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... ("^_^)

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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.

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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... =)