Incision and Drainage

>> Friday, October 31, 2008

The other day at the out patient department, there was a 10 month old baby suffering from an abscess on his right lower buttocks. After carefully examining the patient, we talked to the mother about the plan for the baby and the mother gave us a go signal to do an incision and drainage. Although at that moment the baby was giggling and was smiling, I was thinking what would he look like after doing the incision and drainage.

After preparing the needed materials for the procedure, I was assigned to hold the baby on his trunk while his mom held him at the head. My resident positioned himself with a scalpel and did a 2 cm incision on the abscess and the cute baby started crying and shouting (poor baby). The mother tried to pacify him but to no avail, after doing the incision, we press on the affected part to let the pus ooze out. After each press, the poor baby cried louder and louder. Finally, the abscess size shrunk and it was over for the poor little boy, antibiotics were prescribed and daily wound care was advsied. Hopefully I could see that baby again next week if he follows up. Just a quick reminder to keep your anal area clean to prevent any abscesses from forming. Pleasant Day.

The picture was somewhat the same with the above patient but the position was a little bit lower.


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5 cm Lacerated Wound

>> Tuesday, October 28, 2008

During my tour of duty yesterday at the ER, I chance upon a 55 year old male who suffered a lacerated wound around 5 cms in length above his left eyebrow. He was allegedly drunk and he decided to urinate on a concrete wall then after he suddenly fell to the ground hitting his head, left side causing the said laceration.

So materials were prepared for suturing. I gave it 5 stitches to closed the gaping wound. Anti tetanus were also administered owing to the dirty wound that the patient had. I then advised the patient to follow up at our OPD for removal of his sutures. After the patient, no patients under surgery showed up until morning. I grab myself a good sleep devoid of calls. Pleasant Day

The picture above shows an example of wound suturing


TB of the Bone

>> Sunday, October 26, 2008

The other day, we had a patient, a 23 year old female who was scheduled for ankle debridement the next day. She was diagnosed with TB of the bone 3 months ago and is now up for her 2nd ankle debridement.

3 months ago, she came from Macau, she probably had a soft tissue infection which was taken for granted. When she came back from the Philippines, she was already limping and her left ankle was somewhat inflammed. She sought consult with an orthopedic surgeon and was diagnosed to have Osteomyelits (bacterial infection of the bone) and was given antibiotics. After a few days, her condition didn't improve and was advise for debridement of her left ankle. During the operation, pus was noted from her ankle and this was sent for culture and in turn out to be positive for acid fast bacili which is diagnostic for tuberculosis. After that, she was started on anti tuberculosis medications and yesterday she had her 2nd ankle debridement.

The bone is one of the extrapulmonary sites wherein Tuberculosis can set in, it is usually uncommon compared to pulmonary tuberculosis but it is more harder to treat and usually takes longer and is more expensive. As far as I can remember TB of the bone usually take around 10 to 12 months of medications compared to only 6 to 8 months of treatment when dealing with pulmonary tuberculosis. So, if you have any skin infection don't take it for granted but consult a doctor. Pleasant Day

The above picture shows Mycobacterium Tuberculosis which is the causative agent of tuberculosis.


Pupu Irrigation

>> Thursday, October 23, 2008

This afternoon I was again assign at the out patient department of surgery. Seen a couple of patients, gave advises and then I was down to the last one. The last patient was a 62 year old female who came for follow up at the OPD. She underwent hemorrhoidectomy 2 weeks ago and came to OPD complaining of no bowel movement since 6 days ago.

So after getting the history of his complaint, may resident examined her and advise to insert two Bisacodyl (Dulcolax) suppository per rectum. Then we waited for her patiently hoping that she will defaecate. An hour was given to her, my resident left me at the OPD and gave me instructions that if after one hour no bowel movement was seen, I need to do colonic irrigartion. So I crossed my fingers hoping that the patient would defaecate, she went to the bathrum several times but unfortunately nothing happened.

So times up, after an hour I prepared the materials needed for the colonic irrigation. I inserted a foley catheter via her rectum, and gave her a lavage hoping her feces would come out. After doing the lavage, I was hoping the smell of the feces won't stick on my shirt, lucky for me it didn't. What an experience, actually it was my first time to do a colonic irrigation, and it didn't give me a good first impression. Now, it just gives me a slight disgusting feeling when I remember the smell and the color. Pleasant Day


A Night of Vehicular Accidents

>> Wednesday, October 22, 2008

Last night I was on duty at the ER under the surgery service and the ER was full of peoople. All doctors in each department had their hands full, from the ER department, OB-GYN, Pediatrics, Medicine and who can forget Surgery. The night was filled with vehicular accidents, and they were usually hit by a motorcycle. Other patients suffered only mild concusions but I have one particular patient who came all down from the province, suffered a subarachnoid hemorrhage.

Patient came from Batangas, a southern provcine here in Luzon. According to her she was walking on the sidewalk when a speeding motorcycle hit her causing her to be thrown away and her head to hit the ground. Upon arriving, although she was oriented to the place she suffered a big hematoma on her right eye, big enough that she cant open her right eye. Aside from the bulging hematoma, she also suffered a lacerated wound on her head (left parietal area), it was oozing with blood and I had two make two stiches just to stopped the bleeding. Patient was then sent for a CT scan of the brain to see for any problems. Although the patient was conscious and coherent she was noted to have a subarachnoid hemorrhage. Patient was admitted to the ICU for close monitoring.

After that was done a couple of patients came in the early hours of the morning, still due to a vehicular accident. Eventually after that the ER crowd subsided, and I got my well deserve rest. Due to this increasing cases of vehicular accidents happening on the streets, motorists should pay attention to the road signs and should also acknowledge pedestrians and pedestrians should also take safety precautions for them not to end up in the hospital. Pleasant Day


Talipes Equinovarus

>> Monday, October 20, 2008

Talipes Equinovarus or more commonly known as "clubfoot" is a congenital defect wherein the affected foot is smaller than the normal size and the heel pointing downward and the fore foot turning inward.

This afternoon I met a 27 day old female infant with the said deformity. The affected foot was the left foot but the other one is normal. She was happily giggling with us but she doesn't know the she has a deformity. She was seen by my surgery resident and she was eventually referred to an orthopedic surgeon. The orthopedic surgeon made a cast with a plaster of Paris on the affected leg and advised the mother the she needs to undergo serial casting and hopefully the deformity will resolve so no surgery will be needed.

The picture above resembles the foot of the patient I ve mentioned from this afternoon, hopefully for her, the deformity will resolved with casting and hopefully no surgical intervention is needed. Pleasant Day


Surgery Day One

>> Saturday, October 18, 2008

Yesterday marked my first day in my surgery rotation and I was assigned to the OPD (out patient department) for surgical excisions that are usually scheduled every Friday. Two patients showed up for excision yesterday, one was a 29 year old female for a breast mass excision and the other was a 31 year old male for excision of a cyst on his right middle finger. First one up was the female, my surgery resident did the excision. Although the mass was quite small around 1 x 1 cm, it took him a long time, because the mass was somewhat deep, but still after around 20 minutes the mass was excised, bleeders ligated and dressing was eventually applied.

The excision of the cyst in the finger was assigned to me. It was a movable cyst, soft non tender measuring less than 2 cm by 2 cm. After the materials were prepared, I started by doing a digital block of local anesthesia (lidocaine)to numb the surgical site. The I made a linear excision exposing the cyst, after exposing it, I cut its based and it was eventually free. Sutures were applied to the 3 cm excision wound. After the excision, the patient joked with his wife regarding his finger. That summed up my first day in my surgery rotation. Hopefully more cases will come. Pleasant Day

The picture above shows close resemblance to the cyst that I excised yesterday.


End of ENT Rotation

>> Wednesday, October 15, 2008

Today marks the end of my ENT rotation. I spent 1 week in ENT and tomorrow ill begin my rotation in Surgery. For the past week I was quite sad not being able to assist in any ENT surgical procedures because none were scheduled. For today most of the cases I saw in the out patient were acute sinusitis and the common otitis media. For the past week some of the children if not all, had an impacted cerumen either in one ear or having it in both ears. Although devoid of ENT surgical cases, I still enjoyed my week in the field of Otorhinolaryngology or commonly known as ENT. Tomorrow as I enter another rotation, hopefully I ll be geared to face the new cases which I will encounter in the coming rotation. Pleasant Day.


A Case of Peritonsillar Abscess

>> Tuesday, October 14, 2008

We had a 25 year old male patient in ENT diagnose to have peritonsillar abscess. The problem started 6 days prior to admission when the patient complained of sore throat accompanied by dysphagia (difficulty in swallowing) and odynophagia (painful swallowing) and fever, patient just medicated with paracetamol. 2 days after still with the mentioned symptoms patient sought consult and was given home meds. Persistence of the said condition, patient was then referred to ENT service for further evaluation and managament. Patient was diagnosed to have peritonsillar abscess and underwent tonsillectomy.

Tonsillectomy is the surgical removal of the tonsils if it produces symptoms such as obstrucstions, infection and many more.Absolute indications for tonsillectomy include: Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications, Peritonsillar abscess that is unresponsive to medical management and drainage documented by surgeon, unless surgery is performed during acute stage, Tonsillitis resulting in febrile convulsions, Tonsils requiring biopsy to define tissue pathology. Relative indications include: Three or more tonsil infections per year despite adequate medical therapy, Persistent foul taste or breath due to chronic tonsillitis that is not responsive to medical therapy, Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-lactamase-resistant antibiotics, Unilateral tonsil hypertrophy that is presumed to be neoplastic.

For the patient, tonsillectomy was done because his abscess was unresponsive to medical management. After the surgery patient was eventually ok and was eventually discharge. Pleasant Day.

The picture above shows a sample of a peritonsillar abscess.


Post Graduate Course

>> Saturday, October 11, 2008

Yesterday I attended a Post Graduate Course at the southern part of Metro Manila, it was entitled "Approaches to Common Diseases by Today's Internist". It was sponsored by the department of Internal Medicine. It featured many lecturers which talked about common symptoms which one would usually see as an out patient. Lectures included topics about dizziness, anemia, adult vaccination, heart attack and many more. It was a great learning experience especially for me. The lecturers discussed current trends regarding the management of the above mentioned topics.

Aside from the lecture, the post graduate course also offered great food. In the morning it offered great sandwiches with pasta for the morning snacks. Roast beef w/ vegetables was served for lunch. The roast beef was great but what really caught my tongue was the dessert. It was named "Crepe Samurai w/ Vanilla Ice Cream", its a dessert which could be featured in cooking shows on tv. Congee was served for the afternoon snacks.

Aside from the things I ve mentioned above, another highlight of the course was the exhibit by the different drug companies.. They gave a lot of freebies like pens, bags, toilet paper holder, lots of brochures to promote their products. I was like carrying 4 bags on my way home.

As a whole it was good experience which I would glad to attend again. Pleasant Day


Perforated Tympanic Membrane

>> Thursday, October 9, 2008

Imagine yourself not being able to hear, its like seeing things around you moving but you not being able to understand them that's why the ears are really needed to be given good care. Today marks the first day of my ENT rotation. This morning I met a 68 year old female diagnose to have a perforated tympanic membrane. She was advised to have a CT scan to check the extend of the perforation and to know what type of operation is appropriate for the patient.

The tympanic membrane or usually known as the ear drum, this is the shiny thing when you look inside an ear. The tympanic membrane separates the outer ear from the middle ear and is the organ responsible for hearing. When sound vibrations reach the ear, the tympanic membrane sends the vibrating signals to the middle ear then in turn it goes to the inner ear which produces sound thus making us hear. Ear drum perforations usually could heal on its own but as for the patient mentioned I think the perforation is quite big which makes her deaf on her right ear.

Hopefully after being CT scanned, the extent of the damage wont be that great so she could still regain normal hearing with her right ear. The sense of hearing is important, without it life can be boring and dull, so proper care should be given to our ears. Pleasant Day.

The picture above shows a normal tympanic membrane.


End of Ophthalmology Rotation

>> Wednesday, October 8, 2008

Today marks my last day in my Ophthalmology rotation which lasted for a week, tomorrow ill be headed to the Otorhinolaryngology department or known as ENT (ear, nose, throat). Ill have to say goodbye to eye conditions and be headed to conditions affecting the other parts of the face.

To recap my day, we saw two patients in the morning basically complaining of blurring of vision. Bought of them were diagnose to have blepheritis. Blepheritis in an describes as inflammation of the eyelids. Both of them had the same diagnosis and both were given the same type of oral and topical antibiotics. After seeing both patients, I was given my post-rotational exam, it was a 30 item exam, I think I could pass that exam with flying colors. We only have 1 patient seen in the afternoon. It was a 65 year old male just on his follow up regarding the status of his cataract. Patient was eventually advised and discharge. My evening was filled with patients compared to both the morning and afternoon sessions. We had a total of 5 patients, we were to be off by around 7 in the evening but we ended the evening session at around 8:30 in the evening. Before going home, I had dinner with some of my peers at a nearby fast food store. After filling my empty stomach, I was headed home.

Tomorrow, I ll start in another department, hope to see different cases to add to my learning in my 1 week stay in ENT. Hopefully it will be a happy experience. Pleasant Day


An Article From a Filipino MD

>> Monday, October 6, 2008

In one of my readings, I came across this article made by a Filipino doctor pointing to the struggles of a doctor here in my country and I want to share it out.

A Fighting Chance
by Michael Hussin B. Muin, M.D.

The ‘Sell Out’ stigma has since died down. It is now a footnote in the obscure pages of Philippine medical history. But the exodus continues and the situation is a fierce topic in conferences. Even business schools have taken up the issue and debated on the reasons of the plight and flight of doctors and the effects on the public administration of health care. And the conclusion has taken a gentler form. No, they now agree, doctors didn’t sell out, they just gave up fighting.

And what are they fighting for? Among other things, doctors—and other health workers—fight for better pay and better working conditions. They fight for protection from bogus health companies and quacks in government. They fight for stronger organizational leadership. They fight for a better government. They fight for their patients. They fight for their families.

It is a sad fact that bank tellers and call center agents get better pay than general physicians in HMOs and residents in training. Bank tellers may get as much as P15,000 per month while GPs get P9,000-P12,000. Call center agents get as much as P21,000 per month while residents in private hospitals are lucky to get anything over P10,000. People who handle money and customer service get better wages than those who handle lives. This says much about industry standards, whatever that means.

But isn’t it true that all Filipinos are fighting for higher wages? Yes, but the fight is done in different ways and have different effects. When factory workers stop working, production goes down. When jeepney drivers wage a strike, transportation grinds to a halt. But when doctors go on strike, patients die.

I have seen doctors fight for a collective cause. They threatened work stoppage at a small private hospital unless conditions for better pay were met. They gathered just outside the emergency room and carried placards and signs. But the whispers and conversations within carried in them the futility of their efforts.

‘Tawagin mo ako pag may dumating na pasyente.’

‘Akyat muna ako at mag-a-assist ako sa OR.’

‘Sandali lang, andyan na yung follow-up ko.’

These are phrases uttered by the doctors on strike. Even the venue of the strike is crucial. They to sit it out in front of the emergency room and scramble in when an emergency case arrives. Once the patient is stabilized and brought up to the floors, they then trickle back into the strike area, anxious and ready for another case.

Doctors are not immune to the effects of graft, corruption and poverty. Some doctors are unemployed, while others take double or triple jobs. Many doctors look outside the field of clinical medicine for extra income. Some are into related fields like academics and research, while others go beyond medicine and venture into medical transcription, nursing, information technology and selling jewelry and health insurance.

Not everyone has government officials and actors for patients. In Batangas, moonlighting specialists settle for P1,000 for normal deliveries and P3,000 for caesarian sections. In the provinces, doctors are often faced with poor patients—and rather than exacting consultation fees, most instruct the patients to just buy the prescribed meds with what is left of their money.

Doctors are pinned to the wall. If they fight back, people die. But if they don’t fight back—well, they go home tired and weary. In any case, the health of Philippine society hinges on the Filipino doctors’ sense of decency—the decency to put the patient first—above anything and everything, even their own needs.

Hospitals and managed health companies exploit this sense of decency to a fault. They know doctors will not abandon patients. Yes, some paper work will be delayed if work stops, but they have administrative clerks for that. Patients will still be treated, surgeries will still be performed, follow-ups will still be done.

So, how will doctors fight back without hurting their patients? How will they go to the streets and protest unjust compensation? How will doctors fight unseen ghosts and forces that threaten to push them to acts of indecency and selfishness?

By bringing the fight closer to home. Everywhere doctors are questioning the choices that lay before them. While society continues to flourish in the notion that doctors get full satisfaction from public service, doctors struggle to face the harsh reality that life is full of shit. There are no right choices, just promises and responsibilities to keep. There are no wrong decisions, just consequences and the courage to live with them.

The fight to leave or stay—and yes, it is a fight—is not found in the loud voices on the streets and the echoing chants in demonstrations, but in the grave discussions at dinner tables and the whispered conversations when the children are asleep. Because doctors are slowly finding out that living—and leaving—for one’s family is a battle worth fighting for.

For some, it has come down to choosing between loneliness and poverty. Some choose to be lonely, while others choose to be poor. Doctors are not leaving, they are driven away. And these doctors carry their own personal battles in foreign lands, where they fight extreme depths of loneliness and immense levels of uncertainty. Those who stay fight their own battles of survival, where each day is a search for some sense of meaning in the care of other people’s lives.

In the gloom spreading all over the country, people are asking for a chance to get past poverty, a chance to make a difference, a chance to rise above the muck of helplessness. In the current state of desperation, people are looking for a fighting chance. And everybody deserves a fighting chance—even doctors.

------------ ---------

Michael Hussin B. Muin, M.D. is the Founder and Editor-in-Chief of Pinoy.MD - The Website for Filipino Doctors. He is a professor of Clinical Anatomy and Medical Informatics in Pangasinan.


First Day of OB-GYN review

>> Saturday, October 4, 2008

For the month of October, our review sessions will be handled by the OB-GYN department. Our review started around 10 in the morning. The chief resident of the department gave us the review with a quite long lecture on the physiological changes happening during pregnancy. The lecture was presented via a power point presentation with 205 slides. She discussed changes occurring in every system of the body, from the respiratory, cardiovascular, genital changes, and many more. She also gave us some tips about must knows that might appear in our coming board exam next year. The review ended near lunch time and we had lunch with my peers at a nearby pizza parlor. After then I spend some chit chat time with my peers then I was home ward bound again.

The chief resident gave quoted a quote which up to now is stuck in my head, she said "Pregnancy is the most common pathologic condition occurring in woman". Pleasant Day


First Day High in Ophthalmology

>> Thursday, October 2, 2008

After my pediatrics rotation, today is my first day in the department of ophthalmology. Ophthalmology is the branch of medicine which deals with the disease of the eye and also is the one responsible for doing eye surgeries. The last time I held an ophthalmology book was last year, so I need to do some homework before doing my history and physical examination in ophthalmology.

I was scheduled to meet 3 ophthalmologists today, one in the morning, another in the afternoon and the last is in the evening. The morning session was unremarkable, we were excused because of a lecture to be held around 10 in the morning and we were required to attend. The afternoon session was filled with two patients. One was a little girl while the other one was follow up patient after undergoing cataract extraction 2 months ago. After showing the patient to the consultant, he taught some basic but valuable must knows in the field of ophthalmology. My evening session started around 5:30 in the afternoon, there were around 5 patients. Most of the complaints by the patients were not that serious. After presenting the 5 patients, the consultant signed are attendance sheets and I was done for my first day.

I was a bit nervous today, but after undergoing those 2 ophthalmologists, I thinked I ll be ok by tomorrow. Another set of 3 ophthalmologists tomorrow, hopefully I won't loose my nerve in front of them. Pleasant Day.


Last Day Agenda

>> Wednesday, October 1, 2008

As I have mentioned in my previous post, yesterday was my last day at the NICU, and the last day of my pediatrics rotation. Before leaving a nice case presented yesterday, he was a 15 day old premature baby, previously to be healthy, with good cry and good suck. He was already weaned out of the incubator but around 2 days ago, he was returned back because his lips was starting to be cyanotic (bluish-purple discoloration). He was up for 2D echo last saturday unfortunately the pediatric cardiologist wasn't available. Yesterday the heart 2D echo proceeded, and to my surprise he was diagnosed to the transposition of the great arteries. The arteries being referred here are the aorta and the pulmonary artery.

Transposition of the great arteries is wherein the aorta and the pulmonary artery have exchange places. The pulmonary artery took the location where the aorta should be and vice versa. So instead of the aorta pumping oxygenated blood, it pumps unoxygenated, and the pulmonary artery instead of pumping unoxygenated blood it pumps oxygenated blood. This can cause cyanosis because the body lacks the oxygen requirement it needs which it gets from the blood, in our baby it presented with cyanotis lips. If left untreated it could proceed to heart failure and eventually lead to the babies demise.

The baby was then arranged to be transferred to the Philippine Heart Center for a possible heart surgery (if financially possible). I also had a talked with the mother, she was really concerned with her child's condition and was somewhat teary eyed. Hopefully the baby could get the funds for the surgery and eventually survived and eventually be a normal child.


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