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.

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