Day 8

THE GRAND ROUND

I never knew what a grand round was until today. It's basically like a session where all physicians are present and they discuss about a medical case. And today, they discussed about this condition called Dermatomyositis. It is a disease that involves the skin and muscles of the body.

Patient was 21 years old when she was diagnosed with hypertension and was given beta-blocker to bring down her hypertension. After 5 years she stopped the drug as she felt well. However, she started the feel lethargic and rashes started to appear on her skin. She couldn't do simple exercises and had to quit her job. She was then referred to this hospital from Sibu and initially they thought that she was having heart failure. So when they sent her to Sarawak International Medical Centre, she was diagnosed with no cardiac events! However, her CPK enzyme was high (CPK enzymes are released from muscles so it is not specific to the heart). So then she was sent to SGH for rheumatology unit and they started to identify signs and symptoms that she presented. One of the most prominent one was Gottron's papules. There is also proximal muscle weakness. And so the story went on and she was diagnosed with dermatomyositis. She was then screened for any malignancy. Apparently, in a few studies, it was indicated that there is a higher chance of patient who has dematomyositis to have nasopharyngeal carcinoma. And, an important point to note, dermatomyositis is closely related to malignancy.

Gottron's papules- macular

A differential diagnosis for dermatomyositis is polymyositis. However, the differences between this two diseases are:

1. Dermatomyositis is caused by antigen-antibody complex that accumulates at the tissues that causes the manifestations of the disease.

Polymyositis is a delayed hypersensitivity reaction.

2. Dermatomyositis is a strong malignant condition.

Polymyositis has a low connection with malignancy.

Remember that when doing a confirmative diagnostic test, muscle biopsy should always be taken from the most normal muscle not those which has atrophied AND muscle biopsy should NOT be done after electromyography(EMG) as during EMG, the muscles are excited and is traumatic to the muscle which gives an inaccurate test result.

This is an autoimmune disease and is common in women. So, to know more about the disease, one should read up on it. This post is just a personal note and reference so do not fully rely on what is written here.

Motivational quote

"When you have a bad day because you’re tired, stressed, overworked, and underappreciated, never forget that things are much worse for the person on the cold end of stethoscope. Your day may be lousy, but you don’t have pancreatic cancer." - member of BMJ's editorial board

Day 7

OH MY GOSH! Being at home is SO BORING. I can't wait for 2pm to come so I can go to the hospital, at least learn something. I hope 2 hours in the paed's cardiac clinic will be fruitful today. Boredom is hard to bear. I should have brought a book back from KL to read... >.<

Day 6

Coronary artery bypass graft (CABG) - Open heart surgery baby! :D

I was lucky to be able to enter the OT to see an open heart surgery for CABG.

This patient had Percutaneous Coronary Intervention (stenting) done before but then it's not working anymore and that artery that received PCI had narrowed down. So the surgeons have to replace the narrowed artery and create a collateral branch for it for collateral perfusion.

Patient came in at 8am and got prep for surgery.

First, neck line was set up. They had trouble setting it on the left side so they changed it to the right. While at it, the surgeon marked the surface marking for harvesting the great saphenous vein at the right inner thigh.

Second, urinary catherization.

Third, skin preparation. Basically, sterilization. I guess it's to avoid any pathogens to enter the body through the incisions they were gonna make later.

And of coz, syringes with medications, surgery equipments which I couldn't name and monitoring equipments to monitor the patient's time to time status.

At last, they started the surgery at 9.40am.

There were 4 surgeons doing the surgery. 2 harvesting the great saphenous vein, 1 (main surgeon) harvesting the internal mammary artery and 2 (main surgeon and another surgeon) doing the CABG.

The main surgeon made an incision on the midline of the chest- sternotomy. This will then expose the sternum. The surgeon then used an equipment which worked like a saw to cut open the sternum into half to reach the thoracic cavity. The saw the left lung from the place where i was seeing.

Great saphenous vein harvesting:

The surgeons made 2 separate incisions on the right inner thigh. One is above the knee, and the other one is about 3 fingers above the first incision. When they incised the thigh and initially exposed the great saphenous vein, it was a bit BLUISH! :D and then it turned slightly red. The great saphenous vein is quite big. It's like a white colour wire when they took it out. Diameter is around 3mm? The length they harvested is about 10cm i think. I am not very sure. They ligated the smaller veins that previously drained into it and removed it from the inner thigh.

Internal mammary artery harvesting:

MAN! This is so cool! This is like the happiest day of my life. WHY? I got to see the heart and lungs IN SITU! with the sternum cut open to expose them.The chest was opened up using a retractor. The was chest wide open and u can actually see all the layers. and there, when the surgeon was harvesting the left internal mammary vein, the innermost layer of the chest just above the lungs. I COULD SEE THE LEFT LUNG EXPAND. It's such a historical moment-for me. I could clearly see that the left lung has 2 lobes. However, I didn't get to see the lingula. URGH!

After the harvesting, the surgeons who were responsible for taking out the great saphenous vein put the vein in the kidney dish and sew up the incisions. While the main surgeon and another surgeon worked their way through the pericardium to reach the heart.

They opened the pericardial sac and push it aside, exposing the right atrium (I could see the right auricle too), the right ventricle, the aorta and the pulmonary artery. :D The heart is enveloped by a layer of thick fat tissue. The surgeons then lifted the heart and also started the bypass grafting. Amazing! The surgeon used this super fine thread to stitch the super fine vein when the end of it was a little bit torn. SALUTE! They have this special glasses so I guess that helped them to magnify the fine broken part of the vein when they were stitching. After that the remaining main process was to anastomose the internal mammary artery and the great saphenous vein on the surface of the heart.

At the end of the procedure, which was almost 4 hours in the OT, CABG was finally done and the surgeon used this thick sternal wire to stitch the sternum back together and close the incision.

Open heart surgery is always an impressive surgery to me.

What I learnt:

1. In the OT, never turn ur back against the sterile equipment.

2. Stand one foot away from the sterile equipment.

3. The low temperature, around 16 degree celcius is compulsory to reduce the risk of infectious pathogens being active and infect the opened chest.

4. CABG- they use great saphenous vein and internal mammary artery.

[cont. II] Day 5

CVS history taking report

Personal details

Chief complaint

History of presenting illness

Background /Past medical history/ Surgical history

Drug history: ALLERGIES, medications

Social history

Clinical examination

BP, HR

Systemic review (compulsory)

CVS, RS, GIT, CNS

Examination for the fingers: the splinter hemorrhages can be accentuated by shining a torch on the finger examined.

Auscultation:

1. Basic auscultaion: Mitral , Tricuspid, Aortic and Pulmonary

2. Accentuation of murmurs: Ask patient to breath IN to check for RIGHT side murmur and breath OUT for LEFT side murmur.

3. Ask patient to lean forward for aortic regurgitation murmur and lean to the left side for mitral stenosis murmur.

* cardiac risk factors are to be included in PMH:

- modifiable: dyslipidemia, diabetes mellitus, smoking, alcohol

- non-modifiable: 1st degree relative who have a history of heart disease