Faithfulness Forever

Exactly 2 more weeks I gonna face my Professional 3 exam. Feelings of anxiety and uncertainty begin filling my heart. So much to study, so much to clinical examination to practice. I really dunno how this 2 weeks is gonna be, what the outcome. I wish I could just turn back time and start all over again, but tats of course impossible.
We can try our best to achieve anything but, we cant guarantee anything in life.
With this I put my all my hope and trust in God. Whatever the outcome of this Pro 3, I will still praise Him.
“Do not be anxious about anything, but I everything, by prayer and petition, with thanksgiving, present your request to God.” Philippians 4:6

Hospital Pasir Mas

Its been a few days since I was posted in Hosp. Pasir Mas. Life here was really different than that in USMKK. Arrived here on thursday, I found the scenery here rather peaceful and quiet. There were 17 of us, 6 guys and the rest girls, one house for each. Two dutch students from Holland came and join us in this district posting. Wow, our life here will be much more interesting with their presence. The house was dirty, so the first day was all cleaning and mopping. One good thing we found is that, the previous groups left a map of Pasir Mas in our house, showing those popular food restaurants in Pasir Mas. These restaurants were also rated, imagine that? How creative they were?

The next day, we set out to check out those ‘hot’ restaurants in Pasir Mas, but unfortunately most of the reataurants are closed on fridays. We wanted to eat the ‘Lian Hong’ Loh Mee, but it was closed too. So we just settle down with wan tan mee nearby. That day was also one of our coursemate, Zie’s wedding party. Including her, there were already 4 ppl in group who are married, one of them is already a mother! I am still single.:-( So jealous of them… Anyhow the bride was so beautiful tat day. She was always pretty, but tat day was just extraordinary beautiful. We had another lunch at the wedding party and then took photos with the newly wed couple.

On day 3 which was Sat, We spend the whole day online, chatting, downloading movies. The line here was quite fast, so our computers were on most of the time. I brought my keyboard along and Viki brought his guitar. I taught Toh Jeng, my coursemate to play ‘My heart will go on’ on the keyboard and he was diligently practising it since then. Occasionally his gf (who is also our groupmate) will drop by listen to him playing. How sweet…:-)

Yesterday, was just the usual briefing, running in the wards, doing procedures. We are supposed to go Barkas in the evening, to do some research on the water in Kelantan but due to technical error, the trip was postponed. Tis morning, I went to the Labour room, and there was this patient, 28 year old female, gravida 2, para 1, about to give birth to her second child. No painkiller was given to her. Her active phase of labour was long and she was having difficulty pushing her baby down. Possibly due to her short contraction pain. It took almost 1 hour before finally the the baby’s head came out. Here in Pasir Mas, unlike HUSM, they dont give painkiller to pregnant ladies in labour. Imagine the pain they go thru? I really salute these ladies who choose to deliver in Pasir Mas.

Life here is rather slow paced, unlike in HUSM. People here are more relaxed and not in a hurry. I dont feel so much pressured here.

Massive Oncall

Yesterday I had a massive oncall at A&E, HUSM. It was exciting and eventful. Even my buddy, Vikinesan was there with me, undergoing the challenges of A&E life. For the first time, I forgot for a moment my lonesome, depressing life in USMKK. I was in the A&E from 10pm til 3am.

There was this patient in red zone. She is a 62 year old Chinese lady. She actually came to HUSM tis morning for her regular follow-up. During the follow-up in clinic, the doctor there noted her blood pressure was high. She was then discharged with medication for her high BP. She went back and took the medication. But then she later develop headache, dizziness and chest discomfort and came to the A&E at around 2pm. She was stable and placed in yellow zone before suddenly she collapsed. She was quickly brought to red zone and an emergency ECG was done. ECG shows ventricular fibrillation (VF). It was a sudden cardiac arrest. They started CPR on her she was defibrillated for 10 times before her heart started pumping again.

I went to A&E around 10pm and saw her lying in one of the bed in red zone. Viki told me that the medical side has reviewed her and couldn’t do any definitive treatment for her as she is unstable. She was diagnosed acute myocardial infarction and started on IV medication. Then suddenly around 10.30pm, this patient who was already sedated, develop VF again. We alerted the doctors, and help them do the CPR on this patient. The doctors did defibrillation on her. Me and my coursemates takes turn to do chest compression on her, besides ambubaging and giving IV adrenaline. The patient regain her pulses. But then later, she develop VF almost every 10 minutes. Imagine having to do CPR every 10 minutes. Fortunately, the are many of us. This patient was supposed to transferred to ICU and her condition is unstable and A&E is not the place to monitor patient 24 hours. It’s the ICU. But unfortunately, all the ICU beds in HUSM is full last night. Even the ICU beds in Hospital Kota Bahru and Perdana in KB is full. ICU beds in Hospitals in Terengganu also full.

The MO then asked me to explain things to the patient’s son who was also in the red zone, watching her. I told him there is no bed in ICU, and the patient is very unstable and will frequently develop VF. We might have to resuscitate her until next morning. Even if we send her to ICU, the ICU doctors will do exactly the same thing. But ICU has staffs tat will monitor her for 24 hours. I asked him whether he still want us to do CPR on her if she continue to develop VF. He then insisted that we resuscitate her until he call all his family members to HUSM. So then, the MO let us take care and resuscitate the patient by ourselves. I really feel like im a doctor, being able to manage patient with my coursemates. But when I look the the patient’s son, I feel for him. He is very depressed and everytime his mother goes into VF, he broke into tears.

Finally, at around 3am, one patient in CCU passed away, leaving one bed empty in CCU. The MO then decided to send her to CCU. I accompanied her family members to CCU. I wonder how is she now.
Besides her, there was also another 2 patient in red zone. One 64 year old man came with shortness of breath and another 59 year old woman also came with shortness of breath. The man was diagnosed with Myocardial infarction and the woman was diagnosed with diabetic ketoacidosis secondary to urosepsis. It was a extremely busy night in the A&E.

Mercy and strength

‘Let us then approach the throne of grace with confidence, so that we may receive mercy and grace to help us in our time of need.’ Hebrews 4: 16.

This verse struck to me as I was reading the Bible this morning. This week I gonna orthopaedic posting exams and by the end of the week, is SUKAD. Both stuffs giving a hard time this whole week. In final yr, orthopaedic posting is only 3 weeks, really not enof time for us to cover much. Especially my theory knowledge, i struggle a lot, even during our ortho posting in 4th yr.

In difficult times, we tend to use our own intelligence to solve problems rather than relying on God’s. We doesnt seek God, we figure out our own solutions. In the end, problems multiplied and worsen, we get stressed up. And then we blame God! We blame God because God didnt help us to solve our own problem (by using our own solutions). But I believe God is still faithful. He will never forsake us in times of trouble. We just need to pray n come back to Him… Learn to be dependant on Him!

What ever happens tis week, I juz hope tat it will be something tat glorifies God!

Causes of respiratory distress in term infants

PULMONARY CAUSES

Common

Transient tachypnoea of the newborn – Caused by delay in the resorption of lung fluid and is more common after birth by C-section. CXR may show fluid in the horizontal fissure and additional ambient oxygen may be required. Condition usually settles within first day of life but can take several days to resolve completely.

Less common

Meconium aspiration – Meconium is passed before birth by 8-20% of babies. Rarely passed by preterm infants and occurs increasingly the greater the gestational age, affecting 20-25% of deliveries by 42 weeks. Asphyxiated infants may start gasping and aspirate meconium before delivery. Meconium is a lung irritant and results in both mechanical obstruction and a chemical pneumonitis. In meconium aspiration the lungs are overinflated, accompanied by patches of collapse and consolidation.

Pneumonia – Prolonged rupture of the membranes, chorioamnionitis and low birthweight predispose to pneumonia. In this kind of case, we usually start broad spectrum antibiotics early

Pneumothorax – May occur spontaneously in up to 2% of deliveries. May occur secondary to meconium aspiration, RDS or as a complication of ventilation

Milk aspiration – More frequently in preterm infants and those with respiratory distress or neurological damage. Babies with bronchopulmonary dysplasia often have gastro-oesophageal reflux, which predispose to aspiration

Persistent pulmonary hypertension of the newborn – This life-threatening condition is usually associated with birth asphyxia, meconium aspiration, septicaemia, or respiratory distress syndrome. As a result of high pulmonary vascular resistance, there is right-to-left shunting within the lungs and at atrial and ductal levels. Cyanosis occurs soon after birth. CXR may show pulmonary oligaemia. Most infants require mechanical ventilation and circulatory support in order to achieve adequate oxygenation. Inhaled nitric oxide, a potent vasodilator, is often beneficial. Extracorporeal membrane oxygenation (ECMO), where infant is placed on heart and lung bypass for several days, in indicated for severe cases.

Other rare causes

Diaphragmatic hernia, Tracheo-oesophageal fistula, Pulmonary hypoplasia, Airways obstruction, Pulmonary haemorrhage

NON-PULMONARY

Congenital heart disease, Intracranial birth trauma, Encephalopathy, Severe anaemia, Metabolic acidosis

Neonatal Examination

These are the few tips I learned today on neonatal examination…

1. Firstly we look at the child’s general appearance. See whether the child is in respiratory distress, discomfort, pain. Also we should observe the patient’s posture and movements. (For us to do this, the baby needs to be fully undressed)

2. Find out the patient’s gestational age. If we suspect the patient’s is a pre-term baby, use the Ballard score to assess his/her gestational age. (I will share on Ballard score later…). Also we should not forget to measure his/her birthweight, length and head circumference and plot the growth chart. Take note if the patient’s birthweight/ length or head circumference is below 5th percentile or above 95th percentile.

3. Palpate both anterior and posterior fontanelle. Feel whether is it tense or not. A tense fontanelle when the baby is not crying may be due to raised intracranial pressure and cranial ultrasound should be performed to check for hydrocephalus. Also we should palpate the sutures. The sagittal suture is often separated and the coronal suture may be overriding.

4. Observe the face. Look for any syndromic facies such as flat occiput, flat nasal bridge, hypertelorism, low set ears, unslanting of palpebral brigde, cleft lips, increase intercanthal distance, small jaw. etc etc. This features could indicate Down, Edward, Patau or Turner syndrome.

5. Also look at the face for any plethoric, cyanosis, jaundice or paleness. If yes, check the haematocrit to identify polycythaemia or anaemia. Central cyanosis is best seen on tongue. Jaundice within 24 hours of birth requires further evaluation.

6. Examina the eyes, checked for red reflex with an ophthalmoscope (cataracts, retinoblastoma and corneal opacity). Inspect the palate, including posteriorly to exclude posterior cleft palate.

7. Observe patient’s breathing and chest wall movement. Look for any sign of respiratory distress such as subcostal recession and chest wall indrawing. Confirm it by counting the respiratory rate. ascultate the heart for any murmur and count the pulse rate. The normal rate in babies is 110-160 beats/min, but may drop to 85 beats/min during sleep

8. Palpate the abdomen. Feel for any intraabdominal masses which most commonly is renal in origin. The liver normally extends 1-2 cm below the costal margin, the spleen tip may be palpable, as may the left kidney.

9. Inspect the genitalia and anus. In boys, look for presence of testis in scrotum. In girls, look for labia majora and labia minora. You should be able to differentiate between the two. Also look for any fistula or discharges.

10. Palpate for femoral pulses. Femoral pulses is reduced in case of coarcation of the aorta. This can be confirmed by measuring the blood pressure in the arms and legs. Femoral pulses is increased in case of patent ductus arteriosus.

11. Assess the muscle tone by observing limb movements and on sitting the baby while supporting the head. Most babies will support the head briefly when the trunk is held vertically.

12. Whole of back and spine is observed looking for any midline defects of the skin

13. The hips are checked for development dysplasia of the hips (DDH). This is left last as the procedure is uncomfortable.

Characteristic clinical manifestation of Down’s syndrome

Typical craniofacial appearance
- Round face and flat nasal bridge
- Upslanted palpebral fissures
- Epicanthic folds (a fold of skin running across the inner edge of the palpebral fissure)
- Brushfield spots in iris (pigmented spots)
- Small mouth and protruding tongue
- Small ears
- Flat occiput and third fontanelle
Othe anomalies
- Short neck
- Single palmar creases, incurved fifth finger and wide ‘sandal’ gap between toes
- Hypotonia
- Congenital heart defects (40%)
- Duodenal atresia
- Hirshsprung’s disease
Late medical problems
- Delayed motor milestones
- Moderate to severe learning difficulties
- Small stature
- Increased susceptibility to infections
- Hearing impairment from secretory otitis media
- Visual impairment from cataracts, squints, myopia
- Increased risk of leukemia and solid tumours
- Risk of atlantoaxial instability
- Hypothyroidism and celiac disease
- Epilepsy
- Alzheimer’s disease

Cerebral Palsy (CP)

Def : Disorder of MOVEMENT and POSTURE due to a non-proggresive lesion of motor pathways in the developing brain.

It is the most common cause of motor impairment in children, affecting about 2 per 1000 live births. In addition to disorders of movement and posture, children with cerebral palsy often have other problems reflecting more widespread brain dysfunction. These include:

- Learning difficulties (about 60%)

- Epilepsy (40%)

- Squints (30%)

- Visual impairment from errors of refraction and cortical damage (20%)

- Hearing impairment (20%)

Causes

- 80% is antenatal in origin due to vascular occlusion, cortical migration disorders or even structural maldevelopment of the brain during gestation

- 10% due to hypoxic-ischaemic injury at birth

- 10% postnatal in origin. Preterm infants are especially vulnerable to brain damage from periventricular leucomalacia (PVL) secondary to ischaemia and/or severe intraventricular haemorrhage.

Clinical Presentation

Early features of CP include

- Abnormal limb tone and limb and/or trunk posture in infancy with delayed motor milestone; may be accompanied by slowing of head growth

- Feeding difficulties, with oromotor incoordination, slow feeding, gagging and vomiting

- Abnormal gait once walking is achieve

- Asymmetric hand function before 12 months of age.

There are 3 main clinical types of CP, namely spastic (70%), ataxic hypotonic (10%), dyskinetic (10%) and mixed pattern (10%)

A. Spastic (3 main types)

Hemiplegia : Unilateral involvement of the arm and leg, with the face spared. Affected children often presented at 4-12 months of age with fisting of the affected hand, a flexed arm, a pronated forearm, asymmetric reaching or hand function. Subsequently a tiptoe walk on the affected side may be evident

Quadriplegia : All 4 limbs are affected, often severly. The arms may be affected more than the legs. The trunk is involved with extensor posturing and poor head control. This form of CP is often associated with seizures, microcephaly and moderate/severe intellectual impairment

Diplegia : All 4 limbs, but the legs are affected to a much greater degree than the arms, so that hand function may appear relatively normal. Walking is abnormal

B. Ataxic hypotonic CP

Signs are relatively symmetrical. There is early trunk and limb hypotonia, poor balance and delayed motor development. Incoordinate movement, intention tremor and an ataxic gait may be evident later.

C. Dyskinetic CP

Dyskinesia (fluctuating tone) leading to frequent involuntary movements (generally of all 4 limbs) especially evident with movement/stress. These involuntary movement may be…

Chorea : irregular, sudden and brief non-repetitive movements

Dystonia and athetosis : Simultaneous and sustained contraction of agonist and antagonist muscles involving the trunk and proximal limbs (dystonis) or distal part of the limbs (athetosis)

Ref : Illustrated Textbook of Paediatrics

Acute Asthma

I just finished my clinical exam with Prof. today. Got an acute asthma case. Couldn’t decide whether my patient’s acute asthma is mild, moderate or severe.

This is how we classify acute asthma as mild, moderate or severe in Malaysia.

	Mild (admission unlikely)	Moderate (may need admission)	Severe (admission needed)
Altered consciousness	No	No	Yes
Physical exhaustion	No	No	Yes
Talks in	Sentences	Phrases	Words
Pulsus paradoxus	Not palpable	May be palpable	Palpable
Central cyanosis	Absent	Absent	Present
Rhonchi	Present	Present	Silent chest
Use of accessory muscle	Absent	Moderate	Marked
Sternal retraction	Absent	Moderate	Marked
Initial PEF	> 60%	40-60%	< 40%
SaO2	> 93%	91-93%	<90%

I think I really got a nice bashing this time around. Feel kinda depressed now…

Tomorrow will be MCQ. Hope things gets better…

Post-clinical Exam

I just finished my clinical exam at 4.00pm today. I got a febrile fits case, but the presentation doesn’t seems to be febrile fit. Beside fit, patient has blue spells, shortness of breath, pale. On examination, I found patient to have prolonged expiratory phase. My history and examination doesn’t tally at all. Bad la…

At least the patient was cooperative, although he was only 5 months. I did presented my case to doctor and was asked a number of questions which I couldn’t answer most of them. Dunno how?

Hopefully tomorrow MCQ will be much better. I just can’t wait to go back this thursday. Really cannot tahan staying in this campus…