Ah Yes, Medical School

Yasmin Ahmad 1958-2009

2009-07-26T13:42:00.006+08:00

Yasmin Ahmad
1958 - 2009

I feel like writing something about the demise of Yasmin Ahmad. It was confirmed that Yasmin Ahmad, aged 51 years old has passed away at 11.15pm yesterday in Damansara Specialist Hospital.She was in a coma for 3 days(I think!) after suffering from a haemorrhagic stroke.3 days prior to admission, she was in a midst of a discussion with Dato Siti with her old husband wtf in TV3 HQ Bandar Utama before collapsed.

To me, she was an icon legend.It came as a shocking to me becoz she was one of the few directors in Malaysia who can actually made a difference in the local entertainment scene.She was well known with her movies such as Gubra and the latest Talentime.Though I didnt watched all of them but from the outstanding reviews and the awards that were received, I am sure Malaysia is and will always be proud of her.

This prolific director has her own unique way of reaching to Malaysians heart through her tv commercials for Petronas.Some of them were witty,funny and some were of coz deadly sad.Nonetheless, all of them had special meaning to it. This was a big loss for Malaysia.Great minds like these dont come very often.Let us all pray for her peace and may Allah bless her soul.Amin.

p/s I went to the gym early in the morning and work my a** out and currently energy-less .zzZZzzz...Have a nice weekend everyone! =)

Critical appraisal

2009-07-23T10:13:00.006+08:00

My groupmates and I are currently doing critical appraisal on a medical journal.The title is

'Effect of long-acting Nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatmet (ACTION trial): randomized clinical trial'

Doing clinical appraisal is not an easy task.Now is the time to apply all the knowledge and thats when then the problem comes.
I'm tired and I juz wanna sleep.

edited at 9.15pm today.

This posting is good coz one of its main objective is to ensure u on how to critically appraise a journal so that u wont be duped by a short-wearing skirt drug representative,promoting their drugs later when you work as a doctor.Sadly, there are significant numbers of doctors out there who are clueless/confused about evidence based medicine, therefore become prey for drug companies.
I didnt know that there are a lot of types of medical journals out there .eg diagnostic,prognostic,therapeutic etc.Tomorrow is exam.byebye.

p/s: The Good Clinical Practice (GCP) certificate exam is next week.comon bebeh, nak jadi certifified medical researcher.

p/s2: omg.so many technical terms involved

Bersosial

2009-07-16T01:04:00.003+08:00

Went for workout at the gym just now.Currently having abs cramp, contracting intermittently...

Will be having elective proposal presentation with Prof Khairul tomorrow at 1.30pm....

Will be watching the NEW Harry Plotter movie at Cineleisure tomorrow with a couple of friends....

Will be watching Nik's band performing at the Laundry The Curve Damansara tomorrow night...

Who says medical students cant have social life?

And so the NEW semester starts

2009-07-14T00:39:00.002+08:00

Yes, and so the new semester starts.Will be doing a posting called 'Research and Evidence Based Medicine' or in short 'REBM'.
I quote from my course handout:

'It is crucial and indeed critical for future doctors to be trained in Evidence Based Medicine and how to apply it in daily practice.Many universities neglect this topic, some do not even teach it formally at the post graduate level.Clinical epidemiology is the basis of Evidence Based Medicine, a mantra repeated by many,understood by a few and practice by very few'.

Learning on how to think (critically, laterally and creatively) are essential in a doctor's life.We wudn't want to be duped by the drugs rep when we work later.We need to be able to critically appraise medical journal which are needed to know which facts are fake, which facts are true.Critical and analytical mind plays vital role in the success in this field.

This course will only be for 4 weeks, in which I will b sitting an internationally recognised exam in order to obtain 'Good Clinical Practice (GCP) certificate'.Passing this test will mean that I'll be an internationally accredited as a researcher in medicine( so I was told.I wasnt interested yet upon hearing this).I will b able to conduct experiments using humans!(Now I'm all hyped up!Conducting tests with humans, how cool is that!!!)This course are usually offered at post graduate level but I am indeed lucky to sit this test during my undergrad.It is indeed expensive to sit for this test if u r an independent candidate,probably need to pay a few thousand RM.I dont need to pay a single cent.Now how cool is that.I hope and I will try my best to pass the test.

REBM looks challenging.

ps: I didnt know until about few days ago that there actually people who consistently, diligently read my blog.Looks like I have to take blogging a little bit more serious.yeah?

And so the semester ends....

2009-06-12T02:08:00.006+08:00

Alhamdulillah...

Maka dengan ini tamatlah pengajian perubatan saya untuk tahun ini...

Had my long case clinical exam last Monday.Dapat COAD case.Malangnye patient was rather a poor historian.History was rather here and there.Rasa nk menangis pun ade masa clerking.However, I still managed to get good differential diagnosis in the end.Differential diagnosis sangat penting because without them we cannot suggest relevant investigations to the examiner which carries 20 marks in exam.Discussion part was okay except kantoi sket bila ditanya pasal 'What do you know about H1N1 epidemic?Like need to know how many positive cases so far, mortality rate etc'Nampak sgt tak tekun membaca newspaper...

Theory paper was today.The questions looked easy but actually tricky.Quite frustrated with the Single best answer section.SAQ and EMQ were okay I guess.I seriuosly cannot forget my pre clinical basics because they will still ask them in clinical exams.Like how am I supposed to remember the name of the stain used for Cryptococcus neoformans.The answer is Indian stain by the way....

Went to help my juniors with revision later in the evening.They are about to sit for their first paper tomorrow.Professional exam babe...jgn main-main punya exam.An exam that will determine them whether they are fit,worthy and most importantly safe competent medical students to roam the wards.Good luck guys.

Its 2am,just got back frm 'lepaking' with my old friends around KL.Its good to update myself with their latest gossips hahaha.just kidding

Okla.1 month holiday.Any suggestions on how to spend the holiday?

p/s: Finally Ronaldo is leaving Old Trafford for Bernabeu at a whooping price tag of 80million pound sterling.A warm goodbye to Ronaldo-he's been a good servant , and all parties got what they wanted.Let's leave it at that.

Air mata

2009-06-05T20:39:00.004+08:00

Dear blog, u know what....I have a confession to make.I cried this week!

It happened 2 days ago during bedside teaching with prof.I had a patient who had stroke 2 days ago.She is a 43 yr old Indonesian lady, came to Malaysia about 6 months ago utk mencari rezeki yg halal,workin as babysitter.But she developed stroke and now is paralyzed on her right side.Everything went ok, but soon after I performed neuroligical examination of the lower limb on her in front of prof and my colleagues, she suddenly grab my prof's arm and start to say things like, 'Tuan dokter, tolong obati saya.Saya tak mahu jadi begini.Tolong.Tolong.Tolongg..." Allah...dats when my lacrimal gland starts to produce tears.Ok.I was like wtf, stop crying silly!(umm..I was saying silly to myself n not to d patient)Anyway,its not like tears running down the cheek.Its more like 'air mata bergenang-genang di kelopak mata"I can see that my colleagues are experiencing the same thing.We tahan.Try to look professional.But again, we are also human beings and the emotion sort of transcends right into our hearts.
Similar things happened towards another patient.It occurs the same day.She is a middle-aged Malay lady, came in with intermittent vertigo(dizziness).It was rather an interesting case because she had cerebellar signs such as nystagmus, intentional tremor,ataxia,dysdiadochokinesis etc. Again, after Hanan performed physical examination to elicit cereballar signs on her, she started to say ," Tuan dokter, ni can... can... cancer ker?"...and she started crying.I really admire the way how prof handled and tackled these emotional moments.He motivates patient.He tell them to think positive and be optimistic.By the way, we dont think its cancer because the history does not suggest that it is.Moreover, the cerebellar signs are not vivid.Even if it is a CP(Cerebello-pontine) angle tumour, the ENT surgeon can easily remove them.
It break our hearts to be in this situation.Its hard to be optimistic when you know that the disease such as stroke do not have a good prognosis.There is nothing much we can offer!Once kena stroke, poof... its hard to predict.The only thing to do is to motivate patient,telling them that they cannot lose hope.Patient come to us because they trust us.They hope that, with the help of Allah and to our utmost capabilities ....we can cure them.Ok.This is dilemma right there.I better stop now.Nak pegi dinner......

p/s: My long case clinical exam for internal medicine is on this Monday(3 hari lagi!)at 2.30pm.Doakan ye.... =)

Paeds Surgery

2009-05-31T21:46:00.005+08:00

Me and Hannan went to the Paeds Surgery ward in UMMC for the second time(and yes during the Sunday).Today we followed the morning ward round, headed by Dr Syariz Izri the Paeds surgeon MO (he is my cousin by the way).Managed to see a few cases such as pancreatic pseudo cyst, cystic hygroma, Hirschprung's disease, imperforated anus etc.

Later, we discussed about the topic regarding stoma, since that it can come out in our short case surgery exam.Stoma literally 'mouth' in Greek or Latin.The other name for stoma is colostomy or ileostomy.Depends on where the stoma bag is.There are many types of stoma but the popular ones are loop-type and double-barrel type.We also discussed about the important points that we need to mention during the short case exam.They are:

1.Sitting of a stoma (as a rule of thumb, stoma must be placed away from bony prominences such as the ASIS and away from the umbilicus)
2.Type ( Loop or Double-barrel)
3.Content of a stoma bag (feces colour, consistency etc)
4.Complications ( skin excoriations, paracolostomal hernia etc if visible)

We discussed about few other things la such as indication and complications of stoma.Umm malas nk type dah....
We pinjam-ed a baby who has Hirschprung's disease.Did rectal examination and boy there was a sudden gushed of feces coming out just right after removing our finger out from the anal canal.A sudden gushed of feces is a pathognomonic feature of a Hirschprung's by the way.

Later that day, spend a few hours in the gym and later rushed to Shah Alam for Eda's sister wedding.

ps: OMG logbook internal medicine masih agakkk kosong.Abeslaa 2 minggu lagi dh nak kena hantar

XM

2009-05-28T23:09:00.003+08:00

Final exam of Internal Medicine in 2 weeks time.I must admit that I am starting to feel a lil nervous.

My patient, the 15 year old boy who has hypokalaemic periodic paralysis dh discharge petang tadi.I hope he will achieve his dream of becoming an architect.Rajin.Bile dtg kat katil mesti tgk dia tengah buat soalan latihan.Pastu cepat-cepat sorokkan buku tu.Malu.Haha.Remember dik, poverty should not become your 'batu penghalang' in achieving your dreams.I shall pray for your success!

P:s What a long day.Bedside teaching sampai pukul 8pm.I'm not too sure wht I've learned juz now

Disbelief

2009-05-26T22:19:00.004+08:00

Dear blog, sorry for not updating u for quite some time.It has been a busy weekdays and weekends.Yes, I have to come to the hospital even on Saturdays and Sundays.Saturday in HPJ.Sunday in UMMC at Paeds Surgery department.It's all becoz I am teman-ing my groupmate Hannan who will be doing her elective in Paeds surgery in the UK next month in the prestigious,world-famous Paeds surgery hospital, the Great Ormond Street Hospital.Its good for her to get some early exposure before going there.Good luck Hannan!

I am surprised and totally taken aback by the lack of history taking as well as presentation skills among houseman(HO).Particularly who graduated from that country.I tried not to be prejudiced.But so far I've met 1,2 and 3 HOs graduated from that country who shows similar trait.Tell me, how can you diagnosed a patient without knowing on how to take a proper history.As we all know, 90% of the diagnosis is made thru history taking alone.The rest are confirmatory.Izzit due to the lack of clinical exposure during clinical years?Are they not trained to take history?Lack of practice? Lack of patient access in the wards?Lackadaisical attitude of their lecturers?Easy passing mark during exams?or simply unmotivated during clinical years?Enlightened me.How can you make a diagnosis of chronic liver disease when you cant name any signs of chronic liver disease- palmar erythema, Dupuytren's contracture,spider naevi,caput medusae,gynacomastia and testicular atrophy-to support your diagnosis?I thought these are basic stuff that should have been taught during meds school.These are a must know knowledge!

Consequently,who will suffer the most?Yes,its none other than the patient.It serves as a reminder to myself.I hope that I could improve on my history taking as well as presentation skills.As for now, I tend to jump to the associated symptoms before even giving a good elaboration to the chief complaint.I pray to Allah in every step that I make.

ps:Sorry.I'm being frank here.I dont talk this stuff to anyone.I do this only in my blog.

Altered sensorium

2009-05-13T22:03:00.003+08:00

Today was a bad day la I guess.

Went to the female medical ward early in the morning before the ward round starts.As usual, went to the nurses counter.The usual question came out ,"A'kum dan selamat pagi.Staff nurse, ada brape patient baru admit ke ward petang semalam?" I was a bit unlucky becoz the Sister(Ketua Jururawat) was moody.'Staff nurse, buat ape u layan sgt medical student ni?Jgn layan sgt.Kalau kite layan kerja kita takkan siap.U medical student dh buat orientasi kan?Haa tak faham lagi ka?'
I swear to God that I almost take the BP set and throw at her fat face.Wasnt she listening?My question was simple.'How many new patients admitted to the ward yesterday?'I need to know becoz I have to freakin go and clerk and do physical examination to those new patients.Preparing b4 the ward rounds becoz the Specialist would surely to either ask us to present the case or give the case summary to them.It's not that I am asking that staff nurse to bring me and show me every single new patients one by one!I'm sure that big fat old hippopotamus with that st*pid looking white hat sticking on her freakin hair has sensorineural deafness.Pardon me.Yes,I was pissed.I admit and rela dimarahi if I've done something wrong.But I got irritated if I was freely being lectured for some unknown,unjustified reasons.I dont know.Some nurses and sisters are downright cocky to the core.

At a different note...

Multiple sclerosis,Lung ca with secondary metastases to the brain as well as iatrogenic Cushing's secondary to exogenous steroid-are some of the new cases admitted to the ward yesterday.

PS: Currently doing case write up( 2 long cases and 2 short cases to be submitted tomorrow).Another sleepless night...

Think what patient's think

2009-05-12T22:28:00.008+08:00

So many things have been happening for the past 2 days.On Monday, we witnessed the launching of 'Minggu Kesihatan Angkatan Tentera' bersempena dengan ulang tahun Kor Kesihatan Angkatan Tentera Malaysia yang ke ...... .Ntah, saya pun tak tahu.Will post the video perbarisan once I copied it from a friend of mine.

Did you know that stroke or 'angin ahmar' is believed to be associated with serangan syaitan?That's what some of the Malays thought.I've heard this notion before but had never ever thought that I would come across a patient who believe this so soon.One of my assigned patient suffers from right sided limb weakness associated with facial assymmetry 4 hours prior to admission.He was admitted 4 days ago.He is a known case of uncontrolled hypertension as a result of non compliant to medication.His systolic BP upon admission was unrecordable,while his diastolic blood pressure was 150 mmHg.Thats super duper high.We would grade his hypertension as 'Stage III Hypertensive emergency' under the new CPG guideline.Anyway,during history taking that patient started to tell his own version regarding the 'pathophysiolgy' of stroke.According to him, he believed that a devil would penetrate his body through the heart before being disseminated throughout the body.The most vulnerable part of the body will eventually manifest as limb weakness.He believes that stroke is curable especially when treated by powerful shamans or 'bomohs'.He even suggested me to learn from a few bomohs and that he could recommend me to them if I am interested.
Its interesting to think what patient's think sometimes.Scary.

Pic1: Pic was taken today.This is a tophi at the right elbow.This patient is having chronic tophaceous gout

Pic2: This pic was taken yesterday.The chest x-ray shows 'Boot-shaped' heart.This patient has ischaemic dilated cardiomyopathy.

Happy Mother's Day

2009-05-10T19:47:00.003+08:00

Happy Mother's Day to my mother and to all mothers throughout this world.

Woke up at 8.30am this morning.Its Sunday, I was lazy indeed.However, we had to carry out a medical check-up in Bandar Tun Razak.Waqi contacted me yesterday saying that they need some men to run the booth.The medical check up is part of the activities being held during the Mother's Day celebration anjuran Puteri UMNO bahagian Bandar Tun Razak.Kak Sha was the contact person.

Arrived late, around 9.30am.Sesat.The signboard for Taman Tenaga was nowhere to be seen.We opened the booth as soon as all of arrived at the scene.Once the registration booth were opened, a hoard of people menyerbu.My god.I manned the Blood Pressure taking booth.Bayangkan orang beratur mcm nk mengundi je.Line panjang.I was taking the BP for almost 2 hours straight without getting a rest!Nobody was kind enuff to give me at least a mineral water.Anyway, had a little bit of fun when I get to practice my 'counselling' skill to makcik and pakcik.PLease take care of your diet,stop smoking,exercise more etc etc.Yes.Its important.Doctors ( or future doctor as in my context ) should play roles as a teacher to patients.Educate them with knowledge that they supposed to know.It makes things easier in the end.

PS: I am curretnly back inTerendak.Will have to go to the medical ward tonight to clerk and update new patients.

The Bashing up day

2009-05-06T20:59:00.004+08:00

Today was a bashing up day by prof.From bedside teaching to our TBL session.Extremely tired.The day starts at 8am and finished at 7pm.Extremely tiring, physically,mentally and emotionally.We have the knowledge but the problem is that is how to apply it in a real situation-ie translate it into our working environment such as using those knowledge during history taking so that we could ask relevant questions,looking for focused,relevant physical signs,ordering for relevant investigations etc.

If I were to stop pursuing medicine, this day would justify it

ps: I do not know what to think about myself right now

ps:Patient case presentation for today was about 1) Unstable angina 2) Acute exacerbation of asthma secondary to rhinosinusitis 3)Beta Thalassaemia major.TBL was on "Approach to DM and Dyslipidaemia"

Internal Meddicine Week 3

2009-05-05T14:26:00.004+08:00

Another reason why I dislike Paeds.Sometimes while clerking patients (a.k.a kids) will b busy doing somethingelse.This pic was taken yesterday when adik H was admitted due to Poorly controlled asthma (classification based on the latest Asthma classification-the GINA classification).My friend Hanan was so into clerking his history while he , on the other hand was busy playing with Gameboy.She had to come to the ward at night to clerk his history.And at the end, this is what she gets!

No lar, I'm not making a big fuss out of it.What is more interesting is the chest x-ray findings.His chest x-ray shows tramline and ring shadows which is consistent with the diagnosis of bronchiectasis.We r doing CT Scan tomorrow morning to confirm the diagnosis.Will try to take the chest x-ray pic and paste it here. =)

Ps: Internal Medicine is so tiring.But luckily it is interesting at the same time.

Ps: Had 2 TBL today- 'Lethargy' and 'Cough n Wheezing'.The second TBL was done with Dr Rosman.We have to change to our sports gear and went to a place near the sea shore and had our discussion there in the late afternoon.Dpt tengok sunset skali.......

Ps: Spend 2 hours in the clinic today.Got to clerk and see cases like Asthma, Migraine and Beta Thalassaemia major.

Ps: My patient with Unstable angina is stable.Dr Pakar are keeping him in the ward to stabilise his blood pressure

HO,MO,Specialist,Consultant

2009-05-01T15:13:00.004+08:00

Its labour day.Still, no holiday.Drove from Terendak and reached KL yesterday evening.Attended 2 teaching sessions by Dr Rafizie and Dr Shuhaila this morning in Hospital Putrajaya.Did I mention that they are married together?Hehe.They are so motivated in teaching us.May Allah bless the couple.Seriously, they are both good and nice.

According to Dr Rafizie,

HO = Hamba Orang
MO= Makan Orang
Specialist = Syphilis
Consultant= Con-setan

LOL

Ps: Revision mania syndrome

Critical vs cynical

2009-04-29T19:37:00.003+08:00

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

Bakti Siswa & Anak Anak Angkat program

2009-04-27T16:55:00.010+08:00

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.

Internal Mad-icine

2009-04-23T23:13:00.003+08:00

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.

Of elective posting and research

2009-04-22T21:05:00.003+08:00

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 =)

IM mini homework

2009-04-21T21:24:00.003+08:00

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!

IM first day

2009-04-20T21:37:00.002+08:00

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...

How to succeed IM(Internal Medicine)-pesanan dari Fana hey!

2009-04-19T00:23:00.003+08:00

Hmm...so 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)
>respi
>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~~~!

Holiday

2009-04-13T00:30:00.003+08:00

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
Endocrinology
Neurology
Musculoskeletal system
Haematology
etc.

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

Viva

2009-04-08T20:30:00.005+08:00

Disclaimer
**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%.
-etc.

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.
Answer:
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-30%
Food handlers-20%
Sewerage system-10%
Waste dumping-10%
Food containers and utensils-10%
Premise's floor-5%
Toilet-5%
Water source-2%
Others-8%
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

Busy bee

2009-04-07T15:28:00.003+08:00

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)

SPM 2008

2009-03-23T16:04:00.003+08:00

Dengan ini saya ingin mengucapkan tahniah kepada junior-junior saya.Tak lupa juga kepada Makcik DS yang telah berpenat lelah memasakkan makanan untuk kami.Juga kepada warden-warden block yang sibuk suruh 'lightsoff' setiap malam.

SPM2008: Ranking mengikut Sekolah-sekolah di Malaysia.

MRSM Langkawi (1.4041)
MRSM Taiping (1.5391)
MRSM Pengkalan Chepa (1.5439)
SASER (1.612)
KISAS (1.68)
MRSM Tun Ghafar Baba (1.6865)
ASIS (1.754)
SAMURA (1.83)
SESTER (1.841)
SBPI GOMBAK (1.883)
SAINS JOHOR (1.906)
MRSM Alor Gajah (1.9326)

p/s: PCian...kita aummm skali..Auummmmm! <---- gile tak cheer kitorang dulu mcm ni?

E-hospital

2009-03-19T09:40:00.003+08:00

Much have been said about the letter 'e' here in Malaysia.e-government,e-commerce,e-ni ,e-tu and of course e-hospital.Just like in any system or policy, there would be pros and cons.

E-hospital

Points for E-hospital
1.Patients data will be key-in and kept more efficiently.
No need to take the trouble to find the file in the store room.Patient's history, diagnosis, investigations, x-ray,MRI,CT scan record is just a click a way.I've visited the Medical Record room , a place where medical records are being kept.They are being kept neatly and meticulously with the colour coding and all.I'd go nuts if I were to be the person in-charge of that department.

2.More safety?
Umm...probably since password is needed before access is gained into the Hospital Integrated System (HIS) developed by Microsoft company for Malaysian hospitals.But, again we never know.Hackers are getting smarter and smarter by the minute.

Points against E-hospital
Both of my teaching hospitals are E-hospitals(Hospital Serdang and Hospital Putrajaya).Next year baru pergi Hospital Kuala Lumpur( not an e hospital, more like an eeeeuww hospital.LOL).So at least my points below are valid and reliable.

1.Lack of personal touch from doctors to patients
I've managed to ask the doctors who uses this system, particularly when in the clinic.All they cud say is that they prefer the 'oldies' method.ie writing in papers.Just imagine patient is seating on your right while the computer is either on your left or in front of you.So your gaze is not towards patients but rather at the computer.

2.Computer hang!
Haha this is the usual complaint.Kalau tak hang komputer tu lembab.I've seen a lot of cases where the doctors were frustrated becoz they need to restart the computers quite oftenly.

Note: Pray for me.I have an SPSS exam in about an hour time.Sronok gak dpt apply statistic knowledge yg tak seberapa ni.Faham? ok takpe

Jem

2009-03-12T00:31:00.002+08:00

Jem atau JM atau nama penuhnya Jururawat Masyarakat merupakan anggota kesihatan primer yang sangat penting di peringkat kesihatan awam.Mcm mana nak bezakan mereka dengan Staff Nurse? Mereka ni pakai riben warna ungu dekat tudung.Kalau Staff Nurse pakai riben warna biru.

Tadi pergi ke Klinik Desa Ulu Chuchoh dekat Sepang.Belajarla skop tugasan JM ni.Tak sangkanya tugas mereka ni berat.Perlu mengenal ahli masyarakat setempat dengan rapat.Pergi buat home visit,program bakul JM,tanam benih sayur-sayur dekat halaman rumah etc.Sangat respek dengan profession nursing ni.

Petang lepas tu pergi ke Taman Desa Vista.Nak continue buat community survey.Alangkah sakitnya hati.Tak perlu cerita kat sini.Maghrib dekat surau sana.Nak bina good rappot dengan Kelab Rukun Tetangga sebab tak lama lagi nak anjurkan program intervensi kesihatan berdasarkan result bancian.Ada juga diadakan mesyuarat dengan AJK KRT.Sekarang tengah menulis segala jenis surat-surat yang nk diberi kepada Majlis Perbandaran, Ketua Pegawai Kesihatan Daerah etc.

Esok pegi ke sekolah berdekatan.Nak tengok 'School Unit' dari Klinik Kesihatan menjalankan program dekat sana.Of coz, report tak dilupakan.Semua visit mesti dibuat reportnyaaa......Tak larat sgt

Voice yillekkk

2009-03-08T00:50:00.008+08:00

-Melawat tapak pelupusan sampah utama Sepang.Busuk yang amat k-

Hari ni first day kami buat community survey.The survey or bancian is based on our own Questionnaires ( ada 104 questions kesemuanya).Questionnaires ni melingkupi banyak aspek kesihatan, namely tabiat merokok, iklan merokok (mcm gamba kat bawah ni) women's health, injury, traditional and complementary medicine etc).Soalan2 dibuat berdasarkan fakta yg diperolehi oleh journal jounral public health and epidemiology yang kami baca.Tensyen gak ar.Kena edit Questionnaires tu sampai 5 kali sebab prof suruh.Anyway, dah siap questionnaires, satu hal pulak nak repeat 104 soalan2 sama utk setiap orang yang dibanci.At the end of the day, HILANG SUARA.padan muka.yeay.

Hasil bancian akan direkodkan ke dalam software yang dinamakan Statistical Package for Social Sciences (SPSS).Famousla software statistic ni.Semua medical students tau gune kan kut.Bile ade research je, mesti kena gune ni.Time kerja pun akan gunakan software ni.

-Tengah suruh akak ni rank kan gamba2 iklan merokok -

-We work in pairs la basically-

Pada 28 Mac ni nanti akan ada "Health Intervention Programme".Segala hasil bancian akan dibentangkan kepada penduduk2.Disamping itu nanti akan diadakan aktiviti2 promosi kesihatan seperti medical check up,pap spmear, dental check up,derma darah.Aktiviti2 ni akan berjalan dengan kolaborasi Pejabat Kesihatan Daerah Sepang,Klinik Kesihatan Salak dan JKKK Tmn Desa Vista.Datanglah,semestinya karnival ni lebih berfaedah dari Sure Heboh TV3 yang tak mendatangkan ape ape tu.LOL

Tidak mahu balik

2009-03-01T22:41:00.005+08:00

Boleh tak tajuk post kali ni macam tu? LOL.Hari ni saya membelenggukan diri di bilik.Menyiapkan report District Health Office (Pejabat Kesihatan Daerah -PKD) report.Banyak kemain.Nak masukkan gambar-gambar lagi.Gambar sampah.Gambar dapur kedai mamak.Gambar jejentik nyamuk aedes.Gambar persampelan air.Gambar tandas orang asli.Gambar tempat buang sampah org asli.Segala bagai gambar la.Report tak siap lagi.Rabu kena hantar.Adey.Esok masih ade sehari lagi attachment dekat PKD Sepang.Tinggal unit Enforcement sahaja lagi yang nk kena cover.Tolong.Aku tak larat dah nak belajar unit-unit dalam PKD ni.Namun, aku tabah.

Lepas lunch aku selsema.Kepala pening.Lalu pergi menerjah ke Fitness First gym berdekatan.Perpeluhan dapat mengelakkan diri demam.Kunun.Please, I cant afford to fall sick.So many things to do.Lari di treadmill for 10 minutes, 10 km/h.Sambil dgr Viva la Vida di iPod nano burukku.Cukuplah, sekadar nak panaskan badan.Lepas tu buat weight training pulak.Namun aku masih berselsemaan lagi nih.Mood lebih ceria.Iyalah, lebih banyak endorphine yang telah dirembeskan ke dalam sistem badan.Better than nothing.

Sebelah malamnya pergi KLCC.Makan bersama famili.Lama dah tak keluar dinner sama-sama.Walaupun aku lambat sepuluh minit.Terpaksa drive ke sana sendiri.Tak gune punye mesin isi minyak.Kad Shell ada masalah.Di KLCC, aku pergi mentry perfume Christian Dior Sport for Men baru.Tengah ada harga promosi katanye.'I'll think about it.Nanti saya dtg balik'.Jawapan standard bila tak jadi beli.Terus salesgirl/salesboy to menjawap ,'Kedai dah nak tutup dah ni bannnng'.Amboi.Begitu sekali nada beliau.Lembut kemain.

OKlah.Nak packing.Esok pukul 9am dah kena berada di Pejabat Kesihatan Daerah Sepang.Tolong.One more day lagi.Aku tabah.

Ps1: Malaysia's latest GDP is only 0.1%.Our economy is totally in a dipsh*t hole right now.And yet we can still talk about politics.

Ps2: I miss Surgery sob sob sob

Ada Apa Dengan Kedai Mamak

2009-02-27T00:07:00.005+08:00

Sekali pandang, nampak sedap betul kan makanan dekat kedai mamak ni?Mana tak sedap,kuah kari yang berusia empat hari yang telah dipanaskan berkali-kali maka teramat concentrated karinya.

Tetapi, mari kita lihat dibelakang dapur mereka.

Wow, lalat sedang menari-nari diatas tempat memotong.Tak mustahil terjumpe Cik Lat kat dalam nasi or lauk satu hari nanti ya.Hm perisa tambahan

Peti sejuk? Memang tak payah cakap lah. Amat terserlah akan kebersihannya.

Semalam pergi bersama-sama dengan Inspektor Kesihatan ( nama baru Penolong Pegawai Kesihatan Persekitaran) membuat rondaan kedai-kedai.Untuk makluman tuan puan, sekiranya skor restoran tak melepasi score "50", kedai mereka akan diarahkan untuk tutup selama 14 hari bagi menjalankan kerja-kerja pembersihan.Sekiranya gagal, pemilik restorang bileh didakwa dibawah Akta Makanan 1983.

Sekarang tengah attach dengan Pejabat Kesihatan Daerah.Esok nak melawat tempat pelupusan sampah, kampung orang asli dan dan belajar cara-cara menjalankan persampelan air SYABAS.Ya itulah dia posting kesihatan awam dan perubatan komuniti.Tersangat adventure.

ps: Tak teringin nak makan dekat kedai mamak lagi. Memang aku bagi score 'Fail' la kat kedai mamak tu

Kami Sedia Membantu

2009-02-24T21:46:00.005+08:00

=Pic taken from The Star newspaper =

The Ministry of Health Malaysia, through its latest campaign has reaffirm its commitment in making positive changes towards our healthcare system.

Personally, I think our healthcare system are good.It is something that we can be proud off.A lot of statistics that can proved that.We are efficient.We are tech savvy.Yes, there are a few things that needs to be improved eg: communication skills towards patients.Some might disagree probably due to the long waiting hours that patients have to endure, but hey we are swallowing more than we could chew.

I support the move by the ministry.But please dont forget that we ( or rather me , in the future insyaAllah) are working our A** OFF 24/7 for the citizen of Malaysia.Do not forget our needs.After all, we are also human beings ( not robots ).

Note : Dear patients, please be a good story-teller about yourselves.80 percent of diagnosis come from YOUR story.No, dont believe most of the thing that you see in Dr House.Good doctors have good clinical acumen, they dont rely too much on CT scan or MRI hullo-balloo.

PR

2009-02-23T09:18:00.007+08:00

= Gambar group semasa Jamuan End of Posting, kami bersama 2 lady surgeons=

In medicine, PR may bring two meanings

PR = Pulse Rate

PR = Per Rectal examination

Tapi saya nak bercerita tentang the second meaning of PR.Per rectal examination is part of the abdominal examination.It usually done during Surgery posting for surgical cases.Bagi orang biasa mungkin PR ni setakat memasukkan jari telunjuk ke dalam lubang dubur (anus).Tetapi, percayalah, banyak information yang boleh didapati dari PR.Sebab tu lah doktor diwajibkan buat PR bila ada indikasi.Banyaklah PR yang telah dibuat oleh aku semasa Surgery posting dulu.Memang aku practice betul-betul.

Nak la bercerita tentang seorang patient aku ni.Dia dah tua, umur 75 tahun.Dia ada obstructive jaundice secondary to para aortic lymph nodes metastasis ( Faham? Kalau tak buat buat faham =) )Patient ni tersangatlah comel.Suara pun comel.

Tapi satu benda yang paling comel bila masa buat PR.Tak tahu kenapa, patient ni selalu terkentut. Bile kentut, dia akan cakap ,

" Eh, terkentut pulak.he he he"

"Takpelah nek, kentut lah puas puas".Itu je yang mampu aku reply.LOL

I dont know how is she right now.I hope that she is in good health.Pesanan terakhir, tolonglah bagi consent or permission sekiranya seseorang doktor tu nak periksa.Kami bukan suka-suka nak periksa.Ada reasonnya.

Komen1: Entry ni ditulis semasa public health proposal presentation.Aku mengantuk ni.Balik rumah pukul 5 am semalam.Tidur 3 jam je.krrrohh krrohhh zzZZzz.Tolong tolong, kelopak mata dah layu dah ni.

Komen2 : Public Health specialist ni merupakan seorang yang analytical dan tersangat statistical.Otak asyik nak buat statistic.Tolong, aku mungkin jadi gila kalau lama-lama dekat sini.

Komen3: Nasib baik aku pegi Gym skrg.Kalau tak mesti dah jatuh sakit

Kelinit Kesihatan

2009-02-22T23:15:00.003+08:00

Ya.Kelinit dan bukan Klinik ye tuan-tuan dan puan-puan.Comel betul la patient saya ni.Pergi rumah dia terus terasa macam ahli keluarga.Ramah yang teramat.Jamu kuih ini dan itu.Air dipaksanya minum sampai 3 gelas, kalau tidak tak boleh balik.

"Pakcik, bila appointment pakcik dekat KK Salak?"

'Owh, minggu depan dekat Kelinit tu"

Deym, tak tahu kenapa tapi memang terasa nak gelak guling-guling dekat situ jugak.

PS: Banyak g*le kerja okay.Esok presentation for Questionnaires and Proposal for our Health Intervention Programme.

Public Health and Community Medicine posting

2009-02-17T11:07:00.003+08:00

Baru sahaja hari kedua, tapi dah banyak kerja.

-Journal reports
by this Friday (Power point and Narrative form), encompassing the big 4 areas ( Nutrition, Exercise, Smoking and Mental Health) + Women's Health + Injury and 1 special topic.We chose TCM (Traditional and Complementary Medicine).These journals are important for us to develop Objectives and questionnaires for our Community Survery's Health Interventional program at the end of the posting

-Field visit and reports
will be having a few field visits reports such as Klinik Kesihatan, Klinik Desa, District hospital.The not so nice part will be reports for each visits

-Patients Health Community Studies
I have been given a patient from Klinik Kesihatan Salak yesterday.I have to update him from time to time, in Public Health point of view.Kena call patient petang ni untuk buat temujanji

-Learning SPSS (Statistical Package for Social Sciences)

Public Health plays a vital role in ensuring health of the community.It plays an important role in prevention of diseases.Public Health looks upon the community as a whole in order to come out with what we called as comunity diagnosis.

This posting, I think will enhanced my view regarding Medicine.Medicine is a very very wide discipline.It not only revolves aorund things in the hospital.

Nota: Ok.Saya pun masih dalam kegelapan.

Jogathon

2009-02-14T13:45:00.003+08:00

Saya yakin,anda semua pasti pernah memasuki acara jogathon.Regardless, suka atau benci saya pasti anda semua perlu berlari pada hari tersebut.Saya sangat tak suka jogathon ni.Saya pasti mencari alasan untuk tidak mahu datang ke sekolah pada hari tersebut.Pun begitu, ibu saya seorang yang strict.Ibu seorang yang tidak akan melayan karenah anak-anaknya, lebih-lebih lagi dalam hal memonteng sekolah ni.

Saya nak bercerita tentang dua perkara; sebelum jogathon dan juga semasa jogathon.Apabila kita menyebut jogathon,the the first thing that comes to my mind is mengutip derma.Alah, masih ingatkah kamu semua kepada kad-kad jogathon yang diperbuat dengan kad-kad manila itu.Pada setiap tahun, 2,3 bulan sebelum menjelangnya jogathon kami semua akan dikerah untuk mengutip derma bagi jogathon tu.Frankly speaking, I hate this part right here.I really hate the idea of begging for money in the shopping malls or along the street.Apatah lagi kalau kalau terjumpa dengan sanak saudara along the way.Mana la nak letak muka beb!Anyway, ramailah rakan-rakan kelas yang berlumba-lumba kutip duit.Selalunya mereka semua akan meminta dari makcik or pakcik dikampung.Paling best kalau dapat bawa kad jogathon tu balik kampung semasa hari raya.Tak kurang juga yang akan top up kan kutipan derma tu menggunakan duit raya sendiri.Al kisahnya,adalah seorang rakan sekelas masa darjah enam ni.Dia anak orang kenamaan.Ayahnya merupakan Bendahari Kerajaan Negeri Selangor.So bayangkan networking yang dia ada.Aku masih ingat lagi,hasil kutipan jogathon beliau membolehkan kelas kami membuat school trip ke Melaka.Masa tu Melaka tak diiktiraf UNESCO lagi.Dengar khabar angin, beliau telah menggunakan sampai 4 hingga 5 keping kad manila jogathon tu.Habis penuh setiap ruang.Nak tahu aku gune berapa kad masa tu? Tak payah sembang la berapa kad.Aku hanya menggunakan satu kad yang mana hanya penuh 1/4 sahaja.Semua derma bersen sen je.Paling tinggi pun hanya RM1 je.Hasil kutipan aku? Adalah dalam rm15 je.Hebat tak?

Sekarang nak bercerita pasal hari jogathon pula.Selalunya aku akan mempunyai beberapa geng semasa 'berlari' jogathon.Excuse me, kami berlari juga ya, tetapi larian kami boleh dikategorikan sebagai 'lari lari anak' sahaja.Sori, saya bukan atlet olahraga sekolah.Badan pun chubby masa tu.Semput kalau lari kuat kuat.Setiap kali jogathon, aku akan pastikan supaya ada RM2 dalam poket seluar PJK aku.Manalah tau, kalau kalau tak larat nak 'berlari' nanti boleh la aku tahan teksi kat tepi jalan.Kalau tak tahan teksi, duit tu akan digunakan dengan cara yang lain.Aku dan geng geng akan singgah ke kedai Ah Hong kat tepi jalan.Kami akan tukar duit kertas tadi kepada duit syiling.Nak tahu kami buat apa lepas tu? Kami gunakan duit tu untuk menikam.Alah, permainan yang kita masukkan duit syiling ke dalam mesin yang berhabuk tu.Kalau lucky, dapatlah kad dragon ball satu atau dua.Kalau unlucky, dapatlah kacang kuda.Sedap juga kacang kuda tu sebenarnya.Last sekali, kami pasti membeli ais krim.Bukan ais krim Paddle pop rainbow ya.Kami tak mampu nak beli aiskrim yang mahal-mahal.Duti belanja sikit.Kami beli aiskrim dalam plastik berperisa asam boi je.Nikmat sungguh dapat makan ais krim tu ditengah tengah panas.Kasihan tengok rakan rakan yang semangat berlari tu.Bukan dapat hadiah hebat kalau menang pun.Dapatlah hamper Mamee dan Maggi.

Pun begitu,aku dan geng geng aku selalu dapat tempat pertama dalam larian jogathon.Tempat pertama dari belakang.

Perluaskan

2009-02-13T21:55:00.002+08:00

Perluaskan.Ya aku rasa aku perlu meluaskan jaringan ataupun rangkaian kawan-kawanku.Takde lah dikalangan budak budak medic sahaja.Tapi, jangan salah sangka.Aku masih mempunyai kawan kawan yang membuat course selain dari medic, terutamanya kawan-kawan yang aku semasa aku di sekolah rendah yang aku masih keep in touch.

To tell you the truth, aku sangat terkilan kerana aku kurang keep in touch dengan rakan-rakan di sekolah menengah rendah( SMK St John, KL ) dan juga rakan-rakan di sekolah menengah atas ( MRSM Pengkalan Chepa,KB ).Memori suka-duka kita bersama masih terpahat di memori ini.Adakah salah mereka ataupun aku?Bila difikir-fikirkan balik, rasanya salah aku.Iya lah.Aku ni busy.Tapi nak kata busy sampai tak boleh bersosial rasanya tak betullah statement tu.Ada je masa tengok wayang ataupun berkaraoke dekat Redbox dengan rakan-rakan lama.

Sorry kawan-kawan, bukan nak kata anda membosankan aku.Tetapi, to tell you the truth aku rasa minda kita tak berkembang kalau asyik membincangkan case-case medical ni.Kadang-kadang nak termuntah asyik mengulang benda-benda yang sama sahaja.Aku rasa susah orang lain nak faham kalau kita asyik bercakap menggunakan bahasa medik yang bombastic, yang sampai aku sendiri pun tak tahu nak menyebutnya dengan betul.

So,persoalannya sekarang, bagaimana hendak perluaskan networking? To start with, aku sekarang baru mendaftar diri.Alah, masuk gym Fitness First.Ada banyak reason aku masuk gym ni.Pertama untuk menjaga kesihatan.Tak best la kalau kita asyik suruh patient jaga kesihatan tapi kita sendiri neglect kesihatan diri kita sendiri.Kedua, gym ni menjadi salah satu tempat untuk release tension.Ketiga, untuk menambahkan kenalan.Masuk minggu ni dah minggu kedua dah.Tapi baru hari ni rasanya aku nampak 2,3 orang yang aku rasa berpotensi untuk menjadi kenalan baru.Maybe next session kalau aku jumpa aku nak tegur.Selambalah.Maybe nak tegur ala-ala James Bond.My name is Azmi, Nabil Azmi

Nota1 : Sorrylah entry mengarut

Childhood Cancer Support Programme Fund Raising Dinner

2009-02-09T01:37:00.002+08:00

Juz got back from the dinner.I think it was superb!Good food, good performances (Adibah Nor ade) and of coz...good girls! Congrats to my dear juniors in Young Mercy Malaysia Group 3.I'm so proud of you man...will update with the pics and prolly videos as well later...

'till then..zzzZZZzzz

O&G final

2009-02-06T21:29:00.003+08:00

Wah lama sungguh tak update blog ni.Almaklumlah baru habis O&G posting Final Exam.The exam was tough I guess, especially the Long case clinical exam part.I got a GDM(Gestational Diabetes Patient).My patient was:

-at 37 weeks of gestation
-Gravida 7 Para 3+3 ( into her 7th pregnancy, with two history of miscarriages and 1 ectopic pregnancy)
- a Previous scar ( meaning a history of lower segment caesarean section due to GDM with macrosomic baby in previous pregnancy)
-3 previous MOGTT done ( ujian minum air gula, sampai kena minum 3 kali pulak tu due to various indications)
-Blood Sugar Profile (BSP) ranges 6.5-7.Poor diet control.Not on insulin therapy
-1 history of Dilatation and Curettage for miscarriage and one laparoscopic gynae surgery for the removal of ectopic pregnancy.
- 2 Pap smear done
-history of Menorrhagia

Diagnosis: GDM with previous scar.Poor diet control

In short, gile eventful k history patient aku ni AND I've got around 20 minutes to do the clerking.The most frustrating part was when my examiner Dr S said to me: 'Okay u have only 1 minute left"Adey tensyen tensyen.
Physical examination was alright I guess.The symphysio-fundalheight measured 39 cm.The abdomen is grossly overdistended.My impression was: Uterus larger than date with polyhydramnios.Bleh pulak tu aku lupe nk buat fluid thrill for confirmation.dang!
The discussion part was okay except when the examiner asked me,'So Nabil, what do you want to do with this patient".Daym, you know why I didnt say that we should deliver the baby as soon as possible is becoz she is at 37 weeks.Thats like borderline.My answer should sounded like this ' I would like to deliver the fetus by Caesarean section and not via Vaginal delivery considering that she had many previous gynae surgery.The fetus should be delivered as soon as possible (altho the fetal movement is more than 10 times per day) becoz poorly controlled GDM is associated with Sudden Intrauterine Death(SIUD)". Kan best aku cakap cam tu je....frust frust...

Written exam was fair.MCQ single best answer was rather tough, EMQ alright and SAQ was super fine.We had 3 SAQs-Preeclampsia, GDM and Ectopic pregnancy.

All of us went to Bentong utk mandi manda waterfall the next day.Many thanks to Ridzwan and family for their great hospitality!Will upload some pics in the next entry

Note 1: I'm just glad the examiner didnt asked me to give a counselling session to the patient.A few of my friend were asked to do some counselling to their respective patients during the long case clinical exam.Fiuhhh....

Deprived

2009-01-28T00:43:00.005+08:00

Yes, I am deprived of my social life.

A buddy of mine called me this morning, ajak main Pool and lepas tu Karaoke tonight.But I had to reject those offer.Sorry dude, I have final O&G exam next week.I still got tons of stuff to be revised.However, being me I always offer another alternative date.

Pray for my success.Nak success with flying colours lagi~

By the way, Octuplets were born today via Caesarean section in California, USA.I just cant imagine how could 8 babies being stuffed together in a uterus!I have personally have had the chance to observed twin deliveries, and all I can tell is that it is not an easy task both for the mother and the hospital staff to manage the situation.There is a suspicion that the 8 babies were not there by chance.I suspect that an IVF( In vitro fertilisation) were done.Yes the doctors in the US claimed that it has got something to do with ovulation induction drug( ubat kesuburan) and not IVF.But come on, you think you can fool me?What are the odds of having 8 fertilised embryos in the uterus thru ovulation induction drugs?In my opinion, it was very unethical for the doctors to do that.Multiple pregnancies is never good to both the mother and the babies.It has a significant increase in so many complications such as preterm birth, congenital defects and even death to the mother.Would you risk so many lives just to attained personal glory?

Note 1: I never karaoke-ed before.Ntah kena rasuk ape tetibe nk try haha.Pool pun lama dah tak main.Oh yeah, I forgot.I am deprived.I dont have the luxury of time.

Note 2: Currently addicted to a band called Dishwalla.Genre= Alternative rock .Underground band je tapi lagu best best.One of their song called Angels or Devils were made as a theme song for one of the episode of Smallville. <---- WHY AM I TELLING YOU ALL THESE????

Baby bengkak

2009-01-23T00:51:00.004+08:00

(Apela punye title)

Anyway, hari ni ade case Intrauterine death -Hydrops fetalis.The first pregnancy ada hydrops fetalis.This time the second pregnancy pun ade hydrops fetalis.I wonder whether her Obstetrician have identified the cause.My best bet: She must be a Thalassaemia trait while her husband is also a Thalassaemia trait.So that wud make the baby Thalassamia major.However, there are many causes of hydrops fetalis which I will not deal here.I did not clerk her case so I dont know her story.

Dah la nak tido.Penat + mengantuk.Besok pagi pukul 7.50am dah kena ada kat seminar room for morning pass over...sigh...

Note 1: Pic above:Thats me assisting Dr Dahlia.We were doing Caeserean section on a lady.It was a GDM (Gestational Diabetes Mellitus) mother with macrosomic baby, 4.1kg

ZZzzzzzzZZZZzzzzzzzz.........

Gaza

2009-01-21T23:02:00.005+08:00

I would like to ask everyone to pray for the safety and success of the mision for two of my beloved professors who has just entered Gaza yesterday.Both of them are:

Prof Dr Ikram Saleh ( An Anesthesiologist)

and

Mr Al-Amin Daud ( Hepatobiliary surgeon )

Let us pray so that Allah will always be with them,ensuring their mission under the banner of MERCY Malaysia will be successful.

Masih igt lagi patient yg ada anak takde tempurung kepala tu? She gave birth to the baby at 8.20am today.Didn't manage to see the delivery sbb tgh bekpesmasa tu.Member call, ape lagi berlari lari la dari cafe ke labour room.However, I still manage to see the baby.Excited pun ade, kesian pun ade.Excited sbb dpt tgk Anencephaly bedebuk depan mata.Kesian sebab simpati dgn mak dia.The baby has already passed away masa kat dalam kandungan lagi.Really want to take the picture buat kenangan, tapi tak sampai hati nak mintak permission dari mak dia.The baby was taken away by the father at 9 am camtu.
Anencephaly, or fetus without the skull is due to lack of folic acid in the body.Folic acid is essential for the development of the central nervous system during the period of embryogenesis (at first trimester ).Inadequacy will result in neural tube defects such anencephaly.In Malaysia,folic acid will be prescribed to expecting mothers during the booking date.However, theoretically folic acid should be taken 3 months prior to pregnancy, I repeat 3 months prior to pregnancy.This is to give some time for the body to store adequate folic acid before a mother became pregnant.Tapi iyela, sapa la yang nk makan folic acid saja saja kan?Tapi kan, kenapa ada still pregnant lady yang malas mengambil ubat-ubat doktor.Beringatlah bahawa semua benda yang doktor berikan adalah untuk kebaikan anda dan juga kandungan anda.Semuanya ada sebabnya.fullstop.

Note 1: Mr Al-Amin is one of my idol to become a surgeon.

Note 2: Just came back from on-call.Presented my case to the MO on-call, Dr Dahlia.She is super duper nice.I learn a lot from her, particularly tips regarding the long case exams.Thank you so much Dr Dahlia.I will definitely give u some small present at the end of this posting =)

Takde kepala

2009-01-20T17:25:00.009+08:00

I'm officially in the Obstetric ward.A lot of patients.Both of the wards are full.We had to actually open some pseudobed ( pseudo= tipu, bed= well..it means katil) Haha...

Most of the antenatal cases are Pre-eclampsia and Gestational Diabetes Mellitus.However, I had a patient with an Anencephalic fetus ( Baby without the skull and brain).Yep,poor her.I really really sympathize.She is currently in her36 weeks of pregnancy.However, according to the protocol we need to induce the labour.She is currently on Prostin, a type of progesterone for cervical ripening.The last time I checked, the cervical os is opened at 4cm.My professor is asking me to keep track ofthis patient, especially the management part.

I was on-call-ed last nite.Observed an LSCS( lower segment caeserean section) of a transverse lie baby. I became the first assistant to the surgeon for the second LSCS for macrosomic baby.The birthweight was 4.1kg.Memang nampak montel la baby tu.

Some interesting quotes for the past 2 days

" She does not have early symptoms of pregnancy.However, her husband does"
Med student 1 during case presentation

" Med students are the only human beings who are still alive despite being anencephalic"
Prof Dr H after hearing our case presentation this morning

** Ni lawak medic, susah sket nak paham..

Note 1: Becoming the first assistant for the LSCS has been a wonderful experience for me.I gain so much wealth of knowledge.The MO who performed the operation are so helpful.We actually teach each other.I teach her a little bit about embryology and she taught me like A LOT in return. Surgery surgery surgery...I simply love surgery and being in the OT...

Note2: I think I love seeing blood.fullstop

Note 3: Today,I think I've found a patient for my Obs case writeup.She has pre-eclampsia with impending HELLP syndrome and she is symptomatic.Interesting!She has to deliver her baby by tonight,regardless the method of delivery either vaginally or Caeserean-lly

Midnight ramblings

2009-01-19T00:47:00.007+08:00

It's 12.47 am and I am still stuck with this powerpoint.I have a presentation tomorrow.I just hate doing power point.fullstop.I, on the other hand love teaching(<---- habisla gelak guling guling member-member aku yg baca statement ni).I've had a few occasion volunteered myself to tutor my juniors during my pre clinical years.I dont mind spend my time until late at night so that they understand.I love who participate in class( Come on people, you cannot wait until somebody feeds you!).I hate those who only act merely as passengers.I totally anti-ed those who talk when I am doing the talking.Rasa nak baling kasut.

During pre clinical years, we have exams every friday morning.READ: EVERY FRIDAY MORNING.Exam pun bukan yg memain punye.Ni yg stail duduk kat hall mcm nak amik SPM.The ones that the invigilators would say 'Para pelajar yang didapati menipu didalam peperiksaan akan dibuang dari institusi pendidikan-type of exams'.The idea is to make sure that we are all consistent in our studies.Marks will be counted as part of our final exam marks.So tak boleh kantoi sekali pun.I used to hate those negative marking style of marking.Correct answers will be awarded one mark, but every wrong answers will be deducted 0.5 marks.Mahu dekat 100 kali exam in total masa pre clinical years.Mahu tak tumbuh uban masa tu.Jerawat pun bleh tahan banyaknye...Anyway, back to mentor-mentee tu, I used to senyap-senyap check my mentees punye markah yang diorang tampal kat result board.Kecewa kalau diorang fail.Rasa satu kegagalan dan kebuangmasaan( is there such word?Habisla A. Samad Said marah).Gembira dan bangga kalau markah diorang tinggi.

Why am I telling you all this? I still got a powerpoint to setel....adios!

Note 1: Ada cita-cita nak jadi Clinical lecturer nanti.Bestkan.Dapat keep in touch with basic knowledge.And at the same time bleh buat pahala banyak banyak.Bayangkan that pahala tu beranak-pinak once your students dah berkhidmat jadik tuan/puan doktor!

Note 2: Esok ada temujanji dengan sorang MO ni, Dr Dahlia.Nak buat temujanji kat OT.Its not just a temujanji.I'll become her first assistant for Cesaerian section tomorrow.

Note 3: I'll be officially attached to the Obstetric ward from tomorrow onwards.But that doesn't mean that I'll be missing all the action in the labour room.No way bebeh!Mothers, you will not see the last of me.beware...<--- habis la berlagak macam superhero pulak

A gentle reminder

2009-01-17T02:45:00.009+08:00

I've just got to write something before I'm off to bed

Before medical school...
Is it important to be the best student during your secondary school? Would that be a pre requisite in ensuring success in medical school?Is it important to get the best SPM result in your state?

In medical school...

Is it important to get a straight excellent marks during every exams?

The answer to those question mentioned above is NO!

Yes, good result in every tests and exams during medical school is important.However, it must be combined with good attitude and excellent psychomotor skills ( eg: clinical examination skills, clerking skills,case presentation skill, procedure skills etc).And please... dont be a robot! medicine is actually logic! Tak gune menghafal membuta tuli and during exam just muntahkan segala-galanya and at the end of the day unable to apply your knowledge in the real situation.

I've got a few friends who are still in his/her realm of dream.They think that being the best during their secondary schools will ensure their success in medical school.To me, they have this inferiority complex.That they will always remind themselves that they were once a top scorer during SPM and that nobody is above them.This way of thinking will eventually comfort them.My advice:Please, hang those result at pagar before entering pagar hospital.That wud just be your recipe for disaster!

Just a sincere reminder.My 2 cents.Sekian...

Note 1 : Kpd adik-adik di luar sana, bila dh masuk med school nanti rajin-rajinkan diri k.Jgn malas-malas.Bersykurla sbb dpt buat medic.Bukan semua org apply dapat kan? Yang paling penting sekali adalah attitude kita...and of coz niat kita =) <---- More like a reminder to myself haha =P

Note 2: Episode manga Naruto terbaru dah keluar.Tgh happy nih...

Yatta~!!

2009-01-14T17:13:00.006+08:00

Pic 1: Metal-cup ventouse ( a.k.a. vacuum delivery)

Pic2: Kielland's forcep

Yatta~!! I conducted my first delivery!It was easy becoz the patient was G3P2( meaning this is her 3rd pregnancy and have given birth to 2 children).It was quite fast, probably less than 4 minutes.At first, Staff Nurse A offered me to conduct the delivery not once, not twice but three times.Ditambah pulak dgn member comel aku yg sorang lagi tu yang bernama Burg, asik je menyiku-nyiku aku, 'Bil, pergi ar! Buat je, kau mesti boleh punye' . Hmm so, kite ni pun ape lagi laa kan.Terus amik sterile glove size 7, pakai and pergi conduct the delivery under the supervision of a nurse.The baby had a condition called 'Cord round neck'.Terkejut gak la memula.Alhamdulillah everthing went well.Perlu diingat disini iaitu delivery of a baby is not as easy as what you might think it is.It is an art!Did you know that there are as much as 8 steps during the Second stage of labour ( belum lcakap pasal the first and the third stage of labour).A lot of things to be assessed before, during and after the delivery. Terpaksala tunjuk macho sikit tadi sebab ada beberapa student nursing kat dalam labor suite tadi.Malu la kalau tak betul kan? =P

I also managed to witness a Twin delivery ( At last, doaku dimakbulkan yer) .This was a dizygotic, dichorionic diamniotic twin.Memang respek la mak dia.She really wants to deliver vaginally and not thru Cesaerean section.Twin 1 was in cephalic presentation ( kepala kat bawah), HOWEVER the twin 2 was breeched ( kaki keluar dahulu).It was footling breech to be exact ( There are a few types of breech presentation) .Doktor pakar was there.Again, delivery of a baby with footling breech presentation requires different skills and manouvre.The delivery of twin 1 was quite easy.The baby came out quite easy once the membrane ruptured.The baby came out at 2.25 pm.

The delivery of the second twin was a bit tricky due to the presentation part.The Obstetrician had to do an Ultrasound scan and later did a manouvre called External cephalic version, in order to maintain the baby's lie (twin 2's lie was an unstable lie, kejap dia pegi longitudinal lie, kejap dia pusing jadi transverse lie).Manouvre ni bertujuan untuk memusingkan baby dari luar dengan menggunakan tangan ,so that the fetus will have a suitable position for delivery.According to the book, the delivery of the second twin must be done within 30 minutes after the delivery of the first twin.Therefore, patient was given IV Pitocin to stimulate uterine contraction.After about 10 minutes, the Obstetrician decided to artificially rupture the second twin's amniotic membrane.There was a sudden gush of amniotic fluid.Tak ubah mcm waterfall.To cut the story short, Twin 2 was delivered by using a few manouvres.So dapat la aku tengok camne rupe manouvre Mauriceau-Smellie-Veit manouvre ( manouvre yg sampai skrg aku tak dpt nk sebut namanye).Stylo betul doktor tersebut.Kagum aku dengan dia.According to our professor,there are a lot of risk in breech delivery.You have to be fast and sure in what you are doing.Every second counts.Twin 2 was deliver at 2.43pm.The baby was born flat.She did not cry.A pediatrician was already on standby and she resuscitate the baby.Akhirnya, kedua-dua baby tu selamat.Cuba teka dapat baby ape?Twin 1 was a baby boy while twin 2 was a baby girl!

Today was a busy day.The PAC(patient admission counter) was packed with patients.Labor suites pun agak penuh.Back to back.Kadang-kadang sampai tak sempat nk prepare the instrument pun.I had the chance to do episiotomy suturing on 2 patients and 1 placenta cord traction.

Later in the afternoon, we had a teaching session with Dr S, a senior O&G specialist.We learn about Intrumental delivery using Ventouse( a.k.a vaccum) and Forceps.

Ok la bye.Nak lelap jap.I have on-call tonight.

Tumpah Darah

2009-01-12T17:50:00.005+08:00

10 AM, Dewan Bersalin hospital

One of my patient had a condition called Post partum hemorrhage.Orang Melayu kita panggil 'tumpah darah'.Puan S had a prolonged stage 2 labour, around 45 minutes.Peneranan( is there such word?) tu tak brape mantap dan efektif.Ramai la yang masuk ke dalam labour suite pastu beri sokongan.Macam nk pecah je bilik bersalin tu agaknye.I was beside her, encouraging here to do this and that.Nasib baik baby tu tak lemas.CTG reading was reactive.I was surprised.

Later, I delivered the placenta by using the Continuous Cord Traction technique.Placenta delivery pun agak lambat.Agak-agaknye around 10 ke 15 minit.Slalunye 5 minit je placenta a.k.a uri tu dah keluar.Then she started to feel thirsty.Then she complained that she wants to faint and that her vision was blurry.Ahhh sudah, patient nak masuk hypovolaemic shock.Apa lagi terkejut la kami semua kat situ.BP was taken and the reading was 55/28 mmHg.Bayangkan diastole hanya '28' je.We run a lot of IV fluid both crystalloids and colloids(plasma expander) like mad - Hartman's solution, Voluven, Normal saline you name it.Specialists Dr S was alerted and she came running and panting.

This patient had what we called Primary Post Partum Haemorrhage( meaning excessive bleeding within 24 hours post delivery).The commonest cause is either retained placenta in the uterus or vaginal wall tear.Its unlikely to be from retained placenta.I've checked the placenta thoroughly- cotyledons are complete, 2 membranes, 1 vein and 2 arteries.Impossible.MO check.Check punye check, laa rupe rupe nye ade left lateral vaginal wall tear.Tear dia sangat halus dan susah untuk dijumpai.We sutured the the tear and the bleeding stops.Fuh, akhirnya stop gak pendarahan tu.Estimated blood loss for the whole labour is around 1 litre to 1.5 litres.Tuan-tuan dan puan-puan sekalian, darahtu banyakye.Jangan dibuat main-main

Oh by the way I had the chance to do episiotomy surturing just now.Seriously, the feeling of menjahit tu sangat best.Rasenye aku memang la berbakat nk jadi Surgeon <----- Habisla, puji diri sendiri tak bertempat.Oh well, takde org lain nk puji aku, so aku puji la diri sendiri hahaha...

Oh the best part was when Puan S said to me:

'Akak nak amanahkan adik Nabil utk mengazankan anak akak tadi yer"

OK.The keyword here is 'amanah'.Its such a big word for me and it was such an honour to do that.Bile fikirkan balik, kesian akak tu sakit sakit labour camtu tapi suami masih dalam perjalanan ke hospital from Perak.So bakal-bakal suami disana, jgn lupa temankan isteri anda yang nak beranak.In evidence based medicine, companionship during labour has been proven to lessen patient's pain during labour.

K chow cincau.Nak pegi On-call malam ni!

Sambung cerita...

Juz got back from the hospital.Fuh, penat.Rasa nk hilang je suara memberi sokongan kpd ibu-ibu/bakal-bakal ibu ni.Anyway, I went straightaway to the obstetric ward juz now once arrived in the hospital, dengan harapan nk jumpe Puan S tadi.Cari punye cari tak jumpe.Rupe-rupenye dia still labour room for close monitoring.Blood transfusion is being done in order to bring up her haemoglobin level.Dapat la berborak dgn dia dan ahli keluarga dia.Gembira teramat dia tu.Asik la cakap tenkiu sebab azankan anak dia.Part paling best bile dia cakap dia nak namakan anak dia Fakhrul Nabil.Read, N.A.B.I.L. Hehe...I feel honoured.

Note1: Nasib baik la aku bukan perempuan.Kesian gile tengok patient tadi.Memang betul betul in pain.

Note 2 : Ada midposting exam tadi.Ditunda ke hari Isnin.Ok la kut soalan dia.Yang tak boleh blah bile Prof kate ," Saya akan ambik markah midposting exam ni untuk dikira masa final posting mark ni nanti hanya bile lebih dari 50% daripada kamu semua fail'. One word that can describe that 'K.E.J.A.M'

Note 3: Baru tengok episode 1 cerita 'Code Blue', Japanese medical series.Terasa cerita tu tersangatla over.BUt at least ada substance.Tak mcm Ampang Medikal.

Karenah di Dewan Bersalin

2009-01-09T23:21:00.011+08:00

9 Januari 2009 11.00 am Dewan Bersalin Hospital

Puan R Gravida3 Para 2 at 38 weeks period of gestation,came in with cramping lower abdominal pain since 7 am today.The pain is progressive in its intensity and frequency.The pain is also associated with leaking liqour.On VE, the os is already 7 cm and the fetal presenting part is already 3/5 engaged.Sudah in labour daa....

Semasa 'in labour'

'Missy, tolong.Saya tak mahu beranak lagi.Nak balik dulu.Missy menjawab, 'Macam mane tak mahu beranak ni.Bahagian bawah rahim ni dah bukak 7 cm dah ni.Air ketuban pun dh pecah.Slalunye kena tunggu sampai 10 cm.Puan, cuba bawak bawak bertenang.Bile dah rasa sakit sgt, puan berak tau'.

Lepas dah beranak

"Saya haus.Saya nak air milo boleh tak".

5 minit lepas tu Air milo pun sampai...

'Air milo ni tak sedap la.Tawar sangat'. Houseman jawap' Puan, lenkali saya kasi teh tarik k.Manis terus'

Semasa tengah menjahit luka episiotomy

'Adeh, sakitnya.Ni bukan sakit sikit-sikit ni'. HO bertanya ,' Puan nak beranak lagi pasni?'. Puan tu terus menggeleng-geleng.
HO menambah,'Puan,majoriti org yg kami tanya lepas beranak semua ckp gitu, tapi selalunya setahun lepas tu diorang datang balik kat kami".Puan tu tersenyum malu malu. 'Apa ni lambat sangat jahit ni, saya rasa saya nak terberak pulak la'.
HO menjawap,' Puan sebelum datang sini tak berak dulu ker?' Puan R jawap, ' Tak, saya takut nk berak td sebab dh sakitkan.Takut baby pulak yang terkeluar masuk dalam toilet bowl nanti"

HO jawap,'Hmm gitu.Hmm maybe sebab saya tekan kat bahagian tu masatengah jahit ni.Sebab tu puan rasa macam nak terberak.Puan R menambah," Owhhhh ek??? Kalau kentut boleh?" HO menjawap," Kentut banyak banyak pun takpe.Biar saya kat bawah ni dan adik-adik saya semua ni bau" (Adik-adik' tu was referring to us)

5minit lepas tu,

'Doktor, saya nak kencing la.Apesal lambat sangat jahit ni.Ni bukan geli geli tau, ni sakit betul betul'. HO menjawab ' Puan, puan hisap je la gas tu, nanti kurangla sakit tu.Puan jgn gerak gerak , nanti lagi lambat.Hah medical student, pegi masukkan Foley's catheter, buat CBD(Continuous Bladder Drainage) puan ni nak terkencing pulak.

Semasa tengah sibuk nak try masukkan catheter ke dalam pundi kencing puan ni.

'Eh, takpela dik, dah tak terasa nak kencing pulak"

Panjang lagi cerita ni sebenarnya.Bayangkan dewan bersalin tu tak putus putus orang nk bersalin setiap minit dan jam.Setiap org ade karenah masing masing.Ada yg extremely baik and peramah, ada yang banyak songeh and demanding.Ya Allah, kurniakan la aku satu tahap kesabaran yang agung bila aku kerja jadi HO nanti.Kalau tak jadik ikan keringla hambaMu ini nanti =P

Note 1: Actually saya sangat kagum dengan ibu ibu yang melahirkan anak.Tentu pahala mereka semua ni sangat banyak di sisi Allah SWT.

Note 2 : Apparently the staff here do not use the word 'push' or 'teran' when asking the patient to push the baby.Tapi mereka semua ni guna perkataan 'BERAK!' Bile ditanya, gaya push masa nak beranak ni sama mcm nak berak.Hmm...no comment

Makan tak kenyang, tido tak lena

2009-01-09T00:02:00.000+08:00

Mak aii.....hidup aku semakin tunggang langgang.Bayangkang by 7.30am dh kena terpacak kat bilik seminar Labour room tu for Morning pass-over.After that, kena jumpe patient pastu clerk history dia so that beberapa minit lagi lecturer sampai and kena present case.Pastu barula bedside teaching bermula.So far, dah byk kali dah perut bernyanyi-nyanyi masa tengah present case and masa tengah buat physical examination kat patient depan semua org, kalah high school musical kut bunyi perut ni!Memula tu masing masing gelak antara sesama sendiri, tapi skrg masing masing faham akan nasib perut masing-masing.Perut mu bunyik, perutku pun berbunyik.Yang paling tensyen masa Paeds dulu dlu.Ward round dah la sampai ke tengahari.Masa tu makanan tengahari patient patient semua dah sampai.Bukan makanan cekai cekai.. ni sedap punye makanan.Ape lagi, berkeroncong lagi laa perut ni.Hmm takpe ar.At least tak makan byk sangat so that dpt maintain badan yg tough ni (tough la sangat!) But seriously thinking of going to Fitness First.At least I will have a gym instructor to monitor my fitness.Nama je medical student, tapi kesihatan sendiri tak terjaga sgt.
Anyway, terasa tersangat rugi tak beroncall malam tadi becoz apparently malan semalam labour room tersangat eventful.Ade dua case postpartum hemorrhage, failed vacuum suction eventually kena buat EM LSCS(Emergency lower segment cesaerian section) operation, baby with cleft lip and a baby without fingers on the left hand.Its 12.06 am now, baru balik on-call.Nak mandi and tido!Papai...

Note1: Entry kali menggunakan bahasa rojak.Main taip je.

Note 2: Makk aii, petang esok ade seminar.Dah la tak bace ape ape lagi ni

Labour room

2009-01-07T19:12:00.001+08:00

Hmm..where do I begin

I'm officially posted to the Labour room right now.Its fun to learn manynew things.Its more exhilirating when you get to actually perform things that you only previously see in the texbooks.For instance, I did my first Vaginal Examination or affectionately known as 'VE' yesterday during on-call.It was aight I guess, though I was tired becoz it was midnight at that time.The pregnant lady is already on the Active phase of labor.The cervical os was opened at 5cm, occiput can be felt, station +1.Owh yeah, I also observed the amniotomy (artificial rupture of membrane) using the amniohook before that.
While in the labour room, there are basically 3 areas that needs to be covered - Patient Admission Counter(PAC), Labour suites and also the Maternal Operation Theatre.The idea is to see the whole process of managing the labour.Staff wise...O&G department is more inviting.The nurses,HOs and MOs are extremely nice.Be humble and always asked them questions if in doubt.You'll be amazed at the rate of knowledge that you are getting.They are also accommodative and obliging.They will encourage you to do this and that, even up to the level of conducting the delivery itself.As for now, I have not mustered all the courage yet to conduct a delivery.InshaAllah,one of these days.Do simpler stuff first such as Placenta cord traction, Episiotomy suturing, Partograms, Interpreting CTG, Inject IM syntocinon etc. muahaha...
I've already observed 7 deliveries so far.No complicated delivery except for one yesterday night when I was on-call.A baby was born flat ( ie- no crying, APGAR score was probably 5/10).We had to resuscitate the baby, alerting the Paediatrician at the same time.At the end of the day, we gave the baby Naloxone, an antidote to the opiod-analgesic which was given to the mother to relief the pain while in the labour.That drug must have significantly crossed into the fetal circulation from the maternal's circulation and eventually caused Opiod-induced respiratory depression.Seriously, baby tu nampak macam tengah high,mata terbukak mcm orang tengah berkhayal.Apparently, Serdang Hospital uses many expensive drugs which sometimes cannot be found even in private hospitals.Instead of using Pethidine, they use Nalbuphine( Nuban ).So who says HospitalKerajaan guna ubat murah?Try to say that in front of my face.

I went back to the hospital the next morning and arrived at 7.30am for Morning Pass-over.Its a ritual thing in this hospital to have a morning-passover.Not sure about other hospitals tho.This is when the MO oncall present the cases to the specialists and the head of department.He/she will make summaries regarding the number of deliveries,number of SVDs(spontaneous vaginaldeliveries),number of C section done and why it is done etc.A HO then must also present an obstetric related disease in front of the nurses,sisters, HOs,MOs and medical students.It's a good revision for me.

Note 1: I'll be having my O&G misposting exam tomorrow

Note 2: Kenapa orang tak berenti-renti beranak? Labour room tu sentiasa beroperasi 24 hours

Note3: Most big hospitals in Malaysia such as Hospital Serdang would have around 15-20 percent of Cesaerian deliveries each month.They will try to keep the precentage lower if possible.In a nutshell, never request for a Cesaerian to any obstetrician.They wont do unless indicated.

Note 4: Had two teachings today from Dr Zainurrashid and Dr Suhaimi.Dr Zain had twice conduct deliveries in a bathtub while he was in the UK last time at patients' request.Can u believe that?Evidence-based medicine shows that warm water is known to relieve the pain of labour.Unfortunetely we dont do that in Malaysia.I sure need to bring my swimming trunk next time if we do have that!

Expectation

2009-01-05T20:51:00.000+08:00

I have been extremely busy with my O&G posting.Tomorrow is my last day for Gynaecology for this year.The common cases in the Gynae ward are

1) Miscarriage ( Missed, complete, incomplete etc)
2)Ectopic pregnancy
3)Ovarian cyst ( Ruptured vs torsion)
4)Hyperemesis gravidarum
5) Uterine fibroid

I'll be attached to the Labour room starting from this Wednesday.Previously,I had spent a few times in the labour room and Maternal operation theatre so as to get a glimpse of what will I be facing next.So many things to learn and perform.Definitely need to know how to do Partographs, interprate CTG, etc etc.A few of my friends (who are currently attached in the labour room)had the chance to actually do various procedures such as controlled cord traction, become the assistant in performing Cesaerian section, and also deliver babies.But so far nobody has the gut to conduct a delivery yet.I'll be the first one maybe? I'm definitelygoing to try my best.Really really want to do episiotomy surturing.According to colleagues, the nurses,HOs and MOs are willingly to teach and help.Ahhh yess, good prognosis that is.

Need to submit my long case write up tomorrow.c u...

I still love you even after u have raped me

2008-12-30T00:11:00.000+08:00

I was on-call today (yes, during Maal Hijrah holiday).Spend sometime in the Gynae ward and later in the Labour room.
We are discouraged to actually clerk patients with medico-legal issues.eg rape victims.This morning, I did not even bother to check the big,heavy register book in the ward and straightaway TERrrr-clerk this one patient.I was with a chaperon of mine Kak Yang.Anyway,let us name this patient as Ms K.Ms K was admitted yesterday after being raped( I dont like to use this word actually but cant find any word for replacement) by her boyfriend.She was also beaten by him with leather belt, until there was this huge laceration(luka) over her shin.The laceration was quite deep! At the end of the clerking session, we asked her one last question, " How do you feel right now?What do you feel like doing?" She replied;

"I want to get a phone and try to call my boyfriend.I want to apologise to him"

I was utterly shocked.I mean comon girl! U have been beaten by him and raped!If I were you I wud have wanted to break his neck and shot his head to dust with a shotgun.End of story.I started to think that, Love is blind...

Next, Labour room.Witnessed my first Emergency Lower Segment Caesarian section today.C section had to be carried out due to poor progress of labour.CTG shows Late Deceleration; sign of fetal distress.There was also Light meconium staining,another sign of fetal distress.I also observed a few normal SVD(Spontaneous vaginal delivery). Terasa bersemangat nak conduct delivery next week!

Note1: Currently listening to Nickelback's "Gotta be somebody".Im a big fan of this band =)

Note2: Will be presenting in a seminar tomorrow regarding the "Investigation and Management of Diabetes in Pregnancy". Wish me luck!

Note3: Went to Pizza Hut again, second time this week.I MUST jog tomorrow evening!

Note4: Participated in a Treasure Hunt in Melaka last Saturday.My group was the second runner-up group.Not bad dowhh~~

Am I a boy or a girl

2008-12-24T19:57:00.000+08:00

Today was the Gynae OT day.I observed a few operations.Assist? Nanti la, tak biasa lagi...

Case one: Its about a 16 Yr old girl who never had menses (turun haid).In medical term, it is called Primary Amenorrhoea.There are many causes to this.The O&G specialist had to resort to a procedure called Diagnostic laparoscopy in order to confirm the diagnosis.This procedure involves in making 3 small holes in your abdomen, with one hole from your umbilicus (pusat).The abdomen is being inflated with carbon diaoxide and the area underlying the skin is being viewed by a camera inside the abdomen.Its the 'in' thing in surgery nowadays coz it is minimally invasive.Faster recovery for the patient.Anyway,Dr J asked me a few questions and one of them is 'What wud u make up if we do not find ovaries?' Hmm, lucky for me I straightaway remembered an episode from House Season 2 (I guess..) and answered 'Androgen Insensitivity Syndrome'.In this condition, patient's body produces the guy's hormone ie Testosterone but the body cells are insensitive to it.Therefore, there will be no development of the secondary sexual characteristic of a male, and instead the patient will physically look like a girl.Genetically patient is 'XY' but phenotypically patient is 'XX'.But, in this patient, 2 ovaries were found.BUT, the Uterus was missing.We also assessed her vagina and it was short and underdeveloped (measuring 1cm in length).Therefore, our diagnosis is 'Mullerian agenesis'.Dont ask me coz I have forgotten Embryology of the reproductive tract.I'm always lousy with embryology.haha.Anyway, the surgeon told me that this case is extremely rare and that I am lucky to be able to see during my undergrad.I feel sad for the patient really, but this is fate.We still need to do karyotyping, to confirm that she/he is XY.KUB X-ray (Kidney-Ureter-Bladder X-ray) is next coz 40% of patients with this condition will have urinary tract abnormalities.

Case two: Its about a 49 yr old lady who had abnormal vaginal bleeding in which we called as Menorrhagia.Did a procedure called 'Laparoscopic assisted Vaginal Hysterectomy (LAVH)'.The surgeon had to remove her uterus because of a presence of a Fibroid (Leiomyoma).See pic.

A well circumscribed tumour.Whorling bundle of smooth muscle over the uterine fundus I guess.Hmm...

We had yet another bedside teaching with Dr Jamil the O&G specialist later in the afternoon.Discussed 2 cases, which were presented by my two colleagues Amilee and Faradiana.

Later, I went back to my home sweet home in Cheras.Had a nice nap coz I am not feeling very well the whole day.I had coryza with runny nose.I really blame the cold OT.I also blame myself for not wearing a long sleeve shirt inside.Hmm.

Hannan and Fizie came after Maghrib.We drove to Selayang to Amilee's house for Christmas makan-makan at her house.Merry Christmas!

p/s1: I used to remember the days when I was in Glasgow,Scotland where I was about 4-5 years old at that time.I used to receive many presents during Christmas.Soo happy =)

p/s2: Ish,malu la pulak rasanye letak gambar sendiri.Rasa geli geleman pun ade.Pasni nk delete la

p/s3: Tho tomorrow is a public holiday, I still need to go the hospital to do my long case write up.Sigh...

p/s4:BEWARE.Medical series such as Grey's and House is a piece of crap.Its only good for entertainment, not more than that.Don't get carried away by it.Plus, in medicine knowing rare diseases will not make you a good doctor.

O&G The First trimester

2008-12-23T20:03:00.000+08:00

Like the title? Hehe...

Well where do I start.For the next following 2 weeks, I'll be attached to the Gynaecology Ward,Gynae Clinics and Gynae OT.Yesterday was the first day for me in the Gynae ward, and so yesterday was the day when I started to test my skills in clerking gynae patients.It was okay I guess.However, the only disadvantage for A GUY like me during O&G posting is that, we the guys will be needing Chaperon to do clerking or to do any procedures.We need another female colleague to be with us before we can do anything.This is to prevent any future issues.Our lecturer had told us that a few years ago there was a case where a med student had to be expelled from his/her medical school due to a false allegation by a patient.The woman patient claimed that the male med student had done 'something' wrong to her while he was doing physical examination on her and made a police report.There was no prove to suggest that this poor student had done so and neither that there was any prove that he didn't do so.A police report was made by the patient and after investigation by the police the student had to be expelled.I dont want to comment on the issue.I leave it to you to decide.But, for the time being chaperon is needed.Hate it when the girls came late, or have somethingelse to do and that you end up waiting for them.Sigh~ hehe =)

Today (Tuesday) was the Gynae clinic day.My group came early and clerked a few patient in the ward and later we joined the Specialists for the ward round.Later in the morning, we all went to the Gynae clinic.I was attached to the HOD(Head of Department) Dr Wan Hamilton.She is a strict but a nice lady.She'll be okay as long as you are able to answer her question and show that you know something haha.These are the few cases that we saw in the clinic today

1. Mdm Y, 48 yr old came in with Perimenopausal symptoms such as hot flushes, palpitation,depression,night sweats etc.She is actually on HRT (Hormone Replacement Therapy) already to alleviate her symptoms and was on follow up.The Dr did VE and also the conventional pap smear.Unfortunately , we the guys were not allowed to observe.Sigh.See, we are so at the disadvantage side.We learn about the management, things to look for during examination etc.

2.Puan N came in with secondary infertility.Turns out to be that she has PCOS(Polycystic Ovarian Syndrome) .She has Hirsutism- Misai, acne and was of course infertile.

3. Puan J came in with history of Complete miscarriage and was on follow-up.Did ultrasound on her and the uterine cavity was clear.Nomore product of conception.

In the afternoon, we had TBL session with Dr Sulaiha the O&G specialist.The topic was Early & Late Abnormal Per Vaginal Bleeding.It was an interesting session because all of us shared our cases and we discussed with each other.It's true that patient is your best textbook.

Tomorrow is the day when I have to go to the Gynae OT and observed some operative procedures.Therefore, had to go back yo the gynae ward and clerked those patients.Memang cari nahas la kalau nak observe operation tapi tak tahu apa-apa pasal patient.Tomorrow, I'll be observing

1)Hysteroscopy

-a 49 yr old, G0P0 patient came in with the chief complaint of abnormal per vaginal bleeding of 1 year duration associated with suprapubic pain.The bleeding had become worse 2 months ago.She will bleed everyday, sometimes the bleeding will be so severe that there will be flooding(yes thats the term used here) which was described by her as a gush of blood came out from her vagina.Not going into details here.

2)Diagnostic laparoscopy

- This is one is for a 16 yr old girl who had never had menses before.Primary amenorrhoea case

3)Cystectomy

4)Tubal ligation

There is no better way than ending your tiring day with a few Big Apple Donuts!

p/s: I am actually quite engrossed into the IJN take-over issue.This might be the first step for a complete privatisation of hospitals in Malaysia.It is such a big issue for me becoz I might want to work in IJN in the future and it might jeopardise my chance to do just that.There was an attempt to privatise our hospital sometime ago but it failed because most doctors oppose it( according to a lecturer of mine, not saying who tho ).Why? Becoz the young,the old , and the disables wud get the biggest hit!Did you know that the price of drugs in Malaysia is rising due to privatisation of pharmaceutical industry some time ago?Do tell me your opinion plz (If u have any dat is =) )

Tell me that its ok to...

2008-12-19T21:41:00.000+08:00

Tell me that its ok to be at the bottom of the wheel sometimes...

Tell me that its ok to not being able to meet your expectation...

Received an sms at 2.02pm today from my Surgery posting coordinator Mr Triple A.The message says 'Hmm, not very happy with your marks but jus remember clinicals r different,u gotta approach differently'...I'm sure dat he is talking about my Paediatrics result.All of the coordinators for respective postings had their meeting this morning.Oh well, dats life.You win some, you lose some.But for me, you dont lose too much! Once in a while yes, coz it makes you stronger and it serves as a wake up call.

Anyway, Ive been enjoying Obstetric & Gynaecology so far.I've started clerking patients.We learn many stuff regarding OnG already.Cardiotocography(CTG), Partograph, Labour, Episiotomy, vaginal examination,handheld Doppler (Daptone), pap smear.These are the basic skills that needs to be observe/perform throughout the whole posting.I have faith in this posting.
I was amazed while doing physical examination on the mother when the fetus/baby inside the uterus starts to moved.Thats life inside the tummy!Seriously, God is great.

Cases seen throughout the week:

1. Pregnancy-Induced Hypertension

2.Placenta Praevia

3. Oligohydramnios

Day1&2 of O&G

2008-12-16T23:13:00.000+08:00

I've got no quality time to actually update this blog for the time being.Its only my second day of my O&G posting but many new,interesting things have been happening so far which I am eager to tell you all about.Will do that during the weekends inshaAllah. Oh by the way, I got A- for my Surgery posting.Alhamdulillah.That means my final mark should be between 75-79 over 100.Its something to celebrate really coz it is not easy to get that kind of mark.Alhamdulillah again

What??!!

2008-12-13T22:31:00.000+08:00

What~?????!!!!...Holiday dh habis.Hari ni hari Sabtu,esok hari Ahad, Tulat (hahaha) hari Isnin.Maka bermulalah chapter baru dalam hidup.I'll be doing my Obstetrics & Gynaecology posting for 2 months.Need to do revision for the pre-clinical topics, need to read more and more books and articles and most important thing is that need to do a lot of clerking from as many patients as possible and eventually able to come up with decent case report and ultimately able to present them to the Specialists.Sounds men-tension-kan.I have set a few addtional goals during the coming 2 months of which I hope I could achieve in time:-

1) Deliver AT LEAST 10 babies! ( Highest priority )

2)Spend some time in the Paediatric ward once in a while, especially during Friday when the Thalassaemia patients come for their routine check-up.At least I will be able to palpate more and more liver and spleen.Weee~~The Paed ward and O&G ward is at the same floor after all

[The list will be updated from time to time]

By the way, found a new blog disebalikitu.blogspot.com .I thought that his MotorBasikal ciptaanya was brilliant.Kengkadang tu terasa rugi pulak tak terima tawaran Petronas buat Engineering kat Aussie dulu.Ntah ntah dh grad dah pun... =(

Bye bye Paeds

2008-12-05T05:31:00.000+08:00

Yahoo! I just completed one of the most horrible posting ever.No way that other posting will be as tidious as this.I began the posting with such a negative mind, and it was fairly negative throughout haha.Well probably that was because I fell in love with my Surgery posting.I did Surgery prior to Paeds.During this posting, I had to put a lot of crap with all the mellodramatic moment of the specialists yg tak habis habis nak bebel je.Otherwise, evertyhing would be fine and perfect.They expect a lot of things from us.Plus, they are all mothers and mungkin diorang asik fikir 'haih kenapala anak anak aku mcm ni' thus the bebelan pun sering berlaku.I actually enjoyed Paeds in the end, knowing that they actually care for their students.They want us to be as good as them if not better.I have always love those congenital heart diseases, even when I am still in my pre-clinical years.So, I'm not surprise if I become a Paediatric Cardiologist one day. (Nabil, biar benar ko cakap gitu!!! )
The exam question was tough.We had MCQ(Single best answer type- yang ni memang menggila la, pilihan jawapan semua betul so kena pilih yg mana rasa paling betul), Extended matching question,EMQ ( ni okay kut) and Short Answer Question,SAQ ( Ni laa yang susah, had 3 cases...one with bruising, periorbital swellling and dehydration). Nasib baik takde Essay!

This is the view from the ward.Paediatric ward is situated in the 5th floor of the hospital.This hospital have many, well-maintained Garden or Taman at each floor.So, you'll still feel like you are at the ground floor, though in fact you are actually not.

Playing room in the Paediatric Ward

Byk betul soft toys kan?

Oh yeah, I went to an Asthma workshop 2 days before the exam.Little that I know that at the end of the workshop we had to answer a 4-paged mini test.Hidup asyik bergelumang dengan exam je.And luckily the test is not as tough as our REAL exam.Ni tutup mata pun boleh jawap hehe

The Asthma workshop was really informative.It holistically covered everything about asthma.The theory part, patient management, patient education and also the latest drug and treatment.Plus, the workshop were given by all the healthcare workers- Specialists, Sisters,Nurses, Medical assistants etc. I like the idea when we try to involve as many discipline as possible.In practicing medicine, we need each other.It's all about Teamwork,teamwork and Teamwork!

Clinical Exam Paeds habis

2008-12-01T19:27:00.000+08:00

Mr Mickey with his other toy mates, nicely being placed inside my Adidas bag!

Alhamdulillah.Just completed my Observed Long Case Clinical Examination.I swear to God that my heart nearly stop beating while waiting for my examiner Dr Faizah the Paediatrician to take me for the exam at 2.30pm in Wad 5A.I had psychogenic polyuria all the way.The case was pretty straightforward ( compared to my last Surgery clinical exam, where my patient was a Bangladeshi who does not understand Malay OR English, had to use an interpreter in the end.Plus, he had 2 diagnosis and the case was hard; Bowel obstruction secondary to adhesion colic).My patient for today was a 9 month old baby boy presented to the hospital due to high grade fever of 4 days duration associated with chesty cough and episodes of shortness of breath.Took the history from the mother and presented to Dr Faizah.I did the physical examination the UNCONVENTIONAL way where I decided to auscultate him first before doing the rest .This is becoz he was sleeping and you dont want to auscultate him when he is crying later.My final diagnosis was Right lobar pneumonia.Air entry was reduced on the right lung.Bronchial breath sound was heard with crepitations over the right middle and lower zone of the lung with occasional,scattered ronchi.Tada~~! The discussion part was also alright.I suggested the appropriate investigation as well.The most happy thing was that my patient did not cry.Therefore, I did not have to use Mr Mickey Mouse at all.

One thing that I would like to say is that Mother compared to the Father is a much better historian.Sumpah.I had a couple of times clerking history from the father.And it clearly showed that father is usually a bad historian.They are unsure with a lot of stuff.So, to all the Mothers out there,kudos to you and I really admire you all.

I still have a Written exam this coming Thursday.So,literally my Paeds posting is not officially over yet.Yikes.

Exam Week

2008-11-29T18:08:00.000+08:00

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'

2008-11-25T23:45:00.000+08:00

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

2008-11-24T20:26:00.001+08:00

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

2008-11-24T20:01:00.000+08:00

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!

2008-11-21T01:01:00.000+08:00

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

2008-11-19T21:18:00.000+08:00

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

2008-11-18T20:43:00.000+08:00

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

2008-11-15T01:34:00.001+08:00

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

2008-11-10T23:24:00.000+08:00

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

2008-11-09T15:20:00.000+08:00

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

2008-11-09T00:41:00.000+08:00

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

2008-11-05T01:05:00.000+08:00

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

2008-11-03T19:30:00.000+08:00

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

2008-11-02T02:08:00.000+08:00

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!

Down again with URTI

2008-10-31T22:59:00.000+08:00

I had 2 bedside teaching yesterday, in the morning with Dr Faizah and in the afternoon with Dr R. We did a few short cases with few patients in the ward.I had to examine a hyperactive girl and and who obviously not cooperative as one of my short cases.Gile stress.Dahla specialist garang and kuat membebel.
Went to the NICU again later in the evening(Baik jugak Dr R ni rupenye siap ajak pergi NICU lepas tu).Examined 2 babies.One with Patent Ductus Arteriosus.Examined him and found that he has Continuous murmur( aka Machinery heart murmur), best heard at the infraclavicular region with bounding pulse,exactly like in the textbook!Second baby had Acidotic breathing (aka Kussmaul breathing).He is critically ill.
I'm having sore throat with coryzal symptoms.The paediatric ward is full with viruses!

Kenerakaan

2008-10-30T00:37:00.000+08:00

It's only my 3rd week of posting but I am already suffering.Initially you thought that paediatrician are motherly and caring but in actgual fact they are totally the opposite.I know that u have a 16 yrs of experience of becoming a Dr and paediatrician.Jgn laa nk compare your ilmu with my ilmu.Baru 3 minggu in Paeds.
I had two bedside teaching today, one with Dr Faizah yg baik and another with Dr R yg kuat gile membebel.Has been selected randomly by her to present long case.I dont know why but she always makes me her target.My history was okay except for a few loop holes here and there.Normal lah kan? Didnt know that thee Feeding history as well as Child develpmental history must be THAT detail!!??? Kena tau how the mother prepare the milk, put the water first or the susu tepung later or vice versa,how many ounce, how many times per day, is it full of half-a bottle, when do you start to introduce formula milk, what brand, any allergic reaction,why that brand, when does the baby started to weened?If yes, wht kind of food,semi solid food?nestum? how many times per day? what do you give in the morning,afternoon and evening etc.Haish...blom masuk other history lagi...
Patients are so uncooperative.They will start to cry or run around once you approach them.Or they will start to make noise and monkey-ing around when you are doing the physical examination.Not to mention where there was this one episode when a baby started to sneeze right at my face while I was auscultating!It drains down all the energy and your patience.Seriously the Paediatric Clinic is just like any pasar malam in KL.

In short, Paediatrics is Kenerakaan dan sangat Leceh!I will never become a Paediatrician.A big NO NO

Link or Tagged or whatever you want to call it

2008-10-28T00:49:00.000+08:00

I've been tag/linked to a few blogs.D*amn...got to write a more sensible posts from now onwards! It was never of my intention to write a proper 'blog'.I dont even edit my posts...gaaa

Sacrifice

2008-10-27T23:50:00.000+08:00

Sometimes we need to sacrifice in order to be good.I notice that I am still lacking in terms of my physical examination.Therefore, I sms-ed Dr Faizah and asked her whether I could join her ward round this Sunday.And she replied that I could join her.And so last Sunday I drove to Hopsital Serdang from my house in Cheras just to follow her ward rounds.It took 4 hours just to cover 2 wards; the 5A and 5B.I had to examined the babies and present my findings.No she didnt ask the houseman but me to do the examining.I was quite intimidated at first, sape lah aku hanyalah seorg medical student.But I improved later.Dats what I like about her.She will ask YOU to examine the patients for her.And she will teach you if you do wrong.I intend to do the same next weekend.

Some interesting cases
1. A child with acute Stridor
2.A child with measles- first time tgk

Neonatal intensive care unit

2008-10-25T01:27:00.000+08:00

Yesterday, me and my othe 2 group members had a bedside teaching in the neonatal intensive care unit with Dr Faizah, the specialist in-charge of the NICU in hospital serdang.We had to examined this one tiny preterm baby.It was awkward at first.This is my first time examining a tiny body.After doing physical examination on him,I presented my findings to her.This baby had pansystolic murmur of Grade 4,highest intensity at the tricuspid area.My colleague had to examined a neonate who is having bronchopneumonia.Apparently he had 2 out of 3 cardinal signs of heart failure.He had enlarged heart (cardiomegaly) and tachycardia.However, his liver was not enlarged.Dr Faizah had to break the bad news to the parents.It was really frightening after seeing the way the parents react.They were shocked and in denial.However, I admire Dr Faizah's way of handling the situation.She was straightforward and was being emphatatic at the same time.Life as a doctor is challenging.We still need to be able to handle all sorts of people.People,especially parents have high expectations on doctors.Its hard to be somebody who is a personafication of God's mercy

Finally!

2008-10-20T18:11:00.001+08:00

Today is like finally I got to know the difference between crepitations,ronchi,wheezing,vesicular breath sound and bronchial breath sound.It's really frustrating to just read from the book but unable to differentiate it in a real practice.Had a bedside teaching with one of the Paediatrician,Dr Faizah.I presented a long case to her just know.History taking was good, although I need to reorganize my points so that it make more sense.Did a few short cases as well on respiratory systems.I learned on how to present my findings for respiratory system in a a short but systematic way.Dr Faizah and us had to go from one patient to another patient because each patient had different signs.I am really really glad that finally I get to know the difference!Its hard to just read from the book.We also discuss the case and try to colerate it with chest X-ray findings.

I have another bedside teaching with her tomorrow morning.Need to do some reading.Not forgeting that my group have to give a lecture during our TBL session on the Development with Dr Rohaizah at 2.30pm.
Just checked my email and guess what I received 5 emails from my mentor Datuk Dr Musa Nordin...Why!!?? banyaknye kerja nk kena setel.Makan chocolate waffle je hari ni.I'm hungry

Ringtones

2008-10-18T09:38:00.000+08:00

Yes, today I wud like to talk about ringtones,particularly the ones that the specialists have.
In surgery, surgeons have been labeled as straightforward, no hanky-panky kind of person and will not hesitate to scold you.That's what I thought INTIALLY.I have encountered a few this type of surgeon during my previous clinical posting.They are more relax, cool in nature with non-radiating anger.They will scold you there and then and right after that, all is forgotten and forgiven.They might look stern,but all that image that you have for them were shattered once you listen to their ringtones.And so I have decided to judge them based on their ringtones! haha
Some of their bizarre ringtones are
Dr(Miss) A = A frog which sounded like he is about to puke.Its so funny and little bit annoying when you listen it during the operation.

Dr(Mr) H = A disco song! A cool and alim person with a disco kinda ringtone.Beats me!

In paediatrics...

Dr N = "Touch My Body" by Mariah carey.I mean like wow! I gaggle each time when her phone rings.She is in her 50's (so I persumed) but she certainly is berjiwa muda!Did I mention that she is using a new iPhone too???

Dr H = A song called 'My heart' by Acha Sep...whatever tu. She is garang and persistent PMS-ing.I never thought that she wud have this ringtone, its so contradictory with her personality!And yes, she uses a new iPhone too.Whats with the iPhones??? Apparently people in the paediatric department love iPhone so much.What they got a subsidy for it ar?

Anyway, dont get me wrong.All of them are nice, orelse they wont become a doctor in the first place.It takes a little bit of effort to get to know them.Know what to ask, how to ask and when to ask...

Those cute cuddly little babies

2008-10-17T18:32:00.000+08:00

Yes, I just completed my first week of Paediatrics posting in Hospital Serdang.My impression: A bit boring compared to Surgery.URTI, Asthma, diarrhoea and a few other common illnesses.Thats it so far.Not too interesting for me I guess.
I like those little babies and kids.There were no problems in clerking their history from the parents.The parents are very helpful and will always try their very best to provide us with satisfactory answers.They are not too protective with their child and will assist us during physical examination.However, the tough part is when you actually want to do physical examination on babies.Kids are okay.But babies, phew, really a headache.Sometimes, they will start crying by just seeing the white coat that we wear.Occasionally I had to open my labcoat and not wearing it while in front of them.This is what we called "the white coat syndrome".Some countries like in the UK, it is highly discouraged to wear white coat while in the paediatric ward.It makes your life miserable when your patients starts to cry.
In paediatrics, we had to bring our own rattler, wood blocks and some soft toys.They are meant to attract attention but most importantly to assess development of the child.It is part of the history taking andphysical examination.The history taking and physical examination is significantly different from Surgery.In history taking, paediatric history is added.They consist things such as Antenatal,neonatal history,Immunization, Feeding and weening history,developmental history which consist of fine motor skills, gross motor skills, speech and vision and also social skill.I'm still learning in getting a good history.
I'm really missing Surgery so much!

Surgery Exam Week: Long case exam

2008-10-08T02:00:00.000+08:00

Seriously, I didnot know whether I should be pissed off or be happy with my long case exam just now.
I am not happy because

1) I got a patient who does not know how to speak or even understand Malay or English.He is a Bangladeshi patient to be exact.Came with central abdominal pain of 1 day duration.I had to use a translator for history taking, and it was tough and time consuming.It took 1 and a half hours for everything-ie history taking, physical examination,summary,provisional and differential diagnosis,investigations and discussion.Most of the HOs and MOs in the ward were in disbelief when I got this patient for my exam.They themselves have difficulty in extracting the history from the patient.
The case was a difficult case and I was the only one in my batch to get him as patient!Anyway, I think I did allright, though it could have been better.I manage to come out with the correct final diagnosis.The diagnosis was " Subacute Intestinal Obstruction secondary to Adhesion colic" .My reall really strong point for supporting the diagnosis was " This patient have a right paramedian scar due to his previous abdominal surgery in Bangladesh.During the process of healing, there will be fibrous tissue formation which will make the gut to adhere to each other".Something like that. Initially my provisional diagnosis was "Strangulated Incisional Hernia" due to the presence of that surgical scar but however during the physical examination the cough impulse was negative.So I've decided to change my provisional diagnosis to that adhesion colic thingy.

2) We did not know when is our examination, as in the time.We always need to be ready, handphones must always be with us at all times.I received and SMS from Mr Ahmed the surgeon(my examiner) at 10.45 am while I was at the Surgical clinic.I need to be at the Surgical ward 3A in 30 minutes time for my Long case exam.I was anxious for one whole day yesterday because 7 of my friends had their long case exam already.

I was happy because:

1) I did not really clerked the patients prior to the exam.I did now even bother to know the diagnosis of the patient in the ward.This is to prevent bias in exam.We tend to be bias if we've already know the diagnosis .We tend to forget to ask other relevant symptoms which might be related to other differential diagnosis.Bias is really really really dangerous in any medical examination

Currently preparing for my Best case write up report, SWOT analysis, Reflective diary, Peer assessment, and for my Written examination.Argh!

Nothing is enuff

2008-09-27T06:46:00.000+08:00

Yes, no matter what you do, no matter how much you sacrifice yourself in the sacrificial pit, it will never be enough.So enough, I've had it, I am not going to become the saviour anymore.It's all about me now.Me first!You second!

We'll be amazed of how many superficial people around you, just waiting the right time to bite you...

Key-hole dressing

2008-09-24T23:30:00.000+08:00

It's a type of wound dressing that is usually used for various types of drainage.It was an honour for me as a clinical year MAD medical student, to be given such trust by the nurses and doctors to perform such procedure.Ohhhh well... it's not that complicated anyway.The patient himself was giving me the instructions throughout the process.Haha.

First, make sure the sterility of the equipments and your hands must be clean.Perform the surgical hand washing (yes, there are many methods of hand washing)

What you need is basically a dressing set which contains other stuffs, povidone iodine,normal saline, Hapifax-wide body ( a type of plaster), cotton balls gauze and of course the working brain.Introduce yourself to the patient and make sure he/she is comfortable.Get a good exposure of the abdomen.

Remove the previous dressing and throw it in the waste bin.

Use the plastic forcep, soak the cotton balls with normal saline.Apply that at the wound in circular motion,starting from inside to outside.Do not dab it for so many times.Remember, sterility! Since I am in a government hospital, so boleh laa membazir sikit.The goal is not to develop any nosocomial(hospital-acquired) infections!

This patient has a drain, which is connected to a plastic bottle.It contains blood, originated from the abdominal cavity.Later, wear mask, open the bottle and drain it into the sink.Rinse it with running tap water.Connect it to the vacuum port and depressurized it.Reconnect it to the tube.

Soak the gauze with iodine.Close the wound and secure the tube.Dont let it dangling like a yoyo.Apply Hapifax in order to close the wound with iodinated gauze.And voila my job is done.

Today, did a few venepunctures.I failed once and it was humiliating.Cant blame coz the patient was well built!Veins lari lari okay.Clerked a number of new patients in the ward and did physical examination on them.

Currently its 11.50pm, I'm only half way on my long case write up.I intend to present it tomorrow.I've decided to go to the Dewan Bedah tomorrow so that I can update my patient.Bye

23rd Septembr 2008

2008-09-23T21:59:00.000+08:00

What did I do today

1) Bed-side teaching by Mr Al-Amin, the Hepatobiliary surgeon.I presented a case of an anterior neck swelling.This patient is having a rare thyroid pathology known as Hashimoto's thyroiditis, which is an autoimmune disease where there is an infiltration of T-lympocytes, leading to follicular cells destruction.This patient is a textbook patient.During the acute phase of attack, this patient had transient hyperthyroidism symptoms, also known as 'Hashitoxicosis'.During this period of time, she experienced palpitations, sweating,agitation, loss of weight despite good appetite and anxiety.After a significant number of thyroid's follicular cells( cells that produces the thyroxine and Triiodothyronine) destruction, the patient slowly progresses to hypothyroid state.On neck examination, there is a visible, diffuse neck swelling only on swallowing and not on tongue potrusion.The mass is diffuse, soft in consistency with ill-defined margin.

2) Went to the Emergency department for orientation by an MO

3) Went to the Surgery clinic.Assist Mr Hisham in inserting Foley's catheter for Continuous Bladder Drainage (CBD) to a patient known to have BPH (Benign Prostatic Hypertrophy).Did some venepuncture, not by looking but by palpating the veins at the cubital fossa.Patient to berkulit gelap okay and tak nampak veins!Luckily, my first attempt of withdrawing blood from this patient was successful.

4)Had another bed-side teaching by Miss Sarinah, the Breast and Endocrine surgeon.I presented a new case of 4th degree Haemorrhoid.Did physical examination on him but unfortunately the patient refused to be PR-ed! However, on inspection, there appears to be a single mass at the anal opening which is ulcerated and and thrombosed.Will try to request for PR from him again tomorrow =)

Currently listening to Raya songs while writing my case write up

22nd November 2008

2008-09-22T19:02:00.000+08:00

It really scares me sometimes that we can die, literally anytime when the time comes.Thats what I felt when I was in the surgical clinic today.
Encik A, who is only a 29 years oldmalay gentleman has come to the clinic with a left testicular mass of 2 weeks duration.Yes, its only 2 weeks duration and the mass is already as big as a tennisball.Anyway, I am not going into the details regarding the mass ( like we usually have to describein our case presentation).In order to differentiate whether it is a hydroecele or a solitary mass, me and the MO Dr Syikin did the transluminent test.And guess what the test was negative and the mass is nota hydrocoele.Our impression:Left Testicular carcinoma.The patient is scheduled for urgent ultrasound and we need to perform Orchidectomy(testicular removal) on him.Poor guy.I talked to him later while Venepuncturi-ing( withdrawing blood from veins), tried my best to console him.

I also managed to assist Dr Kerwin in doing Proctoscopy.There was this patient, Encik R who came to the clinic with a TertiaryInternal haemorrhoid ( Piles whichis prolapse upon defecation and can onlybereduce manually).I performed a rectal examination on him and seriously he was in pain whenever I touched the hemorrhoid.I had to slowly push back the pile with my fingers.Later, we used the proctoscopy and did Haemorrhoid rubber banding.He is scheduled to come again later in a month time, and if necessary a surgical procedure known as 'Staple Haemorrhoidectomy' will be done.Oh forgot to mention that this patient works as a Penjaga Kuda, and he used to take care Tun Dr Mahathir's horses.

I joined Hanan'sgroup for their bedside teaching.Hanan had to do clerking to a patient with a right breast lump in front of us and Mr Hisham ( the soon to be Minimally invasive and Bariatric Surgeon).The session ended with case presentation and case discussion

Post call

2008-09-20T00:47:00.000+08:00

It's 12.50am now, juz got back from the Hospital due to on-call.

The day started well.Observed an operation; Total parathyroidectomy.Mr A was mypatient for my 5th long case.He has a conctellation of past surgical and medical illnesses.He was diagnosed with Diabetes mellitus when he was only 16 yrs old and now he is 43.Had generalied oedema in 1995 due to nephrotic syndrome and was treated in Hosp Seremban.His kidney function starts to deteriorate from that day onwards and was diagnosed as End-Staged Renal Failure (ESRF) and is on haemodialysis since 1998, 3 times per week.Later, tertiary parathyroidism developed ( Autonomous secretion of PTH hormone despite normal serum calcium level).Anyway, the operation took 3 hours.It could have been shorter but the surgeons could not locate the right lower parathyroid gland.A parathyroid gland is located posteriorly to the thyroid gland and is only 4-6mm in length.Sgt kecik okay!

I decided to do on-call today.Managed to do a few things such as
1) Set a few new IV lines ( Brannula)
2) a few Venepunctures
3)Went to the radiology department with Mr Hisham and Dr Izyan to see a CT scan of a patient with head trauma.This patient had Extradural haematoma.Biconcave appearance were seen in the CT scan.

Tomorrow, I am supposed to go to a place called Sungai Pelek in Sepang to help out my friends who are currently doing their Public Health(or Hell) posting.They are having their 'HIP'-Health Intervention Programme.Malas tapi rasa mcm kena pergi jugak.Probably going to singgah the Hospital again tomorrow.Hopefully can do Arterial Blood Gas(ABG) again!

6th week already

2008-09-18T18:19:00.000+08:00

What did I do today?Lemme see...I've just presented my 5th Long case.It was a difficult case to begin with.Even the surgeons said it was difficult.But I think I did just fine.I got 7/10, which is a good mark! Susah nk dapat...
We had a bedside teaching by our own lecturer Mr Al-Amin, the Hepatobiliary surgeon.A few of us presented a few cases to him.They did well.I think we have got a good grasp in terms of writing and presenting a good case write up, though it was hard at the beginning because of the nitty gritty stuff and thouroughness.
I did my first arterial blood withdrawal today from the femoral artery.I did not feel afraid anymore.In order to become good at any clinical procedures, I notice that we need to have a good grasp of the anatomy and also...GUTS.Yes, we have to be brave and trust ourselves.InshaAllah everything will be okay.I'm thinking of going to the hospital at 6am tomorrow, so that I will get the chance to do more venepunctures and other procedures.Life is good~ =) On-call at the wards and emergency department tomorrow night! arghh

The absurdity of life

2008-09-12T22:29:00.000+08:00

I've just completed my 5th weekof Surgery posting.Frankly speaking, I like surgery.I can see myself as a surgeon one day.God willing,if I am destined to become one...I am really not that surprise.A friend of mine said that there is a theory that we medical students will fall in love to our first posting in our clinical years( Surgery in my case) and will tend to like it more than the other postings and eventually will become specialist in that area.I leave that to you dear readers for your own thoughts.

Fast and efficient is the word for surgery.As a medical student, aggressiveness is an important asset!We cant afford to be left behind coz nobody will wait for you.Never ever wait for invitation.Make your own initiative.

I've presented my fourth Long case write up today and yet I have just received an sms from the coordinator saying that we need to prepare and present our long case by next wednesday.Usually, the presentation day will be on every Friday.Seriously, give me a break.Not only that, TBL and seminars must be completed by next Wednesday.This is what I called absurdityof life.

TOILET mastectomy O_o

2008-09-04T00:32:00.000+08:00

I am currently doing my Long case.It is regarding a 56 year old lady patient who has an advanced left breast cancer ( TNM Staging: T4c, N1, Mx ) .She cried today right in front of me.I was speechless at first, but later managed to calm her down.I cant imagine if I were at her position at that time.She is scheduled for a CT scan tomorrow morning.She will be undergoing a surgical procedure called "Toilet Mastectomy" in order to remove a fungating breast mass ( which in my opinion doesn't look like a breast at all.There was a complete destruction of the nipple and the general breast architecture.It has active bleeding with puss collection already).Why the name 'Toilet"? hmm dont asked me.Miss Anita the surgeon had explained to me earlier but I still dont get it as to why it was named as TOILET mastectomy.I thought it was a typo error initially and had a great laughed, but seriously...the name is toilet.god knows why...
Earlier that day, I was in the OT observing a Total thyroidectomy ( total removal of the thyroid gland).Makcik H had this one HUGEEEEEE anterior neck swelling.The operation began at 9 am with initial problem because the anaesthetist couldn't set the arterial line due to frequent thrombosis.I was standing like 5 hours straight until when the clock showed 2 o'clock, I had to leave the OT and rush to a TBL session.By that time the enlarged thyroid has been successfully being removed.Try to guess the weight? I bet its around 1 to 1.5 kg.Seriously, it was that hugee man...
K ciao~

Conserving energy mode

2008-09-01T21:19:00.000+08:00

Can somebody teach me on how to conserve energy?I so really need this skill. Can I just put my body on Standby mode while in the OT (operation theatre)? Can I put my body to Hibernate mode during lunch break?

Here's what gonna happened tomorrow

- Bed-side teaching at 7.30am.Lambat seminit Prof takmau sign attendance! Must present a few short cases.Huu..

- Have to srub in the OT.Later kalau sempat pergi Surgical clinics pulak.

-Afternoon: Now its Ramadahan so I plan to use the break to actually take a nap in the surau tingkat lima of Hosp Putrajaya hehe

- Later that afternoon, pergi ke wards and clerk a few patients.I need to select one of them for my Long case.Not forgeting the physical examination and the rectal examination!I need a chaperon because I really hope that I will get a thyroid case this week.Woman are the ones who usually have abnormal thyroid condition!

-Malam: On-call! I really want to Terawikh coz now its Ramadhan.I really love Ramadhan. I think I'll just do my terawikh alone at home.Sigh...

Short form

2008-08-26T18:59:00.000+08:00

In Malaysia, we are flooded with many unauthorized, self-invented short forms.There are many reasons of inventing these short forms.First, it is easier to write notes or jot down something really fast when we have short forms.Second, medical terms can be sometime become a tongue twister, especially when they are combined with few other medical jargons.Below are the short forms that I have learned so far during my Surgery posting.Correct me if I'm wrong, or you have anything to add.

TCA-To come again

AOI-At own risk

TDS- 3 times per day

BDS- Twice daily

Stat - Immediately

PRN - Only when necessary

Imp- impression

These short forms are usually used in writing notes during clerking patients, or being used in any forms that need to be written down by the nurses or doctors.

OGDS- Oesophagogastroduedenoscopy ( try to say it 10 times continuously.haha)

ERCP - Endoscopic Retrograde Cholangio Pancreatography

IND - Incision and Drainage

SNC- Suction and Curettage

DNC-Dilatation and curettage

In order to pronounce these words correctly, you have to be relax, take a deep breath and say it one syllable at a time.But, it is quite impossible to do that when you have to present in front of the Specialists, who are known to be bombarding you with lost of questions.Tak habis ckp lagi dah tanye next question.

What did I did today:

1) Ward rounds, clerk patients, do physical examination, prepare my short cases which I have to present this Friday to Dr ( Mr) Al-Amin.
Note: When a person is a surgeon, please do not call him/her 'Dr'.Instead, if he is a gentleman, call him 'Mr' or if she is a lady, call her 'Miss'.Pelikkan? Dah susah susah jadi Dr, tetibe nk kena panggil Mr and Miss balik.

2) Do Rectal examination on my long case patient in order to complete my abdominal examination

3) Perform ECG on a patient

4) Observe OGDS

5)Observe Colonoscopy with Punch biopsy

6) Observe insertion of Central Venous Pressure line (using Seldinger technique)

How long does it take to greet patients?

2008-08-25T23:28:00.000+08:00

It saddened me to see that the specialists and other doctors in the Hospital Putrajaya to not to greet their patients well.This is usually seen during the ward rounds.You can hardly see them greet and aknowledge their patients.All they do is straight away discuss the problems, complications, treatment plan etc among themselves, although the patient is staring, waiting helplessly in front of them.Sometimes its quite funny to see that it is the patients who greet the specialists.There is no doubt that these specialists are brilliant and talented people.They are always busy due to their tight schedule.But, is it so difficult to say Hi, or give salam and say How are you today?How long would it take? 5 minutes?? No it only takes only a few seconds.I just would like to remind myself and to those future doctors out there that our job is not treating the diseases only, but treating the patient as a whole.I always here that the HOs mention the patient by their diseases."Hey Timah, boleh tak ko check kan patient yang ada paralytic ileus tu, aku busy la" .I mean like...helloo...tak payah laa sampai macam tu skali kan?
Few patients have actually asked me "Doktor ( altho I am not a doctor yet but they insist of calling me by the title 'Dr' ), saya ni sakit apa sebenarnye?" Can you believe that? The patients dont even know what they are suffering from.Where is the human touch? One of the ways of relieving the pain and the suffering of patients is actually verbally treating them well.Try to talk to them.Make them laugh.Listen to their stories about their family, their work ,their children, their hobbies etc. So far, it helped me in doing my task.I felt easier to clerk their history, do physical examination ( Per rectal examination included!) as they become more confident towards you.They trust you more.They know that you are there to help them.
I am currently doing my second Long case.It's about a 74 y.o Malay lady with the history of colon cancer.She was admitted to the ward due to epigastric pain with jaundiced.Due to the history, the doctors suspected of liver metastases and porta hepatis lymphadenopathy.It later confirmed with ultrasound and she will be referred to Hospital Selayang ( The Liver and Gallbladder specialist hospital).That makcik was very cheerful and comel( admitted by my other colleagues themselves)
I helped one of the HO to do wound dressing on an open book fracture of the pelvis due to motor vehicle accident.This patient had a big hole at his right upper buttock.The wound needs to be cleaned every other day.It was not easy as I had to wash the wound with saline, hydrogen peroxide and do suction.It was first my time and it was a good experience.Managed to assist in doing the Vacuum-assisted Closure(VAC).The surgical ward MO, Dr Zamaq asked me to learn and by next week, he wants me to do the dressing myself.Adeker????Dah gile ape?
Other than that, I clerked a few patients today and did some physical examination on them.I really like this one patient, where she was really cooperative.I totally respect her as she told us that she will helped us by telling her problems.She even let us to do PR to her.She work only as a cleaner.Why cant the doctors be as kind as her.
Hmm ok, gotta go.Long case under progress ...............

Tired

2008-08-22T23:42:00.000+08:00

Just got back to home sweet home.Seriously, penat giler... Wards, Sick outpatient department, OT, Emergency department..you name it...clerked soo many patients, physical examinations ( no cincai cincai...must be thorough)...including breast examination, assist this, assist that, prepare shortcase...prepare and present long case for patient.Life is so hard

By 7.30 am, I have to be in the hospital, ward rounds is at 8am with the Surgeons and specialists, MOs, HOs.Then I will wither stay in the wards, or rush to the Clinics or Operation Theatre to see interesting surgeries, depends on my group rotation.Malam, ada on-call both in the Surgical wards or Emergency department.Balik pukul 12 am.Life is so demanding.

Surgery posting: Day 3

2008-08-13T22:41:00.000+08:00

I did a procedure called "Per rectal (PR) examination" today.PR is actually a procedure where you insert your finger into the anus of your patient.It gives a wealth of information which helps in diagnosis and assess the patient's condition. You can say that I was lucky as I already had the opportunity to perform this procedure on my third day of posting.haha.Thanks to Dr Najma.Sungguh baik hati kerana mempercayai dgn skill saya yang tak seberapa ni.
Had my first TBL (Task based learning) session today with Dr Ahmed Ali..We discussed about a topic regarding 'Breast lump" . The session began with a lengthy presentation by Azrul and Benjow .It started off by doing some revision of our preclinicals knowledge about the types, the staging etc of breast tumour.Then we proceed to the signs and symptoms, risk factors, invstigation, diagnosis( triple assessment involving examination, imaging and cytology) and ultimately the physical examination of the breast.Seriously, didn't know that a proper and complete breast examination is that complex.
I clerked a few new patients today and presented my case to the doctor.Ward rounds? of course.Tomorrow I am going to follow my patient with left inguinal hernia to the OT.I am going to take him as my first Long case presentation.

Surgery Posting: Day 2

2008-08-13T21:53:00.000+08:00

I am currently in the comp lab as I am unable to update this blog at the comfort of my newly rented house in Precint 9, Putrajaya.It's cold, I'm tired and exhausted, and I just done on my slides regarding the "Metabolic Response to Trauma & Surgery", which I have to present in the Seminar session tomorrow.By the way, today is my 3rd day of surgery posting and not the 2nd day.I am not able to update yesterday due to unforseen circumstances.You will know at the end of this post.

The second day started at 7.30 am.We waited for our Hepatobiliary surgeon Mr Al-Amin in the lobby of Hosp Putrajaya.Today was our first bed-side teaching and seriously it was interesting.We covered two cases of bed side teaching today.The first case was Dr M, who had a Paraumbilical hernia and the second one was Makcik S who had a Parathyroid Hyperplasia secondary to pr0longed and chronic haemodialisis as a result of renal failure.Azrul and Salwa, two fellow group members clerked the case respectively in front of Mr Al amin.They even did physical examination.Then after a few comments by Mr Al-Amin, we proceed with our activities.As for me, I clerked a few cases.I was a bit nervous as this was my first time to clerk case from a real patient.I am currently attached to the Surgical Ward 3A ( a Male ward).The cases that I manage to see were acute appendicitis, Intrauterine death and Mesenteric tumour.I like this one post-op mesenteric tumour pak cik.He is 73 year old and seriously was healthy.Despite of being a driver of jentera berat who has irregular working hours and had to work 24/7, he appeared to be healthy.He doesnt smoke,.He doesnt have DM or Hypertension.His other 14 children have those diseases instead.Both of him and his wife was really friendly.They even gave their phone number and home adress, asking me to visit them once he has been discharged.So sweet.There is this some feeling of satisfaction in me.

At 2 pm, we had an appointment with Sister Sabariah at the OT department.We had a lecture regarding " Scrubbing, Gowning and Gloving method".Seriously, I felt that going into the OT is not as easy as ABC.There are procedures and steps that we have to follow in order to ensure sterility in the OT.It shows how st*pid that show named Grey's Anatomy is.Haha.Nak jalan kat OT pun ada cara.Nak berus tangan and lengan pun kena ada teknik dan repetition tertentu.No wonder my surgeon told me that as a medical student, do not feel hampa when after finish scrubbing the operation has already ended.As a beginner, it will take quite a lengthy time to scrub in.

The highlight of the day is actually during my On-call hours.Yes, I already have on-call.It began at 7.30pm and ended at 12am.I rushed to the Ward once I have arrived at the hospital that evening.I met a few patients just to update their history.I had ward round at 8.30pm, along with H.O Dr Sufiani( sangat baik ), M.O Dr Zamaq ( Triple A's student masa dekat HUKM dulu, I think) and Endocrine surgeon, Mr Cheong and a few nurses.I was asked to do full abdominal examination to a Pakistani patient, suspected of having Pancreatic tail carcinoma.Doing a full physical examination in front of a specialist, MO and HO for the first time was not easy.I was pretty nervous at the beginning but later managed to maintain my composure.The only thing that I have done wrong was that I forgot to make sure that the patient is lying down 180 in supine position.The head of the patient was actually tilting 45 degress..huhu.Mr Cheong also asked me to feel the difference between the Left iliac fossa and right iliac fossa of this one patient who had just being admitted to the ward, suspected of having acute appendicitis.He said, the problem with medical students nowadays is that they do not know how to differentiate between guarding and tenderness.

Later, I proceed to the Emergency department(ED).Sumpah wallah ramai gile patient malam tu.The department was quite hectic and the staff were running around here and there.Me and my colleagues introduced ourselves to the doctors and nurses there.I was given the task to clerk a patient who had just went into the ED.I later presented the case to a Dr named Dr Hasanah ( sangat baik rupanya) and after a few questions, she gave me two thumbs up.Tak sangka.I occasionally went to the Radiology department and managed to see a few ECGs,X-rays and CT scan.I saw a patient with a multiple infarction of the brain in CT scan.Maybe that's the reason why he is being so restless and is having dementia.There was also a patient who have DM, Hypertension, Gout, history of MI, Left Bundle branch block(LBBB), and Parkinson's disease.Serious, a super combo for me that night.He already have akinesia, cog-wheel rigidity, pill-rolling tremor, slurred speech as a result of Parkinson's disease.He also have bilateral non-pitting oedema of the legs due to his congestive heart disease.However, the chief complaint was SOB (Shortness of breath) .Creps (Crepitations) was heard at the left lung on auscultation.Dind't have time to wait for the X-Ray becoz it was already late.Juru X-ray pun tengah keluar pegi makan masa tu.

One thing I learn today is that do not be shy.Be confident.Ask when you want something.The staff of Hospital Putrajaya is more than happy to assist you,seriously...

Day 1 : Surgery Posting

2008-08-11T18:53:00.001+08:00

Bismillahirrahmaanirrahim, today 11 th August 2008 is the day I blog.Yes, this is the day where I started blogging, pouring out my feelings, views, vent my anger or "ketidakpuashatian' etc.

The day started off by clinical briefing by Prof Latiff at the auditorium.The session started at 9 am and me being the smart ass came late.It was completely unintentional.I began my journey from home and I was caught in a traffic jam.Hang ni pun satu Nabil pasaipa hang pi ikut jalan tu kalau dah tahu traffic light situ mcm siput.The late is not like really late.It was only like 2-3 minutes late! However, I admit my mistake to prof.I know well that 1 minute difference can save lives in clinical settings.And so, dapatlah penumbuk gaban Prof Latif kat bahu tadi.After the briefing, we had sessions according to our respective group.The surgery posting group consists of 16 people and we met 2 of our professors of whom are experienced surgeon.They are Mr Ahmad Awil Adam ( aka 'Triple A') and Dr Ahmed Ali Abdullah from Yemen.We were given our clinical logbook , guidelines and other books.I must say that clinicals is about self-directed learning.There is nomore clear cut stuff like you learned during pre-clinicals.In pre-clinicals you can read, discuss and do the exams and pass with flying colours.During clinicals we have to apply our basic knowledge, apply and improve our psychomotor skills and most importantly improve in our affective domain ( communication skills, verbal/non-verbal skills)

Later in the afternoon, we went to Hospital Putrajaya.I had lunch at the cafeteria.Hanan didnt eat becoz she is puasa-ing and Odi, my senior who is currently doing her O&G posting were there also.She basically told me all the things which made me a little bit worried and afraid.At 2 pm, we went to the surgery ward.I must say that all the H.Os , M.Os, nurses etc were seen to be perplexed.It was as if they were invaded by a group of aliens.Serious sh*t I tell you, it was written all over their faces.That made me a lil bit worried becoz the reception was not really encouraging.But I still think positively, as the old Malay saying goes "Tak kenal maka tak cinta". The we were introduced to 3 lady surgeons.Yes, LADY.One was baik, one was tak nak tengok muka kami lansung, and one was garang.Again, I am not going to judge them becoz "Tak kenal maka tak cinta".

At 3-4 pm, we all gerak to our resource centre in Precint 9 Putrajaya.We waited for our Prof to come.One thing I would like to say is that our teaching and assesment is very much different from our pre-clinical years.In preclinical for example, I had SCTL, PBL,Clinical correlation sessions, OSCE, OSPE etc. But in clinical years, I will have to be accustomed with many new ways of learning and assesment.I am going to have TBLs( Task Based Learning), Seminars, CCP( Combined Case Presentation) , CPC (Clinico-pathological conference), short case presentation, long case presentation etc .Not to mention the ward rounds ( general, pre-op, post-op), clinics hours, operation theatre, bed side teaching etc. I am still trying to digest these new stuff.

One word that can summarise me for today."MIX feeling".I am feeling excited and afraid/worried at the same time.Will I perform?Will I able to meet the expectations?Will I learn things that will benefit me and ultimately to my patients? Only time will tell...