A few days back, I have encountered two cases of hypersensitivity reaction. Here is case number 1:
A 26-year old female, with a known allergy to Salbutamol, minutes after having eaten fried milkfish for breakfast, had a feeling of warmth and appeared red all over. She also started having difficulty breathing, thus prompting her to go to the emergency room.
Upon ER consult, she was tachycardic with a heart rate of around 140s but she was normotensive and normothermic. Respiratory rate was less than 30.
I could not yet remember what the criteria for diagnosing anaphylaxis were, and I had to review it… So, I just looked up the World Allergy Organization guidelines for the assessment of anaphylaxis. The clinical criteria are any one of the following:
Here’s another case:
A 21-year old female came into the emergency room for dyspnea and development of wheals all over her face and chest minutes after touching their neighbor’s pet cat (exposure to dander). She claimed to have been exposed to cats in the past had never had any allergic reaction to them.
Upon arrival, her O2 saturation was 93% and she was immediately given O2 support, injected with 50mg dyphenhydramine and 100mg hydrocortisone.
After reading the guidelines, I now know that these patients truly had anaphylaxis. This is a better and more accurate-sounding diagnosis than hypersensitivity reaction!
Let me try to apply what I have learned with my reading. Earlier this week, our consultant emphasized the importance of choosing the right intravenous fluid for surgical patients; they may have been put on nothing per orem, have electrolyte deficiencies, and it is paramount that we know what effects our choices would make with regards to the patients’ condition.
Now, let us try deciding on preoperative fluid therapy. Let me use myself as an example. According to Schwartz Textbook of Surgery 10th edition, the formula in computing the volume for maintenance fluids is as follows:
For the first 0-10kg, give 100 ml/kg per day
For the next 10-20kg, give an additional 50 ml/kg per day
For weight >20kg, give an additional 20 ml/kg per day
The example given by the textbook using the formulas above is here below:
A 60-kg female would receive a total of 2300 ml of fluid daily:
1000 ml for the first 10 kg of body weight (10 kg x 100 ml/kg per day);
500 ml for the next 20 kg (10 kg x 50 ml/kg per day); and
800 ml for the last 40 kg (40 kg x 20 ml/kg per day)
Now, let’s say I weigh about 47kg:
I would receive a total of 2040 ml of fluid daily:
1000 ml for the first 10 kg of body weight (10 kg x 100 ml/kg per day);
500 ml for the next 10 kg of body weight (10 kg x 50 ml/kg per day); and
540 ml for the last 27 kg of body weight (27 kg x 20 ml/kg per day)
Also, according to the textbook, hypotonic solutions are used such as 5% dextrose in 0.45% sodium chloride at 100 ml/h as initial therapy. So, do I just use one bottle of IVF as initial therapy here or follow my daily fluid requirement of 2040 ml already?
- God is pruning you. Don’t resist.
- You are a fruit bearer. Fruit bearing trees get pruned the most.
- You are being led into a radical life change.
- God is always faithful and always on time.
- Be consistent on the path God has for you.
- He’s still restoring you!
Photo by Yann Libessart/MSF
A mother and child wait for the results of a blood test for malaria in the PK5 district of Bangui. The time from testing to results is 15 minutes, and provides a positive or negative result by searching for parasites in the blood. Malaria is transmitted when one is bitten by an infected Anopheles mosquito carrying the parasite. In 2012, malaria caused an estimated 627,000 deaths, mostly among African children, but is both preventable and curable when caught in time. Control and preventative measures can dramatically reduce the incidence of this disease.
Today was a good day for a nerd like me. Now, let me brief you on my current situation before I find out the reason why the title of my entry is such.
Okay, since May of 2014, I have begun rotating in various departments as a post-graduate intern (AKA intern or senior intern); and as of this date, I have already finished rotating in otorhinolaryngology (ENT) and orthopedics, which took two weeks each. I have just finished two duties of ophthalmology and psychiatry; and will be finishing three more duties before I transition to another two weeks of anesthesiology (to be hidden in the OR cave).
Today was such a fun learning experience for me in ophthalmology pre-duty. In the afternoon, I accompanied GC, my resident in presenting a 17-year old female patient with a 6-month history of a firm doughy mass on the supra-temporal portion of her left orbit which only caused ptosis (drooping of eyelid) on the affected side. The consultant has a specialization in plastics and orbit. The residents were considering an osteoma and they want to rule out if it was a lacrimal gland tumor. When the consultant saw the patient, she palpated the mass, and thought that a dermoid cyst should be considered. There is also a possibility that it could be a sphenoid wing meningioma too. So, she recommended an orbital CT scan with contrast. I hope the patient would be able to do it as soon as possible. We’re all curious on what the mass turns out to be.
Once we returned to the out-patient department and sent home the patient, there was another patient for referral, but this time, to an external disease and corneal specialist. When he arrived, we all gathered to listen to him. He asked several questions on how our resident AS got her diagnosis of sclerokeratouveitis… A sort of long discussion went on. And then he said that it is almost always certain that inflammations occur at the periphery of the eye (limbus, conjunctiva, sclera) and that infections happen in the central area (cornea). He asked why… I answered, “Since the cornea is avascular, it is prone to infections, while the limbal area, there is blood flow, and it would manifest with inflammation.” I got a high five from the consultant! Woot! Another tip as given: when assessing for conjunctivitis, also check the palpebral conjunctiva… Of course, it is still conjunctiva.
Ophthalmology has once again, presented to me as a consideration for residency!
Yesterday was the official day that entitled me to be Doctor of Medicine. I should be elated; fulfilled, even. But how come I did not feel, even until now, achieved? I should be grateful, to say the least, because God granted me with the attributes, as said by our class valedictorian MAA, resilience, courage, and another one (okay, this entry turned out to be a little bit funny and embarrassing because I forgot what the last thing she said was).
Was it because of the next journey ahead, which is about 4 days from now?
Was it because I haven’t been treating my own patients solo?
MAA even mentioned about moments (hmmm, this word was probably the one I was trying to recall regarding the attributes or things we acquired during the clerkship); that we must savor them, bask in them, and embrace them, for they are fleeting. One moment is present here now, and the next they are gone.
Now, I think that there really is fulfillment deep inside of me that is just in my subconscious. I probably just do not want to join the bandwagon of those celebrating. Anti-social, isn’t it?
Was it because I haven’t been doing my best?
Why should I be settling for mediocrity? Why should I stick with being comfortable when there are better things to do than just sit and wait? I remember the inspirational speech of one of our consultants RR, he told us never to underachieve. DO NOT UNDERACHIEVE. There have been times, when I did the best I could, and after being praised or rewarded, I would go back to my baseline of mediocrity or normalcy. It was like when in a Pokemon battle, one move requires losing a turn (e.g. Frenzy plant; Pokemon Black) because the Pokemon must “recharge”. My doing my best came in pulses, not regular. Just intermittent random pulses of greatness. Why not make it a habit, I ask myself? Heck, I think I should remind myself of that question.
I need motivation. I have been regretting that I have not been studying hard or well enough these past years but then one friend HP said, “It’s never too late to do your best.” And yes, the change can start any day, any time. But the best time is now.
So I should. I should always do what is best to be the optimum self I can be. To earn the sense of fulfillment. To be proud of myself.