Community Medicine: The Practical That I Hate

That day, we have to prepare early as the bus will get going by 8.30 am. That night, i flipped through all the spotters written in the record and memorize each and every answer to the question. That night is the first night that we actually preparing for community medicine practical.So, i had no idea what to do, in detail. I had not made any mistakes before and there is no possible way that i could improve or not to make the same mistakes this time because we never had any exams for practicals before. I can't really blame them for NOT having a LOT of practical exams during sessional. I understood , that it is a tedious job for the department to prepare the materials and allocating houses etc for each student.Not to forget the answer sheet is way difficult for the lecturers to mark, you know the lecturers are very old, true story. Hmm, they say why bother coming to class to teach when students were not even  interested to listen what they say  in class. I've always sit in front and blurr all the time. I've always felt bored and unease with people whispering behind,some were reading novels, the noisy drill at the upper floor and with  teachers yelling in front.

I make this entry to remind myself what to do and what not to do for exam. So, i shall start from the beginning of community medicine practical revision.

Revision Time - I have to read the 66 spotters, 8 epidemiological exercises and  statistical exercise. It took for about 5 hours to complete revision as well as memorizing everything by heart. Next, flip through all topic related to field case. For example,maternal  infant morbidity, nutrition,housing, primary health center, environment and a little bit of other topics.

What to Bring - Bring stethoscope,scale, calculator, language book for kannada malayalam and a sheet of copied format of field case. 

Our practical exam consist of 5 part. The field visit to local area, case exercise, spotters, case viva and theory viva..

Field Visit-

The bus goes by 8.30 am. We are not supposed to take our record or bag to the field as it may be considered cheating. However, i just kept mine in my bag and carry it in bus. Well, all equipment needed is in there and i am reluctant to leave my lovely beloved new bag without proper supervision in college. Anyway, we arrived at the supposed area by 9 am. and began to go separate ways under lecturers guide to allocated houses. Each student got one house each. All students are required to take the cases independently without help. For international students and students who did not speak local languages, we were told that translators will be allocated for each student during final exam. But, for that day, there were no translators or lecturers to help us with the translation and thus, i had to figure out everything myself. 

 I got an infant case in a house with family of 13 members. We were given 45 minit to finish the family case and the clinical case. I am so lucky because that day, because they can speak Kannada which is very easy to learn and understand. Plus, the family had a card that list all the members in the family. The card states everything i needed.but, the real problem is i had no idea what is it because it is written in Kannada. Thank God, the card had pictures and numbers on them and i simply 'cook' the rest info on the sheet. The vital info such as name,age,occupation, relation, education level,house environment  and income can be easily acquired. The real trouble is when i needed to figure out the nutrition and family planning. If only i bring the language manual book, i think it would be a lot easier to deal with them. I know  my sheet was totally messed up because it was my first time writing it. I forgot the nutrition table and the answer sheet looked horrible and unsystematic. I managed to finish the interview, physical examination of the infant and write the sheet. When i finished, we went to college at 10am. Attendance were taken in the bus  and the case sheets were given to respective guide lecturers.

Case Exercise

This exercise consist of 2 epidemiological case and one statistic case both to be written in separate answer sheet. The limit to answer the question is 40 minutes. From 20 students in the exam hall, i could see that everyone is trying their best to answer as fast and as they could. Some are like me, trying to figure out what to do without a calculator for statistic question. How could i forgot about the most important thing in practical? Pfftt... Obviously, all the equation and formulas should be remembered.

Spotter

Spotter session started at 11 am.For this part, we have to identify each spotter given on the table within 1 minute. 10 spotters from 66 spotters given in the record must be memorized well. No need to remember calories as we can see the spotters right before entering the exam hall. It will be pretty obvious. Pay attention to drugs and parasite spotters. I messed up a lot for drugs and parasite. So study that more!

Field visit case viva is easy. The batch was separated into two groups. Each group for one examiner.I am among the last students.So, i had ample time to read for the viva. Present the case like we usually do in the clinical subject if the examiner ask you to. If not, take your time to think the answer and answer with confidence. Do not hesitate to say that you do not know to questions you have no idea about. Study everything related to the clinical case. Since mine was infant morbidity case, he kept asking about the antropometry measurement. Well, i  didn't have the wight and height scale that time. I decided to cook everything up not realizing that he actually pay attention towards these  silly little things. I am busted for those question and end up giving excuses that i just jot down what the mother had said and i told him about the languange problem. It seems that he doesn't even care. Maybe next time i should just cheat something but make sure whatever i cooked up make some sense. In the end he gave me just 25/35. Well, quite good i think.

Theory viva. Gosh! It could be anything!Just read more on primary health center and diseases. They asked me this:What is primary health center? What is the meaning of disease? How many type of epidemic do you know? How to prevent rheumatic fever? What is transmissible disease? etc...

So, that is all what i can say about practical. i'm  pretty sure that i messed up a lot.

  Otoke?(What to do? = in Korea) 

Want to do it again? Oh hell yeah! I have to have at least one more time to do it right before the finals. Please don't screw it up next time okayh!  

What i do to pass time in exam hall.

Tik tok tik tok...

I really can't wait any longer.Sitting in the chair with nothing to write on the paper.Pfftt... I was waiting for the right moment to go out. Well , here we can actually go out as soon as we finish writing our answer. Ahaha, to make time pass faster, i counted my future-marks. I assumed that i will not get full marks for all the question and from the total of 100 i will only get at least 78. From 78marks, deduct all the question left unanswered which means i have only 60 marks. For medical students to pass, we were only required to get half on the total points.

So, to take another factor into account, we have to include the leniency of the examiners. If they are really strict (which they won't unless if it is for sessional marks) you will bound to get lesser marks. Now, don't forget we also have to take overall performance of the students into account.  Come on, if the best student answer slash top scorer gets 3 out of 5, an average student will only get at least 1.5 0r 2..

Now, since i am used to write small words, my answers graphically looked shorter than my fellow local Indian students. Plus, as Malaysian, we were thought to write the words sebijik-sebijik and unlike me, they have a large, continuous handwriting on the paper. If my answer for a 10 mark question took at least 4 page, their's would be 6 or 8 pages! Even, for G head took one line, and the tail of the G took the line below! ( Well not all are like that...i exaggerate it  a bit O_0)

Luckily, this is not KTT where exams were conducted in the super-cool air conditioned lecture hall. I am a lizard. When i'm cold, i sweat a lot. Especially my hands and my feet. Sweating hands and feet makes things worst for me as i can't cover them like i cover my body with sweater. I can't use gloves because i can't hold the pen. But, if i wrote with my bare sweaty hands, my hands got cramped. Wearing socks in cold seemed effortless as the sweat trapped inside the socks and air ventilation makes my feet even colder. So, i am thankfull  to be here, where the weather are hot-cool like Malaysia. Oh how i miss Malaysia very much!

Oh yeah, another thing i used to do is counting. Hehe, since all we do is read and read in medical school, by 30 minutes before the exam ended, i used to count fans,windows, lights, or anything that will help me pass  time in the hall. Today, i counted the number of students went out earlier in last hour and the number of empty papers taken by the top scorers and the ones sitting next to me. Well, in short what i do in hall is just being a stalker. Yup, a STALKER!Don't worry, invigilators won't suspect me for copying because i am that good! I didn't do anything wrong really....So, whatever.

Why i do all those things? Why not sleep?

Okay, since high school  i tried to sleep like my fellow friends. They were so confident that they will get 100 out of 100 for the paper. What subject is that? Of course Additional Mathematics or Add Math! I admired their confidence of sleeping during exam just  45 minutes  after the papers were distributed. You can get full marks in Mathematics because it is just logic. If the answer meets what the question wants , then you get full marks. But, we can't do that for other subjects as we have to produce the same EXACT paragraphs from the TEXT book. The more you tried to hentam-keromo, the lesser marks you are likely to get. I wish i had brains like Adi Putra( you-know-who) , living and working you days with just numbers. Good luck dear, hope you'll be a famous Mathematician in the world. Huhu.

I really tried to sleep but to no avail i just can't do that in front of the invigilators.I think i will sleep if i have sooo much confidence in my answers.Plus, my brain just can't stop thinking and working!I can't really get my head a brake unless it is for sleeping.That's why people get insomnia. They think too much!

People, please let's pray that i pass. All i need is pass the 3rd year. All i need is to pass 5 and half year before i become a real doctor. If i pass, i can do whatever i want, the way i want it, whenever i want it.

Brain hangover after too much thinking in exam.

Opthalmology posting

Its eye day.

Here are some snippets of my optho postings in August. Hehe, too lazy to update blog because of eid.

This time, i am much aware of my eyes. I could not resist the temptations of applying my not-so-adequate optho knowledge in my daily life. Whenever i see a yellow eye, i will definitely make my own differential diagnosis. Whoever has a red eyes, i will immediately keep my distance two feet away so as to not contracting any transmissible eye disease. If i had any dark circles or colored halos, i am quite sure that i might have  glaucoma. Ni ler penyakit orang masuk medic. Hihi...Asal nampak je satu bende, mesti ingat ape yang dah belajar dan buat diagnosis sendiri. Orang puteh kate, What mind don't know is when eyes dont' see. Kalau tak tahu, macam mana nak kenal....ye dak? 

Lacrimal syringing test : Performed after 4% xylocaine local  anaesthesia .
Normal saline is pushed into the lacrimal sac from lower punctum with the help of the syringe and lacrimal canula. Free fluid passage from the lacrimal sac into nose rules out any obstruction to the lacrimal passage. Complete obstruction can lead to reflux of the fluid into the eye( indicating blockage at the same canaliculi) or the fluid will drain from the upper canaliculi ( indicating that the nasolacrimal duct or nasolacrimal sac blockage)

Next, these are the pictures during OT day. Although we had not been able to see  the traumatic induced cataractous lens  directly ,we were lucky enough to have a flat TV in OT. So, while the doctors explained the procedure we watch the whole procedure from the the TV in awe. 

This is from one of the not so eventful postings. That day we were thankful because this Dr care to show us some gadgets in the postings. Touched by his kindness, i was so pumped up and volunteered to become a patient. Here are pictures to assess the axial length of the eyeball in mm determined by A-scan ultrasonography.This procedure is indicated for people who needs an intra ocular lens implantation.

That's all for today!

Tada!!!!

  Tons of  topics yet to read.... Can i do it? 

No more Microb and Pharmac !

Ho yeah,

Last week i received my results.You know what ? I passed! Alhamdulillah...

Hurray!!! Ngeee~~*

Congratulation ! Omedeto! Tahniah!

Well, the raya festive is soo over and relaxation time is now come to an end!

Hope i will find my strength to keep holding on those heavy books and small fonts full with pure academic stuff.

Owh, someone please give me a spank if i malas-malas lagi...

Dear YOU! Yes You...Please wake up and Read! 

p/s: I miss tuition and hefty spot question books! 

Plummer-Vinson syndrome:

Guys, this is really important viva question as well as theory question.

Frequently asked for end posting!!!

link : Plummer-Vinson syndrome: MedlinePlus Medical Encyclopedia

Plummer-Vinson syndrome is a condition that sometimes occur in people with long-term (chronic) iron deficiency anemia. People with this condition have difficulty swallowing due to small, thin growths of tissue that partially block the upper food pipe, or esophagus.

Causes

The cause of Plummer-Vinson syndrome is unknown. Genetic factors and a lack of certain nutrients (nutritional deficiencies) may play a role. It is a rare disorder that can be linked to cancers of the esophagus and throat. It is more common in women.

Symptoms

• Difficulty swallowing
• Weakness

Exams and Tests

Some patients develop skin and nail abnormalities that the doctor can see during an examination.

Upper GI series or upper endoscopy may show the web. Tests to diagnose anemia or iron deficiency may be useful.

Treatment

Patients with Plummer-Vinson syndrome should receive iron supplements. This may improve the swallowing difficulty.

If supplements do not help, the web can be widened during upper endoscopy to allow normal swallowing and passage of food.

Outlook (Prognosis)

Patients generally respond to treatment.

Possible Complications

Devices used to stretch the esophagus (dilators) may cause a tear, which leads to bleeding.

Plummer-Vinson syndrome has been linked to esophageal cancer.

When to Contact a Medical Professional

Call your health care provider if food gets stuck after you swallow it or if you have severe fatigue and weakness.

Prevention

Good nutrition with enough iron may prevent this disorder.

Alternative Names

Paterson-Kelly syndrome; Sideropenic dysphagia; Esophageal web

link :

Snake Baby

Have you ever heard or watched about the snake baby in Saudi Arabia?

The baby is not alone.

It is a genetic-related disease called Harlequin icthiyosis.

One of the baby that survived spoke in here.

Want to help?

Got to this http://youtu.be/SM88sZZz2iY

Optho: Glaucoma

Good study and presentation material

~http://video.about.com/vision/Glaucoma.htm

Eye Examination

Ehem!

~That day i wanted to see pupillary shadow. I hadno idea how the shadow will look like. Finally, i've seen it. 

  The shadow falls on the lens when the light is shined obliquely from the temporal site and seen through the pupil.

~General tests to be done.

1. Visual acuity 
2. Rosenbalm test
3. vision test - by using Snellen`s chart and repeat Rosenbalm test
4. Eye movement test - look up,down.left and right
5. Confrontation test : The examiner closes his left eye while the patient closes his right eye. Move the finger in all four quadrant and repeat the test in the other eye.
6. The H test - Move the finger from center outwards in H pattern.Repeat for other eye.
7. Convergence test- From the nose, ask the patient to look far object .The pupil should constrict.
8. Squint and Strabismus test : Shine torch on nose and see the light reflection on the pupil which is slightly deviated to nasal site. Assymetry indicates strabismus.
9. Pupill reaction test- Shine from temporal site.See the pupillary constriction. See the other eye for consensual reflex.
10. Accommodation test- Make the finger on nose. Ask patient to see far object . Pupil should constrict.

Optho : Operation Theatre Day

Friday is an OT day.

But,i didn't bring my OT slippers.

Its okay, they didn't bother at all. Hoyeah!

It was an awesome OT because the case is related to our theory class we just had that morning.

It was wonderful because i still have the Wow! moment in there. I need it badly. 

It is awesome how the eyes are numbed,cut,poked and rolled on the surgery table,while the patient still conscious and he/she could actually see the whole procedure!!! 

These are the highlights during OT.
Might be viva question too.

The screen. Thanks to it, i can see what is going on under the microscope.

~Do you know what is biometry? Biometry is for intraocular lense power calculation. 
  Answer : P=A-2.5L - 0.9K.
  Where P is the power of IOL,A is a constant for lens type, L is the axial length of eyeball in mm determined by A-scan ultrasonography, K is average corneal curvature determined by keratometry.


~Traumatic induced cataract in a teenage girl following needle break in sewing lesson. The needle penetrated the cornea all the way through the vitreous and posterior capsule. Removal of the lense or lensectomy with anterior and posterior capsule removal  is done. Vitrectomy is completed using cutting ,irrigation and aspiration mechanism and implantation of IOL of 22D slightly higher than normal lense. He said even with loss of vitreous there will be no associated diminished vision or  post operative complications. Although, the damaged done is irreversible,they tried to save what they can since the patient is still young and they do not want to disfigure her.




~Pilocarpine injection into anterior chamber to asses pupillary reflex.


~Peribulbar anesthatic injection. I say you, it is painful and scary to us! Imagine a needle being poked straight  into the eye.!!! Gosh, i had anesthesia before, it was painful and i shed a tear. Well, a bit. But this is so scary and painful, even to those watching from bedside!


~Superior rectus muscle fixation. It is also know as bridle suture is passed to fix the eye in downward gaze manner.Sir said it was the most painful stage of cataract removal surgery.


~Tryphan blue dye to stain anterior capsule. A bubble is introduced between capsule and cornea. The bluish 
   tinged capsule is then teared with help of a knife to expose the pearly white cataractous lense.




~Phacoemulsification. 

• It has three significant stage. Irrigation, aspiration and ultrasound.
• Something about needle. Fact: Nucleus of the cataract is emulsified using a needle that vibrates at ultrasonic speed of 40000 times a second. One of great WOW! moments is OT, i must say.

~What type of cataract could develop after ECCE ? Answer: it is also known as after cataract. It has two types, Soemmering's ring and Elschnig's pearls.

~What is IOL related complications? Answer: CMO, corneal endothelial damage,uveitis and secondary which is frequently seen with anterior chamber IOLs. UGH syndrome refers to occurence of uveitis, glaucoma, and hyphema. 

~Students, where do we put the incision for lens delivery in intracapsular cataract extraction ? Is it from 6 o'clock or 12 o'clock?  With pure curiosity and without further thinking i asked " Sir, which clock sir? Your clock or our clock? " while standing on the bedside with surgeon sitting behind patient head. They burst into laughter. Pfft! What a bummer! I cracked a joke when the patient is STILL lying there.I didn't mean to. But, still it is a fair question! Answer: Indian smith method, fix the eye at 6 o'clock and by using another hand put counter pressure at 12 o'clock to deliver the lens out of the capsule through the pupil and anterior chamber.



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Optho:Methods of Drug administration

Ocular pharmacotherapeutics can be delivered by four methods:

• —topical instillation into the conjunctival sac, 
• —periocular injections, 
• —intraocular injections and 
• —systemic administration

a)Topical instillation 

Eye drops may be in the form of aqueous solutions (drug totally dissolved) or aqueous suspensions (drug is present as small particles kept suspended in the aqueous medium) or oily solutions

Eye ointment increases the bioavailability of the drug by increasing tissue contact time and by preventing dilution and quick absorption.

Ocusert is a system of drug delivery through a membrane. These can be placed in the upper or lower fornix up to a week and allow a drug to be released at a relatively constant rate. Pilocarpine ocuserts have been found very useful in patients with primary open-angle glaucoma; by efficiently controlling intraocular pressure with comparatively fewer side-effects.

——Soft contact lenses are also used to deliver antibiotics and antiviral drugs in patients with corneal ulcers.A pre-soaked soft contact lens in 1 percent pilocarpine has been found as effective as 4 percent pilocarpine eyedrops in patients with acute angle closure glaucoma.

b)Periocular injections

These are not infrequently employed to deliver drugs.

These include :

• —subconjunctival, 
• —sub-Tenon, 
• —retrobulbar and 
• —peribulbar injections.

Subconjunctival injections. These are commonly used to achieve higher concentration of drugs.
Further, the drugs which cannot penetrate the cornea owing to large-sized molecules can easily pass through the sclera. 

Sub-Tenon injections.These are preferred over subconjunctival injection. Anterior sub-Tenon injections are used mainly to administer steroids in the treatment of severe or resistant anterior uveitis.
Posterior sub-Tenon injections are indicated in patients with intermediate and posterior uveitis .

Retrobulbar injection: These are used to deliver drugs for optic neuritis, papillitis, posterior uveitis and also for administering retrobulbar block anaesthesia.

Peribulbar injection: These are now frequently used for injecting anaesthetic agents. Peribulbar anaesthesia has almost replaced retrobulbar and facial block anaesthesia.

c)Intraocular injections

Such injections are made in desperate cases (e.g., endophthalmitis) to deliver the drugs in maximum
concentration at the target tissue.

These include:

• —intracameral injection (into the anterior chamber), 
• — intravitreal injection (into the vitreous cavity)