SIRS

infection - microbial phenomenon characterized by inflammatory response to the microorganisms or the invasion of normally sterile tissue by those organisms

bacteremia - presence of bacteria within the bloodstream

sepsis - systemic response to infection

SIRS -  systemic response to infection in addition to presumed infection (dah ada infection)


criteria
1) temp : <36 or >38
2) heart rate : >90
3) RR : >20
4) WCC : <4 or >12

diagnosed as SIRS when it meets two of these criteria


Severe sepsis - a/w organ failure

mari belaja parasito

salam.

- crescent / banana shaped gametocyte => plasmodium falciparum!

plasmodium falciparum tropozoite

- multiple chromatin

- multiple infection

wucheria bancrofti => lymphatic filariasis..

- no nuclei at terminal end

- cephalic space 1:1

- discrete nuclei

brugia malayi => lymphatic filariasis

- two nuclei at terminal end

- cephalic space 2:1

- compact nuclei

tachyzoite yang bentuk crescent.

makanya ini adalah toxoplasma gondii.

ok thats all.

Short Case : Swelling over Right Hand

Instruction : Examine patient's hand.

This patient, a 10 years old boy has swelling/lump at his radial side of right wrist

1) Introduce urself.

2) Ask consent from parents and patient himself

3) Put patient's hand on pillow. Make sure patient is comfortable.

4) Dr cakap tadi supposely kena expose other part so.. kena bukak baju patient sbb nak cek swelling kat other part as well. But, u can ask parents/patient himself.

5) General inspection. Comment on branula attachment/alert/well nourish

6) Now focus on hand, check for muscle wasting, scar, any skin changes, deformity, swelling, pallor. (Cek both dorsally + palmarly)

7) Now, focus on the swelling

- Inspection : Site, shape, skin changes, sinus, prominent vessel, scar, deformity of fingers.

- Palpation :

- Size (eg : 5cmX3cmX1cm)measure dari lowest margin to the other side lowest margin

- temperature

- surface (smooth/irregular)

- consistency ( soft/firm/hard)

- margin (well defined/ ill defined) cek sume side.. xsume side well defined.. can be different.

- tenderness

- check for mobility of the swelling - horizontally, vertically (fixed/mobile)

- transillumination (cystic/solid) *tunnel die depend on size of swelling tuh.

8) Check for Attachment of Swelling

- if u can pinch skin = swelling not attached to skin

- if fixed mobility = swelling is attached to bone

- for muscle, we give resistance as patient dorsiflex his wrist. ask patient to lawan. (ala, macam nk assess power dalam CNS examination.. :) )

- if the swelling is above the muscle = swelling same size, but more prominent

- if the swelling is below the muscle = swelling reduce in size, not prominent

- if the swelling within the muscle = swelling increase in size, not prominent

9) Complete examination with examine the patient pulse

if pulsatile = AV malformation

if pulsatile and expansile = aneurysm

Differential diagnosis of swelling

1) compensable swelling = hemangioma

2) mobile sangat = lipoma

3) fixed/not mobile = think of bone so bony exostosis/osteochondroma

4) +ve transillumation = sebacous cyst/ganglion

5) abscess = carbuncle

BTW, patient ni diagnosis die GANGLION.

Please read a bit pasal GANGLION CYST ni.

ADD-ONS

1) cane nak cek compensable swelling tuh?

ans : bile against gravity die berkumpul kat salur darah, so jadi swelling

then bile kita flexed hand, not against gravity.. swelling hilang..

ini namanya compensable swelling..

biasanya hemangioma..

2) Dr Y cakap, as we examine, we must think and came up with differential diagnosis.

ok that's all.

tips in history taking

salam

oren : aku.

biru : patient

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nak masuk bab social history aku memang berdebar.

tapi aku start jugak. macam biasa lah ayat buku.

"it may be a litle bit sensitive for you. but i need to ask these questions because it may be related to your illness" 

kemudian aku senyap jap. buat saspen.

patient x keruan. 'pemenda student medic ni nak tanya?' dalam hati die kot.

then aku sambung, "emm, do u smoke, miss susan?"

'no, i dont' muke patient berkerut tahan sakit.

"what about alcohol?"

'alcohol, what is that?'

"for example whiskey, beer"

'owh', patient angguk paham then sambung, ' no, i dont take any alcohol.'

"another sensitive question, do u take drugs for pleasure?"

patient buat muka xpaham. 

aku cepat cepat tangkap, "for example, dadah or something like that?"

patient macam nak menangis, sakit sangat kot namun dia jawab jugak 

'nooooo, i dont take drugs like thaaaat.. why u are being like this, asking me lot of nonsense questions.. im having loose motion here, cramping abdomen and all and yet u asked me about drugs, smokes and everything..' 

(imagine okay. her tones sound like she was super annoying.)

aku speechless kejap. xpernah lagi jumpe patient macam ni.

kemudian aku sambung, "im sorry, i need to ask these questions because it may be related to your illness," 

jawapan yang aku boleh fikir time tuh. 

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dialog atas ni sedikit role-play history taking aku pagi tadi.

tadi time ECE. communication skills punye kelas.

im the lucky four (because there are four of us yang terpilih hari ni) today,

because im get chosen to interview 'patient tipu tipu' atau kitorang biasa gelar 'primer'.

things go all 'tunggang tebalik' bila the primer, madam radziah tuh berlakon sakit dengan sangat exaggerated.

i mean, she's like a real-life-patient-yang-kalau-boleh-doctor-want-to-avoid la.

she's really really in pain and easily get irritated.

macam mana nak deal dengan patient macam ni?

cer citer cer citer. ^_^

tips i got from Dr. Ng and Madam Radziah today are:

1) inform the patient awal awal lagi. maknanya, bagitahu patient tuh, history taking ni akan ambil masa 8-10 minutes. explain why u have to take the history and so on lah. pendek kata, make the patient understand first. :)

2) rephrase the ayat yang ini, "it may be a litle bit sensitive for you. but i need to ask these questions because it may be related to your illness".  tukar jadi "i would like to ask you few sensitive questions, because these questions are extremely important for me to know and i hope u can answer me properly". the point here, tell them that the questions are EXTREMELY IMPORTANT. so, the patient will understand the purpose of asking those questions. 

3) and please please please avoid any medical jargon, DONT USE lethargy to ask about tiredness. DONT USE yellowish discolouration of eyes to ask about jaundice. DONT USE hypertension, instead use high blood pressure. and so on. 

4) DONT ASSUME patient know what is alcohol? what is drugs? always provide some examples. :)

yang pasti, i think now i need to mantopkan lagi english aku.

my english sangatlah x fluent.

it seems like i cant construct sentences in a short time.

i tend to mixed up words when i speak in english. and that's suck.

omg. how to mantopkan aa?

kan best if i study kat oversea.

boleh mantopkan english aku teros. hehe

k lah bye.

urethral injury secondary to MVA

my long case. 

clinical summary :
43 years old, Malay gentleman was currently admitted to SH for further management post operatively (uroplasty).
8 months ago, he was involved in MVA and was admitted to SBH.
injured his urethra. was on CBD since then.
hospitalized for 1 month.
cannot passed urine normally.
so, was refered to urology dep at SH for futher investigations.
since then, he he was on follow up with SH to fixed his urethra.
went to SH two times for IVU and it shows obstruction at spongy urethral
planned for uroplasty on 29th february 2012 which was 22days ago.
and currently he was admitted to SH for management post operatively.

present your history
- i say something about cannot control urine. dr ask, what is that called?
- ans : incontinence.

PE. general


i start with vital sign

me : PR -- RR --
dr : what else in vital signs?
me : BP and temp
dr : whats the value?
me : not done.
dr : is it not important?
me : it is important. sorri dr.

but juujur sgt cakap not done.
padahal leh je bantaaii. haiiih.

inspection of genitalia

there is sutured wound posterior to scrotum. extending 3 cm from anal canal. it is clean wound, no pus. on palpation, it was tender and not warmth.

qs : is there any sign of infections?
ans : no

qs : what is sign of infection??
ans : pus, erythema, warmth

inspection of abdomen



on inspection, there are surgical scar at groin region..

qs : are those surgical scar?
ans : yes. (tapi salah sebenarnya kot?)

qs : what is surgical scar?
ans : scar from incision and when we suture it back. (?)

dr told me, surgical scar is scar from surgery that had been done by a surgeon.

qs : is it done by surgery?
ans : ortho dep yang letak besi kat both pelvic dia, nak compress pe sume..

dr says, most probably from the trauma. tapi xfaham sangat konsep besi untuk compress tuh, either surgery or what. baca eh.


proceed :
there is tube attached at suprapubic region most probably from bladder, it was connected to bladder drainage. the content is urine 250 ml, urine are normal with no blood clot, hematuria.

qs : why letak suprapubically?
ans : bcause urethral is damaged/obstructed due to MVA

thats all for abdomen.

qs : what is this? (pointing his finger to hypertrophic scar)
ans : hypertropic scar

qs : how do u differentiate hypertropic scar and keloid?
ans : HS : confined to the wound, kalau keloid dia merebak kan. xtau ayat die cane.

qs : how to check for peripheral pulses at leg?
-dorsalis pedis : between toes and index

qs : do u compare pulses of both legs?
ans : yes.

qs : what other arteries in leg?
ans : post tibial

qs : can u show me?
ans : lateral side of medial maleolus

ok thanx you.

discussion will be update later. :D insyaAllah