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.

are you a SAD PERSON(S)?

Since that I am doing the Psychiatric posting right now, perhaps it would help myself if I share with you something that I have learned from the posting. But then again, this blog is not peer-reviewed, hence making it not reliable to become as the source of reference unless stated otherwise. What I am going to share is very important, as the incidence of suicide is more or less on the rise, even within the Malay community who practiced Islam.

"SAD PERSONS" (Patterson WM, Dohn HH, et al) is a rating scale that is being used as the reference for the risk of suicide of a patient. It may not be 100% reliable, sensitive and specific test. But it is quite handy to be used for screening purpose and every patient presented with suspicious trauma must be tested to rule out suicidal ideation before it's too late. More detailed tests such as Beck scale etc are used for further assessment. A depressed patient must be asked about the suicidal intention and preventive measures must be taken accordingly.

One point is given if the patient fulfill each criteria.

S - Sex : More in male
A - Age : 45 years old and above
D - Depressed and sense of worthlessness

P - Previous suicide attempt(s)
E - EtOH (Ethanol) abuse i.e. Alcoholism
R - Rational thinking (loss of,) - Evidence of psychosis*
S - Single or divorced
O - Organized plan
N - No, or lack of social support
S - Sickness : comorbid or chronic illnesses

Scoring
0-2 equals little risk
3-4 equals following patient closely
5-6 equals strongly considering hospitalization
7-10 equals a very high risk, hospitalize or commit.

* Psychosis: a loss of contact with reality, typically including delusions (false ideas about what is taking place or who one is), hallucinations (seeing or hearing things which aren't there), and disorganized thinking.

p.s. Had a terrible headache earlier today, and I missed a lecture in the afternoon. So I must read up on the topic missed.

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Reminder to myself: Must return to my previous normal sleeping pattern. It has gone haywire lately.

The examiner will be annoyed...

"Speak up, it's very difficult to listen to what you say. You have to speak louder. Otherwise the examiner will be annoyed with you."

That's what was told to me by one of my lecturers. He is a very patient doctor/lecturer. I have been having this problem for quit some time, yet he is still trying to help me to improve on my voice as well as presentation skills. If you are reading this (which is highly unlikely), I would sincerely thank you for your effort to help me. I promise that I will try my best to improve on my weaknesses particularly my soft voice. I can't thank you enough for your help. At least I can safely say that there is some improvements on my presentation skills.

For your information, I have a problem with the tone of my voice. I don't know why, but it persists even after I tried so many times to raise my voice (appropriately, of course). Honestly speaking, I feel like there's something stuck near my vocal cord that had restricted the voices coming from it. Apart from that, I also feel that as if there is some barrier between me and those who are listening to me.

I also had problems with my confidence level, no matter how well I am prepared for the presentation. Even though I have been presenting so many times before, I still have this kind of problem. I am absolutely having problem with showmanship. It really makes me wonder whether it's just in my mind, or there is some underlying physiological problem? Could it possibly be due to hormonal imbalance, for example? Or is it just me, having low self esteem?

I really need to address this problem quickly as the time is running out. This is the 7th week of my last posting, which means that there is only more or less one month left before my final examination. What should I do?

1) Practice more on presenting cases (volunteer if possible)
2) Practice to speak up clearly in front of mirror in my room
3) Spend some time (but not too much) speaking to patients confidently and try to explain about the disease to them (if they're interested) apart from just clerking them
4) I would definitely have to solidify my knowledge so that I am able to argue/discuss confidently during presentation.
5) Last but not least (in fact, the most important thing) pray to God for His help to tackle this problem.


p.s. Reciting al-Quran or singing out loud to a song when I'm alone in the room will also help.

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Reminder to myself: Please adhere to the plan and make sure to do the housekeeping from time to time so that the untidiness of the room will not 'accumulate' and causes huge problem to myself.

Life as a Medical Student

This is just based on my very own perspective and does not necessarily depicts the life of all medical students as a whole. Perhaps others may have different perceptions and feelings towards these 5 years of studying and suffering (lol).

To begin with, I never had imagined of pursuing on medical field, not until I finished my matriculation programme in 2005. When I was in school, I used to aspire becoming a scientist - doing researches and somehow win Nobel prize or something like that. Perhaps because of my bad experience with a 'doctor' (who turned out to be just MA - medical assistant) when I was studying in secondary school in Raub - a small and peaceful district in Pahang.

The MA snubbed my complain and blamed me for something that I had no control of. I had an ear infection, perhaps the MA thought that I intentionally did that somehow. No pain killer, no reassurance, just some suctioning of my ear and antibiotics. But when I think about it retrospectively, I believe that I can't totally blame him because the clinic was quite crowded at the moment and most of the complaints were just cough and cold. But if my memory serves me well, I think that was the time when news about SARS took place in the front pages & in the news. Being a naive and young boy, I was a bit paranoid upon seeing people sneezed and had runny nose. So, if it wasn't because of pain and reduced hearing (which made me difficult to focus to the learning process), I would have not even take the risk of coming to the clinic.

Future fastforward, I've just finished the first semester of matriculation when we were asked to fill in the application form from UPU (for enrollment into public university). I was stuck at the decision making again - something that will change the course of my life greatly. After consulting my family, seniors, and praying to God, I decided to apply for Medicine. Though deep inside, my love for History and study of Human Civilizations was still there. After balancing between the pro's and con's, and pondering upon the prospect in the future, I believed that my choice is right. My sister told me, once you've graduated and becomes a doctor, you can still pursue in your interest (i.e. History), like our very own statesman, Tun Dr. Mahathir Mohamad. Hence the life as medical student.

The first year was quite challenging but still bearable because it was all about basic sciences - which has been covered more or less during my matriculation programme. I managed to get involved in the college activities which were not related to medical field. Second year was more challenging with Pathology as the killer subject. I remember crying out alone in the middle of night because of the difficulties that I faced. Thank God, I managed to get through the troublesome years with help from my batchmates, seniors, and our respected lecturers. This year was when I met a girl of my dream. I fell in love with her, without knowing that her heart had already 'taken' by one of my seniors - the top student in his batch. It was unfortunate when he passed away in a MVA a few years back. But I don't want to further elaborate about this, because it will not serve the purpose of this blog. It would be sufficient for me to say that I had let her go and move on with my life.

Third year was very interesting to me, especially. Because this is when we were introduced to the clinical years. The whole batch was posted in a general hospital away from main campus. A new experience for me. But not long after that I realized the importance of having good communication skills as well as the mastery of language, particularly Bahasa Malaysia and English. Mandarin and Tamil are also important especially when you are soon will be dealing with the multiracial community. Perhaps knowing what "pang sai" means, or what "muchu" means as well as other common words when dealing with patients might help. Showmanship also plays major role. That's where my weakness is. Thankfully I managed to improve myself, though there is still plenty room for further improvements.

Third year ended swiftly and the we were back in the main campus again. Our 'fourth' year (namely phase 3b junior) was "neither here nor there" according to a friend of mine. We where no longer 3a, but we were not exposed to the clinical management aspects yet. We were divided into 3 groups, one doing Gynecological and Primary Care posting, another doing elective projects, and the rest were in the minor postings (ENT, Ophthalmology, Emergency Medicine and Anaesthesiology). At the same time, we observed how our senior facing their final MBBS examination. All of sudden we became extra dedicated to study and worried about our final examination - though it was a year away. T_T

Then the final year came. I started with Orthopaedic posting, which I somehow enjoyed it. Now it's already my last posting, Psychiatry. Time really passes by quickly. With a few weeks left, I believe that I am mentally prepared to become a full-fledged house officer. But the problem is that I am not sure how well my skills and knowledge is to become HO. But fortunately I managed to grab the salient points and developed important skills to function as HO. It's just that I would have to brush them up so that I will become competent and skillful HO. With less than 40 days left, I must practice more on working out a diagnosis and its management.

I enjoyed my life as medical student, just as much as I suffered from it. haha. Like one of my senior used to say to our batch during our orientation week, "If you don't have your heart into medicine, there's no point of continuing. You better quite soon enough before you regretted it in the future". But I stayed. Because my heart is with this profession (as well as other commitments of course). There are a few of my friends who quit from the Med school so to speak.

That's all for now, thank you for spending your time reading. Have to continue studying. But it's Saturday night~ Perhaps I can excuse myself for an hour before continue studying... "^_^

p.s. OK, retreat granted. Enjoy it while you can. Just received a call from a friend. Football match tonight at 11 p.m. Arsenal vs Chelsea (it has been quite some time since the last time I watched a football match. So, why not?)

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Reminder to myself: Growth Study Report and cover Anxiety disorder tonight before going out later. =)

The Last CPC

Yesterday we had our last clinicopathological conference (CPC), which was under the Department of Orthopaedic Surgery. I had a mixed feeling about it. Happy, because soon I will be graduating (hopefully). Worried, of course, because it means that the final examination is really around the corner.

One of the presenter had mentioned that over the last few years, there was no CPC paper from the Department of Orthopaedic Surgery. Thus, the likelihood of Ortho CPC is high. But one can never be 100% sure about it. After all, it was only speculation. In fact, I would have to cover all posting nevertheless. But it's worth considering anyhow. Maybe some extra study sessions for Orthopaedics - and less on Primary Care Medicine, because I have covered most of them. =)

The CPC was about a 5 year old child who presented with complain of left knee pain. Since the patient is under paediatric age group, so we would have to discuss about the different approach in paediatric patient as compared to adults. As the supervisor had mentioned, "children are not small adults". When the child complain of pain, it may not be necessarily be pain, it may be numbness or paraesthesia. Perhaps the child is too young and unable to differentiate between those symptoms. Apart from that, in any case like this, we must take into consideration the possibility of non-accidental injury (NAI). Not only for extra marks during examination, but because the incidence of NAI is increasing over the years. Sad but that's the truth. It really makes me wonder, how can a mother or father did such horrible things to their very own child.

As for the management part, multidisciplinary approach must be taken, which covers "bio-psycho-social" aspect, as what our Psychiatrists cum lecturers had stressed upon.

I have no intention of bringing the whole discussion here, because it was quite lengthy. It's just that after attempting the questions, I noticed that I was still unable to obtain maximum marks. Perhaps I should attempt more past year questions so that I can get used to the questions.

p.s. It has been a very tiring day, so I need to have a good rest for tonight and wake up fresh in the morning. I've been quite busy for the last 3 days, which is why I did not update this blog lately. On call, case summary, growth study project report, and a visit from an old friend. But somehow I was quite happy, since that I believe I have already gained the momentum to prepare for the final examination. Hopefully I can maintain such momentum so that I will be well prepared for the upcoming examination. May Allah grant me success... Amin.

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Reminder to Myself: It's Saturday, time for housekeeping and laundry. And don't forget your appointment at 8 a.m. Then I should continue with my growth study project report which is already half way through. Hopefully will manage to finish it by this weekend. Oh, and on call on Sunday. T_T

Cranial Nerve Examination II

Ok, this time I would like to share with you the technique that I am used to do when it comes to the cranial nerve examination. Like my lecturer used to say, "Every examiner have different techniques of doing it, just adopt the techniques that you are comfortable with and make sure to do it systematically so as not to miss eliciting any sign".

To begin with, these are the cranial nerves, namely:

CN I Olfactory (S)
CN II Optic (S)
CN III Occulomotor (M)
CN IV Trochlear (M)
CN V Trigeminal (B)
CN VI Abducens (M)
CN VII Facial (B)
CN VIII Vestibulocochlear (S)
CN IX Glossopharyngeal (B)
CN X Vagus (B)
CN XI Accessory (M)
CN XII Hypoglossal (M)

S = Sensory
M = Motor
B = Both

There's mnemonics to remember this, you can refer to Wiki or any other sources. But as you go along memorizing these facts, it won't mean a thing if you fail to grasp the concept. I believe that as we practice more on eliciting the signs, it'll be a lot more easier to remember and understand. By the way, this post is just for my revision and not very reliable for educational purposes. Because my blog is not peer-reviewed. And it is way out of my intention to become the reference for medical students or lay people.

Ok let's begin.

1) First, introduce myself and explain that I would like to examine your nerve function. Or just simply say I would like to examine you for a while. Position yourself sitting at the same level, face-to-face to the patient with a distance approximately half meter away.

2) Secondly, ask whether he/she can smell the food that they (I used 'they' to eliminate the gender factor) had for breakfast earlier (CN I)

3) Then, take out mini Snellen chart and ask whether they are literate or not (politely, please). If they are illiterate, use pictorial version of Snellen chart to test for visual acuity. Ask them to hold the chart approximately 30 cm away and to read the words. Usually the examiner would ask you to proceed as this might take some time to accomplish. But sometimes the examiner would not ask us to perform full cranial nerve examination. They might ask to examine one or two of them. They may also ask us to examine patient's visual acuity only. So, if that's the case, ask the patient to do the same procedure, should they failed to do so, change the distance from 30 cm to 15 cm. If they failed to even read the uppermost line, then use "finger counting" technique 15 cm from patient. If finger counting fails, used finger waving. If still unable, take out your torchlight and shine to them. Please refer to Ophthalmology references for the scoring.

4) After that, mention to the examiner that you would also like to ask patient to read from the Ishihara chart for color blindness.

5) Then proceed test for accomodation. Take out your "red-bead-on-a-stick" and tell the patient to look at a far object, then upon instruction, ask them to slowly focus on the "red-bead-on-a-stick". Focus whether the eyes become converged or not. And observe the pupils.

6) Visual field. Ask patient to close one eye using their hand. You also have to close one eye for comparison, assuming that your visual field is normal. If you want to test on the right eye, you close your right eye and compare the field using your left eye. Take out "red-bead-on-a-stick" and held it in between you and patient. Stretch your hand away and tell the patient to inform you once they saw the "red-bead-on-a-stick". But make sure to ask the patient to focus on your face (or nose) and do not move their eyes or face away. (Step 3 to 6 are to test on the CN II - optic nerve)

7) Eye movements. To test for extra-occular muscles. Again, instruct the patient to maintain their face towards you. To be safe (as far as showmanship is concerned), "anchor" their face by putting your fingers on their chin. Then take out "red-bead-on-a-stick" and put it at the center. Ask the patient to follow the movement of the "red-bead-on-a-stick" using their eyes while their face is fixed. Make "H" movement and ask the patient to inform should they see double image of the "red-bead-on-a-stick". As you go along, observe patient's eyes to see whether there is nystagmus present. (CN III, IV, and VI) . More mnemonics - LR6, SO4, the rest of extra occular muscle are supplied by CN III.

8) Take out a cotton wool, make it "pointy" and touch accordingly to respective regions on the face supplied by CN V. Instruct them to mention whether they can feel it and compare the sensation with the reference point, say, on the sternum - "Same or reduced?". Take another 'pointy' cotton wool and test for corneal reflex. Mention to the examiner you would like to do the jaw-jerk reflex. Usually the examiner would ask us to skip. For the motor component, ask them to clench their teeth. Then feel for the temporalis and masseter (muscles of mastication) for any weakness. (CN V)

9) Ask the patient to smile and raised their brows, see whether there is any facial asymmetry. Then ask them to pucker their lips and blow. Press the check gently and see whether there is weakness. Also ask them to close their eyes tightly and then you try to open them using your hands. (CN VII)

10) Pluck your fingers on one of patient's ear (masking effect - but make sure not too loud) and whisper a word on the other. Ask them to repeat the word that has been whispered to them. Mention that ideally I would do proper auditory test as well as Webber's and Ringe's test to test for CN VIII.

11) Ask patient to open their mouth and say "Aah..". Observe the uvula whether it's deviated or not. Then ask them to pull their tongue out and observe whether it's deviated or not. Tongue will deviate towards the site of lesions whilst the uvula is the opposite. (CN X)

12) Gag reflex. Mention to the examiner first, because most of the time you'll be asked to skip it as it is very uncomfortable to the patient. (CN IX and X)

13) Ask the patient to shrug and resist the pressure that you put upon their shoulders. Then ask them to turn their head to one side and try to turn back against your hand. Use the other hand to palpate the strenocleidomastoid muscle of the opposite site to feel whether it's contracting or not. Do the same on the other side afterwards. (CN XII)

14) Finally, said that you would like to complete the examination by doing neurological examination of upper and lower limbs as well.

15) Thank the patient and then present your findings to the examiner (this one you would have to read up and try to find out the possible pathophysiology - haha, reminder to myself...)

That's all for today... Please, do right me if I'm wrong... Thank you in advance... ^^

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Reminder to myself: Tutorial with my tutor 2.30 p.m. in the ward. Read up about psychotic disorders and psychopharmacology.

Cranial Nerve Examination

Optic nerve - CN II

It has been quite a long time since the last time I did a proper cranial nerve examination on a patient (i.e. with findings). While waiting for the lecturer to come, my friend and I decided to brush up on our short case examination skills. He suggested cranial nerve examination and volunteered to do it on me. After a while, we realized how terrible our skills were. The flow was not very smooth, and we had slight difficulty in giving instructions to the 'patient'. Hence we came into conclusion that we did not practice enough.

For a short case examination, it won't be more than 10 minutes per case (there will be 3 short cases back to back for the final examination). So, we are supposed to finish examining within 7 minutes (at most) so that there will be discussion where a lot of marks may come from. "The keyword is showmanship," one of my lecturers used to told us. IMHO, CNS examination is the most difficult among all physical examinations of human body system. A lot of instructions needed to be given to the patient in order to elicit the signs. Moreover, we would have to identify where the lesion might possibly be. Which means, dermatomes and myotomes as well as the nerve supply must be remembered. I remember how terrifying Neuroanatomy and Neurophysiology were when we learned them during our second year of Med school.

Whether I like it or not, I would have to practice more so that I can perform the examination properly. A visit or two to the neuromedical and neurosurgical wards might help. My 'bantal' won't help as 'patient' because in CNS examination the patient need to respond accordingly to the instructions given. =)

p.s. For the time being, I would have to be more of exam-oriented because the exam is around the corner. I know, some people believe that it's not good for the career development, but I personally think there's nothing wrong with that. The examination is done to assess whether we are ready to be "released" into the society to serve them. So, I think it OK to be a bit exam-oriented, in sense that to focus more on the common things that may be asked in the examination. Once I've graduated, trust me, I would do a lot more than this to improve my skills and knowledge - keeping updated with the recent developments via journals, attending seminars etc.

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Reminder to myself: Prepare the presentation slides for the Case Conference. Tomorrow please visit neuro wards to practice on CNS examination (short cases).