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!

iskandariah yang saya rindu

eid adha

HAPPY EID EVERYONE!

THAT'S ALL, THANK YOU.