- 5:07:00 PM
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COMPARTMENT SYNDROME
- 9:47:00 PM
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MY SLIDESHARE
- 12:57:00 AM
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POST END POSTING EXAM - LONG CASE
Fuhhh, I just told you guys that I don't want stroke patient this morning right? Turn out I went to see my patient and suddenly my patient that I got is a stroke patient. WOW. What a case... I almost broke into tears and I became very nervous. Thank God, Liyana was there helping me out to prepare for the case. She did all the research while I try to memorise and smoothing my CNS physical examination flows.
Nina was there too and helping me out with the physical examination. I'm blessed to have friends like them. My subgroup-mates also very supportive and wish me luck with the patient.
I went to Mahsuri ward at 2.00 pm and starting to clerk the patient. Then I receive a message from Dr. Ong that I need to clerk Bed 15 instead Bed 2. I asked her for confirmation, and she said Bed 15 for me. Mann..
I called my friend and I told her our case had been swapped - giving her hints that she need to read about CNS examination and ischaemic stroke 2ry to cardioembolism instead CVS case.
He came due to left upper and lower limb muscle weakness.
My case - The CVS patient
The CNS CASE
The patient was a 65 year old malay gentleman but seems old from his age. He has underlying Chronic Rheumatoid Heart Disease, Chronic Kidney Disease and Gouty Arthritis.He came due to left upper and lower limb muscle weakness.
My case - The CVS patient
My patient was well cooperate and very friendly. 1 hour was not enough for me to clerk and did my examination (suprisingly!). 1 hour given to me was always enough before this, I wonder if changing my style by first listening to all the patient had to say is better than while listening I should jotted down everything and arrange it all together. Hmm. The latter seems better for me.
My patient was a 43 year old, malay gentleman working as hawker and live in Melor, Kota Bharu. He is a smoker with history of 21 pack years for more than 30 years. He stopped smoking last month.
Patient is a known case of hypertension and also hypercholesterolnemia. He was diagnose with hypertension since 2 years ago and not compliance to medication. His hypercholesterolnemia was diagnosed last month and claimed compliance to medication.
His main complaint was chest discomfort, breathlessness and lethargy. Then nothing. Aiyoo. There was 5 days history admission to CCU recently (last month) due to almost similar presentation but worsen than the current one. He was not aware of the diagnosis. But listening to his description about the symptoms is more likely like acute myocardial infarction or acute heart failure.
Upon physical examination, Apex beat was not displace (5th intercostal space, mid-clavicular line), there was thrills present at left sternal edge. Pansystolic murmur was heard best heard by diaphragm at mitral area and radiated to axilla - bloody hell it was mitral regurgitation! And I was so pleased with myself that I can finally differentiate the type of murmur. Bibasal crepitation was heard and there was no sacral and pedal edema.
My differential diagnosis were Acute Coronory Syndrome and also Heart Failure. Dr. Ong asked me about the investigation I would done and management for Acute Coronary Syndrome Disease. She gave me good mark, Alhamdullilah !
Investigation I would carry out :
1) FBC - looking for any infections from total white count and looking for anemia from Hb level.
2) Coagulation Test
3) Renal profiles
4) Liver Function Test
5) Cardiac Biomarkers - Troponin & CKMB
6) ECG - ST elevation in Myocardial Infarction
7) Chest X-Ray - to look for any cardiomegaly or other underlying disease
8) Echocardiogram - To see the LVEF status, cardiac wall, cardiac contractility and to confirm mitral regurgitation
Management:
1) Airway
2) Breathing
3) Circulation
4) Give oxygen if patient still breathlessness
5) Primary PCI
6) Anti-fibrinolytic such as streptokinase or ateplase
7) Anti hypertensive drug - Frusemide
8) Educate patient
💕 READ HOW TO DIFFERENTIATE MURMURS 💕
HERE
- 6:55:00 PM
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Long case exam is just in few hours from now and I'm so nervous about it. What if I got stroke patient? OMGG me,myself will be having stroke in front of the patient. I hope Dr. Ong will give me a straightforward case and I'm able to tackle that case too, in shaa Allah. Ease all my journey today ya Rabb.
So last night I was revising about CVS examination and got confused all over the topics. Like, WTH am I reading for the past 1 hour then got forgot again. Allahu my brain... *sigh*
Having difficulty in differentiating type of murmurs while auscultate a patient? Don't worry, you're not the only one ! Me too having the same problem since I was a 3rd year medical student. During that time, I was at Hospital Tanah Merah and I did not came across any patient with murmur. Cases were limited as it is a district hospital. All severe cases will be referred to Hospital Kota Bharu. So, I'm here now in Kota Bharu as a 4th year medical student. So many patient with interesting physical findings and most of them have murmur! YAY.
So here some tips I learnt from my prof and also from hospital specialist. One of my prof blog about it - A Simplified Approach to Cardiac Murmurs For Medical Students. And it is very helpful for me and makes my life easier. A bit confused in beginning but later you'll be okay.
From the blog:
The basic principles are:
- if the murmur coincides with the first heart sound, it is a systolic murmur.
- If it doesn't coincide with the first heart sound, it is a diastolic murmur.
Sometimes, even if you have done your best and listened while palpating the pulse, and you are still not sure whether it is a systolic or diastolic murmur, well, in the exams, you can guess and you have a fifty-fifty chance of getting it right (or wrong).
If you had to guess, then go for systolic murmurs as they tend to be:
- more common
- easier to hear compared to diastolic murmurs which tend to be low-pitched
Of course when guessing, there is a chance one might be wrong. Rather have no answer, sometimes it is better to guess.
For the sake of simplification, I memorised, as a medical student, four of the more common murmurs:
- Mitral regurgitation
- Aortic stenosis
- Mitral stenosis
- Aortic regurgitation
Here the best part about my prof. She summarised it all like this:
Mitral regurgitation is a pansystolic murmur that is heard loudest at the apex, heard through out the praecordium, radiates to the axilla, and is accentuated by expiration.
Aortic stenosis is an ejection systolic murmur heard loudest at the aortic area, radiates to the carotids, and in accentuated by the patient leaning forward in expiration.
Mitral stenosis is a mid-diastolic rumbling murmur heard at the apex and accentuated with the patient leaning on the left side in expiration.
Aortic regurgitation is an early-diastolic murmur heard best at the left sternal edge/tricuspid area, accentuated by the patient leaning forward in expiration.
Aortic stenosis is an ejection systolic murmur heard loudest at the aortic area, radiates to the carotids, and in accentuated by the patient leaning forward in expiration.
Mitral stenosis is a mid-diastolic rumbling murmur heard at the apex and accentuated with the patient leaning on the left side in expiration.
Aortic regurgitation is an early-diastolic murmur heard best at the left sternal edge/tricuspid area, accentuated by the patient leaning forward in expiration.
Here some video that might help you to differentiate between those murmurs
MITRAL REGURGITATION
AORTIC STENOSIS
MITRAL STENOSIS
AORTIC REGURGITATION
- 10:03:00 AM
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Hi guys, I'm a 4th year medical student from Lincoln University College. Currently in Internal Medicine posting for 4 weeks. This is my second week in this posting and gotta share what I learnt last week.
Four groups has been assigned to four different Medicine wards in Hospital Raja Perempuan Zainab (HRPZ) II; Mahsuri, Bendahara, ward 8/8P and also Puteri. My first week is at Ward Mahsuri.
Then, Dr. Azza gave us a list of specialist in charged for each group. My group was assigned to few specialist there, including Dr. Sinari. She is the consultant of Medicine department. Our favourite specialist for time being is Dr. Grace from Mahsuri ward. She is so nice, graceful and very knowledgeable. She treat her medical officer and houseman so nice that I felt lucky to have her as one of our group specialist in-charged. Bless us. Bless me.
First day was tiring but there was no bed side teaching. Second day of first week, we went to the ward and introduce ourself to the staffs there. Most of the houseman there are very nice. They include us in every ward round and help us whenever we look blur in the cubicle. The medical officer in charged for cubicle 3 in ward Mahsuri is Dr. Mohd. He is the coolest person there. I mean, as a medical officer, he really concern about the patient and also the houseman under him. Those houseman under him and Dr. Grace were lucky. Other medical officer in the ward that I find very amusing is Dr. Hidayah. She is so rock and cool. She got this mighty confident and a very unique lady, I must say.
During ward round, Dr. Grace will include us in the discussion as well. She ask questions and also explain about the case, the decision-making, and also the insight of that case. Dr. Mohd also help us and discuss the case briefly so that we understand the case well when the ward round take place. For the first time, I felt like being welcomed by the specialist, medical officer and also all the staffs there. They are too nice. I can't believe that I'm in medicine posting.
We were given homework at the end of ward round. For me, it is more like a reading list or list of topics that you need to read at home. So here are the list for the 1st week of posting:
1. Hypertensive Intracranial Bleeding 👌
2. Atypical Pneumonia 👌
3. Community Acquired Pneumonia 👌
4. Retroviral Disease 👌
5. Upper GI Bleed
6. Status Epilepticus
👌 = DONE
Till now, I haven't touch those last two topics. Hahaha. Sigh. Then we went for a clinic session. First clinic session was a rheumatology clinic. But we were some sort of not welcomed and kena marah in front of the patient inside the doctor's room. I almost cry but kinda tahan because the fault was not from our side. We did all the things that we need to do; we introduce ourself at the counter. We ask who in-charged for the clinic. We introduce ourself again to the nurses in the doctor's clinic and asked for permission. The person in-charged was not there so we waited outside. Suddenly the nurse came to us and informed us that we can asked for permission from the doctors in the other room. So we all went inside the room and again, introduce ourself to the two medical officers inside that tiny room. It was so crowded. One of the doctor told us to clerk a patient who is currently waiting outside the room. So yeaa. We clerked. We followed the patient went inside meeting other medical officer. And then after everything almost end, a lady came inside the room and marah us for not introducing ourself. We were so puzzled that time as we already did the introduction part and still kena marah. We explained and she was like still perli us about not respecting the clinics. They were not informed yada yada. Sigh. Sometime you buat everything also kena marah. So yeaaa whatever.
Another clinic experience is with Dr. Pong from Respiratory Clinic. She was so nice, so cute, so cool and so friendly with the patient, including us. We sit inside the room and she will ask questions related to each patient that came to see her. We felt like we were welcomed and she teaches us about pulmonary fibrosis that day.
Here are my second week posting reading list:
1. Cushing reflex 👌
2. Renal with hepato involvement
3. Typhoid Fever
4. Pott's Disease
5. Liver Cirrhosis
6. Obstructive Jaundice
7. Upper GI Bleed
8. Status Epilepticus
Date: 18 March 2018
1. Hypergylcemic Hyperosmolar State (HHS) 👌
2. Hypoventilation Obesity Syndrome
3. Cardiomyopathy 👌
4. Uremia
5. Delirium vs Dementia
6. Congestive Heart Failure 👌
7. Upper GI Bleed
8. CVS Murmur Maneuvers 👌
Date: 19 March 2018
1. Asthma / COPD
2. Respiratory Failure
3. CNS Examination
4. Causes of stroke
👌 = DONE
So many things to cover right ?
- 10:56:00 PM
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HISTORY TAKING TEMPLATE
So I'm gonna share with you gaisss my template for clerking patient. Well, this is just a basic thing that you need to ask when you clerk a patient. In paediatric ward, you can't really take genuine history from the child. I mean, how you're gonna take history from a child right? They might be crying so loud that even the parent would thought you're an incompetent doctor at that time. Haaaa, so take history from the parent, NOT from their grandmother, their uncles, their sibling (depend on situation) or other unrelated people who came with the patient. Preferably take history from the mother. Mother know the best! They can provide all information you wanted to know.
There are 2 templates that I did for my study purpose.
- For template A, I put few things from Geeky Medic. Reference source is from Geeky Medic.
- As for template B, I re-edited it and followed a bit like Hospital Raja Perempuan Zainab (HRPZ) II history template. Reference source is from Geeky Medic.
Template A View
Template B View
Please don't claimed this as your own, and do not re-upload or share it without permission. Thank you !
1. TEMPLATE A
2. TEMPLATE B
- 9:16:00 PM
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ANAESTHETIC MACHINE
PREOPERATIVE
MALLAMPATI SCORE
POST OP RECOVERY EVALUATION
POST OP COMPLICATIONS
Student notes
Reference are from google, pinterest directly, lecture slides.
- 11:50:00 PM
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by PUTREEO
Liyana and Audi already settle with their make up, so we all headed to Kamdar Textiles in the heart of Kota Bharu city. Why Kamdar? because you can get saree at a cheaper price there and the salesgirl will help you wear saree with free of charge. But if you're outsider (not purchasing Kamdar's saree but you're just want the service of salesgirl tolong pakaikan your saree) they charged RM 10/person. Okay-lah.
Meet Liyana Mikayla. Ni la anak Umaira and Azim. Budak kecik comel yang menghiburkan my batch last night.
- 12:22:00 PM
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So.... 2nd day of Opthal posting already !!!! So, this is one of the textbook that had been recommended to us by the specialist of HRPZ II.
- 10:02:00 PM
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- 5:31:00 PM
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Definition of
Gestational Diabetes Mellitus
The WHO has defined
Diabetes Mellitus as either a raised fasting blood glucose level of > 7.8
mmol/L or a level of > 11.0 mmol/L 2 hours following a 75 g oral glucose
load.
Pathogenesis of
Gestational Diabetes Mellitus
Fetal hyperinsulinemia
Effects of Fetal
Hyperinsulinemia
1. Reduced lung
surfactant à
Respiratory Distress Syndrome (RDS)
2. Increased
erythropoiesis can leads to jaundice or hyperviscosity syndrome. Hyperviscosity
syndrome will later develops into necrotizing colitis or renal vein thrombosis.
3. Increased fetal
metabolism which will increases O2 demand. Low O2 supply from the mother can
leads to intrauterine death.
4. Macrosomia à shoulder dystocia
5. Hypoglycaemia
6. Hypertrophic
myocardiopathy
Effects of Diabetes on
Pregnancy
1. Increased
miscarriage rate
2. Increased perinatal
loss due to intrauterine death (IUD)
3. Macrosomic baby
hence is at risk of dystocia
4. Fetal lung
maturation may be delayed; if the fetus was delivered prematurely, the risk of
getting RDS is increased
5. Risk of
preeclampsia
6. Risk of
polyhydramnios
7. Susceptible to
infections; mainly UTI and candida vaginitis
Management of Diabetes
A.
Pre pregnancy
The women who are known
to be diabetic and women who have had gestational diabetes should seek medical
attention before they get pregnant. This consultation offers opportunities in
explaining to them about;
1. The reason for
meticulously maintaining her blood glucose at normal level before conception
2. The need of taking
folic acid to reduce the risk of neural tube defects
This consultation can
also be used as an assessment for the presence of any complication related to
diabetes, such as diabetic retinopathy and nephropathy. Women who are on oral
hypoglycemic drugs should preferably be changed to insulin therapy. We should
check for her glycosylated Hemoglobin, HbA1c that reflects her glucose control
over the previous 10 weeks. High levels of HbA1c are associated with an increased
rate of fetal abnormality.
B. Pregnancy
Euglycemic state
should be maintained; with fasting glucose less than 5.3mmol/L and 2 hour post
prandial blood glucose should be less than 6.7 mmol/L. Blood sugar profile
should be checked before or after each meal; preprandial or postprandial
glucose level and the result should be less than 6 mmol/L or 6.7mmol/L,
respectively. Normal blood glucose level should be maintained with a mixture of
short and medium-acting insulin. Ultrasound scan that was done during the first
12 weeks of pregnancy provides accurate estimation of the period of gestation.
Meanwhile, scanning between 18– 20 weeks of gestation allows exclusion of any
major malformations and around 34 weeks of gestation, it permits assessment of
fetal growth. Regular assessment of fetal growth and wellbeing should be
performed.
C. Timing of Delivery
Delivery at up to 40
weeks of gestation is possible if the sugar control is good. But if there is
inadequate blood glucose control, or the presence of polyhydramnios, fetal
macrosomia or maternal obesity delivery at 38 weeks of gestation is indicated.
Delivery at earlier than 38 weeks is not really indicated to prevent
Respiratory Distress Syndrome in the premature baby.
Management of Labour
The intention is to achieve vaginal delivery.
Labour can be induced by doses of oxytocin. An artificial rupture of membrane
(ARM) should be performed. Blood glucose level needs to be monitored at
frequent intervals; mostly done at 2hourly. The fetus should be monitored
throughout labour and during vaginal delivery shoulder dystocia should be
anticipated. On the other hand, a caesarean section may be performed if there
is significant petal macrosomia or poor fetal status (CTG), or if labour fails
to progress satisfactorily. Uncomplicated diabetes not an indication for
operative delivery.
Follow Up of Women Who
Have Had Gestational Diabetes Mellitus
Follow up is important
as up to 50% of women with Gestational Diabetes Mellitus may develop overt
diabetes; mainly Type II. At the follow up visits, we should encourage her to
follow a diet which is appropriate for a diabetic. She should also be advised
to take these following measures;
1. Avoid becoming
obese
2. Take regular
exercises
3. Avoid cigarette
smoking
4. Checked annually
for hypertension
These women have a 50%
chance of developing Gestational Diabetes Mellitus in the future pregnancy. If
she intend to become pregnant again, testing for hyperglycaemia before
conception or in early pregnancy is recommended.
- 12:34:00 PM
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