anxiety is failing me...

2 weeks to come before my final professional exam and anxiety is building up..And I did not even dare to go home for de-stressing myself. Thanks to my last Surgical posting exam that I did it horribly (seriously no kidding!). Here a little bit of what happen during my last exam.

Me: I'm presenting my patient 55 years old Malay lady from KT, Para 3 came w complaint of per rectal bleeding for 1 day duration.

Mr C: Why did you mention about Para 3? Does it relevant? (I kept silent)

Mr N: We are not gynecologist.

Me: Oh ok I'm sorry.

Mr C: You're wearing long sleeve or short sleeve? You should not fold up your sleeves. Button it properly!

Me: Sorry Dr. (OMG...previously I've been scolded for not standing straight, now this? I curse my bad attitude.. In instance, all my confidence had been flushed away)

Summary of my case...

55/M/Lady came with painless fresh per rectal bleeding for 5 episodes in a day that was not mixed with stool. It associated with passing out blood clots, abdominal discomfort and symptoms of anemia. Patient also had loss of weight but no anorexia. Known to have DM and hypertension. On examination, she was pale and per rectal examination revealed there was altered blood.

My diagnosis was anemia secondary to bleeding hemorrhoids

Well in my presentation, I did mention about tenesmus...

Mr N: What is tenesmus?

Me: Feeling of defecation but no production of stool..

Mr N: No..So what is tenesmus? (I think more than 3 times he asked me)

In my history I did say patient had undergone banding.

Mr C: Why did you said that? Did patient see it? Is patient is a doctor?

Mr N: What is the treatment of hemorrhoids?

Me: Sclerotherapy, banding & hemorrhoidectomy...

Mr C: Yes.. May she undergone sclerotherapy..you never know.

Mr N: Ok.. what are the causes of massive per rectal bleeding? 4 causes..

Me: Sorry Dr. I did not know.

Mr N: You are 2 weeks behind professional and you did not know? (This time around I know I flunked it). In this patient what is your diagnoses?

Me: Hemorrhoids, angiodysplasia, colon cancer, diverticular disease.

Mr N: Yes.. At least you should know that for massive per rectal bleeding.

Mr C: Your history has many loop holes & you are assuming too much...What you want to do for this patient?

Me: Resuscitation, admission, blood transfusion...investigations, proctoscopy and colonoscopy.

Later the discussion mainly about colon cancer

Mr N: What is the surgical treatment of colon cancer.

Me: Right & left hemicolectomy, anterior resection, anteroperineal resection.

Mr N: Yes, so that why you have to know what is tenesmus...because if tenesmus occurs, patient may have sphincter involvement.

*sigh*

Then move on to short case, well it was Prof S & Mr Z.

Prof S: Examine this patient upper limb.

I did examine the patient horribly...partly because the patient unable to understand my instructions...when I asked her to grab my fingers, she just pull my hand..seriously it look totally bizarre even from my own perspective.

Mr Z: What are you doing? (Hmm..sorry Dr)

I continued with my examination & found that patient had hypertonia & hyperreflexia of the right upper limb.

Prof S: So what is your diagnosis?

Me: Upper motor neuron lesion involving right upper limb. (The bell rang..time out)

Prof S: Why did you say that?

Me: Because of hyperreflexia & hypertonia on the right side.

Prof S: What else? Ok last question, did you know difference between rigidity & spasticity?

Seriously at this point I have mental block. It is the same question during our teaching. So I ended up resiting for another short case..*sigh*

So moral of the story never ever let your anxiety control your mind or you will end up talking/doing bizarre things...and always be prepared. My poor preparation prove it all.

p/s: tenesmus is a feeling of incomplete defecation. Patient may feel like going to defecate but no passing out motion. If you have any more info do response ok!

[update: Mr C said that tenesmus is after defecation, patient feeling there is still something inside]

Genetics Peril

"MLD was a strange and unfamiliar word within Mohamad and Kamariah's household. But when this enemy took away their eldest daughter's life, they were taken by surprise. From that day onwards, they did not know it the, so things began to get worse.

They were totally unprepared when further tests showed that all their five children had symptoms of dreaded genetic disease. All was not lost, however, for there was a cure but the cost was tremendously high. They were devastated.

It was an endurance test for the family; every minutes mattered, every cent counted, every prayer appreciated. Their plight caught the nation's attention and everyone shared their miseries. It was a suffering like no other; a struggle that was to last more than twenty years!

Share with them this touching and unforgettable experience. For this is a story where we can reflect our own lives, and the true meaning of love.

What lies ahead, no one really knows..."

I've finished reading this book...truly recommended this. Seriously for someone who really, really hate to read even for the academic purpose, it is hard to finish a book what else a novel (I've never finished reading any novel before). One must wonder how on earth that I became a medical student...haha. In life, there a so many ways to study other than diligently reading books. (Hey I do read books ok!)

I amaze on how parental love could do and how the love turned into extraordinary willpower and patience. When I read this book, I wonder if I could act as what Dr. Imran has done to his patients....may ALLAH guides my path.

Currently trying to find the original Malay version of it, Zuriat.

COMEL and MERCI

Haha...it's no about being cute or else...just a mnemonic that I learn during class with Prof Z...but seriously being in paediatrics is full with cute faces haha. Thanks to Prof for very enjoyable and meaningful session

1) MERCI

Medical

Empathy

Right

Communication

Insight

During clerking we should have this thought in our mind. Not only think for medical aspect only. Every person have it right. "Janganlah kacau patient tidur." That one of the things that Prof emphasized. And some of us talk less and less to patient and never try to educate them on their disease (insight component). Should change our mindset.

2) COMEL

Cognition

Optic

Motor

Emotion & Social

Language

For developmental assessment. Prof said that tr to assess playfully and creatively..

3) VITAMIN BCDE

If we stuck during clerking, always remember this to exclude diagnosis

Vascular

Infective

Trauma

Autoimmune

Metabolic

Idiopathic

Nutrition

Behavioural
Congenital

Drugs/Degenerative

Endocrine

Clinical Exam: Short Case with Prof H

Dr : This patient LMP was 27 April 2010. What is her POA & EDD?

Me: 34 weeks + 1 day POA, EDD was 3 February 2011

Dr : (Showing the red book) This is the patient past obstetric history. Summarize it

Doctor's Summary (obviously!)

In summary, the patient, G6P5 at 34 weeks with 4 living children with history of low birth weight baby and history of premature labour at 28 weeks for last child. the child died at 2 months of age. Currently came with premature labour. Examine this patient abdomen.

During examination I could not heard fetal heart upon auscultation (even after given 3 chances)

Dr : You never practice ye...(dusH! head shot..)

So basically singleton fetus with longitudinal lie, cephalic presentation, head 2/5 palpable.

Dr : If you are the houseman at screening what do you want to do.

Me: After history and physical examination, I would like to time contraction. Exclude Braxton-Hick and true premature contraction. I would like to do speculum examination to look for vulva vagina excoriation, liquor, sign of infection such as candidiasis (tembak!) and opening of os

Dr : Really candidiasis? What causes premature labour? Infective causes. (Dr must have expected me to go around the bush with all sort of answer..haha)

Me: Bacterial vaginoses, group B streptococci.....candidiasis, I'm not sure.

Dr : Candida did not cause premature contraction. How would you manage?

Me: I would like to investigate...

Dr : You haven't finish your PE. What else in vaginal examination?

Me: (Knock in the head) I would like to check for the station, cervical opening and effacement...(basically all the bishop score but couldn't remember the other 2)

Dr : OK investigation?

Me: I would like to do high vaginal swab, CTG

Dr : What other investigation? Let's say if it is available here..

Me: Fetal fibronectin

Dr : What is its significant?

Me: If positive, patient is having premature labour. (tet! wrong again...)

Dr : Basically if it is positive, patient will deliver within 1 week. Patient is been admitted, what do you do?

Me: Since patient is at 34 weeks, I would like to give 2 injections of IM dexamethasone 12mg 12 hours apart. Tocolytic agent to let the effect of dexa took place.

Dr : After tocolyse?

Me: I would monitor patient for fetal heart rate, respiratory rate & blood glucose...

Dr : Why glucose? Patient is not diabetic.... ok that all. Did you think you perform well during Long Case?

Me: I'm not sure. (Dalam hati..pasrah)

Clinical Exam: Long Case with Dr B

26 years old Malay housewife from Muadzam, primidgravida at 28 weeks POA, gestitional diabetes mellitus on diet control with acceptable glucose control and asymptomatic anemia on double hematinics (which I don't emphasize earlier during summary) came with complaint of pervaginal bleeding 2 days prior to admission.

Discussion of History

Dr: Why didn't you emphasize on complications of GDM from ultrasound? What are the complications that I want?

Me: Fetal macrosomia & polyhydramnios. I did mention in the history, the fetal growth was corresponding to the date with adequate liquor

Dr: No, you should mention it specifically in this type of cases. (One more thing is that fetal anomalies only occur in preexisting DM not GDM)

(After the history presentation, because patient remember all the details...)

Dr : Did the patient tell you all this?

Me: Yes

Dr : So what is the patient education background?

Me: Err, sorry I didn't ask....(OMG lupa la plak)

(After summary, it is as above but minus the asymptomatic anemia)

Dr : What is other problem that patient had?

Me: Oh, asymptomatic anemia...

Dr : So why didn't you said so? You should not focus on presenting complaint only...treat patient as a whole. Since patient in the low social economic group, did she had basic amenities in house? What kind of toilet that she had? How about her diet? Did you ask?

Me: Sorry Dr, no...(isk3 my social history very poor)

Dr : What is the simple investigation that you would like to do in this patient since patient had anemia?

Me: TIBC, Serum ferritin, stool ova & cyst.

Examination revealed that she was not pale. No signs of infection at the web space of hands, axilla, mouth, neck and breasts. But I didn't look for it at groin & vagina. SFH was 26 cm and clinical fundal height was corresponding to 28 weeks gestation. Fetal part felt but could not appreciate the fetal lie/poles because it is so small with relatively thick skin. (Dr said that must try to assess and find it since we're gonna be HO)

Further Discussion

Must know site of infections in GDM (as listed above)

Dr : If you are in the district what do you want to do to this patient?

Me: I would like to do ultrasound to exclude PP, if PP excluded I would like to do speculum examination.

Dr : What do you want to find?

Me: Vulva and vagina erosion, liquor, cervical erosion, growth, irregular margin. Os opening..

Dr : Do you expect any infection in this patient?

Me: No because patient had good control of glucose.

Dr : Any other specific thing in cervical that you would like to check?

Me: Oh cervical polyps (while knocking my head)

Dr : If you unable to determine what is the cause of bleeding, what is your diagnosis?

Me: Indeterminate APH

Dr : How you manage APH? When to deliver patient?

Me: Take FBC, GXM...Resus...deliver at term

Dr : When?

Me: 38 (Goreng!). I not sure.

Dr : We not allowed post date. why?

Me: Don't know. (until now haha! I'll inform later)

Dr: If patient is in premature labour, what is your management? Patient at 28 weeks. Who to inform other than specialist, consultant, nurses...

Me: (After being pushed) IM Dexamethasone, tocolysis.....(Being pushed further) inform paeds for ventilator (at first I wrongly said "incubator"...pening2)

Neonatal Jaundice Predictive Value

Found this during wardround after been alerted by Dr Suhaiza...

Shiny Teeth and Me...

I found one clip from a cartoon regarding teeth care...kinda cute

take care of your teeth ok haha

Clinic Session with Dr S

Have clinic session with Dr S yesterday....totally enjoy it

34 Malay G2P1 came with uterus larger than date for assessment with history of nose bleeding in early pregnancy, whitish discharge with foul smelling & streak of greenish mucus (forgot when); completed treatment of vaginal pessary for 3 days. Upon further questioning, she had cystectomy for endometriosis 9 years ago & 1 untried uterine scar for EMLSCS due to prolong labour.

So what to highlight in history?

Causes of larger than date such as wrong date, fetus causes (big baby, multiple gestation), polyhydramnios, pelvic mass (uterus/ovarian mass)

Whitish discharge with foul smelling & streak of greenish mucus..what do likely cause?

At first, I thought it was bacterial vaginoses but it is actually candidiasis with superimposed infection because patient was treated using pessary for 3 days which most likely is Canesten pessary

Nose bleed common in pregnancy?

Yes for some because of generalised vasodilatation affecting Little's Area. (some may presented with gingivitis; also due to same causes)

Stages of endometriosis?

(anatomical staging) ---> not related to symptoms/fertility prognosis

stage 1 (minimal) - superficial lesion with filmy adhesions

stage 2 (mild) - as above plus some deep lesions in pouch of Douglas

stage 3 (moderate) - as above plus endometrioma in ovary & more adhesions

stage 4 (severe) - as above plus endometrioma with extensive adhesions

So in this patient at least stage 3

Ultrasound was done & found that normal fetus weight with normal AFI & no adnexal or uterine mass...so what happen?

Possibly of adhesion due to previous surgery that lead to upward stretching of the uterus lead to larger than date (based on SFH)

p/s: little bit sad because unable to clerk uv prolapse today because too many people have clerk it (hard-to-find admission!) and I've clerk 1 patient with PIH..after clerking the BP was 150/100 mmHg. I felt that I'm the one causing it...I did pray a lot hopefully patient did not develop pre-eclampsia/severe hypertensive crisis.

Class with Dr A

Just finish class with Dr A just now... had discussed about 2 cases. (I wrote it here because I forgot to bring my notebook during class, so I think why not share it here..haha)

First Case

25 yo Malay lady G2P1@37 weeks POA came for ELLSCS with conjoint twin. diagnosed at 21 weeks POA

Complications of twin pregnancy?

In general, all possible obstetrics complications!! So early detection of twin is needed to prepare the mother & family...(so friends try to practice scan before becoming MO ok)

Why do we need to take BP every time we clerk patient? (which most of us don't)

Because we afraid of hypertension in pregnancy more specifically pre-eclampsia & eclampsia

Why?

Because it's one of the common cause of maternal and perinatal death... then he started to take about a patient who had twin pregnancy with rapidly progressed pre-eclampsia before. Both twins died in utero while mother succumbed after 1 month staying in ICU

Second Case

18 yo unmarried G1P0@33 weeks POA came with fainting episode that associated with symptoms of anemia. She unable to tolerate oral hematinics lead to poor compliant.

Management of anemia in pregnancy other than typical oral hematinics?

Oral Obimine, IM interferon, IV Venofer (like coke) etc...transfusion is the last resort

Why do we treat anemia in pregnancy aggressively?

Because patient can develop pph, thus lead to maternal death

How to reduce bleeding during labour?

Optimise the hemoglobin level (at least 10 g/dL)

Avoid prolong labour since It could lead to pph secondary to uterine atony. (augmentation of labour if poor contraction)

Active management of 3rd stage where most common time to develop pph (syntocinon injection, control cord traction)

If patient had pph/risks to develop pph, infused 40 unit pitocin after removal of placenta

Complication of teenage pregnancy?

cephalopelvic disproportion due to undeveloped pelvis

Legal issue regarding baby from unmarried mother?

Currently, baby had to be given name with bin/binti of his/her mother...Kesian budak tu bukan dia yang salah tapi mak ayah dia. Seumur hidup la malu anak luar nikah tu dapat pada dia & semua orang tahu. Dulu bin/binti Abdullah..orang tau juga, tapi kurang la sikit stigma tu.

(personally I think this is not a good management of issue by Government)

well that are some of the things that we discussed...enjoy study ok!

A Piece of Knowledge in A&E

40 years old gentleman known case of diabetes came with breathlessness. Dextrostik showed glucose was 20 mmol/L. He was initially diagnosed as diabetic ketoacidosis until ECG was done and found that he had NSTEMI (click here to read for more info regarding myocardial infarction).

Oxygen was given, sublingual GTN was given....IV morphine plus maxolon... all the emergency treatment was done...but patient restless & suddenly collapsed.

CPR was done, intubation was done & atropine with adrenaline was given but patient succumbed to the illness.

Moral of the Story

1. Myocardial infarction (MI) is a number one killer in Malaysia.

Before this accident I've never seen patient with myocardial infarction died...so I thought that may be most of them died years after having MI...come on Afif, wake up! Be more attentive & observant...another few months to go before becoming HO.

So, here some advice for all of us..watch what you eat, take care of your health... even if you have hypertension, diabetes or previous MI, never & never stop taking care of your health because it is the amanah from ALLAH

2. To all medical students, know your stuffs well before becoming doctor...!!

First & foremost your theory must be good... as our doctors always said the eyes never see what the brain never know, which is 200% true. As in this patient he had no angina pain due to his diabetes...so let us start study ok!

Secondly practice & practice all your clinical works during your study especially when it comes to resuscitation. Because when we, medical students do CPR on that day for me it was terrible especially myself. It was asynchronous & shallow in short it produce irregularly irregular rhythm...which is totally opposite to what the medical assistants did..and never hesitant to learn from anyone including your own patient.

3. A&E can be tiring & full of frustration

So be mentally prepared ok! Always remember that doctors are human..even with the best treatment, only ALLAH can save a soul. For those who aim for A&E specialist...gud luck & may ALLAH bless you.

Hope this entry benefit all of us...

Marshmallow Test...

I just put up this video because the children's behaviours were cute...

but there are some psychological importance..read this for further info regarding Deferred_Gratification