Day 5 (10/7) – The Chest Clinic

10^th JULY 2009 – FRIDAY

8.00 AM

• I arrived at the hospital around 8 morning.
• I went straight to the ward, reporting myself to Dr. W.
• There was a patient with case of diabetes mellitus. Dr. W asked about the history taking of a patient with diabetes mellitus.
• History taking of patient with diabetes mellitus is characterized by 3 main complaints – 3P
  • Polydipsia (thirst)
  • Polyuria
  • Polyphagia
• Other complaints are also significant, for example weight loss and blurred vision may suggest nephropathy or retinopathy.
• The diagnosis of diabetes is established when
  • Random glucose sample is >11.1 mmol/l
  • Fasting blood glucose is >7 mmol/l
  • Oral Glucose Tolerance Test (OGTT) 2 hours >11.1 mmol/l

10.30 AM

• After I finished the ward round I went straight to the chest clinic (respiratory clinic), accompanying Dr. W.
• Chest clinic is a special clinic targeting those with complaints of respiratory system diseases. Common cases in which are treated there – Pneumonia and TB.
  • Community Acquired Pneumonia (CAP)
    • I was given the chance to look at the xray of a patient with CAP. The xray shows right-sided shadow at the level of 4^th/5^th intercostal spaces.
    • The same patient also complained of coughing with white sputum, and pain at the right side of the chest.
    • The patient was then scheduled for sputum analysis.
  • Tuberculosis (TB)
  • • Then, there was a patient with tuberculosis.
    • He was a male asian teenagers, with history of smoking since age of 14.
    • He developed cough since 2-3 months ago, with white-yellowish sputum. He also suffered from weight loss.
    • From the xray, I could see the distinguished border of a circle at the upper lobe of left lung, indicating the presence of a cavity caused by the disease.
    • According to Dr. W, upper lobe involvement is more common in asian patient of tuberculosis.
    • I also learned about the drugs used for treating tuberculosis. The drugs are:

• Name of Drugs                         mg/kg (daily)           max dose (daily)
• Streptomycin                                     15                      1000
• Isoniazid                                             5                        300
• Rifampicin                                         10                        600
• Pyrazinamide                                     25                      1500
• Ethambutol                                        25                      1200

• I ended my day in the hospital at 1 PM. I was then allowed to be free.

Day 4 (09/07) – My First Pleural Tap

9^th JULY 2009 – THURSDAY

8.00 AM

• I arrived at the medical ward at 8 AM. I waited for a while, then I joined Dr. W for the ward round. I followed her checking on few patients, and we arrived at the patient with pleural effusion.
• Dr. W decided that the patient needed another pleural tap. She asked whether I want to perform the procedure, with her assistance of course, and I agreed.
• Then she went to do some clerking, while I sat on a corner revising the steps for the pleural tap procedure.
• After a while, the nurses came and they set up the equipments. I put up my sterile suit with gloves and mask. Then I set up the drape area for the pleural tap on the patient.
• The area chosen was posterior axillary line on the level of 5^th Intercostals space. First, I clean the area with some iodine, then I swab it with alcohol to prevent contamination.
• After that, I prepared the local anaesthetic lidocaine solution. I inserted the needle all the way in, avoiding the ribs, and started pushing the lidocaine diffusedly.
• Then I waited for a while for the lidocain to take effect. After that, I inserted the pleural needle at the same site. I felt the tip of the needle touched the rib, so I avoided it and went at the upper border of that rib.
• I managed to enter the pleural. I took off the needle cap, and few mililitres of pleural haemorrhagic fluid came out.
• There was only few mililitres of fluid. I pulled out the syringe but there was no fluid.
• Dr. W took place, and tried to retrieve the fluid again, but there was no fluid too.
• We then pulled the needle off, and put dressing on the site of injection. Dr. W decided to order a X-Ray to determine the quantity of the fluid. Perhaps the previous 2 procedures had drained a lot of fluid, that’s why there was not much fluid taken today.
• The procedure ended around 11 AM. I went for a lunch break.

2.30 PM

• I returned to work at 2.30 PM. I attended the emergency department.
• That evening, there were few cases of injuries which required immediate attentions
• One of them, a middle-aged construction worker had an accident at the working site. His 5^th phalanx were dislocated 90 degrees at the level of interphalangeal joint.
• The doctors decided to do closed fixation. Local anaesthetic was injected, and the patient was given enough analgesic. One doctor held the patient, and the other one pulled the affected phalanx. The patient screamed in pain, and a click sound was heard as the dislocated phalanx returned to it’s normal location. The patient felt less pain afterwards. He was then sent to radiology for X-Ray.
• My session at emergency department ended around 4 PM. I then was allowed to be free.

Day 3 (08/07) – Mumps and Stroke

8th JULY 2009

8.00 AM
•    I arrived at the hospital and went straight to the ward. Today, the day began with the pleural tap procedure on the same yesterday’s patient. There still present a lot of fluid in the left pleural cavity, despite yesterday’s draining.
•    I helped Dr. W perform the procedure. This time, the fluid was taken from the posterior side of the patient, at level of 5th Intercostal Space.
•    Like yesterday, the hemorrhagic fluid was drained. Patient informed that she feels a lot better than yesterday.
•    Then, there were new admissions of patient. One patient was a young girl, who collapsed at school. It was believed that the girl collapsed due to dehydration and lack of nutrition. The girl was trying to lose some weight, therefore skipped some meals.
•    Another patient was a middle-aged woman presented with swelling of the left side of face. The swelling was very painful and sensitive to touch. The patient also seems lethargic. Blood count shows an increase in white blood cell, particularly neutrophils. It indicates that there was an infection going on. Swelling of the parotid glands and lymph nodes confirmed the infection. The diagnosed mumps was confirmed later.

10.00 AM
•    I then followed Dr. W and Dr. B to the clinic. At the clinic, I met with Dr. E who was also conducting the consultation.
•    There was a lot of patients with Diabetis Mellitus, and Arterial Hypertension.
•    Dr. B asked me few question regarding the stroke patient in the ward. She asked me about the type of stroke – hemorrhagic and ischaemic stroke.
•    She also asked me about the clinical examination for neurological system, and asked me about reading the CT scan. I told her that I’m not yet having my neurology cycle.
•    The clinic ended around 12.30 PM. I asked the doctors about the evening session, and they said that the ward round may be conducted but will be very late, so I was allowed to be free that evening.

Day 2 (07/07) – The Pleural Tap

7^TH JULY 2009

9.00 AM

• I arrived at the ward. Today, my day began with a ward round, lead by specialist Dr. T.  We checked out each and every patient, and while we stopped at a patient, Dr. T asked me about the patient.
• Among the questions asked by Dr. T were about the classification of Thalassemia, the Glasgow Coma Scale, and about the pleural effusion.
• Then, he also asked me to do the history taking and perform respiratory examination of the patient with pleural effusion.
• The patient, 80 years old lady was admitted with complaint of breathlessness. I did respiratory examination, and general inspection showed that diminishing respiratory movement on left side of the lung. There was also tracheal deviation. Auscultation was done, and there was no breath sound at the left side of lung, below 3^rd intercostal space. Percussion was done, and I heard flatness over lower part of left lung. The initial diagnosis was pleural effusion, and it was confirmed by the x-ray.
• Therefore, the doctors decided to do the pleural tap, as well as biopsy of pleura, to determine the nature of the fluid. Dr. B conducted the pleural tap. Here’s what I watched and learnt from her: