Anti Hypertensive

1) Beta Blocker
MOA : Sympatholytic at Beta 1 & Beta 2 adrenoreceptor, inhibit NE at the synapse
Drugs : Propanolol, cardioselective Beta 1 antagonist :Metonolol, atenolol
SE : Bradycardia, bronchospasm, hallucinations, muscle weakness

2) Alpha blocker (seldom use in hypertension, use for BPH)
MOA : Alpha adrenoreceptor blocker cause vasodilatation
Drugs : Prazosin, Terazosin

3) Alpha & beta blocker (use in pre eclampsia / emergency treatment of hypertension)
MOA: Block alpha & beta adrenoreceptor & cause decrease in peripheral vascular resistance leads to reduction in BP
Drugs: Labetolol
SE : Drowsiness, bradycardia, complete heartblock, bronchoconstriction, pulmonary edema
Relative Contraindication : asthma, heart failure, any degree of heart block

4) ACEI
MOA : vasodilator as angiotensin is potent vasoconstrictor. ACEI inhibit conversion of angiotensin 1 to angiotensin II by ACE
Drugs : Captopril, enalapril
SE : hyperkalemia, dry cough, hypotension, postural hypotension, angioedema
Contraindication : Renal artery stenosis, pregnancy, impaired renal function

5) Angiotensin receptor blocker (ARB)
MOA: AT₁-receptor antagonists. Block the activation of angiotensin II AT1 receptor on vessels which directly causes vasodilatation, reduces secretion of vasopressin, reduces production and secretion of aldosterone
Drugs : losartan, valsartan, telmisartan
SE : Dizziness, headache, hyperkalemia, postural hypotension on first dose

6) Calcium channel blocker (CCB)
MOA: Block entry of calcium through calcium channel in the smooth muscle of endothelium cause it to relax & vasodilatation
Drugs:
Dihydropyridine (Nifedipine, amlodipine)
Nondihydropyridine (verapamil, diltiazem) --> reduce myocardial oxygen demand & reverse coronary spasm
SE: Dihydropyridine - reflex tachycardia, leg edemadizziness,headache
Non-dihydropyridine - arrythmias
CI ; can worse proteinuria in pt with nephropathy

7) Direct Vasodilator
MOA : at local level. Nitric oxide - potent vasodilator, enhance action of NO direct at vessels
Drugs : Hydralazine, Minoxidil, Na nitroprusside
SE : Hypotension, headache, Tachycardia, tachyphylaxis

8) Centrally acting drugs
MOA : affect on CNS & sympathetic NS
Drugs : clonidine - use or migraine
Methyldopa - safest to use in pregnancy
SE: dizzinessm postural hypotension

9) Diuretics
a) Thiazide (chlorothiazide, indapamide)
MOA: inh reabsorption of Na & K at distal tubule
SE : hypokalemia, metabolic alkalosis, hyperurecemia, hyperglycemia
CI : gout

b) Carbonic anhydrase Inhibitor (CAI) - acetazolamide - use for acute glaucoma
MOA : Inh reabsorption of NaHCO3- at proximal tubule
SE : hypokalemia, metabolic acidosis, hypersensitivity

c) Loop Diuretics - Furusemide, Bumetanide, Ethacrynic acid
MOA : Inh reabsorption of Na, Cl, K at THICK ASCENDING Loop of HenLe & increase renal blood flow by cortical vasodilatation
SE : hypokalemia, metabolic alkalosis, postural hypotension

d) Pottassium sparing - spironolactone
MOA : Aldosterone antagonist - inhibit action of aldosterone at distal tubule & collecting duct
SE : hyperkalemia, metabolic acidosis, gynecomastia

10) Renin inhibitor - Aliskiren
MOA : act on the Juxtaglomerular cells of kidney, which produce renin in response to decreased blood flow
SE : hyperkalemia, hypotension, angioedema

3 Weeks Away

Im at the library right now. Just finished revision on one of the O&G topic (Benign & malignant condition of UTERUS).

So, how do I feel today?? Practically, Alhamdulillah~ Im very happy as usual. Eventhough yesterday, the mood was like a roller coaster. But thats life kan. Touch & Go. Haha.

Everyday I reached the ward & reviewed the patient at 7.40am. But today, I felt like to sleep a litttle bit & woke up at 6.15am & later went to JHC at 7.05am. Today I fetched wahid at Dr Bahiyah's house. She still cant drive her car. Busaha ck wahid!! Who knows, maybe later I may be in need like wahid right now. Life is like a wheel, isnt it??hehe

This morning I supposed to have class with Mr Shukrimi. Yesterday he said he will do it after his OT, but he warned us to just standby in the ward. Initially, I thought of went to the ward slightly late. But at 7.40am, while having breakfast, I saw Mr Shukrimi with Mr Amin walking to the hospital from JHC. So I cancelled my plan & went to the ward as usual. My concept is must be there before 8am.

While im in the ward, leisurely suddenly Mr Shukrimi arrived & asked me "where is the others??" "erm.. tak sampai lagi doctor" "please call them, you are suppose to be in the ward at 8am" & I contact the unscheduled student & my colleague

Im in the ward early, maybe im used to be trained like that by our lecturers since my 3rd years especially in surgical posting. Prof Kyaw and Mr Junaini will inadvertently came to the ward & would like to do class at 8am without informing the students earlier. This is because the student s must be in the ward by 8am. So I always train myself to always be ready at all time & most important is always expect the unexpected

Later, they arrived & we started the classes. We discussed mainly on Osteoarthritis case. Its indeed a beneficial one for me =)

12.30pm: had discussion with Aswad, Farhi, Syaifi & Fendi about Varicose vein examination. Tribute to Mr Faidzal who taught me that. Its indeed a good revision for me.

In the evening, as usual I studied in the library.

And guess what, currently Im following the malay drama at 6.30pm on TV3 - CHINTA. Initially I hate that story as I think there is no values in it. But my oppinion is different when i watched this drama this week. There is changed of the behaviour in the drama which makes me want to watch everyday. hehe

But Dont worry. I will still take care of my study. Hehe

Vital Signs

This is exactly the question being asked by Mr Khairussalleh to each group that went to Surgery posting. Believe me. Hehe. Since my professional exam is around the corner. I will put it here, then. So I will always remember & will use it during my practice later on.

Blood pressure
Systolic
100 - 140 mmHg (male)
90 - 140 mmHg (female)
Diastolic
60 - 90 mmHg (both)

Pulse rate
60 - 100 beats/min

Respiratory rate
14 - 18 breaths/min

Temperature
36.8 C - 37.2 C

Pain Score
0 (no pain) - 10 (the most unbearable pain to the patient)
Prof Azmi did asked how do you standardise the pain score in between?? & I couldnt find the answer until today. Huuu~

Specific Management of CKD

By Dr MOhd Ramly Seman, Nephrologist HTAA

Purpose of the management
1) To delay the progression or to regress the CKD
2) To manage the associated complications of CKD
3) To prepare patient for RRT

A) To Delay The Progression or To Regress the CKD

In research it proves that, slowing the progress of renal disease will retard the progression of renal failure.
For example, renal disease usually progress slowly about about 3ml/mins/year. By this, the person will had renal failure at the age of 55. But slowing the progression for example to 1ml/min/year, will delay the age of occurence at more than 75 years old.

What are the factors that leads to the progression??
1) Angiotensin II plays central role in the renal damage
- Artherosclerosis & vasoconstriction which can lead to STROKE
- Vascular hypertrophy & endothelial dysfunction can lead to HYPERTENSION
- Left Ventricular hypertrophy, Fibrosis, Remodelling & Apoptosis can lead to HEART FAILURE / MI
- Reduce GFR, Increase Proteinuria, increase aldosterone release & glomerular sclerosis can lead
RENAL FAILURE

All this if not treated can cause death to the patient

2)Aldosterone ( in the presence of No & CVS disease - HTN, renal disease, DM, heart failure,etc) can cause vascular damage (vasculopathy) & microischemia
There will be vascular inflammation (activation of cytokines,prostaglandins, etc)
--> cause necrosis & inflammatory cells infiltration --> fibrosis which leads to abnormal tissue remodelling & organ dysfunction
Lastly, the patient end up having Renal failure, Heart failure, MI or stroke

3) Hypertension.
Based on research, the lower the BP, the more renal function will be preserved

4) Diabetes Mellitus.
Good glycemic control will reduce the incidence of complications
retinopathy by 20%
nephropathy by 30%
Macrovascula disease by 16%

5) Proteinuria
A study on renal survival in adult FSGS based on proteinuria
for non nephrotic patient, the survival was very much longer compared to Nephrotic patient
Nephrotic pt only 50% survival in 8 years
Much more worse in pt with GFR >14gm/24H, the whole renal survival is only for 5-6 years

6) Family History in relation to microalbuminuria
In the research: interaction between FMHx of CVA in 1st degree relatives & glycemic control with the prevalence of microalbuminuria
Family hx + HbA1c >8% - dev microalnuminuria in 48%
either have FMHx or HbA1c >8% - only about 2% dev microalbuminuria
Non of both - 0%

7) Obesity
Mechanisms of kidney damage in obesity
1) mechanical: can cause hyperfiltration
2) Metabolic: can cause Insulin resistance, inflammation, hypertension & dyslipidemia
All this cause renal damage

8) Smoking
can cause vasoconstriction, thrombosis & direct toxin effect
& cause the vascular endothelium to increase in urine protein excretion & induce declines in renal function

9) Anemia
CKD patient with Hb <11.2>13
The more severe the anemia, the greater the risk

10) Usage of chinese herbs

So what should be done??

-Glycemic control
Pt with type 2 DM with 3/more injections of insulin per day resulted in lower rate in new or progresive nephropathy over a period of 6years compared to conventional therapy of 1/2 injections of insulin per day

- Control BP
130/80 in pt with proteinuria <1g/day>1g/day

- Use ACE / ARB
Based on research could reduce in getting nephropathy even in pt who is nondiabetic or normotensive compared to given placebo or other types of hypertensive medication such as CCB

So, choice of antihypertensive in:-
1) Diabetic Kidney Disease (DKD) - ACEI / ARB
2) Non-DKD + Urine PCR >200mg - ACEI/ARB
3) Non-DKD + Urine PCR <200mg style="font-style: italic;">Avoid NSAIDs. Use aspirin or tramadol
acute usually reversible decline in GFR
idiosyncratic forms of membranous nephropathy
interstitial nephritis
progressive nephrotoxicity - chronic usage

- dietary protein restriction: 0.6 - 0.8g/kg/day

B) Manage the associated complication of CKD

- Anemia
Early treatment has good impact in increasing the Hb over months compared to late treatment.
The best is given IV iron - Raises & effectively increase Hb compared to oral form
which one is better?? Either given IV iron alone / combine with erythropoitin??
ans: IV iron alone is beneficial enough for treatment. But if patient could afford erythropoietin, you can suggest the usage

- Cardiovascular disease
CVD is already well established at the onset of ESRD
Cause of death in dialysis patient: about 50 - 60% is due to cardiovascular

- Renal Bone disease (renal osteodystrophy)
CRF will cause phosphate retention ( phosphate excrete by kidneys) & will decreased the active Vit D. All this leads to hypocalcemia & later develop hyperparathyroidism
As CKD progressing from stage I - stage 4, there will be reduced in Vit D & increasing of PTH
Increasing of phosphate & calcium (secondary to PTH) - deposits at vessels, soft tissue, joints & viscera

Pt with GFR <60>65 starts given vitamin D therapy or started in pt with stage 3

Elevated phosphate increase mortality

- Metabolic acidosis
adverse effect on bone, nutrition & metabolic
Maintain Bicarbonate - 22mmol

- Depression, anxiety & denial stage
watch out for this in patient. all this could lead to non compliance & later progression of CKD

C) How To Prepare Patient for RRT

- Ultrasound Kidney - mainly TRO reversible cause esp obstruction
- Screen for Viral status - HbSAg, HBSAb, HIV, HCVAb
Done as dialyse patient will be divide according to status & we do not want negative patient to be infected with these.
Done 6 monthly. Extra caution with HCVAb - lots of false positive - so if result not consistent. repeat the test
- Cardiac Status - ECG, KIV ECHO, ask for symptoms of angina
- Eye referral to diabetic patient.
Could cause blindness if start dialysis in severe one
- Preserve the vein
- ?? Connective tissue screening
SHould be done in selected patient. NOt all patient
- Social history, family history, occupation or previous occupation
Important, as the treatment is costly
regarding ex-army. They will be given more money if sponsored by army compared to SOCSO
SOme patient did not know that they are elligible for SOCSO

- Predialysis Education
Goals:-
- Slow progression of CKD
-treat comorbidities of CKD
- educate patient to make informed decisions
- ensure timely selection of treatment modalities
- reduce hospitalization
- improve psychosocial, physical & rehabilitative outcomes
- save healthcare dollars

Who is collaborative team
Nurses, physicians, social workers, dieticians, pharmacist, other healthcare professional & staffs, patient & family

Important fact
Early referral is very important
Late referral will cause 40% of 1 year mortality, longer the hospitalization needed & increase cost

=== Nephrology Update ===

Nephrology Update 2010

Alhamdulillah, This weekend Im able to join Nephrology Update. Organised by IIUM in collaboration with HTAA. I think this is the first Nephrology Update that had been done. by IIUM. Previously, there was only medical update.

Initially 30 seats were allocated for students & it is for free. But later, HOD - Dr Che Rosle changed his mind by saying, students who would like to join must pay RM30 - student rate. But since I already gave my name like 1 month before the conference, I just agreed with the term given. Frankly, I nearly changed my mind. But in my oppinion, if you plan to do good things but suddenly there comes second thought, wouldnt it always came from syaitan, doesnt it???hehe. I guess so~

And Im glad that I made a right decision. Stick to the initial plan. I learnt a lot from it & I enjoyed the session very much. Its sad to say only 4 students attend the conference - Me, Asma, Nabilah & Najwa. But I think it is expected though~ the fifth year students will be having their exams just around the corner.

The speakers invited are the 'OTAI' in this fields (I hope u guys understand what I meant by using the word OTAI. hehe =P) Among the speakers apart from our HOD, Dr Marzuki & Mr Nazli(urologist) are :-
- AP Dr Kamaliah Mohd Daud - Consultant/Physician Nephrologist from HUSM
- Dr Zawawi Nordin - Consultant Nephrologist from Hosp Sultanah Nur Zahirah
- Dr Mohd Ramly Seman. Nephrologist HTAA

I felt very lucky to get lectures from them & they provide so many informations in each topic until the management. You dont have to worry of being ask or need to prepare anything regarding the topics. They just tell you from A to Z. The best part, the speakers acknowledged the students & keep saying, "I believe there is students here so I would like to show this this & this" or "in student days, this thing is very confusing for students but think this way". Oh, how I wished lots of students attending the conference too.

The conference was held for 2 days. The topics that had been covered:-

First Day
1) Epidemiology of CKD (AP Dr Kamaliah)
2) Screening & classification of CKD ( Dr Che Rosle)
3) Nephrotic Syndrome (Dr Zawawi )
4) Diabetes And Kidney ( Dr Marzuki)
5) Lupus Nephritis ( AP Dr Kamaliah)
6) Medical Management Of Stone Disease ( Dr Zawawi)
7) Hypertension And Kidney ( Dr Ng Kok Huan - Cardiologist HTAA)

Second Day
1) Specific Management of CKD ( Dr Mohd Ramly)
2) Obstructive Uropathy ( Mr Nazli)
3) Renal Replacement Therapy Option & Outcome (Mr Mohd Ramly)

As you can see, this course was very extensive & I listened to all the speakers very attentively & I did not sleep at all. In the middle, of course there was break for breakfast, lunch & even tea. The food was very delicious. Hehe. This morning, the menu was nasi goreng, nasi lemak, karipap & doughnut. After the session, we found out that there was still many foods left. So we took back some of it for our lunch. I heard that the caterer is the wife of one of JHC's guard =)

So now, I realised (more than before) how important it is to take good care of our kidney. Dont wait until we had DM or hypertension to worry about the kidneys. But its important to prevent it from happen starting from this very instant.

I purposely ask about additional salts taken in our foods - home made cooking @ outside cooking. The speaker answered to the question by saying, there is no doubt the relation of salt intake & kidney damage. Long term impact of taking additional salts could cause fibrosis to the kidneys which leads to scarring & renal failure.

So our role now is to educate our family members to take good care of their kidneys. Once the problem occurs, it will progress slowly & think about the cost to take care of the damage kidney if a person succumb to peritoneal dialysis or hemodialysis. As well as its impact to the psychosocial of a person.

All in all, Im glad I made a right decision after all. Thank You Allah.

P/s-Unfortunately I accidently left my folders given for the course in the LH3. Huhu. I still had the memory of putting the folders inside my bag. But found out I might just hallucinated it as I cant find it in the beg or in my car. I hope the folder still at the place I left it. Huhu. But for tonight, Im lucky I have the soft copies of the lectures =)

P/s- The medical book that I lost last week still hadnt been found yet. I put on a search everywhere. In my room, the car,the library, common room, all lecture halls & even the wards which I dont bring that book to the ward since Im in paeds posting. Even to the extend I look at the roads ( I had a thinking of did I put the book on top of my car???) I remember it clearly I put it in the car. Guess I might left it somewhere else also & think I did bring the book to my room which the same that happened today. Huuu~ That book is my fav book & in it I put some of my important notes. Ya Allah, please help me in bringing back my book. (Ada sape2 ada doa untuk cari barang yang hilang??)

Updated Transfusion Medicine

Common Session with Assoc. Prof Naznin =)

1st Scenario
Trigger 1
45 yo lady was admitted for elective hysterectomy
Previously was pregnant for 4 times. No history of blood transfusion
Not on any medications
On admission, Hb=8g/dL
1 unit of packed red cells was ordered to correct anemia prior to surgery
Result from lab = Group 0 Rh D positive, cross matched done & compatible

Questions:
1) what did the elective operation meant to you??
Elective means the surgery was planned & patient was not bleeding. The operation can be postponed if there is no compatible blood found for the patient & the laboratory will find what is the cause of incompatibility in the blood
If written emergency operation, the blood bank need to provide compatible blood ASAP as the patient is bleeding

2) What is the significant in stating how many times the patient had delivered & any transfusion before??
Evidence of sensitization to fetal antigen @ to the previous blood transfusion

3) Issue regarding Hb level prior to surgery.
In standard practice, we take 10g/dL prior to surgery
But there was case, patient with Hb as low as 7g/dL was allowed to go for surgery, provided the CVS was good & it also depends on what type of surgery that the patient went for.

4) Is 1 unit of blood is worth to transfuse to this patient??will it make any difference between Hb 8 & Hb 9 prior to the surgery???
This issue is debatable.
One school of thought, No difference, no need to transfuse
The other one, Yes, it increase the oxygen capacity & using only 1 unit, the patient will have less exposure to the donor's blood

Trigger 2
Treatment began at 1.45pm given through standard infusion set
Upon receiving 1/2 unit, she experienced chills & had a Temperature elevation to 39.4C (pre-transfusion-37.2C)
She was anxious
Transfusion was stopped & Dr in charge was notified
Transfusion reaction investigation was initiated
No ID error

Questions:
1) What should you suspect in this patient??
Hemolytic transfusion reaction - ABO incompatibility

& need to look for:
any pain at infusion site @ localised to loins, abdomen chest pr head (related to rapid complement activation at the site of infusion & generation of bradykinin following complement activation)
hypotension, bradycardia or both
nausea/vomitting
dyspnea
flushing
dark color urine (hemoglobinuria)

2) Bear in mind, this patient develop fever, what is the commonest cause of fever in transfusion??
Febrile Non-hemolytic transfusion reaction (FNHTR)
Def: febrile episodes where there is a temperature rise of 1C or more during or soon after transfusion
Occurs with red cell transfusion & platelet transfusion

3) What is the cause of FNHTR?
reaction between recipient's HLA / granulocyte-specific abs with donor leucocytes & the subsequent release of pyrogens principally IL-1, IL-6 & TNF release from leucocytes during the 5 days storage
This is happened because the patient had been sensitised in her previous pregnancy

4) How to treat patient with FNHTR??
Stop the transfusion
Administer PCM 1g orally 1 hour before transfusion
Resume SLOW transfusion, once patient stabilised

5) In future transfusion....
Give leuco-reduced products. Provided after 2 febrile reactions have been documented
The leucocyte was filtered. Can either be done prestorage filter @ bed side filter. The best would be prestorage filter. In bed side filter, there is already cytokines in the plasma, eventhough the leucocyte was filter at bed side before transfused to the patient

2nd Scenario
38 years old male admitted to surgical department from A&E
2 unit of pack red cell ordered due to bleeding with Hb of 7g/dL
2 unit of blood was crossmatched & found compatible
Transfusion of the 1st unit was initiated following ID check & documentation of Vital signs
30 minutes after the transfusion had begun,he developed urticarial rash with itching

Questions:
1) What do you think happened to this patient?
Allergic reaction

2) How to treat the problems?
Discontinue transfusion
Administer Antihistamine
Once resolves, resume SLOW transfusion

3rd Scenario
45 years old male had bleeding from peptic ulcer
Patient was transfused 4 months earlier for similar problem
On admission, Hb was 7g/dL
4 unit of pack cell was ordered, crossmatched & transfused
On 5th day of admission, the patient was found to be febrile (39C) with pallor & jaundice
Hb = 5g/dL
2 unit of blood was ordered but found to be incompatible on crossmatching

Questions:
1) What do you think happened to the patient?
Delayed Hemolytic transfusion reaction (DHTR)
Secondary to immune response following re-exposure to a given red cell antigen in a patient who has been sensitized

Could occur within 5-7 days up to 2-3 weeks following transfusion

sensitization occurs through pregnancy (definitely not in this pt) & result of previous blood transfusion

A few days following transfusion the antibody level rises leading to destruction of the donor's red cells beginning 2 to 10 days after transfusion
(that's why initially indirect coombs test is negative - initially the antibody is too low to be detectable & results in compatible blood result)

DHTR are much milder.
Destruction of sensitized RBCs is extravascular hemolysis (the ab involve is IgG)
Generally no symptoms
If symptomatic - fever, falling hct, jaundice & rarely renal failure

2) Why patient develop jaundice?
Red cells coated with IgG antibodies which activate complement up to C3b adhere to the C3b receptor on macrophages & monocytes & are subsequently removed through extravascular destruction
Immediate extravascular destruction of red cells will cause jaundice & accompanied by hemoglobinemia & hemoglobinuria (dt antibody dependant cytotoxicity) & fever

3) Why patient was febrile (39C)?
Due to anaphylatoxins
C3a and C5a - anaphylatoxins with potent proinflammatory effects
granule enzymes release from mast cells & granulocytes
Nitric oxide production & cytokines production (IL-1, IL-8 & TNF)

4) Why Hb patient drop???
Answer:???
(Prof Naznin said its out homework.Huhu.
In the handbook mentioned, due to immediate extravascular destruction of red cells cause failure to achieve the expected rise in Hb level..is this the answer??hermmm~ )

4th Scenario
55 yo male undergo abdominal surgery due to carcinoma
Hb 10g/dL
2 units of blood was ordered
Patient blood group O Rh D positive
Crossmatched 2 units was compatible
During surgery, 1 unit was transfused following which the patient developed oozing from surgical site, BP fell from 120/70 to 80/40
Transfusion was stopped. Hypotension treated
Blood sample sent for GXM for 2 units of blood

Questions:
1) What do you think happened to this patient??
Immediate hemolytic transfusion reaction

2) Why the blood oozing from surgical site?
In anaesthesized patient, the only signs maybe uncontrollable hypotension or excessive bleeding as a result of DIVC

3) How DIVC happened?
Intravascular hemolysis stimulate extrinsic coagulant cascade & cause sonsumption of platelet which leads to DIVC

Addition:
- Main cause is human error (wrong blood component is transfused-involving transfusion of ABO incompatible blood group
- Main underlying pathophysiology for this is intravascular hemolysis
- Intravascular hemolysis is the most dangerous type of hemolytic transfusion reaction

- Associated with activation of full complement cascade by IgM abs & always due to A, B, anti A or anti-B

- Full activation to membrane attack complex on the red cell surface leads to lysis
- Sign & symptoms are severe & dramatic
- Apparent after receiving as little as 20ml & can occur within minutes - within 24hours of transfusion
- Most fatalities associated with transfusion more than 200ml & mortality approaches 44% for infusions exceeding 1000ml

Thats all about the scenarios =)
Later Prof Naznin shared with us cases that arised from transfusion medicine & I would like to share 3 lessons with you guys

Lesson 1: Check & double check the blood label & Patient's ID WITH THE PATIENT before transfused the blood to the patient. Do not only check the blood's label & ID with the transfusion form. The blood & form might be wrong & belong to someone else. Again CHECK WITH THE PATIENT.

Lesson 2: Do not ASSUME. Do not assume the label of blood & patient ID was checked by your colleagues. Check the label of blood and patient ID YOURSELF. Eventhough the blood was handed to you by your friends for transfusion for a particular patient. Please Check with the patient.

Lesson 3: Do not ASSUME. Do not assume that all the blood in the ice box belong to one patient. Check & double check the blood details before transfuse to the patient. There is no such thing as just take the blood and straightaway transfuse to the patient eventhough it is in emergency situation

Lastly, Prof gave us few OBA & MCQs. This is the summary of it

ONE
Patient develop hemolysis 2 hours after transfusion with 2 unit red cells.
Serology results:
A positive
Antibody screening negative
Direct Coombs test negative

Answer: Non-immune hemolysis (because the ab & direct coombs test were negative. Meaning the problem did not related to immune)
If ab & coombs test are positive meaning we are dealing with immune hemolysis

What can cause this??
Prior to blood transfusion usually we will give normal saline to patient. If prior to transfusion, th e patient was given D5, it will cause hemolysis to the patient.
Transfusion was given via small bore needle --> hemolysis
The blood was not in appropriate temperature or being heat prior to admission

TWO. Patient develop fever, need to sent for culture and sensitivity.
If patient develop reactions due to bacterial pyrogens or bacteria, patient will present with septic or endotoxic shock

THREE. Whole blood transfusion can cause dilutional thrombocytopenia especially in massive transfusion. But it would not occur if patient was only given 2 units of whole blood.

FOUR. Washed red cells only used in patient with PNH.

FIVE. if patient need transfusion but previously patient develop fever after transfusion. What blood should you opt for? Leuco-reduced blood components either leuco reduced platelet or red cells

SIX. If Patient is iron deficiency anemia & her Hb 9 g/dL & asymptomatic. Previously she developped mild fever after transfusion. Physician ask for you to transfuse the patient. What is your choice?? Inform the physician that there is no indication & need to transfuse this patient. Yes, there is mild anemia but patient is asymptomatic. Here,the risk of transfusion reaction is higher than correcting the anemia.

Thats all I could remember from the class. Hope it benefits =)

References:
Prof Naznin's Class
Booklet : Transfusion Medicine for IIUM medical students reviewed by Assoc Prof Naznin, Dr Norlelawati, etc.

Internal Medicine Posting

It's been awhile i havent write anything...many things playin in mind lately..most of the time wud like to motivate myself&think positive&enjoy your day ahead. Its da best thing to do rather than allowing negativities to dominant ur mind. Well,it will decay u&da faster u wl luk older..hahaha=P
Hearing negative words from certain2 people, really make me sick. Its not really bad things happened to them, its just how they perceived things.

Not bein able to express wut i felt is sooo me especially when it cums to annoyance towards how ppl treat u@frustrating towards someone@if anythin goes wrong@whenever negativities cum.I'd rather keep it inside rather than let it out. I wud rather stay in a room or sumtimes went somewhere dat can give me tranquility. As I train myself to forgive&forget (but there's a limit also)

Sooo back to the topic.hehe. Da above was just for my therapy.Haha. Its been an enjoyable time in Internal Medicine Posting. Ive setup my own study group with year 5 consist of AJ, Rodhi, Mekti, Nabilah & Hafis Mat Top. They are very high spirited juniors. Really enjoy sharing knowledge with them. Eventhough after this i will be moving to surgery department, i will still try to join their discussion. I made a promise to myself that i dont want to forget the knowledge that i learned so far. May Allah ease my way through dis 6 months posting =)


Internal medicine - 2nd week (11th July - 18th July) :-
I took 2 days off (selasa&rabu) to send my family to KLIA. They were moving to Jubail,Arab Saudi for about 2/3 years. I resume my study on Wednesday evening. I dont want to miss PBL session by Dr Marzuki. I drove from KL as early as 8.30 - 9 am in the morning and reached Kuantan at 1 pm. Its indeed very hectic but for the sake of knowledge i surpassed the distance challenge. Yeayy~ for me.Hehe. Even Dr Marzuki surprised to see me attending his tutorial as i asked for 2 days off.

On Friday (16th July) I had a long case session wit Dr Marzuki (he is my supervisor for this week) after his usual ward round. I just love following his round. It reminds me how excited we were during my third years following his round. (Me, Yana Nordin&Kakti ) He always shoot us with questions&we try our best to answer him. But most of the time, we got a new homework from him. Ok, back to the point.Hehe. I presented a Non-hodgkin Lymphoma case presented with multiple lymph nodes at his neck& axilla areas which associated with B symptoms. I still remember, we once did short case about lymphoma with him. But today, i could understand this cases even more. Thank You Doctor. I will always pray for your good health & Happiness fiddunya wal akhirah.

On the weekends, i went home again, celebrating my mother in laws 51st birthday. Happy birthday, mak.

Internal Medicine - 3rd Week (19th July - 25th July) -
This week, Prof How was my supervisor. I called him to arrange class. However, he was busy the whole week & postpone to next week. so I try to make an arrangement with Dr Che Rosle. Since he had to go to Jerantut/Temerloh, I forgot.Hoho. We rescheduled the session to next Tuesday. So this week, i joined all 5th years classes as usual, following Dr Marzuki&Dr Hasnur rounds. Then, I realised that I was able to remember most of the topics that i learned before.That makes me very happy. So I taught few juniors of what I learned in order to enhance the memory.

This week also we started our study group with 5th years friends. We cover cardiovascular system& stroke. It was a great discussion. Thank You, guys.

During weekends, i call up few juniors to have short cases&discussion with them (The group dat i taught before). We went to have breakfast as early as 7.45am at PakLah. We had a great chitchat together while eating up our roti canai. Then we headed to JHC to book the discussion room& put our bags in before we climbed up the internal medicine wards. We did neurological short cases. Now i understand how our lecturers felt when we forgot what they had already taught us. Haha. Later, we tried to find any interesting abdominal short case but to no avail. So we made our way back to library for discussion. That day, we discussed about stroke & infections diseases like Dengue, Leptospirosis, Typhoid. Luckily, we also joined by Mekti (5th year friend). she also has discussion wit her group but they finished up early & she joined us. Thank You, Mekti!!

Internal Medicine - 4th Week (26th July - 1st August) :-
This is my last week in this department. This week i will have 3 extra classes with 3 different doctors - Dr Che Rosle, Prof How & Dr Ng (He's my supervisor for this week).

On tuesday evening, i had a long case session wit Dr Che Rosle. He wanted me to clerk a renal cases. So i presented to him a 59 years old malay man with underlying ESRF for the past 10 years currently admitted for parathyroidectomy. My session was joined by dear 5th year friends. Thank You,guys. Its the first time i presented Hyperparathyroidism cases. I clerk him on the morning as I would like to time my clerking. However, i exceed the time & clerked him for 1&half hours.Hoho. He taught us about hyperparathyroidism, how to diagnosed&investigate. Later he touched on renal replacement therapy. It was a detail discussion indeed & I love it!!!! But felt sorry to dear juniors who follow the session, it was a lengthy one & hope da discussion benefits all of u =)

On wednesday, i had short cases session with Dr Ng. Initially, he asked me to do long cases but i requested for short cases because this week i already had 2 long cases. *Saturated mode* So,we did 3 cases - respiratory system (bronchogenic Ca), CVS system (prosthetic valve) & Neuro case (CVA). I learned a lot today. I practiced a lot for this short cases however during respiratory, i fumbled&forgot few things - flapping tremor&vocal resonance. Frustrating!!!!hahaha. Frankly, I was nervous like hell. As usual, my session was joined by dear juniors. Hope they learned from the discussion.

On Friday, i had long case with Prof How after the CPC at his room. I presented a case of 32 years old indian man who is unemployed with the history of chronic heavy alcoholic drinker currently presented with seizure. I really admired prof How. He taught me to the very great details. He easily found my weak spot & advised me to improved. I should understand more about VT, cardioversion & defibb.

Apart from these classes, regarding my study group with 5th year friends- we focused on renal topics (Nephrotic,nephritic, APKD, ARF, CRF, ATN, RAS, RTA ) & we touched on anatomy of renal & relate it to diuretics. Yeayyy~ now i understand more about renal wic i seldom read up previously =)

Yesterday, i had revision with 3rd Years - we discussed on ACS.

So this is it, i already came to an end of my internal medicine posting. 1 Down, 5 more to go. Im looking forward for another great experiences. I thanked Kak Wawa for her assisstance in this 1 month & kindly asked her to pray for my success.

p/s- training myself to start everything with bismillah. As i always forget.Huhu

Welcome To Clinical Years, Dear Juniors~

Minggunie saya membuat keputusan utk 'stay' sahaja di kuantan. Hal ini kerana saya akan pulang ke rumah pada hari isnin depan seusai kelas bersama Dr hasnur. Saya mengambil cuti selama 2 hari.Rabu saya nekad utk bertolak awal kerana pada petangnya akan diadakan kelas.

Keputusan untuk tidak pulang ke rumah hujung minggu ini juga kerana mengenangkan junior tahun 3 yang masih 'blur' dan perlukan tunjuk ajar daripada senior sebelum mereka memulakan posting mereka minggu hadapan. Apabila ditanyakan, apakah yang dipelajari selama seminggu elementary. Mereka menjawab hanya pengenalan kepada setiap posting & cara untuk mengambil 'history' pesakit sahaja. Kali ini,department hendak mempercepatkan proses pembelajaran dgn memendekkan elementary yang selama ini diadakan selama sebulan kepada seminggu sahaja. Jadinya, 'physical examination' akan terus diajar di dalam wad.

Seorang junior mencurahkan rasa hatinya, cuak&gelisah untuk memulakan posting pertama ini. Saya cuba menenangkannya dengan berkata, "Jom,esok akak ajar macamane nak examine patient ok??pukul 9 di wad. Ajakla beberapa orang kawan-kawan kamu. Malam ini,cuba baca sedikit buku talley itu. Esok jangan lupe bawak sekali." Gembira rasanya 'message' yang resah gelisah daripada junior itu bertukar menjadi nada gembira & akan cuba belajar dengan bersungguh2 esok.

Tepat jam 9,kami berkumpul di hospimart. Adik2 nie sangatlaa semangat, 8.50 sudah sampai & menghubungi saya yang masih dalam perjalanan.Haha.Bagus punctuality is a must for a doctor to be.Malu jugak rasanya,kakak senior pulak yang lambat daripada mereka. Saya berkenalan dengan mereka. 5 orang semuanya. 3 orang sudah saya kenali. Mereka adalah, arif, muiz, afifah, tasnim, dayah. Sebelum memulakan perkongsian ilmu, saya menyatakan kepada mereka,

" Apabila masuk clinical years, kamu semua akan dapat ilmu daripada pelbagai orang, tak kira lecturers atau seniors, tapi yang hendak ditekankan, kamu harus tahu dari mane sumber mane ilmu itu datang. Untuk physical examination, please refer to your talley.

Eventhough, i teach u guys the physical examination today, after this make sure u refer from the books. That's why i want you to bring the book along, u can refer straightaway. The knowledge today, please share it with your colleagues & if they ask where did u learn this, please mention it's from talley & dont mention it's from seniors."

Saya menerangkan apa yang mereka patut buat pada hari pertama di wad. Perkenalkan diri pada sister untuk orientasi di wad. Hendak masuk ke rumah orang, perlu berkenalan dengan tuan rumahnya. Kemudian, saya tunjukkan tempat menyimpan beg, di mana buku kemasukan pesakit & serba sedikit tentang keadaan di wad. Terbayang di benak pemikiran saya, perasaan saya apabila pertama kali menjejakkan kaki di wad. Wad ini dirasakan begitu asing sekali. Hendak menghampiri pesakit juga bertolak-tolak sesama sendiri.Haha. Saya luahkan ini kepada mereka.

Next, we approach one pakcik with the history of coughing for 2 months. I show them a little bit how to start clerking the patient, what is the approach, the importance of differential diagnosis in mind, than we proceed with exmaination. We start with respiratory examination. I taught them the sequence & the reasons behind it (All this can enhance my memory about the topic& my skill to detect the signs in this patient. But previously, i have class with dr harris. So I know my finding is correct& had been confirmed by our lecturers.haha)

They are very lucky to have a patient with very obvious finding & dat pakcik was very kind enough that he did not mind being examine many times by the juniors. he even know shoe the juniors how to do percussion!!! haha. Afterwards, we thank the pakcik & i told him, after this, when the juniors practice among themselves, the rewards also will go to him. This is because of him, the juniors can appreciate the findings. Then, we thank th epakcik and moves to the next patient.

( This patient had right lung collapse - clubbing, small muscle wasting of the hand, trachea deviation to the right, findings confine to the right lung where there were asymmetrical chest movement, reduce chest expansion, reduce tactile fremitus, dull on percussion, reduce intensity of breath sounds) - also demonstrate them what is vesicular&bronchial breath sounds, their characteristic&ask them to here their own lungs and also auscultate over the trache to appreciate bronchial breath sounds.

I wish to teach them neurological examination, but there was no patient with neurological deficit at this moment in the ward. So i approach a patient with right side infective endocarditis. Unfortunately, the murmur is so soft that the juniors will definitely have difficulty to appreciate the sound. But the important is they know how to perform the cardiovascular examination. The juniors are very lucky indeed (yeah,unlucky for the patient though~), that this patient has collapsing pulse & alhamdulillah, they can appreciate it on the their first day in the ward.Hehe

Afterwards, we rest ourselves in the nurses room, made a halaqah & discussed back what we had done before. I told them the common cases that they need to cover first. I give few tips for them to survive on their first day.

Selain itu, saya juga mengingatkan kepada mereka,jangan terlalu negatif untuk memulakan posting kamu disebabkan oleh cerita-cerita sensasi yang selalu diceritakan kepada juniors. Pengalaman setiap orang dalam klinikal adalah berbeza. Alaminya sendiri dan baru kamu tahu kebenarannya. Jadinya, saya galakkan mereka untuk membuka minda&hati, be neutral, think positive. InsyaAllah the aura that u transmits to the people around u, will ease your way in your clinical years.

Saya juga mengatakan ini kepada mereka, 'Welcome to the world where nobody cares about u". Jadinya in the ward remember this (Which i learnt from prof Muhaya):

There are 3 types of person

1. Person who make things to happen
2. Person who wait things to happen
3. Person who wonders what happen

Saya menggalakkan mereka untuk menjadi golongan pertama.

Beranikan diri untuk menghampiri doktor & ikut round mereka. Jika ingin pelajari sesuatu, jangan takut untuk bertanya, jadilah pro-aktif. Disamping itu, prosedur di wad, jangan sesekali diabaikan. Ini akan memberi keyakinan kepada mereka sepanjang mereka berada di tahun klinikal & sekaligus memudahkan mereka menjalani 'Housemanship' mereka nanti. Jadilah seorang yang bertanggugjawab untuk 'cover' pesakit yang sudah diberikan kepada mereka. Yes, clinical years will make you busy with lots of things to do, but i assure u, it will be an enjoyable session for you.

"Ya Allah, kau yang maha kuasa&maha penyayang, mudahkanlah urusan kami. Kau bukalah jalan kejayaan kepada kami. Hampirkan kami kepada orang-orang yang beriman & dapat membantu kami dalam kehidupan seharian kami. Aminn~"

p/s- esok saya akan mengadakan diskusi bersama tahun 5 pula. semoga ilmu yang dikongsi diberkati =)