st stare t"e /atient an* re/eat a0ain t"e /ress(re effe'ts s&$/to$s %(t s"e ,e/t as,in0 an&t"in0 e-se a/art fro$ t"atA So I +(st 'an si-ent %e'a(se *on7t ,no. an&$ore ."at to ans.er! T"e e3a$iner to-* $e to ans.er /atient7s =s! So sa*1 If I 'an ans.er1 of 'o(rse I :-- ans.er! I fe-t so %a* in t"is station! T"en t"e /atient as,e* $e a0ain anything that I should do or I shouldn/t do! T"is ti$e I .as tota--& %-an,1 'an7t t"in, an&$ore1 I fe-t # $in(tes 0o 2er& s-o.1 I rea--& .is"e* ti$e7s (/ at t"at ti$e or t"e& sen* $e o(t1 it .o(-* %e %etter for $e1 'a(se t"e -on0er I sta& 1 t"e $ore o%2io(s I 'an7t *o t"is station E T"e /atient as,e* a0ain anything else doctor that u can do! I rea--& 0a2e (/1 *on7t ,no. an&$ore ."at s"e .ante* to "ear! I t"en sai* .i-- refer "er to s/e'ia-ist1 )hat else!! O" *ear1 so 2er& re-('tant-& I sai* it $i0"t %e ne'essar& to 0i2e &o( t31 %(t I .i-- 'a-- t"e s/e'ia-ist first to as, for se'on* o/inion! I t"in, I $a*e $ista,e an* *i0 $& o.n "o-e %& sa&in0 t"at1 %e'a(se t"e ne3t =s as I e3/e'te* .as )hat the medication doctor! So a0ain .it" a "ea2& "eart1 I sai* /ro%a%-& f-(i* ta%-ets %(t not s(re 1 "a2e to '"e', it first .it" s/e'ia-ist! ;ina--& ti$e .as (/! I 'an see t"e e3a$iner .as rea--& not "a//& .it" $e! T"e ro-e /-a&er trie* so "ar* to "e-/ $e %(t I t"in, $a,e it e2en .orse E0! At -east I 'an 'o$e o(t fro$ t"at roo$! 6as t"e .orst station for $e! @! Do(r /atient 'o$e to &o(r G/ for t"e %-oo* test res(-t! S"e7s fro$ 0ree, ori0in!Her %-oo* test s"o.e* anae$ia .it" -o. MC4 an* "i0" H% A21 nor$airon -e2e-! Tas, 5 te-- t"e /atient a%o(t t"e %-oo* test res(-t1 ."at t"at $eans A*2ise /t re0ar*in0 "er 'on*ition an* ans.er "er =s I to-* t"e /atient s"e "as t"a--asse$ia $inor an* e3/-ain ."at t"at $eans! I sai*1 .it" t"is a%nor$a- 0ene an* "er stat(s as a 'arrier s"e 'an /ass t"at 0ene to "er offs/rin0s! T"e 'on'ern "ere is ."en &o(7re 0oin0 to "a2e a fa$i-&G '"i-*ren1 *e/en*s on &o(r /artner &o(r offs/rin0 $i0"t %e a 'arrier -i,e &o(1 $i0"t %e nor$a- %(t $i0"t %e a-so a t"a--ase$ia $a+or ."o "as se2ere s&$/to$s! )t sai* I/m going to marry in three months what should I do! I a*2i'e to %rin0 "er /artner to "a2e t"e test an* t"en e3/-ain ."at .i-- "a//en if t"e /artner a-so "as t"at a%nor$a- 0ene .it" t"e /i't(re an* te-- t"ere7s 28 K ris, for &o(r %a%& to "a2e t"a--asse$ia $a+or!28K nor$a- in ter$ *oesn7t "a2e t"at 0ene1 an* 80K .i-- %e -i,e &o( t"a--s! Minor or 'arrier! S"e as,e* $e what happen if the baby has that condition! I sai* so$eti$es %a%& $i0"t not s(r2i2e insi*e t"e .o$%1 or e2en if 'an s(r2i2e an* 0et %orn .i-- "a2e se2ere anae$ia as t"e RBC :s a0e %e'o$e s"orter1 an* .i-- nee* %-oo* transf(sion for ."o-e t"e -ife! "o.e2er .e 'an '"e', it e2en ."en t"e %a%& sti-- in t"e .o$% %& s/e'ifi' test 'a--e* a$nio'entesis! If /ro2en t"en o/tion ."et"er to ter$inate or 'ontin(e /re0nan'& .it" a-- t"e 'onse>(en'es! T"ere7s a-so .o(-* %e 0eneti' 'o(nse-in0 a2ai-a%-e if (r /artner "as t"at a%n! 0ene!B(t I sai* *on7t .orr& too $('" first1 %e'a(se .e "a2en7t *one t"e test on &o(r /artner &et so *on7t ,no.! An* e3a$iner as,e* $e how you will ad+ise the patient if the partner is

normal! I t"en e3/-aine* to "er1 if (r fian'Me is nor$a- so *on7t nee* to .orr& %e'a(se &o( .i-- not "a2e t"a--as! Ma+or %a%& 1 80K '"an'e for &o(r offs/rin0 to %e -i,e &o(1 80K '"an'e to %e -i,e &o(r /artner ."i'" is nor$a- )atient as,e* $e Do I need any t" for my anaemia! I sai* no1 %e'a(se &o(r iron -e2e- is nor$a-! I 0i2e "er /a$/"-et a%o(t t"a--! An* as,e* "er an& ot"er =sA S"e sai* no! I finis"e* ear-ier I for0ot to arran0e ?NA ana-&sis to see ."et"er it7s t"a--asse$ia a-/"a or %eta 7! A .o$an 'o$es to &o(r G) '-ini' 'o$/-ainin0 a%o(t *is'o$fort an* %-oate* fee-in0 on "er t($$&! S"e "a* '"o-e'&ste'to$& *one %efore for 0a-- %-a**er /ro%-e$ ! &o(r 'o--ea0(e "as arran0e* 't a%* for "er! Tas, 5 as, f(rt"er "31 as, for fin*in0 an* te-- &o(r /ro2isiona- *ia0nosis an* ??G Inter/ret t"e Ct s'an .it" e3a$iner On "31 s"e7s %een "a2in0 t"is %-oate* an* *is'o$fort fee-in0 for fe. $ont"s1 aro(n* e/i0astri($ area1 not /ain1 fee- .orse after eatin01 %(t not s/e'ifi' .it" fatt& foo* 1no /ro%-e$ .it" .ater.or,s an* %o.e- $otion1 no '"an0es to (rin an* stoo- 'o-o(r 1no fe2er1 na(sea1 or 2o$itin0! No 'o(0" 1 '"est /ain1 /a-/itation !"a* o/eration for 0a-%-a**er /ro%-e$ %efore1 "a* a /ro'e*(re ."ere a t(%e .as /assin0 *o.n t"ro(0" $o(t" *(rin0 t"at ti$e ( /atient $ean ERC) 1 no /ro%-e$ .it" in*i0estion1 no ot"er si0nifi'ant $e*i'a- "31 not ta,in0 an& $e*i'ation1 not *rin,in0 a-'o"o-! Last ti$e s"e 'a$e to G) '-ini' an* one of t"e *o'tor "a* arran0e* 't a%*1 no. .ants to ,no. t"e res(-t! On fin*in01 e2er&t"in0 .as nor$a- e3'e/t &o( fin* a -ar0e ro(n*e* an* s$oot" $ass on t"e -eft "&/o'"ron*ri($1 a %it e3ten*e* to e/i0astri($! U/ to t"is /oint1 e3a$iner as,e* $e ."at $& /ro2isiona- *G an* **G! T"e on-& t"in0 t"at 'a$e (/ into $& $in* .as on-& /an'reati' '&st! E3a$iner sai* to $e t"at 'o(-* %e one of t"ose1 other possibility that you can think of! I (n*erstan* ."at "e .ants1 sin'e t"e tas, is a-so a%o(t **G %(t I 'an7t t"in, of an&t"in0 e-se t"at 'an 'a(se a%*! $ass in t"at area as t"e /atient *i*n7t "a2e an& ot"er s&$/to$s so re-('tant-&1 I sai* t"at7s a-- t"at I 'an t"in, of at t"e $o$ent! I as,e* t"e e3a$iner ."et"er I 'an "a2e a -oo, at t"is /atient7s CT t"en a 'o/& of CT .as 0i2en! T"e on-& t"in0 t"at I 'an re'o0niJe .as -i2er an* a %i0 ro(n*e* $ass o//osite to -i2er1 on -eft area! Honest-&1 I 'an7t re'o0niJe CT 1 %(t ."at I 'an sa& t"e e3a$iner .as 2er& ,in*! He trie* to 0(i*e $e %& as,in0 $e ."ere is -i2er1 s/-een1 sto$a'" an* fina--& as,e* $e ."ere *o &o( t"in, t"is $ass 'o$e fro$ (it7s %e-o. sto$a'" !I trie* to ans.ere* "is =s %& (sin0 t"e anato$& of t"ose or0ans1 ."en 'a$e to t"at $ass1 "o.e2er I sti-'an7t fi0(re o(t ."i'" or0an is t"at1 I sai* to e3a$iner1 $ost /ro%a%-& it7s /an'reas! He a't(a--& trie* to "e-/ $e %& as,in0 $e to t"in, a0ain an* *on7t 0et 'onf(se*! An&.a&1 %e'a(se t"e ti$e7s a-so a-$ost (/1 so "e as,e* $e to te-- t"e /atient ."at I t"in,1 ."& s"e "as "is 'on*ition! I on-& 'an te-- "er t"e /ro%-e$1 no '"an'e to e3/-ain %e'a(se t"e %e-- ran0 #! A %(siness $an 'o$es to &o(r G) after .at'"in0 a T4 /ro0ra$ a%o(t %a* effe't of a-'o"o-! He .ants to ,no. ."et"er "e "as %een *rin,in0 too $('" Tas, 5 Ta,e f(rt"er H3 an* as, for e3a$! ;in*in0 fro$ e3a$iner Mana0e an* a*2ise t"is /atient1 arran0e I3 if ne'essar&

10

I t"in, t"e ro-e /-a&er7s a-so a *o'tor !Before as,in0 H31 I as,e* an& /arti'(-ar 'on'ern t"at %ro(0"t "i$ "ere1 /atient sai* not"in0 s/e'ifi'1 "e +(st .ante* to *o '"e', (/ an* ,no. a%o(t "is a-'o"o- *rin,in0! I sai* it7s a 0oo* start1 &o( *i* t"e ri0"t t"in01 t"en I .ent to a-'o"o- =s! On H31 "e /rett& $('" *rin,s e2er&*a&( .ine 1 %eer an* *rin,s sin'e &o(n0 %(t 0ettin0 $ore $ore often1 *oesn7t ,no. ."et"er "as "i0" B) or ot"er $e*i'a- /ro%-e$1 ne2er *o '"e', (/ %Gfore! No /ro%-e$ .it" in*i0estion1 "ea*'a'"e1 %-(rrin0 2ision1 /ins ne**-es1 t($$& /ain1 ne2er 0et /ro%-e$ .it" /o-i'e or -a.1 ."en as,e* a%o(t fa$i-& re-ations"i/1 "e a*$itte* no. a %it *istan'e %et.een "i$ an* fa$i-& (.ife an* ,i*s %e'a(se "e 0ot anno&e* if t"e& ta-, a%o(t "is *rin,in0! No /ro%-e$ .it" se3(a- -ife! Ne2er t"in, a%o(t '(ttin0 *o.n t"e a-'o"o- %e'a(se a-- t"e frien*s a-so *rin, -i,e "i$1 %(t "e *oesn7t 0o strai0"t to *rin, in t"e $ornin0 to o/en t"e e&es1 ."en I as,e* ."et"er "e 'onsi*er "is *rin,in0 is a %it o2er t"an -i$it an* $a,e "i$ fee- 0(i-t& a%o(t itA He sai* no! On )"&s! E3! BMI N1 B) 1@0G1001 ot"ers N1 -i2er 2 '$ /a-/a%-e1 ."en I as,e* a%o(t "eart1 si0ns of /eri/"era- ne(ro/at"&1 t"e e3a$iner sai* a-- t"e e3a$ination t"at &o( 'an t"in, of is nor$a- ( it $eans I *on7t nee* to as, $ore I to-* t"e /atient "is *rin,in0 is o2er t"e -i$it1 0a2e "i$ t"e safe -i$it an* to-* "i$ *e/en*s on ."at "e *rin,s1 it "as *ifferent stan*ar* *rin, for ea'" t&/e of a-'o"o-! I 0a2e "i$ e3a$/-e 1 sni/ of ."is,& is e>(i2a-ent to 1 0-ass of .ine is ."i'" is 1 stan*ar* *rin,1 I7-- 0i2e &o( t"e /a$/"-et a%o(t it an* t"en a*2ise "o. "e 'an '(t *o.n "is a-'o"o- 1 if fin* it *iffi'(-t to *o it a-one1 'an refer "i$ to a-'o"o- *e/en*en'e '-ini' if "e .ants1 t"en I sai* I7-- arran0e so$e %-oo* test for ( ( as I .as ta-,in0 .it" "i$ t"at I 'onsi*ere* as a /atient so I .as not s(re a%o(t te--in0 ."at %-oo* test I .ante* to *o I $entione* .i-- '"e',e* if "e "as anae$ia an* so$e n(trient *ef ( I $eant iron1 B12 an* ;o-ate ! I *i* not $ention a%o(t L;T an* USG1 I e2en for0ot to to('" t"e Hi0" B) *es/ite I .rote it *o.n on t"e /a/er ."en e3a$! to-* $e! I *i*n7t ,no. ."& I 'o(-* $iss s('" an i$/ortant t"in0! In fa't1 after no $ore =s fro$ /atient1 I 'a$e o(t ear-ier %(t $a*e t"at ,in* of $ista,e! If t"e& 'onsi*ere* it as 'riti'a- error1 *efinite-& I .i-- fai-! L ! A $an 'a$e to &o( .orr& a%o(t "is "air -oss! He7s %een "a2in0 >(ite a stressf(- -ife re'ent-&! He7s a-so -osin0 "is ri0"t e&e %ro. as s"o.n in t"e /i't(re ."i'" .i-- %e /ro2i*e* in t"e roo$ Tas, 5 as, e3a$iner a%o(t /"&si'a- fin*in01 ."at I3 ( .ant to *o E3/-ain t"e 'on*ition to t"e /atient I as,e* a%o(t5 Is it 'o$/-ete "air -oss An& si0n of inf-a$$ation on t"e s'a-/1 -i,e re*nessA An& s'rat'" $ar,A An& e3'-a$ation "air aro(n*A E3a$iner .as "a//& .it" t"at an* s"o.e* $e t"e /i't(re for t"e ans.ers! He as,e* $e anything else u want to know or look for! I $entione* a%o(t e&e %ro.1 t"&roi* 1 %(t for0ot to $ention a%o(t nai-s ( If I7$ not .ron0 it7s $entione* in G) %oo,1 /-ease '"e', it T"en He as,e* $e what I" I want to do1 I sai* ;BE1 ESR1 T;T1 6oo* -i0"t ( to *istin0(is" .it" tinea He t"en as,e* $e ."at I e3/e't to see1 I sai* /ro%a%-& ,in* of 'o-o(r '"an0es on t"e s'a-/1 He as,e* $e a0ain if I e2er *o it %efore1 I ans.ere* "onest-&

11

ne2er ( )-ease '"e', it He as,e* $e any other test u wanted to do! Sin'e I 'an7t t"in, of an&t"in0 e-se1 so I ans.ere* s/e'ia-ist $i0"t 'onsi*ere* to %io/s& of t"e affe'te* area ( a0ain1 /-ease '"e', for t"e ans.er He1 t"en as,e* $e to e3/-ain to /atient! I to-* t"e /atient it7s a-o/e'ia areata1 a(toi$$(ne 'on*ition ( e3/-ain ."at it is t"e /ro%-e$ is .it" t"e "air fo--i'-e ( *ra. t"e /i't(re es/! in t"e '&'-e ."ere t"e "air s(//ose* to 0ro. %(t sto/ 0ro.in0 ( fro$ G) %oo, ! I sai* in $ost 'ases t"e "air 'an 0ro. a0ain %(t ta,es ti$e /ro%a%-& a%o(t @9 12 $iont"s! ;or &o(r 'ase as it7s >(ite e3tensi2e1 it in2o-2e &o(r e&e %ro. as .e-- so I .i-- refer &o( to *er$ato-o0ist or "air s/e'ia-ist for t3 ! T"en I to-* "i$ t"e t3 o/tions1 'orti'osteroi* to/i'a-1 intra -esion or 'o$%ine %et.een to/i'a- i$$(not"era/& an* 'orti'osteroi* oraGs&ste$i' ( of 'o(rse .it" si$/-e -an0(a0e I as,e* "i$ ."et"er "e "as an& =s! He as,e* $e Am I going totally bald! I 'an7t 0i2e &o( t"e *efinite ans.er1 %(t ."at I 'an sa& is in $ost 'ases it "as a 0oo* o(t'o$e t"e "air 'an 0ro. a0ain %(t on-& ta,e ti$es 1 a%o(t @912 $ont"s1 In fe. 'ases it $i0"t ne2er %a', a0ain !"o.e2er in &o(r 'ase it7s a-rea*& in2o-2e t"e e&e %ro.1 I7$ afrai* t"e o(t'o$e .i-- not as 0oo* as in $ost 'ases1 *on7t .an7t to .orr& &o(1 %(t I7$ +(st %ein0 "onest to &o(! Ho.e2er1 a0ain I7-- refer &o( to t"e s/e'ia-ist1 "eGs"e $i0"t %e a%-e to ans.er &o(r =s an* see "o. &o( 0o .it" t"e treat$ent! I7-- tr& to $a,e a//oint$ent asa/1 $ean."i-e ( $i0"t .ant to (se .i0 ( in t"e roo$ t"e ro-e /-a&er (se* "at .ow long it takes for my hair to grow! a0ain1 in $ost 'ases it ta,es aro(n* @912 $ont"s %(t in so$e 'ases it $a& ta,e -on0er e2en ne2er 0ro. a0ain1 /ro%a%-& t"e s/e'ia-ist 'an ans.er &o(r =s %etter! An& ot"er =s A No1 so I finis"e* ear-ier 10 A <0 so$et"in0 .o$an 'o$e to &o( %e'a(se of fee-in0 f-(s"e* an* sort of f-( for t"e -ast fe. *a&s Tas, 5 Ta,e "3 for 8 $in(tes As, for fin*in0 fro$ e3a$iner Te-- t"e /atient ."at "er /ro%-e$ is an* $ana0e a''or*in0-& Before I entere* a roo$1 I t"o(0"t it $i0"t %e /re $eno/a(se s&$/to$s as t"e /atient is a%o(t <0 so$et"in01 %(t it7s tota--& *ifferent an* t"e ro-e /-a&er .as a &o(n0 .o$an1 .earin0 t"e s&a- 1 /reten*in0 to %e (n.e-On "31 s"e7s %een fee-in0 "ot1 f-(s"e* an* a'"in0 in a-- of "er $(s'-es an* %o*& for t"e -ast B *a&s! 6as fine %efore1 no r(nn& nose1 no 'o(0" or sore t"roat 1 'an7t s-ee/ .e-%e'a(se of t"at1 No in'rease fre>(en'& of /assin0 (rin1 no /ain1 %(rnin0 sensation1 *iffi'(-t& in /assin0 (rin1 no '"an0es in (rin an* stoo- 'o-o(r1 no '"an0es in %o.e- "a%it1 no '"est /ain 1 SOB1 or /a-/itation1 no '"an0es in s,in 'o-o(r 1 *oesn7t -oo, &e--o.is" or *ar,er1 not a.are of -($/s in ne',1 ar$/it an* 0roin1 "as ni0"t s.eats1 an* a %it ten*er on t"e ri0"t si*e of t"e %a', aro(n* -oin area1 %(t not ra*iatin0 to an&."ere1 not"in0 t"at $a,e it %etter or .orse! Menstr(a- H3 is sti-- re0(-ar1 No /ro%-e$ .it" /ain1 "ea2& or /ro-on0e* /erio*1 no %-ee*in0 in %et.een /erio* 1 $o 2a0ina *is'"ar0e1 not on HRT1 sti-se3(a--& a'ti2e 1(se 'on*o$1 no /ro%-e$ .it" /ain *(rin0 se3 or %-ee*in0 after se31 /a/ s$ear 1 &ear a0o an* no 'on'ern1 no /referen'e for .eat"er1 no .ei0"t -oss1 not e3/ose* to TB /atient1 no H3 of tra2e-in0 to o2erseas or o2erstate1 is a "o(se.ife1 no "3 of %-oo* transf(sion1 no tattoo or %o*& /ier'in01 not fee-in0 *e/resse*1 +(st fee-in0 (n.e--1 no $e*i'a- or s(r0i'a- "3 t"at si0nifi'ant1 not on an& $e*i'ation! U/ to t"is /oint1 I 0ot 'onf(se*1 as not eno(0" fin*in0 %(t I7$ s(s/e'tin0 /ro%-e$ .it" "er (rinar& tra',1 so I

12

as,e* "er a0ain a%o(t (rinar& s&$/to$s ."i'" t"e ans.er sti-- t"e sa$e1 so I 'ontin(e* to as, for fin*in0 On e3a$1 BMI N1 T BL1< C1 )(-se L@ ( I t"in, an* t"e rest .ere nor$a-1 no +a(n*i'e1 no anae$ia1 no /i0$entation1 no -&$/"a*eno/at"&1 t"&roi* N1 '"est '-ear1 "eart N1 a%* N1 no or0ano$e0a-&! I as,e* t"e e3a$iner a0ain "o. a%o(t -oin area sin'e t"e /atient sai* s"e fe-t a %it /ain t"ere1 t"en e3a$iner to-* $e o,1 ."en ( to('" it it7s a %it ten*er %(t no %a--ota%-e ,i*ne&s! No.1 starte* a %it /ani'1 I as,e* a%o(t fin0er /ri', test for s(0ar1 it7s N1 (rin *i/ sti', s"o.e* RBC N 1 6BC N1 Nitrite N! T"en e3a$iner to-* $e to ta-, to /atient I to-* "er s"e $i0"t "a2e infe'tion in "er (rinar& tra't an* t"e infe'tion $i0"t a-rea*& 0o to t"e ,i*ne& so I .i-- arran0e t"e $ore /ro/er (rine test for (1 t"e /eo/-e in t"e -a% .i-te-- ( "o. to 'o--e't t"e (rine an* I .i-- a-so arran0e USG to see &o(r ,i*ne& 'on*ition ( I *i* not $ention t"e .or* O /&e-one/"ritisP1 I *on7t ,no. it7s ne'essar&Gnot 0he asked me whether she needs any t" I sai*1 &es I7-- 0i2e &o( Anti%ioti' on'e it7s 'onfir$1 I7-tr& to arran0e t"e test asa/ so .e 'an 0et t"e res(-t to*a& so .e 'an start t"e t3 i$$e*iate-& In t"is 'ase1 I t"in, I $a*e t"e $ista,e %& not a*$ittin0 t"e /atient *es/ite of I .as s(s/e'tin0 /&e-one/"ritis an* e2en not startin0 t"e Anti%ioti' e2en t"o(0" (rine *i/ sti', .as (N an* not arran0in0 %-oo* test an* %-oo* '(-t(re )SDCHIATRD 1! Do( are seein0 a 80 so$et"in0 o-* $an! He "as "3 of "i0" B) an* on t"e $e*i'ation ( 'an7t re$e$%er ."at it is In t"e /ast "e .as not rea--& 'o$/e--in0 .it" "is fo--o. (/ an* t3! Re'ent-&1 "e7s %een a'tin0 stran0e-&1 t"e .ife 'o$/-aine* t"ere .as one *a& ."en s(**en-& "e '"an0e* t"e -ine ."i-e *ri2in0 an* a-$ost 'a(se* a''i*ent! His *a(0"ter .as a-so (/set .it" "i$1 ."en s"e -eft t"e ,i*s .it" "i$1 "e see$s 'are-ess! Do( *i* MMSE %efore ( I t"in, 1 .ee, %Gfore an* t"e res(-t .as a%nor$a- ( t"e res(-t .as 0i2en in t"e e3a$1 I 'an7t re$e$%er1 /-ease as, .it" ot"er 'an*i*ates Tas,5 Ta,e f(rt"er H3 ?o 'o0niti2e e3a$ination an* ot"er e3a$inations t"at &o( t"in, ne'essar&1 no nee* to re/eat MMSE (n-ess it7s s/e'ifi'a--& nee*e* an* ne'essar& Gi2e &o(r ?G to e3a$iner an* t"e reasons an* ??G1 6"at I3 &o( .ant to *o T"is .as "ar*1 /atient ,e/t ta-,in0 non sto/1 an* not ans.erin0 t"e =s strai0"tfor.ar* %(t 0oin0 aro(n* so$eti$es e2en not ans.erin0 t"e =s s/e'ifi'a--& ! I *i* *o .e--1 as I s/ent too $('" ti$e .it" t"e /atient1 I fe-t re-('tant to interr(/t "i$ in t"e $i**-e1 %(t a't(a--& ."en &o( interr(/t "i$ an* as,in0 =s1 "e -istene* an* sto/ ta-,in0! I s/ent @ $in(tes .it" "i$ as t"e e3a$iner to-* $e I72e 0ot 2 $in(tes -ast so I +($/e* te--in0 e3a$iner $& *G an* t"e reasons an* e2en not to('"in0 t"e I3 as t"e ti$e7s (/ On "31 "e sai* "as B) -on0 ti$e a0o1 not re$e$%er ."en t"e -ast ti$e "a2e it '"e',1 so$eti$es ta,e $e*i'ation1 so$eti$es *on7t as "e fee-s "ea-t"&1 no /ro%-e$! No "ea*a'"e1 %-(rrin0 2ision1 /ins nee*-es1 ne2er "a* '"est /ain1 not *rin,in0 too $('"1 on-& o''asiona--&1 'an7t re$e$%er if t"e /atient s$o,es or not( I s/ent too $('" ti$e .it"

1B

t"is1 %e'a(se first I t"o(0"t it .as a $e*i'ine 'ase an* re$e$%er t"e /atient not ans.erin0 t"e =s s"ort-& %(t ta-,in0 aro(n* %Gfore 0o to t"e /oint 6"en as,e* ."at "a//ene* a't(a--& ."& "e s(**en-& '"an0e* t"e -ine1 "e sai* "is .ife .as o2errea't1 not"in0 serio(s "a//en1 ."en as,e* a%o(t "is *a(0"ter 'o$/-ain1 "e ans.ere* t"e& +(st s/oi- t"e ,i*s a -ot1 &o( ,no. t"is ti$e a-- ,i*s 0et ."at t"e& .ant1 I as,e* "i$ s/e'ifi'a--& ."at "a//ene*1 an& a''i*ent .it" t"e 0ran*,i*s1 "e7s sti-- -i,e t"at1 ,e/t sa&in0 not"in0 "a//ene*1 t"e& +(st o2errea't an* s/oi- t"e ,i*s too $('" ( so I *on7t ,no. ."at7s rea--& t"e /ro%-e$ I as,e* ."et"er "e e2er "a* stro,e or s(**en .ea,ness on 1 si*e of t"e %o*&1 "e sai* no! I as,e* "i$ ."et"er "e see$e* to %e for0etf(- re'ent-& -i,e /(ttin0 t"e ,e& fe. $in(tes a0o %(t t"en 'an7t re$e$%er A He %asi'a--& not ans.erin0 $& = so I *e'i*e* to as, "i$ to te-- $e ."ere "e is no.1 "e ans.ere*1 .e-- I7$ no. ta-,in0 to &o(1 I s(//ose it7s in t"e "os/ita-! 6"en I as,e* "i$ to te-- $e ."at7s t"e *ate an* *a& for to*a&1 "e 'o(-*n7t *o it1 He a-so "a* /ro%-e$ .it" re'a--in0 B o%+e't1 on-& 'an re/eat 1! I *i* not 'ontin(e as,in0 MMSE as in t"e tas, it7s sai* (nne'essar& to re/eat it (n-ess it s/e'ifi'a--& nee*e*! I trie* to r(-e o(t *e/ression %& as,in0 "is $oo* ."i'" is o,1 fee-s "a//&1 no stressf(- e2ent or -oss in "is -ife! He *i*n7t fee- t"at "e "as /ro%-e$ at a--! T"e -ast 2 $in(tes I to-* e3a$iner $ost -i,e-& "e "as *e$entia an* t"e ??G is *e/ression an* I e3/-aine* t"e reasons an* ti$e7s (/ T"at is a--! T"an,s to Go* I 'an /ass $& e3a$ !I "o/e t"is re'a-- is (sef(-1 -earn fro$ $& $ista,es1 On'e I 0ot t"e fee* %a', fro$ a$' ."i'" station I fai-e*1 I .i-- /(t it *o.n1 so ot"ers 'an -earn fro$ it! Honest-&1 for $e so eas& to for0et $an& t"in0s *(rin0 t"e e3a$1 "o/ef(--& it .on7t "a//en to &o( a--! Go* %-ess

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