The break is coming to an end

I have been enjoying my holidays for 2 months without realizing how time flies.

My classmates came to Kuching for 5 days and Diana and I actually hosted them by bringing them around the town. Basically, it was a "Foodthalon". Last night's dinner was the most memorable one as we took a sampan across the river to eat ayam penyet (Originally, we wanted to eat ayam pansuh but when we reached there, they told us that we were supposed to book in advance) at My Village in Kampung Boyan. The place was very traditional with very nice atmosphere if you exclude the wild cats, slow service and free music from the mosque. After dinner, we went to Open Air Market to have supper.



Other than being hosts, Diana and I went followed the doctors for ward rounds this week in SIMC. We managed to pick up different types of heart murmurs. =) During our first ward round, the matron scolded us for washing hands together in one sink. She said that was the first time she saw people washing hands that way. Then, during our second ward round (this morning), the matron scolded us again for not wearing our name tags. She actually warned us not to come back unless we have our name tags so I guess this morning was our last ward round as both of us seriously do not have name tags with us.

Homework 4: Indications for temporary pacemaker and permanent pacemaker

Temporary pacemaker
Class I
1. Asystole.
2. Symptomatic bradycardia (includes sinus bradycardia with hypotension and type I second-degree AV block with hypotension not responsive to atropine).
3. Bilateral BBB (alternating BBB, or RBBB with alternating LAFB/LPFB) (any age).
4. New or indeterminate age bifascicular block (RBBB with LAFB or LPFB, or LBBB).
5. Mobitz type II second-degree AV block.
Class IIa
1. RBBB and LAFB or LPFB (new or indeterminate).
2. RBBB with first-degree AV block.
3. LBBB, new or indeterminate.
4. Incessant VT, for atrial or ventricular overdrive pacing.
5. Recurrent sinus pauses (greater than 3 seconds) not responsive to atropine.
Class IIb
1. Bifascicular block of indeterminate age.
2. New or age-indeterminate isolated RBBB.
Class III
1. First-degree heart block.
2. Type I second-degree AV block with normal hemodynamics
3. Accelerated idioventricular rhythm.
4. Bundle branch block known to exist before acute MI.

Permanent pacemaker
1. Sinus node dysfunction - Class I, Class II, Drug-induced sinus node dysfunction
2. Acquired AV block - Class I, Class II, Drug-induced AV block
3. Post myocardial infarction - Class I, Class II
4. Neurocardiogenic syncope - Class I, Class II
5. Congenital complete heart block
6. Neuromuscular diseases
7. Special circumstances - Long QT syndrome, Hypertrophic cardiomyopathy, Heart failure, Cardiac transplantation, Bradycardia-induced ventricular arrhythmias

Homework 3: Metabolic equivalents (METs)

METs measures an average person's metabolic rate (metabolic rate at rest: metabolic rate while performing a task). A mask is worn to measure oxygen consumption and carbon dioxide exhaled.

Homework 2: Causes and treatments of supraventricular tachycardia

Supraventricular tachycardia is a rapid heartbeat originating from the atria.

Causes:
atherosclerosis
thyroid disease
chronic lung disease
blood clots
pericarditis
cocaine abuse
alcohol abuse
smoking
stress

Treatments:
The objective of treatment focuses on decreasing the heart rate and breaking up the electrical circuits made by the abnormal conducting pathways. Treatment can be divided into 2 broad categories: halting the acute episode and preventing any new ones.

Homework 1: How to investigate coronary ischaemia?

Coronary ischaemia is the most common manifestation of coronary heart disease (CHD).

There are a few investigations which are most available and frequently used tests to identify coronary ischemia in clinical practice.

Exercise testing — Exercise testing appears to be the most suitable laboratory diagnostic test to document coronary ischemia in asymptomatic individuals (eg, patients with no history of CHD) and in those with a history of CHD or exertional angina. Exercise testing is frequently used to screen high risk, asymptomatic persons to identify those with asymptomatic CHD. Conventional ST segment analysis during ETT is moderately sensitive in detecting CHD. As a result, the diagnosis of myocardial ischemia by ETT in asymptomatic individuals must be confirmed by radionuclide imaging techniques (eg, thallium perfusion scintigraphy or exercise ventriculography) before the subject is labeled as having coronary ischemia.

Holter monitoring — Holter monitoring is the second most frequently used diagnostic test for coronary ischemia. It has the advantage of providing long-term ECG recording of ischemic and arrhythmic events while patients are engaged in routine daily activities out of the hospital. Episodes of transient ischemia during Holter monitoring are diagnosed by a sequence of ECG changes that include a flat or downsloping ST depression of at least 1 mm, with a gradual onset and offset that lasts for at least one minute.

Nuclear and echocardiographic imaging studies — Tests other than routine ETT and ambulatory monitoring may be necessary in certain circumstances. As an example, nuclear imaging tests such as stress thallium scintigraphy or exercise radionuclide ventriculography are recommended for the evaluation of coronary ischemia in patients who have an abnormal baseline ECG (eg, left ventricular hypertrophy or strain, bundle branch block, preexcitation syndrome), and those receiving digitalis, phenothiazines, or other drugs that produce repolarization changes. Pharmacologic stress tests with dipyridamole or adenosine plus thallium scintigraphy, or dobutamine stress echocardiography, can be utilized in those patients who are unable to ambulate or exercise (eg, due to advanced peripheral vascular disease)

Electron beam computed tomography — The severity of coronary artery calcification (CAC) on electron beam computed tomography (EBCT), as determined by a calcium score, can identify asymptomatic patients at high risk for coronary heart disease. However, it is not certain if this translates into identification of asymptomatic patients who have coronary ischemia.

In summary, these are the tests one can do to investigate coronary ischaemia:
Exercise treadmill test
Continuous ECG (Holter) monitoring
Exercise myocardial perfusion scintigraphy
Radionuclide angiocardiography
Pharmacologic stress scintigraphy
Hemodynamic monitoring

My 3 months holidays

On the 2nd of December, I finished my EOS 5. My shoulders suddenly felt very light. The first week after my EOS 5, I was busy finding a house to stay in Seremban. I finally found one in Seremban 3 and I will be staying with my other 3 friends. The house is rm800 per month but it is unfurnished. Anyway, after settling the accomodation, I was busy packing and moving all my things to the new house. Man, moving house is definitely very tiring.

I took a short break with my family and relatives after that. It was a great reunion indeed. =)

After the short break, I have been slacking around in Kuching till today. Haha Well, at least I go for hospital attachment at SIMC and I get to learn new things every morning. I can say that is the most beneficial thing I have done so far during my holidays. In the afternoon, I will be baking cookies and cakes with my cousin and his wife while being a babysitter as well. Haha

I watched movies in the cinema very frequent till there is no more movie for me to watch right now and I have to wait for new movies to be out.

Anyway, that is just a bit of update since I have not blogged for a long time. =)

Short case: Heart murmurs

Throughout my attachment in SIMC, I have learned how to present a short case on heart murmurs. When patient comes to you, first, identify the age. If patient is old, it is more likely to be aortic stenosis. If patient is young, it can be mitral regurgitation, aortic regurgitation, mitral stenosis or congenital defects such as ventricular septal defect, atrial septal defect and patent ductus arteriosus. Second, check for clubbing and scars. If none is present, congenital defects are unlikely to occur. Next, palpate or auscultate for the apex beat. If it is displaced, it is either mitral regurgitation or aortic regurgitation and hence, mitral stenosis can be ruled out. Now, one is left with either mitral regurgitation or aortic regurgitation. Auscultate the back for murmur. If a systolic murmur is heard from the back, it is mitral regurgitation since that is the only murmur which can be heard from the back.