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Surgery : Breast Carcinoma

Today, we had a great class of breast carcinoma. It is a very important class. Dr M taught us on the do's and the dont's of breast carcinoma examination.Yeah, and he did that in between the time when patient comes in and out of the OPD. Sometimes, after listening to Medical Representatives suggesting their companies drugs to be used in OPD.After 3 postings of surgery in India, i am now adapting well to norms of system.Well,  Dr M asked us  to present the case and yada yadda we told him about patient's history,inspection and palpation of breast while he expressionlessly  nit-picking using flat toned manner with tons of viva-style questions.

Picture courtesy from Radiology Malaysia.org

Now, here we go and present the case.

Chief complaint :She complains of painful left breast  since 1 month ago.

Long case made short.

Among positive findings that we encountered are :

On inspection there is presence of single ulcer at  the left breast with multiple nodules. The breast of affected site sags and the skin of breast seems normal. The nipple of the left breast is destroyed and floor of ulcer is covered by slough and seropurulent discharge.

By palpation we could feel the hardness of the breast lump which is multiple in number,varied in size between 5mm to 1.5cm. The breast ulcer is tender  and bleeds on touch, fixed to the breast tissue and have sloping edge with indurated margin. Single solitary axillary lymph node is appreciated.

Diagnosis :

 T4b Tumour with involvement of the skin in the form of eodema,ulceration and satellite skin nodules.

N1 Mobile ipsilateral axillary lymph node.

Note: Wear gloves  and wash your hands in between patients dear doctors!

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Seminar! Hate it!

Seminar... I hate seminar. Why? Because i have to speak and present my topic in front of class. Well, pretty much there is a HUGE chance of me getting interogated like a criminal. Making power point. LOVE it. Presenting part, HEARTLESS. Interogation part, HATE it ! Pfft! My topic today : Flexible Fibre Optic in Broncoscopy and Oesophagoscopy. Wish me luck!

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Surgery posting

Our teacher teaching us anatomy.

Syabas lah cikgu ni!

Penat mengajar sampai jadi tulang aje!

Berbekam baik untuk melancarkan pengaliran darah!

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Herniotomy Step By step

  

-indicated in children with inguinal hernia & before herniorrhaphy in adults

-Procedure:

1-ligate & divide the 3 superficial veins
2-divide the external oblique aponeurosis in the direction of its fibers
3-reflect the external oblique aponeurosis &identify the ilioinguinal nerve & reflect it over the aponeurosis
4-separate the cord from posterior wall of the canal
5-divide the creamasteric muscle & internal spermatic fascia
6-dissect the hernial sac up to its neck
7-open the fundus of the sac
8-reduce the contents
9-transfix the sac at the deep ring
10-excise the redundant sac


There are different approaches to surgical repairs to hernia which may include the following:

Hernioplasty when herniotomy is combined with a reinforced repair of the posterior inguinal canal with autogenous (patient’s own tissue) or heterogenous material such as prolene mesh.

Herniorraphy is somewhat like hernioplasty only that no autogenous or heterogenous material is used for reinforcement.

Herniotomy is a surgical operation where the hernia sac is removed without any repair of the inguinal canal.

Read more: Discussion on Hernia Repair, Herniorraphy | Res Ipsa Loquitur - OR Nurse 

*updated

Herniorrhaphy procedure: Bassini's 

Definition: It means herniotomy and approximation of conjoined tendon to inguinal ligament to strengthen the posterior wall of the inguinal canal.

Indication: Indirect  or direct hernia with good muscle tone.

Procedure

Incision: 6-8cm incision is made parallel to the inguinal ligament at the level of deep ring in the medial two thirds of the inguinal ligament. 

Layers opened: 

• Skin
• Two layers of superficial fascia
• External oblique is incised in the line of direction fibres till external ring is open.
• Thin cremasteric box is opened.
• Identification of the sac

1. - glistening white colour,
2. Isolate the cord from the sac by blunt and sharp dissection.The cord is held separately by using cord holding forceps.
3. The sac is mobilise upto the deep ring. Mobilisation is complete when inferior epigastric artery pulsations and extraperitoneal pad of fat are seen.
4. The sac is opened and contents are examined.
5. The contents are reduced.
6. Twist the sac to avoid injury to the contents.
7. Transfixation ligature is applied as high as possible at the neck of sac and it is tightened.
8.  Excision of the sac: After excision , see the excised sac and see whether omentum or intestine have been injured.Up to this stage , it is called as HERNIOTOMY.

Repair

• Conjoined tendon above is approximated to the inguinal ligament below by using nonabsorbable suture such as Nylon, Silk  or Sutupack.
• Nonabsorbable suture is used so that its strength remaines for a long time. This repair is called BASSINI'S HERNIORRHAPHY.

Closure

• External oblique is sutured with chromic catgut or silk.
• Subcutaneous fat absorbable catgut suture.
• Skin with silk.

Post -op

• NPO fro 6-8 hours, oral fluids and soft diet later.
• Analgesics
• Antibiotics
• Scrotal support if the dissection is more(complete hernia)
• Suture removal after 7-10days.

Post-op complications

• Haematoma
• Wound infection
• Severe peritonitis pubis
• nerve entrapment causing pain. 

Source: Shenoy Nileshwar Manipal Manual surgery.

I am Done!

The topic seemed so horrible. A very horrible thing to say and written.

For the record, i've been confined in my room for 1 month straight. Without any books to read or do any academical stuff. I simply quit. I waited in my adequately large pink-walled room. I was wide awake at night but slept in day bright. I woke up to bath,eat and drink. When i gaze at my books, i simply emptied my mind, not wanting to feel any guilt or anxiety. Yes, that is all i do all these while.

I tried not to feel.

I tried really hard not to think.

Although i know that Ghandi did said the key to win the fight is not to fight. Not thinking is same as not fighting.
I guessed that i managed to do that. But, the more i try harder, the more it came. The feeling of incompetency and inferiority towards my own impossible standards. Who wants a second rate doctor rite? I HAD to set my target higher. I HAD to be the best. I had to. I need to. But, the problem is, i never want it. All i want is to feel enough.Yup, enough is enough. Why not be a moderate?Wanting something moderate for my self? Modesty is the the best policy is what all they say.

I may have been deluded  for being stuck in here doing the same routine everyday. Routine i had not much interest in . I need something. Passion. I want to live with enthusiasm. I want to be a person who loves their work and get rewarded for that. I know, in this world, not everybody are lucky. Not everyone can do jobs they love. Some people love their jobs, others just do it for the sake of supporting living expenses. Gregory House always say you can`t always get what you want. In Quran also mentioned that we may hate things that could be good for us and we may love something that could be bad for us. I always knew those. But , right now... i barely take it into my heart.

People say that life is priceless. That chances are to be taken. That all opportunities in the world should be grasped. I had that chance. So, what do i do with it? I've taken the chance. I had it in my hands. but, now it is slipping off my hands.........

I figured that if i am not suitable for this job, i should just quit from now. Before things gets nastier and uglier. Before its too late. I want to stop now. Take me home. Let me live my life as i want to . I want to live a simple life with peace and no unnecessary pressure from outside or inside myself. I just want to do what i like.

Then again, Gregory House whispered :  Hey crazy lady! *YOU CAN`T ALWAYS GET WHAT YOU WANT...*

URGHHHH ...


Then again, although future might be seemed to be so bleak and hopeless... Please know that even though you don't think that you have what it takes to become a  DOCTOR, know that there are people working their ass off just to become a MEDICAL STUDENT. Know that even though you think you don't deserve to be here, to have this kind of luxurious opportunity, know that if you don't hold it firmly in your hands others might take your place.That you are the chosen one, chosen by people to serve the people of the nation.

When you want to reminisce old the good and the bad times, all the bloodysweatytears,all the efforts you took to gain what you want, all the sacrifices you have done to get where you are, all the people who cared and cheriss your talent and persona, all the dreams and wishes you once carved deeply into you heart, all the pains and sorrows that brings you strength to cross the hurdles, all the bittersweet memories that inspired you to continue your journey and see the wide vast world on your own capabilities, all of that.

Remember, that everything is in order.

Be good, you're good.
Be calm, you're at peace.
Be angry, you're mad.
Be humorous, you're  funny.
Be sensible, you're sensitive.
Be pathetic, you're sad.
Be bold, you're strong.

Blah,blah,blah.

Its YOU that make it happen.
You decide your destiny.
Future is in your hands 98% of it.
Only 2% luck and fate MAY change the course of your life.
Event if it does change, YOU have the WILL to change it back to square one...

And that's why humans are gifted by God what we call as COURAGE.
It is the strong will of humans to overcome FEAR so that humans without BRAVERY can go forward not backward.




p/s: Finish your journey no matter what happens.

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!