Dear Diary - Chapter 1

It was weeks ago since my last update. But here I am resuming blogging as a rookie blogger.

Date : 25th June 2008 (Wednesday)

Weather : Sunny, Gloomy, Drizzle


My first day of serious practical training ever in Russia. I was ordered to go to the 5th hospital for the first rotation of the practical training, Internal Medicine.


The alarm rang but my bed didn't let me go. But I was having a weird dream that I thought is weird but I couldn't remember it. Anyways, Raja called and asked me about this practical stuff and asked me what time I'll go.


"Ello, Kok King, ko ari ni pergi buat practical ke?"
Hello Kok King, are you going for practicals today?


"Ya"
Yes

"Pukul sembilan kan? U pukul berapa nak pergi?"
At 9 o'clock right? What time are you going?


"Pukul sembilan kut, I masih tido"
Maybe at 9 o'clock, I'm still sleeping.


"Oh ye keh....hahaha ok la baibai"
Oh really....hahaha ok byebye


So after struggling with King of Slumberland, I decided to get my sorry ass up and get ready for practicals.


Took a bus and reached there. Surprisingly I couldn't see any students. So I went into the doctor's room and asked. I saw the examiner who examined me for my practicals skills during the exam, the name is Natalya Gennadevna. I asked her "Am I supposed to have practicals here?" She answered "Yes" I asked "Who is Nadezhda Evgenevna?" She pointed to me. Then she asked Nadezhda Evgenevna if she could supervise me. "Он хорошо перкутирует!" Nadezhda Evgenevna agreed.


The reason why she wanted to supervise me was during the exam of practical skills, she asked me to show her Kurlov's measurement of Liver Span. So I showed her how and she liked the way of my percussion, saying that it's loud and clear. She told me to answer about the patient's diagnosis and treatment to her but I did not finish my report. Therefore she told me to go to her, she said "Come to me when u're ready, I'll remember you" And when Maria Lvovna(another examiner) came, she told her that I'd answer everything with her. Thinking that I do very slow, she came and asked me if I've finished but I repeated the same answer. Then I asked her if i could answer directly orally without writing in the report. She said okay, but what the hell, she sat down and started to ask me all the stuff. Being nervous and worried, I stuttered answering. But she was kind enough to lead me to make more diagnosis of one patient with Rheumatism + cardiovascular disease.


Blah blah blah.....I'm not gonna go into the details. But the bottomline is I think she likes me. HAHA. I do not wish to hear any feedbacks from anybody regarding this matter. But I heard from my senior that she told them "it's normal for girl to like boys, so I could remember boys' names better"


Anyways back to the practicals, first she showed me some ECG recordings and asked me to diagnose the pathologies. Kinda hard but still managed to get by. Then she brought me to see her patients.


The first patient was a patient with Stable Angina(acute chest pain). Blood pressure and heart sounds were good. Pitting edema was absent. His general condition was satisfactory.


The second patient was a rather younger one, at his 40s. Diagnosis was Unstable Angina(in this case, first time acute chest pain). Heart sounds were good, blood pressure was normal and general condition was satisfactory.


The third patient had lots of cardiovascular diseases. He 4 previous episodes of myocardial infarction (heart attack), 2 previous episodes of strokes. Now he has signs of atrial fibrillation, right bundle branch block, transmural Q myocardial infarction and ventricular extrasystole showed on ECG. But the supervisor told me that the diagnosis is not sure coz she wasn't sure that if it's an aneurysm or a transmural Q MI. Anyhoo, the patient was normal and cyanosed (blue) when we went to see him. When the doctor asked him if he felt any better, he answered yes. But just when we were examining the 2 other patients, he suddenly developed breathlessness and orthopnea(breahtlessness in lying position). So another complication was pulmonary edema(water in lungs).


Enough about the 3rd one. Here comes the 4th patient.


Male, 70-80-ish years old in moderate general condition. He was responding but we couldn' understand what he was trying to say. He has dry skin on the legs with no pitting edema but ascites with caput medusae was observed. Diagnosis - chronic heart failure. She didn't show me the ECG but told me about the diagnosis. She also said that there's no treatment for this patient since he's old and his condition didn't respond to the treatment, the only treatment he needed was family support and wait for his time to come.


After this rounding, we went back to the doctor's room and she started to ask me to interpret the 3rd patient's ECG (I didn't know about the diagnosis before). Hell of a difficult task to interpret the ECG, as I wasn't as brilliant as some other students, but still carry on.


Slowly observing the rhythm, the axis, the heart rate, the waves.... and I slowly told her about the diagnosis I could make. I said QS complex - transmural Q MI, she asked "What else?" To be honest, I've never more than 2 diagnoses in one ECG recording. But I tried to find another pathology. I looked through all leads again. Tried to shoot another one. I answered atrial fibrillation. She asked again "What else?" I started to scratch my head, took deep breaths and kept searching for another pathology. I saw some abnormal waves in V2 but wasn't sure of that, but when I looked through chest leads V4, V5, I saw some "W" waves. Pretty sure that it's a bundle branch block. Then I looked back to the irregular waves and saw many multiple "M"s....So I decided to shoot again - Right bundle branch block. She asked me why and how did I diagnose this. I wasn't really know how to answer but what to do, just use my own words "Coz I saw W in V4,V5 and some funny Ms in V2" She kinda agreed but I think the definition is a bit low class. HAHAHA. Who cares.


Then she shot again "What else". I was like what the fuck!! Then looked through all the leads again and saw some bizarre QRS complaxes without complete compensatory pause. To my shallowness, QRS with complete compensatory pause is definitely a Ventricular Extrasystole. So I sucked it up and answered "VENTRICULAR EXTRASYSTOLE". She was kinda impressed. But after that I asked her why was there no complete compensatory pause in ventricular extrasystole. She told me that sometimes it happens when ventricular extrasystole is not accompanied by a complete compensatory pause due to tachyarrhythmias.


So diagnoses that I learnt to make today in one ECG was :


Nonrhythmic tachyarrhythmia with left axis deviation. Heart rate 142 beats per minute. Transmural Q myocardial infarction. Atrial fibrillation. Right bundle branch block. Ventricular extrasystole.


Blah......the ECG was killing my eyes.


Then after she asked me about the treatment of progressive angina. She took the Russian drug information book - Vidal to me and asked me to find all drugs and their trademarks and dosage.


*Angina - sudden acute chest pain with radiation of pain to the left shoulder, left neck, left arm, less commonly left jaw*


So here are they.....(luckily I brought my personal drug notebook)

1. Antiaggregant - Thrombo Ass (ASA) [she said aspirin low effect, not good ler]
100mg, 1 tab once daily in the evening.

*Clopidogrel too but she said in their hospital they use Thrombo ASS*
really queer name


2. ACE inhibitor - Prestarium (Perindopril) [she said modern long acting, good drug]
8mg, 1 tab once daily in the morning.


3. B-blocker - Concor (Bisoprolol) [I think she didn't like the name of Bisogamma]
5mg, 1 tab once daily in the morning.


4. Short acting Nitroglycerine 0.3 - 0.4 mg SL
Long acting Kardiket (Isosorbide dinitrate) 20mg, 1 tab thrice a day.


5. Statin - Zocor forte (Simvastatin) [Max dosage : 80mg.day]
40mg, 1 tab once daily if patient has IHD + hyperlipidemia.
20mg, 1 tab once daily if patient has only hyperlipidemia.


6. Anticoagulant - Hepasol-Neo (Heparin)
1.0 - 1.25 ml/kg/hour [Max : 18.75ml.kg]


7. Fibrates (Gemfibrozil, Bezafibrozil, Ciprofibrozil) can be given when there is uncontrollable hyperlipidemia and to treat hyperlipidemia if there's more high molecular weight lipids. In this case, it's not used.


I asked her one, I think, stupid question.

"Can we prescribe 2 preparations of one drug group to a patient?"

*Guess her answer*








"What for, one is already enough for the effect"


So pwned!!!


After that there was a presentation about new company manufacturing Warfarin. Don't know the name of the company. So we watched and trust me it was boring. I felt so sleepy watching it. And I bet the other doctors who were watching didn't feel any much different like I did.


Lesson learned 1 : if you are prescribing warfarin, check International Normalized Ratio(INR) of patient's blood before administering. Normal INR value is 2-3. If less, warfarin's dosage should be elevated. If more, there's risk of hemorrhage.


Lesson learned 2 : if you are prescribing heparin, check partial activated thromplastin time of patient's blood.


Every learning session will have homework. So my homework was an information about Warfarin, its mechanism of action, its effects, its indication, its side effects.

Before going back home, I asked her if she's a teacher, she said she teaches the 5th year. So I told her which group is she gonna take for the next year. She said, she didn't hope to get group B. I asked why. She said "I knew them and I talked to their teacher, they have poor knowledge". I told her we all have poor knowledge. But she said they don't even know the simplest basics, also they have attitude problems.

She also praised my teacher, Natalya Viktorovna to be a very good and experienced doctor and teacher. She said usually her students would not have problems in the 5th year. I really felt so proud for being her student. But that doesn't mean that other students are bad. Her students just turned from stupid to more enlightened. HAHA. Maria Lvovna's a great teacher too coz she induced her students to think about clinical features via pathogenesis of the diseases. That's what I heard from her students. All Internal Medicine teachers are great all in all.

I think that's all about now. I bet some readers would not able to understand. But if you have any queries, feel free to IM me or drop me a mail at kochi.kochi@gmail.com . I will try my best to explain to you. It's important to know somehow coz we or our VIP might have such attack like angina. So feel free to drop a message to ask or just to say hello. HAHA.

More information about ECG, please click here.

-End Diary-