Sunday, December 09, 2012

Episiotomy Workshop


Last Thursday, we had to attend Episiotomy Workshop at Seminar Room 3 and 4, JHC. It was held from 8am till 5pm, sponsored by B Braun Company. It was very educational.


The image is a bit unclear, but still readable. Sorry for that.



Suturing of the perineum done by Shake and I on a model. Above is the vaginal opening and below is the anal opening.


By the way, episiotomy means a surgical incision of the perineum to enlarge the vagina, to facilitate delivery during childbirth.

We have to observe 3 epi and perform 2 repairs!




Souvenir from B Braun during Quiz Session. Thanks to Amirah Lotpi, her note helped a lot ;)

Thursday, December 06, 2012

The Official Slip Result


Passing marks for Theory is 50% while for Clinical is >100. 

You have to pass both Theory and Clinical in order to pass the posting.

Your ranking is mainly determined by your Clinical marks. Even if your friend scored higher marks in Theory but lower marks than you in Clinical, your ranking is above her/him because you scored high Clinical marks. Got it?

If you got 49 marks in short case (that's a fail), but 54 marks in Long Case, making a total of 103 marks altogether, you still pass!

We didn't get to know about our OBA and PMP marks? Hmm...

ps. Yeah, I failed the MCQ btw. That's normal ;)

Thursday, November 29, 2012

The Result

Alhamdulillah..

ps. Out of 33 students, 8 failed the exam (4 brothers and 4 sisters) and they have to repeat posting, maybe in the end of Year 3.

Sunday, November 25, 2012

Of The IM End Block Exam




Although the exam period (1 day for PMP/MCQ/OBA and 1 day for LC/SC) was very short, it was seriously unnerving. Here's a brief review on the exam questions.

Monday, 19/11/12

1) PMP @ 9.00-10.30am

PMP is like PBL. We had to answer three sets of questions based on cases given.

The exam was six days ago, I could not quite recall the exact questions, though. If I'm not mistaken, the first question was about Diabetes Mellitus.

There's this one question asking about 8 signs that you might want to look for, regarding the patient's long-standing DM. In other words, the complications of Diabetes Mellitus.

I mentioned about signs of Diabetic Retinopathy, Neuropathy, Nephropathy and Infections. That's all I could think of.

Then, the question asked about the modifiable and non-modifiable rick factors of DM, advice you would like to give to the patient and a few more.  

Second set of question involved Hepatitis/Chronic Liver Disease/Hepatic Encephalopathy.

Remember this pakcik?



Last one was on Rhematoid Arthritis. That reminded me of this makcik, seriously.



Z deformity/Swan neck/Boutonniere deformities, Ulnar deviation, Palmar subluxation, Joint erythema/swelling, Palmar erythema, Tinel's sign.... You have to remember those!  

2) OBA + MCQ @ 2.30-4.00pm

15 Multiple Choice Questions (MCQ) and 10 One Based Answers (OBA) were a bit tough. The questions were easy, but the answers.....not!!

This one question made me go... Wow. It was about the side effects of Anti-TB drugs! I totally forgot about those! Well, I did read about them, but I could not seem to remember.

Rifampin - Orange discoloration of urine, Hepatotoxicity
Ethambutol - Optic Neuritis (remember E for Eye!)
Streptomycin - Ototoxicity, Kidney damage, Skin complications
Pyrazinamide - Hepatotoxicity, Gout
Isoniazid - Hepatotoxicity, Peripheral neuropathy

Read more about them from reference here.

If you are so dedicated to answer past years questions, there's a few repeating questions asked like what are the causes of irregular pulse. (I was only sure about Atrial Fibrillation, the irregularly irregular pulse)

I did not do the senior's compilations much (with so little time and so much to read!), and now I kinda regret it. If only I was more hardworking back that time. 

And there's this question about the signs of hypothyroidism that made me smile.

You know why? The loss of outer third of eyebrows ;)



We had met this very similar-looking makcik before in the ward. The resemblance was amazing! :D 

The opposite of hypo, it's hyperthyroidism! 


Picture source: X'Press Revision in Short Cases, Aids to Undergraduate Medicine by Chew Nee Kong and Lim Kheng Seang. You can buy the book from Syarikat Kamal, KL.

Seriously I tell you, you should totally get this book as it is very very useful!


Wednesday, 21/11/12

1) LC with Dr. Yousuf Rathoor @ 9.00 - 11.00am

Long Case (LC) session was a bit hectic. I did not get my patient's diagnosis at first, since she came in with fever, sore throat, vomiting and diarrhea. I really thought it was a case of Acute Gastroenteritis. Pneumonia? But she had no cough.

On examination, there was no findings at all. I really wish she had bibasal crepitations at least. But she didn't. I thought she had mild splenomegaly?

I asked her whether had the doctors told her that she had big spleen, or she had lung infections of some sort? She said no.

I was like, Hmmm..... 

Half an hour before the time ended, she mentioned about her high glucose level on admission (it was 30 mmol/L), then I was like, that's it!! 

I asked her about polydipsia, polyuria and nocturia. Oh, it was Uncontrolled DM rupanya!

When I was busy constructing my sentences on paper, Dato' Sapari and housemen came to the patient for their round. I managed to hear Dato' mentioned that her lungs were clear and she told the makcik that she had acids collected in her body, due to her DM.

Oh, her diagnosis was Diabetic Ketoacidosis!

Dr.Yousuf came in to hear my case a bit late, so I had ample time to prepare and write my sentences carefully. I was thankful that I got an easy case to start with. 

I did okay in Long Case, I think.

2) SC with AP Dr. Khairul Azhar @ 11.15am

Well, I admit that I didn't do well in Short Case (SC). I was quite nervous, actually.

I had to examine a middle-aged Malay man with a 16cm sternotomy scar and 51cm scar from left leg up to thigh. On CVS examination, thrills were palpable at mitral area. First and second heart sounds were heard. No murmur. Other than thrills, no other significant findings were found.

What do you think this pakcik had?

I was not able to answer regarding his diagnosis, so I looked at his case file after the session finished. The diagnosis was Acute Coronary Syndrome.

By looking at his sternotomy scar, maybe this pakcik have had CABG or Valve Replacement before, and there might be recurrence of his heart problems. Ah, I should have think of that.

Here's a few tips when you have AP DKA as your examiner:
1) When you get a patient with scars, bring out our measuring tape and measure the scars!
2) Make sure you get your techniques right. Especially on how to do the Collapsing/Bounding Pulse!
3) Do not wait for doctor to ask you about your provisional diagnosis after you present the case, just mention them straight away! 

Since this was our first examination, we had a hard time adjusting. But I am sure we could do better next time. Once again, I'd like to wish you happy holidays!

Oh, and have a look at this:


Hehe ;)

Thursday, November 22, 2012

A Break




I was thinking of writing a post about my exam, which just ended yesterday. 

 But that can wait.


You know the reason why ;)

Happy holiday, everybody!

Monday, November 19, 2012

Exam Week.. and Here I Am




Awak ni tak penat ke asyik2 datang sini? Hari tu dah datang dah.. Kalaulah ada Clerking Note awak tu, mesti Doktor dah letak kat depan ni dah... Lagipun, Clerking Note tu spatutnya student tak akan dapat balik...

Kak, memang saya penat pun drive datang JHC. Saya baru je lepas jawab exam MCQ/OBA kat IMC kak, pastu terus saya datang sini. Tapi saya tak kisah pun kak. Saya tak kisah pun datang semata2 nak amik Clerking Note saya.

Saya tau memang Doktor2 lain tak bagi semula Clerking Note pada student. Tapi Mentor kitorang tanda Clerking Note yang kitorang hantar. Saya mana la tau bila masanya Dr. da siap tanda kertas saya, itu yang saya datang je ni, just in case.

Penat saya buat Clerking Notes tu tau, kak. Kadang2 stay up malam2 nak completekan semua. Saya nak la balik semula kertas2 tu untuk dijadikan rujukan, bukannya saya saja-saja je siapkan, semata mata nak penuhkan requirement. Bagi saya, Clerking Notes tu sangat2lah berguna, kak. 

Saya dah abis posting IM da kak, akak jangan risau. Lepas ni saya tak ganggu akak dah ye. Terima kasih banyak2 akak. Saya mintak maaf kalau ada salah silap. Inshaalah kalau panjang umur, kita jumpa lagi tahun depan.

Then again, I was not so brave heartless to reply back to her. Instead, I smiled and went out of the office, feeling moodier than ever.

I passed by the IM Board.

Oh.... so this is how it's going to be... ***Nervous
Which doctor is our Examiner? Cuaknya.... X__X

Speaking of Clerking Note, here's an interesting case to share.


CT brain revealed intraparenchymal hematoma in right posterior parietal region with associated perilesional edema and extension of bleed into right lateral ventricle. The body of right lateral ventricle is compressed. The left lateral ventricle is prominent suggesting early hydrocephalus. No midline shift. The sulci are effaced suggesting right cerebral edema. No fracture seen.



See the outline of prosthetic valve there?
This patient underwent Mitral Valve Replacement (MVR) Surgery in 1992.


I guess that's all for now. I should study. Wish me luck.



God, I don't ask for much. Please let me pass this exam. Just a pass will do. Just a pass. Please.

Tuesday, November 13, 2012

10th in 10




Just finished my 10th (Thank God it's the LAST!) Clerking Note.

My head is spinning.

Padan muka sape suruh buat kerja last minute?! -..-''

Adeh.


ps. This is our last week (Week 10) before end block exam next Monday. Study week pun rasa macam bukan minggu untuk belajar and stay dalam bilik untuk study je, but still kena pegi JHC, ada klass, huhu

Tuesday, November 06, 2012

Friday, November 02, 2012

Short




1) Met a 23-year-old kakak with PDA at 7C.

2) Clerked a kakak with Lupus Nephritis this morning.

3) Followed Ward Round Dato' Sapari, Dr.Che Rosle and Dr.Ainon.

4) Tutorial Cardiac Arrhythmia with Dr.Wan Syahril this evening.

5) We were advised not to be too stressed up about CWU.

6) Been told that our exam questions will be a bit tough.

7) How bit is bit, Doctor?

8) Next two weeks : END POSTING EXAM 

9) Worried.




Work extra hard now, will ya? *pat shoulder

Wednesday, October 31, 2012

Week 8 and counting...




1) When I passed up my CWU to my mentor for final review, later he asked me, 'Who checked your grammar?'

First, I asked my Dad to review my paper, checking all the verbs, vocabularies, grammar and stuffs. Then I double checked it with my former English teachers. I also showed it to a few of my close friends. Oh, maybe I did send few copies to my international friends online. 

I am well-aware that you don't like broken English, Doctor. So I went through all these troubles just for the sake of correcting my grammar, and to get your approval as well. You see how much effort I had put on these 24-pages of papers, Doctor?   

To think that I dare to answer as such to my mentor... are you crazy??!

And you couldn't tell if I was kidding or not, right? Lol

2) Of course I cannot speak English like the way I write. For me, writing is so much easier than talking. You can edit the words when you write, but not when you talk. Once the words got out from your mouth, you can't take them back.

Let's just say, I am more of a listener than a talker.

3) Today I clerked a 21-year-old Malay lady, presented with sudden loss of consciousness for 6 hours. 6 hours! I was like, seriously? Is that possible?

Her twin (yeah, they are twins!) mentioned that her sister went into deep sleep from 5.30am, had an episode of 2-minutes seizure with drooling of saliva at 7.00am during sleep, and she didn't regain consciousness until 12pm, few hours after they reached A&E, HTAA.

During the incident, her twin and other people tried waking her up by pinching and slapping her, but she didn't respond. Ambulance was then called.

She woke up with no recollection of what had happened to her. She was then admitted to the ward for further management. 

She have had similar episodes before, her first being at age 16 and her last being last year. This is a case of epilepsy, so I thought. 

But she insisted that it is not sawan that she experienced. Ni sebab ada benda dalam badan saya yang buat saya jadi macam ni, I quoted her.

Okayy. This is very awkward. How to deal with this? Think. Think.

Since she got upset when I mentioned about sawan, so I rearranged my sentences carefully when I tried to get further history. She has no family history of seizure, and this is her first admission to the hospital, despite having multiple episodes of similar attacks before.

I told her that we can do Brain CT to rule out underlying cerebral lesions. She mentioned that the doctor suggested that too, but her father didn't allow her to do that. He strongly believed that the cause of her 'sawan' is not something you can treat medically.

Wow. If her Dad said so. I dared not to provoke more.

I didn't have the chance to read her case file yet. I wonder how the doctors manage this kind of patient. Discharge at own risk?

4) On different subject, here's a quote from my friend, 'Belajar dengan Dr.Naim buat kita rasa macam banyak gile benda yang kita tak tau..'

I second that.

Next week is Week 9 - our last week in IM posting. After a week of revision, we will have our very first End of Posting Examination.

'I am worried about you guys', I quoted from a doctor.

Yes, Doctor. I am worried about us too.

5) I have heard that our Dr.K was in a good mood during Short Case session with my friends this morning. That's news! I wonder who/what had brighten up his day today :D

I just hope he'll be in the same bright (hopefully, brighter!) mood during the examination two weeks from now.

Tuesday, October 30, 2012

Recap Recap




1) Just finished editing my Case Write Up. But somehow I feel that it is just 3/4 completed, considering the fact that I didn't acquire much details in the HOPI and there are some physical examinations that I had left out. How can I forget to do Pull Test in Parkinson's Disease!! And tandem walking to check for ataxia! And I couldn't remember if I had auscultated her lung or not, because the patient was given Augmentin! If the patient didn't have pneumonia, then why was she given the antibiotic?

I was so excited about her Parkinson's that I forgot to ask about her Hyperthyroidism! Careless mistake! **sigh

After Dr.Naim checked my paper and pointed out things that I didn't ask my patient, I was like, 'Yeah.. I totally forgot to ask her about that!'

Ah. I wish I have my patient's contact number.

2) Rewind back to this morning's ward round, I clerked a makcik with CCF and a kakak with dengue fever. Nothing interesting in particular.

But, But! We saw a patient with Umbilical Hernia! You can see his protruded umbilicus - red, warm and tender. The patient was half conscious, by the way. If you palpate his abdomen, you could feel that it's very distended. Once I thought I could feel his bowel!

If you follow ward round with Dr.Yousuf, you must be proactive and quickly examine the patient if he asked you to. Go touch the patient, don't just look. If not, he'll punch you. Trust me, it's a reaaally hard punch. Lol

3) I talked to a pakcik who has STEMI. He came to the cardiology clinic just to get a refill for his meds. But he was admitted to the ward anyway. He was really frustrated because he didn't want to stay in the hospital - he has to go to work in the morning!

He is a fisherman and he is in need of money to pay for his previous hospital bills. And if he has enough money, he wants to go for balloon angioplasty. If he has the money.

It is sad to hear his stories. It reminds me of how lucky I am. Alhamdulillah.

4) We saw Dr.Kuan and Prof.Fauzi this morning. It's not always you can find them in the ward, since they are very busy. It's nice to see them anyway! :D 

5) Short case with Dr.Che Rosle was fun. We had cranial nerves PE (on patient with dysarthria) and lower limbs PE (on patient with stroke secondary to brain abscess). He told us that in a young thrombotic patient, you should consider four causes; infection (meningitis, encephalitis), infarction (amphetamine, heroine), vasculitis (arthritis etc) or thrombophilia state. 

And we saw ring-enhancing lesion on Brain CT! It was maybe due to abscess (Strep/Toxoplasma) or TB granuloma among other causes.

6) Faizah and I helped Dr.Adlina with venepunctures. We examined a patient with suspected fibroadematosis.

Fibroadenomas are benign breast tumors commonly found in young women. Fibroadenoma means "a tumor composed of glandular (related to gland) and fibrous (containing fibers) tissues."

Breast fibroadenomas, abnormal growths of glandular and fibrous tissues, are most common between the ages of 15 and 30, and are found in 10% of all women (20% of African-American women). They are found rarely in postmenopausal women.

Described as feeling like marbles, these firm, round, movable, and "rubbery" lumps range from 1-5 cm in size. Giant fibroadenomas are larger, lemon-sized lumps. Usually single, from 10-15% of women have more than one.


She had a high fever, you could feel the warmth transferring to your hand while you examined her axilla. We couldn't be able to find the exact lump, though. 

On palpation, there was a firm small area on her left breast at upper lateral region. It has ill-defined border, non-mobile and it was tender upon touch! There were axillary lymph nodes enlargement as well. No nipple discharge noted. 

Doctor scheduled her for mammogram and maybe referred to surgical team later. I doubt it was fibroadenoma, but let's see the result tomorrow.

7) I am too tired to look up for differential diagnoses of breast-related diseases. I really need to sleep now.

G'night :)

Wednesday, October 24, 2012

Cornflakes Madu for Eid




The ingredients

Add butter, milk and honey into pan

Pour the mix into cornflakes. Spoon them into papercups

Put in pre-heated oven 150'C for 10 minutes

Tah-daa! Tempting, eh? :D

Tuesday, October 23, 2012

Emotional




1) This morning I went to see my patient in ICU on second Floor, Teratai 2B.

She was formerly admitted to Medical Ward 7B due to CAP. This was her second admission to the Ward after being recently discharged few weeks ago. She is the AIHA patient that I mentioned before, the one I was thinking to be my Case Write Up. 

I got the news of her being transferred to ICU from her sister yesterday night. 

The first thing I was thinking before I enter the ICU: Am I allowed to go inside without supervision?

Heck, the worst thing that could happen is that I'll be scolded in front of everyone. And if that happens, I'll just get out of there quickly.

So I got in, putting my best professional look on.

When I couldn't seem to find my patient, I asked the Staff Nurse around.

'Oh, patient tu kat Bed 6, Doctor. Kat hujung skali tu, belah kanan'.

I thanked her, smiling. Professional, professional, I reminded myself.

And during that time, a specialist was doing his round, with H.Os and M.Os following him from bed to bed. 

When I walked past them, I could hear one of them whispering, 'Eh siapa tu?'

You don't know me? Good good. Let's keep it that way, shall we? ;)

It was heartbreaking to see my patient in the room with ventilator support and the white 'float thing' put on her whole body. I have no idea what is that or why it's there.

I read her case file but I couldn't be able to understand half of what's written there, though. I've been thinking of asking the Staff Nurse nearby, but then it would be known to her that I am not a doctor. 

So I keep on reading. I got to know that she was unresponsive to treatment given, underwent hemodialysis twice and the implication written was urosepsis. She had DM as well, and I could see from the ABG results, they are not looking good.

I looked at my patient from outside the room. It was just yesterday morning in 7B that I asked her how she felt. I remembered her telling me she felt uncomfortable, she had a high fever. I pulled the blanket over her.



When I was driving home, I got a text message from her sister, 'Akak baru je meninggal'

She told me her sister was pronounced dead at about 9.30am.

I was speechless.


2) Compared to CCU (Cardiac Care Unit), you don't have to wear special shoes to go inside ICU. You just have to take off your white coat.

I wonder what is it like in HDW. I'd like to go in there someday.


3) On a different topic, normally we will choose a patient for our Short Case session and decide on what system we would like to examine, with one of us is assigned to examine the patient. However, with Dr.Kuan and Dr.Harris, it's totally different. 

Dr.Kuan picked an assigned student while Dr.Harris selected a random student to examine a random patient. 

And at both times, I was the one who performed the examination: Abdomen and Respiratory (from the back). Yeah yeah, you probably say, that's the easiest examinations, you can ace that!

'If you examine patient like that, you will sure to fail in exam'

'From the way you examine, it's obvious you never examine patient from the back before. Is it?'

'Your examination technique was bad!'

And twice I got the same last comment from our lecturers.

You see, I am just bad at doing PE, and I hate myself for that.



That's more the reason to keep practicing, right? 

Yeah I know. I did practise on patients. I examine them.

Maybe I didn't examine enough patients. Maybe I didn't practise properly, not following the flow of examination.

But in the end, I couldn't seem to get it right though.


Maybe I am not cut out to be a doctor?



Okay, positive thoughts. Positive thoughts.

I can do this. 


Maybe.


Argh. I hate it when I am being like this.


4) In the process of editing my Case Write Up on Parkinson's. Our Mentor's been a great help to me us, I am very thankful for that.


5) My 12-year-old sister just loves watching this Malay drama on TV3, Mimpi Cinderella. I'd say it's a huge waste of time, she should spend the night reading or do something educational. Better yet, just go to sleep!

It's not that I'm allergic to these kind of stuffs, but I try my best to stay away as far as possible.


You see, I am easily affected.

Instant Cookies



A reason to celebrate ;D

Mix + Butter + Egg = Cookies.

Friday, October 19, 2012

A Dose of Criticism PRN




I used to be very (very!) afraid of our lecturer Dr. K, who always scolds us every time we make mistakes. If we could not provide a clear explanation about a subject, or give him a wrong answer, he will deliver series of stern lectures with comments and critiques.

If I were asked to rank our lecturers, I would say that Dr.K is the most feared among all lecturers.

Dr.Marzuki, Dr.Wan Syahril, Dr.Che Rosle, Dr. Shahrin, Dr.Anis -> Dr.Juita, Dr.Harris -> Dr.Naim, Dr.Kuan, Dr.Nik Fatnoon -> Dr.K

However, after an impromptu Long Case Session with him in the Ward this morning, I had a sudden change of heart.

He was strict and sarcastic as usual, but he gave us advice in between sarcasms. 

Here are few things he mentioned:

+ Don't use 'this patient is a known diabetic..', just state that 'this patient has Diabetes Mellitus since...'. Refrain from using 'noted', 'denied' and 'claimed' repetitively in our sentence.

+ If we meet a patient with Diabetes Mellitus (DM), we should ask about:

1) When and how was he diagnosed with DM?
2) What were his symptoms before he was diagnosed with DM?
3) Did he take any medications? What are the meds? How about his compliance to the meds?
4) Did he have any complications of DM? 

If you meet a patient with underlying DM, HPT, asthma, chronic lung diseases, history of PTB - you must ask details regarding each disease.

+ Since DM and HPT are very very very common in hospital setting, and we meet patients with these diseases every day in the ward, so we should know how to diagnose/manage the patients, what are the complications etc. 

+ What are the stigmata of Chronic Liver Disease? 
Asterixis/Flapping tremor, Clubbing, Leukonychia,  Palmar erythema, Dupuytren's contracture, Bruising, Absent axillary hair, Jaundice, Parotid swelling, Spider naevi, Gynaecomastia, Caput medusae, Ascites, Hepato/splenomegaly, Female pubic hair distribution, Testicular atrophy and Ankle edema.

+ We should be proud of our brilliant Islamic scholar like Imam Syafi'e, he was truly an inspiration.

+ If you know that you are not genius (like Faqih and Nani ;)), you must work extra hard to be successful. Be hardworking.

+ Go to the ward every day. Have a look and clerk a patient, then go back and read about his disease(s). That's how you learn. That's how you should learn.

+ Have an aim in life. What are your goals? Expectations? What do you want to achieve?

+ If we were to compare between medical students who study overseas and us, we are sure to be embarassed by how much we are lacking in terms of medical knowledge.  



I agree that his words are sometimes harsh and hurtful, but personally I think we deserve that. The criticisms are very much needed to make us realise the fact that we have a lot more to learn. We have to improvise in order to become a good Muslim doctor.

 

I felt like crying.

This time, it's not because I got scolded by him.



It is because I could feel his concern.



Being 'malignant' is his way of showing that he actually cares about us.







Thank you, Doctor.