Nota Perubatan

Author: notaperubatan

  • Let’s be Kind

    Sometimes actions speak louder than words and cause less harm to others.

    • “Which university did you graduate from?” (asking while the colleague doesn’t know something that is common / doing something wrong) ❌
    • Avoid asking this question ✅

    • “You are very slow, need to catch up faster” ❌
    • “How may I help you?” (while finding out what the colleague is struggling at) ✅

    • “You are at which posting? Still don’t know this?” ❌
    • Just show / teach him or her the correct way to do certain things ✅

  • Manual VS Fully Computerised Hospitals

    There are many pros & cons between manual and computerized systems in the hospitals. Some people prefer manual system while others prefer fully computerised systems. Well, we have no choice on exactly what system to be used in our workplace, so we have to adapt fast to both systems.

    Manual System

    • Case note is handwritten: all reviews (AM, PM, Round seen by specialist or MO)
    • Lab request form, dietitial referral, imaging request form, etc., all are handwritten
    • Tracing lab result: some hosp has lab results available online; others have to get the printed results from lab
    • Need to prepare a lot of BLACK ballpoint pens. Not because of writing too much, but because of higher tendency to lose pens 😂
    • There might be difficulty to recognize certain words due to illegible handwriting
    • Nurse and doctors are using the same BHT. Sometimes, we have to take turn writing in the BHT
    • Tracing old notes take time, as we can get the old notes within seconds like the electronic medical records
    • Easier to remember the cases because you write it by yourself
    • Easier to flip through the case notes
    • No need to compete computers with colleagues or nurses, especially in certain computerized hospitals that have not enough computers

    Fully Computerised System

    • It can be challenging initially to learn how to order medication, investigation, imaging, trace blood result. If you are slow/ not good in typing, this could be another challenge for you. Your superiors might not have enough time to wait for your typing 😂
    • Good, in terms of ability to copy & paste. Very easy and fast, and your reviews can be done faster. Please use this function wisely. Be careful when copying the info — Monday was 38 weeks 3 days POA, Friday was still 38 weeks 3 days POA, due to copy & paste 😂
    • Tracing old notes within seconds. Easier for doctors working in ED, as we can know patient’s underlying comorbidity more accurately if he / she has visited the same hospital before this.
    • There are periods where the hospital system is down, i.e. everyone can’t assess the Hospital Information System (HIS)

  • Maternal Tachycardia

    Causes

    🔹Cardiac arrhythmias

    🔹Infection (e.g. UTI, chorioamnionitis, pneumonia)

    • Fever, leaking liquor, abdominal pain, dysuria, urinary frequency
    • Cough
    • UFEME (leukocyte, nitrite), Urine C&S, HVS C&S

    🔹Dehydration / Electrolyte imbalance (e.g. caused by excessive vomiting)

    • UFEME (urine ketone), RP, Ca, Mg, PO4, albumin
      (abnornal/normal calcium level is MEANINGLESS without being corrected according to albumin level)

    🔹Hyperthyroidism

    • Signs & symptoms of hyperthyroidism e.g. heat intolerance, increased appetite, palmar erythema, anterior neck swelling, palpitation
    • TFT

    🔹Anaemia in pregnancy

    • Palpitation, reduced effort tolerance / fatigue, clinical pallor, vegetarian/ malnutrition, or parasitic infection
    • FBC

    🔹Pulmonary embolism

    • SOB, SpO2 drops, not uncommon in clinical setting, but it depends on risk factors & clinical situation of the patient (e.g. persistent tachycardia + low grade fever), high VTE scoring
    • ECG: S1Q3T3
    • Might need to send ABG if indicated
    • If indicated, specialist will also order for CTPA to diagnose pulmonary embolism

    Management

    Whatever causes of maternal tachycardia, ECG is a must.

    • Refer Medical for Holter / Echo if indicated (for suspected cardiac problem)

  • Analgesia in Pregnancy

    Intrapartum Analgesia

    IM Pethidine
    • Dose: 1 mg/kg (usual dose: 50 mg, or 75 mg if weight >90 kg)
    •Prior to giving IM pethidine, latest CTG taken 1/2 – 1 hour ago must be normal. Pethidine is an opioid, can cause fetal respiratory distress.
    • Give together with IM Phenergen® (Promethazine) 25 mg

  • Maternal Thrombocytopenia For Investigation

    Miscellaneous

  • Hypertensive Disorders in Pregnancy

    Anti-Hypertensive in Pregnancy

    STOP methyldopa post delivery in patients with PIH on T. Methyldopa because it is associated with postpartum depression

    AVOID Nifedipine if uncontrolled HTN with tachycardia, as nifedipine is also associated with reflex tachycardia

    DO NOT GIVE Labetalol in patients with history of asthma / underlying asthma as it can trigger bronchoconstriction

  • Shoulder Dystocia

    HELPERR

    H – Call for Help
    E – Evaluate for Episiotomy
    L – Legs: McRoberts manoeuvre
    P – Pressure at suprapubic area
    E – Enter: Rotational mamoeuvre
    R – Remove posterior arm
    R – Roll the patient to her hands and knees

  • Caesarean Section

    Post LSCS Plan

    Here is a general plan for post Caesarean section. Different centers would have slightly different details of management plan.

    • Allow transfer out to ward once stable
    • Monitor vital sign 1/4 hourly for 1H, 1/2 hourly for 1H, hourly for 4H, then 4 hourly
    • Keep rest in bed for 6 hours
    • Keep CBD 12H post op
    • IVD Pitocin 40 units in 1 pint NS over 6 hours
    • IVD 5 pints (3 pints NS and 2 pints D5) over 24 hours until tolerating orally well
    • Strict I/O charting
    • Strict pad charting, inform if increase in PV bleeding
    • SC Clexane 40mg OD for 10 days (booking weight _ kg), to commence 6 hours post op, if no contraindication (counsel patient in ward)
    • Analgesia as per anaesth plan
    • Wound inspection Day 2, no need STO
    • Encourage orally, breastfeeding and ambulation
    • Allow trial of scar in next pregnancy if no contraindication
    • Advise on long-acting reversible contraceptives

    Miscellaneous

    Neuraxial opioid-induced pruritus — Patient post LSCS under spinal anaesthesia complains of pruritus

  • Hypertension

    Q&A

  • Cardiotocography (CTG)

    CTG Description for Newbie

    Features (baseline fetal heart rate, acceleration, deceleration, beat-to-beat variability). For each feature, use the description below:

    • Reassuring
    • Non-reassuring
    • Abnormal

    Then, Categorization / Overall assessment based on the features above:

    • Normal
    • Suspicious (one non-reassuring feature)
    • Pathological (two suspicious features // one abnormal feature)

    AVOID USING THESE INAPPROPRIATE TERMS (especially when referring cases): CTG tak cantik, CTG reactive / not reactive, longkang besar etc.

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