Diagnostic and Therapeutic Records

1. Ken Miah’s Report Notes

Mr. Ken Miah was admitted to the hospital after woken up at night by abdominal pains. He was
checked by the doctor at emergency room at 1.45 a.m., then the nurses brought him to the
operation room at 2 a.m.. He was given a general anaesthetic at 2.30 a.m.. Before entered the
operation room, he was diagnosed by appendicitis, because there’s an inflamation on his
appendix.
The doctor performed an appendectomy for approximately 2 hours, the vermiform appendix
which has an inflammation was removed. Mr. Miah lost 650ml of blood during the operation
because of bleeding. After the inflamed vermiform appendix was removed, the doctor inserted
the stitches on his surgical wound.
Mr. Miah was prescribed a painkillers as his medicine for reduce the pains after the operation.
After being treated for a week at hospital, he was discharged from the hospital and continue his
treatment at home.
2. Describing pain, possible diagnosis, and possible procedure to treat the patient
 Find the possible diagnosis for these pain

No. Pain Diagnosis

a. Piercing/boring acute pancreatitis, appendicitis, cluster
headache
b. Extremely severe/intense ureteric colic, appendicitis, sub-arachnoid
haemorrhage
c. Aching acute pancreatitis, appendicitis, degenerative
arthritis, cystitis
d. Scalding/burning sciatica, cluster headache, cystitis, angina
pectoris
e. Like a tight band around my tension headache
head
f. Dull/persistent/vague degenerative arthritis, tension headache
g. Excruciating/thunderclap ureteric colic, sub-arachnoid haemorrhage
h. Shooting Sciatica
i. Spasmodic ureteric colic, sub-arachnoid haemorrhage
j. Crushing/gripping angina pectoris
 Think about the possible procedure to treat the patient
 a. Sciatica : Epidural Steroid Injection (ESI)
b. Ureteric colic : Extracorporeal Shock Wave Lithotripsy (ESWL)
c. Acute Pancreatitis : Endoscopic Retrogade Cholangiopancreatography
(ERCP)
d. Appendicitis : Appendectomy
e. Degerative arthritis : Arthroplasty
f. Cluster headache : Oxygen
g. Cyctitis : Cystoscopy
h. Tension headache : Over-the-counter (OTC) painkillers
i. Sub-arachnoid haemorrhage : Endovascular coiling
j. Angina pectoris : Angioplasty and Stenting
3. Mr. Wood’s pain’s detail information, diagnosis, possible treatment, and report notes
 Pain’s detail description
o Duration/how long the pain : for the past hour
o Site/where the pain : in the center of his chest
o Severity : severe enough because he was prescribed a painkiller
before the doctor continue to ask him about his pain
o Character of the pain : it's not a sharp pain, it's like a tightness, as if someone
squeezing his chest. It started first when he was bending over in the garden about two
weeks ago
o Radiation : at that moment that was just in the center of his chest, but
it was in his left shoulder before
o Constancy : the pain is constant
o Previous episode : not the pain on the chest, he had a pain on his left
shoulder and arm when he was walking to work on the morning about a month ago
o Other problem : he had a dull pain and shortness of breath
 Diagnosis: angina pectoris
 Treatment: There are many options for angina treatment, including: lifestyle changes,
medications, angioplasty and stenting, or coronary bypass surgery. The goals of treatment
 are to reduce the frequency and severity of his symptoms and to lower your risk of a heart
attack and death.
 Report Notes
Mr. Wood was admitted to the hospital because the constant chest pain he felt for a past
hour. He also had a dull pain and shortness of breath. The pain is on the center of his
chest and severe enough because he had some trouble when catching a breath. At that
moment, the pain was just in the center of his chest, but it was in his left shoulder before.
He said that his pain was not a sharp pain, that was like a tightness, as if someone
squeezing his chest. It started first when he was bending over in the garden about two
weeks ago. He had a pain on his left shoulder and arm when he was walking to work on
the morning about a month ago.
Mr. Wood was diagnosed by angina pectoris after the doctor checked him by EKG, Echo
Test, and Lab Test. Mr. Wood was brought to the operation room and was given a
general anaesthetic. Then the doctor performed angioplasty and stenting to make sure that
the blood can flows normally. Mr. Wood was treated at hospital and was given blood-
thinning drugs such as aspirin and clopidogrel to prevent more severe blockage of the
coronary arteries. He was treated at hospital for 15 days then he was discharged from the
hospital and continue his treatment at home.