Wednesday, April 29, 2009

Critical vs cynical

Serious hari yg penat.Went to hospital at 7am.Do necessary stuffs such as taking blood and updating patients info regarding blood test and PE.Followed the ward round with Dr Rosman.Bombarded by him with a lot of questions.Siap soalan physiology pasal Virchow's triad pun ditanya tadi sebab gatal sangat nak gune term 'laminar flow' and 'turbulence flow of blood'.

Had bedside teaching with Prof Rashid just now.Hannan presented a case about bilateral leg swelling in a patient with poorly controlled DM.Again, bombarded with lots and lots of question.Dari history taking,PE,Investigation sampai la ke management of patient.

Later on that day, had TBL session with yet again Prof Rashid.Tajuk 'Cough,Fever and Sputum'.Again, bombarded with questions.Siap prof ketuk ketuk meja lagi.

One thing really important that I learn today is that as a doctor we should not do things blindly.We should not have this tunnel vision mind set.We should think,think and think.Do not simply do things because it is routinely done.I like all the teaching session today becoz they teach us on how to think.How to solve case.They prepare us for the real working environment as a doctor.Like prof said, teaching how to do physical examination is easy but teaching how to think is far more difficult.

ps: Think critically not cynically

Monday, April 27, 2009

Bakti Siswa & Anak Anak Angkat program

I spent 3 days and 2 nights in a kampung called Kg Air Lapis Bangas in Parit Sulong,Johor.I want to retract back my words in my previous post.It was worth it going there after all.The mak,abah and family angkat were super nice.We were treated as if we are their own sons and daughters.At one point, I came to think that their real sons and daughters have become their own anak tiri.For example, Nik and I was with this one family who have 2 sons and 2 daughters.Their son had to sleep on the floor when both of us happily sleeping on his bed.We were also given their cars and motorcycles.We used them as if they were ours.Therefore, there is no surprise when one of us terbabas masuk dalam kolam while learning to ride motorcycles.The food? Owh its super duper good.One of our main activities were eating and eating.We had like 3 dinners everyday.Nasi Ambang, Mee Bandung, Sup gearbox u name it, we ate it.Therefore,it comes to know surprise when I weigh myself this morning and found out that I have gained 1 kg.Gaining 1kg in a 3 days time is a lot.

We had programs like membaja pokok kelapa sawit when the ahli parlimen Dato Noraini Ahmad (Ex Ketua Puteri UMNO) actually came to see the programme,program pemeriksaan kesihatan percuma for the penduduk kampung, program motivasi para pelajar so on and so forth.

Just like in previous medical check-up activity, our Prof Latiff would surely do some clinical teachings there whenever there is an interesting sign and symptoms discovered among the patients during the event.This time, I managed to see things such as chronic tophaceous gout, Marcus-Gun eye sign, Pterygium eye ,Podagra,Heberden's node as well as Bouchard's nodes of Osteoarthritis,symptomatic viral hepatitis,classical chronic uraemia signs and symptoms etc

Pic 1: Pterygium.One of the signs of hypercholesterolaemia
Pic 2: Podagra.Swelling and pain of the first metatarsophalangeal joint in GoutPic3: Heberden's node(at distal interphalangeal -DIP join) and Bouchard's node ( at proximal interphalangeal-PIP joint) in Osteoarthritis.They are caused by formation of osteophytes(calcific spurs) of the articular cartilage

Note1 : I'm currently in Terendak now.3 weeks posting in Hospital Angkatan Tentera Terendak.

Thursday, April 23, 2009

Internal Mad-icine

There are so many things that I want to share regarding my experience in the medical ward so far.There are so many things that I have learnt.So many signs and symptoms that I saw and has intrigued me to do better in this field.So many interesting cases!!!!

Ward round
I particularly love ward round.The specialists is super nice, Dr Nurain.She frequently asked questions to the HOs and also medical students.Many HOs have forgotten their basic knowledge.I DO NOT WANT to become that kind of HOs.Its a pain in the a** to forgot basic things and at the end of the day you will screw yourself becoz u need to do some serious revision for something that u knew before.God, please please prevent me from being dyslexic and receptive aphasia.

History taking and physical examination
I managed to shortened the time taken for history taking and doing physical examination.It is important to try to time yourself.This is a good training becoz as an HO later, I need to work efficiently.Anyway, this should not compromise patient's satisfaction towards the level of care and attention that we are giving to them

Case presentation
I am more able to organize my presentation.Presentation should be sweet and simple and interesting at the same time, without compromising the important details.I am still working on my 'negative relevants'.I still need to elaborate more on my chief complaint.Need at least 10 points before moving to associated symptoms!

Formulating diagnosis
This is particularly a challenging part but interesting at the same time.We were taught on how to think systematically

Interesting case of the day

1.Mr Y, 56 yo, chronic alcoholism.Admitted yesterday for SOB.On PE, hepatomegaly.He had signs of right ventricular failure secondary to dilated cardiomyopathy

2. Mr T, 49,Central chest pain which lasts for 5 hours, occured 2 days prior to admission.ECG done had ST elevated MI with elevated cardiac enzymes

3.Mrs R, 60 yo, came in with diabetic ulcers secondary to chronic venous insufficiency

Ada byk lagi malas nk tulis...

Quiz of the day.
Question 1.Give me 5 predisposing factors for the development of diabetic foot ulcers
Question 2.Types of myocardial infarction (anterior,lateral and inferior),its respective coronary vessels involvement and from which ECG leads that we can see them from.

Answer:In next post!

Note: I need to pack my stuff now.We are having 3 days and 2 nights of program Bakti Siswa in Batu Pahat over this weekend.Program anak angkat and medical check-up stuff.Sigh, I am already tired with this type of programme...............................they should allow us to sleep more at home during the weekend.

Wednesday, April 22, 2009

Of elective posting and research

Finally, I have decided to do my elective posting at the National Heart Institute (IJN) during this coming 1 month break somwehere in August .I am interested in Interventional Cardiology.U know , cardiologist who can do procedures like stenting etc. I love cardiothoracic surgery but I heard that that field is nomore in demand in the market,compared to other surgical sub-specialties.I would love to know more about the world of Cardiology....yezzaaaaa.I have also found the person who is going to be my internal supervisor, a cardiologist in IJN himself Dr Rosli.Thx Dr for accepting me =)

Tuesday, April 21, 2009

IM mini homework

We presented our patient case today to prof Latif.Prof taught us another structured,more interesting way of presenting our case.He reminded us that the first few sentences in history presentation is important because that would determined whether we are an 'A' doctor or a 'D' doctor.He went on correcting stuffs such as by saying its wrong if we say 58 years old where in fact it should be 58 year old (minus the 'S').

Before ending the session, we were given a mini IM homework.Terasa macam budak darjah 1 pulak.

Our IM mini homework for today are to find answers for the questions below.

1.List 15 signs and symptoms of thyrotoxicosis
2. List five macrovascular and five microvascular complications of diabetes mellitus
3.Lists 5 causes of massivesplenomegaly
4. Five causes of palmar erythema and five causes of finger clubbing
5 List as many as you can the major differences between COPD and Asthma
6. Diagnosis criteria for Acute Myocardial Infarction
7. The differences between transmural,subendocardial infarct and acute angina
8. The clinical features of uraemia in CRF(Chronic renal failure)
9. Indication for emergency dialysis
10.The five different types of stroke
11. List all the features of cerebellar signs with its causes
12. The clinical features of SLE(Systemic Lupus Erythematosus) and the criteria for diagnosis.

He says that internal medicine is so wide, that it requires doctors to specialise into certain field in th eend.But as a medical student, we have to know everything under the sun.No short cut.He also added that as physician, we need to be able 'to recognise disease pattern'.Its like getting the bits and pieces of a jigsaw puzzle together.Those who are sharp and well equipped with good background theoretical knowledge will be able to become a good physician.

Looks like I need to do a lot of stuff right now.My otak is so berkarat!

p/s: Prof also reminded us the importance of study group.This is not the time to study alone!Yes you can spend 2 hours a day to have a quality time studying alone but the rest should be in a form of a discussion with your groupmates.I agree with him 100%.There is no way that we can survive medicine if we study alone.Its simply impossible to cover everything alone!

Monday, April 20, 2009

IM first day

Hmm today is the first day of internal medicine.My first impression: Wowww there is a lot of things to be revised man.Most of the theories have been taught during pre clinical years.

Clerked my first patient.It was a 49year old Malay gentleman from Putrajaya.Guess what is he having? Stroke! So young and yet dah dapat stroke.My impression was that this guy ada left ischaemic stroke with right hemiparesis.A known hyptertensive patient who is non compliant to drugs.He also have hyperlipidaemia.I havent seen his investigation result such as CT scan of the brain.But clinically I think he had an ischaemic stroke of the middle cerebal artery.
In IM,the challenging part would be to take a thorough history and also a thorough physical examination.A bit blur sebab dah tak masuk hospital selama 2 bulan after public health posting.I had to sit down at a corner first, trying to revise back my theory.I did Neurological examination both for motor and sensory functions for both upper and lower limb.Not forgetting the cranial nerve examination since this patient ada facial paralysis.CVS examination terlupa buat.Arghh...

Each of us are in-charge of one cubicle in that ward.There will be 4 patients at one particular time in a cubicle.Each of us must know everything about those 4 patients.Tomorrow will be our first case presentation.Prof Latif will randomly pick any patient in any cubicle that he like.I didnt clerk all the patient in my cubicle because tak sempat.Hmm ntah la, the possibility to be bombed is high tomorrow.Hahaha...

Sunday, April 19, 2009

How to succeed IM(Internal Medicine)-pesanan dari Fana hey! nice of my friends.We r helping each other out.Dats the spirit mannn...nway, ni email yg dpt dari Fana hey.I dont edit this.Saje nk post kat blog ni.At least bleh baca slalu.Enjoy reading(to me)!

How to succeed in IM (hehe, insyaAllah)

1. Read and read n read

- based on ur patient's case
- cth nyer kalau dia ade DM ke HPT ke then read about it and must know
the basic things about it (eg how to dx, what are the types, its definition
the classification)
- dont forget to refer books and old folios pls..
- recommended books:
--> oxford handbook of clinical med (a must have)
--> kumar n clark or davidson's
--> tally o'connor or hutchinson
--> old folios

2. Getting the history

- get the history right, HOPI very important (LORD SANFARO)
- all the what where when why where who how
- the chief complaint
- assoc sympts n other hx
- after getting all the hx, karangkan n try to present to ur frens
- get their opinion and ask them if there is anything not complete or missing
or if there is a gap in ur hx
- dont be afraid to dig from ur patients
- and dont salah interpret what ur patient is trying to say (u know pening and
sakit kepala might mean something else to ur patients)

3. Doing physical examination (PE)

- the first day u should already know how to perform PE for every system
- they include :
>CVS (paling senang n best)
>abdomen (as in GIT)
>musculo (some r integrated in CNS)
>CNS (upper n lower limbs)
>cranial nerve
-must have:
>stethoscope (kalau takde bkn med student la..)
>pen torch
>tendon hammer (optional coz bole pinjam from ward, but its better to hv ur own
or at least share)
>orange stick n cotton n tongue depressor for CNS (can always get it from ward)
- pls jgn buat sorang2 takut nnti syok sendiri
- at least the other frens tgk n check anything yg tertinggal or silap
- this might sound cliché but practice makes perfect
- especially for the patients that u want to present to prof ke dr ke u MUST do ALL the
systems (CVS --> CNS)
- jgn buat short cut buat betul2 cam nak exam
- when ur used to it it will only take few mins (awal2 mmg la slow skit)

4. Presentation

- always karangkan the hx [intro, hopi, assoc symt, past med hx, hospitalised/surgical hx,
drug hx, family hx, social hx(wife? anak? work? house where brape tngkat, tepi jln ke?)
dont forget the public health component people, also bout smoking, illicit drugs, sexual promiscuity]
- then followed by the summary of hx
- then present the physical findings (pls include BP, PR, RR, T)
- then PE summary
- finally summary of hx plus summary PE
- a good presentation : by the time uve finished presenting the listeners will have an idea which
system is the prob or at least a differential dx

-not to be included when presenting but have to know:
> must know what drugs patient is having, what doc plan to do, all the investigation findings
must know the nilai dont just say its N or not normal (in case prof or dr wants to know)

5. Long case n short case

- pls do it whole heartedly
- not just cincai2 lorh
- must have good, lengthy, informative, relevant, important, meaningful learning issues (dont
forget the academic n non academic learning issues)
- refer books n include any discussions about the patient

6. Must have your own 'kitab'

- well its actually a notebook (or many notebooks) which contains important n must know knowledge
- knowledge from books, ward rounds, profs n drs, ur own 'michael jackson kene halau balik
india utara' (pneumonics) kinda thing to remember stuff
- the main idea is so that u dont have to refer to books many times because u can just refer to ur
own self made kitab
- u must revise every week n add any valuable new info into the books..
- this is also another cliché but dont study last minute
- prof will give u guys a registered online examination website where there are many questions for
revision.. so bole la practice..

7. Miscellaneous

- during ward round, u guys should contribute to any new info from the history that uve taken
- all of u will meet 2 wonderful doctors dr shu and dr rafizi (dr shu's husband). they're really nice
and determined to make all of us pass our IM posting..
- the terendak people..dont take terendak for granted.
- the lack of patients should not be an excuse to be laid back. in fact u should take the opportunity
to know the patients in depth.

thats all. all the best

Yours truly, <----- Ok ni aku yang tambah.
Fana hey

p/s: Thx Fana~~~!

Monday, April 13, 2009


Yup....u heard it right mister, ITS HOLIDAY~!!! Its only a week holiday, but who cares...I need all the sleep that I can get.Plus, its going to be my last posting this semester-Internal Medicine.For that, there will b a lot of things to revise.Yes, revision honey.Preclinical stuffs!

Cardiovascular system
Respiratory system
Urinary system
Gastrointestinal tract system
Musculoskeletal system

Im goin to concentrate only on CVS,Neuro and Urinary system for the time being inshaAllah.

Happy holidays everyone~~~=) =) =)

Note1: By the way, the semester break after Internal Med will b shortened to only 1 month instead of 2 =( .We have to carry out a research paper for 1 month.Prior to that, we will b having a posting named 'Research and Evidence Based Medicine' for 1 monthDuring this posting, we will be taught on how to do a proper research paper, journal appraisal and stuff.I'm actually excited and sad at the same time.Life is indeed confusing...

Note2: My internal supervisor is a Paediatrician...surprise surprise! I still have about 2 weeks before submitting my research proposal.I still cant think of any interesting research topic...sigh

Wednesday, April 8, 2009


**This post is meant for the next public health group posting.Ni soalan compilation ni.Haha**

Today was viva day.From what I know,viva is a method of assesment used during preclinical years for students who failed their written paper twice.Tapi tak sangka pulak ada viva masa clinical years ni.We do not use patients for public health final exam coz there is no long case exam.Instead, viva is used as part of assessment method.
So layanje la

I was the 9th person to be called for viva.Again, only god knows how jittery and nervous I was.Two professors became the examiners.Both are public health specialists.The Viva can be divided into three components.

A.Public Health Journal
During the posting, we are required to read as many as public health journal that we can.In the end, we are required to list down 10 journals in our logbook.Those journals can be asked during viva.I was given the liberty to pick a journal which I am most confident with.For this purpose, I chose a journal with the title of ,

'The short-term impact of National Smoke-free workplace legislation for passive smoking and tobacco used"

Questions asked were:
1.About the study
2.Study design ( Ans: 2 time cross sectional study, before and after legislation enforcement)
3.Sampling method (Ans: They used cluster sampling method)
4.Other sampling method that you know off and their differences and features.(Ans: Simple random sampling,Systematic random sampling, Stratified random sampling,Cluster sampling,Multiphase sampling and Multistage sampling)
5.Statistical tests that were used
For this journal, they have used various tests.Eg: Chi squared test to assess 2 categorical variables which are exposure to tobacco smoke(ETS)-"Not at all""Less than an hour","1-4 hours","more than 4 hours" and smoking prevalences among employee in various workplaces-industry,services and offices.They have also used a non-parametric test named Mann Whitney U test and test of normality for continous variables such as Kolmogorov-Smirnov,Skewness and kurtosis and histogram.
6.Result and conclusion of the study.
-ETS declined considerably after the legislation.Eg;Exposure was halved in 1-4 hours group.
-Daily smoking prevalences among employees decreased significantly,from 30% to 25%.

B.Health Intervention Programme (HIP)
The second part of the viva was about things regarding our HIP.Questions asked in this section were:
1.Sampling method (Ans: We used Stratified Systematic random sampling.The population were stratified according to the income group, roughly by looking at their type of houses-single storey and double-storey house)
2.Type of study (Ans:Again, this would be a cross sectional study)

C.Regarding attachment to district hospital,health clinic and community clinic.

1.Roles of Medical and Health Officer(M&HO) as compared to medical officer (MO).
Ans: 1. Patients-M&HO's patients consists of the population under its sub-district.Eg.If I am an M&HO in Salak, then I am responsible for the health of the whole community in Salak, and patients consists of the sick as well as the healthy ones.
2.Plays role in administration and management of a health clinic
3.Plays role in health prevention and health promotion.For this question I was asked the differences between 'prevention' and 'promotion'.Annoying gile...

2.Next, I was asked about the weightage system for evaluation of food premises done by the health inspector from food and quality control unit of district health office.
Based on de-merit system.Deduction of marks out of 100 marks.Minimum passing mark is 50marks.Failure to achieve will result in the closure of food premise for 14 days.Can be charged under Food Act 1983
Food handlers-20%
Sewerage system-10%
Waste dumping-10%
Food containers and utensils-10%
Premise's floor-5%
Water source-2%
I was asked," Why do you think that the weightage for water source is only 2%?If you can answer this you can get an A+"LoL.I dont think I answer this question convincingly.It has something to do with primary prevention and primordial prevention method.Pre clinical stuff.So tak boleh ingat.

3.What is the required temperature for hot food in kedai mamak for example.
Answer: 63 Celcius

The end.

Below are the questions asked to my friends:
1.Malaysian Immunization Programme and the 'Cold Chain' system
2.Program Doktor Muda-10 scopes in their module
3.National Indicator Approach/District Specific Approach/Hospital Specific Approach
4.Lists of communicable diseases that must be notified to authority within 24 hours and within 1 week of diagnosis
5.Prevention of the spread of dengue-method,preparation before fogging,fogging mixture,equipments etc.
6.Things that a community nurse do during home visits
7.Recycle plastic bags-types,colour
8.Steps taken in a Needle prick injury
9.Expanded scope programme for health clinic

Tuesday, April 7, 2009

Busy bee

Marilah tengok aktiviti saya dalam seminggu ni...

1.Health Intervention Programme stuff - Busy buat plan of action, jumpe orang ni, jumpe orang tu.Bak kate prof, we shud be able to MARRY the needs between penduduk taman desa vista and klinik kesihatan as well as pejabat kesihatan daerah.Proposal and plan of action dah kasi kat klinik kesihatan.Lepas ni nak konfemkan date for the programmes

2. Revision for public health and community medicine posting final exam bersama rakan-rakan
-banyak kena revise.Semua benda pasal district hospital, klinik kesihatan, klinik desa, skop tugasan, national indicator approach,SPSS(Biostatistics),occupational hazards etc etc.Dont ever make me start talking about these stuff!!!

3. Gym with personal trainer -gluteus maximus,medius and minimus tengah sakit ni. -selain daripada tidur beribadat, inilah salah satu cara nak releasekan stress Ok.Pray for my viva(tomorrow) and written test(the day after tomorrow)