Morning:
-2 cannulations---remember to adjust the position of the hand on 22G needle so that the flush back can be seen, remember to press at the end of the cannula after inserting! (today I pressed on the head and made a mess! :p )
-saw a patient with advanced Rheumatoid arthritis --＞ should revise RA...and hand exam, the patient also has a Ganglion cyst (the Bible bump).
-examine a VRE patient with decompensated chronic liver disease and chronic renal failure due to type II hepatorenal syndrome. He is not feeling very well but kindly let us had a look.
-Tute with Le Page:
1. DDx for painless jaundice---malignancy of the head of the pancreas
2. inguinalscrotal swelling: chronic---testicle(testicular tumour), epididymas( cysts of the epididymis, epididymo-orchitis), tunica vaginalis (hydrocoele, haematocoele), spermatic cord(hydrocoele of the spermatic cord)
-Examine a patient with swollen testis....this is the first time for me to examine a testis. There's a 2 cm firm mass and I couldn't appreciate the the underlying structure. The patient is very kind and willing to let us have a feel.
-GI meeting with lunch~ Thank God and GI department for the great food!
hepatorenal syndrome: Type I acute(rapidly rising serum creatinine and very poor prognosis) and type II chronic(slowly progressive deterioration). It's a functional renal failure due to extensive vasodilatation from advanced liver disease on a setting of ascites and hyponatraemia. It may be precipitated by infection (esp spontaneous bacterial peritonitis), diuretics, nephrotoxic drugs, GI bleeding or large-volume paracentesis.
Mx: monitor diuretic use and stop if hyponatraemia or renal impairment develops. IV albumin if undergoing large-volume paracentesis. Cirrhotic patients with GI bleed should be given prophylactic antibiotics. Nephrotoxic drugs(aminoglycosides, NSAID) should be avoided
-correct hypovolaemia and precipitants.
-if fail to improve---terlipressin(vasopressin analog which insert more aquaporin to reabsorb more water) AND albumin
Afternoon:
PBL-colorectal cancer and haemorroids
ECG tute-may need to revise the basic again and go the lecture nxt see whether I can do thoses correctly
Renal revision-acute and chronic renal failure! great revision
End of block party---great to relax and play table tennis!!! so fun!
Plan for the weekend:
1. revise RA
2. FBE, coag, U/E, LFT, TFT
3. AF, CCF, IHD, Cholesterol and obesity as topics!
4. GI final revision
5. Sunday---long case presentation, do another case. Print revision notes for neuro, renal
6. Neuro Exam!!!!! Neuro basic knowledge revision.
7. Last week respiratory topics: Asthma, COPD, DVT/PE
(sounds a bit ambitious, let's see how many can be achieved)
星期五, 3月 20, 2009
星期一, 3月 16, 2009
today's patient Mon Week 6 of Gastro block...
morning in liver clinic: Hep C medication follow up, responds to treatment(liver enzyme level does not mean the virus is cleared; viral load is cleared patient may still have elevated liver enzymes), Hep B (Pt from china with an interpreter with her own opinion in interpretation, which is bad...), haemochromotosis (Pt with active Hep C had increased Iron, 100% satuaration, increased ferritin whose mother has recently been diagnosed with haemochromotosis too)
12:30pm: Claire's session on FBE, U/E, asthma, DVT/PE, COPD, smoking cessation and medication adherence. ( realised need to learn FBE and DDx, anaemia and consolidate the DDx for U/E. Need to know those topics back to front, practice the questions Clarie asked today:
-COPD: what is the role of pulmonary rehab? What is the role of surgery in COPD? What is your understanding of nutrition in Pt with COPD? What is the role of immunisation?
-Asthma: Please instruct/assess the patient in terms of using inhalers
-DDx for primary hypothyroidism: hashimoto disease, medication (amiodarone, Tx of thyrotoxicosis, lithium), thyroiditis, (then iodine deficiency, etc). Mx: Hx(fHx, medication, infection, Sx), Test(thyroid antibody)
-hyperthyroidism
*DDx for with low TSH and High FT4 and 3: graves' disease, toxic multinodular goitre, Hashimoto's thyroiditis, thyroiditis, Meds (thyroxine, amiodarone)
*Mx: ultrasound of the neck, looking for malignancy, THEN iodine uptake scan
Afternoon saw 2 cardio patients:
1. 78 y/0 gentlement presented with syncope yesterday and atril flutter on ECG on a background of T2DM, previous heart attack, HTN and hyperlipidaemia.
On inspection, he's an obese, pale looking gentlement lying in bed with mild tachypnoea (22 /min), having normal saline infusion. Obs: BP 150/90, afebrile, Sat 90%RA, PR 60/min.
Apex beat could not be appreciated due to obesity. Soft S1S2 with a very soft ejection systole murmur. No peripheral oedema but absent peripheral pulses. Loss of sensation on both legs up to the knee, with multiple lesions/ulcers and fungal infections?.
A brief Hx was taken. The Pt loss consciousness on the way to the toilet and could not recall the symptoms before the syncope. The patient has had silent inferior myocardio infarction ? years ago.
Meds: insulin, mixtard, atrovstatin (lipertor), clavicil,
The interview was stopped because the Pt would like to rest. May go back and talk to him tmr.
2. 34 y/0 5 wk postpartum lady presented with syncope on a back ground of potential 14 yrs Hx of palpitations and rapid heart beats and 3 yrs Hx of anxiety and panic attacks.
Last Thu, after feeling rapid heart beats, dizziness she loss consiousness for about 1 min. The similar event occured again and her husband noticed her faces turned pale before she passed out.
At the age of 20, she noticed these tachycardic episodes occured, various in frequency. 3 yrs ago, she as diagnosed with anxiety and panic attack associated with hot flush and palpitatoins, relieved by breathing technique. However, the rapid heart beats episodes seem to be consistant and not relived by the breathing technique.
There's no particular trigger for the tachycardia. The Pt reported that the beats were so fast that she couldn't tell whether it's regular or irregular and she couldn't tap out the beats. There is an increased in no. of tachycardia events during her second pregnancy. She drinks 2-3 cups of coffee a day and does not notice any association b/w the episodes and coffee. There's no recent infection, no family Hx of similar problems nor any significant health issues, no previous Hx of heart, thyroid problems and anaemia. She has never smoked and drank occasionally. She is currently on Halter moniter.
ECG: SVT with abrency? VT? to be confirmed......
4:00 CPC: lump in the nect and salivary tumour
most common salivary tumour is mucoepidermal carcinoma....
5:00 metabolic bone disease: bisphosphonate, PTH for oesteoporosis. oesteomalacia and Rickett's, Paget's disease (use bisphosphonate to slow down the bone turnover).
12:30pm: Claire's session on FBE, U/E, asthma, DVT/PE, COPD, smoking cessation and medication adherence. ( realised need to learn FBE and DDx, anaemia and consolidate the DDx for U/E. Need to know those topics back to front, practice the questions Clarie asked today:
-COPD: what is the role of pulmonary rehab? What is the role of surgery in COPD? What is your understanding of nutrition in Pt with COPD? What is the role of immunisation?
-Asthma: Please instruct/assess the patient in terms of using inhalers
-DDx for primary hypothyroidism: hashimoto disease, medication (amiodarone, Tx of thyrotoxicosis, lithium), thyroiditis, (then iodine deficiency, etc). Mx: Hx(fHx, medication, infection, Sx), Test(thyroid antibody)
-hyperthyroidism
*DDx for with low TSH and High FT4 and 3: graves' disease, toxic multinodular goitre, Hashimoto's thyroiditis, thyroiditis, Meds (thyroxine, amiodarone)
*Mx: ultrasound of the neck, looking for malignancy, THEN iodine uptake scan
Afternoon saw 2 cardio patients:
1. 78 y/0 gentlement presented with syncope yesterday and atril flutter on ECG on a background of T2DM, previous heart attack, HTN and hyperlipidaemia.
On inspection, he's an obese, pale looking gentlement lying in bed with mild tachypnoea (22 /min), having normal saline infusion. Obs: BP 150/90, afebrile, Sat 90%RA, PR 60/min.
Apex beat could not be appreciated due to obesity. Soft S1S2 with a very soft ejection systole murmur. No peripheral oedema but absent peripheral pulses. Loss of sensation on both legs up to the knee, with multiple lesions/ulcers and fungal infections?.
A brief Hx was taken. The Pt loss consciousness on the way to the toilet and could not recall the symptoms before the syncope. The patient has had silent inferior myocardio infarction ? years ago.
Meds: insulin, mixtard, atrovstatin (lipertor), clavicil,
The interview was stopped because the Pt would like to rest. May go back and talk to him tmr.
2. 34 y/0 5 wk postpartum lady presented with syncope on a back ground of potential 14 yrs Hx of palpitations and rapid heart beats and 3 yrs Hx of anxiety and panic attacks.
Last Thu, after feeling rapid heart beats, dizziness she loss consiousness for about 1 min. The similar event occured again and her husband noticed her faces turned pale before she passed out.
At the age of 20, she noticed these tachycardic episodes occured, various in frequency. 3 yrs ago, she as diagnosed with anxiety and panic attack associated with hot flush and palpitatoins, relieved by breathing technique. However, the rapid heart beats episodes seem to be consistant and not relived by the breathing technique.
There's no particular trigger for the tachycardia. The Pt reported that the beats were so fast that she couldn't tell whether it's regular or irregular and she couldn't tap out the beats. There is an increased in no. of tachycardia events during her second pregnancy. She drinks 2-3 cups of coffee a day and does not notice any association b/w the episodes and coffee. There's no recent infection, no family Hx of similar problems nor any significant health issues, no previous Hx of heart, thyroid problems and anaemia. She has never smoked and drank occasionally. She is currently on Halter moniter.
ECG: SVT with abrency? VT? to be confirmed......
4:00 CPC: lump in the nect and salivary tumour
most common salivary tumour is mucoepidermal carcinoma....
5:00 metabolic bone disease: bisphosphonate, PTH for oesteoporosis. oesteomalacia and Rickett's, Paget's disease (use bisphosphonate to slow down the bone turnover).
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