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.