Exam Week

Next week is the final week for my Paeds posting.My observed long case clinical exam is on this Monday!My examiner is going to be Dr Faizah who is known to be Baik but very particular about clinical examination technique.To her, Hutchison's book is her clinical bible.Habis ar aku dah laa tak khatamkan buku tu.Hm rasakan ar wei.She also likes to ask things pertaining to your basic medical science knowledge (eg pathophysiology etc stuff).Differential diagnosis pun kena mantap.Just praying that I will get a cooperative patient who does not menangis or melalak.InshaAllah everything will be fine.
Written exam is on the Thursday.I dont know what to say.Buat je laa...

'I am happy'

My Teaching Hospital

Dr Rohaizah asked my group to follow her ward round in the Neonatal Intensive Care Unit(NICU)today.Right after that, we had to present to her 2 long cases.I presented one long case to her followed by discussion regarding appropriate investigation,like why do you want to do this and that, management and some theories regarding the case.For the first time she did not comment anything.I wanted her to give comments and therefore I asked her,' Umm Dr Rohaizah, don't you want to give comments ?(like you always do-ni dalam hati je)She replied,' Nothing to comment.Good.I'm happy' 'I AM HAPPY!!!' .What???? Weih biar benar ko ckp gitu!Hm begitula ceritanya.Sesungguhnye kita kena persistent and tahan dengan leteran Cikgu kita because actually they meant well.They want us to be good at the end of the day.

Trisomy 18

My group had a bedside teaching today with Dr Rohaizah.But this time it was held in the NICU.We had to examine two neonates as for our short cases before presenting 2 long cases to her.The first neonate is a Trisomy 18 baby and the other one was Hirschprung's disease.

This baby have many trisomy18 features- hypotelorism, triangular shape face, prominent occiput, overlapping of fingers, clinodactyly etc.This baby is also having ASD and PDA with continuous murmur best heard at the left infraclavicular region grade 4.

I love the incubator.It feels warm once your hand is inside it.Can I have one? This baby had a lot of wires and tubes around and into him.Nasal prong, brannula,BP cuff, Oxygen probe, ECG electrode on the chest, Orogastric feeding tube etc...you name it!Lemas gile hidup

This machine is super canggih.I wonder how much one incubator costs!

HIP

HIP stands for Health Intervention Programme.The goal is to promote health and to reveal the findings in a community regarding their health.It is a must thing to do for every group during their Public Health posting, and last Sunday was group 4's turn to organized it.As usual, many batchmates will come to help and support them.This time it was held in Kota Warisan,Sepang.

Monkey-ing around is certainly another way to help them

There are many posters that shows the public regarding their state of health ( or anything relating to their health for that matter!)

Tengokla tu, ada aktiviti menconteng tangan dan muka budak-budak

Teaching the public regarding the basic first aid stuff

See, ada akak yang mengajar mcm mana nk rescue baby

As usual, like in any other health project a medical check up booth is a must.I 'happily' volunteered myself to man the physical examination booth.Tak check ape pun, just practice on my physical examination skills je, patient kan ramai :P

Ada akak yang ajar cara-cara pemeriksaan payu dara dekat makcik-makcik

Hmm bersungguh-sungguh ye rupenya mereka semua itu


All these will be part of the Public Health final exam assessment which constitute for ONLY 20%!!!!!Penat penat je tapi dapat 20 percent je!

Click!

Yes, the title of this entry is Click! as in like the noise made when you take picture with your camera


I am in the middle of completing my last long case write up for Paeds when I decided to update this blog.Today I would like to show you some of the pictures that I have taken today.

Above is the classical rash in dengue fever.It is described as 'generalized erythematous rash with areas of hypopigmentation in between'.OR 'White islands in the sea of red'.This is due to plasma leakage.Smal,multiple non-blanching petechial rash can also be seen.Petechial rash on the other hand is due to small capillary burst.You'll get more petechial rash if Hess test is positive( which I did on this patient)

Above are what we called 'ecchymoses'.This 4 year old child came in today with multiple bruises over the upper on lower limbs as well as the trunk of 7 days duration.He has no history of trauma or fall.No lymphadenopathy or hepatomegaly.He had history of URTI about a month ago.Therefore he was diagnosed with Immune Thrombocytopenic Purpura(ITP) and not Acute Leukaemia coz Leukaemia must be one of the differentials.

We had another new Kawasaki's Diseases today.Admitted just before I went back from the hospital.We also had a patient with blisters and looks like its going to progress to Scalded skin syndrome.I'm going to take the pictures tomorrow.

I do feel sorry for the patients, but for the sake of studying we as medical student need to take pictures so that we can use it in our presentation later.Thats what I've been told by the specialist ' Take picture,take picture and include this in your case presentation later!You should be taking pictures and videos as long as you gain permission from your patients and that pics or videos will not degrade your patients later by circulating it around in Youtube!' I do feel a little bit awkward when taking pictures of the legs and bodies instead of the faces.

A group presented a TBL on Paediatric Emergency today.Lucky for us that Dr H the Paediatrician did not bebel us too much today.My subgroup will be having a bedside teaching by Dr Faizah tomorrow at 10 am.I'll be volunteering myself to present 2 cases tomorrow.Bioethics class with Dr Musa at 2.30pm.I'll be on-calling tomorrow night but before that I am going to Hospital Putrajaya to the Medical Ward.A colleague told me that they have a patient with Steven-Johnson syndrome.That is like super duper rare, 1 case in 1 million patients!

Just another day in the hospital

Paediatric Ward 5 B

In the morning

-Clerked and examined a few patients

-Bedside teaching with Dr Hafiza the Paediatician.Our practical class for assessing developmental milestones of child in a proper way.Bawak laa mainan byk gile, but most of them did not meet the right criteria :p

In the afternoon

-Had Clinicopathological conference with Dr Musa.We presented a quite number of interesting cases that we saw for the past one week bothwhile in Hospital Serdang and Damansara Specialist Hospital.They are Haemolytic-uraemic syndrome, Status Epilepticus, Autism(I presented this case), Infant of a diabetic mother and Haemophilia A. It was interesting that Dr Musa wanted us to share our own views and experience on the case and not only about the academic part of the case.

-A few interesting cases seen today in the ward: A patient suspected of having either viral myositis or Gullain-Barre syndrome.Had ascending limb weakness and urinary incontinence.Quite a number of Dengue cases and meningoencephalitis

Tomorrow

-Ward round as usual

- TBL on Paediatric Emergency

Things that you MUST have

These two books are essential.a must have.I've been scolded once for using that Sunflower book and eventually I have found the reason.That book is nice because its colourful and have lots of illustrations, however it lacks information.Sunflower book is not the kind of book for examination.Initially , I thought the book was sufficient but midposting exam result proved it otherwise.In short, please use Nelson coz it is known as the bible of Paediatrics.For clinical, plz use Hutchison's.

Every posting is unique and different.They are somewhat different in certain aspects.Paediatrics for example, are known to have a very detail history taking.Sampai cara-cara nak buat susu formula dalam botol pun kena tahu.There are certain things that a medical student need to bring while in the ward.There are also things that are prohibited in the ward, for example textbook!Below are the things that are always with me while in the ward.

ID card

Soft toy.I have a mickey mouse as my mate.He helps me when I'm trying to build a good rappot with my patients.A child will open up to you easily after you have played with them.They become more cooperative and it helps when doing physical examination.

Toys.In paediatrics, toys are essential not only to divert your patient's attention but it also used to assess the development and milestones of a child.That is why we need blocks,legos and also drawing pad.We can use these item in order to determine whether a child is growing appropriately or not.This must be included as part of your history of your patient and must be mention during case presentation.In developmental history,we assess 4 areas:

-Gross motor skill

-Hearing and Fine motor skill

-Speech and verbal skill

-Psychosocial skill

I have an ample stock of toys at home coz I have a 5 yr old brother.I can always take whichever toys I want, without asking his permission first!

Tendon hammer.Is used to check for reflexes.The tip is used when trying to elicit the Babinski reflex

Measuring tape.Is used during physical examination for measuring the liver span.Is also used to measure any swellings or visible mass. Initially, I have refused to bring a measuring tape and prefer to use a ruler instead.But oneday, a surgeon asked me ' Why you didnt have a measuring tape? Oooo Its a girly thingy is it to have one? When I was a medical student I used to have this and that bla bla bla'

Growth charts! Yes, this is essential in paediatrics.Assessing the weight, height and head circumference of a child is part of the anthropometric assessment.Vital in determining whether patients are growing adequately

Penlight, A pen and a small notebook.Notebook is used to jotdown important points during clerking the patient's history.Penlight is used during physical examination.No textbook in the ward please!

Stethoscope. There's a teddy bear clinging on it.It helps to have lots and lots of toys during paediatrics.I call this teddy bear 'Mr Teddy the attention seeker'.He can help in diverting my patient's attention while auscultating.

My group presented a TBL topic named "Assessment of a child with congenital heart disease".I'm just glad that specialist did not bebel-ed us too much!

The Ups and Down

Medical school is really tough.Only a fit and strong person will survive throughout med school.The amount of work is unthinkable.The amount of emotional stress is another thing.Gosh, why do I want to become a doctor in the first place?Anyway, I really hope I could renew my niat.Doctor is Allah's personafication of mercy.Satisfaction is guaranteed.God will repay me in the hereafter,inshaAllah.
I really think that the ward round is too long.Average is 4 hours everyday.Not to mention thenumber of hours that we need to be in the hospital everyday.Usually I came at 7.30am and go back at 6pm.Sometimes, it can go up to 11pm.
At last, Adik A my dengue patient was discharged yesterday.He requested for my autograph and my phone number as well as my email.He said he want to keep in touch with me, telling me about his progress in school.So cute.These are the things that money could not buy.The satisfaction.I felt great.
Presented my long case today to the head department of paediatrics.I got 7/10.Alhamdulillah.Never thought that I would get that kind of mark.You see, Paediatric history taking is so detail.All of the specialists in the hospital expect us to be able to clerk as well as present a good history.90 percent of the diagnosis were made from history taking.What a loong day today.Had TBL about approach to respiratory distress, then later after Friday prayer we had Bioethics class.
I spent the whole day yesterday in the Damansara Specialist Hospital Dr Musa's bedside teaching.In the morning, we were in the nursery where all the newborns were kept.He asked us to examine a few neonates and tell him our findings.The babies are so fragile.We had todophysical examination of the newborn from top to the bottom
Its not that hard really.The only annoying part is when they start to cry.We then spend the rest of the day in his clinic.

Dengue Shock syndrome

Yes, today we had a case with dengue shock syndrome.I clerked and presented the case to one of the specialist.This patient had interesting signs.He had petechial rash(non-blanching), "white islets in the sea of red".On PE, the air entry to the lung is decreased bilaterally,the lung was stony dull to percussion bilaterrally at the middle and lower zone of the lung.Breath sound is not heard bilaterally at the lower zone.This patient was having pleural effusion.He also had ascites.Shifting dullness was positive.Will be doing PE again tomorrow morning before all the signs disappear! :p

OMG

Sometimes I made myself scared to death, especially when I think that I have woken up late.This morning my kakak woke me up at 5.45am because I need to be in DSH (Damansara specialist hospital) at 7 am for my bedside teaching with Dr Musa Nordin the Neonatologist.Anyway, to cut the story short, I woke up late this morning.It was 6.20 am.Yes I tertidur balik after that.Mind you, its Sunday morning and thats the best time to sleep.No need to worry about anything during the weekends.And so I managed to get ready within 10 minutes time(mandi pun tak basah sgt kut) and Super Subuh, and after having a sip of tea and a karipap I'm off to D'sara.I was lucky that the traffic was smooth and I have arrived on time.Dr Musa arrived at 7.10am.Yeay!

Today we learn many things about neonatology, a branch of medicine dealing with the newborns.The babies are so tiny, some of them is only as big as your palm.I SWEAR to god that I would have easily crushed them with my hands if I were not careful.We saw and discuss a case of a baby who was born 3 days ago and almost had a thing called "Hypoxic-Ischaemic Encephalopathy" .Her APGAR score was only 2/10!She was in a mess after a failed vacuumed SVD(Spontaneous vaginal delivery).We discuss her Obs record,how to do physical examination (PE)of a neonate,things to look for during assessment, her complications, things to expect, how to manage her, how to calculate her fluid intake etc.We also learn on how to assess a premature baby, ie-signs to look for during PE.

Later, Dr Musa belanja-ed us for breakfast - me, Hannan and Fizie and we talk about our schools.Dato' Dr Musa is one of the most famous Neonatologist in Malaysia.He is also the president of Federation of Islamic Medical Association and The Honorary Treasurer of the Malaysian Paediatric Association.He is a proud ex-KGV Seremban and was an English Debater.When being asked,'Dr, did you win the debates?" He replied' OF COURSE".Muke serious takleh blah! haha

After the breakfast we followed him to his business rounds and saw a few patients.I admire his profesionalism.He knows how to approach the parents and the kids(ie the patients) both at the same time.Both of them needs different approach.All I can say is that life as a private consultant is way much less stressful than Government.I still have a looong way to go in order to reach his level.I definitely will go the private sector, that is a sure thing!

There was this one time during the ward rounds that Dr Musa asked me,Hannan and Fizie to demonstrate to him the types of audible respiratory sound ie wheezing, stridor, snoring, expiratory grunting etc. Luckily there was nobody at the corridor at that particular time, orelse they would think that we are a bunch of monkeys trying to imitate peculiar sounds!

A Radiologist came to us and ask us to review this CT scan.He said 'This is a good CT scan finding coz they usually ask you during your exam, so plz see ar".Anyway, this CT scan shows Multiple brain lesions over the frontal and parietal region with vasogenic oedema.Its a secondary metastases of a lung cancer.

Nagging

Yes, I declare week 4 of our Paediatric posting as the Nagging week.Where ever we go, we are sure to be nagged by our own professors and specialists etc.. I'm starting to get irritated by them.To that Dr H ,we understand when you have to cover 2 wards and therefore will have no time to do bedside teaching with us.We do not want to hear your nagging about your sad little life.We understand you and we are not dumb.Just say it.fullstop.no nagging plz! :p

Interesting cases throughout the week

1.Status epilepticus
- a boy in the ICU showing signs of upper motor neurone lesion such as hypertonia and hyperreflexia.

2.Complex febrile convulsion - seizure unresolved by rectal diazepam and midazolam.Patient
eventually had to be intubated.All happened right in front of my very own eyes

3.Pyrexia of unknown origin

4.Another case of Kawasaki's disease - I'm starting to think that this disease is not rare after all.The child has all of the diagnostic criteria

5.Rheumatic fever
- we went to the cardiac high dependency unit to see the boy.He has 3/5 of the major criteria in the revised Jones criteria of Rheumatic fever

6. Arteriovenous malformation

7. Haemolytic-Uraemic syndrome

Tomorrow ( as in Sunday morning at 7 am), I have a bedside teaching with Dr Musa Nordin the Neonatologist in Damansara Specialist Hospital.God knows what case is he going to give us tomorrow.No complicated case please!

PUO

We have few interesting cases today in the ward. 3 cases of congenital heart disease, 1 case of pyrexia of unknown origin and 1 case To rule out arteriovenous malformation.
Again, ward rounds was tiring.It lasted for 4 hours.Penat and nk patak kaki dah.However, manage to assist the specialist in doing physical examination.I ausculated many chest today, but sadly all of my findings did not tally with the specialists.Guess that I need to listen more attentively.
My group presented a TBL topic today with Dr Faizah supervising.It went well.
I really need to prepare for my case write up and my MIDPOSTING EXAM which is scheduled this coming Thursday.

Just another day of Paediatrics

What I did today
1. 3 hours of ward rounds.Nak patah kaki
2.Clerking and examining patients
3. Break
4. Clerk and examining newly admitted cases
5.Jogging


Some interesting cases today

1.Kawasaki's disease

2. Pertussis

3.Arterivenous malformation

4. Ventricular septal defect with Patent ductus arteriosus
What do I need to do tonight

1. Complete my powerpoint for TBL presentation tomorrow

2.Write my case write up.

3.Need to finish reading the Failure to Thrived articles

4.Revise about
-Kawasaki's dzs - criteria for diagnsosis, complications, investigations, treatment
-Arterivenous malformations
- Pertussis

5.Types of rash

6.Malaysian Immunization Programme- use Paediatric protocols of Malaysian hospitals

7. Finishing my Hutchisons

Stress

A friend of mine used to tell me this.'Perubatan merupakan satu cabang sains yang mencabar fizikal dan mental'.And by 'mental' I hope she also meant 'emosi'.Its true that we have to work under pressure.We have to put a lot of crap from the specialists.I just hope that they, the specialists still remember that they were also medical students , juz like us!