31.3.16

i should be more concise

salam.  because of too tired, class from morning till evening today.  i slept at 9.30pm and woke up at 2am. end up i cannot sleep after that because of thinking about the things that i cannot figure out after clerking my patient. she has infective endocarditis. she was diagnosed after taking 3 blood culture taking at different site and after 30 minutes of each.

just imagine. a patient come to you. she is pregnant. coming to hospital because she was referred from maternal health centre due to low haemoglobin level which was 7.6 g/dl.
5days prior to admission she also had loss of consciousness for 30minutes and after regain consciousness  she did not directly seek for medical attention.

the problem is she was referred because of  low haemoglobin level. she did not reveled her LOC as the main complaint at the hospital. . as you know, infective endocarditis, patient will come with history of fever. however when the first time im clerking my patient, she had history of fever. at the first trimester of pregnancy and she just told you that it happened at time of having symptoms of pregnancy...  patient was not concerned about the fever. for her that fever is not the chief complaint for her.  she also had history of cardiac problem a the age of 15 years and completed medication treatment for 1 year. however, she do not know the diagnosis and the treatment she had.

just imagine. if she come to general practitioner in private clinic... then complaint of fever... just treated with paracetamol. and just imagine again... in private clinic they dont have enough time to check you from A to Z. which it private clinic. they just check certain systems only base on your complaint like general examination and respiratory system they might auscultate your lungs but not doing full examination for your cardiovascular system. they got a lot of patients waiting outside.

alhamdulillah, this patient admitted to the ward. i ward doctor have plenty of time to review you 24 hours. all systems were examined. and this patient found out that she had pansystolic murmur.

but i am so sad, because i just got to know that her problem earlier at th age of 15 years old. she had fever  for a week then resolved... then fever come again for  a week and resolved again. i just got the point when im clerking for the second time by using straight forward question. initially you just asked any fever before? that question is not enough because patient might think that the proble is not concern her enough. so you need to justify her,that time whether she frequently developed fever ?
make the things clear, so that she can recall the symptoms that she had.

another thing that make me sad because of myself. for the first time i do CVS examination on her. i am only heard pansytolic murmur . and when i checked her hand i only found she had clubbing.

but i met her for another time and do cvs examination again. it was found that she had janeway lesions but i miss it because it just a little point at the palm... and she said that , there is more lesions like that before and it disappeared after the treatment. and another thing i didnot look properly is that se had corrigan;s sign. and after ausculatate her heart for the second time it not just a pansystolic murmur at the mitral area but she also had end diastolic murmur at aortic area. and she also had collaapsing pulse. oh god. i just realized that i miss all those important signs because i that time, when the first time i came to her. i clerking her for half and hour and do CVS examination by just auscultate the heart and not doing proper from general, checking for the collapsing pulse, JVP and all tose menuver after detectiong the murmur, timing for murmur wheter it is the systolic or diastolic. and yes the reason is i want to finish my examination earlier as i need to cover another 2 patients within 2 hour that night. and i miss all those important signs.

so the thing is. after this i will make sure asking patient properly, giving direct questions to rule out all my differential diagnosis and not just asking open ended questions just why you come here and end up my conversation, anyting you want to tell?any symptoms tht you had? bcause patient sometimes not concerned with the symptoms they had and sometimes they did not realized it.

yes i need to buck up!! especially in the way of taking good history and finding relevant positive and negative signs in patient. read more and learn more. from patient i learn more.

11.3.16

alhamdulillah pass.

assalamualaikum, hye. i'm just back to school. for the second last posting.

last block holiday, i am restless. waiting for paeds result whether pass or fail. i know my long case was the worst one in my life. i just presenting my chief complaint, then dr directly ask me the diffrential diagnosis. i got bronchial asthma case, 3 year old girl. giving the chief complaint  with the sentence of "with underlying bronchial asthma" is one of my mistakes as the examiner asked me how confirm you are that she is having asthma? then i gave my points for for the diagnosis and dr said, if this is not broncial asthma? now, i got the point, dr dont want me directly to support the previous diagnosis, she want me to broaden my thinking to rue out many3 causes... i gave viral wheeze, multiple trigger wheeze, foreign body aspiration... all were rejected by the examiner. i was very blurred that time. thinking of heart faailure? but usually they will come with failure to thrive, interupted feeding, prolonged feeding... so i dont want to throw it as my thinking....then i cannot think anymore after she throw her last words " i give you last chance, this is your passing mark, what is the other possible diffrential diagnosis, i'm stuck.  probably it is not bronchiolitis as she is 3 years old. yeahhhhhh my last chance! i cannot think anymore as i was scolded all along the long case duration,.. so sad. and she  left me. she stood up, went to the door, open it. and said, where is your cardiac asthma? where is your loafler syndrome?

my teary eye just sent her leaving me alone in the small room....

i know im gonna fail my long case. the worst long case in my life. i did not present my history. just presenting my chief complaint... did not answered well for my diffrential diagnosis. you know, you will fail if you just achieve that level. usually youknow that you pass your long case if you able to discuss the case up to the management... but me..... even the first level of the questions,  failed.

then waiting for my short case. i was redha... i might fail. i know it. i was depressed that time. all the things that i have study, is useless. all the things that come out during my long case. i did not perform it even i have struggled to read many2 topics before the exams. but it happened like this. very sad.

suddenly, prof nasser called my name. he took me for my short case. i was very lucky to have him. he is very kind. i should perrform my shortcase very well. even my feeling was disturbed that time. i m trying presenting and performing the examinations properly. i got a child with purpuric rash over the both lower limbs. it was palpable, raised,red,painless rash... after examine the child. the discussion startrd. alhamdulillah. i managed to answer up to complication of henoch scholein purpura. however i got wrong answer for my investigations... i was very worried. but dr corrected me, during the exam, he still doing his duty teaching me and correct my answers.


becuase of that, during holiday..  i became restless... hope that my shortcase marks would cover my long case... i just pasrah. if im fail this posting, i need to buck up for the last 2 postings...
alhamdulillah, Allah is the MOST Merciful,ARRAZZAQ.  i PASS!!! alhamdulillah. alhamdulillah...

today, i got the marks for my lond case. yes, i fail my long case. but i got very high marks for my short case.... prof was so kind... his words always remind us towads Allah and Raullullah. during teaching also, he is very struggle to make us understand in the things that he teaches in the class.. he even did our revision class at night up to 1.30 am... its hard to be like him. he is very patience in delivering the knowldge to his students. it hard nowadays to find a teacher like him. i am praying that Allah will always bless him,,, and stay healthy all the time...  jazakallahukhairan kathiran walada walana insyaAllah fil jannah..inshaALLAH FIL JANNAH...... may Allah bless you prof nasser from department of paediatric IIUM...