Friday, November 01, 2013

Of Thursday night oncall and IIMP

Last Thursday night oncall was with Mr.Ariff, our mentor. We went to see about 10-11 cases, so manyy! The round finished at 1130pm and after that, Mr.Ariff taught us stuff until 12am! 

Let me recall what I had learned that night. Well, I clerked a 27-year-old Malay lady presented with right thigh pain, swelling, deformity and loss of function following a fall in the kitchen due to slippery floor. She fell on her right side of body, but the head did not touch the floor. No other complaints of pain at other sites of body, no LOC, giddiness, bleeding, nausea or vomiting. 

And the most interesting part was, she has underlying Beta Thalassemia Major and Type I Diabetes Mellitus! 

Regarding her thalassemia, she had undergone splenectomy and gallbladder removal in 2011. Her first blood transfusion was when she was 10 months old (that's about time beta chains are needed to pair with alpha chains, and gamma chains production is turned off, remember? so when the beta chains are defective in thalassemia patient, thats why the symptoms start to manifest when they bind with alpha chains!!) She had regular transfusion at MOPD daycare every month, transfused with 2-3 pints of blood every time. She is on T.Ferrifox BD, folic acid and calcium lactate. She stopped using Desferral about 5 years ago due to pain at injection site.

Both of her parents are Thalassemia carrier. She is the second among five siblings. Two other siblings (male) have Thalassemia. One of them died at 21 years of age due to hepatitis C after blood transfusions. Other sibling is healthy and working in KL, needs regular blood transfusion as well.

Regarding Type I DM, she was diagnosed 2 years ago. Her mother was told that her pancreas cannot secrete insulin anymore. She is on SC Actrapid 22 unit TDS and Insulatard 26 unit ON. She has no other illnesses like heart or kidney problems.

Let me brief the PE findings to you. Ehem ehemmm *clears throat*

When I examined her at Yellow Zone A&E, she was very thin (growth retardation due to Thalassemia). She looked uncomfortable and in pain, but not in respiratory distress. Her hydration and nutritional status were fair. She did not look pale or jaundiced. She had classic features of Thalassemia such as frontal bossing, prominent facial bones and dental malocclusion. Multiple scars noted at both hands and forearms due to branula insertions.

On right lower limb examination, there was shortening of right lower limb of about 5cm? and the position was externally rotated. There was obvious swelling noted at lateral side of proximal femur, associated with deformity (possibly fracture!) and tenderness. No open wound, no warmness of overlying skin. No deformity at right hip felt (to exclude hip dislocation). Distal toes can move, can dorsiflex and plantarflex. Femoral pulse palpable, CRT less than 2 seconds, sensation intact.

On abdomen examination, vertical scars about 15cm noted at mid-abdomen, due to splenectomy operation. Hepatomegaly present, 5FB. No abdominal pain tenderness. Heart and lungs were normal. 

The XRay showed spiral fracture (due to twisting type mechanism of injury) at proximal third of femur. She was put on skin traction and planned for internal fixation operation later.

So that's about it! Other than this patient, we had seen a 6-year-old female child with supracondylar fracture of humerus (the most common type of fracture in kids), a lady with radial ulna fracture, lumbar compression fracture, carbuncle, gangrene of toes, chip fracture at knee, hand abscess and some more cases that I cant quite remember.

That case of pakcik with hand abscess was interesting. I said interesting because there were firemen involved! Yeahh seriously! I was with them at that time!

Ok ok here's the story.

He is a 41-year-old Intravenous Drug User (IVDU) + Hepatitis C, presented with 8 days' history of left painful hand swelling. He wore a ring at his fourth finger, so when the swelling occured, the ring cannot be removed! It was stuck at his finger! Thus - the firemen. I thought that they were gonna remove his finger, but they just cut the ring! Pheww.

He was on methamphetamine since 17 years old. Sometimes he took morphine and heroine too. In the Green Zone A&E, I asked him about why the swelling occured in the first place. He said that he injected methamphetamine intravenously at his left dorsum of hand, then the swelling occured afterwards. He said that he used a new syringe and was sure that the needle was clean. He never shared needles with his friends.

MO Dr.Suhana advised him to stop using drugs. Mr.Ariff did too. The pakcik said that he was fully aware that doing drugs are forbidden in Islam and that he was trying to quit. All of his drug-addict-friends were already dead because of the drugs.

He was then admitted to the ward for further management of that abscess, gonna do Incision and Drainage (I&D) to get all the pus out!

Ohh. Speaking of forbidden things, smoking is haraam in Islam too! By rightt, Muslim should not smoke! I dont like smokers! Especially the ones with ZERO common sense! You know that there are people who are sitting at the table, eating their meals, so whyyy do you have to get your cigarette out and smoke???! WHYYYYY???! Even if you hide the cigarette under the table, you think that the smoke does not go everywhere? Come onnnnnn, you gotta be kidding me!! I dont even care if you wanna smoke, smoke all you want, smoke all day, smoke till you have no breath left - but pleaseeee dont smoke in front of other people! Or in front of your family even! If you want to smoke your lungs, go ahead! But dont affect others!

And where were we? Hahaha sorryyy sometimes I get carried away while writing.

Ohh. Oncall.

Okay. I remembered one question asked by Mr.Ariff during his teachings that night. Here's the question : Can we eradicate Thalassemia?

Can we?

The answer is Yes! We can eradicate Thalassemia!


By making a rule that does not allow Thalassemia carrier to marry another Thalassemia carrier. Because, the chance of the children getting Thalassemia major is 50% and hydrops fetalis 25%! That's when pre-marital screening is important! Very important! Just like you wanna know your partner has HIV or not, you would want to know about Thalassemia too, especially when you are a carrier as well.

Ahhh I had written too long! Sorryyyyy. Hahaha

Okay okay just a short note on Islamic Input for Medical Purpose (IIMP) that we attended at 215pm today, supervised by Prof.Roszaman O&G specialist. It was on ART - Assisted Reproductive Technologies. The two presenters talked about IUI (Intrauterine Insemination) and IVF (In-vitro fertilisation). These techniques are for couples who do not have babies after years of marriage. Either the problem is with the male (low motility sperm, low count sperm, erectile dysfunction) or the female (older age, cancer, tumour, cysts, pelvic inflammatory diseases etc).

Medline plus here mentioned about two categories of infertility:
  • Primary infertility refers to couples who have not become pregnant after at least 1 year of unprotected sex (intercourse).
  • Secondary infertility refers to couples who have been pregnant at least once, but never again.  
The gist of the evening seminar was that IUI and IVF are permissible in Islam as Allah encourages us to have many kids and raise them to be good Muslims. But it is prohibited when you use other guys sperms (not your husband) and inserted them into your uterus. IUI and IVF are allowed in married couple only!

Awwwww. Babies. Cute little babies!

Okayyy I am done writing! Going to bed nowww. 

You have a good day okayyyy!!! Byebyeee :D

You know I'd walk a thousand miles, if I can just see you..

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