I am showing a case of ECG from this website. Actually if you just google it, you will get it. Nevertheless I put down the list of ECG interpretation here just in case I need to refer, or maybe you who would like to know more.
http://meds.queensu.ca/courses/assets/modules/ts-ecg/right_bundle_branch_block.html
http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson6/index.html
http://www.americanheart.org/presenter.jhtml?identifier=563
http://cmbi.bjmu.edu.cn/uptodate/electrocardiography%20tutorial/ECG%20tutorial-Miscellaneous%20diagnoses.htm
http://ecgblog.com/?tag=rp-interval
http://www.amc.edu/amr/archives/200408/EKG2_ans.html
To date, I am still doubtful of the ECG interpretation, especially the RBBB and LBBB which kind of haunted me and that during the cardiovascular module back in IMU, these are the few ECGs which I could not fully understand. These are the questions I have in mind: what is an RP interval? In regards of ST segment shapes, there are not much literature reviewing the articles about them. Only one reference quote a significant observation to be noticed of, whether the ST segment shape is concave, straight or convex[1].
Loads of websites teaching you but how much can I absorb? Aiz...
Reference:
1. Karadede A., Aydinalp O., Temamogullari A.V., Toprak N. The relationship of ST segment elevation shape with preserved myocardium
and signal-averaged electrocardiography in acute anterior
myocardial infarction. Heart and Vessels [serial on the Internet]. 2002; 16(4): 146-153. Available from: http://www.springerlink.com/content/cqu8tkxdvc83q91j/fulltext.pdf
Sunday, May 23, 2010
Lesson I Learnt from Jefferson -- Sexual & Interpersonal Relationship
Sometimes in your interview, you will come across people with gay or lesbian relationship. First and foremost, do not show any signs of surprise since it will make patient feels uncomfortable. Try to be neutral and more understanding.
Before I begin, quick mention on what kind of words to be used. Start of by asking permission. "I care about you. To do that, I need to ask something private"/ "As a physician, I need to know that. It will be kept confidential." Reassure the patient that you are asking in good will and that you will keep his/her private live in secret. (Homosexuality is still a big issue here despite efforts of making homosexual legal). Afterwards, ask about the sexual history. "Are you in a relationship? With men or women or both?" Same rule applies, do not beat around the bush. Ask straight, but don't do it too prominent, of course.
Ask about screening tests done in any couples. Tests like HIV testing and STDs. (People always think HIV test first then other tests, therefore I can't think of any other tests which you can do)
Ask about a possible abuse relationship. This is not a funny issue as domestic violence or sexual assault is pretty common. Approximately 25% of women in US will be abused by a current or former partner sometime during their lifetime and most of the time (85%), victims are women[1]. Kick start this by asking "How's your marriage?" or "How's things going on at home?". If you suspect possible abuse, initiate SAFE questionnaire. 1. Stress/Safety; 2. Afraid/Abuse; 3. Friends/Family; 4. Emergency plan. Then proceed to Abuse Assessment Screen (AAS) to access how severe the abuse can be. One point I want to mention is patient may indirectly hint you that they are in an abuse relationship. Remember that women tend to cover up this messy relationship and tend not to talk about them too much. Say for example, patient may say their relationship is good but they did argue. Argue but still in a good relationship? Ask more...
Depressed patient. They won't say anything (sometimes), even though they start speaking, it will be slow. It's pretty hard, actually, to get a full history done by a short period of time due to the slow nature of the interview. Nevertheless, you need to be patient and try not to hurry the patient too much. It's bad. Question patient intention of how to overcome them. Let's just start a scenario like this. Firstly, NO BEATING AROUND THE BUSH. Ask him/her "I think you are feeling depressed because ..." Explain to him/her and explore whether he/she has suicidal intention. Questions like "Do you feel you want to harm yourself/other people?" should be asked. Optional question like "Do you own a gun?" can be asked.
P/S: As long as you see a gown, please drape. Assure patient that you have the best quality of care and that you do your best to help. Scenario: Patient indecisive of admission to hospital for treatment as he/she is afraid that he/she will end up dying like of his/her parents who have the same disease as he/she. Assure her: "We have the equipments to make you feel better and that we need to put you early to hospital." (S.P. amazed but the bolded phrase. This is just an example I made up with the intention which I feel from the S.P.) Night sweats. Can be lymphoma, TB etc. In diarrhea, talk about quality of stool (watery? Color? Frequency?) When you want to do examination on female patients, due to modesty, you would need to ask "May I go under the gown?"
Reference:
1. Fortner K B, Szymanski L M, Fox H E, Wallach E E. The Johns Hopkins Manual of Gynecology and Obstetrics. Baltimore: LWW; 2007, p. 355
Before I begin, quick mention on what kind of words to be used. Start of by asking permission. "I care about you. To do that, I need to ask something private"/ "As a physician, I need to know that. It will be kept confidential." Reassure the patient that you are asking in good will and that you will keep his/her private live in secret. (Homosexuality is still a big issue here despite efforts of making homosexual legal). Afterwards, ask about the sexual history. "Are you in a relationship? With men or women or both?" Same rule applies, do not beat around the bush. Ask straight, but don't do it too prominent, of course.
Ask about screening tests done in any couples. Tests like HIV testing and STDs. (People always think HIV test first then other tests, therefore I can't think of any other tests which you can do)
Ask about a possible abuse relationship. This is not a funny issue as domestic violence or sexual assault is pretty common. Approximately 25% of women in US will be abused by a current or former partner sometime during their lifetime and most of the time (85%), victims are women[1]. Kick start this by asking "How's your marriage?" or "How's things going on at home?". If you suspect possible abuse, initiate SAFE questionnaire. 1. Stress/Safety; 2. Afraid/Abuse; 3. Friends/Family; 4. Emergency plan. Then proceed to Abuse Assessment Screen (AAS) to access how severe the abuse can be. One point I want to mention is patient may indirectly hint you that they are in an abuse relationship. Remember that women tend to cover up this messy relationship and tend not to talk about them too much. Say for example, patient may say their relationship is good but they did argue. Argue but still in a good relationship? Ask more...
Depressed patient. They won't say anything (sometimes), even though they start speaking, it will be slow. It's pretty hard, actually, to get a full history done by a short period of time due to the slow nature of the interview. Nevertheless, you need to be patient and try not to hurry the patient too much. It's bad. Question patient intention of how to overcome them. Let's just start a scenario like this. Firstly, NO BEATING AROUND THE BUSH. Ask him/her "I think you are feeling depressed because ..." Explain to him/her and explore whether he/she has suicidal intention. Questions like "Do you feel you want to harm yourself/other people?" should be asked. Optional question like "Do you own a gun?" can be asked.
P/S: As long as you see a gown, please drape. Assure patient that you have the best quality of care and that you do your best to help. Scenario: Patient indecisive of admission to hospital for treatment as he/she is afraid that he/she will end up dying like of his/her parents who have the same disease as he/she. Assure her: "We have the equipments to make you feel better and that we need to put you early to hospital." (S.P. amazed but the bolded phrase. This is just an example I made up with the intention which I feel from the S.P.) Night sweats. Can be lymphoma, TB etc. In diarrhea, talk about quality of stool (watery? Color? Frequency?) When you want to do examination on female patients, due to modesty, you would need to ask "May I go under the gown?"
Reference:
1. Fortner K B, Szymanski L M, Fox H E, Wallach E E. The Johns Hopkins Manual of Gynecology and Obstetrics. Baltimore: LWW; 2007, p. 355
Thursday, May 13, 2010
Lesson I Learnt from Jefferson -- End of Life
Person attending: Patient's wife
Patient's info
Name : Mel Voight
Age : 55
Gender : Male
Diag & Rx : Adenocarcinoma of lung, underwent resection of lung mass followed by chemotherapy and radiation.
Comments : Recurrence of cancer after vacation and metastasize to lymph nodes, brain and lung
History of Presenting Illness
Time : One week ago
Last activity : Gardening
Comments : Patient tachycardic and hypotensive. During transport to ED, patient became pulseless and CPR initiated. Arrival to ED, PEA was reported. Epinephrine and atropine was given, CPR discontinued and intubation started. After 25 mins of ACLS protocol, patient regain spontaneous circulation and was transferred to MRICU on respiratory and BP support.
Patient condition: Stabilized, remain ventilator dependent and failed all trials to wean him from ventilator. Remained unresponsive to voice, touch, painful stimuli.
CT of head : Negative for hemorrhagic or ischemic stroke
Enlarging metastatic lesions spotted.
Comments : Patient diagnosed with severe anoxic brain injury due to prolonged resusucitation effort
CT of chest : Recurrent rapidly progressing adenocarcinoma
Comments : Bad prognosis
Your task as an attendant of MRICU, talk to Mrs Voight as she wishes to talk to you about the events that have occurred since last week and inform her about what his chances are for survival after the event. She has been told briefly about the code blue by the covering intern.
My own personal experience
It's really bad to make patient's relative or spouse to be left in a blank or confused state. I need to be confident in delivering the news and don't be afraid to mention the word "death", but mention them in a correct manner. The phrase here as quoted in my OSCE book: Assure the iwfe of the certainty of her husband's diagnosis and prognosis. [2]I give an example of how to start the conversation, (you can actually ask anything you want since you are the creator):
Physician: Good morning. How are you feeling today?
Patient: Better than I did a week ago.
Physician: I'm glad of that. We have some very serious matters to discuss regarding your health. Do you feel ready for this discussion?
The aforementioned dialog [1] is a nice approach to prepare patient, as in to prepare the patient of the information he or she is going to hear. One can also try to offer a conclusion or the details first. "Do you want the big picture first?" is a nice phrase to be used.
A good handshake (you can use both of your hands to hold their hands) can mean a difference. Even a tap on shoulder or if you want to offer a patient a hug can help the patient, at least to let them feel that death of the loved ones is inevitable and that they need to overcome them. "We really try our best" should be mentioned. Mind you that everyone deep down wants the truth no matter how bad a situation is.
Talking about overcoming them, it's nice. Ask them what else can be done to help, e.g. access to phone to contact family members or access to clergy[2] and always offer support or help. Words like "My doors are opened to you. If you have any questions, you can consult me." If patient's relative still can't make any decision, it's fine mainly because they are shocked about the bad news.
There are a few points mentioned in the handbook. Just act according to situation, and as Dr. Majdan said, "Treat your patient not by your brain, but by your heart."
Correct me if I am wrong in any part of my article
Reference:
1. P Gordon, J Marsh. Crash Course: History and Examination. Philadelphia: Elsevier| Mosby; 2005, p.14.
2. Katrina F Hurley. OSCE and Clinical Skills Handbook. Toronto: Elsevier | Saunders; 2005, p.362.
Patient's info
Name : Mel Voight
Age : 55
Gender : Male
Diag & Rx : Adenocarcinoma of lung, underwent resection of lung mass followed by chemotherapy and radiation.
Comments : Recurrence of cancer after vacation and metastasize to lymph nodes, brain and lung
History of Presenting Illness
Time : One week ago
Last activity : Gardening
Comments : Patient tachycardic and hypotensive. During transport to ED, patient became pulseless and CPR initiated. Arrival to ED, PEA was reported. Epinephrine and atropine was given, CPR discontinued and intubation started. After 25 mins of ACLS protocol, patient regain spontaneous circulation and was transferred to MRICU on respiratory and BP support.
Patient condition: Stabilized, remain ventilator dependent and failed all trials to wean him from ventilator. Remained unresponsive to voice, touch, painful stimuli.
CT of head : Negative for hemorrhagic or ischemic stroke
Enlarging metastatic lesions spotted.
Comments : Patient diagnosed with severe anoxic brain injury due to prolonged resusucitation effort
CT of chest : Recurrent rapidly progressing adenocarcinoma
Comments : Bad prognosis
Your task as an attendant of MRICU, talk to Mrs Voight as she wishes to talk to you about the events that have occurred since last week and inform her about what his chances are for survival after the event. She has been told briefly about the code blue by the covering intern.
My own personal experience
It's really bad to make patient's relative or spouse to be left in a blank or confused state. I need to be confident in delivering the news and don't be afraid to mention the word "death", but mention them in a correct manner. The phrase here as quoted in my OSCE book: Assure the iwfe of the certainty of her husband's diagnosis and prognosis. [2]I give an example of how to start the conversation, (you can actually ask anything you want since you are the creator):
Physician: Good morning. How are you feeling today?
Patient: Better than I did a week ago.
Physician: I'm glad of that. We have some very serious matters to discuss regarding your health. Do you feel ready for this discussion?
The aforementioned dialog [1] is a nice approach to prepare patient, as in to prepare the patient of the information he or she is going to hear. One can also try to offer a conclusion or the details first. "Do you want the big picture first?" is a nice phrase to be used.
A good handshake (you can use both of your hands to hold their hands) can mean a difference. Even a tap on shoulder or if you want to offer a patient a hug can help the patient, at least to let them feel that death of the loved ones is inevitable and that they need to overcome them. "We really try our best" should be mentioned. Mind you that everyone deep down wants the truth no matter how bad a situation is.
Talking about overcoming them, it's nice. Ask them what else can be done to help, e.g. access to phone to contact family members or access to clergy[2] and always offer support or help. Words like "My doors are opened to you. If you have any questions, you can consult me." If patient's relative still can't make any decision, it's fine mainly because they are shocked about the bad news.
There are a few points mentioned in the handbook. Just act according to situation, and as Dr. Majdan said, "Treat your patient not by your brain, but by your heart."
Correct me if I am wrong in any part of my article
Reference:
1. P Gordon, J Marsh. Crash Course: History and Examination. Philadelphia: Elsevier| Mosby; 2005, p.14.
2. Katrina F Hurley. OSCE and Clinical Skills Handbook. Toronto: Elsevier | Saunders; 2005, p.362.
Wednesday, May 12, 2010
Lesson I Learnt from Jefferson
It's about two weeks since I have come to Jefferson Medical College, Philadelphia, PA, USA. Everything is new to me here and I have had really good time, as well as bad time here. Lots of mistakes and just tons of things I need to bear in mind when in clinical examination.
I will just point out the serious mistakes I made, some ideas of thoughts and comments I would like to make.
1) History taking.
I need to be more focus on what I should be doing. Do not shoot like a shotgun, and hoping u hit something, instead ask specific and more case related questions. DO NOT SAY TOO OFFENSIVE THINGS. Say it in a rather indirect and polite way. Do not ask a patient some judgmental questions. "Are you obese?" (Duh, bad question. Whether you are overweight or underweight rely mostly on BMI. In other words, just don't ask this question) "Do you have sex with men?" (You are being judgmental about the patient being gay)
Try to speak in a layman level, besides not speaking medical jargon, as it's not just them altogether. If you suddenly utter some too medical jargons, explanation should be made to make them understand.
Review system. Try to do as appropriate. As told earlier, try to generate some questions pin-pointing yourself to the right track. Housing and working environment can be asked at social history (?). If you have the high likely suspicion that patient is not telling the truth, try to prompt them to saying them, ex. smoking. Patient may just say I quit smoking last year, then they tell you that he/she smoke a few cigarettes yesterday. Same goes for drinking. (I forgot how Dr. Majdan phrase it, but it's something like asking you how many you drink, instead of asking do you drink) ALWAYS DEFINE THE PATIENT'S DEFINITION OF BEING NORMAL. Always ask what is normal to patient, ex. bowel movements (no need to say a lot, you know what I mean. :-p)
ALWAYS REMEMBER TO SIT DOWN. Don't bring into your mind any idea of person seeing at eye-level is respect. They WANT you to really sit down and really care for them, and REALLY listen to what they say. Just imagine if you are standing up and taking history, you can just walk out of the room. But if you are sitting, you are showing to patient that you really a caring doctor. Thus, never stand up. Remember to sit down. Screw the eye-level looking respect thingy.
Obstructive Sleep Apnea (OSA), questions like snoring, sleeping well should be asked. "Does your wife tell you that you snores at night?" "Do you feel breathless during the night?" etc.
SEXUAL HISTORY
Just be sensitive. Maintain confidentiality, that's utmost important. Questions like "Do you have regular sexual partner?" "How do you avoid pregnancy?" "What do you mean by protection" In cases of underage sex, ask "Do you have boyfriend or girlfriend?" "Can you talk about sex?" (I remembered that sexually abused kids normally have a really "adult" knowledge on sex)"Have you been abused?" can be replaced by "Do you feel safe at home?"
RELIGION
"Are you raised in any particular faith?" "Do you still practice them?"
2) Clinical skills
In GI, always make a point of auscultate before you palpate the abdomen. IT'S A MUST! Don't be shocked in front of a lady patient or be stunned. Quote from Dr. Majdan: "Do not let the situation controls you. YOU CONTROL THE SITUATION." Just be yourself, be authoritarian somehow but not too obvious and too exaggerating.
A note about american way of doing clinical examination. First and foremost, is standing on patient's RIGHT side, not only it's for the exam, but all the equipments are on patient's right. So, why not? Why not take this as a note, always go for the equipments side to do your examination. The bed or couch (I not sure of myself) is a fantastic bed/couch which can be extended on the leg side (it won't be taken out, if you don't open them, patient's legs will be left dangling, which is bad. The bed can be tilted 45 degrees too, to do your CVS and Respi examination. Better to use the antiseptic solution than using the soap. Seriously. If vitals are not given, DO ALL THE VITALS, ex. BP, pulse etc. Basically just do everything.
Respi and CVS examination can overlap, especially the apex beat.
3) Conclusion
If you don't know, say you don't know. Do not push your responsibility to other people, ex. the doctor who will be doing the imaging will tell you what's wrong with you (something like that). You are solely responsible of the well-being of the patient upon coming to you. Just tell him/her what you want to do, let him understand the procedures, and to be considerate of patient's possibility of phobia of your words like surgery (maybe the guy have had surgery before and will be traumatized that you tell him/her that she need another surgery).
Oh yeah, most Americans will know the generic name of the drugs. Therefore, be familiarize with the terms so that you will know what drugs they are. They may or may not be as well knowledgeable as you do.
There are lots more to learn. I need time to compile them and put it on my blogspot. I hope that these are all the deterrents that will help me and anyone who is reading this blog. AMITABHA!!!
I will just point out the serious mistakes I made, some ideas of thoughts and comments I would like to make.
1) History taking.
I need to be more focus on what I should be doing. Do not shoot like a shotgun, and hoping u hit something, instead ask specific and more case related questions. DO NOT SAY TOO OFFENSIVE THINGS. Say it in a rather indirect and polite way. Do not ask a patient some judgmental questions. "Are you obese?" (Duh, bad question. Whether you are overweight or underweight rely mostly on BMI. In other words, just don't ask this question) "Do you have sex with men?" (You are being judgmental about the patient being gay)
Try to speak in a layman level, besides not speaking medical jargon, as it's not just them altogether. If you suddenly utter some too medical jargons, explanation should be made to make them understand.
Review system. Try to do as appropriate. As told earlier, try to generate some questions pin-pointing yourself to the right track. Housing and working environment can be asked at social history (?). If you have the high likely suspicion that patient is not telling the truth, try to prompt them to saying them, ex. smoking. Patient may just say I quit smoking last year, then they tell you that he/she smoke a few cigarettes yesterday. Same goes for drinking. (I forgot how Dr. Majdan phrase it, but it's something like asking you how many you drink, instead of asking do you drink) ALWAYS DEFINE THE PATIENT'S DEFINITION OF BEING NORMAL. Always ask what is normal to patient, ex. bowel movements (no need to say a lot, you know what I mean. :-p)
ALWAYS REMEMBER TO SIT DOWN. Don't bring into your mind any idea of person seeing at eye-level is respect. They WANT you to really sit down and really care for them, and REALLY listen to what they say. Just imagine if you are standing up and taking history, you can just walk out of the room. But if you are sitting, you are showing to patient that you really a caring doctor. Thus, never stand up. Remember to sit down. Screw the eye-level looking respect thingy.
Obstructive Sleep Apnea (OSA), questions like snoring, sleeping well should be asked. "Does your wife tell you that you snores at night?" "Do you feel breathless during the night?" etc.
SEXUAL HISTORY
Just be sensitive. Maintain confidentiality, that's utmost important. Questions like "Do you have regular sexual partner?" "How do you avoid pregnancy?" "What do you mean by protection" In cases of underage sex, ask "Do you have boyfriend or girlfriend?" "Can you talk about sex?" (I remembered that sexually abused kids normally have a really "adult" knowledge on sex)"Have you been abused?" can be replaced by "Do you feel safe at home?"
RELIGION
"Are you raised in any particular faith?" "Do you still practice them?"
2) Clinical skills
In GI, always make a point of auscultate before you palpate the abdomen. IT'S A MUST! Don't be shocked in front of a lady patient or be stunned. Quote from Dr. Majdan: "Do not let the situation controls you. YOU CONTROL THE SITUATION." Just be yourself, be authoritarian somehow but not too obvious and too exaggerating.
A note about american way of doing clinical examination. First and foremost, is standing on patient's RIGHT side, not only it's for the exam, but all the equipments are on patient's right. So, why not? Why not take this as a note, always go for the equipments side to do your examination. The bed or couch (I not sure of myself) is a fantastic bed/couch which can be extended on the leg side (it won't be taken out, if you don't open them, patient's legs will be left dangling, which is bad. The bed can be tilted 45 degrees too, to do your CVS and Respi examination. Better to use the antiseptic solution than using the soap. Seriously. If vitals are not given, DO ALL THE VITALS, ex. BP, pulse etc. Basically just do everything.
Respi and CVS examination can overlap, especially the apex beat.
3) Conclusion
If you don't know, say you don't know. Do not push your responsibility to other people, ex. the doctor who will be doing the imaging will tell you what's wrong with you (something like that). You are solely responsible of the well-being of the patient upon coming to you. Just tell him/her what you want to do, let him understand the procedures, and to be considerate of patient's possibility of phobia of your words like surgery (maybe the guy have had surgery before and will be traumatized that you tell him/her that she need another surgery).
Oh yeah, most Americans will know the generic name of the drugs. Therefore, be familiarize with the terms so that you will know what drugs they are. They may or may not be as well knowledgeable as you do.
There are lots more to learn. I need time to compile them and put it on my blogspot. I hope that these are all the deterrents that will help me and anyone who is reading this blog. AMITABHA!!!
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