Monday, July 4, 2011
GP posting #1
Today was my first day learning from Dr. C at ***Clinic through observation. I would say it was awesome (= At first i was worried that i will be ill-treated or neglected as the staffs are very busy. And i was wrong.
Doc was actually a very friendly guy who's willing to teach. He even treated me coffee and toast at the nearby coffee shop at 3pm. He also joked around with his nurses, allowing them to go buy ice-cream and chill when there's no patient.
Gotta see a few cases of dressing done by the nurses. Dr said his nurses mastered it within 3 days, why couldn't i? errr...im flattered.
Cough and cold was the most common case. In a GP setting, it is impractical to treat based on the knowledge of causative agent, where 80% is viral and 20% is bacteria. Because it takes at least 1 week to differentiate by culture and lab diagnosis. It is impossible to ask the patient to come back 5 days later to treat his cough and cold, right? Weak empirical antibiotic is thus the drug of choice to take care of the bacteria; viral will resolve itself and often requires only symptomatic treatment. Furthermore, using weak first-line drug will prevent the emergence of MRSA in the patient you treating.
As a GP you have to know your limitation. Don't try to take dangerous and high risk case, unless you are uber sure you are capable of it. Referring to a specialist or a hospital will not only save your ass but the patient's too. (= Also, treat the most serious/urgent complaint, or the underlying problem first, then come back to other non-threatening illness and treat them symptomatically. If everything returns to normal for a long period of time, no need to pursue the underlying cause, which may require expensive, tedious and time-wasting tests.
The case of the day was a young male construction worker who had a crushed ankle due to a bad fall from a height of 2 stories. The medial malleolus was fractured and protruding outwards to the underlying skin, causing torrent of blood spilling from the deep wound. When doc unwrap the bandages to examine, the blood spilled onto his face. Shit. Poor doc risking his safety. An X-ray was required for diagnosis and treatment and the process of taking it was disastrous. Blood kept pooling on the X-ray plate and it could hardly stopped unless somebody pressed hard against the wound, which is also, bloody painful for the patient. For the survival of the patient, I was asked to apply pressure on his wound to stop bleeding while the doc made his diagnosis. A young strong man yelling and trembling in pain. The pain was clearly beyond my imagination. The patient was carried by 2 of his friends back to the lorry and was referred to ***General Hospital for an emergency surgery.
There's another case of head trauma suffered by a small boy due to falling down. He had a fever lasted for 3 days, but he was conscious, alert and communicative. Doc suspected he had a head hematoma and referred him to a hospital for a head CT scan. His parents, in their 60s to 70s, who accompanied him to the clinic, were unwilling to pay for the scan as it will cost rm400. Here comes the problem.
There's one patient came with a complaint of blood in urine. He had a history of renal stone and had undergone one week of medical treatment. Doc performed renal punch on his back but he had no pain. The patient suspected he had renal infection but the previous urine test showed no pus. To reassure the patient, the doc fulfilled his wish and performed another urine test on the spot. The result, again showed no infection. The possible explanation would be the medicine was working and it may not be necessary a bad news to see blood in the urine during treatment. As the medicine dissolved the stone and allowed it to travel down the ureter, the stone might scratch upon the wall and cause bleeding. But if the symptoms persist, an ultrasound will be recommended.
Today when there's no patient, i read a medical journal and came across an article entitled "Less sleep, early death". "If you sleep less than 6 hours/night and have disturbed sleep pattern, you stand a 48% chance of developing or dying from heart dissease and 15% greater chance of developing or dying from stroke." -Professor Francesco Cappuccio, University of Warwick Medical School.
There's one lady came with complaint of fainting spells. Her BP ok, heart sounds ok. But she was diabetic, old and complained of having a weak beating heart and a stiff neck. Doc prescribed her some medicine and asked for follow-up 2 days later to check ECG and blood glucose level. When she was about to walk out of the room, she nearly fainted again o.O Luckily her daughter was aside to hold her.
One old man in his 60s came with chest pain which he claimed exacerbated especially after meal. He had high BP. Two things came into my mind: either Gastric ulcer or Myocardial Ischemia. X-ray was normal. ECG shows small changes which was not significant enough to pick up anything. This was a high risk case and he was referred to a specialist or hospital to rule out heart disease, which can be life-threatening and rampant in this age and sex group.
There's one boy, around age of 10, came with high fever with no other symptoms. He was crying in fear for injection. No choice, a blood test has to be done and it could only be done by a needle reaching your blood. His mother caught him from running away and I had to assist in grabbing his arms too lol. Doc said if this first poke fail the boy would have to bear a second poke. LOL. the mum covered his eyes and that calmed him down. A lot. It was a good strategy haha!
There's one pregnant woman, who happened to be the doc's niece, came for antenatal screen as she complained of whitish discharge through her vagina. From the ultrasound i can clearly see the baby kicking in the womb. So cute. From head to bottom the baby was 5.2 cm, which was estimated to be 12 weeks and 3 days old. Pregnant women of less than 3 months of gestation are better left untreated if the disease is not a threat to the mother's and baby's health. As the first 3 months of gestation the baby is very prone to teratogenic effect of medicine. And we have to avoid that undesirable repercussion. A topical cream will be good to treat the infection in this case but not through oral medication which has systemic effects. Folic acid and progesterone pill were prescribed to stabilise pregnancy and to prevent still birth.
There were 2 couples came with fever and low platelet count. The husband had rashes over his thighs. Suspected to have dengue but all we have to do is keep monitoring the platelet count everyday and if it falls lower than 100, they would have to be hospitalised.
The nurses are very friendly and willing to teach. Two of them are diploma holder in nursing. One called "Owl" taught me how to dress wound, take an x-ray and do an ECG today :D She aspired to be a doc but her dream never came true due to lack of one A. She's only 20. Younger than me and already working. Nursing is after all a noble job. All nurses have my utmost respect.
