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~

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.

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 =)

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~

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~

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 =)

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

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===========

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~

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 =)

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 =====

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~