Sunday, 25 December 2011

2 weeks full of challenges part 1

Over the past 2 weeks, i have been awfully tired because of chronic cases that i saw in the OPD (outpatient department). I guess these are the challenges in the OPD. We are seeing different and variety of cases and have to make up the diagnosis, in which 50% who came actually plainly wants MC and majority of them has no proper diagnosis (because patients would come with "weird", made up presenting complaints). But among all challenges, the biggest would be TIME factor as we have very little time for each consultation. This is why many patients complaint that government doctors are not thorough enough. TIME CONSTRAIN has been the issue all this while especially when it comes to chronic and complex cases.

Most of the time, cases that I saw was a mixture of simple and chronic cases. Simple cases include upper respiratory tract infections, acute gastroenteritis and fever. Chronic cases include diabetic and hypertensive patients. But over the past 2 weeks, I have been getting chronic complex cases which require lots of time to think and squeezing my brain out in a very limited time frame. At that moment, I felt my brain was boiling and almost burst. The time limitation made things difficult as i need to focus on the condition and make a proper plan for the follow up. Despite all the difficulties, I felt satisfied because i was able to learn from those interesting cases i saw. Better than seeing same 'ol cases again and again.

MONDAY 12/12/11
I was doing my lunch call this week which means i had to work during lunch time from 1-2pm and my break will be at 2-3pm. As usual, the OPD card would arrive late...most of the time, the card will be arriving at us about 1hr to 1 1/2 hour late. Today, during lunch call, they "threw" me 7 cards at about 1.40 pm. Imagine seeing 7 patients in 20 minutes, meaning each patient will only has 2.8 minutes per consultation. Out of these 7 patients, 3 were complex cases. Dont expect me to see 2.8 minutes for complex cases. Really ridiculous.

1) Nepal patient came in without a translator complaining whole body ache. Denies fever. Other history were unable to obtain. This is really common sense. If you cannot speaks Malay/ English, pls bring somebody who does. The problem with this patient is that he brought in a friend but he too cant speaks any languages except his own language. That would not make any different, isnt it? This problem does not only occur in foreigners but also occur among our Malaysian citizen. So..what is it in 1Malaysia when even our own citizen unable to converse in our national language. Bangla lagi pandai cakap Melayu.  The problem with that is patients always believe that doctors have psychic power who can read their mind. "Cik datang sbb apa ye?/ Pakcik makan ubat apa?". The answers always sounded like these "Doktor lah bagitau saya sakit apa/ Doktor lah cakap saya makan ubat apa, saya mana tahu psal ubat2 ni".....  @#4#%^47 so ignorance

2) 2nd patient was deaf/ mute. i dont blame him for the language barrier. But it's definitely taking more than 2.8 minutes to see this patient.


3) the 3rd case was Philipino, just discharge from a private hospital with the complaint of palpitations for the past 1 month.(whom i guess was just recently diagnosed with a heart condition). She had been fully investigated at the private hospital and has her TCA with the private doctor but because of financial constrain, she want to continue her care here. But the problem was, i dont know the diagnosis, she came in without any referral letter from the Private Hospital. Not that i want to shooh her back to the private, I totally understand the financial problem..but at least informed your treating doctor first and get a discharge summary of your condition before transferring your care. This is really commen sence. Again, the thought that a doctor has a psychic power in play. When asked, she dont even know what was her main medical issues/ diagnosis, which further complicated and annoyed me. All she brought in was an envelope containing blood investigations and a few ECGs. If was like playing a jigsaw puzzle,muddling and sorting out little piece of information. Again, 2.8 minutes would not be enough for that, wouldn't it???I noted some blood investigations were taken from the emergency and few were from ICU..so there's a hint...so this must be something serious if she had been admitted to ICU. Basically, i nagged and nagged her for her ignorance. So to safe time, i asked her to do one ECG and to come back and see me after my lunch break. After consulting with my FMS, I referred her to MOPD. It would be easier if the private specialist refer straight to the government specialist. One problem of getting a good referral from private practice is that some private doctors were uncooperative in writing referrals.Some patients come to us to continue their medications as they could no longer afford expensive treatment but what medications, patients were  unsure, so i asked them to go back to their respective clinic to get the list of medications, so these private doctors would scribbles with illegible hand-writing, like as if they just not in the mood to write any letter. (baik toksah tulis gituh)

so for that day, i finished my lunch call a bit late. sigh... annoyed with the registration staff who sent those OPD card so late, annoyed for those complex cases of ignorance.

moral of the day
1) get discharge summary from treating clinic/ hospitals
2) bring translator if you have difficulties conveying your problem
3) time is always the limitation for a good health care in a government setting clinic
4/ doctors are not psychic


TUESDAY 13/12/11

Pt was just discharged from the ward, withholding her Atenolol and Gliclazide due to bradycardia and hypoglycaemia. On the day she met me, her sugar profile was quite high. Her previous OHA (oral hypoglycaemic agent) was only Gliclazide. I had very little information on why she was never been started on Metformin, But it need to re-start her on something for the sugar control. As in normal cases, pt would not be started on Metformin due to renal impairement. Maybe she has renal problem but i need to know her baseline creatinine and to confirm about it, I have to trace her NCD card (at her NCD clinic). At the same time, i asked her to do renal profile so i can see her current renal status. Apparently her creatinine was 149 ( in which increasing in trend), so she definitely cannot be on Metformin nor sulphonylureas (gliclazide/ glibenclamide) as she would go into hypoglycaemia, so i had to start her on bolus insulin. All these take a lot of my time....

WEDNESDAY 14/12/11

This patient was one of my early bird patient, came in with left sided facial weakness. A-ha, it was easy...it was Bell's Palsy, I was sure about it. Yeah but to confirm, i did a few examinations. The strange thing about it was the weakness was not all unilateral. Apparently, his upper part of his face was showing that he has left sided weakness (unable to shut his eyes, unable to wrinkles his left side forehead) but upon blowing up his cheeks, he was unable to blow his RIGHT side...if it was Bell's, he would be unable to blow his left side too.Something fishy about that finding. i was suspicious thinking that it could be CVA (stroke). So i called 2 of my colleagues to confirm, both of them said it was Bells. but i have this strong feeling that it was not as simple as Bells so i called another different 2 colleague and they think it was CVA....now that was confusing. Luckily i checked his BP and noted that it was super high so without any further delays, i referred him to A&E (Left facial weakness TRO CVA with possible Bell's palsy). Because I'm also practicing DEFENSIVE MEDICINE, every referral I made has its own reason. (before the ED MO chased me around for sending Bell's palsy to ED...ED MO loves to chase us here for sending crappy cases...tehehe), I elaborated, reasoned and justify  that the clinical examinations was not tally with Bells as Bells comes in with unilateral weakness (but not in the pt's case).  Thought pt has no comorbid prior to this, his arrival BP was high. And i did not serve him Nifedipine though he has high BP because if it was a stroke, that it would be dangerous to drastically bring down his BP especially in a clinic where we have no observation facilities. He would be better off in ED, if so they decided to give him the Nifedipine, he was able to be well observed in ED. Thank Allah that i did not receive any rejecting calls from ED that day. I wonder what happen to that pt......(if pt has normal BP, i probably treated him for Bells)

MOral of the day - do practice Defensive Medicine to save your own butt

THURSDAY 15/12/11

1) Bee sting case.. apparently i saw lots of bee sting cases where the bee stinged patients while they were riding motorcycle and the favorite target were the lips.Same goes as this particular patient who walked into my consultation room. This patient was special in the sense that his lips was super swollen, the biggest i have seen so far. Most of the patients, i send them back home. But for him, i sent him to ED. His lips were super swollen and that he also complained of breathlessness (though his lungs were clear). The fact that he said it wasnt a bee, that took my attention. The description suits more of a wasp than a bee. (it was bigger that a bee, it was black, not yellow n black striped). A single bee sting would be fine but a single wasp sting, very dangerous, pt need some observation. As my clinic did not have any SPO2 machine, so i reasoned with ED for my referral ( for observation and spo2 monitoring). Again, i was safe from receiving unwanted call from ED.

2) COPD patient, just discharge from ward a month ago, came in for his MDI. So I gatal2 and asked him regarding compliancy of his MDI. Apparently he was using Combivent BD dosing...(usually TDS) and so I was rather suspicious, so i asked him for his discharge summary to confirm his medication dose, so he took off his yellow MOPD booklet, noted that he was supposed to be on Combivent TDS with Budesonide BD dosing. In the notes, I saw that ward doctors have arrange him for an echo and TCA next month, date was not written in the booklet. So i asked for the TCA booklet and discharge summary to see when is the echo scheduled and at the same time, educating him for his compliancy. Relative agreed to bring in the summary for me. Pt wanted his meds so I said to him, "bring me the summary, only then i give you your meds" ( if i gave him his meds, he would have not come back). So pt was pissed off, left the room and made a statement full of sarcasm "kalau mcm ni, lebih baik jumpa doktor berbayar. Ambil ubat pon susah. Tak yah makan ubat  lah" I was trying to help him and this was what I get. Thank God that his relative was understanding and mentioned " ala, nak bayar duit wad pon tak mampu, nak bayar doktor pulak" So after 30 min, pt's relative came back with discharge summary and a torn MOPD booklet. So this pt was really angry with me that he torn off his booklet and threw into the trash can. His relative had to collect it inside the trash. Yes, as i would have guess, he defaulted the Echo TCA and MOPD too. So my assistant helped them back to get a new TCA...this time around, i really hope that he would not default.

moral of the day - some pt never appreciate your work to help them, they think you interfere with their life.asking too many questions, too thorough... yada yada. "tak tolong salah, tolong pon salah jugak".. so whatever you do, you are always on the wrong side.

FRIDAY 16/12/11

1) My first patient of the day. He came with severe bilateral leg swelling up to his groin (mind me,  his scrotum swollen up too)....YES i remember him, I saw him one month ago during my lunch call on a Friday evening, he came for URTI but because he has underlying DM and HPT, and was told by his relative that he defaulted his medications, I checked his sugar profile and BP, noted to have very high parameters. so I sent him off for renal profile for his renal status and urine to see ketones. Renal profile showed that he has some renal impairment. His relative informed me that he defaulted MOPD TCA years ago....so i asked him to come back in a week time to further follow up with his pressure and sugar - defaulted too!!! So that day, he came in with severe swelling for 2 weeks with shortness of breath. He even has ascites (fluid in the abdomen cavity). but his lungs were clear. His BP was high, sugar was high too.I nagged him for defaulting all his TCA....so i shooh him off to ED (CCF with fluid overload)

2) dengue case from Sungai Pelek. Pt was already seen at KK Sg Pelek on the same day, came back to us just to get a referral letter to go to ED as pt already being rejected by ED triage. For ED, why do you have to reject his case as he was very ill and if you check his dengue chart card, you will see that his haematocrit was increasing in trend. He was dehydrated. Worse, Sg Pelek, how cant you discharge pt with HCT of 50, i mean, his HCT was increasing in trend, at least this pt need some hydration.

3) old indian lady just discharge from ward, came in with a discharge summary but nothing written about the changes in her meds. Pt saying that the doctor in the ward changes her medications and to continue care in KK. The thing is that pt was not fully informed regarding her medications that she actually took Gliclazide, Glibenclamide and Metformin all three (N.B. Gliclazide and Glibenclamide are in the same class of drugs so they cannot be given together). She came in complaining of giddiness. Thank God she did not turn hypoglyacaemia. Maybe the HO in the ward did not explained properly to pt. Maybe because pt already old, she may have difficulties in understanding her meds.maybe maybe maybe (sebenarnya rasa nak marah tapi tak tau nak marah sape...sape punyer kerja nih...nasib baik pt tak collapse kat rumah....haiyaa), so it took me sometime to arrange back her meds.

4) end of the day, a newly married Indian couple came to see me, the wife having URTI.... well i have good ending seeing somebody dressed up in a wedding attire coming into my consultation room.very pretty.

moral of the day - 
1)some pt will only come to you when they are in trouble, when we give them proper TCA they refuse to follow up their care, only turns up when it was already too late. then by that time, they will come to you with issues that will EAT YOUR BRAIN
2) we're cleaning up other people's messy work like in case 2 and 3.

to be continued.....

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