Time Table

This is it.

This would be my last post.

Tuesday 1st June 2010 - 8.30am. Assessment Centre, WGH.

Monday 7th June 2010 - 9.00am. Seat Number: Red 13. Hugh Robson Lecture Theatre.

Tuesday 8th June 2010 - 9.00am. Seat Number: Red 13. Hugh Robson Lecture Theatre.

Wednesday 9th June 2010 - 1.00pm. Postgraduate Lounge.

Dear Med School, pls do not invite me for any resits. THANKS.

The world is waiting for me.

I mean the World Cup is waiting for me.

See you angchoonseong.blogspot.com. after exam. Good luck everyone.

Hwaiting.

Team: South Korea.

Number 13.

Name: I Love Yuri.

7 Days

At times like this, I hope the exam comes sooner.

I am writing my elective report.

It was rather like a blog post. Really.

Ha ha ha.

Hopefully the viva ask me about my electives.

I can go for hours.

But if they ask me ethics, or nutritions...

I am so fcked.

Education tips:

The mnemonics for causes of Carpal Tunnel Syndrome:

TRAP MID.

It reminds me that carpal tunnel is a lesion of Median nerve. Sorry I am not so pro to remember so much stuff without these rubbish mnemonics.

T - Trauma

R - Rheumatoid Arthritis

A - Acromegaly

P - Pregnancy

M - Myxoedema

I - Idiopathic

D - Diabetes.

Good luck Ang.

I was told that if I want blessing from any God,

Due to my long list history of evil deeds,

I would need to castrate.

But, I never rape ppl la...why the hukuman so ganas one?

HA HA HA.

btw, i am a mild Buddhist. Just incase you dont know.

I believe in Buddhism because I think, thats the chillest religion.

I hate to think about these things.

But at times like this, perhaps thinking about these things, is much better than thinking the side effects of beta blockers.

I think i have got one of the side effects.

No, not erectile dysfunction. I know this is your first differential.

Not night mares.

Not hypotension.

Not bronchospasm.

Not heart block.

Not peripheral vascular disease.

Not fatigue, GI disturbances, rashes or headaches.

Pardon my french.

Reduced joie de vivre.

I hope you learnt something from this post.

Bright Future Ahead

National Health Care

From Malaysiakini:

Nation's healthcare system ill, needs attention

It is frequently said that a true measure of society is how it treats its weak and poor. To this we would like to add that the true measure of a civilisation is how it cares for its sick and dying.

Recently a friend's mother was diagnosed with advanced bowel cancer. In her mid-50s, with two children of college age, she was obviously desperate to put up a brave fight for as long as possible.

Six months and RM 400,000 worth of treatment later she sadly lost her battle with the Big C, leaving a grief stricken family that had re-mortgaged the family home and were waist deep in debt. Although she had healthcare insurance, the insurance firm would only cover 70 percent of the costs, hence the need to dig deep into savings and release property equity to raise the additional funds, at considerable cost to her loved ones.

Cardiovascular disease, diabetes and stroke are already among the leading causes of mortality in Malaysia, in line with that of the rest of the developed world. Cancer diagnosis is on the rise and over the next 20 years it is projected that 1 in 3 to 1 in 4 of us will develop cancer.

Many of these diseases don't discriminate - at some point in the future either we ourselves or someone close to us will suffer from a potentially serious healthcare condition. How much will this cost us and how many of us will be unable to afford the treatment we need?

In recent years, Malaysia has witnessed the growth of the private sector share in our healthcare system. Whilst many private hospitals provide good standards of care, some are more concerned with profit margins.

Many of us will be familiar with stories of private hospitals performing unnecessary tests and additional treatments as a means of income generation. A friend's uncle tells the hilarious story of climbing a rambutan tree a few years back and falling off a branch, sustaining a mild concussion.

With a bit of a sore head he thought he'd better go and get checked out. Despite little in the way of additional signs and symptoms he was subjected to a MRI scan at a popular private hospital and an IV drip overnight although he was perfectly capable of eating and drinking.

The outcome? He was discharged the next day with a bill for RM5,000. On relaying his story to a doctor friend later on he was berated for having been taken for a ride, when a couple of Panadols and close observation would probably have sufficed.

Profiting from pain

When a close friend was recently accepted into an oncology training programme overseas, her father's friend, a respected surgeon, noted what a good career move she'd made. He congratulated her father on the fact that when she returned to Malaysia she could hope to make up to RM 70,000 a month as an oncologist in the private sector.

She was stunned and clearly dismayed by this proposition -in her mind, no one or no institution should ever be able to profit out of the pain and suffering of others. There is something fundamentally wrong with a system that puts profit and material gain before human life.

Some will argue that a private healthcare system should be allowed to develop and those that can afford it continue to pay, whilst those that can't can fall back on the government system.

We would argue that promoting a two tier healthcare system is dangerous both in terms of ensuring equitable access, maintaining healthcare standards, promoting research and development as well as the inevitable brain and talent drain that follows -as clinicians are drawn away from the government system towards the private sector.

Currently the private sector accounts for 23 percent of the country's hospital beds (12,000 beds per year). Around 40 percent of the country's doctors are employed within the private sector (9,000 doctors) with a doctor to patient ratio of 1 to 1.3. This is compared to a doctor to patient ratio of 1 to 3 in the public sector.

However with the move towards semi-privatisation and lack of a coherent social welfare system, even healthcare provisions within the government sector are not completely 'free'.

Neither are these provisions always affordable. A friend recalls undergoing cancer treatment at University Malaya Medical Centre (formerly known as University Hospital).

She was charged RM30 for her first round of chemotherapy. At the same time in the chemotherapy suite was another woman who was bemoaning the fact that she couldn't afford to have further treatment.

She unfortunately was now onto her second course of chemotherapy for cancer recurrence and this time round had to pay around RM3,000. Apparently this was part of the additional charges for successive chemotherapy sessions.

Ethical dilemmas

Also, doctors in the government sector often face tough ethical dilemmas. One senior doctor was seriously disillusioned by the fact that difficult cost-benefit calculations have to sometimes be made on behalf of patients. Some patients may be faced with the prospect of treatment that may buy them a further 18 months of life but leave their family with RM 20,000 worth of debt.

For many of us, ANY additional time spent with a loved one would be considered immeasurably precious. However for a family existing on RM1,000 a month this could spell financial ruin. In many instances, doctors in the government service heroically choose to turn a blind eye and continue to treat patients regardless of their ability to pay. Many of them however find themselves on the sharp end of rebukes from finance departments and hospital managers.

So what is it that Malaysians need and what is it that they deserve?

We would argue that instead of wasting taxpayers money through superfluous vanity projects and outrageous spending, (the purported RM77 million splurged on the US-based Apco Worldwide consulting firm just to revamp the new Prime Minister's image being a prime example), the Malaysian government should in fact be focusing on providing a world class healthcare system that is free to all at the point of delivery.

And by that, we don't simply mean a few token clinics hastily scrambled together devoid of properly qualified medical officers.

Malaysians are more than capable of leading cutting edge research and providing world class healthcare services that saves lives -the fact that there are many Malaysians in top consultant/research/public health posts abroad in the UK, US, Singapore, Canada and Australia is testimony to that.

Comprehensive plan required

We need to come up with a plan for comprehensive healthcare coverage that ensures we get the treatment we need when we need it, regardless of our ability to pay. We need a comprehensive overhaul of our public health policies that make diabetes, heart disease, stroke and cancer diagnosis and treatment top on our list of priorities.

We need to guarantee that the next time a minister's wife develops breast cancer she is able to access the best up to date treatment on her doorstep without having to fly halfway round the world. Along with our mothers, sisters, wives and daughters.

Breast cancer is, after all, hardly a rare disease. We need to pay our doctors a fair wage and reward initiative, innovation and hard work, so that we retain the talent we need to build a world-class health system within the public sector.

We need to invest more money in healthcare- last year the government spent only three percent of our gross domestic product (GDP) on healthcare (and only half of this-1.5 percent was spent in the public sector).

During the recent economic downturn, public healthcare expenditure was among the first to be slashed by a staggering 30 percent.

It is bad enough that existing levels of expenditure for healthcare fall short of the World Health Organisation recommended level of five percent and that of China and India who over the last seven years have consistently spent over five percent of their GDP on healthcare.

Most importantly we need to remind ourselves that many illnesses, including cancer, do not discriminate, and when you're ill and vulnerable all the money and material wealth in world may fail to make things better.

More than skyscrapers, shopping malls and multi-million dollar vanity projects we need a robust healthcare system that serves the people and can be trusted and relied upon to care for us when we are at our most vulnerable.

Joke of the year 2010

is this

HAHAHAHAHHA

Into the Final Lap!

Mari!

No more sleeping!

IV caffeine!

IM Adrenaline!

Oral Read Bull!

PR Banana!

The best news this week is...

World cup is coming soon, just a day after my last paper.

Ahhhhhhhhhhhhhhhhhhhh

Pulse

Today I examined cardio patient.

Couldnt recognise that the pulse was irregular.

Just reminded me that there once I mistaken some auntie's pulse as regular in GP.

And then found out that the patient is long term warfarin for AF.

at that time, it didnt occur to me that this is such an important thing, now only I realised.

Imagine patients with AF, no other signs, except the pulse, and I blardy miss it. Coz it is impossible for my deaf ear to get a mid-diastolic rumbling murmur for mitral stenosis.

And the same patient that I examined today, has got a prosthetic aortic valves, which I tot was normal heart sound.

I went back to the patient after reading his notes.

Put on my stets, listen again.

I still think thats normal heart sound.

And then I took off the stets, and just using my ears,

I can hear CLICK!

and then i put on stets again, and listen...

I cannot hear click, and still convinced it is a normal heart sound.

And then I went back to the docs room, use my stets and listen my own heart sounds,

and i think it sounds like the patient anyways!

maybe a prosthetic valve was inserted into me when I was younger...

or maybe...actually...

I AM TERMINATOR!

Post 12: Hernia

1. Wash Hands, Intro and consent.

2. Expose and general inspection, and ask; Where have u noticed the lump or swelling?

3. Inspection: Look carefully for scar both sides. Ask the patient to cough, look for visible cough impulse. Ask patient to lift head off bed to increase intraabdo pressure.

4. Palpate: Both sides. Let me know if it is sore. Look at the patient's face as well. Check size, and neck of the hernia. and for 3 Ts - Tenderness, temperature and tension - signs of strangulation. Ask the patient to cough, to feel for cough impulse.

also palpate for pubic tubercle, and ASIS.

palpate the bola.

5. Reduce: Can you push the lump back yourself normally? Can you do that now? If cant, ask permission, do u mind I have a try? Try patient supine if so far the examination is done standing.

Differentiating direct and indirect inguinal hernia. Reduce the hernia, and use two fingers to occlude the internal ring (which is midpoint ASIS-Pubic Tubercle) ask the patient to cough. If didnt come out, its indirect. If come out still, its direct.

6. Auscultate for bowel sound.

7. Shine light the scrotum as well.

8. Would like to have a complete GI exam to look for any cause of increase intraabdo pressure. which is hepatomegaly, splenomegaly, bladder distension, ascites, prostatism. and USS abdo. and CT abdo

Anatomy of inguinal hernia. - Mneumonic - MALT from wikipedia.

Start writing A first of the MALT. Coz A stands for anterior - so it is the anterior wall. and A = aponeurosis of..? if anterior must be damn superficial, and so its the EXTERNAL oblique. Thats how i remember.

So done A. Aponeurosis of External Oblique.

Now L? Ligament. Inguinal Ligament.

so left M and T. Thats the two hardest one but then i somehow remember that the first two MA is oblique muscles, so actually M according to wikipedia stands for Muscles - Internal Oblique and Transverus abdominis, but i choose to remember internal oblique only.

And the T is Transversalis fascia. I choose not to remember conjoint tendon adn all other shit.

So MALT - Muscle (Roof), Aponeurosis of external oblique (Anterior), Ligament Inguinal (Floor), Transversalis Fascia (Posterior). I dont have to remember the which is which for posterior or roof coz just naturally, A=anterior and Ligament has to be the floor. and the other two just sink in nicely. For me.

Now the other anatomical thing that i hate the most is the hasselbachs triangle. So medial to the internal ring, is where the inferior epigastric artery travels past.

and medial to my great body is my impressive six pack rectus abdominis.

And so the triangle of this hasselbachs, is inferior epigastric laterally, rectus sheath medial, and the inferior border would be the inguinal canal.

Hernia coming out from this circle would be due to weakness of the deepest muscle in this post, ie, the posterior wall, ie...the T...ie...Transversalis fascia.

If this helps...

And so, the other types of hernia; femoral. Easily incarcerated with high risk of strangulation. urgent repair.

Types of surgery; Open and put a mesh, Open and suture it closed, and laparoscopic.

Practice

Come on!

Practice Practice Practice.

Home Made Steak

Pls call 07894992989 to make reservation.

This is the one and only, Halal Steak in Edinburgh.

Homemade!

U can also call the same number to make reservation to befriend the chef.

..

...

...

Spoiler:

(I ate liau got dizziness and fart damn smelly for the next few days.)

Learning points:

I check my U & E's and the urea was increased out of proportion to creatinine, an indication of a massive protein meal.

This can also happened in GI bleeding. Coz hemoglobin pouring into the gi tract is essentially protein meal.

It gives me wings

Read Bull

Post 11: Tremor

Examine this patient's tremor.

Came out in one of our short cases.

Inspect the tremor at rest. Nature? Speed per sec?

Then ask the patient to stretch out the hand straight in front, and spread his fingers and keep it there. (Spread the fingers for fun...dunno got difference or not)

Tremor types:

1. Resting tremor. 3-4 cycles a second at best. Coarse. Pill rolling. Abolish on active movement like when the patient move his hand to stretch out for the second instruction. Should be asymmetry. Parkinson.

2. Intentional tremor. irregular. large amplitude and worst at the end of a purposeful act. Cerebellar lesion, MS or cerebellar stroke.

3. Postural Tremor. Absent at rest. Present at maintained position, like when hands out straight. divided into benign essential or acquired.

Benign essential - asymmetry, slower and persist throughout action and keeping posture. Idiopathic.

Acquired - symmetry, faster, purely postural. Abolish on active movement. Causes: Thyrotoxicosis, salbutamol, anxiety.

Treatment for both, beta blockers, and for acquired, rx underlying cause.

4. Last type is the flapping tremor in liver failure and respiratory failure.

Extras!

I think it would be a parkinson's patient. So likely to ask you to inspect and tell findings.

Lack of facial expression and got unku (flex neck) a bit.

Core features of parkinsons - TRAP.

T - Tremor as described.

R - Rigidity - check tone, looking for rigidity cog wheeling, which is spastic + tremor.

A - Akinesia or bradykinesia. chcek the finger pinching and piano playing speed.

P - Posture which is very observational - Stoop posture, ask the patient to walk across and turn, slow initiation, hard to get up from the chair, minimal hand swing, hand over hernia postion, festinant steps ie getting faster and faster, very slow in turning, shuffling gait.

Treatment - LDopa with peripheral dopa decarboxylase inhibitors for side effects. Dopamine agonist, Anticholinergics, COMT inhibitors...cannot remember liau. And surgery is the new thing. Deep brain stimulation i think. HAHAH. dun care.

Causes of parkinson - Idiopathic, vascular - stroke, trauma - muhd ali, drug - antipsychotics, lithium, metoclopramide, metabolic - copper ie wilson's disease, parkinson plus - MSA, Shy Dragger cant remember liau la...

Election

Seriously they should form a political party.

Tae Yoon can be the next president of South Korea...

Not only our country has funny politicians, funny courts, funny police, we have funny elections and even more funny election song.

Hahahahaha.

Chill

I realised how I mengeboringkan some of you with the non stop medical postings.

Hohoho.

If you think you are bored by those, IMAGINE HOW I HAVE BEEN FEELING OVER THE PAST FEW WEEKS!!

I cant help la.

Depress is an understatement.

Really all my life now is on that stuffs only.

18 days to go i think. After that, hohoho.

FREEEEDDDDOOOOMMM!!

The first thing I would do is hit the field!

Last picture taken 3 weeks ago, in Heriot watt indoor. I look thinner and fitter than real life. HAHAH.

This is what I have been doing this for the past 5 years. Koreans, Pakistani, Chinese, Hongkies, Japanese, Scottish, Arabs (ya play for the koreans against arabs. hehe).

Ang Choon Seong.

Can you pls,

GO AND STUDY.

Its blardy 2am now, and you have been doing nothing since 2 am yesterday bugger.

Post 10: Rheumatoid Hands

Apparently this is a confirm station!

So better spend more time on perfecting the osce.

I like Loco examinations coz it is very clear cut. No hidden rubbish.

Look

Exposed hand up to shoulder, beyond elbow.

I think of Look from the superficial down to the inner structure. and compare with the other hand. for symmetry.

So it would be starting with: Deformity-Skin changes/Subcutaneous Nodules-Scar-Swelling-Muscle wasting.

1. Deformity. Ulnar deviation of the hand at the wrist joint. Z thumb deformity. Swan neck deformity and Boutonnière's deformity. and Subluxation of the MCP. Prominence of ulnar styloid.

Boutoneire's deformity. PIP flexion and DIP extension

Ulnar deviation of the hand at the wrist joint and Z thumb deformity

Prominence of ulnar styloid

Swan neck deformity

2. Skin Changes - Palmar Erythema (It helps me remember and wont forget. I appreciate that palmar erythema is not skin changes) Redness

3. Scar - Carpal Tunnel Syndrome Scar. I just realised it is on the palm area near wrist quite distally not on the wrist where we take ABG.

4. Swelling - Spindling of the PIP join, loss of valley at the knuckles - MCP joint (can ask the patient to make a fist)

Spindling of proximal interphalangeal joints

5. Muscle wasting - check the thenar eminence for wasting, comparing side by side. And also dupuytren's contracture.

6. Look at the Nails. Pitting and Onycholyis = psoriasis.

Also, ask the patient to make a fist to check MCP (as stated above), looking for triggering when he/she release the fist sign of tenosynovitis as well as diabetes and RA, and how much the patient can flex the fingers.

Also, ask the patient to make a praying position to look for again the boutoniere's or fixed flexion deformity

Check elbow and behind the ear. For RA nodes or psoriatic plaque. Ear also might have tophi for gout.

Next, FEEL and MOVE

Temperature of wrist and MCP. Takkan wanna feel each joints meh.

And squeeze for tenderness, each and every joint. I would do from distal towards proximal.

While squeezing, move it, flex and extend.

and then do the function thingy.

1. Squeeze ur two fingers. Assessing grip.

2. Pinch testing precision.

3. Piano movement for fine finger movement.

4. Pick up objects or do and undo button. To assess precision and hand function.

and then the books said do some arm function, quickly.

So stretch the whole arm out. bend the elbow. turning taps. Cock wrist up and down. Hands behind head and hands doing bra.

DONE.

I like the way they suggest presenting the findings:

There is a symmetrical, deforming polyarthropathy of the small joints of the hands in a rheumatoid pattern. The differentials would be RA and psoriatic arthropathy.

And as you can see from the picture, I think I have RA.

Dear Diary

Where are the wings you promised me Mr Bull? Will I die drinking 2 cans of red bull in the space of 10 mins?

I have a problem.

Big one.

I cant seem to wake up in the morning.

WHY?

And whenever I tried to study and revise, I need to read at least all the news on BBC before proceed on to The Star online and then a few blogs.

WHY?

Please lah ANG.

Nearing the finishing line.

WIth the right state mind.

Forgot what brand is that already.

Why I chose Medicine?

ps: Congrats Mr Cameron. 43 years old, the Prime Minister of Great Britain.

In our great nation of Malaysia, 43 years old should be around the level of Ketua PeMUDA.

Be PM when you are about to retire. What a great pension route planned.

Post 9: Mitral Stenosis

I am praying for a Cardio case for my OSCE.

But at the same time I hope it is not Mitral Stenosis though.

To date, I have yet to catch a murmur, and get it right. Usually a pansystolic would be heard as ejection systolic, and vice versa. Diastolic murmur doesnt exist in my CN8.

Anyways; after examine the patient in the station, paling best if can really get all the signs.

This patient of mine has a malar flush on his face on general inspection, and irregularly irregular pulse on examination. On examination of the chest, he has a left submammary scar. Apex beat is tapping in nature, not displaced. On auscultation, the first heart sound is very loud, with a soft second heart sound, and a rumbling, mid diastolic murmur heard. It is of 4/6 intensity, loudest at the apex, accentuated by the patient lying on his left and holding his breath in expiration. There is no radiation noted. There is no signs of infective endocarditis noted on my examination, and no signs of right ventricular failure. These findings are in keeping with my diagnosis of mitral stenosis.

A few clues I found helpful for myself:

1. Apex beat.

It is always very hard to remember or even understand apex beat. My problem is firstly, where is the apex beat? I dont know how to count ribs also. But i usually pretend to count and just show that is in 5th intercostal space mid clavicular line. So how to remember the nature of apex beat?

Apex Beat. - I only remember 4 types of characters. Heaving, Thrusting, Tapping and Double Impulse.

Heaving - H = Hypertension = Pressure overload. So I remember things that can give pressure overload. So it is aortic stenosis, HOCM, systemic hypertension. Ya, thats it lo. And because it is pressure, it causes hypertrophy which is NOT dilation. So no displacement!

HEAVING= Pressure.

Thrusting - Because H - hypertension, maka this T must be for volume overload. So things that can cause volume overload. For the sake of murmur, i only remember it together with valve regurgitation, coz more blood in the ventricle mah. Logic? And more blood, need more space, dilation loh. So it is aortic regurg and mitral regurg gives thrusting apex beat.

THRUSTING = volume = dilation = displaced.

If you say heaving apex beat and displaced = you heading shit liau.

And the last two is easy. Double beat = HOCM, wont have a chance to feel that case at all. i hope.

TAPPING = loud first heart sound. = Mitral stenosis, coz thats the last murmur we had left with.

2. Opening Snap and rumbling shit.

I think, thank goodness, i am using a cheap stets. Chance of hearing a rumbling shit is very small, so just ignore that part of the knowledge. Opening snap, u got to listen damn careful, and i have never heard anyway.

A good point to know, if asked, how to quantify the severity, it would be the duration of the rumbling, and the duration between opening snap and second heart sound.

3. I'll talk about AF later. I think AF is very likely to be asked if they have a Mitral stenosis case. Too many parts to explore.

Study la read blog read blog.

Kungfulogy

I just realised, actually, a lot of things in medicine are kungfus.

If you know the ancient china kungfu master, you know the crouching tiger hidden punggung etc etc...

they kan pass down their kungfu in hard copies, rare collections and high level kungfu usually got one copy only available.

And usually Blue in color.

with the title written on the right hand side only.

The rest of the book are all pictures of what posture they should adapt. and usually there are some captions written, usually in form of sajak.

If you flip faster then you can see the combo movements, the very basic idea where the science of animation came to this world.

Lebih kurang la...the things I am studying now.

Kungfu Genggaman Panda Merah

Kungfu jejari sakti maut

Kame-Hame Hahahhahahaa....

Study la...babi 20 hari lagi. SHITYE

Post 8: Cracking the EYE!

I hate you EYE!

Spent whole day to understand this eye thingy. ARGH.

Internuclear Opthalmoplegia or ataxic nystagmus. All the same.

Essentially, in this babi, the problem is HORIZONTAL gazing.

IE: the Cranial Nerve 3 and contralateral 6. I dun care, thats how i remember it. To look to the right, i need right CN6 - Lateral rectus, left CN3 - Medial rectus.

And the two nuclei are connected by Medial Longitudinal Bundle.

And that connection, the Medial Longitudinal Bundle, is the crux of the pathology.

So, when you have INternuclear Opthalmoplegia, the affected side/eye cannot gaze INward.

If you ask the patient to look to his left, so now his left eye would gaze outward, and right eye would gaze inward.

But if the lesion is on his right, his right eye is affected, it cannot gaze inward.

SO you have a right eye stays at the middle.

And your left eye, normal unaffected left eye, due to your right eye staring at the middle, it has to come to middle to align with it, but ur head is asking it to go outward, therefore..NYSTAGMUS!

But if you ask the patient to look to his right, the affected eye has no problem to look outward, and the unaffected eye has no problem to look inward as normal.

And there's no problem for affected eyes to gaze inward if you are doing accomodation test.

And, If the affected eye cannot look outward as well, you have this syndrome, called...the One-and-half-syndrome. BODO PUNYA NAMA.

So in conclusion, Affected Side punya eye, stays in the middle, when patient try to gaze inward, unaffected eye nystagmus.

Causes of this Medial Longitudinal Buddle defect or Internuclear Opthalmoplegia or Atazic nystagmus - bapak ar...from now onwards is called the Ang's Palsy, senang kan! babi betul. EMO SIAL.

Answer: If affect one eye - Stroke. If affect two eyes - usually MS.

Post 7: GCS

Really need to nail this!!! ARGH!

EMV

E - 4 Spontaneous, 3 To speech, 2 To pain, 1 NIL

M - 6 Obeys command , 5 localising pain, 4 withrawal to pain, 3 abnormal flex, 2 abnormal extension, 1 NIL

V - 5 Spontaneous, 4 Confused conver, 3 Words, 2 Sounds, 1 NIL

ARGH!! Always cannot get it out!

Post 6: 2222

I missed the countdown showing 22day 22 hours 22 minutes 22 sec which my fellow blogger friend managed to capture a printscreen.

A rare sight I must say. haha

But is so special about this 2222 2222?

It is a crash call!!! OMG! Crash Call for us to study even harder now and stop panicking!

Dial 2222 is to call for immediate support because someone is about to die! (Or in my public health department in the university, 2222 is the number to dial for fire!)

So lets talk abt Cardiac Resus! (Random? hehe)

I am shit at resus actually. Failed both resus stations in OSCE and OSCA

So, I tried to read from the edinburgh's emergency bible:

Tiba tiba Ahpek pengsan!

D - Danger? Check the safety around the surroundings.

R - Response? Bos, u ok bos? Bos, u ok bos?

No response - Shout TORONG!!

A - Airway: Open and secure airway. Head Tilt and Chin Lift normally, or Jaw Thrust in cases suspecting cervical trauma. Jaw thrust is actually harder than I used to think.

B - Breathing: Is the ahpek breathing himself with the airway open? Look (Chest movement), Listen and Feel (to the air flow out of ahpek's mouth) I think assess that for 10 sec.

Not breathing? - any kaypohchee around? Ask the kpc to call 2222. If not, storm to the nearest phone to call 2222. Leave ah pek alone, dun care. Calling help is much more important.

Of coz dont go buy roti yet, come back and give CPR: 30 Compression (100/min, straight arm and deep 1/3? cant remember liau roughly la) and 2 kisses.

Continue assess for signs of life, mainly breathing? Dont stop pressing and kissing.

Dont stop. Until you kenot take it already, or help team of 2222 arrived. or fella byebye.

Then: ALS already.

So still doing ABC: but in a team!

Airway: probably want to put in a oropharynx or nasopharynx to secure airway. Or even ETT terus. Suction prn.

Breathing: Attach breathing mask, with breathing reservoir bag, pressing 1/3 of the bag. each two times after 30 compressions.

Circulation: Continue checking. Pulse? Take some bloods off to do test. ABG.

Once the AED is attached:

Assessed rhythm: If VF or Pulseless VT - Shock samadia. ALL CLEAR 150 biphasic.

CPR back. 2 mins. Means 30 presses, 2 kisses. kira sampai 8 kisses i think. thats 2 mins rite...? 100 compressions a minute, so 200 compressions in 2 mins...lebih kurang 4 cycles la..ya should be correct la. hahahaha. forgot liau.

Repeat ABC assessment and CPR at the same time.

Before third shock, give Adrenaline 1mg IV. Repeat every 3-5 min. (before the 5th shock, and 7th shock)

To make things even more complicated, Amiodarone 300mg IV before the 4th shock.

And always reassess ABC and investigate causes.

4H and 4T. Hypoxaemia, Hypothermia, Hypo-Hyperkalemia, Hypovolemia. Thromboembolism, Toxins, Tamponade, Tension pneumothorax.

Ohya, for the non shockable, ie PEA and Asystole - continue CPR and assess rhythm, check pads, check ABC etc. Adrenaline 1mg still the same, every 3-5 minutes ie alternate cycle. In asystole or brady PEA, give Atropine 3mg IV. and pacing lo.

Damn long post. But essentially, I always panicked in the station and fail the resus.

ARGH.

Kungfu Neighbour

It was a fine Sunday afternoon.

I was just about to go toilet and shit, before my flatmate, Wafi, came to my room and said; "Wei..come come...see this"

So I followed him to our living room, and looked out to the window...



The killer move is the Buddha Palm at 0.31.

To the master of kungfu, sorry if you are watching this. Dont come and kill me. We are interested to learn your kungfu.

OK. Study!

Post 5: Pleural Effusion

Today I examined someone who I thought might be an effusion. Not sure tho.

So, had a discussion about pleural effusion. Got into some confusions regarding the numbers and so, came back home, and reread Davidson;s and now decided to write whatever little i can remember.

So, Pleural effusion = fluid within the pleural space. If blood - hemothorax, if pus - empyema (complicating pneumnia, show finger clubbing, yeap kto)

We will talk about the causes later, presentations first.

Obviously the symptoms would be SOB, pleurisy...hmm..cant think of anything else.

Examination: I have to go through this in my mind so so many times, scared forget.

Hmm..would need to present like this:

Patient is dyspnoeic at rest, breathing air, and not cyanosed. Respiratory rate was 20 per minute. There was no evidence of digital clubbing, mediastinal shift (unless its damn big), or lymphadenopathy.

On inspection of the chest, there was a mark/scar/tube for chest drain. (I think it would be a few intercostal spaces below the upper border of the percussed dullness. Dont know where I get that from)

On palpation, chest expansion was reduced on the right side.

On percussion, the percussion note was dull (sorry, i wouldnt even trying to differentiate between stony and just dull...) at the right lower zone.

On auscultation, the breath sounds were reduced/diminished on the right lower zone. There is no added sound (can say pleural rub i supposed, but again, what is that? hehe. Also, there is this lawak says you can get bronchial breathing on top of the level of effusion, but again...hmmm?)

Vocal resonance was decreased as well on the right lower zone.

The differentials in keeping with findings of reduced expansion, dull percussion, reduced breath sounds and vocal resonance would be, pleural effusion.

Investigation:

CXR - Check the costophrenic angle for bluntness, and if large i think give whitish shadow all over the lungs. This test is not as good as a USS coz u need quite a large effusion to get the signs.

USS and CT.

Pleural Aspiration:

Nah, this is the part that gets me into confusion.

Aspiration of the fluid will help us in finding the underlying cause of the effusion.

1. Appearance - if got blood, malignancy lo. if with yellowish stuffs, pus means empyema lo.

2. Cytology - I like this posh word. Essentially, we are looking at the concentration of the protein in the fluid. Anything above 30 would be exudate, and lower than that would be transudate.

Now, there is thing called the Light's Criteria, which underlines 3 things. If the fluid protein to serum protein ratio is more than 0.5 that would be exudate. If the fluid LDH to serum LDH ratio is more than 0.6 , that would be exudate as well. And lastly, if the fluid LDH is more than 2/3 of the upper limit of normal serum LDH, that would be exudate as well.

3. Culture: For bacteria if found to be murky?

Causes:

Transudate: <30 - Hypoproteinaemia or increase venous pressure.

So, it would be liver failure, nephrotic syndrome, or congestive heart failure or constrictive pericarditis.

Exudate: >30 or any of the 3 Light's (0.5, 0.6 and 2/3)

It would be Infection - pneumonia and TB, Infarction - PE, Inflammation - SLE, RA, Malignancy - bronchogenic carcinoma or mesothioloma.

Treatment:
1. Underlyign cause.
2. Drainage - if symptomatic, slowly less than 2L da day.
3. Use some agents to stick the two layers between the pleural cavity.
4. Surgery.
5. Recheck underlying cause. And treat it.

DOnt think would get that in osce anyways.

Finals 4: VTE ( DVT and PE)

I find this mneumonic extremly helpful, for the risk factors of VTE.

EMBOLISM

E - Ex VTE

M - Malignancy

B - Baby? - Pregnant?

O - Oestrogen - Patients on OCP or HRT?

L - Large - Obesity

I - Immune Diseases - Antiphospholipids? or Inborn Congenital Disease - Thrombophilia - protein C or S deficiency?

S - Surgery recently?

M - Mobilization

Lets talk about DVT.

Use Well's score to stratify the risk of having a DVT/PE, and most of the criteria in the scoring are within the mnemonic above. Plus the symptoms of DVT.

Local - Leg pain? Calf tenderness? Erythema? Swelling? Warmth?

Systemic - Fever, Rigors etc.

Investigations:

D-dimers - Rubbish. Also elevated in pregnancy, cancer, surgery, etc.
A positive D dimer with high Well's = diagnosis - treat as DVT plus do a US to confirm.

A negative test with a high Well's score means bring back the patient in a week's time to do US to catch DVT.

A negative test with low Well's score means adios patient.

A positive test with low Well's...i dunno.

Treatment?

Low Molecular Weight Heparin - Enoxaparin - 1.5mg/kg/24 hrs SC. and start warfarin immediately, aiming INR 2-3, for 3 months normally, and 6 months post surgery. Stop enoxaparin when u hit the therapeutic INR and after at least 2 days coz warfarin is prothrombotic in the first 2 days.

Vena Cava filters. Inferior Vena Cava.

Prevention better than cure.

Happy Birthday!

Time flies.

If you know this dude, I am having 8 markus' memorial books with me - A Shooting Star, pls let me know if you would like to have one. I'll post to you.

Ok. Back to work!

If Pass...

Hi Choon,

Can I just check whether you are taking up Foundation posts in the UK in Aug (if so, I will require a Transfer of Information form to be completed) or if, in fact, you are returning home.

Many thanks.

Carole

Carole Tomlinson
Examinations Secretary/
Administrator for F1 Doctors
College of Medicine and Veterinary Medicine,
Academic Administration,
The University of Edinburgh,
Room SU204/205, The Chancellor's Building,
Little France, Edinburgh EH16 4SB
Tel: 0131 242 6377
Fax: 0131 242 6479

-----------------------------------

Dear Carole,

Thanks for the email, I am not doing the FY training in the UK. I have a bond to serve back home for the training post. Have a nice day!

Regards;
Choon

Adult!

I have decided to make this adult content.

AHAHHAHAHAH

The effect of boredom!!

Hmm...

Nah adult content!

Long

Imagine...

You were somewhere doing something...

running...or driving...or eating...

And then...POM!!!

...

...

You dont remember what happened...

All you remembered was that you think you were somehow lying down on a bed...

And voices talking to your ear every now and then...

You just cant open your eyes...

Or move...

You cant feel a thing...

And

You dont really know how long time had passed...

And then...

One day...

You heard someone said...

You have been lying down, comatose there for five years...

Oh!!! 5 Years??

What! That long?

and then...

Somehow...

One fine day...

You regained consciousness...

You opened your eyes...

and then there's a kind yet unfamiliar face were right beside you...

Very chun...

Holding your hand...

With tears rolling down her eyes..

And you thought...

Wow...I got a chun chix wife/girlfriend...

and then she said...

Wellcome back!

You have a finals to pass in 30 days.

...

...

...

Thats exactly what I felt.

Right NOW.

FML

Finals Post 3: Presentations of Cushingoid

Head downwards.

1. Head - Moon facies, acne, plethora, hirsutism, thin hair, Cataract.

2. Body - Truncal obesity, kyphosis, striae, muscle wasting and aches, thin skin, bruisings, puffy legs

3. Check for hypertension, Dexa for osteoporosis, OGTT for Diabetes mellitus, Refer to opthalmo for cataract, appropriate pyschiatry assessment for insomia, depression and psychosis, check peptic ulcer if there's abdo pain, avoid vaccinations as am immunosuppressed.

Other mneumonics - I AM CUSHINGOIDS

Immunosuppressed
Acne
Moonfacies, Muscle wasting, muscle aches
Central Obesity, Cataracts
Ulcer, Peptic
Hirsutism, Hypertension, Hair thinning
Insomia
Nuts - psychosis
Glycosuria, Diabetes
Osteoporosis, Oedema
Infection
Depress
Skin thining

Hmmm...

Finals Post 2 - Malabsorption

Malabsorption - Failure to absorb nutrients or final products from digestion process

Causes: Intraluminal, Mucosal, Post Mucosal.

1. Intraluminal - Structure or Enzyme def for absorption

A - Structure: Small bowel carcinoma, Ileal Crohns, err...etc. hehee.
B - Enzymes: Bile - Liver pathology: obstruction, hepatitis, biliary cholangitis.. Pancreatic - pancreatic carcinoma, chronic pancreatitis, CF....

2. Mucosal: lack of functional small bowel to absorption.

Small bowel syndrome - ileal resection due to Crohns or damaged due to pathology such as celiac disease....er...haha..thats the only small bowel mucosal patho i know due to a pathology i remember as villous atrophy i think.

3. Post mucosal: Pathology with the lymphatics absorption to system

Lymphatics circulation obstructions in some lyphomas, etc...heheheh...cannot remember la shit.

Presentation:

As per cause. Generally if u have a malabsorption, u have systemic symptoms like weight loss, malaise, tiredness...all the not enough food thing la. Plus all the vitamins or nutrients deficiencies symptoms.

Other symptoms, which i like, and i can remember is because or orlistat, a drug used by fatties. That drug causes the malabroption of fat, so u get Steatorrhea - shit float and damn smelly.

Hmm..actually i just realised I cant remmeber much liau. Hmmm...

Investigations:

So we do all the basic investigations:

Bloods, Imaging and Special Tests.

I think the most common causes would celiac disease and pancreatitis. So do those tests to rule these two out first. For celiac, an autoimmune, so can do antibodies, antigliadin or something like dat, then enteroscopy with biopsy. Then for pancreatitis, might need to some levels of enzymes, and then imaging using ultrasound first or MRCP.

Management:

As per cause. Give nutrients supplements for any deficiency and removal for any structural abnormalities.

Finals Post 1 - Dysphagia

Dysphagia = difficulty in swallowing.

Causes: Mechanical, Motility and Others.

1. Mechanical - Benign , malignant, extrinsic pressure, pouch.

A. Benign - Oesophageal web ring (dunno, but i remembered because its so funny...web ring...), peptic stricture.

B. Malignant - Cancers of any 3 structures: Pharyngeal, oesophageal, and stomach

C. Extrinsic - Mass from nearby structures: Lung cancer, mediastinal - lymphnodes, lymphoma, aortic aneuryms, goitre...hmm..

D. Pharygeal pouch - food stuck in the blardy bag.

2. Motility - Neuro vs Non Neuro

Neuro: Bulbar palsy, stroke, GBS, MG,

Non: Systemic Sclerosis: CREST syndrome..just learned today, Achalasia (from malaysia), Chagas disease - like this.

3. Others - Food stuck at the stricture, psychiatric - globus thing. Oesophagitis caused by infection of candida.

Symptoms: Ask further info: pain? solid? liquid? Onset? Site? Getting better? PMH? etc etc etc. and all the GI questions la. From head down to asshole. Any vomiting, nausea? Mouth ulers? Waterbrash? Heartburn? Dyspepsia? Distension? Bowel habit? Jaundice? Shit blood? Vomit blood? what else? itu saja kot.

Signs - Cancer systemic signs. Weight loss, Anemia, Cachexic, Night sweats, erm....itu saja kot. And other signs of the differentials above.

Investigation:

1. Bloods: FBC (anaemia), U and E's (hydration), ESR (Any inflam? disease)...erm...itu saja kot.

2. Imaging: CXR. Barium. Upper GI endoscopy. Dx, biopsy and Rx.

3. Special test: Erm....tadak kot.

Management:

1. Underlying cause.

2. Endoscopy: Dilate the stricture.

2. Medical and surgical management as per cause.

Hooray. Spent sometime blogging...but feel good coz macam studying...