End Posting 9th term OBG

Erm, lambatnya update. 

Sorry, malas sungguh. Tapi, mengenangkan ini akan membantuku di kala nak dekat finals nanti, ku laratkan jugak. 

Kali ni dapat viva dengan cekgu old-school. The HOD. A very quiet male doctor. The only  old Beetle surrounded by Flowers in the OBG garden. Heheh. I wonder why they made him the Head of Department. Maybe he is guy? An d female can't take the post because they are too emotional and not as rational as the male colleagues when put under pressure? People keep saying that it is really distressing being in this specialty.

I got this  combination of worst case scenario during postings. A combination of many differential diagnosis and topics in both Gynaecology and Obstetrics. 

I think it is better to present the Obstetric case first as the questions are quite predictable.

Viva End Posting (Obstetrics)

Summary : 33 year old, G2P1L1  at 38 weeks 5 days of gestational age, with previous lower section caeserean section and overt diabetis melitus with single fetus, cephalic presentation and mobile head.

• Urine pregnancy test. Other method of confirming pregnancy.
• Folic Acid. Why it is given?
• History of fever with rash. How Rubella is manifested?
• Tetanus toxoid. Why it is given?
• History of pedal oedema(pitting type). Differential diagnosis of oedema in pregnancy.
• History of previous LSCS indicateed by Cephalo pelvic disproportion. Was started insulin after delivery. Stopped after 2 month. 
• What is Lower section caesearean section? Describe the incision made. 
• Past history of Diabetes melitus since 1 year.On Medication.
• On Examination: thyroid enlarged
• Inspection: overdistended abdomen, globular shape. Falnks full.Horizontal scar present 3cm above symphysis pubis measuring 13cm wide. No keloid, non tender scar.
• Palpation:

            Fundal grip: Soft irregular, broad mass suggestive of breach.

            Lateral grip: Right- Continuos uniform resistance with smooth hard surface                                             suggestive of spine.

                                 Left: Small irregular Knob like structures, suggestive of limb                                          buds.

          1st Pelvic grip: Ballotable mass, non enggaged.

          2nd pelvic grip : Fingers converged, not enggaged.

• Auscultation: Fetal  heart sound not heard. Why?

Viva End Posting(Gynaecology)

Summary: 53 year old(menopause) P3L3 with chronic cervicitis/vaginitis/endometrial polyp/adenomyosis/malignancy of cervix/endometrium

Chief complaints : History of passage of white discharge x 3 month

                              History of backache and abdominal pain x 1 month

                              H/o bleeding per vagina x 1 month 

• DDx of discharge per vagina. Colour? 
• What is clue cells?
• DDx of painful lower abdomen.
• DDx of mass in the lower abdomen.
• DDx of bleeding per vagina in menopausal woman.
• What is PID? Definition.

Lesson learnt: 

-Bring ALL books related. Even the note books. 

-Fight and dont give till the end. Open your mouth and speak clearly and loudly These people are getting old. Make their job easier. Dont say a word if you dont know anything. Just shake your head and ZIP your mouth.

End posting 8th term Medicine Unit 5

Alhamdulillah.
Segala puji bagi Allah yang memegang hati dan takdir manusia. Sesungguhnya, pencapaian dan pujian hari ini bukanlah milik mutlak bagi diri. Tetapi, milik Tuhan yang meminjamkan kekuatan untuk belajar.Yang menjadikan ujian itu setimpal dengan keupayaan diri. Saya mampu sebenarnya.

Tapi, hakikat manusia itu lemah dan tidak sempurna. Sesempurna manapun persiapan diri, masih ada kesilapan dan khilaf yang berlaku. Ye, saya juga manusia biasa. Buat silap dan tidaklah mahu berbangga dengan kesilapan itu... InsyaAllah, akan aku baiki diri dan tidak mengulangi kesalahan itu. Ya Allah, jauhkanlah aku daripada menzalimi diri sendiri dan pesakit-pesakitku kelak.

Jika aku jatuh dan berlemah hati, berilah aku kekuatan untuk kembali padaMu. Jadikan aku hamba yang bergantung harap sepenuhnya padaMu. Jadikan aku hamba yang bersangka baik dengan janjiMu.

Segala pujian di langit dan di bumi hanya padaMu.

Alhamdulillah.


Do not repeat this mistske.
B/p values never in odd number! Only 2mm calibration.
Dont forget history n sign of meningeal irritation.
Dont forget to write impression at the end of your case sheet.

p/s: Dr. S of unit 5 medicine said, "Good" at the end of case presentation.

Today is my first ever CNS examination.

Summary: Middle aged male pt came with h/o left sided weakness 5days back with history of inability to sit up from bed, drowsiness and past history of hypertension, smoking and alcohol consumption.

Impression: Cerebral thromboembolic stroke of left hemiplegia with lesion at level of internal capsule suggested by generalised motor deficit with sparing of facial nerve palsy.
 

2nd sessional Final Year Mbbs

I have to stay strong.

I have to.

InsyaAllah...

Oh, you should.

Because,

Life is short.

Aim high dear,

Aim to shoot the moon,

At least,

When you fall,

You'll land among the stars...

Surgery Note

Hernia 

• Herniotomy 
• Herniorhaphy-approximate the inferior border inguinal ligament 
• Hernioplasty 
• Incisional hernia  
• Children inguinal hernia-rx:herniotomy, coz no post wall 
• Must know-anatomy of inguinal ligament. 
• Pure tissue repair 
• Mesh,sutures used 

Varicose vein  

• Tests 
• Hemorrhage  
• Complications  
• Investigation 
• Treatments 

Carcinoma of stomach 

• 
  

Appendicitis 

• Left iliac fossa pain radiating to right aggravated on hip flexion n adduction 

Gall Bladder palpable  

• Troisiers law, in jundiced pt, any palpable gallbladder is not due to stones. 

Jaundice  

• Obstructive jaundice 
• Achylorius jaundice 
• Typhoid Mary : enteric fever 
• Back pressure 
• Surgical jaundice 
• Congenital hyperbilirubinemia 
• Splenectomy 
• ERCP 
• Charcot's Law:  
•  itching 
• Parts of CHD : supra,retro.inferior,intra 

Umbilical hernia 

• Infant: no surgery,self limiting 
• Linea alba,  
• Vertical vs transverse incision  
• Induce hernia, child n adult. Cough n cry baby 

Colon 

• Choletectomy 
• Choletotomy 
• Valvulos colon 
• Haustra 
• Sigmoid colon,maize 
• Congenital mega colon 
• Hiershsprung disease,ganglia... 

Epigastric Hernia 

• Many multiple defect 
• Weakness over the fascia 
• Linea alba is further defect 
• Mesh sutured around,the defect 
• Below or above the umbilicus 
• Paraumbilical vs umbilical hernia 

End posting 9th term Paediatrics

Arghhh...

This time i didn't do well. I was told to read more. This is not enough. Yeah, i didn't come prepared. Not 100% prepared.

I left my notes and books at home.I shouldn't do that next time.
Geram geram geram....
Geram sebab kes ni dah banyak kali aku present. Pastu, still tak confident nak jawab apa cikgu tanya.

I've repeated my answer soo many times and yet she didn't understand. Maybe i spoke too soft? Too slow?Mumbled? My accent? Okey, i admit it was my fault... *sigh*

My patient this time is super cooperative and playfull but i screw things up. I knew it was my fault...

There is no next time. Because next time it would be real. I hope i will be better next time.

Viva Questions

• What is nephrotic syndrome? Give proper definition.
• What is remission? What is relapse?
• Treatment for first time episode of nephrotic syndrome.
• Rx for relapse?
• Rx for remission
• Rx for steroid dependance?
• Method of assessing organomegaly in presence of ascites.
• Child draw a stick man. Give the age of the child.
• Development - motor,fine,social,personal of 7 year old.

Actually i realised that this kid had supraclavicular pulsations and elevated JVP of which i didn't say because it is too risky and way beyond my expertise. So, i stated only the OBVIOUS and most common findings in nephrotic syndrome.

He has fast breathing >30cycles/min, tense, distended abdomen, positive fluid thrill, positive shifting dullness. Just not confident enough to mention that the kid had signs of hydrothorax. No hydrocoele. There is puffiness of the eyes, abdomen distention and pedal edema of pitting type. No organomegaly. No hematuria. No fever. No artralgia. Nails have white bands, pale palm. He had history of hypertension and maybe that's why he had elevated JVP.(well it looks like it)...(-__-)" im not sure....

Next time, be sure.Be confident. You will get this right next time.

Aminn.

 

Rambles...

What is the point of attending posting if there is no one teaching us something?

Now, i finally get it.

Even though there are no people like Malaysian teachers who spoon feed us to succeed in big big examinations like PMR and SPM.Here, we have to totally depend on ourselves.

Depend on our own interest and passion towards medicine. Depend on our ability to make friends and gain help from them in times of need as they were our only support system.

They wont care about you coming to class or not or is passing in exam's. They have patients to worry about. All they care is your attention for them during their classes.

The point of such system is that they require us to be INDEPENDENT and strive for our own DREAMS PASSION.

I may have been too comfortable in tuition and mentor mentee system that i failed many of my exams at the lack of such system here and was aggravated by unpolished independent learning skills.

Or maybe, it was just about the lack of my own will to SUCCEED has faded over the time. Degraded and demotivated by the so unsupportive education system, lack of inspiring teachers, lack of little notes and motivation camps that we used to have everytime the exams is around the corner, really rude or lack of discipline everywhere with no one to catch or give punishment to students. If there is any teachers willing to care, they have remind those students countless of times of their behavior. I was studying for the sake of my own guilt. Guilty for a lot of things. I didn't study for the sake of LOVE of KNOWLEDGE.

Why is it so difficult to LOVE something ?

What happened to the girl who loved to study for her own sake ?

Posting or classes are more important than studying alone in the cozy room and in the end falling asleep and not remembering what has been read. I too, faced the same dilemma.

Class or self study? Which one is better?

I learned it the hard way that what ever happens,or how bad the class was or the teaching was, class and posting during day times is precious and can never be replaced by notes we made by reading books.

Reading and going to classes is like going to charted ocean. Not reading and going to postings is like sailing an uncharted water. Not reading and not going to class is like not going to the sea at all!

Knowledge makes us prepared of what is happening,but experience makes us CONFIDENT in upcoming situations. Be it a predictable ones or the unpredictable ones.

So, attend your classes and posting no matter how boring it is. Because you will never know what will you NEED from classes that has been lost...
 

The Boy who had Guillain-Barre Syndrome

Post Mortem Exam : Day 3

Yeah i know.

I'm supposed to write this few days back. But i was too emotional to do so. I've been really moody and sensitive since that last practical exam. Traumatized i would say.

2 cases, each 40 marks with instruments.

We were supposed to come at 8 am. Luckily i came  30 minutes early and get ample time to finish history taking and case examination. There are a lot of confusions as that was the only case i took since forever. It had been a very long time since i took and Opthal case.

I just want to tell that the first case presentation went well. However, the second one was a disaster. i couldn't even answer a basic most simple question which brought me to panic attack as well as inability to hold my tears right after i finish my exams. Yeah, i didn't cry in front of those people. I cried for my stupid mistake in front of Allah, the one who knows whats in our hearts. I rather not say anything when i am feeling bad or weepy.I just cry and just say what i want to say in front of Him during solah.


I made a mistake where i mistook 10 years of decrease of vision which was aggravated since last 1 month with loss of vision.

It is not SUDDEN, but GRADUAL onset of loss of vision which contribute to my failure to diagnose the case.

The moral of the day is : 1 month is NOT SUDDEN ONSET, but rather a GRADUAL ONSET.It may started suddenly and progressed for 1 month duration. 

Among questions asked:

-What is uniocular movement
-causes of gradual loss of vision
-complication of pseudophakia
-


 1st case: Right Nebula on the inferior-lateral margin of the cornea surface was right. They did asked about treatment, management.(keratoplasty,soft contact lenses, tattooing, peripheral iridectomy)


2nd case: Pseudophakia. Yup, i was wrong. I didn't see the whole picture although i've given it a thought about the man having a cataract removal few days back. But, because i was SOO FOCUSED ON SUDDEN ONSET LOSS OF VISION, i missdiagnosed my case as anterior uveitis wtih scleritis following surgery.

She also said that,

"You don't know ANYTHING!"

With that utterly disappointing look on her face.

Well, it was bad for the second case presentation compared to the first one. I was given compliment and said it was good. Two different aura in two different case.

That night i studied all the theory parts and out weighs the practicals part which was the instruments and probable cases. I didn't think straight and was so obsessed with theory part and sacrificing the score-marks on instruments and diagnosis.Argh, they didn't even bother to do a theory viva unlike community medicine as if they already given up on us, the reapeaters. Although, this is my first time taking this exam, i think i did okay.

When people start asking hows your exams? My answer would be, OKAY. Because i want it to be okay. I did okay. It will be okay.

It is not GOOd or not FINE.

 Good means you did extremely good and you are confident enough to say you will pass with flying colours.

Fine means that you did terribly but hoping that you actually get a different outcome.

Okay means it is in the middle. Not to positive. Not too negative. Just prepare ourselves for the worst case scenario.

I promise my self to be better. Better at managing my time during exams and control the urge to sleep. Sleep freshly. Use time wisely. Prepare for the worst. THink simple and basic. Schedule your priority.

Post Mortem Exam 3rd Year : Day 2

Community Medicine

I slept only for 2 hours. If i'm not mistaken. But, i'm glad i had finished whatever target that i want to achieve within one day of studying. More than 70 slides spotters, epidemiological cases, exercises on statistics and so on.  I didn't read the theory part because i am depending on what i have read last two weeks during my theory exams. Anyways, i've got plenty of  time to study while waiting for others to finish their viva. I'm somewhat contented of becoming among the last in a row. Any exams will give that extra time to study and gained something from the ones who have the honour to answer first.

So far, i think i did good. Alhamdulillah.

8.30 am- Went to Y Hospital. Waited at lobby. Said on third floor. Went up by foot. Saw no one there. Text my friend, said its not in hospital. Fast paced walk to college building. Climbed three floors before seeing the others. Waited  while sweating profusely.

9.00am- We sat and waited. A chubby looking invigilator came with answer sheets. We filled in our details. 3 sets of papers were given. One for Medico social case, epidemiological case, and spotters.45 minutes were given to answer epidemiological case. I did okay. Forgot the IMR,MMR,CBR values but it was okay. Then, we had spotters. 1 half minutes for each spotter. I answered all. Alhamdulillah. Then, we were told to pick a random paper with patients name and department. I was the first one to pick and i chose the paper which was thrown out of its group. Alhamdulillah again i got paediatric case. Razika,14 year old. We were told to get back to the hall by 11.40am.Owh, plenty of time to take case. :)

10.45am- Rushed to the  hospital straight to 8th floor. Climb becaused waiting for the lift took so much time. Again, sweating profusely upon arriving the deparment. The kid looked flustered and giggled a bit when she saw sweat dripping from my forehead. I looked aroud and there is no one to help me. So i did the examinations first making sure nothing was left. Yes, i did learnt my lesson yesterday. No findings because she was healthy and was about to get discharged. I took  the history by my self even though there is language barrier. I'm thankful because the kid was able to speak little english and i was able to memorize little Kannada.we complement each other.Ngee. (^_^) So, i scribbled on some A$ paper and rushed to the hall 3 minutes away from the hospital. Again, walking from 8th floor down to the third floor up. Arrived with sweating again. Searched a seat directly under a fan. Wrote the case in the answer paper. was told to shift to lecture hall 5. It has air conditioning. Alhamdulillah, i need it so much. Allah, your blessing never end.

11.40am- Case presentation started. I was the last to go. I had a female examiner and she didn't ask much. Only Investigations and treatment of malaria. Any variations in fever grades...She asked why not typhoid ? What differentiates between typhoid and malaria fever? What test to be done in typhoid? How to prevent typhoid?Then, she let me go. Alhamdulillah, it was clean and satisfacory.

1.00pm-Theory viva started. there three examiners altogether. I waited too long and managed to read the book. I just flipped through all the pages quickly as if i can read like Superman. Heheh...(-__-)"

Examiner 1 : Looked hard at the topics to be question and later he came up with ,

 What is sewage disposal types? I answered and he seemed satisfied although i hesitated a bit. Then, he asked "What is incineration?". I was bewildered but answered anyway. Then, the bell rang.

Examiner 2 : The female lady was there yawning. Already sleepy due to rain or maybe she is just so hungry.

Name some Polio Programs. What is Oral Polio vaccine? How does it transfer? What is Intensified Pulse Polio? How to prevent transmission?

Examiner 3 : Its my Head of the department in our college. First thing he asked was," how was your paper? You think you can pass this time?" I said, it was good and i think i can pass with a smile. Then he proceed with the questions. What caught me was his question about if given a choice to work in hospital or in PHC with same salary which one i would choose? I said, " Sir, i would love to go where i was needed. There is more self satisfaction. Anyways, i'm using peoples money to  study and its time for me to give back to community."He agreed and question of my intention so as to impress him by choosing helping the poor and needy. I clarified my intention and he smiled. Alhamdulillah, with that i was let go.

What is emporiatics? what is ergonomics? Which chapter is it? Define Primary health center. What is Multi Purpose worker? What is Mudeliar Committee?  

p/s: The theory part was so random. I t could be anything. Bye, gotta go break fasting. 

Post Mortem Exam : Day 1

ENT

• We were given two cases.
• Took the case for 15 minutes each.
• Did all the tests necessary before taking the help of translator for history taking.
• I did forgot to do few vital tasks.
• It was so haphazard and unsystematic at all.
• The case presentation was okay. Although i gave a different provisional diagnosis from others. The examiner says its ok, provided that i've given a solid strong reason for my opinion.
• The viva..hurm, i don't know what to say.
• Instruments? No need to say much. Just take what ever that i know and describe it. St Clair Thompson adenoid curette with guard was the one i chose without any thinking. Actually i chose that because i finished presenting a case related to it. He gave the the marks in front of me. i could care less. Pufft.
• So, i wrote provisional diagnosis as Hypertrophied Rhinitis with Sinusitis and Total perforation of the tympanic membrane of atticoantral type.
• I argued and gave reasons as why i did so, but unfortunately the diagnosis i gave was not perfect.
• It should be adenoiditis with sinusitis which usually present over early childhood and persisit for long time as causes nasal obstruction.
• The second case could be subtotal perforation( i can't really make out the annulus or margin, hence total perforation) because of the continuous discharge of the ear. I deduced it based on the fact that the patient had foul smelling discharge and total perforation with no ossicles left in the middle ear cavity.

1st Sessional

Alhamdulillah. 

Medicine  dan pediatrik shaja yang tidak stadi betul2. Perlu improve utk 2nd sessional. 

Just take it

Kalau dah kena marah masa kelas, just take it.

Bear it for the moment.

Widened your eyes,
Wrinkled your forehead,
Tightened your lips,
Look your teacher into their eyes
Then,nod to whatever they say.

Next time,

Be honest.

Just say,

"I don't know, sir."

"Sir,no idea."

Or you just geleng kepala.

This is what Kak Tasya called, ILMU TAK TAHU.

Don't dig your own grave.

Think carefully before saying anything.

Say sorry if you've spouted the wrong terminology.

 

Surgery 9th term: Bedside class

Today we have a class with Dr. RCP who is an excellent physician. So,they say. He has this chubby happy grandpa look-a-alike.

"You are terrific but sometimes terrible."

Sigh.

 "You read,but you don't read carefully."

Was what has been said by THE Dr AK. He was realy popular among students. I even got a lovely smack on my head with a roll of A4 paper.

Today, as i was standing beside Dr RCP, my mouth just keep spouting answers and he HAD TO STOP ME and remind me to give others the chance to answer.He was also like AK. He gave me a proper smack with his fist on my shoulder.

I think old people tend to do that. They can't help themselves. Its instinct and in nature of a parent as well as a teacher. They just care about us. At least someone do care teaching us something. Guide us where we should read. Or at least  to have an idea of what to read.

They know what we dont know and what we know. We know that they know what we dont know. Lalalala~~~


Finally,i can understand the pathogenesis of cholecystitis gall bladder and hepatomegaly.
He even taught how beautiful JAUNDICE development in many case scenario.

So, buckled up dear self.
That was your First class with him.

p/s: Dont be tempted to bunk anymore class. Even with finals exam are nearing,please spend 5 high quality hours daily on clinicals is far much better than studying alone in your room and not understanding anything.

OPERATION THEATRE : Adenocarcinoma of Colon

Patient present with severe abdominal pain.

Surgical treatment include right ascending colon removal,caecum,appendix and proximal part of ileum.

No hard questions asked.Just needed to palpate the specimen.

Must know the anatomy of colon,appendix and caecum.

Variation of appendix position.

Appendical artery.

Surgery 9th term: OPD day

It's raining heavily last night.

All my targeted topics to be read hadn't been accomplished due to a huge compulsion to sleep on the bed. I was getting rest for 10minutes and fortunately my housemate woke me up at 4am telling me
to switch off the lights. The inverter wont be able to supply enough energy to illuminate the room as she has an upcoming university BDS exam today. Luckily,i managed to finish few topics before going to sahur and Subuh prayer.

We were supposed to have OPD(Out Patient Department) today. In Malaysia it would be the clinics in the government hospital or maybe there were some like these in private hospitals.Nah,I've never been to one. So,i didn't know how private hospitals works.

It seemed that no one is willing to come outside today. Hence,we the medical students were left jobless in the demonstration room. With no one to supervise and teach some surgical knowledge, here i am updating this junk blog.

My two other unitmate was deeply immersed with Greys Anatomy season 7 on tablet. The other tried to find some kind of job or things to read.

Finally,
The one and only Dr in charge,with the minions male and female PGs and two junior interns joined him in the OPD and we final year medical student finally have something to observe from the side.

I can't forget the disappointed -hopeless face when we couldn't get the answers right. Plus, he was looking at me in the eyes.Me, the one and only Malaysian and a foreigner in the batch. I supposed he had a high expectation of me. Sigh....

I need to prove them that we somehow worthy to be here and its worthwhile to spend some time teaching us. Before he can teach us something, i need to read first.

Although,i am hugely tempted of bunking the posting for the sake of university exam which will be around the corner, i need the set my priority straight. Its not about prioritizing the schedule. Instead,its scheduling the priorities you had in you life.

As for me, 8-1pm daily is reserved for final year subjects. The rest of the day, i just have to utilise each second optimumly for my carried paper subjects.

Rabbuna Yusahhil.


Do pray for my istiqamah in studies.

Amin...
 

Surgery 101

Today we had an incisional hernia surgery observation. Most of us 9th term-ers, were excited and focused on the surgery.

Dr Rohan seemed to be immersed in teaching the new PG who recently won the seat for surgery post graduate. He seemed composed and silent. Not the bullying type of staff,hopefully.

Tonight,it rained again as usual and i had to go to OT as soon as finish drying my clothes on the rack and went off while hoping it wont be raining.

I have lots of things to read and endless topics to by heart. Not to mention about the hypochondrium pain I'm having since yesterday. I am so lazy to go and consult the doctor for this while we recently finished the gall bladder topic. It was just the cholecystitis(inflammation of the gall bladder).I know I'm intolerant to oily meals and never knew that one piece of fish fillet would make me suffer so much pain. I need to get my self together and bear the pain. Painkillers wont work for me and i have been feeling that anti-spasmodic drugs would make me hypotensive instead of relief of pain.

Had to go study now. Tata...