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.

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.

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:

10.30 AM

• Pleural Tap
• First, she made sure that the area was clean and sterile. She put on the sterile gown and gloves, and prepared the instruments with the help of the nurses.
• The site chosen for pleural tap was between 4^th and 5^th intercostal space at midaxillary line. Dr. B prepared the site with iodine and alcohol, and put on the drape at the patient.
• First, solution of local anaesthetic lidocaine was prepared. Dr. B injected the needle of the syringe all the way in, and gradually removing the needle of the while injecting the LA.
• Then, she waited for a few minutes for the LA to take action. Then she prepared the special syringe for retrieving the pleural fluid. She were planning to take some of the fluids for laboratory investigations, and will proceed with drainage of pleural fluid to relieve the breathlessness of the patient.
• She injected the special syringe at the site, all the way in. Then she pulled out the syringe, sucking the pleural fluid, and removed it into the prepared container. The fluid appears to be hemorrhagic.
• Due to unusual appearance of the fluid, she decided to do the biopsy of the pleura. A special needle for biopsy was used, and a piece of the pleura was taken successfully.
• Dr. B continued with the drainage of the pleural fluid. After a while, almost 1.5L of the fluid was retrieved successfully.
• She then sutured the local incision, and applied a simple dressing.
• The procedure ended at 12 PM. I went for the lunch break.

2.00 PM

• I stopped by at the Emergency Department. I was told to have a look at the ED, because there might be some interesting cases over there.
• I reported to Dr. A, the doctor in charge of the Emergency Department at the moment.
• There are one case of a patient who developed osteomyelitis. The patient had an broken femur last few years, and an internal fixation was applied. However, he developed a fistula at his thigh with pus flowing. Xray confirms the development of the osteomyelitis.
• There are also few patients with accidental injury, and one patient with acute renal failure.

3.00 PM

• I left Emergency Department and reported back to the medical ward. There, I studied the case reports of the patients. Around 4 PM, I was allowed to go home.