Thursday, December 30, 2010

USMLE Step 1 Prep

Dear readers, this is it - my sharing post on preparation for USMLE Step 1, after receiving quite a number of enqueries for this exam.
Disclaimer: This post is neither a guide nor a suggested study plan. Instead, it is just my own opinion based on past experience. Please take note that I did this exam in '05 (during my 4th year), hence the information may be very much outdated. ;)

The United States Medical Licensing Examination (USMLE) is a multi-part professional exam sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). Medical doctors with an M.D. or M.B.B.S degree are required to pass this examination before being permitted to practice medicine in the United States of America.

There is a huge variety of resources that can aid you for this exam. It is practically impossible to cover everything (in your usual preparation duration of 3-6 months), hence the choice of material is important. I have not tried out all resources, therefore I'll be only sharing those that I've read/ accessed to.

First Aid for USMLE is a must-have - my sincere opinion. Some call it the "Bible", or "Secret-weapon", generally, it is an indispensable tool in your prep. It is very concise, updated (yearly edition) with full of useful tips and mnemonics. The Rapid Review section is its trademark. And I think that, even if you're not sitting for this exam, an undergraduate should also get this book - it's extremely helpful and will strengten your basic science knowledge.

High-Yield Series are an excellent companion for your study prep. I was lucky to have access to the full series (thanks to my university library), and I find the volume on Gross Anatomy, Embryology, Neuroanatomy and Pathology particularly helpful.

Underground Clinical Vignettes (UCV) series are another high-rated study aids. The format is case-based, and designed to be used as a conjunction with a primary review course. I find the volumes on Biochemistry, Behavioral Science & Microbiology (Vol I & II) very helpful.

PreTest has a wide coverage on all the topics, but I think it's quite impossible to study all. I think maybe you should just get the book on Clinical Vignettes - which are all exam-simulated questions with detailed explanations. You can use it as a self-evaluation tool, i.e. a "Mock" examination for yourself just before the real exam - and time yourself!

Apart from books, online Q-bank (Question bank) is almost as popular (and as important). As far as I know, the 2 top-rated Q-banks are:

Kaplan Medical - The questions supplied are well-written, and very similar in style with actual exam. Very time-consuming though, and cost can be a concern especially to undergraduates.

USMLERx - developed by the authors of First Aid - the contents are outstanding, with much cheaper cost.

And lastly, there are many online USMLE forums where you can discuss and share tips among yourselves. Some even share what kind of questions they encountered in the latest paper that they just sat for - hence giving you a rough idea on your coming exam.

I guess that's all of my sharing. I'll probably write another one on prep for Step 2 CK later.

So, good luck and, Happy NEW YEAR! ;)

Saturday, December 25, 2010

My PACES Experience (2)

Ya, as promised, this post is about case presentation in PACES exam, in my humble opinion. There are more than plenty of resources on approaching this exam, hence I won't really elaborate too much. I'd just like to share a "format" that I think is "safe" and can be used even when you're in a panic state (Well, at least it works for me).

Let's just take an abdomen station as an example, and renal transplant case is one of the common ones. Upon completing your examination, you turned to the examiner,

1. General physical findings

"Mr Smith (always use patient's name instead of "this gentleman") is comfortable at rest. He has sallow complexion, conjunctival pallor and I noticed that he has finger prick marks and half-and-half nails, with an arteriovenous fistula at his left arm with no recent needling marks. I also noticed that he has gingival hyperplasia as well as fine tremor of his hands."

2. Main System

"...Moving on to his abdomen, there is a scar at right iliac fossa, with a firm mass beneath which is non-tender and dull on percussion. There rest of the abdomen is soft, and there is no hepato or splenomegaly. The kidneys are not ballotable. There is no ascites, and he has no sacral or pedal edema. "

3. Summary (The most important part - score at this point!)

Always go by - Diagnosis -> Etiology -> Function -> Complication (from disease & Rx)

"In summary, Mr.Smith has a transplanted kidney, which is functioning well, for his underlying end-stage renal failure, which most likely was due to diabetic nephropathy. He has features suggesting that he is on immunosuppressive treatment, most likely a calcineurin-inhibitor. He has no signs suggestive of fluid overload or uremic encephalopathy. There is no lymphadenopathy or any suspicious skin lesion."

Easy? Let me break down the important tips for you:

First of all, spot that this is a renal failure patient (The fistula is obviously the tell-tale sign), then switch on your brain engine and the visual survey, looking for:

1. Other signs of renal failure - as mentioned in textbooks, PLUS the evidence of previous dialysis (neck scar of catheter insertion, abdominal scar for peritoneal dialysis, failed fistula at other sites etc);

2. Possible etiology of the renal failure, e.g
- Finger prick mark - diabetes mellitus. If young patient, suspect Type 1 DM and look also for scar of pancreas transplant (usually done together with renal transplant);

- Nephrectomy scar - trauma, hemorrhage from angiomyolipoma, polycystic kidney, obstructive uropathy etc;

- "Gaunt facies" - lipodystrophy due to underlying Mesangiocapillary glomerulonephritis (Easily missed!);

- Autoimmune features - SLE malar rash, scleroderma, or even just skin vitiligo - could be associated with Type 1 DM - think broadly! ;)

3. Graft function status

Clinically by looking (carefully) at recent needling marks, graft tenderness, and signs of fluid overload/ uremic encephalopathy.

4. Side effects of Immunosuppressive treatment

Steroid: Cushingnoid features (long list)
Calcineurin inhibitor: Tremor, gum hypertrophy, hirsutism
And others (azathioprine, MMF, sirolimus etc)

5. Malignancy - Important!

Mentioning lymph node examination and skin lesion shows that you're aware of the risk of malignancy in post-transplant patient - most important ones being skin cancer (SCC/ BCC) and lymphoproliferative disease.

6. Lastly, mention about blood pressure. It shows that you're aware that cardiac death is the most important cause of deaths in post kidney-transplanted patients, which all cardiovascular risks need to be aggressively controlled. Besides, it could also be the etiology of his renal failure (Hypertensive nephropathy) or as a side effect of cyclosporin/ steroid.

So that's about it. Remember, it's a postgraduate exam so you need to look for "more things" so that you can make the impression. A holistic approach will be essential.

Good luck!

Related posts:
My PACES Experience (1)
PACES Case Sharing

Saturday, December 18, 2010

My PACES Experience (1)

Finally I received my formal result. A pleasant surprise indeed. I scored 93/100. The passing mark this time is 75%, and the passing rate for this diet is 38%, for UK/Non-UK candidates. I'm glad that the hardwork did pay off and in my next few posts or so, I'll be sharing some of my thoughts about this exam (a.k.a my worst nightmare of the year, really!).

If you ask me what is important in the preparation, broadly speaking, I think there are 3 components - REMEMBER, these are EQUALLY important:

1. Knowledge

You might have heard that PACES is about practising. But believe me, if you do not have the core knowledge, you'll have hard time interpretating signs and correlate them together and bear in mind that this exam you are under direct observation and face-to-face oral Q&A, without adequate (or more than adequate) preparation and reading, "thought-block" and "verbal constipation" is extremely common.

As compared to the written tests like your Part 1 & 2A, I think PACES is much more tougher in terms of the spectrum of the questions that you may be asked, it can range from the most basic (eg physiology), or common diseases but in details (eg prevalance and epidemio), or rare stuff (eg a rare sign), to the updated management (most current practice guidelines, trials and future developement).

Hence, for reading material, I'd suggest the "gold standard" - "An Aid to the MRCP PACES" Vol 1&2 by Ryder and the "250 Cases in Clinical Medicine" by Baliga. But bear in mind that these books do not cover the "Station 5" - a new format in PACES.

Beside the books, do keep yourself updated with the latest guidelines (eg NICE, SIGN guidelines) and important medical trials (you need to confidently name them out - to show that you're practising evidence-based medicine).

2. Showmanship

Now we come to the practising part. It's a blessing if you can find a mentor (usually they'll be too busy to guide), or at least you can form your own study group. No doubt for this exam an extensive amount of time need to be spent on practising, for the clinical method, examination routines, history taking and communication skills. I think the tip is you really have to merge it into your daily practice, meaning seeing all your patients like your exam cases, then you'll improve fast.

Among all, I'd say bedside manner is of the utmost importance, and this is really something will make you stand out from other candidates. And make sure that you perform it as something natural, not like showing it just for the exam's sake. Greet the patient warmly, examine them with respect and dignity, and thank them sincerely!

3. Luck

Now we come to the most difficult part. Believe me that this is a highly unpredictable exam, therefore luck does play a role here. The set of examiners that you get, the patients/ surrogates, or even the candidates in your carousel - all are crucial factors in deciding whether or not you will pass. You may be very confident about your knowledge and skill, but luck MAY as well go wrong, and failed you totally. So, for your luck to go smoothly, my sincere advice is - do pray a lot! ;)

Next entry: Case Presentation in PACES

Saturday, December 04, 2010

HO, MO and Specialist (5)

Specialist is doing a quick round, and HO is documenting down his words in the notes.

Patient #1 - Middle-aged man with uncontrolled hypertension.

Specialist: "The BP is still poorly controlled despite 3 anti-hypertensives. He looks acromegalic, do the hormone workup later."

*HO quickly wrote down*

Patient #2 - Lady with food poisoning, stool culture grows Salmonella.

Specialist: "So this is Salmonella food poisoning, remember to notify the Salmonella."

After round,
Specialist said to MO, "The HO is new right? He seems lost. Just make sure he wrote down the things properly ok."

MO then went back to the bed tickets and see the documentation. He then nearly fainted...

Patient #1's ticket: "Patient looks ?garlic, check the hormone later."

Patient #2's ticket: "Diagnosis is Salmon food poisoning. To notify the Salmon."

MO & Specialist: "Did he really take medical course, or was it a cooking course??"

Related posts:
HO, MO and Specialist (4)
HO, MO and Specialist (3)
HO, MO and Specialist (2)

Wednesday, November 24, 2010

To The People Who Have Inspired Me

I have been receiving wishes for past few days and I must say that I really appreciate it. I'm glad that I've come to another milestone in medicine. Looking back, I'd also very much like to thank those people who have inspired me along the way.

The first is Dr Leong WS, who made me decided that I want to do Internal Medicine (I bet he didn't know this). The history traced back to the time I was doing my medical posting as my first posting of housemanship. I was placed in his ward for total of 3 out of 4 months. He is a tremendous teacher. I learnt a lot (directly and indirectly) from his impressive bedside manner, clinical method and way of thinking. He makes the ward rounds interesting, something that I was looking forward everyday as it's just full of learning experiences. And after I completed my medical posting, I already know that, Internal Medicine is what I'd pursue.

The next is Dr Lee BS, a senior of mine working in medical. If you can remember, I wrote a post congratulating her on her passing her MRCP. She is like a role model to me, and has been giving me advices for exams. I truly admired her that she could complete the exams by age of 28, I set it as a goal, and I'm glad that I achieved it!

Last but not least, the nephrologist that I'm currently working with, Dr Indra. I started my nephrology rotation since July. He has an amazing personality and extensive knowledge in general medicine. I was rather depressed when I didn't get through in my first attempt and he encouraged me to keep going. He used to tell me that doing medicine cannot be half-hearted, it should be a dedication, and I'll quote his words, "I breathe medicine, I think medicine, and I dream medicine."

To these great people, I'd like to say, thank you.

This is Dr Leong, I'm very glad to meet him again in one of my friend's wedding. He's now doing cardiology, and he just forever looks young! Thank you, Dr Leong!

Saturday, November 20, 2010


Yesterday night, I was sitting in front of computer, with mixed feeling. It was a similar night few months ago, which then I had my confidence crisis.

This time, I have with me S/L GTN (for unstable angina), antidepressant (for acute major depression) and IM Haloperidol (for acute delirium) - to standby for any unwanted serious reaction after knowing the outcome.

And yes, the moment has come. It's out.

I made it! MRCP (UK). My biggest nightmare of the year (seriously).

Just want to say big thanks to everyone who gives me support, and especially those during the time that I was most depressed. Words can't really express how much I actually appreciated.

Once again, thanks!

And I know, it's not the end. It's just a beginning of my another journey!

P/s: Ok, I was joking about the medication part. I was just having a cup of coffee to keep me awake and that's all=p

Wednesday, November 17, 2010

Random Jokes

I'm sure some of you do read MMA's monthly journals. I actually quite like the "SP's Korner" - it always gives me good laugh. Just picked 2 randomly:

The skydiving instructor was going trough the question and answer period with his new students when one of them asked the usual question always asked:
"If our chute doesn't open; and the reserve doesn't open, how long we would have till we hit the ground?"

The jump master looked at him and answered:
"The whole rest of your life."

Albert Einstein, Palo Picasso and George W Bush arrived at the Pearly Gates and introduce themselves. St Peter says, "You'll have to prove to me that you are who you say you are."

Eistein takes out a piece of paper and writes e=mc2 and starts writing with formulas. St Peter says, "I believe you, come on in."

Picasso takes out a pencil and paper and starts to draw. St Peter says, "I believe you, come on in."

Goerge W Bush says to St Peter, "Who are those guys?"

St Peter says, "Come on in, George."

Saturday, November 06, 2010

My Birthday Campaign

On 22nd Jan 2011, I'm turning 29.

But this birthday will be a little different.

Let me give a short intro about myself. I'm a practising medical doctor in Malaysia as the full-time profession. In other time, I perform magic as a hobby, as I like seeing people entertained, and laughter is always a good medicine.

While I'm thinking of helping more people, I came across Charity: Water, founded by Scott Harrison, and I'm truly amazed by it, the concept, and the people working behind it.

A billion people in the world are living without clean water - but how much are they really living? Millions contract deadly diseases from contaminated water. 45,000 people will die this week alone. The lucky ones won't, but still walk hours each day to get dirty water to give to their families.

So this year, I decided giving my birthday up.

Instead of asking for gifts, I'm asking for $29 or more from everyone I know. It's not going to me, though. All of it is going to build freshwater wells for people in developing nations.

My birthday wish this year is not for more gifts I don't need; it's to give clean and safe drinking water to some of the billion living without it. I want to make my birthday matter this year.

Please join me to make this happen. The ability to give is a gift, and you never know how considerable the changes will be to the people with your contribution.

You can make the donation here. (or

I'd like to thank you in advance.

Charity: Water

Dear readers,

Please spare your few minutes to read this.
I might be kinda late to get to know this, and some of you may be already aware of, the Charity: Water. It's a non-profit organization founded by Scott Harrison (Read his story here), aiming to bring clean, safe drinking water to people in developing nations. How did he come out with this idea? Have a look here,

That's the story - everything started from a birthday party, in such a meaningful way!
It raised $150,000 and brought clean waters to hospitals and schools in Kenya. And the following year - it went even bigger.

Things seem to be working. The September birthday campaign raised $1 million, and helped 50,000 people in Ethiopia.

And this year, they are planning to build wells for Bayaka people, in Central African Republic. Though the September Campaign is over - you can still always provide your help!

There are 3 ways to help:

1. If you're a September baby, give up your gifts and fundraise with them!

2. If you're not, consider donate to them.

3. Share the story, with friends, family, everyone that you know.

The message: Clean water offers improved health, a better quality of life, and hope for a better future.

You definitely can do something to help them.
I'm not a September baby, so I've carried out the way No. 2 and No. 3.

What about you?

Friday, November 05, 2010

A Need for Clean Water?

Imagine you're like her, in a place with no access to clean water.

How would you feel?

Do you think you can do something to help them?

Thursday, October 21, 2010

Patch Adams is Coming to KL!

No not Robin Williams. I mean the "real" Patch Adams.

Read this from MMR - that he's coming to KL on 26th Nov.

But 26th Nov is a Friday...why?! Too bad I'm just gonna miss this annual leaves are finished! I think it'll be great to see him in person, and share his concept of "joy and laughter are an integral part of healing process"...just like magic? XD

But I also found out something interesting in Wikipedia - that he actually doesn't like the movie "Patch Adams" so much. According to Wiki -

"Adams has criticized the film made about him, saying it sacrificed a lot of his message in order to make a movie that would sell. He said that out of all aspects of his life and activism, the film portrayed him merely as a funny doctor. Patch Adams also said of Robin Williams in an interview 'He made 21 million dollars for four months of pretending to be me, in a very simplistic version, and did not give $10 to my free hospital. Patch Adams, the person, would have, if I had Robin's money, given all 21 million dollars to a free hospital in a country where 80 million cannot get care.'"

Well, I didn't know that!

Wednesday, October 20, 2010

CPR Guidelines 2010 (NEW)

AHA (American Heart Association) has just released the latest CPR guidelines on 18th Oct. This is undoubtedly something very essential in our daily working life - so make sure you are aware of the new changes.

Some of the highlights in the guidelines:

* "Look, listen, and feel for breathing" has been removed from the algorithm.

* A change in the recommended sequence for the lone rescuer to initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). The lone rescuer should begin CPR with 30 compressions rather than 2 ventilations to reduce delay to first compression. (Evidence: Improved outcome and survival with early chest compressions)

* Compression rate should be at least 100/min (rather than 'approximately' 100/min - Evidence: more compressions are associated with higher survival rates)

* Compression depth for adults has been changed from the range of 1.5 to 2 inches to at least 2 inches. (Evidence: Compressions of at least 2 inches were shown to be more effective in generating critical blood flow and oxygen)

* Routine use of cricoid pressure in cardiac arrest is not recommended.

* The recommended initial biphasic dose for cardioversion of AF is 120-200J, and 200J if monophasic. (Old guidelines recommended 100J starting dose for monophasic)

* Atropine is no longer recommended for routine use in management of PEA/ asystole and has been removed from the algorithm. (Evidence: Use of atropine is unlikely to have a therapeutic benefit)

There are many more key changes.
You can access the full guidelines here.

Read it today!

Tuesday, October 19, 2010

Cause of Ascites?

Think this is an interesting CT scan of abdomen.

A lady was admitted to medical for "Ascites for invesigation" - as usual, everything under the sun will be "for medical to find out". She complained of progressive abdominal distension and discomfort, and there was a vague mass felt on abdominal palpation.

What do you think the CT (circled area) shows? (You can click to enlarge)

Wednesday, October 13, 2010

Interesting ECG (5)

You were asked to examine this gentleman's cardiovascular system. By only inspection, you should have gathered two possible diagnoses in mind.

Got it? If not, then have a look at the ECG (not his but just to give you a hint):

(ECG from

Now shout out the answer! ;)

Thursday, October 07, 2010

A Simple Thought?

Recently there's a case of severe anaphylactic shock requiring intubation for respiratory distress. It was secondary to severe allergic reaction to honey consumption. Surprisingly, according to family members, the patient is fully aware of the fact that he's allergic to honey, and would develop allergic reaction (pruritic urticaria and wheezing) each time he takes it. However, he still continues to take it, despite repeatedly advised by family members against it, and for this time, he took extra amount just because "he feel like eating it".

Why would anyone insist on doing something that actually risking his/ her own life?

Come to think of it, similar stories often occur. It's not something uncommon at all.

Have you seen patients with advanced COPD (Chronic obstructive pulmonary disease) but still smoking? I'm sure you do, don't you?

Or patients with congestive cardiac failure/ renal failure but still never compliant to fluid restriction? - common cause for the recurrent admissions.

What about diabetic patients who are still taking high sugar diet? - Extremely common, needless to say.

And those who's already having severe deforming gouty arthritis, but still continue drinking beer? Same for those with advanced alcoholic liver disease? Plenty, too.

The common answer is always, "Ya I know..but I just can't resist it..."

Can't resist a simple thought. But think carefully, this is a thought which may lead you to a life-threatening complication, irreversible outcome, or even, death.

Still think it's a simple thought? I'd say it's an irresponsible thought, to self, to the people around you. Please think again.

Monday, September 27, 2010

Full Diagnosis?

A classic referral again.

HO: "Hi I'm calling to refer a case, this patient is a known case of Parkinson's disease on oral Flecainide..."

MO: "Wait, she's on Flecainide? Why? Do you know what is that?"

HO: "'s one of the Parkinson's treatment..."

MO: "No it's an antiarrhythmic agent. You sure of the drug name? And you're calling from which department?"

HO: "I'm calling from obstetric ward..the patient is pregnant..."

MO: "Pregnant? You mean she has Parkinson's disease and she's now pregnant? How old is she? Is she a case of young Parkinsonism?"

HO: "Err...I'm not sure. I'm just reading out from her medical history card...and she said that the diagnosis is confirmed. Actually the full diagnosis is kind of long, do you wanna hear it?"

MO: "Kind of long? Yes please...*preparing to hear a diagnosis of young Parkinsonism due to secondary causes*"

HO: "The full diagnosis is W-o-l-f-f Parkinson W-h-i-t-e I pronouncing it correctly?"

MO: "*Speechless for a few seconds* you, actually know what's the difference between Parkinson and WPW?"

I bet he doesn't.

So, another major mixed up between a diagnosis of neurology Vs Cardiology. Just like the other one who thought the SA node is at around the pelvis.

I'm getting really, really worried. What about you?

Friday, August 13, 2010

Where's the SA Node?

Just heard this story today.

One houseman is not happy that he was being extended in Orthopedic posting.

Medical MO: "Why did it happen?"

HO: "This is totally unreasonable. They were asking me something unrelated to orthopedics and they failed me just because I answered wrongly!"

MO: "Oh that's bad. What did they ask you?"

HO: "They asked me where the SA (sinoatrial) node is!"

MO: "Oh...that's like really testing your anatomy knowledge learnt in foundation years. But you're right that it's not really related to orthopedics and they shouldn't fail you just because of that."

HO: "'s not reasonable at all!"

MO: "So what did you answer then?"

HO: "I said it's somewhere around the pelvis."

MO: "....*deadly speechless*"

I think most of you will know by now why he can't blame ppl extending him. If not, you can take a look here on the location of SA node, and whether or not it's anywhere near pelvis! ;)

Sunday, August 08, 2010

Morning "Live Show"

Ward rounds are usually a 3-level thing: Earliest round by housemen at 7am, then by medical officer at 8am, then specialists will come at around 9 or 10am.

If the ward MO/ Specialists are nice and friendly, the HOs are blessed. But more often than not, if HOs are placed (or abandoned) in a ward with "malignant" superior, then, good luck to them.

The morning round will become a torture, a daytime "nightmare" to them. Non-stop screaming and shouting, sometimes I think that, isn't it like a "live show" to the patients?

Examples are like: (Believe me, I've modified it to a milder version)
"Your knowlegde and management is totally out. Are you sure you've graduated from med school?" Ouch..that hurts. But this is one of the most common "scripts" you'll hear.

"This is nonsense. Stupid!"

"Your work is rubbish!"

You know what's even worse? Remarks like:

"This is totally unacceptable. Do you know that the medication you gave could have killed the patient!" (Then cancel off some medications from the drug chart, which was already served in the morning)

Saying remarks like this at the bedside. Just imagine you're the patient. How would you feel? (What? I was just served a med that will cause me to die??)

Many more examples.
The point is, why have these"superior" lost their basic ability to respect others? Isn't medicine supposed to be practised in a more professional way?

Remind me of what one of my consultants once told me, "Practise intelligent medicine, not emotional medicine. Straight to the point and solve the problem. Pointless shouting and screaming..just not gonna help!"

Sunday, July 25, 2010

PACES Case Sharing

The UK trip is very rewarding in terms of learning experience. Here I'd just like to share a few "tricky" cases that I've seen during my attachment/ courses:

In station 5, you're asked to see a lady complained of lethargy and joint pain. This lady has intermittent fever, arthralgia and history suggestive of Raynaud's phenomeon. She also has background history of Hypertension for years. So you suspect this is a case of SLE.
Straightforward? Not really.
Examiner hintingly asked what is the link btw hypertension and SLE.
Further history (only if you specifically asked) revealed that she was treated with Hydralazine for months before symptoms onset. So ya, this is a drug-induced lupus. Did that come into your mind?
Questions discussed were about percentage of anti-histone ab positivity (only about 30% in Hydralazine-induced, as compared to other drugs) and what are slow/ fast acetylators.

Cardiac murmurs!
This is gonna be the best case I've auscultated.
Basically there are full of murmurs: You hear ESM over aortic area to carotid, EDM over LLSE, then also systolic murmur over apex to axilla, with MDM in mitral area as well.
So you thought this is a case of mixed mitral (MS/MR) and mixed aortic valve disease (AS/AR)?
Examiner then said there's no primary mitral valve disease.
The diagnosis is actually mixed aortic valve disease. At mitral area, the systolic murmur you heard is just part of the Gallavardin phenomenon, and diastolic murmur is the Austin Flint murmur due to AR.
Tricky enough?

Station 5 again. You're asked to see a lady presented with seizure, and you should examine her hands.
She has family history of epilepsy. On visual survey you noted she has an AVF at left arm.
ESRF with seizure? Was it due to electrolyte imbalance?
In her hands you noted lesions suggestive of peri-ungual fibroma. So you thought this is a case of Tuberous sclerosis, but there's no facial angiofibroma.
Time's up.

Wanna know the answer? Yes she's a case of tuberous sclerosis with epilepsy. ESRF was because she underwent bilateral nephrectomy due to severe renal angiomyolipoma hemorrhage.
Then why is that she doesn't have the typical facial angiofibroma?

Well, she underwent laser therapy for cosmetic reason!

So these are a few..will share more later!

Tuesday, July 13, 2010

The Perfect Drug?

I'm not sure whether you're aware of this drug, it's really powerful. (I guess you might have heard of it somewhere)

It's basically a "magic drug" for practically everyone.

For children, it enhances the immune system. Be worry-free of infection. You know, some even said that child who takes this drug will never need to visit a doctor!

For teenagers, it's good for brain development. Want a smart boy who can score excellent in exams? This is the right drug!

For working adults, it keeps you energetic all the time. And of course, if anyone thinks that his certain "function" is insufficient, this will keep you really energetic! And for young women, this can regulate menstrual cycles, make your skin super smooth, guaranteed!

Can you take this drug during pregnancy? Of course you can! Your baby will be extra-healthy and extra-cute, and with very strong immune system!

For middle-aged people? Ya it can be used also. It's very good in preventing prostate enlargement, memory loss ( Ya, I know you've been looking for such magical drug for long time) and joint pain. Some actually said that their uncles/ aunts who's got Diabetes Mellitus are actually CURED by this drug! Seriously, their doctors are very surprised too!

Oh I forgot to mention, it has another function. If you grind it into powders and mix it in water, guess what, it can be used as eyedrops! You can use it to treat conjunctivitis, glaucoma as well as cataract!

You ask how come this drug is not available in hospitals and it can only be bought from my company? Come on, this is a state-of-the-art product of the latest technological breakthrough which is patented, of course it's not available anywhere else!

So, you wanna get this drug?

If you think the above statements sound familiar, you might have heard it from a traditional medication/ direct-sales product seller. I think I have heard too many. And I noticed that regardless of the product that they are selling, there are some commons in the products:

1. This product can benefit ALL age-groups. From the unborn to the elderly. For both genders, healthy or diseased, and for all kinds of medical conditions! The "Eye-drop" story is real. Gosh, I really can't imagine what will happen if you simply mix it and put in your eyes. Can treat glaucoma and cataract simple as that? The ophthalmologist will be jumping!

2. This product can CURE chronic medical condition (diabetes, hypertension) and prolong survival in cancer patients. Well, please analyze how true can this be. But those vulnerable groups are usually targeted and they would actually choose to believe.

3. This is a product of a new tech, hence not available in hospitals, and hence your doctor never told you this. Oh come on, you mean there's actually a cure for diabetes (by oral medication) and the docs are not aware of it? Think again.

I'm doing nephro rotation now, and seeing patients who suffer the outcome of believing this could work. Irreversible kidney failure. The worst thing is, will the seller ever be responsible for it? The asnwer is, sorry, NO.

Sad, isn't it?

Saturday, June 26, 2010

"Arterial Blood Gas"

In UK, I met a few other Malaysian candidates from different hospitals. During casual conversation, we mentioned about HOs in our respective hospital - Don't get me wrong, we're not like particularly interested in talking about this, it's just one of the topics among many others ha. So one of the stories is this:

One new HO (House officer) was asked whether he knows how to take ABG (Arterial blood gas) sample. He answered quite confidently, "Ya I used to take it during my medical student time."

So he was asked to demonstrate as ABG is needed for one patient.
He took the needle, inserted it to patient's wrist at an obviously wrong site for radial artery, and obtained nothing but some air. (Specialist and MO frowned, thought he was going to withdraw and re-attempt).

Surprisingly, he pulled out the needle like ending a procedure, passing it to the nurse, "Go and analyze this in the ABG machine..."

Specialist stopped him, "What are you going to analyze there? It's just air!"

And he said, "Ya, you asked me to take arterial blood GAS right? I got it!"

Apparently, he thought ABG sample is just...GAS!!
(I'm sure you can imagine how's the specialist's face like aftering hearing this "new" fact) lolz.

Monday, May 10, 2010

Couple Jokes (5)


Husband said to wife, "You know what, woman with natural beauty really doesn't need any make-ups."

Wife: "Wow, I'm flattered! You hardly praise me..."

Husband: "So I think you'd better put up some make-ups."

Wife: "......"


Wife: "Dear, I notice that you always keep a photo of me in your wallet. May I know why?"

Husband: "Oh, it's very important. Whenever I face any difficulty, I'll look at it and I'll feel strong again."

Wife: "That's really mean by looking at my picture actually motivates you so much?"

Husband: "Yes it does. I'll look at the picture and tell myself, 'If I can endure the difficulty like this, what else should I be afraid of?"


A man rushes into a police station and tells the police, "I committed an offence, please lock me in the jail now."

Police: "What did you do?"

Man: "I accidentally hit my wife's head with a stick."

Police: " look really terrified and frightened. Is is that she became unconscious?"

Man: "No she's still conscious. That's why I need to run to here!"

Related posts:
Couple Jokes (1), (2), (3), (4)

Sunday, March 07, 2010

Top 10 Amazing Diagnoses

Over the years (actually not many years), I've come across some really interesting diagnoses, which I think I can now make it a "Top 10". Some have appeared in my posts before, and some are newly encountered. Let's have a look: (List not in any particular order)

Failure to Thrive
Comment: Looks quite normal, except that this is diagnosed for a 53 year-old man.

Acute urinary retention secondary to benigh prostatic hypertrophy
Comment: Again, looks nothing wrong. But it's for a 70 year-old WOMAN which it'll be the headline if you can find her prostate.

Alleged drug overdose secondary to scolded by mother
Comment: No doubt, the mother's gonna be in deep trouble. (and she'll hate the doc for sure)

Alleged bitten by a living creature
Comment: The other MO told me that, we should be worried that some "monsters" might be in town now. (origin of this diagnosis)

Uncontrolled hypertension secondary to Portal hypertension
Comment: It's simply amazing that how these two unrelated things can be related.

Depression with Sadism
Comment: I was very curious when I saw this, on how the HO could get the history about the "sadism" part. Later I realized that she thought "sadism" means "sad-ism", as the patient feels sad most of the time.
She made me feel sad, too.

Pseudo-pseudo Seizure
Comment: This is new in medicine. I've yet to find out whether this actually is a new term, or maybe someone thinks this is the plural form of "pseudo-seizure"!

Hyperkalemia secondary to excessive bananas
Comment: This is amazing, as the potassium is 6.5mmol/L. I wonder how much bananas has the patient actually swallowed to get potassium this high.
But this remind me of, someone actually tried to use bananas to correct hypokalemia!

PUO (pyrexia of unknown origin) secondary to liver abscess
Comment: So is the origin known or not known now?!

Hypoglycemia attack secondary to his wife
Comment: Ok la, this is by me. Although it's the true "mechanism" of the hypoglycemia but I didn't put the diagnosis as such. You can read the story here.

So these are just some 10 diagnoses I selected, I'm sure there are many more out there. The idea is not to blame anyone but to amuse you, as sometimes we do need some light moments on top of our heavy work time! ;-)

Sunday, February 14, 2010

Happy CNY 2010!

Dear all,

I'd like to wish you all happy Chinese New Year! May the year of Tiger brings you and family abundance of happiness, health, wealth, success and prosperity!

Yours sincerely,
Darren Lee

Friday, February 05, 2010

HO, MO and Specialist (4)

HO: House officer
MO: Medical officer


During ward round. HO, MO and specialist stopped at one patient with abnormal FBC (full blood count) result.

Specialist: "The Hb (hemoglobin) only 5.6g/dL? But no pallor? He looks clinically pink!"

MO: "The FBC is very different from the yesterday's one. Today FBC is all low and looks like a diluted sample."

Specialist looks at the HO, "And the patient is on IV drip. So, what do you think has happened?"

(Specialist and MO is expecting for a simple answer - blood could be taken from the IV drip arm)

HO: "Oh..(confidently) this patient is pseudo-pinkish!"

He just invented a new medical term!


A HO is infamous of frequently getting emergency leave (EL) in the last minute for just minor problem.

This time he just did it again by sending SMS to the MO, "Hi Dr, I'm so sorry that I have to take EL today. I'm having runny nose. I really need to rest."

Then he sent another SMS, "I've tried very hard to look for replacement but really couldn't find any. I hope you don't mind. I'm gonna rest now."

After a while he got the reply from the MO,

"It's ok. You please rest in peace. Bye."

Sunday, January 31, 2010

HO, MO and Specialist (3)

HO: House officer
MO: Medical officer


HO came to see the MO.

HO: "I'm sorry...I'm really having difficulty in setting a branula for a patient. I've already asked help from 2 senior HOs, we have tried 5 times but still couldn't get..."

MO: "5 times? Hey you're supposed to get help from MO after 3 attempts...don't make the patient suffer ok..."

HO's face turned very pale.

MO: "Why your face looks like that? You tried more than 5 times is it? It's ok you can be honest..."

HO: "Hmm...err...actually I meant each of us tried 5 times."

MO fainted.


During ward round. Specialist and MO is going into an isolation room but there are only 2 masks left.

Specialist told the HO, "It's ok, you don't have to go in. But just make sure no one comes in without the mask ok."

HO nodded. So he waited outside.

After a while, a staff nurse called the HO to do an urgent blood taking. Thinking that he has to make sure no one can go into the isolation room, he came out with a great idea: He locked the door from outside.

After the blood taking, staff nurse asked the HO to get consent for another patient. Then new case came in for clerking...

After a good while he suddenly realized the ward round is not finished yet and he hasn't seen his MO/ specialist around.

So he rushed to the isolation room and unlock the door. Ya, you know what he saw, 2 extremely green faces.

A very "smart" HO isn't it? ;)

Related post:
HO, MO and Specialist (2)
HO, MO and Specialist (1)

Saturday, January 30, 2010

Interesting AXR

This is an abdominal Xray of a lady who has long-standing diabetes/ IHD/ chronic kidney disease and presented with poor oral intake and vomiting. My HO showed me her Xray asking what is the "worm-like" thing seen at left upper quadrant.

What do you think it is?

Friday, January 29, 2010

David Blaine on TED

Holding the breath for 17 minutes, "How is that possible?", you may ask. It seems that nothing is impossible for him, David Blaine, the magic man.

On April 30, 2008, David Blaine broke the world record by holding his breath for 17 minutes and 4 seconds - it's more like a temporary apnea - and it's thought to be beyond human limit but he did it. "The body can be trained," said his chest physician. With the medical knowledge that I have, I still think that hypoxic brain injury occurs after 6 minutes of oxygen deprivation, and maximum maybe up to 10 min but definitely not more than that. But David Blaine has proven it wrong, and appeared in the TED talks sharing with audiences how he did it.

After listening to his explanation and the "training" that he has undergone, I have to say this is truly amazing and human's strong will can make almost everything possible. Good job to David Blaine - Think he has just shared another wonderful piece of inspiration!

Thursday, January 21, 2010

Do Not Call Your Consultant at 3am

Heard this from one of my friends working in the other hospital:

This happened during a night that he's on call. Actually a general rule is we don't usually disturb our specialists/ consultants after 12am to discuss cases, unless really indicated. This is based on, of course, a courtesy (for not disturbing your boss' resting time); and for yourself not to hear some unhappy tone (who will remain pleasant if called to be awake in the middle of the night?) as well.

But he's got quite an unusual experience.

He had a tough case which came in at 3am, with some issues that he must discuss with his consultant. So he called..

He: "Morning boss, I'm so sorry to disturb you at this time. I just have one case to discuss..(presented the case). May I know what to do next?"

Consultant: "(Silence)..."

He: "Boss?"

Consultant: "Hey, I was caught by police actually..."

He: "What? What happened boss?"

Consultant: "I can't talk to you right now. I got to go...(hung up the phone)"

Left my friend who's frightened and confused, and thinking whether he should inform his head of department.

After 5 min, his consultant called back.

"Hey did you just call me?"

He: "Yes I did, boss..."

Consultant: "Please erase it from your memory what you've heard just now. I was in my dreamland when you wife just told me that."

Oops. What an awkward moment.

So that's the other reason of not to call your boss in the middle of the night - you might hear him sleep-talking to you!

Saturday, January 16, 2010

Card Collection + Magic Vid '10

Ordered a few new celebrate new year I guess (or just an excuse whatever) hehe. And it finally arrived!

The Bicycle Vintage 1800 series is really a classic. Look at the vid and you'll understand why I say so.

-Pic from Theory 11

And these are the Bicycle 125: Anniversary edition. It's of limited supply hence there's no reason of not keeping it in the collection lol.

My growing card family. Yay lol.

Meanwhile, I guess I'm just a bit too free so I edited my magic vids to become one as a recollection with my favourite music, enjoy! ;)

Sunday, January 10, 2010

Color Change - Update

Card magic - or "Cardistry" is progressively advancing and it's always exciting. New techniques or sleight of hands are being invented, and the old ones are regularly revised to a higher level. One example is the color change (for non-magicians, it means "card-changing"). There are some recent updates of the skill, and some are really, really beautiful.

Bertram Change performed by David McLeod. So flawless isn't it?

This is pure madness. Insane card change originally by Daniel Madison.

Last but not least, this Snap change of Aces is ultra-visual. Done with cards facing up! Speechless! ;)

Thursday, January 07, 2010

Best Song in 2009

I think no one will question about this "song" as the best song in 2009.

This is an annual mash up by DJ Earworm where he mixes the top 25 pop songs of 2009 on Billboard into one ultimate pop song:

The Black Eyed Peas - BOOM BOOM POW
Lady Gaga - POKER FACE
Lady Gaga Featuring Colby O'Donis - JUST DANCE
The Black Eyed Peas - I GOTTA FEELING
Taylor Swift - LOVE STORY
Jason Mraz - I'M YOURS
Kanye West - HEARTLESS
The All-American Rejects - GIVES YOU HELL
T.I. Featuring Justin Timberlake - DEAD AND GONE
Kings Of Leon - USE SOMEBODY
Keri Hilson Featuring Kanye West & Ne-Yo - KNOCK YOU DOWN
Jamie Foxx Featuring T-Pain - BLAME IT
T.I. Featuring Rihanna - LIVE YOUR LIFE
Soulja Boy Tell 'em Featuring Sammie - KISS ME THRU THE PHONE
Jay Sean Featuring Lil Wayne - DOWN
Miley Cyrus - THE CLIMB
Beyonce - HALO
Katy Perry - HOT N COLD

Love it!

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