Wow, version 3 already? There seems to be a lot of info on Australia, guess many interested to practice there eh? Oh no, here comes the brain drain

Anyway, I do realize the lack of post grad discussion in this thread. Seems to me not many are keen for further studies

To my knowledge, most people who attend med schools in developed countries do have the intention of working there upon graduation (scholars not included). So anyhow, privately funded medical students studying in developed countries do largely contribute to the brain drain phenomenon.

Anyway, no harm discussing about postgrad studies here even though the thread is meant for medical students. Perhaps a senior doc like yourself can start the ball rolling. It would definitely be nice for a senior clinician such as yourself to shed some light on this matter.

To my knowledge, uk's door has long been closed for non eu citizens. Imgs can only do foundation years there, and will be required to leave upon completion. As for oz, they are still taking in mos who has completed amc test (some of my classmates just went). Just that the internship post is limited.

Btw are u from Kuching? Do you know anything about cardiology department in Sarawak GH? I heard training under Dr Sim is very good.

Oh my bad. What I meant was non eu citizens who have completed their studies in uk.

So without dr sim, does the cardiology in SGH still offer good training?

Dear medical students/doctors, pls point out the mistake in this discharge note from a peripheral hospital.

Yeah, one of the mistakes is the bad hand writing. Doctor's writing supposed to be neat and tidy

This patient was diagnosed with ACS and warded. Upon discharge, he was prescribed the following meds:

T. Perindopril 4mg OD
T. Aspirin 150mg OD
T. Clopidogrel 75mg OD
T. Lovastatin 20mg ON
C. Gemfibrozil 300mg ON
T. Cardiprin 1tab OD
T. Isordil 10mg TDS
S/L GTN 1tab PRN

Now, please find the mistake in this list of drugs.

Good. Even someone who has just passed first year can pick up the error.

The list of meds was prescribed by a junior MO who has just completed Housemanship. This MO is a graduate of an IPTA which is recognized by Singapore medical council.

I really hope this is an "accidental" or "postcall" mistake. If not the rural folks are in big trouble.

BTW, statin with fibrate is also not a good combination, as it can cause rhabdomyolysis. This combination is only used as second line therapy.

This post has been edited by hypermax: Dec 17 2012, 05:40 PM

Monotherapy is always recommended as the initial therapy. If TG is > 5.7mmol/L at presentation, fibrate is started instead of statin. Combination therapy is only recommended if optimal monotherapy has failed to bring the lipid level down to target lipid goals after 8-12 weeks.

Pls refer below pic for more info (from KKM guideline)



This post has been edited by hypermax: Dec 17 2012, 06:45 PM

As mentioned, I hope this is an unintentional mistake. If not then I am very worried about the quality of medical education.

yes, agreed with the statin part. Statin should be started regardless of lipid profile post ACS/STEMI. Like you, I am also not comfortable with starting both fibrate and statin.

if I am not mistaken, PCI is not routinely done for ACS. It is however, a gold standard for STEMI. Also, district hospital has no cardiologist, so PCI can't be done.

Well, I am equally surprised that pharmacist didn't pick up the mistakes.

I guess you are confused a little. Let me clarify.

1. The guideline says optimal monotherapy before considering combination. Does 20mg of lovastatin or 300mg of gemfibrozil sound optimal to you? Are you aware of the max dosage for each drug?

2. Date of admission and discharge clearly written on the discharge note. Pls read it carefully.

3. All drugs taken by the patient are on the discharge note (usual practice for hospitals)

4. You dun only start statin post stroke or cardio event (where did you get this fact!?). Statin can be used in simple dyslipidemia as suggested by KKM guideline and guidelines all over the world.

5. tqeh is right on beta blocker for ACS. Beta blocker reduces the myocardial oxygen demand, thus it benefits patients with ACS/STEMI as well as CCF.

I would suggest you do a read through of KKM's guidelines as well as books such as Sarawak Handbook of Medical Emergencies. Are you a doctor btw? If I am not mistaken, you are a pharmacist right?

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Added on December 17, 2012, 8:38 pmCardiprin is combination of 100mg aspirin and 45mg glycine. It causes less gastrointestinal effect than conventional aspirin.

This post has been edited by hypermax: Dec 17 2012, 08:38 PM

Simply because lovastatin is the cheapest, and the only statin MO in KKM can prescribe (other statins need specialist prescription)

This post has been edited by hypermax: Dec 17 2012, 08:56 PM

For your info, some consultants even routinely prescribed statin for all type 2 diabetic patients above the age of 40 regardless of baseline lipid profile.

Maybe you should start taking statin then j/k

ACS refers to both unstable angina and NSTEMI, as both shares similar treatment plan. Plavix is usually continued for 6 weeks post ACS, and up to a year post PCI (dual antiplatelet therapy).

Not really. Nowadays in hospitals we use more of lova and simva. Reason: cheaper

This post has been edited by hypermax: Dec 17 2012, 09:55 PM

U mean in the case of ACS? That's because in ACS the cardiac function is relatively well preserved, unlike in CCF. Thus diuretic is not needed to get rid of the extra fluid.

Beta blocker should be given to patients with ACS, STEMI and CCF, as it reduces the myocardial oxygen demand. However, it should be introduced slowly as patients may complain of worsening of symptoms upon initiation of therapy. Also, beta blocke is contraindicated in COAD or Asthma patients.

Like what zstan said, combination of diuretic and b blocker can cause new onset diabetes melitus. Thus close monitoring is required.

In diabetic patients, statin is still the first line therapy for risk reduction, unless TG>5.7 then fibrate will be used instead.

Btw, the mechanisms for both aspirin and clopidogrel are important for MRCP part 1. One has to know them by heart if keen for MRCP.

This post has been edited by hypermax: Dec 17 2012, 10:52 PM

B blocker is contraindicated in both coad and asthma as it causes bronchial constriction. I have not seen patients with coad or asthma being started on b blocker. Perhaps the patients u have seen are having cardiac asthma?

The cardio selective bb loses its receptor selectivity at higher dosage.

http://en.m.wikipedia.org/wiki/Beta_blocker

Read under the section adverse effects.

This post has been edited by hypermax: Dec 18 2012, 10:11 AM

OK, again. Pls spot the mistake in this discharge note.

Good one.

The list of meds were prescribed by a senior MO graduated from a renown university in developed country. From the same hospital as the previous case.

That's why I am against judging a doctor purely based on where he graduated from.

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Added on December 18, 2012, 11:40 pmFurosemide is needed in this case as the patient has CCF. This is again a case of benefits outweigh the risks.

This post has been edited by hypermax: Dec 18 2012, 11:40 PM