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)