1. Completed my 5th Mini case record today. Patient with a known Hx of Colorectal Ca presented at the A&E with a one week Hx of abdominal distention worse after eating. Associated with non specific abdominal pain that involved the back, altered bowel habits and one episode of non-bilious vomitus. All these were classical symptoms of intestinal obstruction. My initial impression was adhesion colic because of a previous history of abdominal surgery. However, the patient was also mildly jaundiced and slightly febrile. Physical Examination was unremarkable except for the fact that he was jaundiced. Blood investigations revealed a normal full blood count, there were no dilated loops of bowel in the abdominal x-ray. An ultrasound of the pancreato-biliary tree and liver was carried out. The findings were, a thickened gall bladder wall and stones. A serum amylase was subsequently ordered, it was in the thousands - 2206. A Provisional Diagnosis of Gall stone Pancreatitis was made.

The interesting thing about the patient was that he looked too well for his condition.

At the A&E, the differentials that the houseman arrived at were 1. Non-specific abdominal pain 2. Colon Ca with secondary metastatis.

In the ward, the surgeon's impression was adhesion colic. This was before the abdominal x-ray results were ready. On seeing that there were no abnormalities on the abdominal x-ray, the surgeon subsequently ordered a serum amylase as well as USG abdomen which nailed the diagnosis.

Lesson- In non-specific abdominal pain, do not forget serum amylase!

2. Met up with the boys the day before, was most impressed when

David said: " I'm not making full use of the NLB"

Darren said: " Sometimes, I find that prep is too short"

3. Ps Tan spoke about turning points. Whenever Naaman looked at his baby like- skin, he is reminded of his object of service; whenever Gehazi looked at his leprose skin, he also is reminded of his object of service

4. The traveling experience is less then satisfying but the destination is worth it