Persediaan Sebelum Housemanship ( BLOOD BODY FLUIDS SAMPLING)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindunganNya Amin;)

BLOOD BODY FLUIDS SAMPLING

One of my item of study lists before entering Ho soon. During my elective posting (Prehouseman) at USM Kubang Kerian, my senior taught us briefly about the different of colours of each tubes.

So untuk menyenangkn kerja kita as Ho soon, lets study about these bottles and theirs content. 

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Persediaan sebelum Housemanship

Assalamualaikum dan semoga kita sentiasa berada dibawah lindunganNya Amin;)

Salah satu cara untuk buatkan kita semangat nak study sebelum housemanship ni bagi saya ialah ruang yang selesa, bersih dan kemas.

Jadi saya selalu pastikan meja study saya tidak bersepah, buku-buku disusun rapi, nota-nota dalam bentuk kepingan kertas dibinding atau diletakkn dalam satu fail dan dilabel pembahagiannya.

Tujuannya supaya nanti dah start masuk Housemanship nanti, senang nak rujuk bila dalam keadaan tergesa-gesa nak cari ilmu tentang disease or management.

Nota-nota spjg kursus anjuran medicorp juga saya bind dan jadikan satu buku.

Nota-nota dari senior, senior femes di facebook dgn perkongsian notesnya semua saya print dan letak didalam satu fail.

Kompilasi nota-nota daripada Dr2 hebat di facebook saya print atau salin semula.

Buat satu buku khas "prehousemanship book". Kandungan dalam buku itu terdiri daripada nota sendiri yang diambil dari facebook, google, nota senior (pendek kata what needs to know as HO).

Nota drpd source yang femes cthnya Ampang Ho Guide saya print kesemuanya dan bindkan utk menjadi satu buku.

Habiskan sebanyak Rm200 untuk photostat semua CPG. Walaupun tidak terdaya nak bca dan faham semua sebelum housemanship, sekurangnya dah ada salinan. Ingst sempat nanti HO nak bca dalam softcopy yang tulisannya sgt kecil dan padat. Apapun jua, CPG ialah jantung stiap Dr perubatan di Malaysia. Mostly management of disease dirujuk daripada CPG, bukan?

Perfectionist a bit, and vigilence. 

 My favorite spot.

Prehouseman Attachment at USM (Last Day)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindunganNya.:)

1) Observe OGDS(oesophago-gastro-duodenoscopy).

2) Observe MO doing TAS

3) Attend HO teaching at ONG department.

TAKE HOME MESSAGES

• In low lying placenta, GP claimed the patient having it at 20 weeks gestations and plan to repeat the scan at 32 weeks. The mistake of GP is he should do the scan at 28 weeks because LUS form at 28 weeks.
• In placenta previa, must:

-Must do general examination of patient ( detect sign of anaemia)

-Detect the lie because placeta previa mostly lead to abnormal lies.

-Must exclude abruptio placenta.

-Can do PSE (perspeculum examination) on placenta previa but must place on front only to look at the cevix not in advanve manner. (can see cervical mass or erosion)

-Must do TAS then TVS

-Must admit to PREM (premature room) for close observation eventho the patient not having contraction pain or bleeding. //In district or ward must place in acute cubicle for close observation also)

-Can SVD in condition with no PV bleeding, If bleeding persists, must CS

Prehouseman Attachment at USM (Day 18)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindunganNya amin :)

1) Observe specialist and MO doing the colonoscopy in patient having colon polyp.

2)Entering operation room, observing the Lower segment caeserian section (LSCS) and suturing the uterus and surgical sites.

3) Perform blood taking on pregnant mother.
* Taking blood in pregnant mothers usually are very easy because most vessels are in vasodilatation state.

4) Observe MO perform TAS (transabdominal scan) on pregnant mother.

5) First time in my life, successfully delivered my first placenta. Alhamdulillah I did it well.

TAKE HOME MESSAGES

• After artificial rupture of membrane (ROM) using amniohook if suspicious CTG for eg deceleration, must anticipate the patients worrying if patient having chorioamnionitis / fetal distress. Must inform MO STAT.

• If patient coming with rupture of membrane (at home) must compulsory do PSE (perspeculum examination) to detect the leaking is blood or liquor.

• Risk of GDM in Malaysia are mothers above 24 years old ( exclude the written ages in antenatal book 35 years old), family history. 

• MOGTT done in A DAY  fasting and 2 hours postprandial during antenatal.

• In pregnant woman, must set line in hand . Taking blood must do at area of cubital fossa because at dorsal of hand must reserve for line (fluid / medications)

• To preparing CTG on mother :  -Put the CTG on upper abdomen. Another probe on fetal back (to make sure, look for baby heart rate in CTG screen)

• When patient arrive in labor room, firstly must set line, prepare CTG for the patient, ready to plot partogram, doing documentation of the patient, V/E vaginal examination and prepare the labor set.

• After baby had delivered, clamp the cord near the vagina to detect the sign of palcental delivery ( lengthening of cord) and clamp the cord near the baby's umbilicus to cut the cord while reciting selawat for Islam.

• In cases of ANC (history of placenta retention) must observe carefully the time 30minutes maximum for delivery of placenta. If more than 30 minutes must call MO .

•  In delivery of placenta, after finished massage the uterus till uterus feel hard and globular, when want to pull the placenta, must do C traction on lower pubis in order to prevent prolapse of cord.

• Details must written in BSH when doing TAS :

-singleton, breech

-placenta US, no retroplacenta clot

-FH seen by mother/ shown to mother (must ask mother, "Puan nampak tak jantung baby?"

-BPD (Biparietal diameter) 5.95 (24W2D)

-HC (Head circumference) 21.51 (23W4D)

-AC (Abdominal circumference) 18.73 (23W4D)

-FL (Fetal length) 4.39 (24W3D)

-AFI (Amniotic Fluid Index)  *must take atleast 3 area

-EFW (Estimated Fetal Weight ) 639g

*Everytime write all the items found in TAS, must write in bracket the  period eg  (BPD (Biparietal diameter) 5.95 (24W2D)

• Difference between POA (period of amenorrhea) and POG (period of gestation)

-POA taken from LMP (Last menstrual period)

-POG taken from REDD (Revised expected date delivery)

Prehouseman Attachment at USM (Day 17)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindunganNya Amin:)

1)  Met Dr Fasihah (HO) she taught us on how to do dressing on the surgical site wound.
-Do CBD on the patient
-The surgical site wound (some) must be left open to reduce infection and must do dressing everyday.

2)Met Dr Amalina Nudin and her friends. Observed them doing dressing on bed ridden patient.

Take home messages :

• Common cases in surgery department : 

-appendix

-stoma

-cholecystectomy

-pancreatitis

-breast cancer

-mastectomy

-cholelithiasis

-gall bladder

-carbuncle (must do dressing)

-abscess

• Housemanship in USM Surgery Department:

-End of assessment with 30 questions of MCQ only

-Auto off tag in surgery

-mostly plan of management according to ED & pre operation

-Medication must also refer to old medication patients had taken before.

-Plan also change when SP/MO doing rounds. Must carry out new plan after that

-Mostly HO presenting the cases in surgical department.

Prehouseman Attachment at USM (Day 16)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindunganNya Amin:)

Visit the wound care clinic

1) Today, visit wound care room (Room no 10) at emergency department.

-Met KakYah and two male nurses and two Hos. (they are very nice and treated us well).

-Patient usually came to the clinic (outpatient clinic) EOD to clean and dress the  wound.

-The nurses explained concisely to us about the tools needed for dressing and the techniques.

-Observe full cleaning and dressing the wound for DFU (diabetic foot ulcers), venous ulcers, bed sores at sacral, post appendicectomy wound with colostomy.

-Followed a nurse to respective wards to clean and dress the wound mainly bed sore patient.

He taught us how to document the wound inspection.

Documentation of wound inspection

-Met Dr  Amalina Nudin at HDU ward.

WOUND ASSESSMENT

1) ages (extreme ages)
2)diseases /comorbidities
3) medications (steroids or chemotheraphy)
4) obesity
5) nutrition
6) impaired blood supply
7) lifestyle (smoking / alcohol)

LOCAL WOUND ASSESSMENT 

SIZE :
Measuring wound surface area (length, width, depth)

SURROUNDING SKIN:
Assess for sign of maceration, infection, ischemia, crepitus.

T.I.M.E
T : Tissue
 = viable (granulation and new epithelial)
 =non viable (necrotic and slough tissues)

I : Infection /Inflammation
= signs and symptoms of infection as presence of pus,pain,malodour

M: moisture imbalance
= exudate level dry,minimal or moderate/wet

E: epidermal margin
= advancing
= non advancing

DRESSING SET

Dressing set

Dressing set 1

Dressing set 2

Dressing set 3

1) Clean with cleansing foam ( berbuih tapi tak perlu dibasuh dengan air just lap)

aloe vera cleansing foam

2) Hydrocyn  water for healing faster (Increase O2 to wound)

Hydrocyn aqua

About hydrocyn aqua

3) Gel for the epithelization (Increase granulation tissue)

Debride gel

4) Foam - as bacterial barrier to cover exudate) *usually if use use gauze, must use 64sheets to give maximum function so foam is more better.

Foam

5)Aqua cell Ag - Hydrofibre to absorb exudate

Aqua cell Aq covering the venous ulcers (grey colour)

6) aloe vera oil - to prevent bed sores, dryness of skin and reduce itchness

7) Bandage

+ Sline : something that cover the wound from healing . During cleaning the wound,must debride the sline till healthy and bleed tissue seen .

Bandage

8) Blade - to cut the aqua cell Ag into respective size of woun,foam and necrotic patch.

Blade

9) Hypafix plaster. -

10) Wound ruler - to measure the size of wound length x width

11) sterile  water - apply all around the skin surrouding the wound

Sterile water

There are 2 type of debridement which are :

a) mechanical debridement : manually remove during cleaning of wound
b) autolytic debridement  apply gel on the wound usually on post operation.

+Bed sores usually happen at bony prominence as sacral, scapula, occipital.

+In bed sores, if necrotic patches present, the wound is unstageable and must remove the necrotic patch with blade first to promote healing at that area.

Bed sores wound

Example of bed sores documentation

Prehouseman Attachment at USM (Day 15)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindunganNya Amin :)

1)Join ward round team A with consultant, registrar, MO and Hos about the post Flex Ce operation review.

Example of post operation review.

2)Clerk patient with case of hiatus hernia (doing fundoplication at HRPZ before). Underlying factor of his condition because long term lifting weight at gym .

 3)Join short case CNS examination with neurosurgery team.

 4)Join bed site teaching with USM students about examination of wound and inspection of colostomy

 5)Join class with USM students at Bilik Tutorial 10 . (colorectal cancer, IBD, diverticular disease, anal fissure and anal fistula)

*IBD cases are very rare in Malaysia. Only 1 case per year.

Prehouseman Attachment at USM (Day 14)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindungaNya Amin :

Our first day elective posting at Surgery Department.

1)Met HOD of Surgery Department USM (Prof Zaidi)

-Introduce ourself to him
-He sugggested what should we do here and places that we can go and learn.
-Gave some advice regarding the Hoship
:The most important during Hoship is attitude. (Having strong passion in this profession, willing to learn and not make any problem)
:Before taking decision to resign (quit) from this profession (Nauzubillah) think well about our aims, family conditions and their hopes.

2) Met Ketua Jururawat (KJ) at ward 2 Intan.

-He divided us into few sections.
-I was placed in bilik ESWL (operation room) to observe the procedure and operation.

3)Went to bilik ESWL. Meet Prof Hafizi and HO,Dr Athikah.

-Dr Athikah explained to us about role of HOs in operation rooms.
:assign the surgeons to do the operation before and after such as inserting CBD, taking blood, retracting, write details of patients on the white board, document post operation review and etc.

4)Observed few operations such as:

-antegrade pyelography
-flex ve
-decompression T10/T11 + mass excision + post. instrumentation T8/T9/T10/T11
(Diagnosis is T10/T11 spinal cord compression and gouty arthritis with cutaneous tophi)

Prehouseman Attachment at USM (Day 13)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindungaNya Amin:)

1)Join HO teaching with fellow ONG HOs and a professor at ONG department.

Topic: POST PARTUM HAEMORRHAGE [PPH]

Important points taken about PPH;

a)As HO, must identify the patients that have high risk to develop PPH after labor and must anticipate :
-Grand multipara
-MAcrosomia
-advanced maternal ages
-Twins pregnancy
-maternal obesity
-polyhdramnios

b) Precipitate labor in patient drinking air selusuh, ubat selusuh (minyak kelapa dara, bunga kembang semangkuk, bunga manjakani)

-if the os 2cm but contraction like 7cm, must ask the patient if she takes air selusuh.

c) cases of prolonged labor such as,
-operative VD trauma as forcep

-Hx postpartum Hge
-retained placenta/membrane
-pt previous cs
-pregnancy with fibroid
-pt with coagulation (DIC)
-prolonged administration of pitocin

d) Treatment of PPH:
-uterine massage (first plan)
-snytometrin (oxytocin)
-if fail give hemabate up to 8cc
-balloning as Bakry ballon (must ask sister because usually nurse kept this in her room because quite expensive)
-Foley's cathether ( 3 way cathether red color)
-B lynch suture done by MO or registrar
-ligation of artery (rare and dangerous) because tortous int. iliac vein.
-hysterectomy (last choice)

e) In manual removal of placenta, if clot more than 500ml, call MO and call for help.

*if 300ml only dont call MO yet.
**1 kidney dish 150ml
**1 blue sheet : 500ml

f) Pitocin sometimes in bolus (not unit cc) because in PPH want good contraction then maintain by drop.

!!!TAKE NOTE!!! ----> 14 days MIA, automatic will be expelled without any reasons. But can apply back apply in MMC & SPA within 2 years.

2) Enter dengue at emergency department to see how clerking the dengue cases and review.

Example clerking dengue cases page 1

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Prehouseman Attachment at USM (Day 12)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindungaNya amin:)

Day 12

- Join ward round at postnatal ward (1 Topaz) with registrar, Mo and Ho.

-Study about how to document post operation review after labor.

-Join USM students class "Bed site teaching" with the topic PROM.

-In the labor room:
* Observe normal delivery and examine the placenta either complete or not.
*prepare pitocon 40cc after delivery uterine contraction.

-Join oncall at labor room from 9.30 pm till 4.00am.

Take home message taken:

1) - NRC (next review contraction) done every 2hours.
    - NRVE (next review vaginal examination)  check every 4 hours.

2) Before doing placental removal do uterine massage until feel the uterus is globular.

3signs of placental separation:
-Gush of blood
-lengthening of cord
-uterus hard & globular

3) Before delivery, pitocin 40unit in normal saline to stimulate uterine contractions.

One bottle contain 10cc pitocin, must use 4 bottle 40cc pitocin into normal saline.

4)after delivery of placenta, check the:
-cotyledon must all present
-2 membrane
-chorion and amnion
-vessels (2 arteries one vein)
Then put in plastic, timbang and  put into the paper bag with name of mother and NRC no.

5) after delivery, inject syntocinon IM at mother's thigh to stimulate uterine contraction to prevent PPH.

6) In active phase of labor, do urinary catherization to drain the urine because full bladder can make delivery process lengthen.

7) For mother, during delivery, dont lift the buttock if not tear may happen.

8) After do ARM (use amniohook) , tick on CTG paper where is the point of ARM.

Amniohook

9) Learn how to plot partogram with USM students. 

Prehouseman Attachement at USM (Day 11)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindunganNya amin:)

1) Clerking case on my own with my friend.

2)Dr Julia taught us the way to proper clerking the Obstetric cases, how to read antenatal book (pink book)  and extracting history from the ante natal book .

Template ong clerking 1

Template ong clerking 2

3) Dr Julia taught us how to do vaginal examination (V/E) , antiseptic technique before doing the examination and point need to document (write in BSH patient) when do V/E and PSE (perspeculum examination) .

4) Followed Dr Julia [HO] and MO [Dr Chan] into Bilik Rawatan to do PSE & VE on patient and observed MO expressed the findings into the word and HO interpret the findings to the BSH.

5) Observe HO [ Dr Hazrin ] to do branula insertion.

6)Followed morning ward round with HO & MO .
-Observe MO reviewing the cases , make physical examinatiom on pt (P/A)
-MO give the instructions to the HO to formulate or add new plan after the round and HO will carry out all the plans after the morning round.

7) Dr Julia taught to palpate the abdomen .

Point need to find during examinations:
-Fundus length
-Fetal parts and fetal head
-Gestational age
-Head to abdomen
-Lies

8) First time doing the vaginal examination.
Os : 2cm.

Prehouseman Attachment at USM (Day 8)

Assalamualaikum dan semoga kita sentiasa berada dibawah lindunganNya:)

1)Join bed side teaching with year 5 USM students at Wad 2 Akik.

Topics:Gestational Diabetes Mellitus on Insulin.
-one student presented the cases (Complete clerking until physical examination)
-After finished presenting the cases, Dr Haji discussed with the students about the important points regarding the disease in which the patient had.
-noted with HO Ampang Guide.

2) Follow one dearest MO .
-She taught us about how to plot partogram (what details need to be write in the partogram chart) and how to read CTG.
-She explained to us about the ward work.
-Must study MgSO4 preparation (different hospital, different MgSo4 preparation)
-Told us to observe delivery first then try to conduct the delivery.
-Her advise : "Learn as many as possible during Hoship. It is okay to feel "bodoh" as long as we are always willing to learn. Management can learn later when we are treating the cases".

Partogram

3)In labor room:
-Observe Dr do the episiotomy and vaginal examination to detect opening of the Os.
-Helping Dr and fellow nurses to prepare pt after delivery.
: putting pad on the patient, tie the pad.
:check the placenta before putting into the paper bag to bring back home.

4) Join medical ward oncall at 7 Utara ward with my secondary school senior Dr Afham .
-He taught us about how to put on branula and taking blood (VBG & ABG)
-Managed to draw blood on 2 patients on myself.
-He guided us on how to proper clerking pt in medical department. ( must tally and make reference on doctor in ED clerking the cases because most patient come to Medical ward are from ED) .
-Another Ho, Dr Farhana taught us how to key in data about blood investigation  to send to the laboratory after filling the blood into the respective blood tubes.

[TAKE HOME MESSAGE DURING ONCALL MEDICAL WARD]

a) First call ward round malam untuk patient ada issues sahaja

b) MO di ED clerk case yang sampai ke ED terlebih dahulu then HO Medical clerk once again when patient entering the medical ward.

c) Common reason for haemodialysis in medical ward are:
- metabolic acidosis
-hyperkalaemia
-uremic symptom
-infection

d) When HO clerks the cases from ED :
- refer kertas kuning dan merah (clerking sheets) from ED
- Ix yang dah dibuat, refer and trace the result into observation charts.

e) For ABG result , important markers to be noted are ph , pCo2, lactate and bicarbonate.

f) Tips for blood taking (Branula insertion, ABG, VBG)

-Bila ambil darah, jangan inject di tempat yang ada edema or swelling.

-In ABG procedure,ambil dekat radial artery. Elakkan ambil di branchial artery sebab that area cuma ada satu artery.

-After done taking ABG, must compress at least 1min at injection site to avoid haematoma. (if any problem when doing ABG, might be a reason for extension in medical ward for 1 month)

-In CKD patient, usually difficult to take blood because most veins are collapsed.

-Tips inserting branula, masukkan only 1/4 of length of needle and adjust the needle tilll succeed.

Trolley for blood taking

 Each blood taken must put in the respective plastic with label with corrrect patients' name. 

Key in data for blood taking to be sent to each related laboratory.

3.30 am after night oncall at medical ward.