Reporting for Duty

Just finished my induction course today. I will be reporting in for duty this coming Monday. Another batch of housemen will start serving the community. Hopefully I can do my best. I was posted somewhere in Negri Sembilan (there are only two hospitals available for housemanship in Negeri Sembilan, make a guess and you'll have 50% chance to make a correct one).

The new phase of my life begins this Monday. The transition period between a medical student and a houseman has come to an end.

So be it.

"I haven't decided yet..."

I went to the hospital to settle the matters regarding MMC membership registration forms. I was accompanied by two friends when we went to see a child psychiatrist (Dr. 'A') for her signature as our 'witness'. After exchanging a few words, she asked about which specialty that we would like to join. I was stunned. One of my friends answered "O&G" while the other said "child psychiatry" (I wonder whether it is genuine or just to please the lecturer. But that's another story). As she turned to me, I was speechless for a fraction of time before I answered "I haven't decided yet,"

The "O&G" guy (yep, a guy, but please don't get him wrong. His interest is genuinely academic and has nothing to do with perverseness) has already decided the field ever since we were in the first year of med school. The "child psy" girl is actually interested in anything pertaining to children (and obviously Paediatric is her main interest). But me? I never pondered upon it seriously. As I mentioned before in one of my previous posts, I was interested in Psychiatry. But I wasn't really sure about it.

There are a lot of things to be considered before making such an important decision in our career. At first I was planning to undergo the two-year housemanship before I make the decision. But I think it might be too late, because if I were following the plan, I will surely miss the opportunity to embark on an academic training scheme known as SLAB (for Bumiputera) or SLAI (the similar scheme for non-Bumis). [By the way, why should there be any difference between the two?]

What should I do now?

Too bad I didn't attend the "Postgraduate Talk" organized by the college administration. But it is never too late. Fortunately, a friend of mine recommended an e-book entitled "The Ultimate Guide to Choosing a Medical Specialty". I haven't finish reading the book yet. Maybe I should finish reading it first before consulting my seniors regarding the choices. But before that, I should complete the registration form first and submit it by this Monday.

What's next?

As I was packing my stuffs and preparing to transfer them back home, I found a booklet which was distributed to us a few months ago by the Dean's Office. It is entitled "SCHOMOS Guide Book 2009". Basically this booklet is a guideline for those fresh graduates from the med school regarding the steps and procedures to be done once we've graduated and so on. I found it very useful. Thank you MMA and SCHOMOS for preparing such booklet for us.

But for now, I'm planning for a low-budget, short trip around the Peninsular Malaysia beginning next week. Hopefully everything will be fine and work as planned.

The End of the Beginning

Alhamdulillah... I passed my final professional MBBS examination. Many thanks to my teachers, hospital staffs, colleagues, and especially those patients (who "sacrificed" themselves to be interviewed, examined, and being set up procedure upon by the 'noob' like me). Without their support, I don't think I will be able to pass this exam. Thank you very much.

I would also like to express my gratitude towards my parents and my siblings for their relentless support, financially and more importantly, morally. Not forgetting my relatives who really support my effort - particularly my auntie who taught me on proper technique of interview skills when I was going for interview with JPA a few months back. Thank you very much.

Too bad, some of my friends didn't make it. I bet this is how life is. Sometimes you are on the top, the next day you may fall to the bottom. Some of them are much better than me. But God knoweth best. Surely there is hikmah behind all the events that took place.

As for me, I will not take this success for granted. Perhaps a week of relaxation and vacation might do, but soon I will resume my struggle to become more competent than I am today. Medicine is a lifelong learning process. You may know best in certain area, but absolutely not in ALL area. With this, I hereby wish myself luck and all the best for my career path as a medical practitioner / healthcare worker / or just simply, a doctor.

"Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning". - Churchill

Developmental Assessment

Theoretically, it is straight forward & well guided. Practically, it is quite difficult if you are not used to it. So, the keyword is "Practice". Basically, it is divided into four components, namely, "Gross motor", "Fine motor and vision", "Language and Hearing", and "Social". (DA is culture specific. Although there is not much difference, it is better for us to refer to the one in the Paediatric Protocols by KKM in addition to those in the Paediatric textbooks from the Western countries - Nelson, 'Sunflower' etc). Some of them can be assessed by simply observing the child whereas the others may require cooperation from the child. Most of the time, the child would be irritated at most, and shy away at least. Some might even cry and refuse to cooperate. Sigh, this is one of the reasons why I don't like Paediatrics. It's because it is difficult for me to get close to the kids. My lecturer used to tell me once when I was examining a baby, "Why are you being so formal to the child?" (lolz).

Part of the reason is that I didn't have enough experience playing with kids (except during my childhood, of course). I am the youngest sibling, and my cousins live quite far from my home. Furthermore, I was sent to a boarding school for five years. By the time I finished my secondary school, they have all grown up. But the good news is that, my eldest brother is married! Soon, I will become Uncle and I would have all the opportunity to improve my difficulty in dealing with kids. As for the time being, perhaps I should be frequenting the ward to get used to doing DA on a child.

p.s. The exam is over, but I still have to prepare just in case I might be called to sit for special examination (i.e. viva borderline) on Monday. Till then, please wish me luck and pray for me. Thanks~

Short Case - Useful Tips from (a) Friend(s)

1- i know looking at patient face very important, but look at examiner face more important ah!!!.. if cant see, then listen for voices like 'huh? ermmm' and so on.. dun hesitate to change ur answer haha

2- plz identify questions to say yes to!!
eg: when examiner ask u direct question like- dont u think the spleen is enlarged? plz say YES!!!!

- a quote from a friend, taken from the discussion board of a facebook group where we compile all the questions asked during this final exam.

Yes I believe he is right. As far as I remember, one of my lecturers used to say, "For your level (MBBS) , the examiners will always try their best to pass you. Unlike the post graduate exam. " So if they are asking you, say,"Are you sure?", then it is time for you to reconsider your answer immediately.

Calm down, even if you perform quite badly on the first case (there will be three cases within 30 minutes).

Make sure to use "standard" sentences, such as "I would like to complete my examination by doing neurovascular examination,..bla,...bla..." just like what is written in the textbooks as well as those useful reference books.

Always "back to the basics" whenever you are stuck. For example, if a Paediatric patient presented with a syndromic facies that you are not sure of, just describe whatever you see even though you don't know the diagnosis. Some of my friends (or should I call them fellow doctors by now, albeit unofficially) had had a patient diagnosed as osteogenesis imperfecta, but they failed to provide the diagnosis. However, they managed to describe the facies as well as other signs properly and the examiners were satisfied. Of course I am not sure whether the examiners will pass them or not, because the result is not out yet. But that's the least that we can do rather than kept ourselves silent for the next few minutes during the exam.

Last but not least, practice makes perfect. Must start from the very beginning of the clinical years. Then, once you are in the final year just top it up with the management of the diseases. Do as I say (read:write), not as what I did. I was not so serious with the physical examination when I first entered the final year. I never practiced the whole steps every time I did my physical examination (because in a long case, we have the information about the patient prior so that we can focus on looking for the expected findings) .Instead, I just focused on the area where there's possible findings only (except during end of posting examination). The result is, I still have to keep reminding myself not to miss the steps in the physical examination and have to arrange them accordingly.

***This post is written based on my personal experience, as well as from the advices given by my fellow colleagues and lecturers throughout the last two years. You should know yourself better. Hence whatever is best for you just take it, and leave the rest. And if you don't mind, do correct me if I'm wrong. Thank you in advance...

Alright, now it's time for me to continue struggling... Please pray for my success... =)

Unwell

I'm feeling a little bit unwell for the last few hours. Feverish. I'm worried that it might last long enough to affect my revision. Hopefully I will get well soon.

This is one of the reasons why last minute revision is not good for students. If you are the ones with such habit, please break it. You'll never know what might happen to you in future at the crucial moments. Accident may occur, or at least you might end up being unwell just like me. An orthopaedic specialist cum visiting lecturer once shared with us the story of his friend who suffered from sports injury while playing rugby weeks before their final exam. He suffered a blow to his face during the scrum which resulted in basal skull fracture and amnesia. He was lucky to survive and managed to sit for the exam. He passed the exam. He's a specialist now. If I were him, I don't think I will be able to sit for the exam, let alone passing it.

Of course, it is never too late. "It ain't over till it's over" - quote from a song. Keep on struggling with all the resources that you have, within the period of time left. Just make sure not to repeat the mistake. I don't want to be the last minute man anymore. That's for sure.

===============

To-do list for the remaining 2 days:

1) Obgyn and Ortho physical examination.
2) Travel to nearest teaching hospital to practice on real patients
3) Respi and CVS
4) Abdominal and Neurological
5) Paediatrics - especially Developmental Assessment.

Long Case - Lessons Learned

The key to guide your history taking during long case exam lies within the line, "Which ward are you admitted currently?", "Which doctor?" or "Which clinic that have been following you up?" ; because it will indicate what is the chief complaint that should be tackled. Of course, it may not be entirely true as some patients may have been followed up for certain chronic diseases but they volunteered for the exam with different presentation or with a totally different diagnosis that has no relation to those chronic diseases at all.

I may be wrong, but it is imperative to make sure that you try your best not to refer to the written text when you are presenting the history to the examiners. It is part of the "showmanship", so as to make us appear confident and well prepared to answer any questions that will be asked later. Unfortunately, I still have to take a peek to the scribbled text during presentation. Apart from that, like any other "interview", other soft skills such as mastery of English, proper use of terms, smooth narration (rather than point by point), manipulation of tones (to stress some points from the others) etc are just as important. However, like I have mentioned prior, "showmanship" is my biggest weakness. Even though there are much improvements, yet I'm still not at my personal best. There's still room for further improvement.

If the patient is not a good historian, do mention about it to the examiners earlier during case presentation. It will affect their perception towards your history taking and presentation skills, which in turn will affect your marks.

Never ever forget to include systemic review in your history. Most of us will forget, unless we are consciously reminding ourselves about it.

Don't wait for the examiner to prompt you, keep on presenting unless you are stopped by them.

Summary - Keep it short and simple. Summary must lead the examiners to your working diagnosis rather than repeating the chief complaint. E.g. Chief complaint: Low mood, loss of appetite, reduced sleep for three weeks, and suicidal ideation. Summary : [Patient's particular] , presented with symptoms suggestive of depressive disorder, associated with suicidal ideation for the last three weeks. [I still have to practice... T_T]

Usually after the presentation, we will be brought to the bedside to perform physical examination or mental status examination for psychiatric patients. Plan with the patient on how he/she should respond when she was given certain instruction in front of the examiners as you proceed with physical examination prior to presentation. E.g. "Makcik, nanti bila saya minta makcik beritahu saya bahagian mana yang sakit, makcik tunjuk pada bahagian yang paling sakit kemudian baru beritahu kawasan lain yang turut sakit..." (Ma'am, later when I ask you to show me where the pain is, please pinpoint the site where it has the highest intensity and then show me the rest of the site that is less painful if any).

This is just my 2 cents worth of advice. I am not the best, just feels like sharing so that you won't repeat my mistakes. Hopefully this will be my last long case presentation as a medical student. Hopefully I will secure a pass for this examination... Ameen.

===============

Next: Short Cases examination on Saturday. The final 30 minutes for this examination.

Long Case... 8 hours to go, and counting...

This is it. The day has come. Approximately 8 hours left before it's my turn to sit for the long case examination. I'm prepared... But perhaps I would still have to revise for the last few hours. Just to refresh my mind, especially on the aspect of management as well as the normal values for the investigations.

This session, and the short cases on Saturday would be my final few 'official' hours as a medical student. Hopefully I can make it and doesn't have to extend my studies for the next 6 months. Hopefully I will get a simple and straight forward case, answerable questions, a cooperative patient, and finally nice and helpful examiners. Ameen.

Come what may, I will accept whatever the outcome will be with open heart (figure of speech). Yet I will still struggle for the short cases session no matter how well I perform during the session later today.

p.s. Nervous... Have to calm myself down.

"Dear Me, don't compare yourself with others, whether the ones who were doing much better than you, or those who were not doing well. Just focus on yourself and pray hard. You can do it~!"

Long Case! (btw, it's my 40th post - deleted ones included)

From tomorrow until Wednesday, we will be sitting for long case examination. Then followed by another three (3) days for short cases examination. My turn for long case will be on Tuesday, whereas for short cases will be on the last day, i.e. Saturday. Hopefully I will perform well for the last two 'papers'. Facebook statuses of my fellow batchmates have already shown aura of nervousness and anxiety especially for those who will be sitting for the exam tomorrow. Me? Surely I am extremely nervous and anxious to the extent that I don't know what else to do. So, I turned to God and prayed hard that I will be given a simple and known case, in a package with kind and cooperative patient as well as good & 'angel'-like examiners. However, I still have to revise more, especially on the aspect of management. Perhaps I should flip through the CPGs for the purpose of covering the aspect of management.

Hints? I don't know much. And based on previous recent history, I don't want to rely much on hints. It didn't work out for the CPC and Theory Paper. Neither it was during OSCE day 1. However, I should not totally ignore them. So, I decided to flip through the case summaries that I have made throughout the clinical years based on the hints, as well as based on "common cases" that have been listed by my seniors.

A friend of mine once told me, "For long and short cases, these three study weeks are not the key. It is either you practiced enough throughout the clinical years or not that really matters". He may be right, but I'm not taking any chance. In fact, there is still time for me to prepare. At least physically and mentally. Should practice more on showmanship and brush up my presentation skills. "There is still hope..." (quoting from the LoTR trilogy).

Basically, that's what I am going to do from tonight onwards until the end of examination. Once I'm done with short cases exam this Saturday, I will take a break for half day before preparing just in case my name were listed in the viva list. Obviously not viva distinction, if you were asking... lolz...

Till then, see you again next time (as if there is anybody reading my rantings... ^^) ~!!!

Earth Hour Malaysia - March 27, 2030H - 2130H

Earth Hour is here again. Last year's Earth Hour had caused an intense debate among my peers regarding its role and impact. Some even argued that with all lights being turned off, crime rate will increase and many youngsters may get involved in immoral activities. Others responded that all those things can occur at anytime, any place even before and after Earth Hour. However both sides agreed that it's just a symbolic awareness campaign rather than having powerful impact by itself. However, this is the moment for us to show our solidarity and raise the awareness towards saving the Earth. We have observed how humanity had recklessly manipulated and squeezed the Earth resources to the limit. We have also observed so many destruction made by our hands. Now it's our time to do something to make sure that Earth is still safe for our future generations. We can make a difference - no matter how small it is, it really matters.

To all Malaysians out there, let's forget our differences and support Earth Hour. Just for one hour, please switch off the lights and don't use the cars starting from 8.30 p.m. tonight. Unless you have urgent matters, of course.

Post OSCE - Gloomy yet the light of hope still flickers

Yesterday was a gloomy day - literally. After nearly 5 hours of quarantine, soon the sky became gloomy and there were lightnings and thunders for approximately 30 minutes before the rain poured. And it suited my mood as well, after doing quite terribly in the OSCE Day 2. I was so silly that I missed to ask patient's name and RN before I perform venopuncture for blood test. And I made a mistake that could not be forgiven - defibrillation for unconscious patient with pulseless electrical activity (PEA) at the Accident and Emergency department (A&E) CPR station! I've cried enough for the spilled milk (terrible performance in OSCE). Hopefully I managed to secure at least minimum pass for OSCE and other components. I must focus on the upcoming rest of the clinical component i.e. long case and short cases.

OSCE Day 2

Station 1: Primary Care Medicine. Patient presented with urethral discharge and back ache for 3 days. Obtain the sexual history and advise the patient accordingly.

Station 2: Rest Station

Station 3: Otorhinolaryngology (ENT). Two exhibits. First, acute tonsilitis - we were asked about the clinical findings based on McIsaac score. Then we were asked about the first line antibiotics and duration of treatment. Second exhibit showed picture of ear toileting. Questions, what's the indications, precaution, and complications of the procedure?

Station 4: Anaesthesiology. Patient presented with trauma due to MVA. Suddenly developed respiratory difficulty. We were given arterial blood gases (ABG) results and had to interpret. Then followed by the management of the patient (ATLS - primary survey). After intubation and ventilation, another set of ABG results given for interpretation. Lastly, patient was put under FiO2 0.8. What does this indicates?

Station 5: Emergency Medicine. There's video showing patient with signs of paradoxical breathing. Asked about the diagnosis and further management of this patient.

Station 6: Otorhinolaryngology (ENT). Two exhibits. First: Inflammed inferior turbinate and it's management (medical and surgical). Second: Cholesteatoma, the complications, and whether the hearing loss secondary to it is reversible or not.

Station 7: Rest Station

Station 8: Anaesthesiology. Venopuncture for full blood count and renal profile. (Missed a lot of marks here. Silly mistakes, should have scored full mark!)

Station 9: Obstetrics and Gynaecology (O&G). Running commentary on how to prepare for episiotomy repair and demonstrate on how to do the suturing.

Station 10: Emergency Medicine. CPR and then given an ECG. What's further management? (Follow the algorithm). If VF or pulseless VT, defibrillate. If otherwise PEA or asystole, continue CPR and at the same time ask for assistant to give IV adrenaline 1ml. (I failed miserably despite practicing it so many times).

==========

Ok, now let's get back to business. Should revise more on managements of common diseases - starting from O&G first for tonight. But first I want to have some hearty meals for dinner... =)

OSCE Day 1 - Checked. 3 more clinical exams to go~!

I fell asleep relatively early yesterday, so I didn't have the opportunity to blog on that day. Now, the first part of OSCE is done, with 8 stations plus two rest stations. Tomorrow will be the second half of it, comprising of the remaining disciplines in the syllabus. As for today, the eight stations were as such:

Station 1 : Primary Care Medicine. A young male adult (Damn, I forgot to ask his name. I only introduced myself to him) presented with history of back ache for 3 days. After detailed history and physical examination, you have made the diagnosis of muscle sprain. However he requested for an x-ray. How do you respond?

Station 2 : Rest Station

Station 3 : Ophthalmology. Picture of cataract given (My friends answered with complete full mark i.e. posterior capsular cataract). We were asked about the findings and give the diagnosis. Then we were asked to list one local cause and 2 systemic causes. We were also asked to name two procedures that can be used to treat the condition and list 4 complications that may arise from the procedures.

Station 4 : Radiology. We were provided with two exhibits. The first one is a PA erect chest x-ray with haziness and consolidations all over the lung fields - diagnosis: miliary TB. Then what is the other test to confirm the diagnosis? - Sputum culture and sensitivity or smear to look for acid fast bacilli (choose one).

The second exhibit shows the x-ray of knee joints from two views, AP and lateral. A male patient in his 30's presented with history of sudden pain on the left thigh associated with swelling while he was playing badminton. Comment on the findings (AP view, no visible fracture but there is multiple cystic lesions on the distal part of the left femur. Lateral view, there is spiral fracture at the distal part of the femoral shaft of the left lower limb). What is the diagnosis? (Pathological fracture secondary to aneurysmal bone cyst).

Station 5 : Surgery. You as an HO in the ward saw Mr. Z unconscious following a surgery. Re-assess the Glasgow Coma Scale (GCS) level. It was written on the question "Treat mannequin as a real patient". After assessing, summarize the findings (supposed to be at the minimum, because a mannequin will surely not respond to any stimulus. Hence it will be 3 over 15.) . Then the examiner will give you another set of finding and asks you what is the GCS? Finally you will be ask what is the GCS level that you would intubate the patient? (I answered less than 8. But please check because I'm not sure. Some of my friends said 8 and below.)

Station 6 : Primary Care Medicine - Drug Prescription. 2 year old (weight and height provided) presented with history of fever. Prescribe antipyrexia for this patient from what is listed. Tablet Paracetamol, Syrup Paracetamol, Tablet Aspirin, Soluble tablet aspirin. (I'm sorry I can't recall the dosage.)

Station 7 : Rest station.

Station 8 : Ophthalmology. Do visual acuity test. Since the test was done in limited, confined space, mirror had to be used. ( I knew the "patient". She is a doctor. lol)

Station 9 : Psychiatry. Patient presented with history of low mood for three months, and had suicide intention for two weeks. Assess the suicidal risk in this patient. Use SAD PERSONS scale, and "SAMPAH" mnemonics to assess whether the suicide was well planned or just to gain attention from others. [S - Suicidal note. A - Avoidance (e.g. want to commit it in a locked room) M - Method (e.g. overdose, hanging, or slit wrist etc) P - Plan (when, where) A - Arrangement (I think it's redundant, but that's what the mnemonic is) H - Hint (e.g. by writing will, buy insurance).]

Station 10 : Orthopaedic Surgery. Patient had a fall and suffered anterior dislocation of the shoulder on the left arm. Ask for written consent for this patient for the close manipulation and reduction (CMR).

==========

So, for tomorrow there will be no more stations for Ophthalmology, Surgery, Primary Care Medicine, Radiology, Orthopaedic Surgery and Psychiatry. Let's revise for Obs-Gyn, Paediatrics, Emergency Medicine, Anaesthesiology, and Otorhinolaryngology (ENT). Medicine? I'm not sure, because some said that it won't come out because we have had our CPC under Department of Medicine (SLE with Anti-phospholipid syndrome). But, I think I still have to prepare just in case it may come out tomorrow. But for sure, I have to cover the rest first!

Let's do it...

p.s. Have to struggle for tomorrow because I think I'm not doing well enough. I must secure at least pass for this component. After this paper, there will be a gap before my long case paper on Tuesday and Short cases on Saturday (the last day!). Please, please, please, dear God please guide and help me to pass this exam and become a good and safe doctor. Ameen.

Wohoo... 2 days to go~

Yes, two days to go and yet I still feels 'empty' without much input for the last few days. Even though there's much progress but I felt like I'm not doing enough for this exam. Just like previous exams. Hopefully I will be able to pass this exam. I think I should stop from blogging for now. Maybe, just maybe, I will come back after I'm done with theory paper, the day before OSCE. Please pray for me.

Action plan:

1) Proceed with Past Years Questions attempt

2) Review on the investigations and their interpretation (including radiology)

3) Flip through short notes that I've prepared prior.


That's all for now. Till then, bye~

Graphics from HERE. Special thanks to Mr. Adnan i.e. the owner of the blog for the pic. Now it's my turn for the exam. =)

SIGECAPS - Mnemonics for Major Depressive Disorder

Another mnemonics. This time it's for symptoms of major depression and dysthymia.

S - Sleep disorder* (insomnia or hypersomnia)
I - Interest deficits (anhedonia)
G - Guilt (worthlessness*, hopelessness*, regrets)
E - Energy (lack of energy)*
C - Concentration deficit*
A - Appetite reduced*
P - Psychomotor retardation or agitation
S - Suicidality - (to assess suicidal risk, use SAD PERSONS scale).

NOTE: To meet the diagnosis of major depression, a patient must have four of the symptoms plus depressed mood or anhedonia, for at least two weeks. To meet the diagnosis of dysthymic disorder, a patient must have two of the six symptoms marked with an asterisk, plus depression, for at least two years.

Reference: American Academy of Family Physicians (AAFP)

An Act of Stupidity

As far as I can remember, I never openly call someone stupid. But this, I think, is an exception. There is no other suitable word that I can use to describe such act. It's a waste of valuable life saving resources. Allow me to enlighten you, if you are not following the news lately. Please read the news HERE. For English version, click HERE.



One could not imagine what's the rational behind such act. Even if there is any, I don't think it outweighs the benefits that can be gained should the blood were donated to the proper cause. It's a pity that even blood was used as political tools, when it was supposed to be used for greater life saving purpose.

[Special thanks to BangkokPost.com for the graphic]

5 days to go~

... before the beginning of the final professional MBBS examination. I hope that I can manage to pass the exam. Otherwise I will be spending the next 6 months for extension and resit for another exam (God forbid). And it won't be easy too. So, I will try my best to score as much as I can in the exam to the very last minute.

Our batch has created a history I guess, with the highest number of students being barred from the examination. However I could not be sure of that. But one thing for sure, it is a stark contrast as compared to the previous batch, whereby there was none of them being barred.

Most of them, not to say all of them, were being barred mainly because of lack of attendance. Our faculty has set up minimum 80% of attendance, and we were all had been warned of the consequences of failing to fulfill the requirement. Yet, obviously some of us were not bothered by such reminder. Hence, they were barred from sitting for the examination.

Some of them have their reasons, while the rest were simply not coming from the class for no reasons. Of course, they would be asked to write a show-cause letter. But unfortunately none of them were accepted by the dean's office. It's a pity for them, for not even having a fighting chance. It's a pity, because some of them are very,very,very knowledgeable as compared to myself. And one or two of them had once ridiculed me before for my "lack of knowledge and skills" - according to their definition. But that's another story. I don't mind, and of course I won't say to them "serves you right!". Yet, what really hurts my feeling is that they would still hope and pray that I would soon join them. They even sarcastically wish me luck by saying, "Nanti jangan tinggalkan kita orang jauh sangat ye. Jangan buat master cepat sangat."

I won't judge them, there's no point of doing so. It won't affect the outcome of our exam anyway. Some of them have their own reason and problems that hindered them from attending the classes. But it is all written then. I wish them luck, and of course I hope for the best of me too~

As for me, I will try my very best and leave the rest to God. I will accept whatever the outcome of the exam is, but I really hope that I will pass the exam and become a safe doctor once I've graduated.

Ok, it's time to get back to the business. Five days to go. I should bombard myself with past years' questions and quick revision based on them. This would also be the time for proper sleep hygiene and diet so that I will be at the best of my health for the upcoming exam. Ganbate~ Chaiyo~ All the best~ Bittaufiq wan najah~ Semoga berjaya~!!!

I would also like to take this opportunity to wish all my coursemates the best for the exam (if they happened to read this blog, obviously).

Mode: RED ALERT

Schneider First Rank Symptoms

This is the mnemonics of Schneider's first rank symptoms. Presence of these symptoms proves the likelihood of schizophrenia (but bear in mind that it is not diagnostic for schizophrenia).

A - Auditory hallucinations (third person, running commentary)
B - Broadcasting of thoughts (thought broadcasting)
C - Controlled thought (delusions of control)
D - Delusional perception.

and thought insertion, thought withdrawal

Possible OSCE question for Psychiatry; apart from SAD PERSONS, mental state examination, or mini ental state examination.

Mechanism of Vaginal Delivery

We can be asked by the examiner to demonstrate the mechanism of vaginal birth in the OSCE station for O&G. While explaining the mechanism, we would also have to use the exhibits (mannequin - baby's head, and pelvic bone). Here's the steps in the mechanism:

1. Engagement (definition)
2. Descent and flexion of fetal head
3. Internal rotation - fetal head rotate and assume occipito-anterior position, facing towards maternal rectum.
   
4. Delivery by extension - fetal head extended.
5. Restitution - Fetal head turns 45 degrees to the maternal right hand side, restoring normal relationship with the shoulder.
6. External rotation of the shoulder.

Then, we would assist the delivery by gently pulling the fetal head downward in order to deliver the anterior shoulder before we pull it upward to allow the passage of the posterior shoulder.

Bipolar Affective Disorder

"DR ABC"

It would be much beneficial if I practice the cardiopulmonary resuscitation instead of just simply write about it. But in order to do what you are supposed to do, first you would have to know the steps. In short, it can be summed up in an acronym DR ABC. This method has been taught to us since our first year of med school. I still remember the whole batch gathered at our college's Dining Hall with our final year seniors as our supervisors and not forgetting the instructors (lecturer and nurses from EM). Approximately 100 mannequins were brought to the hot and humid Dining Hall for the program. I remember, one of my supervisors (cum senior) even wrote the 'magic' word "DR ABC" on my forearm using pen. Future fast forward, it was our turn to supervise our juniors doing the CPR a few months ago. But I forgot to bring a pen, so I could not do the same. In fact, I don't think I will do it anyway, because the juniors in my group were all females. Anyway, let's go back to the main business, what is DR ABC? And how do we perform the CPR? Again, this is just for my revision.

Patient suddenly fell unconscious. First of all,

D - danger; look for any danger to the patient as well as to yourself in the surrounding.

R - response; ask the patient to see whether he's conscious or not. "Sir, do you hear me sir? Please respond to me, sir. Sir, sir!) and simultaneously pat patients shoulder with both hands.


A - airway; head tilt - chin lift if there was no suspicion of cervical spine fracture/dislocation. Clear the mouth from anything (food etc)

B - breathing; put your ear close to the patient's mouth - to hear his breath and turn to face patient's chest - to see chest movements indicating the respiratory effort.

C - circulation; check for carotid pulse.

If the breathing and circulation are normal, turn patient into recovery position. (steps, check for any injuries - don't move them if patient is hurt; bend the right arm to avoid him from rolling; gently turn patient to the right side; bend left leg to support the position; tilt his head up and tuck in the left hand underneath the cheek; call for help while someone is watching over him).

If breathing and circulation are abnormal, then call for help from people nearby and ask for AED (automated external defibrillator) if situation took place outside hospital setting.

Give two rescue breaths (don't forget to pinch his nose) within 2 seconds and 30 chest compressions (rate 100/min). Make sure it is uninterrupted for at least 5 cycles or until help arrives.

In the hospital setting, there is further management of patient involving defibrillation and drugs. There is an algorithm to follow in the guideline. However, I do not wish to further elaborate upon that, because it would be easier to revise by looking at the algorithm. Thanks, that about it for now. ^^

Ovarian Mass - approach

History: (hypothetical) A 24 year-old lady presented with complaint of mass over suprapubic region.

Further history: Onset? Is it single mass or multiple? Any associated symptoms? Such as dysmenorrhea, menorrhagia, or pain over the private part? Constitutional symptoms (fever, loss of appetite, loss of weight) - possible : ?germ cell tumor in young women? Abdominal distension? Swelling over other part of body? e.g. Virchow's node (enlarged and hard lymph node at left supraclavicular area - common site for metastasis from abdominal/pelvic CA). Sexual history: ever had sexual intercourse? When is the last menstruation (possible - ?ectopic pregnancy)?

Physical examination (abdominal + 'lumps & bumps')

General condition: Alert? In pain or comfortable? Cachexic? Pallor?

Abdomen: Observe for mass; or distension, everted/flat umbilicus (ascites). Palpate for mass, ascites. After that, move on to describe the suprapubic mass (site, shape, size, uni- or multilocular, well-defined edge, central or lateral, can get below? mobile or fixed? - to differentiate between ovarian and endometrial origin).

Complete the examination by checking left supraclavicular region for Virchow's node as well as breast examination - mention only, examine only when you are asked to do so.


Investigation

1. Full blood count; mainly to look for evidence of anemia.
2. Renal profile, liver function test (to rule out other causes of ascites; hydronephrosis, liver metastasis)
3. Tumor markers: CEA (usually CA colon, CA rectum) , CA125 (normally serous type, non-specific; irritation of peritoneum).
4. alpha fetoprotein - for germ cell tumor in young patients.
5. Ultrasound scan; doppler's - echogenicity to differentiate between benign cyst and malignancy.

Differential diagnosis: ovarian cyst, ovarian tumor (germ cell tumor), endometriosis, leiomyoma, molar pregnancy, ectopic pregnancy (less likely, because patient will come with different complaint)

Further management

Surgical intervention (exploratory laparatomy). Surgico-pathological staging ('washing'cytology, liver surface, peritoneal cavity) - if normal = 1a, if presence of tumor = 3c. Even if 1a, lymph node biopsy is required to confirm the staging. If already 3c, plan for adjuvant chemotherapy post-operatively.

If patient has completed the family, opt for TAHBSO, omentectomy, and cytoreductive procedure for enlarged lymph nodes - in advanced stage of ovarian CA.

Post-operative

1. Chemotherapy if confirmed stage 3c. (cis-platinum)
   
2. Long-term follow up: observe, CA125 (if raised, do a CT-scan), any signs and symptoms of recurrence / metastasis. alpha fetoprotein (if confirmed germ cell tumor)
3. CT-scan : normally done after completed chemotherapy, and repeated after 1 year unless there is rise in CA125 as mentioned before.

Prognostication - 5-year survival

Palliative care

----------

p.s. This is my personal answer based on what I have been taught. Should there be any mistake, please kindly inform me. It was not meant for academic purposes (such as research study etc.), instead it was just for my revision. Thank you.

And I always thought 'F' is never good before...

Fuh, it has been a while since the last post. My apology, it's just that I was preoccupied with my studies (which is good, anyway). This post may not have much significance towards my study, but I was quite amazed by such event that took place. I was listening to a local English radio station when suddenly a commercial break caught my attention. Perhaps most of you might have heard about it long ago, but to me it is something new. The commercial is about F-cup cookies.

I was surprised by the way the commercial is presented. It involves a conversation between two person, a guy and a girl. That guy is promoting F-cup cookies to the girl, but the girl hesitated because she was on "diet". Then that guy would go on elaborating the fact that the product is widely accepted in Japan etc. What catches my attention the most is the fact that the guy openly mentioned about the girl having "two apples" and said that he would have preferred "two watermelons". Oh my... That was way too straight forward. I dunno about your culture, but it is not widely acceptable in my culture. And definitely not something to be discussed openly with your female counterpart (unless you are spouses, of course).

Is it true that "the bigger they are, the better"? Well, I think it depends. To me, any size would do as long as they are not too massive or too flat. Opss, am I being naughty here? Uh-uh, not really. By the way, I have to admit that I don't know much about the measuring and classification of breast size (except the Tanner staging, but that's for pubertal sexual developmental assessment and has nothing to do with the bra size). But from my simple internet search, I noticed that almost 70% of women worldwide are wearing the wrong size of the bra. So, it is not something to be ashamed of if I don't really know much about it. It's not that I am going to wear it anyway. lol

Honestly, I really don't mind about "the shape". Partially because I am no "muscle man" or "six-packers" to begin with. Apart from that, what really matters are the personality and the quality of the girl. Of course, considering the fact that I am planning to spend the rest of my life with that girl (as my wife). Physical attribute won't last forever. Soon, those hour glass figure and flawless complexion will fade away as the time goes by. If you are equating love as being directly proportionate to physical attribute, then for sure the love will fade away as the women you are married to is becoming older.

Oh, not forgetting to mention that, being a Muslim I will always consider her religion as the main criteria. She can be from any race or country. Pale white, pinkish with freckles, dark, brown, yellow, whatsoever. As long as she is willing to accept my flaws and understands me. And of course, it will be mutual. I swear that I will try my best to become a good husband and treat her well.

But that will come later. First I must focus on my studies. That's for sure. With 11 days to go, there's not much time left. This is the final lap, I must gather all my strength and "sprint" my way towards success.

"Dear God, please grant me health and peace of mind so that I can sit for the exam in a proper way. I will try my best, and leave the rest to You. Please grant my wish and make a good and safe doctor out of me. Ameen..."

Study weeks...

Our first week out of three study weeks has started. It seems like yesterday when we started our clinical years in Klang and then in UMMC. Now it's our juniors' turn to 'suffer' from what we've been through. I can see white coats roaming through the dining hall after Maghrib prayer, but this time with different faces. It used to be us being the ones struggling to clerk the cases for tomorrow's ward round or staying in the ward for on calls (which is much,much,much relaxing as compared to the HO's oncall). Sometimes, we have up to 8 beds to be covered in details within a day. Of course we'll be able to do so, provided that we're free the whole day. (and we're dedicated to this field). But the truth is, half of the day is usually filled with teachings, tutorials, seminars, etc. Now, it's their turn to experience this. And not forgetting the facebook statuses such as "Post call syndrome", or "Case summaries~!" etc.

But that's nothing when compared to the life as a house officer. Even though I'm not there yet, but I knew it based on what had been told by my seniors. Some even mentioned that they were too busy to the extent that they do not have much time for themselves anymore.

Well, I am mentally prepared for that ever since the very first day I stepped into the college approximately five years ago. It's just that I have to brush up on my knowledge and skills so that I can become a competent HO and sailed safely through the career as a clinician. Lately, there has been news about how terrible some HOs were. But I believe they were just isolated cases. Generally speaking, our med schools have been producing qualified and safe doctors throughout the years. Especially UM, followed closely by UKM, and USM. No, I'm not saying this just because I'm from UM Med School. Even though there has been some decline in the sense of quality as compared to our super-duper seniors (as being mentioned by a senior paediatric consultant during a ward round), but I can safely say that the public can put their trust in our very own locally trained doctors.

Enough said, it's time for me to continue revising. Oh, my GI disturbances had somehow subsided. Now I only had loose stools from time to time, but there's no more increase in frequency of visits to the toilet. Hopefully I will fully recover by tomorrow so that I can focus on my studies... Ameen.

GI Disturbance - very disturbing~

For the last two days I have been suffering from diarrhea. I have frequented the toilet like never before. I tried to figure out what's the probable causes, but I am not sure what's the real cause. I started to have diarrhea after I went to have dinner at Medan Selera somewhere in PJ with my friend. Both of us were having satay together, but he does not suffer from diarrhea. So I think it is unlikely to be the cause. What, you were implying that I didn't wash my hands before eating? If you think so, then you are wrong.

Hmm... maybe, just maybe, I might be suffering from 'functional gastrointestinal disturbance'?. Irritable bowel syndrome, related to anxiety, maybe? I think it is possible, since that I will be sitting for my final exam within three weeks from now on... A quick search on the net (it seems that I have the tendency to look for info from internet rather than flipping through the med books) and I think it is possible. Hopefully it will resolve soon. I can't focus on my study with this condition. Thank God the classes are over, otherwise I may have to waste my time visiting the Student's Clinic which was like 3 or 4 kilometres away from the college. Some might say, "Ala, dekat je pun. Naik motor 5 minit boleh sampai,"

Well, that's if you have a vehicle to begin with. I don't have any. Anyway, just forget about that. I personally think that it is ridiculous for us having to visit the student's clinic when an outpatient clinic is available in the hospital just within stone throw away. But one of the staff at RUKA (that's what UMMC's outpatient department is known as) tried to justify the policy, by saying that the hospital is already overburdened. So, unless you are dying from massive haemorrhage or other life threatening conditions, go to the student's clinic (well, the latter sentence is from me). You would have to get a referral letter from there if required. OK, fine thank you. It's not that thousands of medical students will visit the RUKA, and nobody will be bothered to visit if they are healthy, unless you have hidden agenda or something. But a policy is a policy. That's the way it is.

By the way, what should I do for now? If the problem persists tomorrow, I would go to the clinic. For time being, I would have to make sure that I am adequately hydrated. And be prepared for the "blast". Wearing a sarong and keep the towel within my reach would also help. Hopefully it will resolve soon... Ameen...

Great, More Mnemonics! "MUDPILES"

Causes for increased anion gap in metabolic acidosis:

M - Methanol
U - Uraemia
D - Diabetic Ketoacidosis
P - Paraldehyde* / Propylene glycol
I - Iron, Isoniazid
L - Lactic acid
E - EtOH, ethylene glycol
S - Salicylates

* Paraldehyde is no longer used medically, so the "P" in the MUDPILES mnemonic currently refers to Propylene glycol, a substance common in pharmaceutical injections such as diazepam or lorazepam. Accumulation of propylene glycol is converted into lactate and pyruvate which causes lactic acidosis. source

p.s. Perhaps I should spend a day to practice on interpretation of the investigation data from blood works to the radiological findings. Because it will surely be asked for the clinicopathological paper. Should make sure that I am able to memorize the important values as well as the interpretation. Because every mark counts.

Define Beauty

Nope. That's not the question that has been asked during the eop test written paper yesterday. We were asked to write short notes on premature ejaculation instead (among other questions). Oh my God! I never expected such question at all. Thank God I managed to write something about it, and as far as I remember, somebody had told me before that SSRIs can somehow help to treat premature ejaculation. It also been used by some psychiatrists to treat those serial rapists. Perhaps by making use of its side effect, in reducing libido. But I'm not sure whether it is evidence-based or not. I put it in the answer anyway... ("^_^)

---------

Anyway, let's go back to the topic of this post. I found this in the net while searching for some entertainment (not that kind of 'entertainment', if you ask me). I was looking for some updates on Korean movies or drama series so that I can ask a friend of mine to download them for me. Or at least I can look for them in the nearby video stores.

If you ask me to define beauty, then this would be my answer.

P.s. Anyway, she has nothing to do with the question about premature ejaculation. Thank you and get your mind out of the gutter, please...

Selfish

I don't blame them entirely. They have their own reason in doing so i.e. being selfish. Among them, it's because for every year, there will always be certain percentages of students that would have to be "sacrificed" and fail the examination in order to maintain the standard of the faculty (and of course the ones who didn't perform included). It really hurts myself, especially when they are my friends, at least for the last 5 years. Playing and suffering together. But when it comes to survival, you are left on your own. That's the way life is, I guess.

No, I'm not implying that I am totally dependent to others. Just because I am a Malay, so-called being "anak emas" and spoon fed by the government, doesn't mean that I am unable to survive in the level playing field. Thank God, I managed to be where I am today because of my capabilities. I don't have connections or cable higher up. And even in the current system where Malays are favored (of which has made me feel guilty and uncomfortable, for sure), I still have to compete with hundreds, not to say thousands of others who tried their best to enter the Med school. The NEP doesn't benefit the general population of Malays. On contrary, it only benefits the 'elite' Malays, so to speak.

Besides, I don't think the exam will be biased anyway. Especially when it involves the life of people out there at stake. Nobody wants to see a half-baked doctor went out on 'killing spree' in the hospital in order to fulfill the racial-based quota. By the way, just in case that somebody might ask, I am all against the "master race" ideology. I can go on for pages regarding this issue but I don't think it would serve the purpose of this blog anyway.

I don't mind if they don't want to share tips or refused to lend me the important notes or past years questions. I don't give a damn if they decided to discuss in the language that I don't understand just because they don't want me to benefit from the discussion. I can live with that. What really makes my heart bleed (figure of speech, not literally) is that they (no particular race mentioned) would go to the extent of hiding the information or announcement, at least to the last minute, from me. It happened before, quite a number of times. For instance, I missed a tutorial once just because they didn't forward the message to me regarding the changes. There is also an occasion whereby I nearly missed a ward round; I am lucky to be around the ward. When I mentioned about it to them, they don't even feel guilty. Instead they would simply said, "there must be somebody who didn't forward the message," and turned away. Oh my...

I think that would do. I'm somehow relieved after 'blurting' this out. Time to get back on the track again. Here I come!

Quick Revision 5 - Agoraphobia (Short Note)

Short Note (25 Marks)


What is agoraphobia? How do you treat patient with agoraphobia?

Agoraphobia is the fear of being in public places. It can be diagnosed alone or as panic disorder with agoraphobia; 50 - 75% of patients have coexisting panic disorder. It occur more in female than male. Symptoms include palpitations, shortness of breath, and sweating when being exposed to such condition.

DSM IV criteria

• Anxiety about being in places or situations from which escape might be difficult, or in which help would not be readily available in the event of a panic attack
• The situations are either avoided, endured with severe distress, or paced only with the presence of a companion.
• These symptoms cannot be better explained by another mental disorder

Management of patient with agoraphobia involves psychoanalytic therapy. He will be attended by a psychiatrist which will guide him to tell about his past since childhood days until recently. He will be seated on a comfortable chair and faced away from the psychiatrist. The psychiatrist will listen to his story and made an analysis from it.

Patient will also undergo desensitization by gradually exposing him to face the situation. Prior to that, patient will be taught of relaxation technique and was given ample time to practice before being exposed to the situation.

Pharmacotherapy : Since agoraphobia is usually associated with panic disorder, selective serotonin receptor inhibitors (SSRIs) such as sertraline, are also considered as the first-line treatment.

When agoraphobia is not associated with panic disorder, it is usually chronic and debilitating.

---------

Does this enough for 25 mark-question?! I don't think so... What else should I include or further elaborate?

end of posting test - Psychiatry

"This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning." Sir Winston Churchill once said.

As for what I'm experiencing now, it's seems that his words are true enough to me. I will be sitting for the last end of posting test tomorrow. Hopefully it will be the last, because I don't want to spend another 6 months and re-sit the final MBBS.

There are two papers for Psychiatry posting, one on Monday (tomorrow!) and another on Wednesday. The first paper was written theory whereas the second is video session.

I am experiencing the "butterfly in stomach" sensation now. Palpitations, and sometimes sweating (perhaps due to the weather as well. Hot and humid). These are the symptoms of anxiety. Oh, and some degree of gastrointestinal disturbance as well. T_T

Plan:

Last ditch attempt

1) Attempt on all the available past year questions.
2) Memorize (yes, memorize) all the important drugs in Psychiatry.
3) Mnemonics
4) Revise based on the questions attempted.
5) Pray for the best...

p.s. I love Psy and I am considering to continue for my postgrad in Psy. But I'm not sure yet. Have to go through all the postings first during my housemanship before I make my decision. But for the time being, focus on my undergraduate final exam first!!!

=)

Poor memory retention?!!

Oh dear, what happened to me? It seemed that I failed to recall some of the topics that I have covered throughout the years. Sometimes, it feels like I know the topic, but when it comes to answering the past year questions for the topic, I still couldn't obtain maximum marks. Bits of memories lost here and there. Must do something about it. Perhaps I 'm too stressed out to the extent I am unable to retrieve the memory back. Or maybe I'm not doing enough to consolidate the memory.

What should I do?

A quick search on the net, and I found this site mentioning about how to improve your memory. Useful tips, but do I have enough time? I hope so. So, from now on, I must rush full speed to catch up with my studies and improve on my memory as well. I would do whatever it takes to make sure I am competent enough to pass the exam and become a safe doctor.

Lifestyle modification is the keyword, I guess... No more junk food. Regular exercise. Proper sleep hygiene. Relaxation technique. And the most important thing, pray to God for the best of me.

Study technique? Rote learning is not a plausible option, but somehow it might helps, given the fact that time is running out. So this is the only option for me in order to consolidate the memory. But first I have to grasp the principle of the topics first. Plus the tips from the site that I've mentioned above.

Positive. Be positive. Repeat after me. "I am going to pass the exam and become a safe doctor".

I AM GOING TO PASS THE EXAM AND BECOME A SAFE DOCTOR.

Ameen...

Quick Revision 4 - Rheumatoid Arthritis part 1

Rheumatoid Arthritis = Symetrical polyarthritis of unknown aetiology that leads to joint erosions. It is a clinical diagnosis supported by rheumatoid factors as prognosticating factor.

ARA criteria for RA (4 or more of the following criteria)

"RF RISES"

R - Rheumatoid factors - RF and anti-CCP positive likely RA
F - Finger / hand joints involved for 6 weeks or more

R - Rheumatoid nodules
I - Involvement of 3 or more joint areas
S - Symmetrical arthritis 6 weeks or more
E - Erosions on X-ray
S - Stiffness (morning stiffness for 1 hour lasting for 6 weeks or more)

Other related problems:

1) Splenomegaly: due to Primary disease, Felty's syndrome, Sjorgren's syndrome, amyloidosis

2) Anemia: of chronic disease, Felty's, bleeding gastric ulcer (due to analgesics), bone marrow suppression (cytotoxic drugs)

3) Respiratory complications : Pleuritis/effusion, Interstitial pulmonary fibrosis, iatrogenic - asthma (NSAID), interstitial fibrosis (MTX)

4) Neurological complications : Carpal tunnel syndrome, atlanto-axial subluxation leading to cervical myelopathy, and mononeuritis multiplex

Quick Revision 3 - Presenting CXR Interpretation

This is the suggested template for interpretation of a chest X-ray. I am not sure whether we will be asked to present the interpretation of CXR verbally during OSCE or not. But it is important especially for junior HOs (of which I am going to become soon, God willing) to master the skill in order to communicate with the consultant as well as senior HOs and MOs regarding the findings.

Systematic approach

1) Patient's details: Name, age, gender

2) Film details: Date taken, projection (PA, AP, Left or right lateral), whether it is a single film or one of a series.

3) Technical details: Rotation (if rotated, one can't comment on cardio-thoracic ratio), Inspiration (count the ribs), Penetration (good = able to see pedicles of spine)

4) Heart: Size (Cardio-thoracic ratio), Border (from aortic knuckle and work round to superior vena cava)

5) Trachea: Central or deviated

6) Lungs: Hilar (size, level, any congestion?) ; Fields (use 'zones' instead of 'lobes')

7) Diaphragm: flattened or normal? Costophrenic and costocardiac angles - blunted/loss, normal

8) Mediastinum: size and shape

9) Bones: Including humerus, clavicle, scapula, and ribs.


Some clinicians prefer to describe the CXR 'inside-out' while others prefer the other way round. It's up to us to choose, depending on our preference. Do practice on describing the CXR using this format so that we won't be having "verbal constipation" as one of my lecturers had mentioned in one of his book(s). All the best~ (to myself as well)

p.s. I would like to suggest you to read up Chest X-Ray Made Easy book in order to help you to grasp the knowledge and skills required. Plus, never miss the Radiology classes and make sure you are giving your attention to the fullest because some of the radiographs might be used for OSCE examination. Or at least the ones similar to those. And please get use to the terminology used in describing a radiograph, such as consolidation, opacity, honey-comb appearance, etc.

Emergency Department experience and CBD insertion

This post is not for educational purpose, just for sharing my very own experience in handling the procedure. I was flipping through the OSCE guidebook prepared by my seniors based on the common questions asked for OSCE in final MBBS examination. Then I came across the page where the step by step method of continuous bladder drainage (CBD) insertion is explained. All of sudden the memory of my first CBD insertion came to my mind. It was awful, both to myself as well as the patient (or the 'victim', I might say). I felt sorry for the patient, but unfortunately there will always be the first time in everything, isn't it?

I was in the Emergency department doing my emergency medicine posting. I was the only medical student available. It's not that I am extra hardworking or diligent. It's just that most of the boxes of signatures for my logbook procedures were empty! But I am grateful to be around on that night, because I learned a lot from the doctors and other healthcare staffs.

That night was exceptionally quiet with not much patients. So I went to the observation ward just in case the doctors there require extra hands. One of the MOs there noticed my presence and asked me to join in. She even showed my some findings in the X-rays etc. She also told me that it is always like that in the ED (emergency dept, not erectile dysfunction) during weekends. Wait until about 1-2 a.m. and surely the department will become "merrier". At first I was puzzled, but just as I was about to ask, she told me, "that is when the clubs and pubs closed".

"Oh... drink and drive after the happy hour, I guess..." came across my mind... And she was right. As I was about to leave the ED a few hours later, I was told by the staff at the reception counter there was an accident involving a motorcyclist- allegedly drunk. So I followed the ambulance and help the paramedics to bring him to ED. After resuscitation done and serious injuries being ruled out, I was asked by a doctor to set in the CBD for the patient. I was stunned as I never did it before! I was fortunate that one of the staff nurses was willing to guide me.

1) Make sure you are well prepared. For a list of equipments required, please click HERE

2) Try to be as sterile as you can (of course it's impossible to have 0% bacteria in such environment). Wash your hand properly.

3) Don't forget to ask for patient's consent. I was told that for this instance, verbal consent is acceptable.

4) Decide the size of the Foley's catheter accordingly. For adults use FG 12 (French Gauge).

5) Make a hole in the middle of a drape and set it upon the patient's private part, with the hole exposing the genitalia.

6) Wear sterile gloves and the clean the genital using cotton wool soaked with normal saline. Note: Use forceps to hold the cotton wools

7) Insert lignocaine gel into patient's urethral orifice.

8) Apply KY jelly to the tip of the catheter and insert it into the orifice carefully. Inform the patient first about the discomfort / mild pain and tell him to calm down. Breath in and breath out. Be careful not to cause trauma.

9) Once the catheter is inserted accordingly, inflate the balloon using 10 ml of normal saline.

10) Pull the catheter slowly to see whether the balloon was inflated to prevent the catheter from being dislodged.

11) Attach the tube to the CBD bag.

12) Clean up after finishing the procedure.



It was messy. Seriously. The staff nurse was called by the doctor at the next bay, so I was all alone for this 'challenge'. The lignocaine gel spilled over my gloves and I had difficulty to hold the penis as I inserted the catheter. Slippery. And this has caused further discomfort to the patient. When I was trying to inflate the balloon, the normal saline splashed because the connection between the catheter and the 10ml syringe was not properly attached. Thank God I managed to avoid the splash, but the drape was soaked with it. I had to refill another 5ml to make sure the balloon was adequately inflated. I managed to clean up before the staff nurse came back to the bay and before the doctor came to review the patient's progress. Sigh...

But the nightmare was not over. Another doctor came and asked me to set another CBD. "Dah pandai kan... Buatlah ye. Saya ada kerja sikit," (Now that you are used to it, you can do it by yourself. I have some work to do) said the staff nurse before he left the bay to the reception counter.

"Err... sure..."

p.s. The second CBD insertion was much better as compared to the first though... =)

Quick Revision 2 - Manic Symptoms

If you are referring the First Aid book (for Psychiatry), you will find the easy to remember mnemonic for the manic symptoms i.e. "DIGFAST". But sometimes it's not good for us to rely heavily on mnemonic as most of us may have the tendency only to remember the mnemonic and forgot what the mnemonic is all about. Anyway, there is no harm in doing so. Just make sure to recall what's the points behind those mnemonics from time to time. Here goes:

D - Distractability
I - Irritability
G - Grandiosity
F - Flights of Idea
A - Activity/Agitation
S - Speech (pressured)
T - Thoughtlessness

Abnormal and persistently elevated or irritable mood together with at least 3 of the aforementioned symptoms (4 if the mood is irritable) lasting for at least one week.

Additional note:
1) Mania may present with psychotic features.
2) Hypomania - last at least 4 days, with no marked impairment in social or occupational functioning thus does not require hospitalization. Hypomania does not have psychotic features.

Quick Revision 1 - CXR Features of COPD

Features of classical COPD (Chronic Obstructive Pulmonary Disease) chest x-ray:

1) Hyperinflated lungs (as evidenced by numbers of ribs within the lung field - more than 6 ribs)
2) Flattened diaphragm
3) Widened intercostal spaces
4) Tubular-shaped heart
5) Central trachea
6) Prominent pulmonary vessels

Cases That I've Clerked, but...

I was away to my hometown for the last few days during the Chinese New Year break. It's not that I can't go online in my hometown, it's just that I decided to spend quality time with my family members, away from all my routine. So that I can kick-start my revision fresh and free from all the mess that I faced before.

Upon returning from the holiday, I took the initiative to flip through all the notes that I have been jotting down throughout the years. Then I realized that I have clerked quit a number of cases before. Unfortunately most of them are lost because they were written on a piece of paper without proper filing system. Sometimes lost at the 'mercy' of the washing machine. T_T

However, I managed to recover some of them and decided to do something about it. Perhaps compiling them and trying to improve them by identifying all the salient points not to be missed in the history, proper physical examination techniques and interpretation of the lab investigations etc. My lecturers and seniors used to remind me about the habit of jotting down on pieces of paper, but the habit seemed to be difficult to be changed. Yet, it is not too late for me. In fact, by tracing back all the cases and 'refurbishing' them, I would somehow be able to revise as well as prepare for the upcoming exam and my future in the medical career.

I just noticed that I have clerked quite a number of patients with chronic illnesses such as DM, hypertension, ischaemic heart disease etc - be it as comorbidity or the main problem secondary to the complications of such diseases. Perhaps I can just do it in a single go, by tackling from primary care setting (prevention, follow up, education etc), until the management of its complications as well as the complications secondary to the medication etc. I should have mastered the skill that required for these diseases as well as their management up to date.

By the way, my advice to the junior medical students who are about to start their clinical years:
Please, never ever abandon those knowledge that you have obtained during your pre-clinical year. They are definitely useful particularly in order to understand the pathophysiology and the natural history of diseases. Otherwise the faculty won't waste two precious years for them. And if you are aspiring to become a surgeon, please keep your Anatomy textbook (be it Snell or Grey's) handy. Biochemistry may not be of much use for the undergraduate clinical years, (in my humble opinion) but that doesn't mean that we should 'format' those 'folders' for the subject in our brain.

I think that's about it for now. Need to work on 'unfinished businesses' before the end of next week (i.e. before the beginning of study weeks.

Why do you smoke?

There are quite a number of my friends who have medical training background that smoke. It really makes me wonder, how are they going to advice others to avoid or quit smoking when they themselves are still smoking?

I know, I know, most of us have been hearing about this sooo many times before. But the truth is, smoking is not only bad for your health, it affects others' health even more from second-hand smoke. And quite recently, some researchers from US had came out with third-hand smoke theory.

I remember a father used to justify his smoking habit by saying that he would only smoke outside in absence of his children and wife. But if the theory has been proven to be true from further studies, then the justification is not acceptable at all because the third-hand smoke also present with risks to others.

My question is, why do you smoke in the first place? For fun? To release your tension/stress? To be accepted among your peers?

I don't think smoking is fun at all, to begin with. The smell, the bad breath... Stress? There are so many other methods of releasing your stress. Karaoke might help. sometimes. For Muslims, they can perform their prayer and for those from other faith, they can meditate themselves. By the way, with the government increasing the taxes for the cigarettes, for sure the price would eventually increased. Wouldn't it be more stressful for having most of your money spent on something that may even worsen your health condition?

My words meant nothing unless you (yes, those who smoke) yourself make the move and take your initiative to quit from smoking. Even though there is not enough evidence linking smoking directly to lung cancer etc, but why take the risk?

To all smokers out there, the choice is yours. It's your call.