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