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Sunday, December 12, 2010

Anti -thyroid

Hyperthyroidism

1) Thioamides - carbimazole, propylthiouracil, methimazole --> block synthesis of thyroid hormone
How to start??
starts at a high daily dose of 15 - 40mg continued until the patient has normal thyroid function. Then reduced to a maintenance dose of 5 - 15mg.
Treatment is usually given for 12 - 18 months followed by a trial withdraw
SE : rashes & pruritus --> if due to carbimazole cn change to PTU
bone marrow suppression (ask patient to come if has fever,sore throat)- Monitor WBC 3monthly
PTU can also cause fulminant liver failure --> death
PTU & methimazole - use in pregnancy. PTU (1st trimester) da rest is methimazole

2) Beta blocker - adrenoreceptor blocker
treat tremor & tachycardia

3) radioactive iodine (131 - I)
MOA : incorporate into storage follicles & destroy tissue internally

4) Iodide replacement agent (pottasium iodide)
MOA : inhibit thyroglobulin proteolysis --> inh hormone release --> decrease overactivity of thyroid

Hypothyroidism

Levothyroxine (synthetic T4) , Liothyronine (synthetic T3)
MOA : actions as endogenous hormone. enter cells, convert T4 to T3, T3 enter nucleus, bind to specific receptor protein, activate the synthesis

Anti Hypertensive

1) Beta Blocker
MOA : Sympatholytic at Beta 1 & Beta 2 adrenoreceptor, inhibit NE at the synapse
Drugs : Propanolol, cardioselective Beta 1 antagonist :Metonolol, atenolol
SE : Bradycardia, bronchospasm, hallucinations, muscle weakness

2) Alpha blocker (seldom use in hypertension, use for BPH)
MOA : Alpha adrenoreceptor blocker cause vasodilatation
Drugs : Prazosin, Terazosin

3) Alpha & beta blocker (use in pre eclampsia / emergency treatment of hypertension)
MOA: Block alpha & beta adrenoreceptor & cause decrease in peripheral vascular resistance leads to reduction in BP
Drugs: Labetolol
SE : Drowsiness, bradycardia, complete heartblock, bronchoconstriction, pulmonary edema
Relative Contraindication : asthma, heart failure, any degree of heart block

4) ACEI
MOA : vasodilator as angiotensin is potent vasoconstrictor. ACEI inhibit conversion of angiotensin 1 to angiotensin II by ACE
Drugs : Captopril, enalapril
SE : hyperkalemia, dry cough, hypotension, postural hypotension, angioedema
Contraindication : Renal artery stenosis, pregnancy, impaired renal function

5) Angiotensin receptor blocker (ARB)
MOA: AT1-receptor antagonists. Block the activation of angiotensin II AT1 receptor on vessels which directly causes vasodilatation, reduces secretion of vasopressin, reduces production and secretion of aldosterone
Drugs : losartan, valsartan, telmisartan
SE : Dizziness, headache, hyperkalemia, postural hypotension on first dose

6) Calcium channel blocker (CCB)
MOA: Block entry of calcium through calcium channel in the smooth muscle of endothelium cause it to relax & vasodilatation
Drugs:
Dihydropyridine (Nifedipine, amlodipine)
Nondihydropyridine (verapamil, diltiazem) --> reduce myocardial oxygen demand & reverse coronary spasm
SE: Dihydropyridine - reflex tachycardia, leg edemadizziness,headache
Non-dihydropyridine - arrythmias
CI ; can worse proteinuria in pt with nephropathy

7) Direct Vasodilator
MOA : at local level. Nitric oxide - potent vasodilator, enhance action of NO direct at vessels
Drugs : Hydralazine, Minoxidil, Na nitroprusside
SE : Hypotension, headache, Tachycardia, tachyphylaxis

8) Centrally acting drugs
MOA : affect on CNS & sympathetic NS
Drugs : clonidine - use or migraine
Methyldopa - safest to use in pregnancy
SE: dizzinessm postural hypotension

9) Diuretics
a) Thiazide (chlorothiazide, indapamide)
MOA: inh reabsorption of Na & K at distal tubule
SE : hypokalemia, metabolic alkalosis, hyperurecemia, hyperglycemia
CI : gout

b) Carbonic anhydrase Inhibitor (CAI) - acetazolamide - use for acute glaucoma
MOA : Inh reabsorption of NaHCO3- at proximal tubule
SE : hypokalemia, metabolic acidosis, hypersensitivity

c) Loop Diuretics - Furusemide, Bumetanide, Ethacrynic acid
MOA : Inh reabsorption of Na, Cl, K at THICK ASCENDING Loop of HenLe & increase renal blood flow by cortical vasodilatation
SE : hypokalemia, metabolic alkalosis, postural hypotension

d) Pottassium sparing - spironolactone
MOA : Aldosterone antagonist - inhibit action of aldosterone at distal tubule & collecting duct
SE : hyperkalemia, metabolic acidosis, gynecomastia

10) Renin inhibitor - Aliskiren
MOA : act on the Juxtaglomerular cells of kidney, which produce renin in response to decreased blood flow
SE : hyperkalemia, hypotension, angioedema

DAY 1 - Be Strong~

Tomorrow Is The Day. Today is My last day to recap most that Ive studied before. Please pray that I make it this time. There is a limit to a person's strength.

But for now, I just want to do my best, prepare the best that I can, be positive, be SUPER happy, MEGA happy, have INFINITE happiness & the rest I leave it to Allah. Human has so much limitations. Just live with it & be happy with it.

Allah knows best for me. I always believe Allah will definitely help those who ask for his help & those inneed~

Akhir kata. benarlah kata-kata Allah (Always believe in his promises) =)

Saturday, December 11, 2010

Warna Warni 2010

Tiba-tiba tengah stadi, teringat kepada kemeriahan sanak saudara apabila berkenduri. Ini yang membawa saya kepada entry ini. Warna Warni 2010 pastinya membawa seribu kenangan.

Terutamanya kepada saya dan pastinya kepada saudara mara sebelah saya & suami juga. Agenda paling hangat adalah majlis perkahwinan yang dilangsungkan sepanjang tahun ini =)

Pembuka tirai 2010. Perkahwinan saya dan suami pada tanggal 1hb & 2hb Januari
Venue: Bandar Baru Bangi & Saujana Utama


Seterusnya perkahwinan Iwan dan Ila - September 2010
Venue : Melaka & Sg Besar


Penutup tirai 2010. Perkahwinan Kapten Fizi & Shida - November 2010
Venue : Sg Besar
Sayang, hanya ada satu gambar sahaja. Huhu~ Selebihnya ada di rumah pula~

Seronok melihatkan gambar-gambar ini. Teringat betapa gembiranya saya pada ketika itu. Eh, tak bermakna sekarang saya tidak gembira. Gembira juga~ hehe

DAY 3 - THE ROAD

With just a glimpse (5months ago), the road seems to be rough & bumpy with no ends to it.....


Yeah, definitely the journey requires a lot of works & sacrifices.........


Need to juggle between so many things~


But I chose to be happy & enjoy the things that I did till the very end~

Always be grateful of what I have & make the best of it....SMILE~


KAU RAHMATILAH KAMI YA ALLAH~ AKU REDHA DENGAN KETENTUANMU~

Friday, December 10, 2010

DAY 4 - WiLL I ?

Will I be able to fit perfectly into the glass slippers?

As this is my last chance to achieve my childhood dream. Pray hard it wont fall & break into pieces like the other side of my delicate slippers. Help me through ya Allah~


I wonder how it feels when it does.....

Dear Liyana.....

only 3 days left...use the time wisely....

May Allah help me along the way...

Lend me your strength, Ya Allah~

Friday, December 3, 2010

KeLetiHaN~


Hati tenanglah dikau, setenang awan di langit~

Sangat bersyukur setiap hari kerana Allah sangat memudahkan urusan saya. Positiviti yang saya ada sangat-sangat membantu & makin sampai kepenghujung, terbit pula rasa sayang nak tinggalkan lecturer2 & UIA.

Dalam semangat untuk meneruskan saki-baki perjuangan, mula merasakan kepenatan yang mula melanda diri. Sebelum ini ada study group, jadinya bila kita penat, kawan-kawan yang tolong ajar & turn kita mendengar & bergilir-gilir dalam berkongsi ilmu. Tetapi sekarang tidak lagi, semuanya harus diusahakan sendiri & hanya kepada Allah saya memohon pertolongan.

Manusia kudratnya sangat terbatas. Apabila kita menginginkan sesuatu, memang kita menggunakan kudrat kita, tetapi siapa yang membenarkan setiap otot-otot kita ini berfungsi??Siapa yang membenarkan sel-sel otak kita memainkan peranan??Semuanya daripada ALLAH kan~

Jadinya, have fun & teruskan usaha & bergembiralah dengan apa yang kamu ada =)

Sikit-sikit kan lama-lama jadi bukit~ hehe

"Ya Allah~ kau lembutkanlah hati examiner2ku nanti~ "

Thursday, December 2, 2010

DAY 12

Today's activity:-

1) clerk papillary thyroid carcinoma case for longcase with prof wahab next wednesday

2) short case session with Prof Hamizah; normal pregnancy, twin pregnancy & breech
- It was just So -so. huuu~ Im frustrated with the performance though~
- nway, learn from your mistakes!!! SMILE~

3) preparing & continue revision O&G.....

Tomorrow, planning to join Dr Bahiyah's class. Im sure the session will be very beneficial to double check how much basic knowledge I had grasp with me. It is also to check wether what I understand is a correct one & lastly, it will help me in answering my PMP paper, insyaAllah =D

=Me: Just be hepy with the things I already have & just do my job the best that could =========================================================

Dear self, Just do the best & the rest leave it to Allah. Nothing to worry rite~ SMILE =D

Wednesday, December 1, 2010

DAY 13

Harinie semasa pulang dari JHC..mendengar ceramah daripada radio IKIM. Ustaz yang memberi kupasan tu sangat famous, tapi malam nie saya terlupa namanya. Ia menekankan tentang betapa pentingnya seorang manusia itu mempunyai sifat redha walau dalam apapun situasi =)

Beliau menceritakan kisah Urwah Ibnu Zubair..antara yang diceritakan ialah~

“Barangsiapa ingin melihat seseorang dari ahli Surga, hendaklah ia melihat ‘Urwah bin az-Zubair” (Abdul Malik bin Marwan)

Dan pada suatu tahun dari kekhilafahan al-Walid bin Abdul Malik (khalifah ke enam dari khalifah-khalifah Bani Umayyah, dan pada zamannya kekuasaan Islam mencapai puncaknya), Allah Azza wa Jalla berkehendak untuk menguji ‘Urwah bin az-Zubair dengan ujian yang berat, yang tidak akan ada orang yang mampu bertahan menghadapinya kecuali orang yang hatinya penuh dengan keimanan dan keyakinan.

Khalifah kaum muslimin mengundang ‘Urwah bin az-Zubair supaya mengunjunginya di Damaskus, lalu Urwah memenuhi undangan tersebut dan membawa serta putra tertuanya. Dan ketika sudah datang, Khalifah menyambutnya dengan sambutan yang hangat dan memuliakannya dengan penuh keagungan.

Namun saat di sana, Allah SWT berkehendak lain, tatkala putra ‘Urwah memasuki kandang kuda al-Walid untuk bermain-main dengan kuda-kudanya yang tangkas, lalu salah satu dari kuda itu menendangnya dengan keras hingga dia meninggal seketika.

Belum lama sang ayah yang bersedih menguburkan putranya, salah satu kakinya terkena tumor ganas (semacam kusta) yang dapat menjalar ke seluruh tubuh. Betisnya membengkak dan tumor itu dengan sangat cepat berkembang dan menjalar.

Karena itu, Khalifah memanggil para dokter dari segala penjuru untuk tamunya dan meminta mereka untuk mengobatinya dengan segala cara. Akan tetapi, para dokter sepakat bahwa tidak ada jalan lain untuk mengatasinya selain memotong betis ‘Urwah, sebelum tumor itu menjalar ke seluruh tubuhnya dan merenggut nyawanya. Maka, tidak ada alasan lagi untuk tidak menerima kenyataan itu.

Ketika dokter bedah datang untuk memotong betis ‘Urwah dan membawa peralatannya untuk membelah daging serta gergaji untuk memotong tulang, dia berkata kepada ‘Urwah, “Menurutku anda harus meminum sesuatu yang memabukkan supaya anda tidak merasa sakit ketika kaki anda dipotong.”

Maka Urwah berkata,
“O..tidak, itu tidak mungkin! Aku tidak akan menggunakan sesuatu yang haram terhadap kesembuhan yang aku harapkan.”

Maka dokter itu berkata lagi,
“Kalau begitu aku akan membius anda.”

Urwah berkata,
“Aku tidak ingin, kalau ada satu dari anggota badanku yang diambil sedangkan aku tidak merasakan sakitnya. Aku hanya mengharap pahala di sisi Allah atas hal ini.”

Ketika dokter bedah itu mulai memotong betis, datanglah beberapa orang tokoh kepada ‘Urwah,

maka ‘Urwah pun berkata,
“Untuk apa mereka datang?.”

Ada yang menjawab,
“Mereka didatangkan untuk memegang anda, barangkali anda merasakan sakit yang amat sangat, lalu anda menarik kaki anda dan akhirnya membahayakan anda sendiri.”

Lalu ‘Urwah berkata,
“Suruh mereka kembali. Aku tidak membutuhkan mereka dan berharap kalian merasa cukup dengan dzikir dan tasbih yang aku ucapkan.” K

emudian dokter mendekatinya dan memotong dagingnya dengan alat bedah, dan ketika sampai kepada tulang, dia meletakkan gergaji padanya dan mulai menggergajinya, sementara ‘Urwah membaca, “Lâ ilâha illallâh, wallâhu Akbar.” Dokter terus menggergaji, sedangkan ‘Urwah tak henti bertahlil dan bertakbir hingga akhirnya kaki itu buntung.

Kemudian dipanaskanlah minyak di dalam bejana besi, lalu kaki Urwah dicelupkan ke dalamnya untuk menghentikan darah yang keluar dan menutup luka. Ketika itulah, ‘Urwah pingsan sekian lama yang menghalanginya untuk membaca jatah membaca Kitab Allah pada hari itu. Dan itu adalah satu-satunya kebaikan (bacaan al-Qur’an) yang terlewati olehnya semenjak dia menginjak remaja.

Dan ketika siuman, ‘Urwah meminta potongan kakinya lalu mengelus-elus dengan tangannya dan menimang-nimangnya seraya berkata, “Sungguh, Demi Dzat Yang Mendorongku untuk mengajakmu berjalan di tengah malam menuju masjid, Dia Maha mengetahui bahwa aku tidak pernah sekalipun membawamu berjalan kepada hal yang haram.”

Kemudian dia mengucapkan bait-bait sya’ir karya Ma’n bin Aus,

Demi Engkau, aku tidak pernah menginjakkan telapak tanganku pada sesuatu yang meragukan
Kakiku tidak pernah mengajakku untuk melakukan kekejian
Telinga dan mataku tidak pernah menggiringku kepadanya
Pendapatku dan akalku tidak pernah menunjuk kepadanya
Ketahuilah, sesungguhnya tidaklah musibah menimpaku sepanjang masa melainkan ia telah menimpa orang sebelumku

Al-Walid bin Abdul Malik benar-benar merasa sedih terhadap musibah yang menimpa tamu agungnya. Dia kehilangan putranya, lalu dalam beberapa hari kehilangan kakinya pula, maka al-Walid tidak bosan-bosan menjenguknya dan mensugestinya untuk bersabar terhadap musibah yang dialaminya.

Ketika ‘Urwah diangkut ke Madinah dan dipertemukan dengan keluarganya, dia mendahului mereka dengan ucapan,

“Jangan kalian merasa ngeri terhadap apa yang kalian lihat. Allah ‘Azza wa Jalla telah menganugerahuiku empat orang anak, lalu mengambil satu di antara mereka dan masih menyisakan tiga orang lagi. Segala puji hanya untuk-Nya.

Dan Dia memberiku empat anggota badan, kemudian Dia mengambil satu darinya dan menyisakan tiga untukku, maka segala puji bagi-Nya. Dan demi Allah, Jika pun Dia telah mengambil sedikit dariku namun telah memberikan banyak untukku. Dan jika pun Dia mengujiku satu kali namun Dia telah mengurniakanku kesehatan berkali-kali.”

Ketika penduduk Madinah mengetahui kedatangan imam dan orang ‘alim mereka, ‘Urwah bin az-Zubair, mereka berbondong-bondong datang ke rumahnya untuk menghibur dan menjenguknya.

Di antara untaian kata ta’ziah yang paling berkesan adalah perkataan Ibrahim bin Muhammad bin Thalhah kepadanya,

“Bergembiralah wahai Abu Abdillah! salah satu anggota badan dan anakmu telah mendahuluimu menuju surga dan yang keseluruhannya akan mengikuti yang sebagiannya itu, insya Allah Ta’ala. Sungguh, Allah telah menyisakan sesuatu darimu untuk kami yang sangat kami butuhkan dan perlukan, yaitu ilmu, fiqih dan pendapat anda. Mudah-mudahan Allah menjadikan hal itu bermanfaat bagimu dan kami. Allah lah Dzat Yang Maha menanggung pahala untukmu dan Yang menjamin balasan kebaikan amalmu.”

============================================================

Subhanallah~ Lihatlah keimanan Urwah Ibnu Zubair~ begitu berat ujian yang Allah lemparkan, tetapi dia tidak sedikit pun menyalahi takdir, malah terus memuji kekuasaan Allah. Subhanallah~

Jadinya sahabat-sahabat, jadikanlah keimanan yang ada pada urwah ini sebagai contoh teladan & motivasi kita seharian ok =)


Tuesday, November 30, 2010

DAY 14


This morning I had a long case presentation with Prof Wahab - AECOAD secondary to pneumonia

Well, today he did comment a lot on my presentation. The content was complete but the way I arranged the points is not up to his standard. Its good when an experienced speacialist corrected your presentation as it will help you to present as houseman in future. Apart from all, I could feel his passion in teaching & he hopes me to do better this time & pass my exam~ So, I listened to all his comments & saved it into my long term memory. hehe

So, he would like me to present again next week on Wednesday. But this time, he would like me to present a surgery case (ntah2, saya akan dapat kes surgery kot kalinie.ahaks=P)

So, here I am & I promised myself that Im going to take the challenge & present better next week up to his standard. Go LIYANA!!! =)


Evening Time:
Revision as usual - BPH & renal stones
& I did lots of MCQs today =)

And guess what~
I got a walnut brownies today!!!thank you awis..u made my day & I studied in the library happier than before.

This is all because yesterday he put up a status in FB saying he made a walnut brownies & I was like...nak!!!haha (siyes xmalu mintak..harap awis xkesah ye~ tapi ni mintak daun keladi,nnt lepas akak xm nak lagi...muahahaha..mmg sah tak malu) Yelaa~ andaikata akak abis blaja tahun nie, ntah bile akak bole rasa lagi kek awis.hehe

Awis is a great cook!!!jeles!!!I wish I have my own kitchen & can experiment with lots of dishes,cookies & cakes. Dik, U should do side bussiness in future.

One more thing that Im craving his yummies sandwiches...huuu~ wat la lagi awis~ akak mengidam nie...sob sob~ =P (dramatik.muahahaha)

Nie Awis yg buat..hebatkan kan kan...hehe

p/s- Still got time & Im gonna use it wisely..Please Help Me Ya Allah~

Monday, November 29, 2010

DAY 15


Today I followed Mr Junaini's class with the final years. We supposed to have an extra class with him but our class clashed with final year time table. So its been rescheduled to this Wednesday. But no heart feeling at all as I still able to joined his teaching =)

Its indeed a good one & I learned a lot too. Afterwards, I asked him lots of questions which I got confused or not sure after doing lots of MCQs.

Guess what, Mr Junaini patiently answer all my confusions & explain everything to me eventhough at that time he was about to go somewhere else. We walked from the ward, went down by lift & stopped near the A&E and sat at the waiting chair to discussed my confusions & misconceptions. Thank you Mr Junaini. He said, its good to asked questions, so that you double checked what you understand to avoid any malpractice in the future due to misunderstanding of certain diseases & management.

Sunday, November 28, 2010

Keep Moving~

Since yesterday morning, more topics successfully revised..Alhamdulillah~
Not only understand the diseases but also managed to do MCQs related to the topic.Syukur~

Thyroid diseases
Breast cancer&benign diseases
Pancreatic diseases - pancreatitis & pancreatic carcinoma

Hopefully - tonite can cover LGIB (colon ca,diverticulosis,hemorrhoids&differences btwn UC,CD)

"Ya Allah, Kau lah yg Maha Pemurah, yg Maha Mendengar, yg Maha Berkuasa...
Kau mudahkanlah urusan kami...."


PS - My family will return to Malaysia on 1st dec..Yipppeeee~

PS - Yesterday had a wonderful talk regarding life as HO, but I chose not to go eventhough deep down im screaming to attend the talk. Huhu. After deep thinking, I made a decision to sacrifice from attending the talk & prioritise my work - focusing on my exam. Plus my husband came to kuantan yesterday.

It was great, I do my revision next to him. Whenever I did my MCQs & there's something that I couldnt find in the book, he will help me to search for the information in the internet.
Semoga Allah melindungi kamu & mudahkan urusan kamu =)

Friday, November 26, 2010

Surgery Revision

Morning revision: Hematemesis; Esophageal Varices, PUD

Esophageal varices:
accounts for 30% of UGIB
commonest etiology in msia: hepatitis B, Alcohol

Pathophysiology:
Liver cirrhosis
--> increase in flow/portal vascular resistance
--> Portal hypertension
--> Development of portosystemic shunt when hepatic venous pressure gradient (HVPG) more than 10mmHg (Normal <5mmhg)>Development of collaterals including esophageal varices

Causes of CLD
- Alcohol
- Hepatitis B&C
- Aflatoxin
- Drugs - amiodarone methotrexate
- metabolic causes - wilson dz,hemochromatosis, alpha1 antitripsin deficiency,etc
-autoimmune - Primary biliary cirrhosis, primary sclerosing cholangitis

SELINGAN--> Causes of ACUTE liver failure
Viral hepatitis (A,B,C,D,E)
Drug reactions (halothane, isoniazide-rifampicin, antidepressants, NSAIDS, Valproic acid)
PCM overdose
Mushroom poisoning
Shock & multiorgan failure
Acute Bud-chiari syndrome
Wilson's disease
Fatty liver of pregnancy

Portosystemic shunt (Portal Tributaries) (Systemic tributaries)

Esophagus&gastric LEFT GASTRIC VEIN Azygous & Hemiazygous

Umbilicus Paraumbilical Vein in Falciform ligament Superficial ant abdominal vein

Anal Canal Sup rectal Vein Medial,inferior Rectal Vein

Retroperitoneal Venous radicals of: asc+desen colon, duodenum, pancreas
Retroperitoneal Veins: renal, suprarenal, gonadal, lumbar, phrenic veins

Bare Area of liver Portal branches veins of diaphragm

Child Pugh Score1 2 3
Encephalopathy NONE Minimal MARKED
Ascites NONE Slight MODERATE
Se bilirubin
se albumin
INR

Risk factor of predictive rebleeding
- age>60
- degree of hepatic decompensation
- active bleeding of time of initial endoscopy
- severity of initial bleeding
- size of varices
- level of portal pressure
- renal insufficiency
-hepatoma

Japanese classification of Esophageal Varices
Absent
Grade I: small straight varices not dissappearing with insufflations
Grade II: Medium varices occupying <1/3
Grade III: Large varices occupying more than 1/3 lumen

Acute Management:-
Stabilise patient hemodynamically
ABC
Take VS - BP, SPO2, RR
2 large bore IV branula & take blood for investigations
KNBM (prevent aspiration & for surgical intervention later if needed)
NGTube
CBD - monitor input output
CVP - to monitor volume given as not to overload pt esp pt with heart problem

Investigations taken:
FBC, GXM, BUSE, RP, LFT, PT/APTT, RBS

Blood transfusion should be given when:
Systolic BP <110mmhg>110/min)
Significant postural hypotension
hb <8g/dl> whole blood
otherwise--> pack cell
FFP if INR>1.5
platelet transfusion <50> for endoscopy ligation

Endoscopy sclerosant therapy has more SE: ulcer, stricture

Pharmacological - Vasoactive drugs (reduce pressure & flow within varices)
I list down based on generation
1) vasopressin (man made ADH) - increase blood pressure by causing vasoconstriction
has more systemic Se: MI, mesenteric ischemia, infarction

2)Somatostatin - produce by delta cell in pancreas
function: reduce blood flow to intestine. Half life: only 2 hours
SE: transient bradycardia, cramping
irreversible SE: thrombocytopeni, extrasystole

3) Octreotide (Somatostatin analogue) - half life-longer~ 8hours

4) Terlipressin (Vasopressin Analogue) - longer half life, fewer SE
Effective in control bleeding. shown to have more sustained hemodynamic effect compared to octreotide

Other modes of treatment if problem persist:
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
used only in uncontrolled variceal bleeding after combined pharmacological & endoscopic treatment

Pharmacological prophylaxis
non-selective Beta blocker~ Propanolol

CounTDowN~



Its down to 2weeks left. Cepatkan masa berlalu.

I think Im able to feel dis way because I really enjoy along the way. No point of blaming others, thinking you should pass & they made a BIG mistake. No point of blaming fate. No point of feeling sad & depressed. No point of thinking negative about yourself.

The best way is to take this opportunity (never think it is a setback) to grab more knowledge & learn more from the lecturers. Correct all the mistakes that you did before & strive for the best. You might not know what's a head of you. Yes you are not sure wether you could make it this time or not. BUt hey~ what's the point of worrying. Just fulfill your responsibility & the rest leave it to Allah. Ape2pun, you already have the knowledge. So SMILE~

Orang Islam harus menerima Qadha & qadar, teruskan usaha & tawakal pada Allah. Allah kan Maha Mengetahui dan Maha Adil. Apa yang Dia tetapkan pasti ada kebaikan & hikmah disebaliknya. Ini adalah janji-janji Allah. Jadi kenapa mahu susah hati??betul tak??hehe

Thanx to my parents, my family, school teachers, lecturers & friends for teaching Islam since I was born until today. If not because of them, I definitely will be just like some of people out there whose life is chaotic & miserable with nothing to hold on to. Im so fortunate to be blessed with a strong&positive heart & mind. For me now, my 5months challenge nearly come to an end. Please pray that Allah will ease my way through & im able to pass my final exam this time.

Minggu nie, saya banyak revise medical. Terasa banyak yang sudah samar-samar dalam ingatan kerana medical adalah posting pertama saya (4bulan yang lalu). Jadinya, apa yang saya buat, pagi-pagi adalah saya praktis short kes & kemudian ikut ward round. Jadinya di situ saya dapat menilai di mana kelemahan saya. Sebelah petang pula, saya revise teori & tekankan pada apa yang sudah terlupa pada siang hari. I miss my study group very much. The best thing now is to make the best of what you have and be happy with it =)

The best part for this week was Dr Hasnur offered his time to do extra short cases with us. Abdomen system & cardiovascular system. He said he picked this 2 systems for our short cases during this Pro. Ouhh thank you for the tips doc!!Indeed~ you are an inspiring lecturer with vast of knowledge. Keep teaching IIUM students & shared your knowledge with us. You always make things easy for us. May Allah bless you & your family =)

This weekend I will revised surgery as I have revision session with Mr Junaini on monday. And I promised to myself to give my VERY best =)

Ya Allah, please lend me your strength & ease my way through~

P/s - ouhh, i really need a vacation. Yipppeeee~


Monday, November 15, 2010

Home

Im going home tomorrow. Kena packing malamnie.

Esok bangun pagi-pagi kena check air kereta, isi minyak & jangan lupe beli keropok lekor mak mintak tolong belikan =)

Rabu - beraya
Khamis Jumaat - Stadi medical (saat terdesaknie kena stadi wpn balik rumah.huuu~)
Sabtu - blk kampung
Ahad - balik kuantan

A Warm Welcome

Alhamdulillah~ akhirnya saya memasuki final posting. Psychiatry posting.

Seawal jam 8pagi, saya berjumpa HOD; Dr Ramli Musa. Setelah berbual-bual dengan beliau, akhirnya beliau memutuskan kami hanya perlu mengikuti posting ini untuk minggu ini sahaja. Bermakna, saya akan dapat 2minggu revision week!!yuuuhuuu~ terima kasih Dr Ramli.

Berkenaan psychiatry, beliau hanya suruh saya menekankan aspek teori. Tiada kes klinikal yang akan keluar untuk peperiksaan kedua saya ini.

Dr Ramli pada awalnya,bertanya serba-sedikit apa yang terjadi ketika long kes saya yang dahulu. Seperti biasa, saya tidak dapat menjawab soalan beliau. Yang saya katakan adalah kemungkinan saya tidak cukup bagus untuk mempertahankan point yang saya jual dan di situ tidak kelihatan cukup konfiden. Dan saya juga menyatakan mungkin saya banyak juga jatuh ke dalam perangkap examiner saya. Apabila sudah terjerut, nah~ inilah akibatnya. Haha. Saya memberitahu Dr Ramli yang saya tidak menyalahkan examiner saya & saya ambil 6bulan ini untuk mengasah skill komunikasi dengan examiner.

Tapi, Dr Ramli mengakui pakar paeds di UKM sesungguhnya memang strict & tidak memberi muka. Huuu~ Beliau juga membuka rahsia bahawa sebenarnye pada hari exam yang lalu ramai yang fail untuk long kes paeds. Beliau membuka rahsia bahawa doktor yang sangat kite kagumi (Doktor penulis buku protokol kita) sebenarnya sangat strict dalam memberi markah. Dalam 3 pelajar yang present kes paeds padanya, hanya seorang sahaja yang lulus.Huu~

Kemudian, Beliau menyatakan beliau gembira melihat saya mengambil semua ini dengan positif. Saya hanya tersenyum. Dan malam ini saya terfikir, doktor dah wat mental state assessment pada saya dalam diam-diam kah.Muahahaha~ Apa-apa pun, saya gembira bile orang gembira melihat saya. Bile mereka gembira, pastinya mereka akan doakan kita kan. Sesungguhnya, Dr Ramli sangat mengalukan kami di psychiatri posting minggu ini =D

Kemudian, saya menyertai klinik Dr KArtini. Seperti biasa, hanya saya dan junior. Banyak yang dapat dibincangkan. Pada akhir sesi, saya bertanyakan soalan yang saya keliru semasa saya membuat soalan MCQ semalam. Terasa ringan kepala apabila apa yang dipelajari makin difahami. yeayyy~ Thank U Allah~

Kemudian, selepas kelas saya memaklumkan kepada Dr Kartini bahawa kami akan di posting ini seminggu sahaja. Kemudian, beliau bertanyakan tentang pelajaran saya setakat ini. Rupa-rupanya banyak yang Dr Kartini tahu tentang kami berdua. Memang gembira berbual-bual dengan beliau, terasa beliau sangat memahami saya. Tak semena-mena, beliau memahami saya yang selalu kena handle my colleague. Terus terasa ringan di dada. Thank you, Dr Kartini.

Petang tadi, join kelas anxiety disorder with Dr Hajee. Tringat masa Nazu present. Hehe.Oh ye, Nazu juga sangat tabah selepas ayahnya meninggal. Alfatihah untuk arwah~

Indeed today is my happy day. Betullah kata Mr Kamarul, walau apapun orang buat, jika kita jalankan tanggungjawab kita dengan baik, the news will spread & the truth will reveal by itself.

P/s - Malamnie, nak abiskan stadi psychiatry, balance topik yang tak cover =) Esok nak tanya soalan banyak-banyak kat doktor. Yoshhh~

Saturday, November 13, 2010

A New Day

List aktiviti harinie:

Subuh - Ya Allah, kau mudahkanlah urusan Kami~
Kemas bilik, basuh baju, susun nota
Breakfast - Bayroute - nasi dagang.Nyummm~
JHC library til evening - cover CVS
Dinner Outing with roommies - Santai - My menu:Spagetti bolognaise, fries & Lychee drink
Room - Watching Nobuta Wo Produce + reading psy notes

Just now, I received message FB from Dr Hasnur asking do we want any revision with him. Straightaway I said YESSSS~ rezeki jangan ditolak. So I will see him on Monday to arrange our timetable. Thank You doctor, both of us really appreciate it =)

Thursday, November 11, 2010

3 Weeks Away

Im at the library right now. Just finished revision on one of the O&G topic (Benign & malignant condition of UTERUS).

So, how do I feel today?? Practically, Alhamdulillah~ Im very happy as usual. Eventhough yesterday, the mood was like a roller coaster. But thats life kan. Touch & Go. Haha.

Everyday I reached the ward & reviewed the patient at 7.40am. But today, I felt like to sleep a litttle bit & woke up at 6.15am & later went to JHC at 7.05am. Today I fetched wahid at Dr Bahiyah's house. She still cant drive her car. Busaha ck wahid!! Who knows, maybe later I may be in need like wahid right now. Life is like a wheel, isnt it??hehe

This morning I supposed to have class with Mr Shukrimi. Yesterday he said he will do it after his OT, but he warned us to just standby in the ward. Initially, I thought of went to the ward slightly late. But at 7.40am, while having breakfast, I saw Mr Shukrimi with Mr Amin walking to the hospital from JHC. So I cancelled my plan & went to the ward as usual. My concept is must be there before 8am.

While im in the ward, leisurely suddenly Mr Shukrimi arrived & asked me "where is the others??" "erm.. tak sampai lagi doctor" "please call them, you are suppose to be in the ward at 8am" & I contact the unscheduled student & my colleague

Im in the ward early, maybe im used to be trained like that by our lecturers since my 3rd years especially in surgical posting. Prof Kyaw and Mr Junaini will inadvertently came to the ward & would like to do class at 8am without informing the students earlier. This is because the student s must be in the ward by 8am. So I always train myself to always be ready at all time & most important is always expect the unexpected

Later, they arrived & we started the classes. We discussed mainly on Osteoarthritis case. Its indeed a beneficial one for me =)

12.30pm: had discussion with Aswad, Farhi, Syaifi & Fendi about Varicose vein examination. Tribute to Mr Faidzal who taught me that. Its indeed a good revision for me.

In the evening, as usual I studied in the library.

And guess what, currently Im following the malay drama at 6.30pm on TV3 - CHINTA. Initially I hate that story as I think there is no values in it. But my oppinion is different when i watched this drama this week. There is changed of the behaviour in the drama which makes me want to watch everyday. hehe

But Dont worry. I will still take care of my study. Hehe

Wednesday, November 10, 2010

CLOUDY

Currently its raining cats & dogs everywhere. I guess lately its raining in my heart too. Initially I just ignored this feeling & move on. But I guess, I just cant help it & need to write this down.

Its just 3 weeks to pro & suddenly I felt like this. WHy?? I just couldnt know why. Am I stress? Am I not happy? Am I not prepared? Am I...& still I dont know why.

BUt I hate to be sulking around, being pesimistic & just lock your self up. I want to be freed from this feeling. BUt I just dont know how.

I think since last week I noticed I couldnt open my book during night time after isya. Usually I will study atleast one topic during the night & later sleep tightly. BUt I just couldnt do it anymore since last week. I want it to be stop but its still recur day after day.

Time & tide wait for no man. If all this persist, my future will be at stake. I dont want it to get in my way. Maybe I need a little rest & pray more to Allah.

May Allah help my way through. There are times I felt soooo hopeless & just want all this to come to an end, pack my things & run away. BUt that is soooo not my style. Run away definitely wont settle the problem, instead it will pile up more problems than before.

Maybe I just need to bear this feeling for awhile & just do what I can as usual. Hoping all whis will just fade away~

Dear myself,
Please Be patience. Its just for awhile. When the going gets tough, the tough will always gets goin. With all the patience you showed, Allah pasti takkan sia sia kan kamu. So held your head high & SMILE AS ALWAYS =)

Shoulder Examination

The other day, I did not complete regarding the shoulder cases that I saw in the clinic with Mr Amin. Today Im eagerly would like to share the knowledge that I had. Today, after the session in the clinic had ended & I asked Mr Amin to teach us a proper way to approach shoulder pain.

In my oppinion, eventhough it wont be tested in our professional exam, but during practice, we need still need to know regarding this, right =)

Mr Amin said
"SHoulder is quite difficult for undergraduates & the examination is quite long. So things that Im going to teach today is the basic one" =)

PREPARATION:
1) Expose patient adequately. If male, ask him to take the shirt out. If female, expose the best as you can.
2) make sure the patient shoulder is at the same level as you especially if the patient is too tall or too short. You can examine in sitting position, facing the patient, but make sure the patient did not lean to the seat.
3) Make sure both ( you & the patient) are comfortable.

LOOK: ( Need to do from front, lateral & back. Make sure you compare with the normal side)

Anterior
a) Contour of the shoulder - Shape & any swelling

b) Skin changes - scar, inflammation (redness)

c) Wasting of muscle - indicate prolong immobilisation
- supraclavicular region
- Trapezius, SCM, Deltoid, pectoralis

d) Deformity - any bony prominence such as prominent clavicle due to facture

e) Sulcus sign
- loss of normal shoulder contour with a visible step from the acromion process to the humeral head due to wasting & weakness of the deltoid / subluxation of the glenohumeral joint

f) attitude of both upper limbs
-shoulder internal/external rotation
-elbow flexion / extension
-wrist & fingers deformity

Lateral (go to patient side)
- Skin changes
- WAsting of deltoid muscle

Posterior (go to the back)
a)contour of shoulder

b) skin (scar/inflammation)

c) wasting of muscle
- suprascapular region
- trapezius, deltoid, supraspinatus, infraspinatus, latissimus dorsi

d) prominent medial border of scapulae
- winging of scapula
- long thoracic nerve palsy

FEEL
Palpate along these structures & look for tenderness / feel for any abnormal bony prominence

( Initially stand infront of patient)
From sternal notch --> sternoclavicular joints --> along the clavicle --> acromioclavicular joint --> acromion process

(then, go to the back of patient, continue palpation from the point where you left)
palpate along the spine of the scapulae --> medial border --> tip & lateral border of the scapulae --> until back to the acromion process--> go to subacromion & palpate downwards the humeral head until mid upper arm

tenderness could indicate:-
- sternoclavicular/ acromioclavicular joint OA
- subacromial region for impingement

MOVE
Ask patient to lift the arm upwards with elbow extend in few positions:-
Lateral position (normal position - 20 degree) - 0 - 180 degree
Flexion (0 - 180)
Extension ( 0 - 70 degree)
Abduction (0 - 180 degree)

then ask patient to do:-
Adduction ( 0 - 75 degree)
Internal rotation (0 - 90 degree)
Extrenal rotation ( 0 -90 degree)

Then go to the patient's back & ask patient to flex the elbow & move the shoulder like cycling. Do it simultaneously at both sides, gently & slowly ( but not too slow)
From the back, we put our hand on the scapula, observe & feel the movement.
Normal: there will be slight movement
Abnormal: if the movement is too obvious/marked
Suspect abnormality at the scapula - winging/long thoracic nerve injury

SPECIAL TEST
1) Instability Test (check for any instability - to suspect any dislocation)
a) Anterior drawer test
b) Posterior drawer test
c) With hand dangling downwards, pull the arm downward & observe for sulcus sign
Positive: multidirectional instability

2) Apprehension Test (anterior instability)
- abduct the shoulder & flex the elbow
- then slowly, externally rotate the shoulder
- when patient feels that the shoulder is dislocating anteriorly, he will resist the movement

3) Impingement Test ( empty can sign)
ask patient to abduct the arm
the hands do the thumbs up sign but facing downward (empty can sign)
while patient abducting the arm, we give patient downward resistance
Positive: pain felt at affected shoulder

4) Rotator cuff muscles test
a) Hawkin's test (test supraspinatus muscle)
- abduct the shoulder with elbow flex
- then slowly internal rotate the arm until patient felt pain
- do in few positions as you would like to test the whole supraspinatus muscle
arm abduct, lateral position, flexion
positive: patient felt pain

b) Napolean test (muslim's prayer) - test infraspinatus & teres minor
ask patient to put both hands on the belly like performing prayer
ask patient to push the hand outward & you give resistance to it
positive: patient felt pain at affected side

c) geber's test (test for subscapularis)
- ask patient to put both hands at the back
- try to move the hand upwards until the thumb reach the middle of the back
or you could ask the patient to push outward & you give resistance to it
positive:pain on the affected side

d) felt for biceps tendon tenderness

5) drop arm test
patient lift the arm up
alowly lower the arm
at around 105 degree patient will experience the arm is beyond his control
then arm will drop --> positive

reasons: deltoid muscle requires the intact rotator cuff to pull the humeral head towards the glenoid fossa & stabilise the humeral head to the glenoid fossa in order to allow a lever arm for further abduction by the deltoid
- with tear of the supraspinatus tendon, the leverage is not effective, therefore the deltoid is unable to hold the arm even above 90 degrees

Until here was our lesson with Mr Amin.
But I forget to ask, must we complete examination with checking the sensation
(autonomous area of axillary, radial, median & ulnar)

========End===========

Tuesday, November 9, 2010

Vital Signs

This is exactly the question being asked by Mr Khairussalleh to each group that went to Surgery posting. Believe me. Hehe. Since my professional exam is around the corner. I will put it here, then. So I will always remember & will use it during my practice later on.

Blood pressure
Systolic
100 - 140 mmHg (male)
90 - 140 mmHg (female)
Diastolic
60 - 90 mmHg (both)

Pulse rate
60 - 100 beats/min

Respiratory rate
14 - 18 breaths/min

Temperature
36.8 C - 37.2 C

Pain Score
0 (no pain) - 10 (the most unbearable pain to the patient)
Prof Azmi did asked how do you standardise the pain score in between?? & I couldnt find the answer until today. Huuu~

Sunday, November 7, 2010

Eating Frenzy

Alhamdulillah. Im having a good time this weekend. Too much study& no play pun tak bagus jugak kan.

So yana decide minggu nie minggu berehat-rehat yana. I dont want to stress up myself. I want to reach to the end with a smile on my face. Im doing the best as I can & always believe Allah will always help me.

Weekend nie, I noticed Im craving to eat lots, lots, lots, lots of things. Haha. Ive said to my husband many, many, many, many times that I had made a list that Im dying to eat (dramatik =P) Maybe banyak sangat blaja & dah lama tak enjoy other food than nasi putih. Hehe. So this is what we had in the past 3 days~

1) Seafood esp sotong goreng tepung & udang (xkisah masak ape2,janji udang besar=P saya mmg hantu udang.Hoho), Tanjung Lumpur.

2) Snack plate, KFC

3) Mushroom steak - we ate kat kedai berdepan Hotel KOSMA. Initially nak pegi coffee street. Tapi husband insist try kat sini (taste ok but I think sedap lagi kat coffee street & daging dia lagi tebal. Husband agreed to it. But actually im still craving nak mushroom soup&garlic bread kat coffee street.Huuu~ )

4) Satay (nie makan kat kedai sama di atas. Bungkus & makan sambil tengok TV.Memang heaven. Lama tak wat makan sambil tengok TV. Hehe. Satay dia sedap, nie cawangan kecik Satay Zul)

5) Nasi kukus Mazenah. (berdepan grand city hotel. My husband favourite's right now. Asal datang kuantan mesti singgah sini. Ayam berempah dia memang superb!! Nyummm2~)

6) Gerai Paksu - makan goreng2. Udang goreng tepung, sata, pulut panggang, ikan goreng tepung, fish ball.

7) Roti canai Pak Lah - nie memang dah jadi aktiviti kesukaan saya dikala weekend. Since husband datang, jadinye heret skali =D

Quite a lot kan. Haha. Tapi ikutkan hati ada few things lagi yang I want. Tapi tak sempatla kan.
- cheesy 6 pizza (wpn haritue da mkn dgn roomate, tapi saya mau lagi..Huuu~
- Kopok sagu, Tanjung lumpur
- Spagetti

Dah, dah. Kalo di listkan ape nak makan skang, memang takde kesudahan. Haha.

I guess, I really enjoying my life as a student & a wife =)

Wednesday, November 3, 2010

Sports Injury & Shoulder Day

Wednesday in Orthopaedic clinic is for subspecialty (sports injury, paeds case, OA, shoulder, etc)
Yesterday, Mr Shuk advised us to find sports injury cases as it will definitely come for our short case in december. (Soalan bocor!!!hehe)

So we follow Mr Amin, as currently Mr Amin is the one who will do the ligaments reconstruction

me: Mr AMin, can we follow your clinic.
mr AMin: Yes (with a smile)

BUt Mr AMin had a right knee pain today (gout) - syafakallah doctor

1st case is one of IIUM staff.
Previously had underwent Left knee ACL reconstruction in 2004. Currently came with left knee pain.

Examination revealed : positive patella grinding & medial joint line tenderness
Diagnosis : Patellofemoral & medial compartment arthritis
Management: Physiotherapy, cycling, analgesic. TCA 3/12

Later we had lots of shoulder cases

(will complete the entry later.Huuu~ currently something need to be done.)

Day 2 (second part)

Later I went to clinic & follow Mr Shuk Clinic

One of the case was:-
An early 30th gentleman, overweight, walked into the room using stick (both sides)

Mr Shuk: hah, liyana, examined this patient leg. Tell me what you see
Me: terkebil-kebil...ok..here I go~

Look:
There is multiple scars at the left leg
3 vertical scars
1st: medial side estimating about 25cm
2nd: anteriorly but slightly lateral measuring around 30cm
3rd:lateral side estimating 25cm
all of the scars are well healed
There is also multiple puncture scars extending from the distal third of leg up to the lateral thigh - due to external fixator crossing the joint
One irregular healed scar at the middle third of tibia measuring about 10cmx5cm)
Otherwise the leg is not swelling, no deformity & not wasting

Feel:
The scars are non tender,
no edema of the leg
no bony discontinuity felt (try to find bone gap - in case of nonunion)
No bony tenderness (try to locate the fracture site if it is still tender)
pulses equal & CRT <2secs

Move:
fracture site is not mobile
ask patient to move the leg & the joint actively

In conclusion (explanation based on scars)
This patient had closed fracture of upper third of tibia
complicated with compartment syndrome - fasciotomy done (scar at medial&lateral side)
fracture was stabilised with external fixator (external fixator scar)
after wound closed by SSG (the irregular scar), pt undergo plating (the anterior slightly medial scar)


Fuhhh~
Initially dah tertipu ingatkan open fracture due to EF. memandangkan ada fasciotomy trus tuka it is closed fracture. EF was put after fasciotomy done

DAY 2

Yesterday I had one short case session with Mr Azril. He chose Diabetic Foot Ulcer Case & Im the one who examined the patient.

Our session was joined by elective student from Jogja. But since they are still preclinical. So I think many things they still blur.

This is what we had discussed yesterday.

Mr Azril: This patient 37 years old with history of diabetes melitus for 5 years presented with an ulcer. Please do lower limb examination =)

General: (eventhough the Q is LL, but still we need to give the general overview of the patient. Just observe about 30seconds for overview of patient condition. )

This is 37 years old with medium body build
Alert, conscious & comfortable.
Not in pain, not in respiratory distress.

Lower Limb Examination: (make sure to expose the patient adequately)
Look
Both leg is in normal attitude
There was no deformity, no foot drop, no clawing (hyperextension of prox phalanges & flexion of interphalangeal joint) or hammer toes, no pes planus or pes cavus
No muscle wasting ( in this patient - to detect any disuse atrophy)
No scar

There was hyperpigmentation at bilateral leg up to the knee
Skin is very dry & there is some scaly lesion
There is presence of wrinkle sign (indicate previously patient had swollen leg)
There is loss of hair
The nail is brittle
Presence of callosities at the sole

There is a gross, big & deep ulcer at the sole
extending from the big toe to the "ball of 1st toe" --> Mr Azril said to use this term
Estimating about 10cm x 5cm
with regular margin which is due to incision
The ulcer is wet, there's blood & pus with granulation tissue
There is also presence of necrotic tissue
It is foul smelling
There is expose of bone
The surrounding is dry & scally

Feel:
The leg is not warm, no edema
The ulcer is slightly tender
There is no collection of discharge/pus
The bone is not tender (to check any evidence of osteomyelitis)
For Pulse
DPA were palpable bilaterally with equal volume
PTA were not palpable
CRT <2> doc did not discuss detail which I really want to know how it is done
(use 10g monofilament, test at 10 sites..but do no how many pt cudnt feel can we say it is positive)
ABSI (assessment of healing potential)

Q: What is your diagnosis??
Diabetic foot ulcer
based on: (do give reasons straightaway, do not wait for doctor to ask)
- he's DM since 5 years ago
- there is trophic changes, callosity
- site of the ulcer

What is patophysiology behind the DFU?
Triad of neuropathy, ischemic & immune

Neuropathy - sensory, motor & autonomic
what is 1st sensory to loss in DM?? Vibration

How callos is formed?? due to loss of autonomic regulation (the sweat glands), loss of perspiration, later thick, dry callus is form. Could become crack hrough dermis & become source of infection

How clawing happened??
due to imbalance between extensor & flexor of intrinsic muscle of foot
abnormal pressure on plantar expect would lead to either pes planus or pes cavus

How DM have immunosuppression??
impaired leucocyte function (but the number of leucocyte is still the same)
slow chemotaxis & phagocytosis

How you managed this patient???
Investigation
blood investigation
1) FBC - Hb, WBC (as baseline before treatment & as preparation for pt to go to OT)
p/s- eventhough WBC pt normal doesnt mean pt does not have infection of the ulcer. its just because pt is immunosuppressed
2) BUSE
3) Renal Profile (screen for other DM cx)
4) UFEME
5) HbA1c ( glycosylated Hb - to assess the Dm control for past 3months)
6) se albumin - help in healing
7) Lipid profile
8)Swab C&S of wound

Radiological
Xray of the affected toe

===== end of session =====

Monday, November 1, 2010

What A day~

Setinggi-tinggi kesyukuran ke hadrat Ilahi.

Alhamdulillah, I already went through my first day. As usual, I woke up early, pray to Allah to ease my way today & upon reaching JHC, I took good breakfast. I always noticed,having good breakfast in the morning makes my endorphin&serotonin level increased & I feel more relax, happy & could think clearly.

When I reached the ward, I reviewed few patients. Do simple clerking but no PE done yet. I saw Dr Goh reviewed his patient & straight away went to him & introduced myself. But unfortunately he was not the MO doing round that morning. So he just gave me a list of things that I need to cover for my second Professional exam & he told me to focus on it.

So today, I followed Mr Azril at his clinic. He was my supervisor back then when I was Year 4. He still recognised me as one of his mentee.

Currently, Im happy to see Mr Azril in a good health because I still remember previously he had hematemesis & collapse in JHC. He was resuscitated in the A&E & everybody was sooo worried about him. After investigations, he was found to have gastric ulcer due to chronic usage of NSAIDs. After that, he took long MC & we, the mentee had only few classes with him. But that doesnt mean we can skip from going to ward. Instead our groupmates always joined other lecturers for teachings.

Today, most of my time spend in the clinic seeing lots of oncology patients under Mr Azril's supervision.

There was a patient middle age gentleman, medium body build came in with a small lump at his right hand - medial tu cubital fossa. Estimated size was 4x5cm, oval shape, not erythematous, no punctum, no discharge. The mass was non tender & not warm, has regular border, firm to hard consistency, irregular surface, slightly mobile & attach to underlying muscle. suggestive of a tumor.

Mr Azril : What muscle do u think it might attached to / arise from??
Me: Superficial flexor muscle.
Mr Azril: Just say flexor muscle, by palpation it can still arise from deep group muscle.
Me: understood~

Afterwards, mr Azril was flipping through the patient's radiograph but couldnt find the xray of the forearm. But there was CT Scan & MRI belongs to the patient & he look at me....

mr Azril: would like to see the patient's CT scan??
Me: me Looking puzzled~ why?is there any finding??But sorry doctor..what is actually your question?? (laughing~)
Mr Azril: Im trying to find the Xray..so, would you like to look at The CT scan??
Me: No~ (with confident)
Mr Azril: Good..If not I would ask you to go back & read books. (& the laugh continued)

Later,the patient was plan for tru cut biopsy of the small mass to send for HPE next week. The diagnosis was not confirmed yet.

Second patient:
A 50+ year old gentleman came in with a very gross & enlarged swelling of his left arm.

The swelling was from the middle third of upper arm extending down to the middle third of forearm (Series sangat besar - bayangkan macam popeye nye arm. tapi popeye hanya dekat forearm).

Estimated size nearly 40cm length but I coudnt estimate the circumference of the arm. There was scar at the lateral side (incision post biopsy), well healed & presence of dilated veins seen. Otherwise, not erythematous & no discharge
The mass was nontender, not warm, hard in consistency (felt like bone) & irregular surface.

Patient still able to lift the hand, flexed, extend & pronate the hand but the range is reduced compared to the normal side. To my suprise, you could no longer feel the elbow from below when you flexed the affected hand. If you just hold the upper arm & move only the distal forearm. You could feel as if this patient had pseudarthrosis - the forearm was able to move side to side & up& down. The joint was actually destroyed. However, the sensation was intact.

Reviewing the patient's CT scan of left arm. The diagnosis made was synovial chondromatosis. In this patient, it is a benign condition.

Other cases, I able to see were fibrous dysplasia (the deformity in the femur called shepherd's crook deformity - I cant answer this Q, luckily all the HO also cant answer the Q. haha), exostosis & osteoarthritis.

Later, I made an appointment for short case with Mr Azril tomorrow morning at 8.30am before he went for his clinic duty.

Im sooo looking forward for tomorrow's lessons. *Bersemangat mode*

p/s - ouhh ye, one HO asked me "dik, cari ape??" & I was like...erkk..ermm...cari kes tuk shortcase esok with Mr Azril"

HO: kamu year berapa??
Me: Final Year
Ho: bukan exam ke??
Me: saya special skit. kat ortho nie 2mggje
HO: aikk..asal waktu kitorang takde pun??
Me: eh??doktor nie UIA ke??xpenah nampak pun..doktor batch brape??saya sbenarnye remedial...
HO: oo yeke...a'ah.saya batch 8..saya mmg tak duk hostel.duk umah & xbercampur dgn orang sangat. Haha
Me: ouhh 8???atas saya je tue..saya batch 9..meaning doc nie batch mok, nazhan,etc
HO: a'ah angguk2...kamu camane??ada stress2ke??jgn risau ok, kamu mesti boleh wat nye. Kalo ada apa2 xpaham, tanye je saya. tanye je ape2, surgery,paeds, Im, O&G, sume boleh. Nak ajar shortkes pun boleh. If saya takde wad masa tue, call je operator suh sambung kan ke Dr Azrul HO ortho. Biasanya orang macam kamu nie yang akan sambung blaja sampai speacialist... (sambil tersenyum~)
Me: erkkk.. (terkedu seketika)..tima kasih doktor...(dalam hati terkejut dgn keramahan senior yang sorang nie)
later,I end up review some patient with him =)

Sesungguhnya, pertolongan Allah itu selalu ada dimana-mana, btul tak???
Jadinya, kenapa kita selalu bersedih & menyalahkan takdir??
Fikir-fikirkanlah~

Sunday, October 31, 2010

Revision & Weekend

Tomorrow will be my first day in Orthopedic department. Its only for 2 weeks.

Last 2 days, I already went to ortho office & inform them of our presence. I did this because they also a human beings & human sometimes do forget. However, the staff there told me to call Mr Shukrimi as previously he was the one who will arrange teachings for us. So, I did.

Mr Shukrimi asked me to informed HOD ; Mr Nazri. BUt since Mr Nazri is about to leave Malaysia for conference next week, he will be the one who will call Mr Nazri. So far the plan for Monday is follow rounds & go to clinic until further notice.

So, here I am. studying for ortho & cancelled my plan to go home his weekend. Yesterday, I went to traumatic course & yeah it did help me in revising the important points in the topic.

Wish me luck in orthopaedic. Hope I can bring my positivities in it.

p/s - Topic for 1st stage revision - common diseases in ortho
- Open Fracture (as well as close fracture)
- Complications of open fracture - compartment syndrome, fat embolism, shock
- Non-union, delayed union, malunion
- Traction, POP
- Diabetic foot ulcer (classification, pathophysio, management & short cases)
- Antibiotics
- Anatomy of Upper Limb & Lower limb
- Nerves (brachial plexus, lumbosacral plexus)
- Peripheral nerves (ulna, median, radial)
& Important physical examinations

=== Islam Is A Way Of Life ===Proud Covering My Aurah ==== Proud To Be A Muslim====

Saturday, October 30, 2010

Trauma Seminar: Management of Open Fracture

Yesterday (30th October) I attended a one day course organised by Orthopaedic department.


(I will complete this entry later. Hehe)

Friday, October 29, 2010

From This Moment

A Song From Shania Twain...

I always love this song as it reminds me of something which I adore very much =)
Yes, you are right...its My Dear Husband~

This will be the longest time we are not be able to meet each other..... for 3 weeks~

But both of us know, we gotta do what we gotta do....
And eventhough you are far from my sight but you are always close to my heart...

As always, lets keep praying for each other & hope to see you soon~




p/s- next week, Im going to start another new posting. Orthopedic
Tomorrow Ill be joining an Orthopedic Course which is Open Fracture Management =)
I believe it will be a good revision for me, insyaAllah

"Ya Allah, engkaulah yg maha kuasa, maha kasih & maha penyayang. Kau berikanlah aku kekuatan & semangat & sinarkanlah hidup kami dengan cahaya RahmatMu. Ameen~"

Wednesday, October 27, 2010

HectiC

This week is the last week of paeds posting. Same applied to the current final year students. So lots of classes had been cramped into this very precious weeks.

Since yesterday, I had classes non stop. Thank you to our lecturers for the time they had spend & knowledge that they share with us.

This morning, we had seminar at 8.30am (for 3 hours) & then I went to the ward to clerk & review patients. At 2.30pm, I had a short case session with Dr Nargis. Just now, I just finished another class with Dr Siti Noor at 1140pm. Eventhough, it was a late night class but learning with Dr Siti Noor always makes you energetic. Hehe. Lots of things had been discussed eventhough only 1 case had been presented just now. (was so tired to write about the case. HUhu. Sori~)

Tomorrow has another session with Prof Wahab at 9am & followed with short case session with Dr Aye Aye. Frankly, Im starting to feel tired but I have to bear it for the sake of knowledge.

But I really looking forward for last session with Dr Nargis this Friday =)

p/s - havent had proper meal today. Huuu~ & noticed time went by very fast~

==== Time & tide waits for no man ====

Tuesday, October 26, 2010

Physical Examinations

I always find that practicing physical examination is fun.

But to make it fun of course we need to read before hand. The atmosphere become much more fun and interesting when we do short cases with close friends We will present to each other & others will act like an examiner & ask questions.

This I believe a very good practice. Practice always makes perfect right.

In my previous professional exam, I will always came early to hospital at 7.30am to do short cases with friends until 9am. We will do 2 to 3 cases. Do a little bit of questions and answers until management. Sometimes, we will use saturday or sunday morning to do short cases. The colleagues that I shared doing this activity are Ijat, Cik Nana, Cik Nun, Kakti & ck Yana Nordin. Oh, how I missed them right now.

Short cases need a lot of practices in order to make the flow go smoothly & present fluently. Everyday I will review my l'ittle book of causes' to refresh back the common causes that will be asked by doctors depending on the systems. But as time goes by, it will just come naturally because you understand the topics.

And today, I still continue to practice short cases every morning. But this 2 weeks I could not make it because of classes in early morning. Huhu.

Sometimes, I asked few juniors to join me & do some teachings with them. This could also enhanced my memory & I always love to teach dear juniors.

I always believe that our lecturers could instantly know wether the student did practice a lot just by looking how we handle patient & how we perform the examinations.

And as usual, I always enjoy doing short cases =)

p/s- currently practicing the examinations using pillows by myself (I already sent back home my little teddies.Huhu) & you know what, Im practicing with my imaginary friends. Hahahaha =P

=== Always make the best of what you have & Move forward ===

Sunday, October 24, 2010

Specific Management of CKD

By Dr MOhd Ramly Seman, Nephrologist HTAA

Purpose of the management
1) To delay the progression or to regress the CKD
2) To manage the associated complications of CKD
3) To prepare patient for RRT

A) To Delay The Progression or To Regress the CKD

In research it proves that, slowing the progress of renal disease will retard the progression of renal failure.
For example, renal disease usually progress slowly about about 3ml/mins/year. By this, the person will had renal failure at the age of 55. But slowing the progression for example to 1ml/min/year, will delay the age of occurence at more than 75 years old.

What are the factors that leads to the progression??
1) Angiotensin II plays central role in the renal damage
- Artherosclerosis & vasoconstriction which can lead to STROKE
- Vascular hypertrophy & endothelial dysfunction can lead to HYPERTENSION
- Left Ventricular hypertrophy, Fibrosis, Remodelling & Apoptosis can lead to HEART FAILURE / MI
- Reduce GFR, Increase Proteinuria, increase aldosterone release & glomerular sclerosis can lead
RENAL FAILURE

All this if not treated can cause death to the patient

2)Aldosterone ( in the presence of No & CVS disease - HTN, renal disease, DM, heart failure,etc) can cause vascular damage (vasculopathy) & microischemia
There will be vascular inflammation (activation of cytokines,prostaglandins, etc)
--> cause necrosis & inflammatory cells infiltration --> fibrosis which leads to abnormal tissue remodelling & organ dysfunction
Lastly, the patient end up having Renal failure, Heart failure, MI or stroke

3) Hypertension.
Based on research, the lower the BP, the more renal function will be preserved

4) Diabetes Mellitus.
Good glycemic control will reduce the incidence of complications
retinopathy by 20%
nephropathy by 30%
Macrovascula disease by 16%

5) Proteinuria
A study on renal survival in adult FSGS based on proteinuria
for non nephrotic patient, the survival was very much longer compared to Nephrotic patient
Nephrotic pt only 50% survival in 8 years
Much more worse in pt with GFR >14gm/24H, the whole renal survival is only for 5-6 years

6) Family History in relation to microalbuminuria
In the research: interaction between FMHx of CVA in 1st degree relatives & glycemic control with the prevalence of microalbuminuria
Family hx + HbA1c >8% - dev microalnuminuria in 48%
either have FMHx or HbA1c >8% - only about 2% dev microalbuminuria
Non of both - 0%

7) Obesity
Mechanisms of kidney damage in obesity
1) mechanical: can cause hyperfiltration
2) Metabolic: can cause Insulin resistance, inflammation, hypertension & dyslipidemia
All this cause renal damage

8) Smoking
can cause vasoconstriction, thrombosis & direct toxin effect
& cause the vascular endothelium to increase in urine protein excretion & induce declines in renal function

9) Anemia
CKD patient with Hb <11.2>13
The more severe the anemia, the greater the risk

10) Usage of chinese herbs

So what should be done??

-Glycemic control
Pt with type 2 DM with 3/more injections of insulin per day resulted in lower rate in new or progresive nephropathy over a period of 6years compared to conventional therapy of 1/2 injections of insulin per day

- Control BP
130/80 in pt with proteinuria <1g/day>1g/day

- Use ACE / ARB
Based on research could reduce in getting nephropathy even in pt who is nondiabetic or normotensive compared to given placebo or other types of hypertensive medication such as CCB

So, choice of antihypertensive in:-
1) Diabetic Kidney Disease (DKD) - ACEI / ARB
2) Non-DKD + Urine PCR >200mg - ACEI/ARB
3) Non-DKD + Urine PCR <200mg style="font-style: italic;">Avoid NSAIDs. Use aspirin or tramadol
acute usually reversible decline in GFR
idiosyncratic forms of membranous nephropathy
interstitial nephritis
progressive nephrotoxicity - chronic usage

- dietary protein restriction: 0.6 - 0.8g/kg/day

B) Manage the associated complication of CKD

- Anemia
Early treatment has good impact in increasing the Hb over months compared to late treatment.
The best is given IV iron - Raises & effectively increase Hb compared to oral form
which one is better?? Either given IV iron alone / combine with erythropoitin??
ans: IV iron alone is beneficial enough for treatment. But if patient could afford erythropoietin, you can suggest the usage

- Cardiovascular disease
CVD is already well established at the onset of ESRD
Cause of death in dialysis patient: about 50 - 60% is due to cardiovascular

- Renal Bone disease (renal osteodystrophy)
CRF will cause phosphate retention ( phosphate excrete by kidneys) & will decreased the active Vit D. All this leads to hypocalcemia & later develop hyperparathyroidism
As CKD progressing from stage I - stage 4, there will be reduced in Vit D & increasing of PTH
Increasing of phosphate & calcium (secondary to PTH) - deposits at vessels, soft tissue, joints & viscera

Pt with GFR <60>65 starts given vitamin D therapy or started in pt with stage 3

Elevated phosphate increase mortality

- Metabolic acidosis
adverse effect on bone, nutrition & metabolic
Maintain Bicarbonate - 22mmol

- Depression, anxiety & denial stage
watch out for this in patient. all this could lead to non compliance & later progression of CKD

C) How To Prepare Patient for RRT

- Ultrasound Kidney - mainly TRO reversible cause esp obstruction
- Screen for Viral status - HbSAg, HBSAb, HIV, HCVAb
Done as dialyse patient will be divide according to status & we do not want negative patient to be infected with these.
Done 6 monthly. Extra caution with HCVAb - lots of false positive - so if result not consistent. repeat the test
- Cardiac Status - ECG, KIV ECHO, ask for symptoms of angina
- Eye referral to diabetic patient.
Could cause blindness if start dialysis in severe one
- Preserve the vein
- ?? Connective tissue screening
SHould be done in selected patient. NOt all patient
- Social history, family history, occupation or previous occupation
Important, as the treatment is costly
regarding ex-army. They will be given more money if sponsored by army compared to SOCSO
SOme patient did not know that they are elligible for SOCSO

- Predialysis Education
Goals:-
- Slow progression of CKD
-treat comorbidities of CKD
- educate patient to make informed decisions
- ensure timely selection of treatment modalities
- reduce hospitalization
- improve psychosocial, physical & rehabilitative outcomes
- save healthcare dollars

Who is collaborative team
Nurses, physicians, social workers, dieticians, pharmacist, other healthcare professional & staffs, patient & family

Important fact
Early referral is very important
Late referral will cause 40% of 1 year mortality, longer the hospitalization needed & increase cost

=== Nephrology Update ===

Nephrology Update 2010


Alhamdulillah, This weekend Im able to join Nephrology Update. Organised by IIUM in collaboration with HTAA. I think this is the first Nephrology Update that had been done. by IIUM. Previously, there was only medical update.

Initially 30 seats were allocated for students & it is for free. But later, HOD - Dr Che Rosle changed his mind by saying, students who would like to join must pay RM30 - student rate. But since I already gave my name like 1 month before the conference, I just agreed with the term given. Frankly, I nearly changed my mind. But in my oppinion, if you plan to do good things but suddenly there comes second thought, wouldnt it always came from syaitan, doesnt it???hehe. I guess so~

And Im glad that I made a right decision. Stick to the initial plan. I learnt a lot from it & I enjoyed the session very much. Its sad to say only 4 students attend the conference - Me, Asma, Nabilah & Najwa. But I think it is expected though~ the fifth year students will be having their exams just around the corner.

The speakers invited are the 'OTAI' in this fields (I hope u guys understand what I meant by using the word OTAI. hehe =P) Among the speakers apart from our HOD, Dr Marzuki & Mr Nazli(urologist) are :-
- AP Dr Kamaliah Mohd Daud - Consultant/Physician Nephrologist from HUSM
- Dr Zawawi Nordin - Consultant Nephrologist from Hosp Sultanah Nur Zahirah
- Dr Mohd Ramly Seman. Nephrologist HTAA

I felt very lucky to get lectures from them & they provide so many informations in each topic until the management. You dont have to worry of being ask or need to prepare anything regarding the topics. They just tell you from A to Z. The best part, the speakers acknowledged the students & keep saying, "I believe there is students here so I would like to show this this & this" or "in student days, this thing is very confusing for students but think this way". Oh, how I wished lots of students attending the conference too.

The conference was held for 2 days. The topics that had been covered:-

First Day
1) Epidemiology of CKD (AP Dr Kamaliah)
2) Screening & classification of CKD ( Dr Che Rosle)
3) Nephrotic Syndrome (Dr Zawawi )
4) Diabetes And Kidney ( Dr Marzuki)
5) Lupus Nephritis ( AP Dr Kamaliah)
6) Medical Management Of Stone Disease ( Dr Zawawi)
7) Hypertension And Kidney ( Dr Ng Kok Huan - Cardiologist HTAA)

Second Day
1) Specific Management of CKD ( Dr Mohd Ramly)
2) Obstructive Uropathy ( Mr Nazli)
3) Renal Replacement Therapy Option & Outcome (Mr Mohd Ramly)

As you can see, this course was very extensive & I listened to all the speakers very attentively & I did not sleep at all. In the middle, of course there was break for breakfast, lunch & even tea. The food was very delicious. Hehe. This morning, the menu was nasi goreng, nasi lemak, karipap & doughnut. After the session, we found out that there was still many foods left. So we took back some of it for our lunch. I heard that the caterer is the wife of one of JHC's guard =)

So now, I realised (more than before) how important it is to take good care of our kidney. Dont wait until we had DM or hypertension to worry about the kidneys. But its important to prevent it from happen starting from this very instant.

I purposely ask about additional salts taken in our foods - home made cooking @ outside cooking. The speaker answered to the question by saying, there is no doubt the relation of salt intake & kidney damage. Long term impact of taking additional salts could cause fibrosis to the kidneys which leads to scarring & renal failure.

So our role now is to educate our family members to take good care of their kidneys. Once the problem occurs, it will progress slowly & think about the cost to take care of the damage kidney if a person succumb to peritoneal dialysis or hemodialysis. As well as its impact to the psychosocial of a person.

All in all, Im glad I made a right decision after all. Thank You Allah.

P/s-Unfortunately I accidently left my folders given for the course in the LH3. Huhu. I still had the memory of putting the folders inside my bag. But found out I might just hallucinated it as I cant find it in the beg or in my car. I hope the folder still at the place I left it. Huhu. But for tonight, Im lucky I have the soft copies of the lectures =)

P/s- The medical book that I lost last week still hadnt been found yet. I put on a search everywhere. In my room, the car,the library, common room, all lecture halls & even the wards which I dont bring that book to the ward since Im in paeds posting. Even to the extend I look at the roads ( I had a thinking of did I put the book on top of my car???) I remember it clearly I put it in the car. Guess I might left it somewhere else also & think I did bring the book to my room which the same that happened today. Huuu~ That book is my fav book & in it I put some of my important notes. Ya Allah, please help me in bringing back my book. (Ada sape2 ada doa untuk cari barang yang hilang??)

Friday, October 22, 2010

Peranan Doa

Harinie hari Jumaat. As usual, petang jumat jika saya tidak pulang ke KL. Pastinya saya akan mengajak rumet pergi ke pasar malam.

Tapi semasa perjalanan pulang, sesuatu hampir terjadi & alhamdulillah Allah selamatkan kami.
Kami satu kereta hampir-hampir mahu dilanggar oleh bas yang laju dibelakang. Mungkin penumpang belakang tidak perasan kerana kereta saya sudah berhenti dengan selesa, & masing-masing tengah berbual tetapi saya melihat perkara ini melalui cermin pandang belakang. Huhu~

Ceritanya begini....
Jika orang kuantan pasti tahu trafik lite simpang empat besar depan Masjid Tengku Ampuan Afzan, dekat dengan pasar malam...

Jalan itu lurus, saya selalu berhati-hati kerana di situ kereta selalunya sangat laju walaupun sudah mahu menghampiri trafik lite.

Setelah masuk ke 'main road' saya mahu masuk ke len kanan untuk ke UIA. Jalan itu ada 2 lorong kan. Bile masuk dari bahu jalan, semestinya berada di len kiri dahulu. Tapi untuk ke UIA, kena berada di len kanan kerana lepas trafik lite kena belok kanan.

Jadinya apabila line clear, saya masuk len kanan & rupanya barisan kereta di len kanan itu sangat panjang dari trafik lite sampai ke depan masjid & dengan segera kena berhenti. Memang mengejutkan jugak. Kereta depan pun berhenti mengejut jugak kerana dia pun laju & tak sangka kereta depannya kena berhenti.

Sebelum menekan brek sempat saya mengerling cermin tuk melihat ada kereta dibelakang atau tak. Alhamdulilah tidak ada. Tapi saya melihat sebuah bas yang jauh di belakang. Tapi kelihatan agak laju. Walaupun pada mulanya bas itu agak jauh, sekelip mata saja dia sudah mahu menghampiri kereta saya.

Apabila bas itu menghampiri kereta saya yang sudah berhenti, ia masih laju & saya sudah risau bas tersebut tidak sempat brek. Bas itu kelihatan cuba memintas masuk ke len kiri kerana ia menekan brek tapi momentumnya yang besar menyebabkan ia masih meluncur kehadapan tetapi dia di hon oleh bas lain yang berada di len kiri & dibawa dlm keadaan laju juga.

Menyedari keadaan bas tersebut yang sudah memusingkan sedikit kepala depannya ke kiri untuk memberi ruang sedikit supaya tidak menghentam saya & ia juga sempat berhenti, saya juga menggerakkan kereta saya ke hadapan & ke kanan sedikit dengan harapan sedikit ruang yang saya bagi itu, cukup-cukup untuk momentum bas itu berhenti.

Dan alhamdulillah ianya berhenti sangat rapat dibelakang kereta saya.

Saya sangat bersyukur kerana tidak terjadi drama di situ petang tadi & Allah telah selamatkan kami. Saya terkenang ini mesti berkat doa emak, ayah di perantauan yang senantiasa mendoakan keselamatan & kejayaan anaknya di mana sahaja berada. Tidak lupe juga kepada Encik suami yang sentiasa mendoakan isterinya dalam lindungan Allah. Juga pastinya doa mak, ayah mentua, adik-adik diperantauan dan sebagainya.

Paling penting, diri sendiri juga perlu sentiasa berdoa & sentiasa mengingati Allah walau dimana sahaja berada kan kan =)