Trauma Seminar: Management of Open Fracture

Yesterday (30th October) I attended a one day course organised by Orthopaedic department.


(I will complete this entry later. Hehe)

From This Moment

A Song From Shania Twain...

I always love this song as it reminds me of something which I adore very much =)
Yes, you are right...its My Dear Husband~

This will be the longest time we are not be able to meet each other..... for 3 weeks~

But both of us know, we gotta do what we gotta do....
And eventhough you are far from my sight but you are always close to my heart...

As always, lets keep praying for each other & hope to see you soon~




p/s- next week, Im going to start another new posting. Orthopedic
Tomorrow Ill be joining an Orthopedic Course which is Open Fracture Management =)
I believe it will be a good revision for me, insyaAllah

"Ya Allah, engkaulah yg maha kuasa, maha kasih & maha penyayang. Kau berikanlah aku kekuatan & semangat & sinarkanlah hidup kami dengan cahaya RahmatMu. Ameen~"

HectiC

This week is the last week of paeds posting. Same applied to the current final year students. So lots of classes had been cramped into this very precious weeks.

Since yesterday, I had classes non stop. Thank you to our lecturers for the time they had spend & knowledge that they share with us.

This morning, we had seminar at 8.30am (for 3 hours) & then I went to the ward to clerk & review patients. At 2.30pm, I had a short case session with Dr Nargis. Just now, I just finished another class with Dr Siti Noor at 1140pm. Eventhough, it was a late night class but learning with Dr Siti Noor always makes you energetic. Hehe. Lots of things had been discussed eventhough only 1 case had been presented just now. (was so tired to write about the case. HUhu. Sori~)

Tomorrow has another session with Prof Wahab at 9am & followed with short case session with Dr Aye Aye. Frankly, Im starting to feel tired but I have to bear it for the sake of knowledge.

But I really looking forward for last session with Dr Nargis this Friday =)

p/s - havent had proper meal today. Huuu~ & noticed time went by very fast~

==== Time & tide waits for no man ====

Physical Examinations

I always find that practicing physical examination is fun.

But to make it fun of course we need to read before hand. The atmosphere become much more fun and interesting when we do short cases with close friends We will present to each other & others will act like an examiner & ask questions.

This I believe a very good practice. Practice always makes perfect right.

In my previous professional exam, I will always came early to hospital at 7.30am to do short cases with friends until 9am. We will do 2 to 3 cases. Do a little bit of questions and answers until management. Sometimes, we will use saturday or sunday morning to do short cases. The colleagues that I shared doing this activity are Ijat, Cik Nana, Cik Nun, Kakti & ck Yana Nordin. Oh, how I missed them right now.

Short cases need a lot of practices in order to make the flow go smoothly & present fluently. Everyday I will review my l'ittle book of causes' to refresh back the common causes that will be asked by doctors depending on the systems. But as time goes by, it will just come naturally because you understand the topics.

And today, I still continue to practice short cases every morning. But this 2 weeks I could not make it because of classes in early morning. Huhu.

Sometimes, I asked few juniors to join me & do some teachings with them. This could also enhanced my memory & I always love to teach dear juniors.

I always believe that our lecturers could instantly know wether the student did practice a lot just by looking how we handle patient & how we perform the examinations.

And as usual, I always enjoy doing short cases =)

p/s- currently practicing the examinations using pillows by myself (I already sent back home my little teddies.Huhu) & you know what, Im practicing with my imaginary friends. Hahahaha =P

=== Always make the best of what you have & Move forward ===

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??)

Peranan Doa

Harinie hari Jumaat. As usual, petang jumat jika saya tidak pulang ke KL. Pastinya saya akan mengajak rumet pergi ke pasar malam.

Tapi semasa perjalanan pulang, sesuatu hampir terjadi & alhamdulillah Allah selamatkan kami.
Kami satu kereta hampir-hampir mahu dilanggar oleh bas yang laju dibelakang. Mungkin penumpang belakang tidak perasan kerana kereta saya sudah berhenti dengan selesa, & masing-masing tengah berbual tetapi saya melihat perkara ini melalui cermin pandang belakang. Huhu~

Ceritanya begini....
Jika orang kuantan pasti tahu trafik lite simpang empat besar depan Masjid Tengku Ampuan Afzan, dekat dengan pasar malam...

Jalan itu lurus, saya selalu berhati-hati kerana di situ kereta selalunya sangat laju walaupun sudah mahu menghampiri trafik lite.

Setelah masuk ke 'main road' saya mahu masuk ke len kanan untuk ke UIA. Jalan itu ada 2 lorong kan. Bile masuk dari bahu jalan, semestinya berada di len kiri dahulu. Tapi untuk ke UIA, kena berada di len kanan kerana lepas trafik lite kena belok kanan.

Jadinya apabila line clear, saya masuk len kanan & rupanya barisan kereta di len kanan itu sangat panjang dari trafik lite sampai ke depan masjid & dengan segera kena berhenti. Memang mengejutkan jugak. Kereta depan pun berhenti mengejut jugak kerana dia pun laju & tak sangka kereta depannya kena berhenti.

Sebelum menekan brek sempat saya mengerling cermin tuk melihat ada kereta dibelakang atau tak. Alhamdulilah tidak ada. Tapi saya melihat sebuah bas yang jauh di belakang. Tapi kelihatan agak laju. Walaupun pada mulanya bas itu agak jauh, sekelip mata saja dia sudah mahu menghampiri kereta saya.

Apabila bas itu menghampiri kereta saya yang sudah berhenti, ia masih laju & saya sudah risau bas tersebut tidak sempat brek. Bas itu kelihatan cuba memintas masuk ke len kiri kerana ia menekan brek tapi momentumnya yang besar menyebabkan ia masih meluncur kehadapan tetapi dia di hon oleh bas lain yang berada di len kiri & dibawa dlm keadaan laju juga.

Menyedari keadaan bas tersebut yang sudah memusingkan sedikit kepala depannya ke kiri untuk memberi ruang sedikit supaya tidak menghentam saya & ia juga sempat berhenti, saya juga menggerakkan kereta saya ke hadapan & ke kanan sedikit dengan harapan sedikit ruang yang saya bagi itu, cukup-cukup untuk momentum bas itu berhenti.

Dan alhamdulillah ianya berhenti sangat rapat dibelakang kereta saya.

Saya sangat bersyukur kerana tidak terjadi drama di situ petang tadi & Allah telah selamatkan kami. Saya terkenang ini mesti berkat doa emak, ayah di perantauan yang senantiasa mendoakan keselamatan & kejayaan anaknya di mana sahaja berada. Tidak lupe juga kepada Encik suami yang sentiasa mendoakan isterinya dalam lindungan Allah. Juga pastinya doa mak, ayah mentua, adik-adik diperantauan dan sebagainya.

Paling penting, diri sendiri juga perlu sentiasa berdoa & sentiasa mengingati Allah walau dimana sahaja berada kan kan =)