Friday, October 31, 2014

Getting Older

My Mom had been talking about how we (my sister and I) should start looking for potential husband and get married. We are not getting any younger, my eldest sister will be 26 next year, and I'll be 25. My Mom had been asking me whether I know any Syed in my college, seniors or any friends. I told her many times before but she kept askingg. Even if I know one, I am not gonna tell her LOL

I don't mind marrying a non-Syed. As long as he's a good Muslim, I am fine with it. If some day I found a guy that I really really like, I will marry him no matter what his name is! Oh yeah wish me luck with that.

The topic came up a few times before, and my Mom gave hints as if telling me to talk to my sister to find a husband quick, and that I should do the same too. The problem is :

I don't really know how to 'find a husband'!

And I haven't found one that I like so far. Well, I like someone before, but I don't think my parents will approve of him, he is not very religious. Plus, he lives so far awayy. He has a girlfriend now so yeahh he's off-limits. And after him, I kinda like this one guy - but I don't think he's ready to settle down. He travels around the world and he has problems of his own. So there you go, two guys in my life that I can't really have. Pretty sad, huh?

I don't wanna settle down with just any guy - just because I am getting old so I have to get married. I have this silly thought that I cant get out of my head - the idea of a happily married life, with someone that I love, growing old together and have kids and...and I have noo idea why I am writing about this.

So, the conclusion is...wait, what the conclusion is?

Why can't I just wait here until my prince comes and marries me! What took him so long? I am here, come on alreadyy!

That sounds ridiculously....ridiculous, Nurul Ain. How do you expect to get a guy when you are not seriously looking for one, huh?

Noo I dont wanna 'seriously looking for one'!!

Yeah whatever. Then you can wait until you are 40 years old, and watch alll of your friends getting married and have kids.


Start what? LOL

Off to bed now. Goodnight people!

Oh yeah. And goodnight to you too, my prince - wherever you are. I'll be here waiting, don't lose your way okay.

Pfft. Such a dreamer.

Wednesday, October 29, 2014

What Is She Like?

When I was in Manchester, my housemate told me that she once wondered what am I like. Since I am from International 'Islamic' University Malaysia, she was worried that I might be too 'extreme' and rigid about things. I just laughed. I told her that she doesnt have to worry, I am moderate.

When I was backpacking in Cambridge, I stayed in a female dorm. I met a lady (age around 50) from America. She was all alone because her husband went to Ireland to visit his relatives. She was about to go out to buy her dinner when I came into the room. We ended up talking for some time. She looked surprised when I took off my scarf in front of her. She even asked me if Malaysians are moderate Muslims or not. I giggled - because I could tell that she was choosing her words carefully to talk about Islam and Muslims. That's cute.

When I checked into a hostel in Bath, the receptionist offered me a discount for all meals in the pub. He also showed a discount coupon on beers/wine and told me I can use that - if I am looking to drink that night. I laughed and said, 'Oh no, I don't drink'. Then he quickly said, 'Yeah, I figured'. He looked embarassed. I smiled. Awkwaaard.

When I was in Edinburgh, Kak Sara asked me if I want to eat only in halal restaurants, or strictly Malaysian food. She was worried whether I am choosy about food. I told her that I can totally eat any vegetarian food from any restaurant.

When I was in Salford, Lamees (my good friend who's doing attachment at the same hospital) told me that her family and friends asked her, how can she trust a 'stranger' (that is me) and go travel together to Birmingham and Cardiff? She just met me for less than a week! What if I am a bad person? I laughed.

I always tiptoe when I take photo with tall people LOL
Meet Larissa, she is from Germany! I met her in Tartan Lodge, Glasgow.

Basic things that I think you should know about me:

1. I am easy to get along with, if I like you.
I do like to make new friends. I am open to meeting different people, but I am very selective when it comes to letting people into my circle. If I like you enough, you can have me do anything for you.

2. Introvert much?
Maybe. It is true that I don't like parties and hangouts and loud people, but I can totally go out and have fun if I want. IF I want. I like to read, listen to music and spend time with people that I love.

3. I believe in a lot of things.
I believe that if you do good to people, you will get good in return. I believe in heaven, rewards and punishments from God. I believe that everything happens for a reason. I believe in a lot more things.

4. You do yours, I do mine.
We all have our own ways of living life, so let's respect each other. Even if I dont agree to how you live yours, I dont think it's right to say anything about it. You make your own choices, and I make mine.

5. See this wall? It's there for a reason. 
I am not big on telling people that I have just met about my personal feelings. If I dont like something about you, I'd rather keep it to myself. Generally, I find it easier to write about feelings than to talk about it.

6. Mess with me - I will never forget. 
Oh yes, that is true people. Do what you wanna do to me, I will forgive you sooner or later. But to forget is a little bit harder. Don't worry, what I will do is just to keep my distance away from you. I am not gonna hunt you down, or make you pay - that's just not me. I'll let you settle with God.

So that is how I am like. Scared enough? 

You better! Hahaha.

Ohh its late. I am off now. Goodnightt! :D

Monday, October 27, 2014

Ibis Budget Sheffield Arena

Finally - July is DONE yayy!! Good job Nurul Ainn!! *pat shoulder* :D

Now moving on to August, the first day when I went to Sheffield. The very first solo trip.

On the first night, I stayed here - Ibis Budget Sheffield Arena. It was awesome!

Booked through for GBP36
Yeah it was a bit expensive since I booked it last minute. You will get less than 20 pounds if you book early!

Here, some photos of the hotel and the room:
It's easy to find the hotel. See there?

Yup! This is it!

My room number is 408

The door, obviously LOL

Hotel policy

Uuuu coooooolll ;)

Tah-daaa!! Love itt!

It does look comfy, right!

The TV

Free WiFi

Oh okaayy, selfie hahaha

The simple toilet
Outside view from my window

We have to pay for breakfast, for about 5 pounds

You can take the bus to the Interchange, the bus stop is just outside the hotel, down by the road

Little do you know, I love you 'til the sun dies :)

Okayy I better go sleep now.

Bye bye youu! And good nightt! :)

Sunday, October 26, 2014

Behind a Photo

I was going through my photos in Liverpool, and I found this one:

There's a funny story behind it. See that guy on my left? On that day, I saw him in gallery (Tate Liverpool) earlier, taking photos of the art displays with his phone. He looked so cool and I thought, why not follow him for a little while before I went out of the gallery room. So I pretended to take photos and at the same time, keeping an eye on him. Sounds crazy, I know. But hey, I was in a place where no one knows me, so yeahh. I was allowed to be crazy hahaha

He seemed so engrossed in reading the art explanations - maybe he's an art student? That would make him super cool then! And he's tall, with brown (or was it blonde?) hair. Not bad not bad. I was so busy focusing on him - then I realised that I should move ahead, because my friends will be waiting downstairs. I said goodbye to him (in my head! hahaha) and walked along to find the way out. I found a door, but I wasnt sure if it was an exit door or not! I was thinking whether to open the door or not, when that guy (yeah, that guy!) walked pass me and opened the door, asking me if I wanted to go in.

I was like, ohmaigawwdd he's talkingg to meee!! Okay okay, not that excited. Well, a bit happy. Just a bit. In a controlled voice, I asked back, 'oh, is this the way out?' He said that it's not the way out, he then showed me the main door, for exit. I said thank you and walked to the main door, smiling. Ahhh I should have gone through the door with him!! hahaha

And I went to the second gallery, taking photos of the beautiful displays. Then I saw him again, not so far away. My heart skipped a beat. I was actually thinking of saying hi, but of course it was all just thoughts inside my head. I didnt have the guts to do it for real. Worried of being late, I walked quickly and scanned the room, reading a bit here and there, and then went downstairs.

I didnt see my friends outside, so I walked around and take photos. When I went out, I saw him again!! What a coincidence! He looked like he's lost, because after he went to the right lane, he came back again to the museum entrance. I saw a map (like in the photo above) and went to it to take photo. When I was finding a perfect angle to capture the map, I felt him coming to me! I mean, to the map. The map. Maybe he is not from Liverpool? Is he really lost? Does he need any help? I am also a tourist, if I offer my help, what if I cannot help him? That would be embarassing! Thousands of thoughts running through my mind at that time.

Then I received WhatsApp msg from my friends saying that they already finished, and waiting for me at another place. So I thought, why not take a photo of him? I quickly snapped one and walked away. Yeah, I walked away. I should have said something to him, right? Like, asking him if he needs help or not. Or, or, if is he alright or not. Or maybe his name. No no not his name. Thats too much. I should have said something!

Oh well, at least I have a photo with him! Hahahaa

So that's the story behind it. Sweet sweet memory (>.<)

Now you stop playing around and get back to work!! Yeah, I need to continue working on my long overdue photobook. No more procrastination! Yeah GO GO!

Have a good dayy, people! :D

Saturday, October 25, 2014

Movie Day!

These are the movies that I watched today, on Diva Universal, Channel 702. I do prefer to watch sad, romantic movies by myself - because I can cry as much as I want! LOL 

Here here:

1. Nearlyweds (2013) - IMDb rating 5.9

Starring : Danielle Panabaker, Jessica Parker Kennedy, Britt Irvin etc.

It is a story of three best friends who are just married (or nearly married!). They receive a letter saying that their marriage is not official, because the pastor had died before signing the required paperwork - so they have to go to the court to legalise their marriage. But the problem is, do they wanna get it done? One has problem with her unromantic, clueless husband and his ex-girlfriend. One with the impossible, hateful mother-in-law who lives together. And another one has to deal with a controlling husband who does things his way.

Ok. Questions to the guys. Let's say if you are married to a very lovely wife - will you accept your ex-girlfriend (of 3 years!) to become your personal secretary at work? Are you willing to spend hours with her, working at the office, rather than be with your wife at home? Do you dare to go to a romantic hotel, even if it's for work purpose - with your secretary, a very hot and sexy secretary? I cant believe that that guy in the movie thinks it is okay to do those things to his wife! And he actually thinks that his wife feels okay with all of it! Jeez.

2. Unconditional (2012) - IMDb rating 7.2

Starring : Michael Ealy, Lynn Collins etc.

I really like the setting of this movie, she lives in a farm house surrounded by a beautiful scenery! She has horses and chickens and other animals! And her hideout, the place where she always do her work (she draws!) is neat and awesome! This is a story of two main characters who are childhood friends. They grew apart, live their lives and meet again after 20 years. Its a sad, sad story! :'(

3. October Baby (2012) - IMDb rating 6.7

Starring : Rachel Hendrix, Jason Burkey, John Schneider etc.

Ok this one, is about a college freshman and her journey to find her true identity. She found out about her being an adopted child, that her biological mother wanted to abort her, that she was born as premature baby with a lot of health issues, about her twin brother, her biological mom who refuses to acknowledge her and a whole lot of other stories. It's a lot to take and she's a strong woman. I imagined being in her place, and I would do the same exact thing as she did - run away from home and go find the truth.

And....there's the handsome childhood friend. He already has a girlfriend, but he is always there when she needs him. I am so glad they are together in the end! I dont like his girlfriend, she is mean!

4. Forever Young (1992) - IMDb rating 6.2

Starring : Mel Gibson, Jamie Lee Curtis, Elijah Wood etc.

Well, this story doesnt seem logical to me. It's about a man who is freezed inside a machine for 50 years! Yes, I know. But, but - the idea of waiting for 50 years to say 'I love you, will you marry me?' to the person you really really love is really sweet!

Time waits for no man, but true love waits forever.


So...that's all folks! Enough stories for today!

Okayy, so what to do tonight? Read a novel? Watch TV? Or movies? Internet?

Oh boy, I sound like an anti-social. I should go out and hang out with friends or something. thank you. I'd rather sit at home and do stuff.

Well, what can I say, I am a boring person. Hahahha.

Youuu...go do whatever you want!! See ya!! :D

Friday, October 24, 2014

Holiday Mode ON!

Hope that you fall in love, And it hurts so bad
The only way you can know, Is give it all you have
And I hope that you don't suffer, But take the pain
Hope when the moment comes, You'll say...
I did it all :)


Wednesday, October 22, 2014

End Surgery Posting Examination Sept-Oct 2014

Yesss!! We have finished our exam!! Alhamdullilah, hopefully all of us will pass!! Here's a review on what came out during the exam.

MONDAY, 20/10/14


Surprisingly, there were not many repeated MCQ questions from previous years. Sometimes, even very simple and basic stuff I forgot! Or I have read it before, but forgot! What the heck Nurul Ain! Some of the questions that I can remember:

1. Stomach cancer is the second most cancer worldwide - FALSE
Gastric cancer is the fourth most common cancer in the world. Source : US National Cancer Institute

2. Familial Adenomatosis Polyposis is an autosomal recessive inherited disease - TRUE
Familial adenomatous polyposis can have different inheritance patterns. When familial adenomatous polyposis results from mutations in the APC gene, it is inherited in an autosomal dominant pattern. When familial adenomatous polyposis results from mutations in the MUTYH gene, it is inherited in an autosomal recessive pattern. Source : Genetics Home Reference

3. Alcohol cannot kill bacterial spores - TRUE
Endospores are resistant to heat (>100 °C), radiation, many chemicals (i.e. acids, bases, alcohol, chloroform), and desiccation. Source : The Microbial World 

4. Bacterial spores can be killed during sterilization - TRUE 
Sterilization is necessary for the complete destruction or removal of all microorganisms (including spore-forming and non-spore-forming bacteria, viruses, fungi, and protozoa). Source : WHO Pharmacopoeia Library

5. Orphan Annie eye nuclear inclusion is found in papillary thyroid cancer.
Characteristic Orphan Annie eye nuclear inclusions (nuclei with uniform staining, which appear empty) and psammoma bodies on light microscopy. The former is useful in identifying the follicular variant of papillary thyroid carcinomas. Source : Wikipedia

PMP 1 - Carcinoma of caecum

The most difficult questions were:

1. Pathology of colon carcinoma
Write about adenoma-carcinoma sequence and microsatellite instability pathway. The mutation of KRAS, APC and p53 as well as loss of 18q. Progress from normal => early adenoma => late adenoma => carcinoma. The MSI, MSH2, PMS2 etc.

Also write about adenocarcinoma (mucinous, colloid), polyps (adenomatous, hyperplastic), the tubular, tubulovillous or villous adenomas, sessile and pedunculated etc. I did not manage to write about them all though, not enough time =..='' 

2. Principle of management in this patient
If you have upper rectum carcinoma and above - the principle is resection! Only when you have rectal carcinoma and below, you give neo-adjuvant first. After resect, give adjuvant chemotherapy and long-term follow-up. Elaborate.

PMP 2 - Carcinoma of bladder

The most terrifying questions:

1. Pathology of bladder carcinoma
The most common type is transitional cell carcinoma. 90% of them develop from papillary tumour that projects into bladder lumen and if untreated => penetrate basement membrane, invade lamina propria and muscle => metastasize. 10% of them develop from CIS, the flat, noninvasive, high-grade urothelial carcinoma that spreads along the bladder surface and over time => invasive.

Other type is squamous cell carcinoma, develops from urothelium of bladder, purely squamous type. Adenocarcinoma is only 2%, mostly in congenital problem (exstrophic bladder, persistent urachal remnant). Other rare forms are leiomyosarcoma (most common bladder sarcoma), rhabdosarcoma (in children), carcinosarcoma (mesenchymal and epithelial), lymphoma (arise in submucosa), and small cell carcinoma (poorly differentiated, same morphology like in lung). All rare carcinomas have poor prognosis, except lymphoma. Source : Medscape

Pftt. If only I can answer this well in the exam =..=''

2. Principle of management of bladder carcinoma
You do cystoscopy, transurethral resection of tumour (TURT), intravesicle BCG/Mitomycin, review HPE and decide from there - either non-invasive or invasive. Don't forget staging of tumour. Cystectomy is an option. Elaborate. 


5 stations altogether, 2 minutes for each. Not enough time to think!! >..<''

The pictures were about thyroid swelling, Chest XRay (air under diaphragm?), an instrument used for vein stripping (Mr.Fadel told us that), CT brain (ring-enhancing lesion) and one more picture I cant remember.

TUESDAY, 22/10/14

LONG CASE (Mr. Islah & Mr. Hisham)
Obstructive Jaundice secondary to choledocholithiasis

29-year-old Malay man from Pekan with history of cholelithiasis and mitral valve replacement was admitted 3 days ago, presented with 4 months' history of yellowish discolouration of sclera associated with tea-coloured urine, pale-coloured stool and epigastric pain. He is on warfarin for 4 years. He has history of multiple blood transfusions. His Hepatitis B, C and HIV results were non-reactive. He does not smoke, not consume alcohol and no history of high-risk behaviour. Currently admitted for laparoscopic cholecystectomy tomorrow.

On examination, patient was on heparin infusion 1.4ml/h. He was alert, comfortable and afebrile. He had mild jaundice of sclerae. There was no stigmata of chronic liver disease. Tenderness at epigastric and right hypochondriac region. Hepatomegaly 2-finger-breadth noted. There was no splenomegaly, ascites or pedal edema. Per rectal examination was not done due to patient's refusal. On cardiovascular examination, a 21 cm of midline scar from mitral valve surgery noted on chest, well-healed with no keloid or hyperthrophy. Prosthetic click heard on auscultation, mostly prominent at mitral valve area.

Questions asked by Mr.Islah:

1. Why the patient is on heparin infusion? Why not continue oral warfarin?

The most common indications for long-term oral anticoagulation with warfarin are venous thromboembolism, mechanical cardiac valves (like in this patient) and atrial fibrillation. Source : Australian Prescriber

The approach options for patients on long-term anticoagulants can be one of the following: 
a. Continue warfarin therapy 
b. Withhold warfarin therapy for a period of time before and after the procedure (like in most cases we see in the ward, withhold warfarin 4-5 days pre-op, these patients have low risk of developing thromboembolism)
c. Temporarily withhold warfarin therapy and also provide a "heparin bridge" during the perioperative period (like in this patient)

Which management option to follow is primarily determined by the characteristics of the patient and by the nature of the procedure. 

Do you know half-life of heparin is how many days? It's only ONE and A HALF HOUR!! Thats why in this patient, you stop warfarin and start heparin!! Before surgery, you need 5 days to get warfarin out of your system (warfarin half life is 5 days), but you cannot leave the patient without anticoagulant (he has mechanical heart valve for god's sake! it will increase the risk of thromboembolism!), so you start on heparin infusion because of its short half life!! Now I understandd!! :D 

It has been suggested that patients on long-term warfarin therapy (including those with mechanical heart valves or atrial fibrillation) who are undergoing minor elective invasive outpatient procedures (eg, colonoscopy, dental procedures) may have a slightly increased risk of perioperative bleeding if placed in some form of heparin therapy (eg, heparin bridge) than those who have their oral anticoagulation withheld for 4-5 days (major hemorrhage 3.7% vs 0.2% and significant nonmajor hemorrhage 9% vs 0.6%, respectively). The perioperative risk of bleeding when using a heparin bridge appears to be higher and the risk of thromboembolic events appears to be lower when Coumadin is stopped than what is reported elsewhere in the literature. Source : Medscape

2. Differential diagnosis of obstructive jaundice:

- Choledocholithiasis
- CBD stricture
- Cancer of pancreas, peri-ampullary, cholangiocarcinoma
- Parasitic infestation
- Mirizzi syndrome

3. What is Mirizzi syndrome? 

Gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of CBD or common hepatic duct. Obstructive jaundice can result from direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis. Source : Wikipedia.

4. Management of this patient

As usual, start with rescucitation. Since he came with abdominal pain, give analgesia. Put on CBD, monitor urine output and vital signs. Do investigations like FBC, PT/APTT, GSH, RP, LFT as baseline, pre-op assessment and to investigate cause. Do HBS US, ERCP and later get date for cholecystectomy.

5. How ERCP is done? Uses of ERCP?

Ask consent from patient to undergo endoscopic retrograde cholangiopancreatography. Review blood investigations. Bring patient to endoscopy room. Insert scope through mouth until duodenum level 2 (because thats where your ampulla of vater is). Then, inject contrast. View the biliary tree on the screen.

ERCP can be diagnostic (you want to look if there is stone, tumour, stricture or any abnormalities in the biliary tree) or therapeutic (stones can be removed, stents inserted, cut the sphincters or dilate the stricture using balloon).

6. Indications of cholecystectomy. How cholecystectomy is done?

Cholecystectomy is indicated in the presence of gallbladder trauma, gallbladder cancer, acute cholecystitis, and other complications of gallstonesMore controversial are the indications for elective cholecystectomy. Cholecystectomy is done in symptomatic patients with cholelithiasis escpecially with non-functioning gallbladder. Source : PubMed

Other indications are porcelain gallbladder, if gallstones are big (>5cm), gallbladder polyp (>1cm) and multiple recurrence of gallbladder stones because we are afraid of GB stones go into CBD causing obstruction. 

Cholecystectomy can be done in open surgery or laparoscopic. In open surgery, you do Kocher incision (right subcostal region).

30 MINUTES'S UP!!! Thank you Mr.Islah! :)

SHORT CASE (Mr. Nazli)
Non-toxic multinodular goitre

Patient is a middle-aged woman, sitting comfortable on a chair. She looks well with good hydration and nutritional status.

There are multiple nodules noted at anterior neck region. It moves with swallowing but not move during tongue protrusion. There is no dilated veins noted, no surgical scar and no colour changes on skin.

The swelling is not warm on touch. It is located at anterior neck, multinodular with a dominant nodule (measured 7x4cm), has regular margin, firm in consistency, not attached to skin or muscles. There is no lymphadenopathy. Trachea cannot be assessed due to the swelling.

There is no retrosternal extension of the swelling.

There is no carotid bruit heard.

General examination:
Patient's hands are dry and warm, not sweaty. Pulse is regular in rhythm and volume, no atrial fibrillation. There is no ophthalmopathy.

Questions asked by Mr. Nazli:

1. What is Pemberton's sign? How to test?

You ask the patient to elevate both arms until they touch the sides of face. Pemberton's sign positive when you see the patient's face become cyanosed and congested, and patient develops respiratory distress after one minute. This is because of substernal goitre in the mediastinum, causing superior vena cava syndrome. Source : Wikipedia

2. What is Berry's sign? How to test?

Berry's sign is the absence of carotid pulse. It results from the tumour encasing thyroid artery and muffling the pulsation. It indicates a malignant thyroid tumour!! Source : Emergency Medical Paramedic

3. What is your diagnosis for this patient?

Non-toxic mutinodular goitre

4. What is the common cause of MNG?

Patient with long-standing multinodular goitre is usually due to deficiency in iodine, it is called colloid goitre.

5. How do you manage this patient?

I would like to take blood for investigations such as FBC (check for anemia and neutrophilia), TFT (check for high T4), RP, PT/APTT (as baseline for surgery) and GSH. I would like to do ultrasound of thyroid to see if the mass is cystic or solid. Then, I would like to send the patient for surgery.

6. What surgery do you want to do? Complications of the surgery?

I would like to do total thyroidectomy. The complications of surgery can be divided into early and late complications. Early complications include haemorrhage and haematoma formation causing stridor, external laryngeal nerve injury causing weak voice and left recurrent laryngeal nerve injury causing hoearseness of voice. Late complication is patient will develop hypocalcemia and hypothyroidism (I forgot this last one that's why I felt that something was missing ughhh what were you thinking Nurul Ainn!!)

7. What are the signs in hypocalcemic patient? How do you test them?

Patient will have positive Chovstek sign and Trosseau sign. For Chovstek sign, you tap patient's facial nerve (perioral area) and patient will develop facial spasm. For Trosseau sign, you inflate blood pressure cuff on patient's arm, and the patient will develop contracture (wrist and MCP joints flex, DIP and PIP extend, fingers adduct).

TIME'S UPP!! Thank you Mr. Nazli! :) posting done - FOUR more to go!!  


Hello PSYCHIATRY!! Hehehe

Have a good dayy people!! :D