Wednesday, September 26, 2012

W3 D3 : Case Write-Up!!




Day 3 was the day I get to know the HOs in Orkid 8B. There's Dr.Hafiz who is sporting enough to let you take blood without supervision, Dr.Hanis who is cute and friendly, Dr.Farih and Dr.Belzinder Singh who look kinda cool too, Dr.Siti Hazwani who is a bit strict and this one H.O who is always with Dr.Sujana. I didn't get to know his name, but I bet he must be in a very stressful mood everyday. 

I think every H.O in Orkid 8B felt the tension somehow. They look up to Dr.Sujana and afraid of making mistakes, I guess that's a good thing then?

I clerked a patient with Acute Coronary Syndrome. Well, actually I talked to his 40++ year old son because the pakcik was fast asleep when I walked past his bed. While interviewing his son, I got to know that he is my uncle's friend. He knows my Dad as well. Wow, what a small world. 

I talked to a 12-year-old with Thyphoid Fever (demam kepialu - Salmonella typhi) and he had palpable liver two fingerbreadths under costal margin (hepatomegaly). 

Short Case with Dr.Wan Syahril was entertaining. He's very cool, and sometimes he likes to joke around too. He has a very pleasing 'built-in' smile, I like that. We learned Abdominal and CNS exams with him. He suggested highly of Express Revision Book by UM.

This is my eldest Sister's book. Warisan turun temurun, heheh























CHINA and MMM



We learned a lot from Dr.Syahril. He asked us to read this book because it's very useful.

Causes of enlarged kidney - Polycystic kidneys, Obstructive neuropathy, Renal Cell CA etc.

Investigations - Blood, Non-blood and Imaging.

SAAG (Serum Albumin Ascites Gradient) > 11 g/L = 90% of portal hypertension.

The session ended at almost 2.30pm. Then Aina told me that we are supposed to go meet our Mentor right after that, because Dr.Naim waited for us since 12.45pm.

Aina would like to ask about our Case Write-Up and Case Presentation, plus building a rapport with Dr.Naim as well, us being his Mentees and all. At first, I did not agree to that last part, but looking at Aina's very-determined expressions, I didn't have the heart to say no. So I called Irfan and we met up at Level 3 JHC.

It's hard not to notice our Mentor's half-empty room. That's his new office, Aina told me when I pointed that out. Irfan laughed when I mentioned about Dr.'s extra-fluffy pillow on his bright-pink chair. That's a touchscreen phone for sure, iPhone or Samsung I couldn't tell. And he drives a Honda Jazz, how cute is that! :D

When we were asked about our Case Write-Ups, Aina asked Dr's opinions about her patient with Kidney Disease while Irfan wanted to do SLE case.

Me? I haven't find any case yet.

It's already Week 3, you should find a case starting from now, he told me. 

**Stressed out!

Right after our brief discussion, Aina, Irfan and I went to lunch. After that, I went straight to Mawar 7B/7C to find a case for my report.

Nope. I couldn't seem to find one that I like.

Arghh!!! Seriously!!

Tuesday, September 25, 2012

W3 D2 : Procedures!




This day started with me getting to JHC early to finish up my Clerking Notes. Aina already sent three set of notes to our Mentor, but me and Irfan hadn't had ours done yet. So, we had to keep up with her :)

At 10.00am, we had Long Case Session with Dr.Anis Shah. My friend Wani presented a Leukemia case while Rusli prepared a case of Infective Endocarditis.

Causes of Raised Jugular Venous Pressure - Venous Obstruction (Right-sided Heart Failure), Fluid Overload/Retention, Constrictive Pericarditis, Pleural Effusion and Tricuspid Regurgitation/Stenosis.

Pansystolic Murmurs - Tricuspid Regurg, Mitral Regurg and Ventricular Septal Defect (VSD).

After lunch at Kompleks Teruntum, I went to UIA to get my Matric Card done. I lost it somewhere, can't remember exactly when it was missing from my pocket. I had to report the lost card to the Security Office and went to Koperasi to get my picture taken. The fee is RM35 and I'll get the card maybe in a week or two.

I went back to the hospital and learned Cranial Nerves Examination from Kak Fatimah. It was a simple one if you know what are the nerves you are testing. Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulococchlear, Glossopharyngeal, Vagus, Accessory and Hypoglossal. The 12 Cranial Nerves altogether.

Me and Syira stayed late this evening to help Dr.Maria and Dr.Puteri took blood from patients. Dr.Puteri was a really cool H.O, I just got to know her today. She's friendly and easy to talk to. I watched Dr.Maria took ABG and did Venous Cannulation too.

I had performed three Venepunctures today.

And I got signatures from three different H.Os - Dr.Maria, Dr.Puteri and Dr.Siti.

Yay! :D

Monday, September 24, 2012

W3 D1 : Orkid 8B?




I just realised how difficult it is to keep writing/updating my routine here. Well, considering the fact that from Monday-Thursday, I usually stay in the hospital from 8am till more or less 5pm, and when I got home I have clerking notes to be completed or tutorials/PBL to read on.... so there you go, that explains it all :D

Today is Friday 28th but ironically, I am writing for last Monday's post. Haha. Procrastinate Procrastinate. The reason? I went to bed at 10pm for the last two days, arghh how I regretted that very much! Now I am on coffee, so you bet I could stay up till Subuh lol

Okay, this post is dated on Monday. So Monday it is. What did I do on Monday, hmm~ (pardon the informal bit, I am 'high' while listening to Hot FM at 2.48 o'clock in the morning, so yeah.. do understand lol)

Where's my note book? Okay, here it is.

Monday Monday. The first day. Our first day in Orkid 8B. 

I clerked two patients today. One presented with Dengue Fever with no warning signs (febrile phase) and another patient had sudden right upper limb weakness for one day duration, accompanied with slurring of speech and facial asymmetry. After the Brain CT result was out, the final diagnosis was Lacunar Infarction in Right Thalamus.

At about 11am, my friend got scolded by Dr.Sujana. He didn't like us bothering his patients early in the morning. He told us that we should let specialists completed their Ward Round first before we clerked the patient. My friend was so nervous that she told me she almost peed in her pants. We laughed.

So we went to Orkid 8C. Oh Orkid 8C. 

We watched Dr.Marzuki did his round, he taught us the Risks of getting Metabolic Syndromes: Central Obesity, Diabetes/Impaired Glucose Tolerance, Hypertriglyceride, Low HDL and Hypotension.

At 4pm, we had Short Case Session with Dr.Juita. We learned two Cardiovascular Cases and it was very educational. Dr. reminded us to check for Radioradial Delay, Radiofemoral Delay and Collapsing Pulse, as well as Parasternal Heave and Thrills. Don't forget the bibasal crepitations. Must read on Systolic and Diastolic Murmurs.

Among the causes of Heart Failure: Cardiomyopathy (Dilated, Hypertrophic, Restrictive), Diabetic HF, Hypertensive HF, Thyrotoxicosis, Heart Output Failure, Ischaemic Heart Disease, Chronic Rheumatic Heart Disease etc. Read the CPG for Management.

So that's how my first day went. I think I like Orkid 8C better.

Sunday, September 23, 2012

On Call




1) I reached Orkid 8C at 8pm. This is my Last Day here, tomorrow we'll be posted in Orkid 8B next door. Ah, so sad. I have come to like this Ward, the Doctors, H.Os and Nurses. Many interesting cases are mostly here, predominantly patients with Respiratory problems.

The lecturers I had seen doing their Ward Round so far are Dr.Naim, Dr.Nimm and Dr.Juita. We saw Dr.Marzuki once. I wasn't always following their round because there were times I couldn't understand what they were discussing about, other times I clerked patients or joined my friends did PE on them.

We have met the tall and good-looking Dr.Liong on our first day here, he taught us abdominal exam who had Splenomegaly. He is friendly and always been very helpful. He talks fast too. Dr.Maria is another friendly H.O (who talks fast, sometimes I have to replay her words in my mind just to understand the meaning) who had just started her first posting two weeks ago. She lets you do the procedures if you ask her. I had always seen Dr.Aizat and Dr.Gaddafi hang out together. They are cool and you can ask them questions freely. Dr.Badrul is okay too, I guess. I did not talk much with him. Same goes to Dr.Anna and Dr.Kelcina (she has nice handwriting!). And also two other H.Os with glasses whom I rarely talk to. I don't know their name.

Staff Nurses and Nurses are good. I've never been scolded by them up to this point. We have met Trainee Nurses who did their Practical there. They are friendly and talkative if you get to know them. Don't call them kakak, some of them are younger than you! :D 

2) I talked to a pakcik with Acute Coronary Syndrome. He knows his disease very wall, he told me that the doctors from previous hospitals told him that he has Papillary Stenosis and his Cardiac Murmur can be heard faintly. He have had many tests before: Exercise Stress Test, ECG, Echo, Angiogram etc. He has an appointment scheduled in Institut Jantung Negara (IJN) this October, but he was admitted to HTAA earlier due to sudden onset of shortness of breath.

3) I saw an uncle who had been stung by hornets. The initial rashes disappear after medications were given yesterday, but new rashes appears today. Dr.Maria told me that it was due to the Tramal (Tramadol - a pain reliever) given. If we stop the drug, the rashes will be gone.

4) My friends and I watched Dr.Maria took Venous Blood Gas (VBG) from a patient suspected of PCM Poisoning. The blood was sent for Therapeutic Drug Monitoring too. She said that VBG is less painful than ABG. We did VBG mainly to check the Bicarbonate ion level in the blood, not the Oxygen level.

5) The pakcik 'Pacemaker' who has AECOAD told me that his abdomen felt full and hard started this evening. I told him to tell the Doctor in charge. It's very worrying because his family members (I think 3 of them) had died due to Liver Cancer years ago.

6) The two patients aka inmates from nearby jail are still in their beds. When asked, they said they are feeling better now. They were admitted to the Ward due to suspected Infective Endocarditis (they are IVDUs). My friend had examined one of them and she told us that we could hear Mechanical Bruits in his heart.

7) There's this very old, cachexic and sick-looking pakcik who suffers from Grade IV Lung Carcinoma. When I walked by his bed to talk to him, he asked me for a Rokok. I was taken aback. He is sick and he asks for a cigarette?

And I told him no, of course.

8) By 10pm, I got into car and drove home. Got nagged by my parents due to the constant night outs. If I were a boy, I think they don't mind me coming back home late, even at 12 midnight.

But I'm a girl. 

And girls are not supposed to drive alone at night, or coming back home as late as 10.30pm.

Friday, September 21, 2012

W2 D4 : Procrastination




1) Today my friends and I practised CNS Examination on a patient who was admitted to the Ward with complaint of slurred speech and right-sided body weakness. He had distal weakness and facial asymmetry. We tested him for Babinski Sign but he kept on laughing, I wasn't sure if the result was positive or not.

2) A Year 5 Brother who happened to be in the Ward with us taught me and Aina briefly on how to do Hands Examination (Rheumatology). He mentioned that we should read more on Rheumatoid Athritis, Osteoarthritis, Gouty Arthritis, Spondyloarthritis and Dermatomyositis. 

3) Our friend told us about the topics often asked in exam: Murmur, Asthma, Pneumonia, Bronchiectasis, Hepatosplenomegaly, Kidney problems, CNS and Rheumatology Examination. 

4) Short Case session with Dr.Anis Shah was very informative. He asked us to examine a patient with AECOAD, the one who wears a pacemaker. We could hear vesicular breath sound with prolonged expiration and rhonchi on both lungs.

These are the things I've learned from him:
x Acute causes of SOB - Asthma, MI, Pneumonia, Pneumothorax.
x Chronic causes of SOB - Pulmonary TB, Bronchiectasis, Heart Failure, COAD

x Symptoms that we must ask if patient has SOB - Cough, Palpitations, Chest Pain

x Ecchymosis > Purpura > Petechiae 

x Causes of tachycardia - Anxiety, Fever, Pregnancy, Respiratory distress, Arrhythmia, Shock, MI, Heart Failure, Pulmonary Embolism, Hyperthyroidism.

x Grades of Clubbing:
Grade 1 - Increase fluctuations in nail bed (difficult to detect)
Grade 2 - Straight line of nail bed, loss of angle
Grade 3 - Increase curvature of nails from side to side (parrot's beak)
Grade 4 - Tissue hypertrophy, swollen terminal phalanges (drumstick appearance)

5) My patient was discharged from the Ward yesterday. This evening, I asked for his Case File from the Staff Nurse only to discover that the file had been dispatched to the Record Office. Obviously I was too late. 

My Clerking Note is already half completed, I just want to check the Management Plan! 

Now I need to find a new patient. This time, I'll keep in mind to read the patient's Case File thoroughly and complete my Clerking Note right after I interviewed the patient.

Thursday, September 20, 2012

W2 D3 : Gloomy




1) You know every H.Os and M.Os were given a Pre-Inked Stamp bearing their own Name with Pegawai Perubatan UD41, HTAA on it. If they do not have the stamp, and they must write down their name on every patient's report, I bet their handwriting could not be easily recognized. Then we will have problems finding the doctor who wrote the terribly written report. Patients' progress cannot be read, proper treatment cannot be provided and patients' life might be in danger!

So you see the importance of the Name Stamp now :P

2) It's frustrating when you could not understand what was written due to the not-so-clear handwriting of dearly doctors. For me, every time I read Patient's Progression Note, I have this tendency to see who's writing the report with such handwriting.

And again, the Name Stamp helps a lot ;)












3) Tutorial Session with Dr.Khairul Azhar (DKA) was unnerving. The topic was Gastrointestinal Bleeding. He asked each one of us taking turns to write on the whiteboard on Definition, Signs & Symptoms, Causes and Investigations of GI Bleed.

a-Definition: 

x Upper GI Bleed - Bleeding above Ligaments of Treitz
x Lower GI Bleed - Bleeding below Ligaments of Treitz

Ligaments of Treitz arises from right crus of diaphragm and inserts into third and fourth portions of duodenum (duodenojejunal flexure).

b-S&S:
x Upper GI Bleed - Hematemesis (vomiting blood), Melena (black tarry stools) 
x Lower GI Bleed - Hematochezia (bright red blood in stools), Colicky abdominal pain
and S&S for Anemia (fatigue, shortness of breath, headache, palpitations, pallor) and Shock (Cold clammy skin, dizziness, hypotension, tachycardia, low urine output, rapid shallow breathing, fast weak pulse) etc.

c-Causes:
x Upper GI Bleed - Peptic Ulcer (NSAIDs in elderly and H.pylori in young), Esophagitis, Mallory-Weiss Tear, Esophageal Varices, Malignancy etc.
x Lower GI Bleed - Hemorrhoids, Anal fissures, Diverticulosis, Iscahemic Colitis, Infectious Colitis, Inflammatory Bowel Diseases, Angiodysplasia, Tumour etc.

d-Investigations:
FBC, BUSE, OGDS, CXR, Colonoscopy, CT Scan, Barium Enema, Blood C&S etc.

When the session ended, we all breathed a sigh of relief. I made a mental note to prepare myself well before his class starts next time.

4) At about 3.15pm in the Ward, a patient's heart rate suddenly dropped (bradycardia). Doctors were called and CPR was done immediately.

I could hear a nurse said to a H.O who performed CPR on the patient, 'Doktor, macam mana Dr. buat CPR ni..'. I could see clearly that the H.O did not have enough confidence to do the chest compressions on the patient. The patient's condition did not even improve.

Then the staff nurses took turns to do the CPR. What I noticed was that, staff nurses performed CPR way better than the H.O, I could see it in their face. They were all sweating and looked very determined to save the patient. In the end, it was the H.O who got praised by the Doctor who came afterwards to have a look at the patient. The nurses did not take credit for their work. Hats off to them.

But sadly, the patient was stabilised only for a short while because his heart was too weak to be saved. The patient's wife cried and his family gathered around his bed to say goodbyes.

5) We also saw Incision and Drainage (I&E) Procedure done on a patient with Abscess on his sole of foot. It looked very painful, the patient was given local anesthetic beforehand.

Then, we watched H.Os took blood sample from a patient who had Methicillin-Resistant Staphylococcus Aureus (MRSA) Infection. They wore aprons, gloves and used sterile equipments. We helped them calming the patient down.

We also saw a H.O performed Venepuncture for Blood Culture in a patient with Retroviral Disease (RVD) aka HIV. He used sterile equipments too.

I've got more to tell you, but this post is long enough. Till next time then :D

Wednesday, September 19, 2012

W2 D2 : Boo Hoo!




1) At 10.15am today, Aina, Wani and I witnessed Cardiopulmonary Resuscitation (CPR) done on a patient with Cardiac Arrest. The chest compressions, not including mouth-to-mouth rescue breathing.

We were busy clerking our assigned patients before it happened. When the patient suddenly stopped breathing, the doctor called out his name several times but the patient did not respond. Seconds later, the nurses gathered around his bed - brought medicine cart, patient monitor, defibrillator etc. Curtains were closed.

Chest compressions were done by H.O and medical students, taking turns. Blood was taken to be analysed. Drugs were given intravenously. The doctor defib the patient when he suddenly went into V-Fib. The heart rate became stable again. I thought I could see the patient opened his eyes slightly.

At almost 11.00 am, the patient was stable. Or so I think.

After that, I did not know what happened. But the patient died anyway.

2) Rewind to the moment the medical staff were busy saving the patient's life, this one M.O came and drew the curtains aside to check on a patient lying two beds away. She was explaining something to a Doctor regarding the patient's condition. 

I glanced at her, amazed that she could not be more 'sensitive' than that. I mean, a patient is fighting for his life but you still can act like nothing is happening? If you don't want to help, at least please show some respect. Your patient can wait, he's not dying. You can still clerk him afterwards.

A trainee nurse who was watching the CPR with us whispered to me, 'Nanti akak jangan jadi macam dia tau..', referring to the insensitive M.O.

I smiled.

3) I was about to ask something to a Doctor, but she asked me to wait for a second while she's finishing her work. Okay no problem.

But there's this M.O sitting next to her, just shooed me away. Gi sana! I remembered he said exactly that to me.

I was like, what was that about? I wasn't asking you, Duh! And was that even necessary?

But of course I did not blurt that out to him. It was just plain rude to say that.

See? Even a Medical student knows what are the things you should say and what you shouldn't. I was surprised that he didn't seem to be able to grasp the idea of what rudeness is. Seriously.

4) Speaking of which, I recalled my friends 'gossiping' about this one M.O who was rude to them while they were watching her doing a procedure in the Treatment Room. She spoke in a hurtful tone, making my friend left the room.

I had also heard about this one Doctor who doesn't like medical students go near him. My friend advised us to set a perimeter around him, maybe 2 meters apart. Initially I thought he was joking, but he stressed that we should really be 'careful' around him.

Wow. That's.....


5) At 3.00pm, we had our first Short Case Session with Dr.Shahrin at Orkid 8B. He picked a patient and chose one of us randomly to examine the patient's abdomen. Our patient had mild ascites so we were able to hear the shifting dullness but not fluid thrill. 

Then we asked Dr. to teach us Central Nervous System (CNS) examination. He demonstrated how to test for Muscle Tone, Power, Reflex, Babinski Sign, Proprioceptive, Heel to Shin Test on the patient's Lower Limb. Dr. mentioned that the same principle applied to Upper Limb as well. We did not have time to learn about Cranial Nerves exam because it was almost 5pm. And Dr. hadn't had his lunch yet :)

Personally, I think that CNS exam is really complicated, I need to revise the steps back.

Tuesday, September 18, 2012

Week 2 Day 1: Phew, I'm Still Fine




Today was a busy day. We had Long Case in the morning and PBL in the evening.

1) As usual, I get ready at 7.15am, drive to the hospital, and arrive just a few minutes before 8.00am. It's not that I am always eager to get to the Ward, but it will be very, very difficult to find a parking space available near JHC when you get there past 8! I know it because I was once late, it took me almost 20 minutes to get my car parked. 

So the lesson learnt - I've got no other choice other than getting there earlier than the other students.

2) I went up to Orkid 8C and clerked a patient with Acute Exacerbation of Chronic Obstructive Airway Disease (AECOAD) Secondary to Partially Treated Pneumonia. COAD = COPD.

This pakcik was admitted to the Ward due to complaints of shortness of breath and cough for 6 months duration, accompanied with loss of weight and loss of appetite. He was diagnosed with asthma 8 years ago. He is an ex-smoker for 32 years. He smoked cigarettes 16 packs/year. 

What's interesting about this patient is that he is wearing a pacemaker. You could see the outline of the pacemaker under his skin. He mentioned that it can only last for 8 years.

During auscultation, you could hear rhonchi very, very clearly in both of his lungs. I was truly amazed.

3) Long Case with Dr.Harris started at 10am and ended at 12.30pm. Aina presented a case of Bilateral Lower Limb Swelling for one month duration. The patient also has abdominal distention and fever. He has Liver problems.

The Top 4 Differential Diagnosis (Ddx) would be: Congestive Cardiac Failure (CCF), Chronic Liver Disease, Chronic Renal Failure and Nephrotic Syndrome.

Other inputs mentioned by Dr.Harris are:
--> If the patient has Diabetes/any other disease, we must also ask about Duration, Control, Compliance and Medication that he took for his Diabetes.
--> The books that Dr.Harris highly recommends are Talley O Connor and Dr. Mustafa Embong's Guide to History Taking and Physical Examination.
--> Explore more on the symptoms of the patients. We must have Ddx in mind and ask questions to patient based on the Ddx.
--> Mnemonic for 'Precipitation Factors for Hepatic Encephalopathy) is HEPATICUS - Hemorrhage, Electrolyte (hypokalemia), Protein-rich diet, Alcohol/Analgesic, Trauma, Infection, Constipation, Uremia and Surgery.

We managed to hear from one presenter only, because Dr.Harris gave comments and explanations about the Case. He also gave us advice, reminding us to keep on reading about how to take correct history from patient. He asked us to finish reading the recommended books.

4) PBL with Dr.Marzuki was fun. However, 33 students in a PBL discussion is not very convenient. I could see my friend played random game on phone and some yawned or fell asleep because they could not concentrate on what we were discussing. 

Dr. Marzuki is the first lecturer to ask us to introduce ourselves before we start the session. He's cool. And funny too. You could hear brothers laughed out loud every time Dr. cracked a joke. He has quickly become our Favourite :D

Oh. I would like to tell you about our new classmate, Kak Fatimah. She is 26 years old, and she is a graduate from Newcastle University, UK. Apparently, she has to join us for another 3 years of studies because of some problems with her former university, the degree is not recognized by Malaysian government or something, I did not ask her much.

She is like our Senior, she knows a lot of things and she teaches us lots too :)

5) Trying my very best to finish my first Clerking Notes. Me and Aina would like to ask for our Mentor's (Dr.Naim) comments on the Notes first before we send another one. **Nervous

6) Tonight, Syira and Wani asked me to join them On-Call. We talked to a 16-year-old patient with Down Syndrome + Pneumonia and we saw few Dengue cases in the Ward.

Ah. Exhausting Tuesday.

Friday, September 14, 2012

Day 5, Still Alive




Today was my Case Presentation Day with Dr. Che Rosle at 9.00am and I was fairly anxious. I wasn't feeling very confident to present this case because I just clerked the pakcik yesterday, I felt like I haven't prepared much. I wasn't really sure if I'll manage to present the Case correctly or not.

1) At 8.00am, I went to the Ward to see the pakcik, to see how he progressed. I looked for him in his usual bed, in the Respiratory Wing. He wasn't there. I panicked.

Is he dead? :O He was still fine yesterday!

I checked the Discharge File and looked for his name. His name was still here. But where is he? 

I asked the Staff Nurse and she pointed to a bed in the Acute Observational Cubicle. I saw the pakcik wearing an Oxygen Mask around his face, and his wife was sitting next to him.

I greeted him and asked about what had happened. He told me that at 4.00am today, he felt breathless and couldn't breathe. His son called the nurses and they gave him Oxygen. He mentioned that he felt like he was almost dying and that I am close to not being able to see him today. He told me that there was pain at the puncture site.

The pakcik coughed and the sputum streaked with blood. There was a H.O Doctor writing his progression on the case file. She auscultated the pakcik's lungs and told me that there were significant findings heard. She asked me to hear it myself.

I thought I could hear crepitations at his lower part of his right lung. Pneumothorax, perhaps.

When he coughed badly, his wife patted him gently on the back, comforting him. I glimpsed at him and saw tears pooling inside his eyes. His wife wiped away the tears and I slowly walked away.

2) My Case Presentation was a little bit messy. I left out a few important histories and my Chief Complaint (CC) was incorrect.

My initial CC: 
Mr.Z, a 63-year-old male was admitted to the hospital due to persistent cough for five months duration.

The correct CC:
Mr.Z, a 63-year-old male was referred from Hospital Muadzam to do CT-Guided Biopsy.

I really thought that chief complaint must be a Symptom, so I chose the Cough. According to Dr. Che Rosle, the CC should be the reason why the patient came to the hospital. So, in my case, the patient came to the hospital because he was scheduled to do the Biopsy. In the HOPI, only then I should mention about the Cough.

If the patient came to the hospital for the purpose of the exam, you must say that 'This patient was admitted due to exam purposes'.

I got 6 marks over 10, the lowest among my three friends. They all got 7. Of course I was sad, but my friend Sally reminded me that I should be grateful for it.

Yeah. I definitely should. Based on my insufficient information and the wrong CC, I knew that I could get a lower mark than that but Dr. gave me 6. It was more than enough. Thank you Dr. Che Rosle.

This served as a lesson for me. I should learn how to recognize a Chief Complaint. I need to brush up on my History Taking skills.

3) Tonight my friends and I went to the Ward to clerk patients. I checked on the pakcik and I was glad to see him in the Respi Wing. He looked better than this morning. My friends and I chatted with the pakcik for a while before we saw other patients.

There were new cases admitted tonight - Two dengue patients with white mosquito nets hung over their bed. A young, married Indian male and a 17-year-old teenager who live in Semambu and Kem Batu 10 respectively.

They both have fever and headache. Other presentations were dengue rash, pain behind the eyeballs, exhaustion, joint pain (arthralgia) and muscle pain (myalgia).

We went back at 10.00pm, I dropped off my friend at the Terminal Bus station and I drived straight home.

Monday is Malaysia Day. So I'll be back in the Ward on Tuesday morning.

Happy Holidays, everybody!! :D 

Thursday, September 13, 2012

Day 4, There's More?




1) This day started with Long Case Presentation with Dr.Kuan at 8.15am. Our friends Syahir and Syira presented their case one by one in front of the class. After that, Dr.Kuan asked one of us to summarize the case. 

We were all new at this, and frankly, we were a bit blank regarding the correct way/flow to present a Long Case. So Dr.Kuan explained to us about the things we should include in our presentation. 

The case must start with:
1. Chief Complaint (if possible, pick one complaint only ie. chronic cough)
2. History of Presenting Illness (HOPI) + Systemic Review
3. Past Medical/Surgical History + Drug History/Allergy
4. Family History (Patient's Parents and Siblings)
5. Social History + Personal History

Case Presentation with Dr.Kuan was a tough one. He likes to ask questions related to the case to us, not the presenter. I was taken aback when Dr.Kuan asked me about the investigations that we need to do for a patient with Myocardial Infarct (MI). 

I knew the answer, I think everybody knew the answer, but when your Lecturer stood in front of you and stared directly into your eyes you can feel them piercing through your skull, you couldn't help but to stutter.

I managed to utter Full Blood Profile only to be asked again, 'Why do you want to do Full Blood Count?'

'Er.. to look for the signs of anemia?'

'Why do you need to look for anemia in patient with MI?'

I paused nervously, but I was asked again, 'Why do you need to do FBC in MI patient?'

'To see the White Blood Cells count, to look for signs of infections..'

'Why do you need to look for infections? This patient doesn't have fever, so it is definitely not a case of Infective Endocarditis. So, what investigation would you order for this patient?'

I blinked my eyes several times as I could feel my tears burning inside my eyes. I can't think of an answer, please stop asking me.

Then I heard my friend Yani at the back whispering, Lipid Profile.

So I quickly said 'Lipid Profile'.

Then Dr.Kuan said, 'Fasting Lipid Profile. What are the components in Lipid Profile?'

I slowly said, 'HDL, LDL...' Then what is another component? I can't remember!

Yani again mentioned, Triglycerides.

Thank you very much Yani. I owe you much.

Then Dr.Kuan asked the reason we need to do Fasting Lipid Profile. It is to assess the lipid/cholesterol amount that is a predisposing risk factor for Ischemic Heart Disease.

Phew. I almost get a Heart Attack myself. 

I think I like him better in Seminar session than in Case Presentation :) 

My classmates asked a lot of questions to him, and we saw things a bit clearly now. He mentioned that if you discover a new symptom in a patient, you have to ask the details about the symptom (SOCRATES).

For example, if a person has Fever, you have to ask about the Pattern of Fever, Variation with Time and whether it is relieved by PCM or not.

If the patient complains of Headache, you ask about Site, Duration, Radiation, Character, Variation, Relieving and Aggravating Factors etc.

Then Dr.Kuan told us that we need to learn to recognize a certain type of medication commonly used by  patients. For instance, Metformin is a large, white pill taken twice daily by diabetic patients. Glipizide is a smaller white pill, Perindopril/Enalapril is an oblong pill to treat hypertension (ACE inhibitor).

2) I went to the Ward to have a look at the Case File of yesterday's patient. I wanted to record his investigation results, but his Case File wasn't there. When he is transferred to Hospital Serdang, they bring the file together with him. 

Arghhh! I should've known better! Now I have to find another patient for my Case Presentation tomorrow!

I found a pakcik with Severe Sepsis due to Allergic to Medication. Initially, he has skin problems, so he asked his friend to buy medicine for him in the clinic. But little did he know that the Griseofulvin he took made his skin condition worsen. Other than that, he had no other problems.

That evening, I met a 63-year-old pakcik with Respiratory problem, chronic cough that still persists even after he completed his Pulmonary Tuberculosis (PTB) treatment 5 months ago. He mentioned that he was referred from Hospital Muadzam to HTAA because his CT Scan and Chest X-Ray (CXR) revealed abnormalities - there's a mass inside his right lung. So he was here to do CT-Guided Biopsy.

I checked his lungs but no significant findings was noted. 

I am out of option. Maybe I'll present this case tomorrow.

When I was about to copy his investigation results from his file, the nurses asked for the file because the pakcik was going to do the Biopsy.

I waited for about half an hour for him to come back (because I needed that file badly!!) but he didn't.

I went back disappointed and decided to come back tonight to get the file.

3) At 8.30pm, I reached the hospital. I went on to see the pakcik and talked with him. He mentioned that during the CT-guided biopsy, the doctors discovered air inside his lung. Hmm, Pneumothorax?

When I read his case file (Yeah, I got his file already!) it was reported that this pakcik developed Right Pneumothorax post-procedure. I felt bad for him.

He is an amputee (he had hip amputation/articulation) due to Motor Vehicle Accident (MVA) six years ago. He has just recovered from PTB 5 months ago. He is suspected to have Lung Carcinoma because of the mass found in his CXR. And now he has Pneumothorax.

Above that all, he is still in a cheerful mode to joke around, flashing his toothless grin.