rindu saya

* pictures are from here and wiki

Gerak Khas Attachment: Final Day

Salam people.

*you know who is in charge in cases of difficulty, don't you?*

People are waiting for season finale in every single drama series. But for my drama series, I hate the season finale. My season finale means a good bye to a 15 days adventure in this beloved wards.

Anyway people, I came like usual today but looked and felt a bit lethargic. I come and disturb a petite HO doing her work. We chatted about the whole wards and department story, it was fun though to see people in other perspective. She also taught me about ECG.

ECG

First thing to see, whose ECG is that. Them move to the rhythm. If the rhythm is regular, count the rate. How? Let's count the big box from Q to next Q, e.g. 5 boxes. Then 300 divide by those boxes e.g. 300/5= 60bpm! Easy huh? Next, see the axis, which if lead I is positive, and AVF is negative, then it is left axis deviation and vice versa. In normal ECG, both leads are positive. After that we need to see any abnormalities in leads.

V1, V2, V3, V4- anterior

I, aVL, V5, V6- lateral

II, III, aVF- inferior

So, see on that leads if there is ST elevation or depression, T inversion, hypertrophy or bundle branch block etc. And uh yes, yesterday the specialist asked about what causes QT elongation. What popped in my mind was erythromycin as the specialist told me last two weeks after CME about CAP. Other causes include MI, myocarditis, head injury, hypothermia, U&E imbalance etc.

Enough about ECG, I was after that was asked to assist a HO to remove the chest tube. That procedure is aseptic one, thus needing me to scrub, wearing apron and put the surgical gloves properly. I gotta help him to pull the chest tube and doing other assistive task. It was not that hard actually but I need to be more alert next time. I was asked why we should ask the patient to inhale first before we pull the chest tube. I answered about lung expansion and pleura come to each other and all. But the answer is about the negative pressure created in case of patient inhale during pulling that tube off. Hahah..I need to read more so that my answer is of medical student standard not a layman one.

Continue to round business, today we were not met by any asystolic neither apnoeic patient so no CPR today! It had been very dramatic today. There is this schizophrenic patient who was left at a hut by her parent to live by herself. It is very sad actually and the specialist add the drama by telling us another story when she was a MO. There is this makcik having CVA, on RTF and have bed sore. Obviously this makcik needs special attention and nursing. She was on first class ward back then and that reflects the children wealthiness. But, when it is time to discharge that makcik, their children refuse to take that makcik back! WTH right (this is not included in glossary)? Then that makcik stayed in the first class ward for like one year until her death. Dramatic enough, right? Another story, a son putting his mom inside a store and give his mom food in a plate that left on the floor of the store. OMG, he did not even invite his mom to eat together? When you were small, your mom wouldn't even care to eat if you don't have enough food but now?

C'est la vie, people! It is very much make me sad to call it an end. Then, I bid farewell to all the doctors there and leave before jumaat prayer. While waiting for my dad to pick me up, I listen to my iPod. Then I accidentally played this song. I was touched. I thank my teacher here in HoSHAS in Medical Department, in ward XX especially. The specialist, Dr S, Dr. H H; the MOs Dr N, Dr. R and Dr. K, Dr. H, Dr. Y; the HO, Dr. M.N, Dr. A, Dr. L, Dr. S, Dr. I, Dr. N, Dr. M, Dr. Iz, Dr. E; the sister and staff nurses. You all had been a very good teacher. Thank you! God bless you all!

Glossary

ECG- electrocardiogram

CME- continuous medical education

CAP- community acquired pneumonia

MI- myocardial infarction

U&E- urea and electrolyte

CVA- cerebrovascular accident

RTF- Ryle's tube feeding

THE END

Gerak Khas Attachment: Day 14

Salam people

*MO on call is Dr. Glossary, Specialist on call is Prof. Dr. Google*

So today I started by following the ward rounds as usual, menyibuk-nyibuk with HO. Then when the MO came, I started to follow them la. My first case to be noted today is a patient with decompensated CCF and ?stage III CKD. He was on HD yesterday 4hr and 2hr day before. After yesterday's HD, his renal profile showed elevated urea but normal creatinine. This disproportionate renal profile is likely to result from either dehydration or sepsis. But sepsis is unlikely cause the patient is currently on broad spectrum antibiotic. So the MO taper down diuretics he got and see his progress. We also learnt from a visiting nephrology consultant that in severe heart failure, like what the patient had, is likely to be manifested with low BP. But the patient come with high BP, so renal failure in this patient is prominent regardless of his quite high eGFR.

Since the patient is haemodynamically unstable (CCF), CAPD is likely to be an option for that. Also we see patient with peritonitis PD which will complicate as reduce ultrafiltration due to inflammation. This will further manifest as fluid retention and increased BP. In all of these nephrology patient, the consultant want to reduce the dry weight. Dry weight? Everyone got water in them, right?

Dry weight

It is a weight after HD/PD with controlled BP by minimal anti-hypertensives and clinically no fluid retention (pedal edema,pulmonary edema, LL edema, edema, anasarca etc). To know what to do in decreasing dry weight, try to reduce the patient's anti-hypertensives, if BP is high restrict fluid and/or extract more during dialysis.

Ok back to general medicine rounds, we met a patient with altered sensorium (loss of orientation of time, place and people). He is now treated as meningoencephalitis. Revise your meningitis people; know that GCS is not affected in those patients. Pathogenic causes may include; meningococci, strep pneumonia, haemophilus influenza, HSV etc. Also in meningitis, assess maculo-papular rash because it is very much exclusive for meningococcal which is highly contagious. In case of that event, all of us doing rounds needs to take rifampicin and one of the cephalosporin (I don't remember which one). I haven't come across GTC patient for long time but I saw two of them during rounds. That case is under police supervision!

Then, while doing rounds in sub-acute ward, we were encountered with a apnoeic patient hence CPR is indicated. I was like yaay! Not yaay that patient is critically ill, but I got to do the CPR. That pakcik is a 60+ years old having CCF, cellulitis, morbidly obese. He is rather less ambulating in the past few weeks. so we got to do the chest compression and one of the HO intubate him. He is really big, that when I got on the bed, my knee is almost landed on his shoulder. Then we do chest compression and alhamdulillah this is my most successful chest compression I've ever done. I got to raise the HR to 120-200. But the cardiac monitor is rather unreliable, because this pakcik is so big and hairy so the leads fails often.

Anyhow, after series of chest compression we failed to save the patient. A little bit sad because I just chatted with his wife yesterday. He is clinically ok the day before and asked to ambulate before can be discharged, but all of the sudden he develop this apnea. His wife cried when the specialist told her about her husband. I went to utility room to wash my hand and all. Right after came out of that room while drying my hands, a USIM student said there is likely to be one more CPR. That Malay pakcik is having aspiration pneumonia 2ry to CVA. Then it is proven that the family request NAR. Then, we just watch that pakcik departing just like that. Alhamdulillah, his son taught him syahadah and all of us can see that he depart peacefully.

Back to rounds, we attend a lot of cases and the most complicated one should be ACS and all the heart medication. Then we encountered one pakcik presented with pseudo-bulbar like syndrom. He is then diagnosed with tetanus, by the history of being poked by a wood days before. In medicine, drama is compulsory. We saw a makcik with DM and manifested with melioidosis. It is a disease caused by Brukholderia pseudomallei. The thing is that makcik has her first daughter marrying on 31st of August despite the antibiotic course of 2 weeks. Then it was giving the specialist dilemma. Anyway, we then saw another makcik with CVA and global aphasia. All medical and dentistry student were asked about the types if dysphasia. I tried to answer but I swapped the definition of receptive and expressive dysphasia.

We finished rounds on 3.30 and the specialist invites me to the 'buka puasa with department' event that evening. I can't refuse since it had the second time the specialist invites me to that kind of event. We were loitering around the ward when on of the HO approached me to ask me a favor. She asked me to send a cross match sample to the blood bank. When I got up to the ward, one of the MO was about to do LP procedure. It is sort of once in a while procedure because not often it is conducted. I watched that and sitting on the counter having a chat with a MO and HO about future career prospect.

Then I got to attend the buka puasa la. It was a bit awkward at first, but the specialist was there and she is very nice and making me in sort of not-anymore-awkward mood. It was good actually to know the people in leisure time. Also a HO that contracted meningitis and admitted in the hospital attend that buka puasa event. It seems everyone really live in peaceful and harmony manner in this holy month. After buka puasa, I got up again to the ward. Then I was met by two nurses asking me to insert a IV line. I never do that before but I would like to try. I waited for a HO to come and I sorta assist him in doing that. It was so difficult that I tried twice for a makcik but failed two of them. Then I ought to call the HO to do that. Then it was almost 10pm that time. I asked from a HO to withdraw a blood from a patient with dengue fever. As you all should know, dengue patient should have blood collected for FBC TDS. I collected his blood which is easy because he is young and with prominent artery and call it a day!

Glossary

CCF- congestive cardiac failure

CKD- chronic kidney disease

HD- hemodialysis

PD- peritoneal dialysis

BP- blood pressure

eGFR- glomerular filtration rate (estimated)

CAPD- continuous automated peritoneal dialysis

GCS- Glasgow Coma Scale

HSV- herpes simplex virus

GTC- generalized tonic colonic seizure (grand mal)

CPR- cardio-pulmonary resuscitation

HR- heart rate

CVA- cerebro-vascular accident

NAR- no active resuscitation

DM- diabetes mellitus

LP- lumbar puncture

IV- intra venous

FBC- full blood count

TDS- ter die semendie (thrice daily)

ACS- acute coronary syndrome

Gerak Khas Attachment: Day 13

Salam people!

*MO in charge, Mdm. Glossary, Specialist in charge Dr. Google*

Well today I came as usual. Doing rounds with the same friendly HO, finishing all his 4 patients. There is some issue with the patients' insulin. There is some misunderstanding in off-ing some medication. I asked him to consult MO regarding the medication. He consulted the MO after that while I was joining the specialist doing rounds. We were joined by a group of dentistry student from USIM. I asked a HO about persistent hyperkalaemia, which is one of indication of PD/HD. He said, after 2-3 times hyperkalaemia in BUSE result, we consider the patient have persistent hyperkalaemia.

The specialist also do a lot of teachings today, since dentistry student is in their first day posting to this ward. She taught us about things to ponder in CT brain namely; ischaemic changes, ICB, cerebral edema, coning/herniation. So this is what you want to see in CVA patient. You may want to see other lesions in other cases e.g. SOL, psychosis etc. So, as you guys knows eh, brain is divided into 3 different circulation that interconnecting each other.

Posterior infarct may likely to come with cerebellar sign (ataxic gait, incoordination, dysdiodokinesia) and giddiness. While in middle cerebral artery infarct may manifest with hemiparesis and poor GCS. If GCS is dropping, it is indicated to repeat the CT brain to see any bleeding, extension of infarct to penumbra and cerebral edema. We were also asked about DM complication and its' classification.

- Macrovascular

* CVA/TIA

* MI

- Microvascular

* Nephropathy

* Neuropathy

* Retinopathy

Also, in AIDS patient there is defining illness to diagnose that RVD patient had advanced to AIDS stage.

* Cerebral toxoplasmosis

* Cryptococcal meningitis

* Cerebral lymphoma

* Kaposi sarcoma

* Oral-esophageal candidiasis

* Pulmonary Aspergillosis and/or PCP

* TB (not specific to the AIDS stage)

In clerking a patient with RVD, identify his risk factor so that control can be done. They are sex promiscuity, drug usage (esp IV usage), frequent blood transfusion, needle prick in health worker.

Back to the case of misunderstanding in off-ing the medication. The specialist asked why the HO off the drug but the HO remains silent. I don't know what is in his mind but he desperately in need of good reasoning and diplomacy. Anyway, the specialist asked me about AF type which I read few weeks ago but forgot it already. There are 3 types of AF i.e. paroxysmal, persistent, permanent. There is a long list of condition that can cause AF. Among others, they are

* HPT

* MI

* persistent pneumonia

* thyrotoxicosis

* PE

* MS

* alcohol consumption

* heart failure

* Hypo K+

(caffeine can only precipitate the present AF)

While doing rounds, I noticed one of the most crucial preclinical subject; PHARMACOLOGY! There's a lot of situation where your basic pharmacological knowledge is applied. After finished the morning rounds with specialist, I come to the library to read newspaper and read a little bit. Half an hour before 3pm, I came up to the ward ready to join CME. Then I met that friendly HO clerking a dengue patient. As FBC in dengue is needed TDS, I'm quite lucky that the HO allow me to take the blood from the patient. I withdraw the blood and the HO put it in each tube. Then, we intend to do BFMP which I tried to do but failed it. I put 2 drops for the thick smear which is enormous! Then the HO take over and do a proper blood film.

At 3, I followed the specialist to attend CME. While walking there, she showed me a good book to read for better understanding ECG named Making Sense of ECG, A Hands-on Guide. It is available at Sykt Kamal, KL for RM 65.00 only. Before the CME started, I heard about some drama which a HO leaving a comment in a blog bad-mouthing about the hospital administration. Then the 'pengarah' got so angry that he passed a memo on every HOD to find the truth about what that fella said. Dramatic enough huh?

Glossary

PD- peritoneal dialysis

HD- hemodialysis

BUSE- blood urea serum electrolyte

CT- computed tomography

ICB- intra-cranial bleeding

CVA- cerebro-vascular accident

SOL- space occupying lesion

GCS- Glasgow Coma Scale

DM- Diabetes Mellitus

TIA- transient ischaemic attack (an ischaemic attack that last less than 24h)

MI- myocardial infarction

IV- intra venous

AF- atrial fibrillation

PE- pulmonary edema

MS- mitral stenosis

CME- continuous medical education (a class presented by HO in front specialist, MO & HO)

FBC- full blood count

TDS- ter die semendie (latin thrice daily)

BFMP- blood film for malarial parasite

ECG- electrocardiography

HOD- head of department

Gerak Khas Attachment: Day 12

Salam people!

*As usual, in case of any difficulties. consult glossary or Prof. Google*

Actually, today is a long day but there's nothing much to write. I started my day like days before. Came a bit late then go o the ward. I'm intending to follow HO rounds but that friendly HO said that he will not be there for the rest of the day because he need to go to the clinic. Anyway, I saw a patient with empty blood specimen bottle.

I told the USIM student that we still could have the opportunity to do blood sampling. She asked from the HO in charge of the night shift to do blood sampling. After that, I approached the same HO to do blood taking. Luckily, he still not take any blood in acute female cubicle. All of them need ABG except this one 'nenek' that only need FBC and RP. So I tried to take blood from this nenek la. It was quite hard actually to take blood from elderly since their skin is wrinkled and make the vein searching a bit difficult. Luckily, I got to feel the vein. I prick her skin but there is no blood getting in the needle. I tried to adjust it a little bit but to no avail.

I pull off the needle and reinsert the needle after search for the vein for the second time. Alhamdulillah, this attempt is a success. It is quite hard at the beginning but practice make perfect people! After doing that, I thanked the HO and go to the USIM girls to see what happened. There's two of them but they do it together, so as I come there they just completed one patient. They tried to withdraw blood from the second patient but to no avail although they tried it twice. I take a chances to withdraw the blood and praise to God, I can withdraw 3 cc of blood.

But when filling the specimen tube, I notice that the syringe is quite hard to push. Maybe there's clot in that and I was right as soon as I remove the needle. Don't tell sister (head nurse) about this haa? I removed it by using gloves what? It was so dangerous for me actually but I cant think of another maneuver. We just fill the two serology tube but leave the FBC tube empty because the specimen is clotted. Then, after that I followed MO rounds until the specialist come. Today the specialist in charge for this ward before is back from her holiday.

She asked a HO why we can not bring down the BP quickly following ischaemic stroke. The answer: to prevent further stroke to ischaemic penumbra. And the doctor should not hesitating to give aspirin in such patient unlike the patient with hemorrhagic stroke. Also, we were asked about the feature of peritonitis in patient with PD. It is among others, abdominal pain, cloudy dialysis fluid and diarrhea. But the patient got DM also, so gastropathy is more likely since the peritoneal fluid is clear. It is caused by the autonomic dysfunction along the GIT. There is a patient with newly diagnosed PTB. The specialist prescribe INH, rifampicin, ethambutol and pyrazinamide but didn't asked the patient to go the nearest KK or KD for taking the medication as obliged by the DOTS strategy. She said, the DOTS therapy is needed for patient with suspected non-compliance in taking medication e.g. RVD pt, ex-IVDU etc.

After rounds with specialist, I went to the library and took a nap (a 2hour one). When I came up, I was joining the USIM student to search for cases and all of a sudden a chinese elderly pt have asystole. CPR is indicated but was delay due to dispute in NAR status. As usual, we joined the CPR session again this time. Too bad the patient LO already. After that, we observe a PD installing procedure. The tube was inserted to the peritoneal and drained from the same hole. The fluid inserted is the peritoneal dialysis fluid 1.5% dextrose. After that procedure, we continue our observation in IJC procedure. It took a little bit longer time due to patient in-cooperation and ?abnormal vein structure. After that I excuse to go back and that's all for today folks!

Glossary

ABG- arterial blood gas

FBC- full blood count

RP- renal profile

BP- blood pressure

PD- peritoneal dialysis

DM- Diabetes mellitus

GIT- gastrointestinal tract

PTB-pulmonary tuberculosis

INH- isoniazid

KK- klinik kesihatan

KD- klinik desa

DOTS- direcly observed therapy-short course

RVD-retro-venereal disease

IVDU- intra-venous drug user

CPR- cardiopulmonary resuscitation

LO- a term for passed away

IJC- internal jugular catheter

?- query, put in front of a fact that is not confirmed/unknown

Gerak Khas Attachment: Day 11

*Refer glossary or Prof. Google if encounter difficulties*

Ok. I'm back after 2 days off. I came a bit late today, was not hoping for any blood sampling procedure. I headed to that friendly HO cubicle, and he asked me, "tak ambik darah ke hari ni?". I don't know whether that question is sarcastic or is he just saying. Anyway, the ward admission rhythm is not regular lately. There's a lot of patient admitting despite day after tomorrow is active day.

I followed the HO round on his cubicle then 5 new USIM students come to us and observing. That HO asked the student why they followed us. That HO is actually known to be the least 'terror' HO than others. Nevertheless, I think that HO is a very much talented but maybe in other discipline, orthopedic maybe? That students went to follow a MO in other cubicle.

Me myself joining another MO for rounds. But before that, a HO asked me for a favor. She asked me to do blood sampling for patient in sub-acute cubicle. There were three patients to do blood sampling, which two of them is elderly. The first be the mak cik that needs PT/INR sampling. I tried that once but failed. That mak cik is fairly overweight. Then I gave up and tell the patient to wait for another doctor to come. Then I tried to take blood from a young female patient which is presented with fever TRO leptospirosis, malaria. Again, I failed. I gave up and tell her the exact same thing I told that mak cik.

I followed the round as usual and the MO asked me what is the common cause of psychosis. Namely, SOL, drug usage, electrolyte imbalance. I also asked to read about dementia too. After that, another specialist came to the ward for rounds. We joined him, and remember about the RVD pt with PCP? He said, if immunocompressed pt come with pneumonia, suspect CAP first. But this time we need to cover everything (CAP, HAP, atypical pneumonia, PCP and other fungal pneumonia) since his CXR is worsening. We also learned that insensible water loss in Malaysia is higher than that of country in the west by 300 cc, which usually have insensible water loss of 500 cc.

The specialists asked us about bronchiactesis, its common cause.

a) Infectious

- PTB

- pertussis

- persistant penumonia

b) Non-infectious

- Aspergillosis

- Kartagener's syndrome

For bronchiactesis, the most important treatment is to do chest physiotherapy. Because the bronchial is always inflamed that we need to clear that lungs from purulent sputum.

Thalassemia patient although not very much common but comprising of the most challenging problem. These patients having blood transfusion as contraindication unless you know the serum ferritin level. In case of accidental ordering of blood transfusion, iron overload is the case. In iron overload, the most common site for iron deposition are;

a) Pitutary gland

b) Heart > hemosiderosis in heart

c) Liver > cirrhosis

d) Pancreas

e) Adrenal gland

We see a male patient with UTI, which is less common but if encountered, suspect renal stones, vesico-ureteric reflex or other organic causes rather than microbial causes. The other patient was admitted for cellulitis, was ambulated well previously. But after admission, he can't even walk. So the specialist explained to us about deconditioning of Geriatrics. It is a condition where the patient feel comfortable enough of the environment in the hospital that he wouldn't even care to walk or taking care of himself. So, counsel the patient to make sure he is still conditioned to continue his life independently. That's all for day 11, folks!

Glossary

PT/INR- prothrombin time/international normalized ratio

TRO- to rule out

SOL- space occupying eison

RVD- retro-venereal disease

PCP- pneumocystis carinii pneumonia

CAP- community acquired pneumonia

HAP- hospital acquired penumonia

CXR- chest x-ray

PTB- pulmonary tuberculosis

UTI- urinary tract infection

Gerak Khas Attachment: Day 10

*As usual, refer glossary or Prof. Google in case of any difficulties*

Ok. Sorry for the late update. Some familial emergency does take my precious time. Anyway, I had a rather short day today. I went to the ward as usual every morning. I got to be on the same lift with the specialist. She said, "Today we got hospital CME from 8-9am. You can join it and I'll do rounds afterwards". I said ok and thanked her. I went to the ward, putting on my coat, and preparing to do rounds.

I joined on of the HO for morning rounds. She asked me about lots of thing. And we were joined by the USIM student.

First question, in what condition is subclavian lymph node is enlarged?

The answer: gastric CA, which also you may be asked about the pathway of lymph drainage.

Second question, What will we see in Grave's disease patient's eye?

The answer: Exophthalmus, Lid lag, Lid retraction, Ophthalmoplegia

Tricks to see fine tremors better, put a piece of paper on the extended upper limb! Easy! Thyroidism is a fairly frequent case in Malaysia. So you just need to study both hypo- and hyper-.

Come to the most exciting moment of the day. Well, we sort of having this patient suffering for CCF, also some AF but he was not on Warfarin so we were all suspecting the patient have cardio-embolic stroke. He was planned to do plain CT scan for brain and to put on ventilator. Unfortunately, before the Anesthesiology

team install the ventilator, he develop ventricular fibrillation and needs CPR. We were all asked to be ready for any consequences. Initially just the MO and HO doing the cardiac compression. But after a while, the specialist asked me to wear on the rubber gloves and be ready to do the chest compression.

How to do chest compression

I was shaking when putting on the gloves, and the specialist told me to relax and don't panic. That's the key, people! I put my hands on the sternum 2" below the upper border and 1" above the end of xiphoid. And start to push my hand on the patient's chest, I sort of hesitating but nevertheless we need to push 2" deep. While doing compression, we must see the cardiac monitor. That's all I think for CPR today. Also, the specialist asked for the homework she gave yesterday. Thank god, I searched for it and share with you guys!

Glossary

CA- cancer

CCF- congestive cardiac failure

AF-atrial fibrillation

CT-computerized tomography

CPR- cardio-pulmonary resuscitation

Gerak Khas Attachment: Day 9

*Please refer glossary below*

Today, I came a little bit early. As yesterday, there's no blood sampling to be done. I just followed the HO doing morning rounds. He is a good doctor actually, and very friendly. We stroll through his cubicle, seeing patients' progress. Then, I was joining MO rounds. She asked me, "Kau berapa lama attachment, dik?". I answered 3 weeks which she replied, "lama eh macam posting houseman pulak". Well, after that, the specialist came and we followed her.

She reminds all of us, that patient with RVD may come with opportunistic pneumonia. But, if the opportunistic pneumonia worsening, consider covering the patient with appropriate ABx to cover HAP. Also, it is very important for us doctor to know each drug side effects especially in treating elderly. Charcot's triad, a diagnostic triad for ascending cholangitis and biliary sepsis. It includes;

i) Fever

ii) Jaundice

iii) Hypochondral/ abdominal pain

We were also asked to read about Child-Pugh grading for cirrhosis and King's College hospital criterion for liver transplantation.

Child-Pugh grading for cirrhosis

	1	2	3
Serum bilirubin	<34 μmol/L (<2.0mg/dL)	34-51 μmol/L (2.0-3.0 mg/dL)	>51 μmol/L (>3.o mg/dL)
Serum albumin	>35 g/L	30-35 g/L	<39 g/L
Ascites	None	Easily controlled	Poorly controlled
Neurologic disorder	None	Minimal encephalopathy	Advanced coma
Clotting properties	PT prolonged 0-4 s (INR < 1.7)	Prolonged 4-6 s (INR 1.7-2.3)	Prolonged > 6 (INR >2.3)

It is scored from 5-15. Which 5-6 is Class A, 7-9 is class B, 10-15 class C. For more info, please refer Kumar and Clark's Clinical Medicine 7th Edition, page 347, box 7.3.

King's College Hospital criteria for liver transplantation

Paracetamol induced toxicity

blood pH less than 7.3 24h after paracetamol ingestion

or All of the following

PT > 100s

Creatinine > 300 μmol/L

Grade III/IV Encephalopathy

Non-Paracetamol

PT > 100s

or 3 out of 5 of the following

Drug induced liver failure

Age <10 or >40

> 1 week from jaundice to encephalopathy

PT> 50s

Bilirubin > 300 μmol/L

Ok, too much isn't it?

Glossary

RVD- retro-viral disease

ABx- antibiotic

HAP- hospital acquired pneumonia

PT- prothrombin time

INR- International Normalized Ratio

Gerak Khas Attachment: Day 8

*The title should be 7 1/2 because today is holiday*

*Also, in case of any short form toxicity, please consult the glossary*

Well people, today is Nuzul Quran public holiday in Pahang. I went to the hospital with all the spirit (medical student spirit la konon). So today is considered weekend round which means specialist less likely to come. Nevertheless, I still come early in the morning, hoping to get any blood sampling job but to no avail. So, the JMO in charge taking blood this morning is very much efficient lah! Good for him, but pity me lol.

Then I went to see one of the HO, which is friendly enough to get along with. He is medical graduate from Medan, Indonesia. Actually I'll meet him every morning because now he's undergoing his 'denda'. He was amerced like that because he don't show up to work one morning without valid reason. The result, he need to do every morning shift, in addition to other round he may have. Pity him, but this is HOD decision. Well, we were going through some cases and also talked about our past. Yeah, he's actually brilliant just maybe lack of skill (he is first poster, what do you expect?). Otherwise he is a very good, friendly, emotionally tough doctor.

Then there comes the time for MO round. Same round everyday, but today I learn something about swallowing test. It is a test where we assess the ability to swallow for CVA patient. We give the patient ten spoon of water. The patient fail the test if;

i) Cough after giving water

ii) Drooling

iii) Voice changes after few spoon

If patient fail the test, consult patient's/relatives' consent to install Ryle's tube. If Ryle's tube is not installed, patient may have aspiration pneumonia as complication.

Also, we saw a patient with pleural effusion. He was transferred in from CCU. The pleural fluid is exudative. It is known by calculating the fluid over serum. If more than 0.6, then it is exudative while lower ratio shows transudate. Then, there's this one patient which have malarial disease. His BFMP show 400+ asexual stage but there is new appearance of sexual stage. Thus, this patient should be kept in the bed net most of the time since his blood is ready for transmission by mosquito bite.

After that we saw a CKD patient with fluid overload. Likely to be, she don't follow the ROF given. She developed APO with loud crept after sharp rise of BP. All doctors are working on giving her IV Lasix but her peripheral line is hard to find. Finally, the MO set up a central line in her femoral and give her lasix 120mg stat. She improved and after that, the PD machine and ventilator came. Then she is short of relieved. Also, HO insert CBD in her urethra and that is my first time seeing a doctor inserting CBD to a patient. After that, I sort of tired and excuse from the ward since there is no CME today. I need half day off, I'm not yet a HO (they have 10 days off in 4 month posting!).

Glossary

JMO- Junior medical officer (senior HO, 4th poster above)

HOD- Head of Department

Ryle's tube- a nasogastric tube (inserted in mouth till stomach)

CKD- chronic kidney disease

ROF- restriction of fluid

APO- acute pulmonary oedema

CBD- continuous bladder draining

CME- continuous medical education

Lasix- furosemide (a diuretic)

Gerak Khas Attachment: Day 7

Please refer glossary below

Ok. Today I came a little bit early. It had been a very congested post-active ward. I came up, putting on my stuff, comforting myself and heading to the ward. One of the HO doing ward rounds and I ask him if I can do any blood withdrawing or any procedure. Unfortunately, there is no luck with him. I wander around the ward and asking another HO. Luckily a HO, have some patient's blood still not taken.

I went to that patient, a dengue makcik in fifties, her veins is very much 'hidden' owing to the fact that this makcik is slightly obese. I opened the tourniquet and just left. After that, I got a second patient, a SLE patient, 10 cc blood is needed for this patient which should be filled in 4 plain tube, 1 FBC tube. It is a large amount of blood. Then I went to the patient with tourniquet, alcohol swab, 10 cc syringe, green needle, and cotton ball. She was on IVD in left hand, but her right hand was bruised and edematous. So, I decided a wrong decision. I TOOK THE BLOOD SAMPLE FROM THE LEFT HAND!! I asked from the other HO. She said just don't tell the other HO that asked me to do that blood sampling. Otherwise, all sample was all in good condition! heheh

After that, another Ho, asked me to take blood from a dengue patient. He is young and fair. It should be easy, but I failed the attempt. I withdraw the needle to fast, which is no need because I'm at the right place that time but I just need to reposition the needle a little bit and wait blood to come out. Then I can't do it again although pressure was applied to that site. I then realized this is a dengue patient which compulsorily presented with thrombocytopenia. I excused myself and said another doctor will come. I'm quite disappointed with that. Luckily, as soon as I came out from that room, the HO that offered me SLE patient said there is another patient that need FBC blood sample, a AE COAD patient. She was a rather skinny patient, so it was quite easy to take blood sample.

After that, I followed ward round as usual. I was asked about ascending cholangitis. Also the specialist assessing the HO skills on neuro exam. It was good because I can refresh my memory on how to do the exam.

i) We need to assess the tone then the power then the reflex.

ii) Also, all the power should be assessed group by group

iii) Remember all the motor power grading by heart!

iv) For reflex, please make sure the patient is fully relaxed

v) If reflex negative, do Jendrassik maneuver

A MO also asked me what to see in dengue patient FBC, so it is Hct, Plt, WBC.

Hct- for showing the stage of the infection

Plt- detect any hemorrhage

WBC- increase WBC show case improvement.

Then, we saw the SLE patient, the specialist asked me how to diagnos it. I said depends on criteria. But I can't recall anything but it's mnemonic. It is A RASH POInts aN MD.

1) Arthritis

2) Renal abnormality

3) Antinuclear antibody

4) Serositis (pleurisy/pericarditis or other)

5) Hematological disability

6) Photosensitivity

7) Oral ulcers

8) Immunological abnormality

9) Neurological abnormality

10) Malar rash

11) Discoid rash

We were also asked to read about MODY. There is 4 types of MODY which the most common one is MODY-2. It is caused by glucokinase deficiency. You can search about the rest, huh? I need to go to prepare home-made murtabak for my family!

Glossary

SLE- systemic lupus erethymatosus

FBC- full blood count

IVD- intravenous drip

AE COAD- acute exacerbation chronic obstructive airway disease

Hct- hematocrit

Plt- platlet

WBC- white blood cell

MODY- maturity onset diabetes in young

Gerak Khas Attachment: Day 6

PLEASE SEE GLOSSARY BELOW

So, I'm back people! After 2 days off from the ward, I'm back to K14. Today is active day which means all admission is to this particular ward. Before I went up to the ward I saw a group of student presumably from USIM. I asked them, they are 4th year student. Then, obviously I will have sorta 'gang' in here. I came up then see on of the HO but they all rushing to morning prayer/TO. I waited there with another HO and waiting for them to finish. It took almost one hour for them to finish.

When they came back, I joined the MO supervising HO doing rounds. I joined them until the second cubicle. After then, the specialist arrived. She said to me "Oh, Ibrahem da ada kawan eh sekarang". We were doing round and the specialist asking the USIM student to interpret the ECG. I was sorta 'kantoi' over there while interpreting it. The patient have first degree heart block most likely due to septal MI reflected on V1 ST segment elevation. Then we were met by a CVA pt. The specialist asks the USIM student to assess patient's GCS. I had been seeing it for the past 5 days. I'm not saying I know everything about GCS, but assessing GCS for a patient is not really hard actually once you know how. Practice makes perfect, folks! We continue on rounds until the specialist was instructing a patient to receive PD stat. Then we joined the procedure as observer. It runs smoothly, until a USIM student asks the MO assisting the procedure what is indication for PD/HD. She straightly direct that question to me owing to my short experience following ward rounds.

I stammered while answering that, since I never thought about it. So here's the list!

i) Uremic syndrome (RP)

ii)Persistent Hyper K+ (RP)

iii) Severe metabolic acidosis (VBG)

iv) Fluid overload

v) Drug toxicity

vi) Anuria

I felt relieved, at least I can think at least 3 of it. That means my last 5 days tiredness worth it! Then we continue the round until almost 3pm. We all excused for Zohor prayer. And I promised the USIM students to teach them GCS. Well we assessed 1 patient but stop after that because of inappropriate timing (unfortunately it is time for evening snack!) Those student also went to clerk a patient. Luckily, I reviewed her last week and I told them to hear course crept. It was fun though, chasing for the very low frequency sound.

After that, I encountered this very nice HO. He asked me to withdraw blood from a patient. I nervously tried it. I MADE IT! YEAY!!!! I managed to take blood from an old patient. He is CVA patient, so as patient courtesy, we took blood from the affected side so that he won't feel very much pain. I just wandering around the ward looking for anything to do. Then the same HO asked me to take blood once more but from another patient which is young. He said "patient muda ni senang sikit nak ambik darah, tapi kalau kantoi kena marah teruk sikit la". I smiled while my heart skips beats. I made it once again. Alhamdulillah. I would like to thank the HO to allow me to withdraw blood from his patient. I'm now addicted. Until next time folks!

Glossary

USIM- universiti sains islam malaysia

morning TO- morning take-over

MI- myocardial infarcts

GCS- glasgow coma scale

CVA- cerebro-vascular stroke (a vague word for stroke)

PD- peritoneal dialysis

stat- immediately

PD/HD- peritoneal dialysis/hemodialysis

RP- renal profile

VBG- venous blood gas

Gerak Khas Attachment: Day 5

So, today I started my day by going to pasar pagi to pick up ikan patin. Wearing full formal cloth and shoes is so overdressed for going to market. But I miss going to market in the morning (buat-buat rajin pulak nak pergi pasar).

Ok. Back to attachment story eh. I came this mo

rning and seeing the HO which I did round with her yesterday. I was noted that a patient in our cubicle LO last night. Also a critical patient that has long been there after referral from CCU. Then I meet one of male HO. He is very friendly and I

was with him until the specialist came. Then I follow the specialist on her rounds. She taught me about patient with CBD, after CBD off we need to make sure normal PU because of weak bladder after CBD (especially long CBD usage).

She also ask me to see a tonsilitis patient tonsils. It is very much enlarged, almost at the midline but no kissing (meeting of two tonsils by huge enlargement). And there's this one patient which have eosinophilia, which DDx for eosinophilia include allergic reaction, parasitic infestation, Wegener's syndrome. For high eosinophilic count + mouth ulcer + hepato-splenomegaly, consider HES. Also, she told all of us that in Master program unlike undergraduate degree, you are fail until proven otherwise. New fact huh?

kissing of the tonsils

Also we meet a pt with rather distended abdomen. 5F for causes of distended abdomen is

i) Fat

ii) Faeces

iii) Fetus

iv) Fluid

v) Flatus

One of the most important thing you need to know is how to evaluate GCS. Quarter of the ward need to be GCS evaluated. Then I clerk a pt of new admission. He is suspected from dengue fever. P/W fever day 4, thrombocytopenia, high hematocrit, also from dengue prone area and fogging history. I clerk him, with another HO. She was showing me how to clerk the pt. Last few days she also asked me to clerk an anemic pt. I got this one scheme for clerking the pt.

1) Demographic detail (age, sex, work, where he live etc.

2) Complaining Of (C/O)

3) History of Present Illness

4) Severity Rate

5) Past Medical & Surgery Hx

6) Medication Hx

7) Allergy

8) Family Hx

9) Social Hx

10) Summary

That patient on examination both lung clear, CVS DRNM S1S2, Pulse Rate 78. My impression is dengue fever, because of fever, thrombocytopenia and from dengue prone area. And Dengue (IgM) Rapid Test is pending. After those clerking, I went to jumaat prayer with one of senior HO. After got back from the prayer, I go and check the dengue pt and make sure he is comfortable. After assessing the pt, I was asked if I wanna try to do venepuncture on a patient. I did it half way. I wrongly inserted the needle subdermal, which it should be in side the vein. KANTOI!!! (Malu gile! Kesian patient). Then the HO did it. It is easy actually when you know how (Tak serik, nak buat lagi tuh). Then at 3, we all went to HO presentation CME. It was about CAP, sign symptom, Mx and Tx. It was a long topic. It took hour and half to be finished.

After CME presentation, we all went up to the ward and do ward round. The specialist is teaching me about reading ECG which I consider difficult. So, when you see an ECG, there is a long lead II wave called rhythm strip or long II strip. It is used to see sinus rhythm which is defined as a cardiac rhythm started with P followed by QRS complex and T (occasionally U). I never think a lot about ECG before, but she said ECG is made of 3-D 'imaging'.

Lead V1, V2 is for anterior region, V3,V4 is for septum area, V5 , V6, I, aVL is showing lateral region while II and III and aVF is for inferior region. While aVR is only to see whether ECG is properly measured because the wave should be positive, if negative it should be repeated. Then we met a pt, which is non-responsive on we waking him up. The special way to know whether it is true LOC or the pt just made it up is to induce pain or to lift his arm on his face. If his arm hit his face, then it is true LOC but if he avoided the face, the pt is likely to see for extra attention.

Glossary

LO-a hospital way to say passed away. (abbrev. of ?)

CCU- cardiac care unit (unit rawatan jantung)

CBD- continuous bladder draining (insert catheter in urethra)

PU- pass urine

HES- hyper-eosinophilic syndrome

GCS- Glasgow Coma Scale

P/W- presented with

Hx- history

CVS- cardiovascular system

DRNM- dual rhythm no murmur (normal heart sound)

S1S2- heart sound heard

CAP- community acquired pneumonia

Mx-management

Tx/Rx- treatment (Rx is specifically for medication)

ECG- electrocardiogram

LOC- loss of conciousness

*other abbreviation see below eh? (malas nak tulih laa hahahah)

see you again on monday!

Gerak Khas Attachment: Day 4

Ok. Alhamdulillah today I got no embarrassment tragedy in the morning. I entered the toilet today only after double-checked the toilet label. I head to ward, to be exact cubicle 1-6, yesterday it was taken care of other HO. But, today a female HO take care of this cubicle. She was quite blurred with all the patient there. I shared everything I know about those patient with her. She is ok about me being there but not what I call her. I call her Dr. which she asked me just to call her first name. It is very much awkward to call your senior just names right?

Anyway, I was with her and her supervising MO until the specialist came. I then join the specialist for grand ward round. She is doing grand ward round every day rather than only on active day as what has been practiced by some other specialist. Then we do rounds like every other day. I should call today's round as Humor Round! The specialist told us lot of story of her past experience like confronting alternative healer in ward which against the rule, experience on various background of patient in STD ward etc. She asked me about a dengue patient which have psoriasis in his scalp and face. She asked me what is that? I am not well-acquainted with dermatological patient. I just stare her right on her face and say nothing. She then asked one of HO. Luckily, a HO know the answer and I'm saved from that misery.

There is also patient with snake bite. You can clearly see his very much edematous left hand. Also, the specialist tell me that we need to know what's the snake's species because snake venom are either neurotoxin or haemotoxin. Ah, yes! Sarawak Handbook for Medical Emergency is must have book for all medical department HO. Also, the specialist asked me to auscultate the lung of the patient with HAP, which I heard as crept. of course type. I stammer while answering "I think it is a course crept. She said, "You think it's course?" while ausculatating the patient's lung. Then she pull her steth and my heart skipped a beat. Finally, she said, "Good, Ibrahem. It's a course crepts". I was flattered (padahal biasa je, tapi jakun first time specialist puji, LOL!). Then I continue on her round, which I got to feel a newly post-AVF op hand. It feels really thrilling. The feeling is so weird cause you can feel arterial pulse superficially. Also I ask the specialist to stay at this ward for the rest of these three weeks and Alhamdulillah she allowed me to. YES!! I'm gonna stay at this ward!

Oh, ya! I followed the HOs to CME session. It was interesting for me, I think but I know how many time they heard this so I think they lost their focus. One by one left the auditorium and went back to the ward. So, to sum up from the CME, for those who intended to practice at Pahang, please know Leptospirosis and Melioidosis very well. They are in your daily practice.

Tomorrow, CME at 3pm I will giet you guys updated. Wasalam.

N.B

AVF- it is abbreviation of Arterio-Venous Fistula. It is a procedure to form a fistula between brachial artery and cephalic vein. It is used for HD patient where venous that had been connected to artery will be stronger and can withstand frequent injection. You guys need to read it for better understanding! Happy reading!

Gerak Khas Attachment: Day 3

So everyone, how do you all start your day? I start my day with the biggest embarrassment of the year. I WRONGLY ENTERED LADIES ROOM! I just noticed that after I came out from the toilet cubicle while washing my hand, I see from the mirror a female staff nurse fixing her pants. I foolishly asked, 'ni tandas perempuan ke?". She replied, "saya rasa ya!" which I replied "takpe, jangan bising-bising, saya salah masuk tandas ni!".

On my way to the ward I can't stop LOL-ing! I entered the ward and pretend to be professional, wearing my white coat, stethoscope and books heading to first cubicle. Meet one of HO there, ask if I can join him clerking and thank God he allowed me to. Basically, our cases today is MVA infarct with U/L HPT, SVT with HAP, first fitting episode in 26 yo patient and some other more complicated cases. Alhamdulillah, experience of clerking a patient yesterday gives me some confidence in approaching a patient. Even that kind HO told me to do PE on the SVT patient which have bibasal crepts (because she had HAP). Also he showed me the very much patchy X-Ray. Alhamdulillah, HO of this particular ward are very much cooperative.

Also, after a MO came and ask me a few question and reminding me about GCS and suggesting MacLeod's book to learn clinical examination. Then I saw the specialist came in. I joined her round and seeing lots of new case since yesterday is active day (Ward have three different days in one cycle namely active, post-active and passive, where active day is for active admission and passive means no new admission).

The specialist also tell us about some clinical classification of hypertension and DDx for secondary hypertension. After that, there is this Down Syndrome with failing kidney. She was not suitable for PD because of non-compliance and easy irritability. But she can't undergo HD due to central line stricture. Then, sadly the specialist told the parents that she is departing. The patient didn't say anything, but I can see the gloominess of her mother's eye. Her mother almost cried when she was informed that her 26yo daughter is departing. I am not very good at translating what I saw today but who can? Only her mother know the feeling of knowing your 26 years raised daughter is departing. So, that's the drama for today (Dramatic rounds started to show EOD pattern).

Then, after rounds I came down to library and have a nap (one hour and half sleep is considered nap, kan?). I came up to the ward at 4pm and the HO that I joined this morning asked me, "Eh, kenapa tak pergi CME?". I said I was in library. Hahah..pretty good excuse, right? So in this department/ward, CME is on Wednesday. Then, I excuse myself to go back early. Tired meh...see you again soon!

Glossary:

HO- house officer (pegawai perubatan latihan siswazah)

MCA infarct- middle cerebral artery infarct

U/L- underlying

HPT- hypertension

SVT- supra-ventricular tachycardia

HAP- hospital acquired pneumonia

PE- physical examination

MO- medical officer (pegawai perubatan, basically those who finished their housemanship)

GCS- Glasgow Coma Scale

DDx-Differential diagnosis

PD- peritoneal dialysis

HD- hemodialysis

EOD- every other day (alternat day pattern of events)

CME- continuous medical education (sort of seminar where HOs present about pre-assigned topics of clinical subject)

Gerak Khas Attachment: Day 2

Ok. I start my day quite early today. I came to the ward 7.30, greeted one of the HO. She said, "kenapa awal sangat?". I answered, last year, when I came to the ward at 7.30, all HO finished clerking. She said the usage of paperless system, and some changes in timetable make HO work start a little bit later than before. Alhamdulillah for us future HO!

Then I and other student joined her for morning round. So, when the specialist came, we joined her for ward round. Today's round witness less drama than yesterday. But I see how the specialist scolded the HO on malaria patient. That was really scary and very much worrying, so folks, please ah don't forget your parasitology. Also seeing patient with cerebral toxoplasmosis. She is Retro Viral Disease patient, but the first antibiotic giving her maculo-papular rash so the Dr. need to change to antibiotic that free from sulphur compound. It took to reference book and one phone consultation to solve that problem.

Then I meet my primary schoolmate, Fikri. Have a chat after round and Alhamdulillah his mother is doing good. After rounds, I have rest at pantry, before joining one of Junior Medical Officer, doing pleural tap for a patient with pleural effusion. While assisting a little bit, I was asked to take his BP reading by automatic machine. Then I did one of the biggest mistake of the day. I use hand rub sanitizer in front of him. His face changed to a sad expression. I did not mean to offend him. But I was told by my colleague not to do it again.

Right after coming out from that procedure room, I was confronted by another HO. She asked me a favor. I was asked to clerk a patient. I was like, what??? I never clerk any patient before. I asked her if she will be with me. The answer is NO! I need to do it by my own. Then I clerk the patient according to guidelines stated in Oxford Handbook of Clinical Medicine (note that Oxford Press never pay me for this, lol).

I clerk the patient, but my clerking is not deep enough, I didn't notice that she had gout, didn't notice her previous hospitalisation and other relevant medical history. But I learnt something today, that clerking is not as tough as I thought before. So, people please revise your history taking skills ok!

Then the doctor asked me to take her BP and I missed it! I need to polish up my skills. It is sort of hard to take manual BP after leaving CVS block 3 semester ago. Then I was asked about iron deficiency anemia signs and symptom. It was ok, but I need to read more. Well, one of the toughest thing I need to master is understanding what the doctor and nurses ask. Abbreviation, low voice, high noise contribute to its difficulties. Last time, I was asked to find ECG sheet for the patient, but end up ordering a new ECG reading from a nursing student.

p/s: this one is off record ah, I saw a 7-days houseman crying in front of the computer. Take note ya folks. Learn how to manage your emotion from now ok!

Gerak Khas Attachment: Day 1

So, basically, today is just like other normal day to others, but for me, my heart start skipping most of the beats this morning. Today is my first day doing attachment this year. Although I had gone through this last year, but it is a whole new experience! (Just because I learnt all the preclinical component)

I reach Hospital Sultan Haji Ahmad Shah, Temerloh (HoSHAS) at 8. Heading to administration office, seeing En. Moorthi. He send me straight away to Pejabat Pakar. At the office, I spent a lovely 15 minutes waiting for the doctor. Dr. Raj, HOD Medicine was informed to have morning prayer. After a while Dr. Sharifah ask me to go to Kenanga Ward 14 wait for her there. I went upstairs, heading to that ward, seeing Dr. Kavitha. She asked me to see Dr. Sharifah first, but I said she asked me to wait for her at the ward.

Then, I started hanging around. I followed Dr. Kavitha and Dr. Chong (the HO) until Dr. Sharifah came and supervise us. She is very much interactive. Explaining me about atrial fibrillation, describing the pulse, and some ECG reading. Then, she also asked me to examine a patient abdomen. I did it wrongly. I didn't see the patient's face, didn't sit to inspect. I go straight to palpate the abdomen, skipping inspection. Then, she showed the exact way. Once again I do wrong. I percussed the abdomen by left hand which look so weird. Ok..that's was embarrassing.

Then one of unforgettable thing, is when Dr. Sharifah told this one patient that he is HIV. He shut his eye tightly. Then he open his eyes and said, "Tak ape lah doktor, dah nak sakit nak buat macam mana". He looked deeply to his pregnant wife. Thank god, his wife and baby is so far safe from that disease. I just observe this situation quietly while piling my condolences on patient's family. Then seeing around, a patient with Horner's syndrome. He is affected by lung cancer. I noticed, a lot of patient having dengue fever and leptospirosis. The most famous non-infectious disease is chronic kidney disease. So, for future practice, those disease are of importance!

Until next time fellas!