Monday, December 29, 2008

Last Days in A&E

It's year end and I'm leaving the Emergency Department. Informed by my hosp director that I'll be transferred to Medical department starting Jan 09.

If you remember my story, I initially applied for medical while finishing my JMOship and due to medical was full, I was put in A&E "temporarily" till there is vacancy (for details you can read this).

And this wait has been 6 months! Much more than I expected, but I found it a very rewarding experience. I like the environment, though busy, but it is never boring! It certainly exposed me to a greater ranges of problems of all disciplines and making diagnoses have never been so difficult but yet challenging. I've really, really learnt a lot.

And not to mention the great staffs that I worked with. To all medical assistants, staff nurses and community nurses, a big thanks to you all!

I'll always remember that every morning there'll be one Nasi Lemak for me (they know I'm very prone to hypoglycemia), and with some cute wordings =)

And now I'm moving on to the next stage. The bigger challenge I think.

Which I need to be more well-equipped.

Here I come, Medical!

Monday, December 22, 2008

No Room for Ignorance!

I'm sure most of you read the article on The Star - "No room for ignorance in hospital wards" by a Seremban doc, I think he/she has made a few good points. Just to extract a few,

"How do you call yourself a doctor when you do not even know how to perform CPR? Most importantly, one must work with a conscience. Yes, they are allowed to make mistakes, but never at the expense of the patient’s life due to their lousy attitude or severe deficiency in knowledge.

To the parents of these young doctors, have you heard the other side of the story before defending your children? Did they tell you why they got scolded at work?

And if you find out that your child caused a patient’s death, simply due to his poor knowledge and lousy working attitude, will you be able to sleep well at night?

To the house officers who complain a lot, if you can’t even handle negative comments from your senior colleagues, how can you survive when you face demanding patients and family members?
It’s disheartening to see that the public is trying to sensationalise this issue without hearing the other side of the story."

I pretty much agree with what he said, and I think these are what most of the MOs thinking of the current batches of HOs now. After I read also Yew's & CCC's stories, I think hospitals are more like horror places to public now, at least the images will be altered, not sure whether to the extent that affecting public's confidence towards us. But as what fibrate said, "If you care enough, you reprimand them, so that they’ll become better doctors." I guess that's what we eventually want!

So to all HO-to-be, hope you all hear what we're saying!

Sunday, December 21, 2008

Interesting ECG (3)

Since some of the students were kinda confused about how WPW (Wolff-Parkinson-White) syndrome ECG looks like - so coincidentally I just came across one last night!

Looking at the above ECG, delta waves (the slurred upstroke) can be seen in every beats, broadening the ventricular complex as well as shortening the PR interval. Very typical!


Also read:
Interesting ECG (2)
Interesting ECG (1)

Thursday, December 18, 2008

Bad Assumptions

Bad assumption #1

A Bangladeshi man walked in accompanied by a Malay woman.
After the consultation,
Dr spoke to the woman, "Alright you can settle the bill over the counter there. Are you his employer?"
Woman: "I'm his WIFE."
Dr: "(oops..)"

Really Bad assumption #2

A middle-aged uncle walked in with a baby, accompanied by a 20+ young lady.
Dr greets the man, "Hello uncle, this must be your grandson? So cute..."
Man: "I'm his FATHER. Can't you see that's my wife?"
Dr: "(Oooops...)"

Extremely Bad assumption #3

Consultant doing ward round with all the MOs/ HOs.
Reached a bed of patient with coronary heart disease.
Consultant: "Uncle you really have to control your cholesterol la. Do you exercise?"
Patient: "Not really. I have to work..."
Consultant: "That's just an excuse la. What do you work as? Selling Nasi Lemak?"
Patient: "......I'm a LAWYER."
MOs & HOs: "(Ooooooooops...)"

Moral of the stories: Be very careful when making assumptions! These are real stories and you certainly do not want them to happen to you!=)

Wednesday, December 17, 2008

"Floating Elbow"

Fracture above and below the elbow joint - making it like a "floating" joint.

The feeling that you get while examining it can be quite scary!

Tuesday, December 16, 2008

Bomoh's Sorrow

Saw this 60 year-old man in ER early morning, who alleged was knocked by a cow's horn at left sided chest.
On examination by doing a gentle chest spring, the crepitus can be clearly felt. So I told the man that he's likely to have sustained rib fracture.

His response was of kinda dramatic one.
He actually turned angry, "Doc, how sure are you that I'm having fracture? *pats on his chest a few times* If my ribs are broken, how come I don't feel much pain?"

Then the story gets interesting.
"I tell you, I'm actually a Bomoh (traditional healer in village). I used to treat fractures! This morning I was "demonstrating" how I could be knocked by a cow without getting injured (now I get to know the true history), now you're telling me that I've broken my ribs? This is ridiculous!"

In view of his hyper-emotion, I told him that why not we look at the Xray.

It shows fractured left 3rd & 4th ribs.

Then he really got into deep denial, "This is not my Xray! I DON'T BELIEVE IT! Doc, I'm a Bomoh! (he mentioned this not less than 5 times) You don't try to cheat me OK! I have no fracture! I will not get injured!"

Then the next thing is he refused all treatment including painkillers, then took an AOR (at own risk) discharge.

Think it's the end of the story? I thought so but apparently it's not. Since I was on call that day, so I got to see the 2nd half of the story at night.
Around 10pm, a man was pushed in for complain of dyspnea. I had a glance on the patient, OH MY GOD it's the Bomoh again! The first thing that came into my mind was he must have massaged himself at home and self-induced some pneumothorax or lung injury.

But luckily it's not. He came because he really couldn't stand the pain.
And the first thing he said when he saw me was, "Doc, I'M SO SORRY. I shouldn't act so rude this morning. Pls forgive me. Pls admit me to the ward for treatment. Thank you."

A 180-degree change.
But I'm glad that he came back for treatment though.
And what a special experience on my encounter with a Bomoh! ;)

Monday, December 15, 2008

Interesting ECG (2)

Saw this ECG in ER.
It belongs to a lady who has underlying bronchial asthma, presented with palpitation.

Took me reaaaally some times to figure it out.
Irregular rhythm with variable PR interval, tachycardia...what do you think it is?

*The leads are well connected for the ECG so there's no cunning magic here^^


Related post:
Interesting ECG (1)

Saturday, December 13, 2008

Magician's Getting Tricked?

Saw this young man in ER. Suspected to have Dengue fever due to the abnormal FBC result.

Me: "Hi, how many days have you been having the fever?"
Pt: "Day 3 of fever."
Me: "Ok...did you notice any bleeding from gum?"
Pt: "No, no bleeding tendency. Actually, you can ask me in medical terms. I'm a medical student."
Me: "Oh great! Sure. You having any SOB?"
Pt: "Pardon? S.O. what?"
Me: "Oh sorry...I mean any shortness of breath."
Pt: "No no...I don't."
Me: "How are you feeling actually?"
Pt: "I only have a bit of dyspnea."
Me: "......(suddenly dunno how to continue)"

No shortness of breath but has a bit of dyspnea?
Hmm.
Oh maybe he's trying to trick me whether I know the meaning of dyspnea! Hehe.

(Shinyin, you have a cute junior!^^)

Friday, December 12, 2008

Interesting Case! (2)

Saw this patient in ER. Think it's interesting to share.

A 84 year-old man was pushed in for progressively worsening dyspnea. According to his daughter, he only has history of gastritis. The dyspnea has been there for 1 week, but he denies any chest pain. There is history of reduced effort tolerance but not much of orthopnea or any ankle swelling. Upon further questioning, the daughter told that he has been feeling lethargic and having poor appetite for the past 2 months.

On examination, he looks mildly tachypneic with SPO2 94% on room air. Lungs were generalized crepitations on auscultation. Abdomen has a spleen palpable with shifting dullness positive. No pedal edema. Multiple cervical and axillary painless lymph nodes palpable.

Then the daughter showed some blood results that he just took in a private lab few days ago.
Hemoglobin: 8.4 g/dL
Total protein: 118 g/L
Albumin: 19 g/L
ALT: 40 IU/L
ALP: 120 IU/L
Se Calcium: 2.4 mmol/L (2.1-2.6)
Se Mg: 0.8
BUSE - within normal limits

ECG shows ST depression over I, aVL, V4 to V6.
Trop T stat: Negative

Your colleague thinks that he should be treated as Acute Coronary Syndrome with left ventricular failure, based on the ECG and chest findings.

Do you agree? And if not, why?

(Answer's in comment)


Related post:
Interesting case! (1)

Thursday, December 11, 2008

A Beautiful Mind (2)

Ya. The unlucky me again.
Saw this patient who came in the midnight.

"Hello uncle, any problem?"

"Hmm. My problem is, I don't even know what's my problem!"

(*swallowed saliva* I know I'm in trouble, deep one)

"You see, I always feel like I have fever but actually I don't."

"I like to put one hot towel on my forehead, but if you ask me whether I have headache, actually not really. Why is it like that ah doc?"

(HOW am I supposed to know why you like to put hot towel on your head?)

"Then on and off my right hand will shiver. It happens more when the weather is cold, but sometimes when it's not so cold, it shivers a bit also."

"Then I also feel discomfort over my abdomen. No if you ask me whether it's pain, actually not really. Endoscopy? Ya I've done it. Even colonoscopy also. All normal."

"Sometimes I feel anxious. My job? Oh I work as a teacher. Stressful at times but strictly speaking, not to a level to cause me anxiety. Thyroid problem? Oh I just went for a complete health screening, all blood tests are normal!"

"My appetite is fine. Not much of weight changes recently also. But I on and off will feel tired also...you know? Like not interested to do things..."

"My symptoms sound like neurological symptoms? Ya one of my doc friends told me also. I've already gone for a brain scan and it's normal too."

"So doc, actually what's my problem?"

The whole consultation took me 30 min. And I think I sweated. The problem is not about the diagnosis, but difficulty in getting even the symptoms! Can you get a distinct symptom from his history? All also quite vague...and when you think of something and he'll tell you, "Oh I went for checking already and it's normal."

Tough isn't it? Any brilliant diagnosis other than "A beautiful mind"? ;)


Read also:
A Beautiful Mind (1)

Wednesday, December 10, 2008

Goodbye, Old Friend

He's gone.

My good old friend who has accompanied me since my first year as a medical student...a good 7 years of friendship.

He has never failed to be my best working partner...and I've always tried my best to maintain it at good condition. I dare to say that its function is still as good as new!

But I was shocked that he gave up yesterday. After a while of thinking, I think I found out the precipitating factor. It's all due to the stupid missing tendon hammer in the casualty la! It has been missing for the past few weeks and made me having to use my stethoscope to elicit the reflexes! See now what happened to the diaphragm! Gosh...I can't believe that I indirectly (or maybe directly) caused harm to it...sigh. But it's just too late.

Nevertheless, probably it's a sign to me for system upgrading.

Hey Yew, I think I'm definitely joining the club already la! ;)

Tuesday, December 09, 2008

Picture Quiz (2)

Ya time for picture quiz again! Let's look at the following ECG:

Ques: Please give a spot diagnosis.

Hint: It might not be an ordinary diagnosis!^^

(Answer's in comment)


Related post:
Picture Quiz (1)

Sunday, December 07, 2008

Couple Jokes (4)

#1

GF: "Dear, after we're married, will you quit smoking?"
BF: "Yes..."
GF: "Will you quit alcohol?"
BF: "Yes..."
GF: "Will you quit clubbing too?"
BF: "Yes.."
GF: "So good..anything else that you'll quit?"

BF: "I think I'm quitting the thought of getting married..."


#2

Wife: "Dear, pls tell me honestly that do I look pretty?"

Husband: "Yes you surely do."

Wife gets satisfied and walked away happily.

After 10 min, wife asked again, "Dear, actually, were you telling me that just because you didn't want me to get hurt?"

Husband: "No...I didn't want myself to get hurt."

Wife: "......"


Related posts:
Couple Jokes (3)
Couple Jokes (2)
Couple Jokes (1)

Saturday, December 06, 2008

Smoke & Mirrors 2nd Edition

"Illustrated by renowned artist Si Scott, the Smoke & Mirrors playing cards were developed by Dan and Dave Buck. Dan and Dave spent over eight months working with Si on the design, with the goal being to create a deck that is elegant, refined, and modern.

Interest in the decks has been unrivaled since word first emerged of their existence. All of the artwork was illustrated by hand in pen and ink. Smoke decks are white; Mirrors are black. Both decks feature a custom designed Ace of Spades, Joker, and tuck case.

From the intricacy of the design to the feel, finish, and quality, Smoke & Mirrors are a case study in attention to detail. The feel and finish is flawless - printed on premium Aristocrat quality stock.

The result is an artistic expression of royalty: a true luxury deck."

- Theory 11

Let's have a look at the preview:



Truly a masterpiece. I'm just so gonna get this!! ;)

Monday, December 01, 2008

Couple Jokes (3)

Saw these from a mail that dear forwarded to me. Found it really funny so just thought of sharing it;)

#1
A woman worries about the future until she gets a husband.
A man never worries about the future until he gets a wife.
A successful man is one who makes more money than his wife can spend.
A successful woman is one who can find such a man.

#2
To be happy with a man, you must understand him a lot and love him a little.
To be happy with a woman, you must love her a lot and not try to understand her at all.

#3
Married men live longer than single men do, but married men are a lot more willing to die.

#4
A woman marries a man expecting he will change, but he doesn't.
A man marries a woman expecting that she won't change, and she does.

#5
A woman has the last word in any argument.
Anything a man says after that is the beginning of a new argument.

I'd say..these theories are quite true! =p
What do you think?^^


Also read:
Couple Jokes (2)
Couple Jokes (1)

Thursday, November 27, 2008

My Article is in Newsletter!

Thanks to Tiffany, the Editor of the UCSI's newletter for the invitation, that I'd have the chance to share my article on her university's newsletter (issue Nov-Dec 08).

I've read through the newsletter and I think it's really a nicely done work. Good job to Tiffany and her team!=)

My article. Modified from my post "What exactly is Housemanship?".

Hope the students will like it ;)
Indeed I'm so glad to be able to share the article, and certainly will hope to contribute more in the future!=)

P/S: The article was modified a bit so that it sounds less "emotional" and I added a small paragraph at the end of it:
"Words from author:
Please take note that I did not mean long hours of working are good. Efforts are being made to cut down our working hours as it is really tiring. What I am trying to say is, before you're disappointed with the current working system, think first whether you can learn something from it, and also take the chance to train yourself physically and mentally, then you'll find it a good challenge rather than a torture!"

Monday, November 24, 2008

Why These were Missed?

I've seen a few cases over the last week and I really have some thoughts to share:

Case 1

A 70 year-old man complained of progressive abdominal distension and went to a hospital. He was told to have "angin" in the abdomen and was discharged with Syr MMT (antacid).

Case 2

A 8 year-old boy complained of "abdominal discomfort". He was told to have "gastritis" and was discharged with Syr MMT, too.

Case 3

A 50 year-old man complained of 2-month history of cough and generalized lethargy and reduced appetite. He went to several clinics, was given reassurance and multiple courses of multi-vitamins and cough mixtures.

Simple cases? Let me tell you what happened in the next half of the stories. I was really, really shocked to find out that:

Case 1

The abdomen is really distended and instead of "angin" inside, it's gross ascites! Baseline blood tests showed anemia with reversed alb:glob ratio - he was then admitted to check for the cause of paraproteinemia - and it then turned out to be multiple myeloma.

Case 2

8 year-old boy with "gastritis"? This is really not a good diagnosis that you give to a young boy. The abdominal discomfort was actually due to large hepatosplenomegaly, and also generalized lymphadenopathy was noted. The FBC showed pancytopenia. He's suspected to have hematological malignancy.

Case 3

Looking at the chest Xray, I don't think I have to say much:

A huge suspicious mass at the right upper zone. Need to rule out lung tumour.

What's happening?
Honestly, to pick up the gross ascites and the enlarged liver and spleen is nothing great. I think even a medical student can detect them. Maybe what they needed is, a person who REALLY examined them.

The moral of the stories is:
1. Eventhough the clinic/ outpatient is always busy, pls really spend some times to see the patients. Shorten the time by focal history and examination, but never "just symptomatic treatment".

2. Pick up the "alarm symptoms" - If an elderly complained of lethargy and poor appetite, "Multi-vitamin" is not the first-line treatment - Investigate properly!

3. If a patient tells you that his symptoms persist despite multiple courses of treatment, an alternative diagnosis should be strongly considered!

4. If you're not sure of something, consult the experts. You might get some unpleasant responses, but it benefits the patients!

At the end of the day, just ask yourself:

Are the patients happy with the diagnosis and the treatment?
Have you done sufficiently for the patients?

Thursday, November 20, 2008

A Special On-call: Bodyguard Experience

I'm back from a special mission, sort of. Ha. I was on-call two days back, and it turned out to be an unsual one. Got an order from my department head that, a VVIP is coming to Taiping to visit and he requested a medical team to standby throughout his trip, and ya, I'm the MO who's going!

It's a rather new experience to me. In fact, it's less stressful than what I thought. Basically what I need to do is, carrying a stethoscope and following him around throughout his trip and of course, hopefully an uneventful trip - medically. Something like a personal doc for a day. ;)

And the good thing is, I get to stay in some nice places.

Water Chalet (Kampung Air). Staying in one of the executive suites. Pic taken during the afternoon lake cruise.

Oh and I have one cool thing to show..

This is something that I have to bring around. If you've seen enough of basic first-aid box, let me show you what's in this advanced one which is used in special occassions...

All the emergency medication and equipment. It even has a small oxygen tank inside!

It can be further opened up..a total of 3 layers. Almost everything that you need to attend a medical emergency, and it's just like a portable emergency trolley!

Then at night we went to the "Night hoot" in Ecopark. Something like Night Safari but I think this one is more exciting. Holding torchlight like walking into a jungle at night.


The da*n scary crocodile and the giant python.

So the trip ended the next day morning and it was an uneventful one. *thank god that I wasn't so Jonah hehe*

View from my room at 7am.

Think it was actually a quite fun experience. What a special "on-call" that I had! ;)

Thursday, November 13, 2008

Dance with Crutches?

I sorta came across this on Youtube and I was deeply captivated (make sure you watch till it finishes):



A long "Wooow"? I initially thought this is just so cool and the guy must be a genius. But I had one thing to ask, as most of the ppl would, that "Does he really need the crutches?" Then I read a little more about him at his website. Then I was stunned.

Bill Shannon, aka the "Crutch Master", has bilateral hip deformity due to Perthes disease. He then invented a unique technique for dancing on crutches - called Shannon technique that derived from his experience in their use as a mobility aid. For years, Bill has been a renowned dancer and choreographer and has motivated thousands of ppl around the world.

Take a look at his another clip:



Determination makes things possible.

How inspiring!

Friday, November 07, 2008

My New Magic Video!

Ya..finally! My new magic vid after the last one which was shot in 06..before my housemanship actually ha. Took this in the Starbucks at Gardens. This vid is a compilation of some of my new ideas in flourishy card revelations, plus two of my favourite card effects "Twisting the Aces" and "Bizarre twist". Very classical tricks, and have been included in my signature performance routine all these while!;)

So everyone, here's my 3rd magic vid:



Like it? ;)
And one thing I think I need to explain a bit here..the background song is not the original one that I put in. I had to replace it due to Youtube's restriction on song's use=(

 
My previous vids:

Friday, October 31, 2008

Master Close-up Magician



Jean-Pierre Vallarino, one of the greatest world-class close-up magicians, with his famous routine. His elegant way of handling the cards are definitely the smoothest of all that I've seen. Enjoy the clip of his classical act!;)



This is a clip that I filmed in 2005, during my first ever major show, the KENT event. That last part when I did my card revelations, it's actually a combination of what I learnt from Jean Pierre, plus some of my own ideas. I really wish I can do as smooth as he does one day..keep on practising!=)

Wednesday, October 29, 2008

Doctors - The Most Difficult Patients?

I'm wondering if you agree with this statement? Well, through what I've seen or heard, I think I now do agree with it. I've encountered:

#1
A doc who smokes and with cigarette's smell whenever he speaks. And he tells, "You know, it's very difficult to quit this. Easier said than done."

#2
A doc who's diagnosed leukemia and get frustrated and refused all chemoradiotherapy. Finally he said, "You know, honestly, I never believed in all these treatment."

#3
A pregnant doc who's admitted for acute pulmonary edema secondary to severe pre-eclampsia. Being asked about why BP was so uncontrolled, she said, "I just don't feel like taking the medications..."

#4
A doc who has been having intermittent per rectal bleeding but has never sought any investigation or treatment simply because, "You don't have to counsel me. I won't go and check...I'm afraid to know the diagnosis."

#5
A child with G6PD deficiency presented with acute hemolysis, after taken Fava beans from his parents, who's surprisingly medical personnel. The reason was given as, "I have no choice..child kept on crying and nagging, and so I gave him a little bit..just a little bit only..."

#6
A young doc who's been having progressively worsening ankle swelling, and diagnosed thyrotoxic cardiomyopathy, admitted that he actually had the onset of hyperthyroid symptoms 6 months earlier. His explanation to the delay for seeking treatment, "My work is so hectic. Where to find time to really check?"

#7
A middle-aged doc came with slighly high BP (160/90), and by himself he took 3 tabs of Nifedipine 10mg (a dangerously high stat dose which may lead to rapid BP drop and subsequent stroke). When being asked to justify what he did, "I have been practising for more than 20 years. I know what I'm doing!" said by him impatiently.

I'm sure there are many more stories.

So, are doctors the most difficult patients?
I think you find it not easy to deny the statement now.

Friday, October 24, 2008

Project Magic - Therapeutic Magic

David Copperfield, the greatest man in the magic history. I look up to him not only because of his astounding achievement in magic, but he has such a great mind to develop the use of magic in a therapeutic way, which is what I'm going to share about today.

"Project Magic" is a program designed by David Copperfield, to give the gift of magic to people with various physical, psycho-social and developmental disabilities. It is beneficial to those with a variety of diagnoses, such as arthritis, spinal cord injury, brain injury, drug and alcohol abuse and learning disabilities.

Project Magic assists individuals to achieve new skill levels and also the achievement-orientated behaviour, which is necessary for the disabled individuals to successfully re-enter the outside community. Combining the talents of professionals in the entertainment field and those in medical field, it provides a quality of therapeutic training far in advance of traditional rehabilitative programs and techniques.

"Project Magic" is used in over 1,000 hospitals worldwide. It achieved not only physical success, but showed remarkable improvements in patients' cognitive function, speech, self-esteem and social skills.

"Learning magic can help them to learn a variety of skills," says Copperfield. "It's fun and challenging."

Pics from daylife

"To date, through Project Magic, David has spiritually and physically enriched multitudes of patients across the globe over the 25 years. He has enabled them to break out of the poverty of imagination, and to enter the world of dreams."

How inspiring. I've long been captivated by this thought that, magic combined with medicine, and how it can do good to the patients. Copperfield has really made a giant step beyond "magic as entertainment" to a whole new realm of "magic as a form of therapy" which truly works.

I'm wondering, what about "Project Magic" in M'sia? Mission possible or otherwise?;)
I have some thoughts and would like to see what you all think about it. Feel free to put in your thoughts!;)

Wednesday, October 22, 2008

Signs of Anemia?

A group of medical students are having a bedside teaching session with Prof. (MO and HO just happened to be doing work at the table nearby)

Prof: "In a patient that we suspect to have anemia, what clinical signs do we look for?"
A: "Cyanosis."
Prof: "Very good (sarcastically)..you can get out from the ward now. Make sure you prepare adequately before you come to my class again."
B: "(shivering voice) Capillary refilling time..."
Prof: "(shakes his head) Why you look at CRT in anemic case? You all ah..(sigh) Tell me, in what cases do you need to look at CRT?"
C: "Heart failure..."
D: "Ischemic heart disease..."
E: "Hyperthyroidism..."
F: "Uncontrolled Hypertension..."
G: "Cerebrovascular accident..." (Prof's head shaking non-stop)
H: "Finger clubbing?" (MO: Wow...)
I: "Rheumatoid arthritis?" (HO: What?)

Finally a distinction-looking student said out confidently, "Takayasu's arteritis!" (MO & HO: Woww...)

Prof: "ENOUGH! ALL GO BACK AND READ AGAIN!" Then walked off the ward leaving the frightened group of students.

What happened to the medical students (quite senior batch) ler.
CRT is to access hydration and circulation status. Simple as that.
High-5 diagnoses do not mean they're correct, and most of the time, to quote a famous saying in medical school, you're digging your own grave by saying things that you don't know!

Moral of the story: "Think and answer smartly!" and, "Make sure you master the basics, before aiming for higher level!" ;)

Wednesday, October 15, 2008

Couple Jokes (2)

#1
Wife: "Dear, tonight I feel like sleeping with the light on. Is it ok?"
Husband: "Oh..hmm can but..."
Wife: "But what? You'll be uncomfortable with it?"
Husband: "Well it should be fine, as long as you keep your make-up on..."

#2
Wife standing in front of the mirror.
Wife: "Oh dear, I think I look old, fat and ugly. Can you just give me some compliments?"
Husband: "Oh sure. Well, at least your eyesight is still perfect."
Wife: "......"

#3
Husband is playing with a cat.
Wife came and shouted angrily, "I've been looking for you! Why are you playing with a pig?"
Husband was confused, "Huh? I thought it's obviously a cat that I'm playing with?"
Wife: "Don't interrupt! I was talking to the cat..."

#4
Husband came back home and told his wife,
"You know what, I went to apply for pension allowance just now. I didn't bring my IC so I showed them my silvery chest hair and they believed my age."
Wife: "Oh I see. Then you should have dropped your pants, and you'll get the disability allowance, too."


Related post:
Couple Jokes (1)

Monday, October 13, 2008

Magic Medicine Formula (3)

3rd part: Time for microbiology!
Always confused by various types of bacteria & viruses? Well, not anymore!=)

You only need some codes..

Gram Positive cocci - SSE
S - Staphylococci
S - Streptococci
E - Enterococci

Gram Negative cocci - MN
M - Moraxella
N - Neisseria (N.meningitidis & N.gonorrhea)

Gram Positive baccilli (rods) - ABCD.LN
A - Actinomyces
B - Bacillus anthracis
C - Clostridium group
D - Corynebacterium diphtheriae
L - Listeria
N - Nocardia

Obligate intracellular bacteria - R.CML
R - Rickettsia
C - Chlamydia & Coxiella
M - Mycoplasma pneumoniae
L - Legionella pneumophilia

Spirochaetes - BTL
B - Borrelia
T - Treponema
L - Leptospira

And the rest are (very much mostly) Gram Negative bacilli!

And trust me, with these simple codes, you're just gonna tell the types of bacteria almost instantly!=)

As for the viruses, a few rules can help:

1. DNA-containing viruses are the HHAPPP(Y) viruses (Herpes, Hepadna, Adeno, Papova, Pox, Parvo); and the rest are RNA-containing viruses.

2. All DNA viruses are double-stranded except Parvoviruses.
3. All RNA viruses are single-stranded except reovirus.

Again, hope it helps!
Ok my dear friends, I've shared with you my (season 1) magic medicine studying tips;)

Hopefully I'll come up with more in the near future, and most importantly, pls let me know if they really help in your study and I'll be glad to hear it!=)

Friday, October 10, 2008

Magic Medicine Formula (2)

Ok..now we come to the 2nd part. Well, MRCP really likes to ask about genetic diseases and mode of inheritance. It'll be a waste if you do not master this part, but to memorize all that is obviously not an easy task.

A general rule is, Autosomal dominant conditions are mostly with "structural/ phenotypical" abnormalities; whereas autosomal recessive conditions are with "metabolic" disorders.

A list of major genetic diseases with which genes they are linked to:

Chromosome 1: Gaucher disease
Ch 2: Gilbert's syndrome
Ch 3: Von Hippel-Lindau syndrome
Ch 4: Huntington's, adult polycystic kidney disease (APKD 1)
Ch 5: Familial adenomatous polyposis (FAP)
Ch 6: Hemochromatosis
Ch 7: Cystic Fibrosis
Ch 8: Hereditary spherocytosis
Ch 10: MEN II
Ch 11: MEN I
Ch 12: Von Willebrand's disease
Ch 13: Wilson disease
Ch 14: HOCM
Ch 15: Marfan's syndrome
Ch 16: APKD 2
Ch 17: Neurofibromatosis Type I (von Recklinghausen's disease)
Ch 21: Autoimmune polyendocrine syndrome (APS) Type I
Ch 22: Neurofibromatosis Type II

Long and boring list? Any simplifying method? Ok here we go:

"Von Hippel-Lindau" = 3 words = Ch 3
"Huntington" = "Hunt 4 food" = Ch 4
"FAP" = "polyp has 5 alphabets" = Ch 5
"Hemochromatosis" = "HemochromatoSIX" = Ch 6
"Cystic Fibrosis" = "Think F is a mirror image of 7" = Ch 7
"Spherocytosis" = "Think 8 has double spheroids" = Ch 8
"Wilson" = "WIlson looks like 13 if you rotate the W a bit?" = Ch 13
"Marfan" = "Marfan's syndrome has 15 alphabets" = Ch 15
"APKD" = "APKD has 4 alphabets, polycystic kidney has 16 alphabets" = Ch 4 & 16!
"Neurofibromatosis Type I" = "von Recklinghausen has exactly 17 alphabets!" = Ch 17
"Neurofibromatosis Type II" = "Type 2 = 22" = Ch 22

Easier? After I found these linking methods, I think I'm just not gonna forget them for life!

Hope it helps!=)
And in the next post, I'll share about how I remember bacteria family!


Magic Medicine Formula (1)

Thursday, October 09, 2008

Magic Medicine Formula (1)

Hi dear friends, time to share my studying tips. Well, to relate magic with medicine, hmm I would say that learning magic has definitely improved my memory. However, I think to study medicine, such a profound and broad field with countless facts and terminology involved, mere memory might not be adequate. Then I found a very useful tool, it's definitely not something new, which are "mnemonics". Quote from English artist William Wolcott, "Nothing is ordinary if you know how to use it." You might think mnemonics are nothing special, but if you know how to use it, my personal experience is, it's purely magical.

Mnemonics help to memorize facts in a quick, organized and (far) painless way. But take note that, the quality of mnemonics are extremely important, as the bad ones, will not only waste your memory space, it may fail you! For example, let's take a look at this (found this in snowy's blog but not by him, just for eg purpose, no offence):

SAM Suka Fry Ayam Peha - Classification for ischaemic heart disease.

S - sudden cardiac death
A - angina
M - MI
S - silent IHD
F- failure of heart (heart failure)
A- arrhythmia
P- postinfarctional cardiosclerosis

A few things to point out:
1. Poorly organized, and most importantly, do we need a mnemonics for classification of IHD?
2. Facts are not entirely true, e.g. arrhythmia is not a "type" of IHD?
3. Do you think "SAM Suka Fry Ayam Peha" is an easy-to-remember phrase?
4. Facts not "concrete" enough. To improve the quality, try use more professional terminology (so that you can impress your examiners).

An example of good one:
Wilson's disease : ABCD

A - Asterixis
B - Basal ganglia degeneration
C - Copper accumulation with reduced Ceruloplasmin level, causing Cornea deposits (Kayser-Fleischer rings), Choreiform movements, psyChiatric abnormalities, liver Cirrhosis and treatment is with Chelation.
D - Dementia

See the difference? So much essential facts in just 4 alphabets.

And to further improve it, sometimes the mnemonics are purposely made "naughty", and some will find it even easier to memorize! (Of corz, this is subjected to personal preference)

For example, adverse effects of Amiodarone: BITCH

B - Bradycardia
I - Interstitial lung fibrosis
T - Thyroid dysfunction
C - Corneal microdeposits
H - Hypersensitivity/ Hepatitis

I'm sure you're gonna remember it for life? Effortlessly?=)

Or one more way is, try to create a "funny" relation between the facts.

E.g. 1: Have you heard of "Argyll Robertson pupil" is like a prostitute? Because it accommodates but does not respond! (to light)

E.g. 2: 3 zones of adrenal cortex: GFR - glomerulosa, fasciculata and reticularis, which mainly regulate balance of salt (mineralocorticoids), sugar (glucocorticoids) and sex (androgens).
So the mnemonics for this: The deeper you go, the sweeter it gets. =)

And lastly, when you get familiar with the system, you can always create mnemonics of your own! First, look for the facts that you find it very hard to remember. E.g. from my own experience, I'm always confused with the terms of signs for aortic regurgitation, until I found a way to remember it!

(Darren's mnemonic) "In the MCQ about AR, the answer D is True!"
So from head to toe,
M - de Musset's sign (head nodding)
C - Corrigan's sign (carotic pulsation)
Q - Quincke's sign (nail bed capillary pulsation)
D - Duroziez's sign (femoral murmur)
T - Traube's sign ('pistol shot' in femoral artery)

Piece of cake now?=)

Ok so in conclusion, what I have shared are the principles of mnemonics and how they can help you to study. Obviously it's not possible for me to show all the mnemonics that I know (my blog will get out of space!). But if you have any problem remembering certain group of facts, feel free to tell and probably I can share the related mnemonics to help.

Finally, thanks for reading.
In the next post, I'll share about how I remember genetics and chromosomes!=)

Friday, October 03, 2008

Preparing for MRCP?

Ok since there are quite some questions on how did I prepare for my Part 1, hmm probably I'll just show you what have I got for my preparation:




The top and the bottom form the essentials. Many seniors told me that the minimum requirement is to finish Oxford handbook and K&C Clinical Medicine..cover to cover. To be honest, it's true. Painstaking and time-consuming but, this is what MRCP is about!


And the rest of the books that I displayed, are the supplementary. (Disclaimer: I'm not the best person to recommend which books to get, I'm just sharing my opinions) After the exam, I would now sort the books by their "usefulness" like this:


1. "Best of Five" - The questions' format are quite close to the exam's, hence a good practise book.


2. "An Aid to the MRCP" - Fantastic mnemonics! Though the facts provided are quite limited, but the mnemonics are helpful for quick revision.


3. "Update for the MRCP" - I think this is a should-get. Up-to-date information is essential when you sit for the exam, which you'll be tested on the latest facts!


4. "Basic Medical Sciences for MRCP" - This book I'm planning to sell it. Anyone's interested? (oops I hope the author is not reading this). Well, my humble opinion is, maybe the facts are somewhat inadequate and contents are not focused enough on Part 1=)


Beside books, I do have somemore things to share.


From USMLE Step 1, to Step 2 then now Part 1, I have to confess that, yes, I did use magic in my exams. HEHE. They're called "Darren's magic medicine formulas".
I'll share about the "formulas" in my next posts. Hope you all will find it useful!=)

Saturday, September 27, 2008

HO, MO and Specialist (2)

Case 1

During ward round. MO's talking to an elderly patient rather loudly.
MO: "Uncle, what medications are you taking?!"
Specialist: "Hey, is that the way you're supposed to talk to pt? Must ask politely la." Turned to patient, "Hello uncle, may I know what medications are you taking?"
Pt: "Huh?"
Specialist: "Sorry uncle, I was asking what medications are you taking?"
Pt: "Huh?"
Specialist: "(raised the tone) Uncle! I'm asking you what medications are you taking ok!"
Pt: "Oh oh..i'm taking atenolol and metformin."

Specialist turned to MO and HO, "See, some patients if you don't raise your voice ah, they won't answer you one."

MO and HO: "......"


Case 2

During departmental meeting. Big bosses were making jokes about pharmaceutical companies.
HOD: "You all heard about '3F'? Something the drug representatives like to provide to buy our hearts. One is food, one is flattering, the last one I can't remember. Hopefully not something obscene."
Everyone got the joke and laughed out.

HOD turned to a blur-looking HO, "You know what are we talking about ah? What is the 3rd F?"
HO: "(answering seriously) Ah..err..Is it flatulence?"

Everyone: "......"


Related post:
HO, MO and Specialist (1)

Wednesday, September 24, 2008

Interesting Case!

Early morning at 8am, a patient was pushed into red zone. A 60 year-old man, no known comorbids, has history of fever and vomiting for 1 day, then noted became unconscious this morning. GCS upon arrival was only 3/15. Very limited history available. Family members claimed he has no history of recent travelling/ river swimming/ jungle trekking.

Clinically, his BP was lowish, having high grade temp, normal SPO2, ABG acidotic. Pupils, cardiovascular, respiratory, abdominal examination are unremarkable. Noted he has got generalized purpuric rashes, slight jaundice and no urine output. Capillary blood sugar "low".

So the clinical picture seems to be severe sepsis with multi-organ failure. But what is the cause of sepsis? And the hypoglycemia seems unusual in a sepsis case. Then I was informed by the nurse, the sugar after Dextrose 50% 50cc bolus, only increased to 1.5mmol/L, still low.

Strange.
Think.
Wait, oh I think I got the diagnosis!

Some key treatment was given. He was sent to ICU.
Later the medical MO and physician also agree with the diagnosis.

What could be the most likely diagnosis?=)
(Answer's in my comment. Think before you open it!)

Tuesday, September 23, 2008

"Ada-ada" Syndrome (2)

Ok now we've gone through the definition of it, maybe we can share some tips on diagnosing it. And bear in mind that this syndrome is most commonly seen on Saturday morning (coz can get a 2-day MC for good weekends off) and Sunday night (feeling lazy to go back to work after enjoyed weekends).

From what I observed, most common "excuses" are headache, abdominal pain with diarrhea, low back pain, URTI symptoms and some others.

The key point is, patients can fake the symptoms, but rarely the signs. (Of course, it's possible in "professional" malingering pt or in factitious disorder/Munchausen syndrome etc.)

For complaints of cough/fever/sorethroat, it's not difficult to differentiate the "self-made" cough from the chesty ones. And, look for temperature, chest signs, injected throat or enlarged cervical lymph nodes. If they are present, then "Ada-ada" syndrome is unlikely.

For AGE (acute gastroenteritis) symptoms, you should be able to spot whether the abdominal pain is really "colicky" in nature, if you have experienced before. Things hard to be faked including the hydrational status, the abdominal tenderness and also the hyperactive bowel sounds. Look at pt's facial expression when you examine abdomen. Pt with "Ada-ada" syndrome, will forget about their abdominal pain with little distraction like, talking to them while examining the abdomen.

Low back pain are way too common. Some "smart" ones will know how to fake the SLRT (straight leg raising test). But there's a way to counter it. If you see a patient is able to sit upright with both knees extended on bed, and without pain, you know the SLRT is definitely negative. It's just same as you've raised their legs to 90 degrees!
And remember to look for muscle spasm. Tenderness is easy to fake but muscle spasm is a real sign.

Hmm I hope the tips will be useful. But I think the most difficult one would be "headache", as this complaint is so subjective, with hardly any obvious signs. Anyone has any good idea?=)

Ohya one last important diagnostic sign. If you see a patient who told you he has got severe back pain/ abdominal cramp, after given MC, walked off happily like healthier than you, it's highly suggestive of "Ada-ada" syndrome too.

But that will be a bit too late la. =)

Monday, September 22, 2008

The "Ada-ada" Syndrome

Ya, another newly-defined syndrome. To diagnose this, you need to learn some key phrases:

"ada-ada" means "got got"
"Kadang-kala" means "sometimes"
"Sikit-sikit" means "a little bit".

A typical conversation will be like this:

Dr: "So you said you've been feeling giddy these 2 days..any headache?"
Pt: "Ada."

Dr: "Severe throbbing kinda pain?"
Pt: "Ada-ada."

Dr: "Ok..what about fever?"
Pt: "Ada-ada-ada."

Dr: "Feel like vomiting?"
Pt: "Kadang-kala ada."

Dr: "Hmm..blurring of vision?"
Pt: "Sikit-sikit ada."

Dr: "Woo..(don't tell me you also have) abnormal jerking movement?"
Pt: "Oh..kadang-kala ada sikit-sikit."

Dr: "Then this is something serious. You need to be admitted for investigation."
Pt: (frightened) Oh no no..no need la. Actually my problems are just little bit and sometimes only. No medication also nevermind. Maybe I just need to rest.

Can you give me MC for 1 week ah?"

Ya, there you go. When the word "MC" comes out, you know you're seeing the "Ada-ada" syndrome, a.k.a "Give-me-MC" syndrome. Very commonly seen, not easy to diagnose and quite difficult to treat. Basically they'll say "yes" to all symptoms, but in the end MC is the only treatment that they want.

I'll share some tips on handling this "disease" in my next post. =)

Sunday, September 21, 2008

Are You Sure This is "Love"?

"KATE MOSS’s little girl loves the smell of petrol fumes, says mum — who’s been partial to a sniff herself over the years.

Kate said that when she fills up she has to leave the car door open so Lila Grace, five, can catch a whiff.

Kate has just released new fragrance Velvet Hour and said of her daughter’s habit: 'I’ve heard it is one of the most preferred scents in the world — maybe that’s something to study for my next fragrance.'

Perhaps trendy Diesel might be interested in marketing that one.
And Kate gushed: 'I really miss Lila when I’m away — though I try not to be away for more than two nights.'

'I love her more than anything in the whole wide world.' "

- News from The Sun

This is just too bizarre. Instead of discouraging this gas-sniffing act to turn into a dangerous habit, this modern mum actually encourage whom she "loves more than anything" to indulge it?

Two very contradictory things, I think I just don't get it.

Love, anyone?

Sunday, August 24, 2008

Million Dollar Question

Ya I have a million dollar MCQ here. Choose the best answer:

It's 4am. Sleeping time for every normal human. Somehow (I really dunno how), you realized your lips are quite dry. Maybe cracked a little bit. You will:

A. Continue to sleep.
B. Drink more water.
C. Get up from sleep, drive to hospital emergency department and see doctor.
D. Call ambulance to come get you to go hospital to see doctor.

If you choose either A or B, it's very likely that you're doing something normal ppl will do. If you chose either C or D, and so happen that you're seen by a tired mad doc, beware that you stand a high chance to get admitted. Yes admitted for dry lips. To a special ward. It's called psychiatric ward.

I have no idea what's in certain patients' mind nowadays. This "tragedy" happened to me, that while I was doing night shift, having seen all the crazy cases that drained me physically and mentally dried, I still had to see all the "non-emergency cases" that came in continuously. (Night shift is something scary, that one people is covering all 3 zones).

So I was very, truly deeply shocked by this young man, 24 year-old, healthy-looking, came to casualty at 4am, telling me that he found his lips dry, and slightly cracked. And pls believe in me that, HE HAS NO OTHER COMPLAINTS. I examined him with my widest imagination of all possibility of diseases but in the end the final diagnosis would just be: cracked lips. Treatment - the simplest being "pls drink more water", or if not, maybe a lip balm can help.

4am. Cracked lips. Drink more water will do.
Can someone tell me what's the urgency to see doc?! This is not something normal people will usually do right..

Sooner or later, maybe it's the poor doc who'd be forced to go mad and be admitted to psychiatric ward!=)

Friday, August 15, 2008

What a GREAT Day!

As I said, good or bad things, they just happen. Anytime, no signs, and most of the time when you least expected it.

I had another "special visit" again today. My hospital director suddenly came down to emergency department, wanted to see me and my department head. Apparently it's regarding the incident which the "VIP" was managed here few days back.

She looked serious. She asked to trace back the ticket, looked through it slowly. I was just having kinda rapid heart rate, wondering what's going on.

She looked at me, "Dr Lee, were you the medical officer who attended him?"

"Yes." (swallowed saliva)

"In fact, Dato has personally contacted our director-general (Health ministry DG) regarding this, and DG just called me this morning."

"(OMG, is it something good or bad?) I see..may I know is there any issue with this?"

My director raised her eyebrows, "OF COURSE there's an issue. If not I won't purposely come down and see you right?"

"(Heart rate increased to 180 again) Issue?"

"He wants to say congratulations to you. Dato's very satisfied with the management here, he said thank you, and he's impressed with the efficiency here," Finally she smiles and shakes my hand, "Good job."

I think no one can really imagine how relieved I was. And also my department head. He should be quite palpitative too.

The whole team found this very encouraging and was happy with it. I think my boss is the happiest, he has been smiling the whole day. Then he asked me, "Hey Lee, well done. I think you just stay in the department la, forget about medical.." I was like, "Errr..hmm haha. I'll see..maybe..." But seriously it's becoming difficult to decide, since emergency medicine just seems quite as interesting as medicine. See how la.

But anyway, this is really my "kembang" day la. Happy. Yay=)

Wednesday, August 13, 2008

Doctor & Patient (3) - Frustrating Chapter

Case 1

9 year-old boy complained of mild giddiness.
On examination, he's perfectly fine.

Doc: "He doesn't really need medication.."
Mother: "Huh? No medication? Nothing at all?"
Doc: "Hmm..alright..." (planned to give some vitamins)
Mother: "But is it ok for him to take medication? He's still small right..."
Doc: "That's what i said, no need medication."
Mother: "But what if he feel giddy again? At least give something.."
Doc: "So actually you prefer me giving medication or not?"
Mother: "How I know? I'm not the doctor. It's up to you..."
Doc: "Then no need medication."
Mother: "Huh? No medication? Nothing at all?"
Doc: "......"
Neverending story...

Case 2

18 year-old young man.

Pt: "I noticed something wrong with my..testes."
Doc: "Oh..which is?"
Pt: "The left one is lower than the right."
Doc: "Huh..you only noticed it recently?"
Pt: "Ya..during yesterday's shower. Something's wrong isn't it?"
Doc: "It's perfectly normal."
Pt: "(Doubtful) Is it? Coz I asked my dad, he also said it's not normal."
Then the dad came in, "Doc, do you think you can refer him to a specialist?"
Doc almost fainted.

(What you think will happen if this is referred to a specialist? It'll become a national news man!) Lesson - Bring your anatomy book around during clinic. You never know when you'd need to show "proof" to the patient.

Case 3

17 year-old girl comes for a urine pregnancy test.

Pt: "I'm afraid i'm pregnant. I missed my period this month."
Doc: "Ok..you got a bf?"
Pt: "Ya..."
Doc: "Were you..together with him last month?"
Pt: "Ya..."
Doc: "Ok understood. Ya let's check your urine."

Urine pregnancy test negative.
Doc: "Hmm it's negative. Actually, the 'together' you meant was..."
Pt: (started crying)
Doc: "It's ok..don't worry you can tell me..."
Pt: "He kissed me.."
Doc: "Kissed...hmm...(pls don't tell me that) you mean kiss ONLY?"
Pt: "Ya I already told him not to but he still kissed me..I'm so worried I might get pregnant...(sobbing)"
Doc: "......"

Doc feels like crying, too.

* This incident just happened this evening in the casualty. I'm really wondering what's wrong with the current sex education system. Apparently, she asked her mom and her mom also asked her to come for the pregnancy test. Sigh.


Related posts:
Doctor & Patient (1)
Doctor & Patient (2)

Friday, August 01, 2008

Inspiration




This is Barton Kamen, MD, PhD, professor of pediatrics and pharmacology, as well as chief of the division of pediatric hematology/oncology in Robert Wood Johnson Medical School.

From a classic doctor’s black bag stashed beneath his desk at The Cancer Institute of New Jersey (CINJ), Barton Kamen, MD, PhD, pulls out a couple of magic tricks. Now you see the scarf. Now you don’t. Kamen incorporates these magician’s props into his life as a pediatric cancer specialist just as if they were real medical tools. Not in league with a chemotherapeutic agent, stethoscope or thermometer, of course, they are the “ice breakers,” he explains, which help to engage children’s senses and break down their defenses and fears.

...When asked what he might do when confronting the tears of a mother, he answers, “I’d cry with her. I can’t take care of kids and not be human. I don’t believe in keeping professional distance. I just don’t.” And therein lies the magic of Kamen’s best medicine. In fact, look up the definition of magic: “the use of means … that are believed to have supernatural powers to produce or prevent a particular result (as in … death or healing).” A magician is someone who is “able to produce startling and amazing effects.”

- Extracted from UMDNJ magazine "Magic + Medicine = Cancer cures"


Magic undoubtedly brings happiness. Looking at him holding the bicycle cards, I'm just wondering whether i'll be doing the same thing in future, pulling out cards and magic tricks from my bag (like now) and keep on entertaining the patients.

I guess I will. Magic and medicine are just inseparable in my life!=)


Related posts:
My Love with Cards
The Wonder of Magic

Thursday, July 31, 2008

HO, MO and Specialist

Case 1

Specialist: "HDL and LDL stands for?"
HO: "High-density lipoprotein and Low-density lipoprotein."
MO: "Highly-desirable lipid and life-destroying lipid."
Specialist looked at MO, "Not bad..you're right."

Case 2

Specialist: "What's idiopathic?"
HO: "Means no cause is found."
MO: "It's a diagnosis of exclusion, after you've ruled out every other causes."
Specialist: "Right, so if you simply use this diagnosis, it means you are an idiotic doc treating a pathetic patient. Hence the word idiopathic."
HO & MO: "......"

Case 3

Child's coughing vigorously.
HO: "Is that barking cough?"
MO: "OMG what did you just say? You can't even differentiate how barking cough is like? You should go back to your school and learn again. Barking cough is such a basic knowledge, and don't make me laugh by saying that is it OKAY."

Specialist passed by..."Did you all hear that? It's a TYPICAL barking cough. One should never miss that ya. Very typical."

HO looked at MO, MO looked at ceiling.

(Note!: In this case, I wasn't the MO k. Just to clarify lolz)

Case 4

HO: "This patient presented with SOB..."
Specialist: "I hate ppl using short forms. What is SOB?"
HO: "Shortness of breath..."
Specialist: "But it can mean son of bitch also right? Why you so bad saying ppl got SOB?"
MO's ROTFLOL.

Thursday, July 24, 2008

My Fav Song..and It's M'sian Product!

Well, I could be outdated..but who cares. The song i'm putting now, is one I really like, and have been addicted to it for reaaaally quite sometimes. First time when I heard it, i really thought it's from some Taiwanese singers. (No offense to M'sian singers, but this really sound different..i mean, much better actually hehe)

Until I found out it's a song called "一起飞" by Henley 许俾文 with 陈威全. I guess they're some "Superstar" winners..ha pls correct me if i'm wrong, and pls forgive me for bit of losing touch with the current entertainment field status (i'm getting old...)

Anyway, just wanna share the song and hope you'll like it too!=)

Tuesday, July 22, 2008

What Exactly is Housemanship?

Lately, the new batch of housemen does not seem to be happy. Apparently some housemen (yes, THE new batch) are very unsatisfied with their jobs. Ya they have been making noises, but lately they're making more. Most of them made complaints about long-hours work, too much workload, always got to miss meals, always get scolded, work stress is depressing etc. And one of the HO's parent (apparently the over-protective type) even personally called the hospital director, complaining that the "36 hours on call" is unacceptable and it made her son "stress till constipated for 1 week (she can't possibly be serious)" and she requested on "less call, regular meal time, and can go off work on time" for her son.

This is just not so right.
I'm just wondering, do they ever know what exactly is housemanship? What was their expectations before they start working, or even before they chose to study medicine? Did they think it's gonna be easy?

First of all, housemanship is a training. A TRAINING. Not honeymoon or whatsoever. It's never easy. You'll do everything under supervision, and your knowledge, attitude, responsibility and endurability etc is tested, before you can be fully registered as a practising medical officer.

The "on-call" is 36-hour working and it's been there for ages and already like setting a "trademark" for doctors' work. Yes, it's tiring, for sure but I can assure you that this is the one of the most vital parts of your learning. Let me just quote my good friend, Steve's saying: "Being on call is clinically, physically, psychologically, socially, spiritually, and technically challenging. So, Bravo! to all doctors who had endured housemanship."

I can honestly tell that I learnt the most from calls. It's the time you learn to (or forced to because you're alone on the night) be independent handling and managing the patients. And talking about long hours, have you heard of back-to-back call? Meaning 2 calls in a row? What about a stretch 3-calls? And, the ultimate, 4 calls?

The shown punch card is of my worst month in surgical posting when the housemen were in awful shortage, and we had to do stretch calls. Note that those are active calls, so go figure how many hours of working was that. But I DID NOT complain. Nor did my mom.
(To all the respectful seniors, i'm not trying to show off at all. Just to put as an example. I'm sure there are some of you who had even worse time than it)

So the conclusion is, pls stop complaining. Housemanship year is crazy/mad/whatever-you-call-it but every medical officer has gone through it. If you think this is unacceptable, pls re-evaluate yourself before you have doubt on this working system.

And a piece of advice to all concern and over-protective parents: It's time to let your child go and learn. There's bit of suffer for him/her, but it's all for his/her own good.

I can bet with you, if housemanship has turned into a relaxed, goyang-kaki 9 to 5 job, in the end of the day, you'll most probably call the hospital director again and say,

"I want to complain! How come my son/daughter is now a fully registered doc but he/she doesn't seem to know anything one?
Did you all train him/her properly or not?"
_
Related post:

Sunday, July 20, 2008

Miracle (2)

"An Indian man has survived an operation to remove a 1.5-metre (five-foot) long iron bar that stabbed right through his chest, reports said Friday, calling it a medical miracle.

The rod was lying on a construction site when the taxi Supratim Dutta was travelling in smashed into it on Saturday.The bar crashed through the car's bonnet and dashboard before hitting the 23-year-old, who was sitting in the car's front passenger seat, The Times of India said. It measured 10 centimetres by 10 centimetres (four inches by four inches).

The man remained conscious and called family and friends from his mobile phone while he waited at the scene for an hour before being taken to hospital, the newspaper reported.

"I was shocked to see him. He was on the stretcher holding the iron angle. Groaning in pain, he kept asking people to move aside so that the angle (of the rod) wasn't disturbed," Tej Prakash, one of the first doctors to see Dutta, was quoted by the paper as saying."

- news from Indian man survives after iron rod pierces chest

Another miracle!


Related post:
Miracle (1)

A Beautiful (or Colourful?) Mind

Tell me what would you do if you were me.
Busy day. Admissions non-stop. Then I saw this patient (the unlucky me).

20 years old. Student nurse.

"Doctor, i noticed something funny with my stools. Over the past one week i've been passing darkish stool..but not really like malenic you know? More like dark BLUE..with some mucous..i'm not sure whether it's mixed with some tissue debris? And that day i also saw something orange colour..looks like the Vit C tablet that i took? Not fully digested..why like that ah?"

"Any blood?"

"Blood..yaya..that day after a difficult strain..i saw a few drops of bright red blood.."

"So isit black or red? I'm sure you know how malenic stool looks like..isit like that?"

"Hmm it looks like black but not really black..sometimes i even got green stool! *giggles*"

*Slightly nauseated* "Any abdominal pain?"

"Oh ya..i have left hypochondriac pain..but tak tentu one, sometimes like needle-pricking sensation, sometimes like spasm..then when the pain comes, i feel headache also, then giddy and feel like vomiting, but just mild one la.."

"Pain is localized?"

"Hmm..*hand make a 360 degrees round over the abdomen x2*, sometimes the whole abdomen also feel uncomfortable..ohya then my bowel habit, it's altered i think.."

"Like how?"

"Used to be twice a day, but now 3 times a day. I'm not sure if it's bcoz i'm eating more?*giggles*"

....this is just the 1st half of the history. Honestly, in a mad busy day, but you're stuck in seeing a patient like this, you'd really feel like killing yourself.

Noticed that she has already given more than 10 symptoms?
Basically the summary of the history is,

Non-specific abdominal pain with Rainbow-coloured stool. (Yup, a new medical term.)


Someone pls give me the diagnosis. (Or is that the diagnosis?)

Thursday, July 17, 2008

Combination of Durian and Alcohol Kills or Not?


It's durian season again..so the popular myth about whether durian mixed with alcohol kills, is kinda brought up for discussion again.
I read it from MMR's Durian and alcohol - the death mix myth, then I just further did a little bit of research about it. Just to show some extracts:

"In 1981, J. R. Croft wrote in his Bombacaceae: In Handbooks of the Flora of Papua New Guinea that a feeling of morbidity often follows the consumption of alcohol too soon after eating durian. Several medical investigations on the validity of this belief have been conducted with varying conclusions." - Wikipedia (notice that it mentioned morbidity..what about mortality?)

Then I found a more scientific explanation:

"...The presence of harmaline in durian kernels as well as in the fruit pulp has been confirmed. It will, in conjunction with alcohol, induce hypertensive periods, whereby the blood pressure is raised to absurd high levels, sometimes even reaching life-threatening values of 300. Durian is also a source for tyramine. In absence of alcohol tyramine is converted in the gastro-intestinal tract swiftly to the corresponding N-oxide, but this conversion is greatly inhibited by harmaline in the presence of alcohol. Thus, the tyramine level in the blood reaches unacceptable high levels, eventually leading to a stroke." (Hmm hypertensive crisis causing hemorrhagic stroke leading to sudden death..quite convincing..)

Then some mythbuster's experience:

"I thought I was a goner. I felt my head spinning, and it was hard for me to breathe. The pain on my chest was unbearable..Alcohol and durian can generate so much heat if taken. If both are taken at the same time, the human body would not be able to stand the heat."

It happened before?

"..A middle aged man in Batu Niah was recently found dead on the floor of his room by friends. He was covered with foams of mixed saliva and blood in his mouth. Friends found that Panggau, in his 50's had been drinking four bottles of branded liquor and ate some durians in his room." - Winedragon (In fact there were also a few cases in M'sia..ppl found to have unexplained sudden death after consuming the lethal combination)

So were there any scentific studies done or not?

"Some scientific studies have actually been conducted to investigate the validity of this belief. Despite the important contributions to our knowledge of durians and human/animal physiology provided by these experiments, some flaws are evident. Most of them were lacking a control treatment in which animals were fed an equivalent mass of some food item other than durian. Thus, any effects on alcohol absorption might be due to the presence of food in the stomach, and not durian per se. At this point, it is fair to say that consumption of durians with alcohol has not been shown to be harmful." - Singapore Science Center

Any Malaysian mythbuster tried it?
Yes, they even had a durian party with alcohol. Timothy didn't take the risk actually, so he's still fine.

What about his friends then? Hope they're fine, too.

Wednesday, July 16, 2008

Mad Referrals (2)

Mad referrals are back! Recently i saw these two:

#1
(I think i can put the whole content here because it's very "simplified")

"Dear doctor,
Thank you for seeing this 14 year-old girl, who's previously well,
currently unwell.
Kindly do the needful."

Look at this. Fantastic isn't it. Patient's problem is perfectly summarized. I just feel like replying to him, "Dear doc, thanks for your referral. I think, hmm, if patient comes to see me, you think I dunno she's unwell??! Next time you can just omit your referral letter thank you."

#2
I saw a 29 year-old gentleman in casualty. Had a short chatting while i opened the referral letter. I almost fell from the chair when i saw the diagnosis: "Imp: Acute myocardial infarction (AMI)"

You know why I was so surprised? Because, from the chatting, he told me that after he saw the GP, he rode his motorbike, went home and took a shower, then rode motorbike again and came.

First thing, 29 year old is quite unlikely to have heart attack. (I then checked the ECG stat, it was just a high take-off in only one chest lead, and the clinical picture was more suggestive of costochondritis.)

The problem is, when you think that someone has a MI, it's an EMERGENCY, no doubt. Your reaction won't be like, "Hey, I think you're having heart attack..faster take your bike and go to hospital ok?"
"Can I go back home and take a bath first ah?"
"Hmm..can la but after your bath, faster take your bike and go to hospital ok?"

Make no sense isn't it. MI patient should never drive, and there should never be any delay in getting treatment. Time loss=muscle loss, remember. But of corz, luckily this was not really a MI patient, if not the GP is gonna be in deep, deeeep trouble.


Related post:
Mad Referrals (1)

Tuesday, July 15, 2008

Pachelbel's Canon (Canon in D)

Read a post in shinyin's blog which she was playing her piano. I think she did a very fine performance.

I'm sure everyone's familiar with the song?
Pachelbel's Canon (also known as Canon in D major), is the most famous piece of music by Johann Pachelbel. It was written in or around 1680, during the Baroque period, as a piece of chamber music for three violins and basso continuo, but has since been arranged for a wide variety of ensembles. (i'm not that good with history, this piece of info is from Wikipedia lol)

This music has been played with various instruments, and all are widely acceptable. I just wanna share a few clips:



A version with electric guitar. This guy is amazing. I've seen this clip on youtube few years back, and now it has already got over 40 millions view. Very very nice.



Legend in the making. Sungha Jung, a Korean boy who's extraordinarily talented.



And this is the last clip that I wanna share. Not about Canon but, is he not amazing? He just showed us that with strong determination, nothing's impossible!

A superhero in real life.

Monday, July 14, 2008

Interesting Chest Xray (3)




This is a Xray of a 60 year-old lady who presented with severe breathlessness. It's pretty straightforward, think a 4th/5th year medical student should be able to describe it. It's basically a massive pleural effusion of left lung with mediastinal shift. But what I wanna show here is the marked trachea deviation, and if you look closely, even the carina can be seen!


Related posts:
Interesting Chest Xray (2)
Interesting Chest Xray (1)

Sunday, July 13, 2008

Couple Jokes

Let's have some light moments. Saw these somewhere.

#1
Wife: "Dear, we have married for so many years."
Husband: "Ya..."
Wife: "Tell me, which part of me you like the most? Is it my beautiful face or my gorgeous body?"
Husband: "...I think I like your sense of humour."

#2
In an art gallery.
Wife: "I think the portraits are overall excellent."
Husband: "Ya..."
Wife: "But there was one I saw just now was simply terrible, the worst of all."
Husband: "...I think you were walking past a mirror."

#3
A lady loves to sing loudly at home.
But whenever she sings, her husband will walk out to the balcony.
Wife asked, "Why must you stand there when I sing?"
Husband: "I have to. I want to let our neighbours see me, so that they won't think that i'm physically abusing you or something."
Wife: "......."

Thursday, July 10, 2008

Welcome to the Mad House

This is what happened when supposingly 3 ppl doing the shift, but one went to do the post-mortem and one went to attend some courses. Left a poor doc in the department, running like a mad dog.

"Doctor, patient's BP high la..260/120mmHg. Complained of vision blurring."

"Doctor, patient complained of chest pain la..ECG looks not good."

"Doctor! Patient's fitting! Fitting!"

"Doctor, I think you should see this first..per vaginal bleeding..still actively bleeding la.."

"Doctor, patient's collapsing..BP's down to 60/30mmHg! Wanna start inotropes?"

"Doctor, MVA case, severe head injury."

"Doctor, call for you from district clinic to consult."

"Doctor, the green zone patient said she's waiting for quite long already..she said if she go back later during lunch time the traffic very jammed one.."

"Doctor, patient's fitting again! Fitting!"

"Doctor, just to let you know, later got third-degree burn patient coming. Got THREE."

"Doctor, the uncle very tachypneic la..SPO2 85%, on high-flow oxygen already.."

"Doctor, can you see me first ah, I'm a hospital staff la. I feel veerrrry pening today. Can you write me a MC ah? Now can ah? Now ya.."

"Doctor, patient collapsed! Quick!"



"Doctor!"

"Doctor!"

"Doctor?"

.

.

.

.

.

.

"Doctor are you ok? Are you ok?!"

.

.

.

"Help! Everyone help! Doctor's collapsed!! Quick!"


The end.


P/s: Of corz, the last part didn't happen. Docs are not allowed to collapse during work, no matter how tired, as one of the work rules.
Enjoy the mad house.

Wednesday, July 09, 2008

Must It be Private Hospital?

My emotion is quite affected by one incident today.
A man brought in by ambulance, 40 year-old Chinese, alleged MVA (motor-vehicle accident) - car vs lorry, sustained a bleeding forehead wound. GCS on arrival was 8, with unequal pupils, showing that head injury with intracranial bleeding is likely. We stabilized him, then I called up surgical team and spoke to radiologist to arrange for an urgent CT brain.

Everything was quick and smooth. He was ready for a scan then an emergency op if needed. But then suddenly the family came and said, "No need for the scan! We are bringing him to Hosp X (a private hosp in Penang). My friend told me there's a very good neurosurgeon there."
Penang? We explained to them that this would cause unnecessary delay in management, which is highly unwanted in such case. And surgeons, we also have plenty here.

"Nonono! We are bringing him there. I called there already..they said they can send their ambulance to here now."
" But how long is it gonna take?"
"They said around 30 min will do."

Rounds of explanation were given by us and the surgical team on the possible risks and complications of such decision, but in the end they insisted and signed the "At own risk" discharge. By hospital's policy, this is something like you're refusing hosp's treatment despite advice, and of course, you're fully responsible for your action.

Everything was settled at around 11am. Patient was electively intubated to protect the airway, I guess this is the last thing that we could do good for him.

30min passed.
1 hour.
2 hours. (At this time the family was calling the ambulance, they said on the way..)

And guess what, the ambulance finally arrived, at 2pm!!
3 freaking hours.
If every second is a golden second for a head injury patient, please do the calculation that how much time was wasted and how much that we could have done for him, if only they allowed us to, which they didn't.
Invariably, the outcome and prognosis is gonna be less favorable.

Is private always a better place? What made them so sure? That they could risk their closest family's life just because they thought so?
They thought they have made a good decision for him. They thought.

Tell me why.

Tuesday, July 08, 2008

Miracle

"A 70-year-old from Muzaffarnagar, India, became the world’s oldest woman to give birth after she delivered twins Friday. Omkari Panwar, the wife of a retired farmer, delivered the twins — a boy and girl — via Caesarean section.
Panwar, who has two adult daughters and five grandchildren, underwent in-vitro fertility treatment so she could produce a male heir.

Her husband, Charan Singh Panwar, 77, mortgaged his land, sold his buffalos, spent his life savings and took out a credit card loan to finance the treatment.
“At last we have a son and heir,” he said. “We prayed to God, went to saints and visited religious places to pray for an heir."
“We kept no stone unturned and God has rewarded us. The treatment cost me a fortune but the birth of a son makes it all worthwhile. I can die a happy man and a proud father.”"

- Pic and news extracted from FoxNews

Miracle does happen.

Wednesday, July 02, 2008

You Made Us Proud

A record was made.

For the first time in the history of Malaysian advertising, a Malaysian television commercial, directed by Yasmin, was awarded a Gold Lion at the Cannes Advertising Festival, 2008. The commercial was entitled "Tan Hong Ming In Love" and i'm sure everyone is familiar with it.



Another commercial in the same campaign, "Race", was given the Bronze Lion in the same category.



I'm truly so proud of her.

Her ads are always inspiring. Very simple messages, but delivered in her unique storytelling way, never fails to touch everyone's heart. Look at the recent news in the country, and look back on the ads, don't you think that if we're all "colourblind", isn't that everything will be so different now?

Sunday, June 29, 2008

Interesting Chest Xray (2)


This is an Xray of an 11 year-old boy, who presented with 4-month history of coughing, with intermittent fever and generalized lethargy. He has been in contact with his neighbour, who's an IV drug user with refractory chronic cough.

I guess you should be able to get the diagnosis now. His sputum AFB is >50/L (++++)! Bad pulmonary tuberculosis. Xray showed multiple cavitative lesions bilaterally with patchy consolidation in right middle zone.

Beware of your coughing neighbours!=p


Related post:
Interesting Chest Xray (1)

Friday, June 27, 2008

New Card Collection




Yay. New decks arrived!
Top (from left): Split Spades by David Blaine, blue, black and red Lion series, Bicycle Faded;
Bottom (from left): Bicycle Tragic Royalty, Split Spades, Bicycle Guardians

Split Spades are designed by David Blaine and are recognized as must-haves among card magicians. Lion series are the next generation of it, with even more excellent quality, revolutionary design and perfect finish. If you do notice, the "split spades" logo actually symbolizes david blaine's initials. So cool isnt' it.



Master sleight-of-hand magicians - Dan and Dave doing card flourishes with Split Spades.

Bicycle Guardians is another classic. It's designed and produced by theory 11, based on the classic Bicycle Rider Back's design, now the angels are given new images. With the signature air-cushion finish, the handling is simply..marvelous.



Have a look at another of my magic idol, Daniel Madison flourishing with Bicycle Guardians.

My hands just can't wait to "taste" the cards!

Wednesday, June 25, 2008

Favourite Quotes

Just to share some of my favourite quotes:

* We can live with dignity, we can't die with it. --House MD

* I submit to you that if a man hasn't discovered something he would die for, he isn't fit to live. --Martin Luther King, Jr

* Will you stand in shadows, or step forward and become a leader? It's in your moments of decision that your destiny is shaped. --Anthony Robbins

* Will you look back on life and say, "I wish I had" or "I'm glad I did"? You do have a choice. --Vicki Hitzges

* Failure is the inevitable result of an accumulation of poor thinking and poor choices. --Jim Rohn

* For those who believe, no explanation is necessary; For those who do not, none will suffice. --Dunninger

* You don't get into magic, magic gets into you... --David Blaine


The last is the coolest=p
What's your fav quote in life?

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