Thursday, August 25

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!


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

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