22.6.16

its real!

an orang asli presented with jaundice, abdominal pain, and fever.

guess what?

if you do not take the social history properly, you cannot rule out ascariasis as the cause of her illness.

i ask her, she lives in kebun, perigi as the source of water and she does not have any toilet.
eating without properly wash her hand.


after ERCP, she was diagnosed with ascending cholangitis secondary to ascariasis!!! he eosinophils also elevated.

ok, case reported

18.6.16

collection of my posts in fb

i have 2 FB. making another fb, to open some study stuff during exam.. now no more use because we already share study stuff trough telegram.
 not going to confuse my friend. will be deleting the old FB soon.how to delete your FB? http://deletefacebook.com/

just something memorable things to paste here. will be missing the posts that i shared trough my old FB. but its ok. past is just the past. lets create new and sweet memory again!!!


**Malam oncall wad sakit mental.
Bual-bual dengan pesakit perempuan.kawan pun perkenalkan diri dengan nama samaran.
Belum sempat turn saya perkenalkan diri sendiri,dia dah tanya."awak?"
Dia pun baca nametag, "A.M.A.L.I.N.A. oh amalina yeh.amalina yang pandai tu ke?yang ada banyak A tu?dia ada..(sambil mengira jari dia sampai nombor 11) yang dapat 11 A tu? Banyaknya A awak.macam mana awak belajar?"
Banyak kali dia puji. Jadi saya pun cakap. "Tak,saya amalina lain.bukan amalina yang banyak A tu.."
Borak sekejap je sebab waktu tu dia macam tak berapa tenang. Jadi saya pun minta izin pergi tempat lain.
Hari ni lepas 5 hari berlalu,kawan pergi ward. Pesakit tu dah bertambah baik. dia nampak kawan, dia pun tegur.
"Eh awak juita kan? Kawan awak lagi sorang, amalina mana?"
*terharu kejap walaupun patient sakit.tapi ingatan dia kuat. Malah dia lagi pandai dan mengingatkan kita..
"doc K ajar saya baca ya ghafar...ya qahar..ya fattah..."
saya pun sambung "ya alim"
Dia pun kata," tak ...mana ada ya alim"
(Apa yang kita sampaikan,patient boleh ingat. Lagi bagus dari orang yang sihat. jadi jangan ada stigma terhadap pesakit mental ni.even diorang azan dan mengaji pon lagi sedap dari suara dalam TV tu. Kagum kan.**



**How many of you had covered quran's translation from cover to cover?
Interesting to learn every surah which has the story behind it that we should take it as a lesson so that we are not repeating the same mistakes like previous nation.
(By Dr. Razali,radiologist in iimp class.)

*thanks doc for the reminder. Just amazed with him even how busy he is, he already spent 3years learning the tafsir...**

** Marriage does not guarantee you will be together forever, it’s only paper. It takes love, respect, trust, understanding, friendship and faith in your relationship to make it last.**
**“Barangsiapa yang mendo`akan kebaikan bagi saudaranya (sesama muslim) yang berjauhan, melainkan malaikat akan berkata: ‘Aamiin dan bagimu kebaikan yang sama.’ (HR. Muslim: 2732)**


**dr psychiatry bercerita tentang perbualan dia dan pesakit.
Doktor: awak ada rumah tak?
Pesakit: ada.
tapi Bila pergi home visit rumah pesakit tu.Yang ada cuma satu tiang je.
Rupanya itulah rumah yang dimaksudkan. :(

Bersyukur dengan rahmatNya didunia ini.**


**
Assalamualaikum. .nak jumpa A (3rd year junior) boleh?
Kawan A datang.oh dia takda..awak ni 1st year ke?
Tak..
Second year?
Tak..
Habis tu?
5th year..
Oh....krik3...dia malu jap.
* muka macam budak2 kot..**
Sepanjang hidup saya.first time jumpa orang yang senyum 24 jam. Tengah mengajar pun memang sentiasa senyum. Students tak faham pun senyum. Dari awal sampailah habis kelas memang senyum je. Dah habis kelas pun senyum.bMemang orang tu gifted Allah bagi muka sentiasa senyum. :) patients pun tenang tengok muka doctor


** Kita takkan merungut bila tahu semua perkara tu hanya sementara sahaja. Ya dunia ni sementara saja. Bear with it. Tapi kita akan terlupa dan terus tenggelam bila tiada orang sekeliling yang sudi mengingatkan kita.**

**Bila kita nak A. ALLAH bagi B.
Semua ketetapanNya adalah yang terbaik.**
 a statistician.·
Cohort study. Multivariate. Relative risk. Poison regressions.
Kenapa lelaki terror bab2 ni?
Samsul Draman perempuan good at verbal task,memory for object location,fine skill and sharing on everything**
** Spread the love.then u will become adorable. Pesanan untuk diri sendiri....
Tak mohlah jadi garang**

**Masuk kedai perabot ,
Ada 2orang anak tokey kedai. Umur dalam bawah 9tahun.
Sorang duduk meja depan,buat kira2.
Sorang duduk meja hujung, buat homework english.
*aku kecik2 dulu,petang2 selalu pergi padang kot,duk main guli,main ting2,main getah,main roda blade,main gasing,main baling selipar,main galah panjang. Macam2lah ;)
rajin anak depa study di sore hari..**

**Kenapa manusia jiwanya kacau?
Syaitan sentiasa hasut hati dan jiwa manusia.
Apakah kehebatan quran?
Banyak.antaranya:Alquran diturunkan sebagai penawar didada(hati) manusia.
Nabi berpesan didiklah anak kamu 3perkara.
1)Cintai nabi
2)Cintai keluarga nabi
3)Didiklah anak kamu baca quran.
Mungkin lepas ni bila tension ke stress ke buka quran.kena sentiasa berdamping dengan quran.**


**Sesungguhnya quran diturunkan pada malam lailatulqadr.
dalam hadis sohih: laitulqadr adalah pada malam 10 terakhir.
Tetapi kenapa nuzul quran disambut pada 17ramadahan?
Quran diturunkan pada 3peringakat.
Peringkat pertama pada luh mahfuz(surah buruj)

Peringkat kedua dibaitul izzah.(langit pertama)
Peringkat ke3 melalui jibril kepada nabi.
Jadi kenapa 17ramadhan kita menyambut nuzul quran?
Surah alanfal ayat 41:pada peringkat pertama quran diturunkan pada Hari furqan (hari pertempuran perang badar 17ramadhan.)**


 **Siang tadi saya di ingatkan balik...
Bro: cuba anda semua sekarang fikirkan seseorang yang dibenci semua orang.sekarang ni semua orang tengah marah dia..kutuk dia... bayangkan...memang ramai sangat tak puas hati dengan dia..ok rasanya semua orang fikirkan orang yang sama...
Tapi nanti kat akhirat nanti,kira hairan.eh kenapa dia masuk syurga level lagi tinggi dari kita??kita yang teruk sekali..(nauzubillah)
*sebab kat dunia,ramai sangat kutuk dia... sekarang habis semua pahala orang ramai dapat kat dia..sampaikan dosa dia pun dapat ke kita...
‪#‎pentingnya‬ jaga percakapan.**

** Tadi pelajar jordan kongsi pengalaman dia yang ziarah yaman,hadhramaut. 24 jam orang mengamalkan sunnah. Terjumpa seorang pakcik pakai tongkat di tepi jalan. Ditanya mahu pergi ke mana. Dia nak pergi solat terawih 100 rakaat.disana semua pakai jubah putih berserban. Membawa kayu sugi sentiasa. Perempuan tak nampak muka.semua berniqab berpurdah. Saya suggest siapa nak belajar kat sana memang bagus.ilmu dia memang terbaik. Tapi cuma sijilnya saja tak diiktiraf di malaysia.**

** Saya ada seorang lecturer berumur hampir 70 tahun. Dia masih mampu mengajar. Kadang2 bedside teaching dekat hospital sampai 4hari berturut2. Sangat impress sebab dia masih kuat lagi dan paling penting ingatan dia dalam ilmu medic ni pon masih power. :)
Kena bersihkan hati n fikiran supaya ilmu tak mudah lupa.**


When u sad,remember it just a temporary.
When u happy,remember it just a temporary.
When u r in pain remember it just a temporary.
Yeah everything is just temporary.

my beautiful niece






first time jumpa QURAN kat chalet



Saya di kesempatan ini ingin memohon maaf kepada semua yang mengenali diri ini diatas segala salah dan silap yang sengaja atau tak disengajakan.moga amal ibadah kita diterima. May Allah bless.
Everyday is wardwork. Trying to find interesting case and do clerking.
But we often forget that visiting the sick is sunnah.
Hope we can reduce their pain by saying
"Bersabarlah kerana Allah maha mengetahui hikmah disebaliknya"
"Sakit itu penghapus dosa"
"Semoga Allah menyembuhkanmu."






We r struggling 4 dunya.but we often forget bout the akhirah :(

Ask Allah. He will answer u. And everything he gives is the best 4 u. Trust it.


Al-quran paling comel,semua page ada!bila baca ciliary muscle will contract and lens become convex.betul x?

*jom khatamkan satu quran ramadhan ni!
 


Poster bertemakan sunnah rasulullah.. saja-saja masuk pertandingan waktu mawlid uia kuantan yang lepas,dapat hadiah saguhati. =p

"Yaumul jumuah yaumul aid" friday is the hari raya....My physiology lecturer, always talk about balance,he always reminds us.
1. everything in life need to be balanced.
2. Make us ponder why Allah swt create things like that.
3.Everything created by Allah has the hikmah behind it
4.and treat your patients wisely as Allah will ask you, don't you remember what dr ahmad kait told you in the class????.

#the best profession is a teacher who spread the good knowledge.





Medical lecturers always have islamic input in their lectures.thats the thing i like being in UIA. =p
 


The best speaker in comparative religion..just like ahmad deedat...come and grab this opportunity. Its hard to have him in Malaysia =p


normal cell tengah senyum.tapi bila damage occur cell jadi sedih.parent dia p53 xdapat membantu.akhirnya cell bertukar wajah yang jahat iaitu cancer

Here we are..Jazakallahukhairan khasiran to @athirahhamzah91 and family...banyak sangat juadah raya..roti canai pun ada! ;) terima kasih daun keladi tahun depan raya lagi. Tahun depan palpitation nak pro exam... hehe ..Here we are..Jazakallahukhairan khasiran to @athirahhamzah91 and family...banyak sangat juadah raya..roti canai pun ada! ;) terima kasih daun keladi tahun depan raya lagi. Tahun depan palpitation nak pro exam... hehe
Salam jumaat penghulu segala hari~
16Ramadhan .jumaat yang ke3... YaAllah bantulah aku dalam mengingatiMU mensyukuri nikmatMu dan memperbaiki amal ibadatku...

Selalu berdoa minta keampunan. Selalu zikir
Lailaha illallah. Minta Allah untuk masuk ke syurgaNya dan dijauhkan dari azab api neraka. -dr sayuti
*bersihkan hati sebelum masuk dalam bulan barakah. Ahlan wasahlan ya ramadhan.moga Allah sampaikan kita kepadanya. InshaA
llah.


Beruntung nya menjadi pengajar apabila mengunakan setiap peluang yang ada untuk berkongsi nasihat. Antara nasihat-nasihat yang diselit dalam kelas besama ear nose and throat ENT specialist di uia.

1.Belajar tentang anatomy of larynx.doctor kaitkan tentang
Allah tak terima taubat seseorang apabila nyawanya sampai ke hujung halkum. Itulah larynx.
2.Vocal cord untuk phonation. Mengeluarkan suara. Paling bagus kita bertajwid ketika membca al-quran.

3.contoh-contoh penyakit telinga dan pada lidah yang Allah bagi adalah antara kafarah kepada manusia yang suka mengumpat dan dengar perkara sia-sia.
4.pharynx. dikenali sebagai aeropharyngeal airway. Merupakan saluran untuk pernafasan dan juga saluran untuk makan. Dimana ketika makan, untuk lalu saluran pharynx ini tak sampai sesaat pun makanan melaluinya. Dan pada masa yang sama pernafasan akan terhenti seketika ketika makanan melalui saluran ini. Yang mana setiap hari manusia makan, saluran ini berjaya menghalang makanan daripada termasuk ke dalam saluran pernafasan. Sangat besar bezanya antara hidup (nikmat dapat makan dengan baik)atau mati(kerana makanan termasuk dalam saluran pernafasan) *blessing is countless. nikmat yang mana kadang manusia tidak sedar akan kehadirannya *menjaga mulut daripada mengumpat. Terutama bila dah kerja nanti. Jangan umpat patients sendiri dan juga rakan sekerja yang lain. *ingatkan patients tentang solat.bukan sekadar bertanya pakcik macam mana nafas,makan ok, buang air ok? Luangkan juga masa untuk bertanya tentang solat.Dan Instead of bertanya, pakcik dah solat? Better tanya, pakcik solat dekat mana tadi.

Nak pergi hospital.parking tepi longkang.suddenly,hp kawan jatuh dalam longkang.panggil seorang uncle dekat renovation house berdekatan.dia datang bawak cangkul.dia pun ukur kedalaman air. Pastu dia terus turun. Celup tangan dia dalam air yang hitam sangat.tak nampak apa2.jumpa!!!
Bila bagi duit,dia kata,tak apa...dia cuma minta kalau dia datang hospital nanti tolong rawat dia... ; )

kosong...kosong..kosong...
Hati ini kosong...jauh dipukul ombak...
Tiada yang datang menyelamatkan..hanya iman dihati menjadi kekuatan...
remind my self again!
#beclosedtoAllah
 

hadis Rasulullah SAW yang di riwayatkan oleh Abu Hurairah r.a. : setiap pekerjaan yg tidak dimulai padanya dengan ucapan Basmalah, maka pekerjaan itu akan terpotong & terputus (iaitu cacat & kurang keberkatan dan rahmat)” bismillahirrahmanirrahim. Habis sudah cuti,moga Allah permudahkan untuk posying forensic dan orthopedicsoc: Interpret the ECG.
Student: "Allah in patient's heart."
Doc:cantik ECG dia.takda penyakit hati. InshaAllah boleh tambah lagi 1..

Masjid sultan haji ahmad shah. Uia kuantan. Moga hati sentiasa ingat padamu yaAllah.ameen




 Ada orang potong rumput malam2. Masih kuat bekerja.mungkin dia mencari duit lebih.kita pulak masih rasa tidak mencukupi.

Ada orang tak dapat belajar bidang yang dia nak. Kita pula stress kena belajar banyak2.

Ada orang tak boleh tidur malam. Kita pulak rasa tak cukup tidur 1malam.

Ada orang sakit sampai tak boleh berjalan.kita pulak asyik mengadu kepenatan.

Ada orang sedih pabila ditinggalkan pasangan. Kita pulak sibuk mengadu tiada berteman.

kisah kita takdelah sesedih mana. Rupanya ade lagi yang menderita.
Jangan pandang mereka yang diatas. Tetapi
Pandanglah mereka yang dibawah. "Hanya sedikit hambaKU yang bersyukur."
Moga kita termasuk dalam golongan yang sedikit itu.ameen.

Whoever says subhanallah wabihamdih 100times a day will be forgiven all his sins.even if they were as mich as the foam of the sea.(bukhari)


Malam semalam, jumpa dengan maknyah2 kat lorong2 area kuantan. Diaorang semua dah tau dah kalau nampak pajero putih memang diaorang akan lari. Tapi semalam ada haji bakri@kak jun. jadi haji bakri ni minta diarong jangan lari. Haji bakri ni dulu seorang ibu ayam.dan sekarang ni dia tak pernah putus asa ajak kawan2 dia ni untuk kembali ke pangkal jalan. Boleh dikatakan semua layan kedatangan kami dengan baik walaupon diorang cuak dan takut sebab ramai sangat serbu. Ada yang menceritakan "saya dah solat tahjud dah.dah berdoa oh ya Allah kau kurniakanlah rezki yang melimpah ruah.tapi xmakbul pon doa sampai sekarang". Ye memang susah nak bagi diaorang ni faham.kita hanya mampu menolong dengan memberi sedikit nasihat. Memang semua ibubapa keluarga yang dipersalahkan bila anak2 ini tak menjadi. Memang betul peranan ibubapa sangat penting dari segi nasihat didikan agama. Kerana anak2 ni memang dari kecik lagi perlu dilayan.dinasihati. ye jangan pernah jemu untuk menegur anak nanti. Bukan masalah doamu itu tak dimakbulkan. Ia cuma cepat ataupon lambat.Allah akan bagi pada masa yang sesuai.Allah tau bila terbaik untuk bagi rezki tu semua. Hidup ni Bukan sekadar doa dan pelbagai permintaan duniawi yang kita minta.tapi perhubungan dengan Allah. Peliharalah solat kita.walau susah mana pon.walau sesakit mana pon.walau malas mana pon.kalau kita jaga hubungan dengan Allah.insha Allah urusan kita didunia ni dipermudahkan. You have a choice dont blame the others. Moga satu hari nanti Allah ketuk pintu hati kita semua untuk kembali kepadanya.walau banyak mana pon dosa kita.sesungguhnya Allah itu maha Pengampun dan menerima taubat hambaNya.

#Thanx to my family teachers and friends yang banyak mendidik saya

"Bestnya dia dah grad,aku belajar lagi"
"Bestnya dia dah kerja,aku pon tak habis belajar lagi"
Manusia sentiasa pandang kepada orang yang lebih daripada mereka.sedangkan masih ramai lagi mereka yang tak mencapai seperti apa yang mereka kini ada.
YaAllah bantulah kami dalam mensyukuri nikmatmu


Everything is about religion and best manners.its not about money. Its not about good features.its not about position. If u choose religion first, u wukl find ur happiness #everafter
Everything everywhere everytime.... just pray and ask from the creator....#solattiangagama

Barangsiapa yang berselawat ke atasku(nabi Muhammad s.a.w) nesxaya Allah turunkan rahmat ke atasnya 10kali ganda. (Hadis riwayat muslim)

ibubapa cemerlang

salam hai!
yesterday i had class with KKM dr.. dr zainal abidin emergency medicine physician...
it was in the evening after solat jumaat, he brought her daughter in the class.

she was properly dressed. covering her aurah, perfectly with scarft, stocking, all complete..very small person, i think she is about 7-8 years..maybe..

during the class, my  friend heard she was reading ayatul quran.. you know now is ramadhan month. even she is small, very innocent.. she appreciate her time with reading the quran..

even her father is a busy person. you know. head of department emergency and trauma. with oncalls. but he can train her daughter very well...

i hope i can be a good parent. no matter how busy you are. there is no excuse to abandon your children in term of nurturing them to become a good person especially in religious view.  

16.6.16

last year story

With dr nora and dr rasyidah. 2weeks in grossing.first time waktu prof naznin suruh attach dekat grossing..macam pelik..grossing tu apa?hehe Thanks for the grossing knowledge doctor...histopatho examination.. how to prepare a slide to be observed under microscope? Alhamdulillah..dapat tengok breast cancer...fetal part in placenta... macam2! Pathologist akan try confirm the diagnosis!dan proses dia bkn nya slide siap macam tu je...
Fixation>grossing>tissue processing>embedding>trimming>slicing>fishing> at the end barulah staining... barulah tissue/slice tu dapat bertahan dan dapat disimpan berpuluh2 tahun!

9.6.16

Tazkirah Prof Azarisman [cardiologist] 5 ramadhan

-Know that your task in this dunya is easy. your situation is not hard as the day of prophet Muhammad s.a.w..
-La tahzan innalllah ha ma a'na... Everything Allah is always there to help you.     
find Him. Allah will be there for those who seek him especially at the last 1/6 of the night.and will grant his prayer.
-you will get the maghfirah from Allah.He will forgive you no matter how big the sin you had done.the key is turn back to Allah.
-dont delay solat.. If azan go pray first.Allah is the ptiority.have faith in Him. You will get the barakah. if you need to finish your last 3pages of reading. choose to solat first. believe in Allah. He will help you.
-study..Allah will not burden you to the extend of what you cannot.. your problem.. just a small matter. Try your best.has an effort.
-War to you: who are picky to money time and effort. volunteer. help those people who are in need.
-pray...Continue in patience and continue solat. solat is not hard to those who are khusyuk. 2:46
-Allah knows whats in your heart. Allah near to you, near than your jugular vein.
-our aim is jannatul firdaus.
-.tawakkal......hasbunallah wanikmal wakil.....
 Remember Allah in every  situation. Go back to Allah.rukuk and sujud. Find peace.
-redha......the best u can do. Mastatok. Suddenly if you get the result that yo didnt aspect. Accept it.  Ma qaddarallahu khairThe qadar of Allah is the best for that time.
-go through the task/ exam with peace.

We must have our own perspective...
Think about other people sufferings, our problem with exams are nothing compared to our bro and sis who had dinner with their families suddenly woke up and had dinner in jannah (palestine, afghanistan, syria)
Do not lose hope...
Employ strtegies to employ urself...
Never skip meals...
Never overdose in caffeine, energy drinks..
Good sleeping habits...
Have time outs sometime... time outs must be tenting to help those who are less fortunate , not like hanging out or went to the cinema...
Keep giving (infak in terms of energy, emotion, not just wealth)...
Solat, solat, solat and doa...
Solat is heavy unless u carry it out with khusyuk...

2.6.16

they inspire you.

dato Harbahajan. i still remember  my class during my 3rd year time with him. having one bedside teaching with him. lot of things he shared. from thehistory how to clerk, take  a good history. alhamdulillah during my end posting exam during 3rd year. the same case that he had taught me. i can answered. he is humble. now im in my final year. but he is retired from uia. and i joined his ot room. he was very kind and allow us to observe the surgery. you know, usually, students like to take signs for the logvook procedure. and dato' very kind, it was easy for us as he finished the ot he directly sign our logbook. he is very humble..very3 humble. unlike nowadays, MO, junior specialist sometimes they tired and have no time to entertain us. sometimes new lecturers they are more sarcastic in the class and felt tired to teach and repeat the same teaching with us, with too many groups. but i just salute with senior lecturers, even we like to irritate them by not giving correct answer to their questions in the class, they still lecture us, taught us.

you know, being a lecturer at the same time doing your duties as a specialist is not an easy job. i respect all my lecturers as they have passion in teaching us even they are tired.. although we are not able to achieve to their expectation. their teaching make us more wiser and they mould us to be a good doctors. thank you, i just pray that all of my lecturers who sacrifice their time, and energy will gain soemthing in the hereafter as have been promised by Allah. May Allah bless all of you.

i dont know how to repay it. but i hope i can be a good doctor, and treat my patient well, and my lecturers will get the same pahala as they taught me how to treat people wisely.

22.5.16

67days before pro exam

salam.
hai friends.
last block my o&g posting. i had  shared about one of my patient right before this. who had infective endocarditis, with collapsing pulse,corregen sign, mitral regurge with aortic regurge. with clubbing and janeway lesion..

sadly, i got this message after end of my posting.

"Bgi sesiapa yg previously OnG or sesape yg mengenali, sumber dari ho through senior, pt..... dah meninggal d/t subacute bact endocarditis, then septic emboli ke brain n cause mycotic aneurysm."

just felt guilty inside.
she had expressed her felling. she felt scared as she was put on intravenous jugular catheter and many people who are not concerned enough told her that her disease become worst as she was on IJC and need to do haemodialysis. she was touched. it was just to give antibiotic intravenously.

i said to her. dont think what other people said. its not like that. she herself knows that it was for antibiotic insertion. for her, she said that if having haemodialysis(kidney disease) is very worst thing and she dont want people to say that.

i know she was having cardiac disease. it involves the main organ of your system. i just dont want to tell her that her disease is a serious case too. so that she will not worried of it. but im gulity inside as i dont even remind her about solat and zikr to Allah. as her situation happened is the opportunity to her to be close to Allah.

Alhamdulillah.
yesterday, i met a makcik with pancreatic cancer with comorbid disease.
she was planned for palliative treatment as she is old and having comorbidity.
she said to me.
"makcik nak balik"
i said "sabar ya makcik, tunggu Dr rawat dulu"
she answered "misi bekeng"  (nurse is strict)
i told her "takpe makcik,kalau misi bekeng makcik makcik buat tak tahu je,jangan ambil hati ya makcik"

she had palpable gallbladder. and even many students and doctors had exmaine her, she still gives us to examine her again. she was very nice.

thinking about her condition, it is pity as she having a cancer plus she is activity daily dependent because of stroke.  i take this opportunity, to say to her.

"makcik, sabar ya..banyak kan zikir dalam hati..ingat Allah selalu  ya makcik.."

that makcik was nice and just nodded

patience who have serious illness are very strong.

they have opportunity get close to Allah.

and alhamdulillah i am  still young, healthy. i just hope that my life ends with husnulkhatimah and kalimah LAILAHA ILLALLAH.
even though you are young and healthy doesn't mean that you live longer than them who are sick.

18.5.16

competent

hai!
salam all.
look! 2months left before my final pro exam.
today vascular clinic with Mr A.Faidzal.
this is your last posting.
everyday open browse.
sleep with browse.
let it be osmosis during your sleeping time.

if you do not perform your exam.
you will fail.
oh sorry.
you are not fail actually.
but you will not become a competent doctor enough and will be extended for another 6 months.

so,,,,,,,
lets strive!!! buck up!!!!!!



and


pray for me.
thank you.

4.4.16

repost from senior.road to pro exam

Surgery Revision Day MBBS 2015

Yesterday we had Surgery Revision Day for MBBS. It started at 8.30am and ended at 1.00pm. We gathered at Lecture Hall 3 JHC first, and then went to separate rooms in Exam Room. 

We were divided into 9 groups and there were 9 stations altogether, 20 minutes allocated for each station. I was in Group 6, with my other 13 friends. 

Here's a summary on what each station is all about.

STATION 6 
Lump and Bump - Dr. Yusuf

Lipoma Lipoma Lipoma. Please come out in exam lol

A middle aged man, comfortably sitting on a chair. On inspection, there is an obvious swelling just below left scapula. There is no overlying skin changes, not erythematous, no punctum, sinus opening or discharge. 

On palpation, the size is 13 x 10 cm, oval in shape, has well-defined margin, soft in consistency, smooth surface, diffuse swelling, mobile, non-tender, not warm, not attached to skin or muscles, dull on percussion, transillumination test negative.

Provisional diagnosis : Back lipoma (fat accumulation in subcutaneous tissue)

Ddx:
1. Sebaceous cyst (collection of sebum in a sac located in dermis or subcutaneous tissue)
Points against : sebaceous cyst has punctum, non mobile and attached to skin

2. Abscess (collection of pus in a confined space) 
Points against : abscess is erythematous, warm and tender

3. Carbuncle (subcutaneous tissue necrosis with multiple sinus opening)
Points against : carbuncle is hard and tender, with sinus opening


STATION 7
Surgical Instruments - Mr. Chan

This station was a bit difficulttt. Must know the name of instrument, how to use it, indications and contraindications.

1. Trucut biopsy needle

The needle
Image taken from this website 

Principle of trucut biopsy
Image taken from this website

2. Sigmoidoscope
The scope
Image taken from this website

Different types of endoscopes
Image taken from this website

3. Triple lumen Foley catheter

The three-way tubing has an outlet for drainage of urine, an inlet for water inflation of the balloon, and an inlet for normal saline used for irrigating the urinary system most commonly for gross hematuria.

Different types of foley catheters
Image taken from this website

4. Chest tube

The tube and trocar inside
Image taken from this website

How to place the chest tube
Image taken from this website

Safety triangle
Image taken from this website

5. Skin stapler

Advantage is faster, less scar. Disadvantage is that it's expensive!

The stapler
Image taken from this website 

6. Last question, Mr. Chan asked us - what is this?

Image taken from this website

It's actually the cover of chest tube lol that was funny


STATION 8
X-Ray - Dr. Hisham

We did not have time to go through all xrays, basically we revised on how to read xrays.


Case 1

65 year-old gentleman with history of myocardial infarction 5 years ago, did angioplasty, on beta blocker and frusemide, presented with 5 days history of worsening dyspnea. Interpret his chest xray.

This is the chest xray of Mr.S, taken on (date) at (time), AP view (portable), right side is marked correctly. The patient is rotated, however it has good penetration and exposure. There is homogenous opacity over the right lung with blunting of costophrenic angle.

Diagnosis - Right pleural effusion

How to assess rotation, penetration and exposure?
1. Rotation : look at the distance between clavicle and spinous process (teardrop shape). It must be the same between right and left side.

2. Penetration : look at the last few lumbar vertebrae, near the heart, they must be visible

3. Exposure : can see first rib, diaphragm and lateral border of ribs. Anterior axillary line must intersect the middle of 6 1/2 anterior ribs.

How to manage this patient?
ABCDE first! Remember to do step by step, insert 2 large bore branula, take blood for investigations, CXR, ECG, and then chest tube insertion.

Case 2

65-year-old man, psychiatric patient, bed bound, presented with recurrence abdominal pain, abdominal distension and constipation. Interpret his abdominal xray.

Coffee bean sign!

Diagnosis - Sigmoid volvulus

Management?
ABCDE! Branula, hydration, consent for immediate sigmoidoscopy to derotate sigmoid. Then, put rectal tube. After that, can decide for rectopexy or sigmoid colectomy.

Complications of sigmoid volvulus?
Can cause bowel obstruction, ischaemia, perforation.

Case 3

Barium swallow : bird-beak appearance

Diagnosis? Achalasia!

Case 4

KUB XRay : Right staghorn calculi!


STATION 9 
CT Scan - Prof. Saufi

We were given 5 minutes to discuss on the findings, and then Prof came in to discuss.


Case 1


CT scan of thorax and abdomen, non contrast, axial view, soft tissue window. There are multiple hypodense lesions in liver, irregular margin. Spleen and kidneys are normal. Right pleural effusion noted in right lung.


Ddx for hypodense lesion in liver?

Liver abscess, liver metastasis or liver carcinoma

Your provisional diagnosis?

Liver carcinoma with lung metastasis

What investigation you want to do next?

Contrast CT scan of thorax and abdomen

Case 2


CT scan of brain, non contrast, axial view, soft tissue window. There is a heterogenous lesion lesion of mixed density, crescent shape, noted at right temporo-parietal region. Shifting of midline structures noted with left ventricle dilatation.


Impression?

Acute on chronic right subdural haematoma

What are the symptoms and signs patient can come with?

Altered consciousness, vomiting, seizure, dilated right pupil, left hemiparesis


STATION 10
Pathology Pictures - Dr. Azim :)

Dr. Akmal Azim is our new lecturer - and he is a plastic surgeon! So cool!


1. Specimen of thyroid gland with multiple nodules on right and left lobe.


Diagnosis?

Multinodular thyroid

Investigations? 

Blood (TFT, FBC), Imaging (US neck) and Special tests (FNAC)

Management? 

Medical (carbimazole), Surgical (thyroidectomy) and Radioiodine therapy  

2. Endoscopic view of pedunculated and sessile polyp


Symptoms patient can have? 

Alteration in bowel habit, per rectal bleeding, symptoms of obstruction 

Any special condition/disease you know that is related to this picture?

- Hereditary Non Polyposis Colorectal Cancer (HNPCC)
- Familial Adenomatous Polyposis (FAP)

What to do if patient has one of these condition?

Patient needs regular surveillance as there is risk of malignant change, need to screen family members

3. Specimen of large intestine showing multiple outpouchings with gangrenous area


Diagnosis?

Diverticular disease or diverticulosis

Cause?

Reduced fiber intake, predispose to constipation and straining, recurrence leads to weakening of colon wall and then outpuching

Symptoms patient can have?

Usually patient comes with pain, rarely per rectal bleeding. 

Complications?

If the area becomes inflamed and infected, can cause abscess formation. Can also cause perforation and fistula.

4. Middle aged man with scleral jaundice


Differential diagnosis?

- Pre hepatic : haemolytic anemia, G6PD
- Hepatic : hepatitis, alcoholic liver disease, chronic liver disease
- Post hepatic : bile duct stone, stricture, head of pancreas tumour, Mirizzi syndrome

Risk factors of gallbladder stone?

Female, Forty, Fat, Fertile

5. Specimen of gallbladder and pigmented gallstones


Types of gallstones?

Cholesterol (most common), pigmented, mixed



STATION 1
Abdomen - Mr. Mizam

Who wants to volunteer to examine this patient's abdomen?


Middle aged Chinese man comfortably lying in supine position. He looks pale but not jaundiced. On inspection of abdomen, there is no surgical scar seen, no dilated veins, visible pulsation or stigmata of chronic liver disease (spider naevi, gynaecomastia,  loss of axillary hair, caput medusae). There is no inguinal hernia. 


On palpation, there is a mass located at left iliac fossa measuring (? cm) that has well-defined margin, round in shape, can get above and can get below, smooth surface, firm in consistency, not mobile, tender on palpation, dullness on percussion (don't percuss if patient is in pain), not attached to skin or muscles. There is no hepatosplenomegaly, kidneys were not ballotable, no ascites.

Points to remember:

1. Stand at the end of patient's bed for general inspection
2. Look at patient's face when palpating abdomen or mass
3. Ask patient to flex his neck to check if mass is below or above muscle
4. Do skin pinch to check for attachment to skin

We didnt manage to discuss about the diagnosis, investigation and management because the time's up. Our friend says that it's a case of rectosigmoid carcinoma.




STATION 2
Thyroid - Prof. Junaini

Must master thyroid examination, confirm will come out in exam! At that time, there was no real thyroid patient, so one of us had to examine a normal male with no thyroid enlargement.


1. Ask patient to swallow water and protrude tongue

2. Do thyroid examination from back of patient
3. Check trachea and percuss retrosternal, check lymph nodes
4. Auscultate carotid bruit, check Pemberton sign
5. Check peripheral - fine tremor, sweating palms, pulse for atrial fibrillation, eyes for ophthalmopathy, shoulder for proximal myopathy

What do you know about thyroid carcinoma?

I made this myself, for future reference. Some of the information is from the internet.


STATION 3
Breast - Mr. Faiz

Practice, practice, practice! No patient with breast lump, so one of us had to wear fake boobs to be examined lol

Organise your examination:
1. Inspection - look for asymmetry, skin dimpling, peau de orange, discharge etc. 
2. Ask patient to raise both hands (look if there is anything underneath breast). Ask patient to press hands on hips (if there is attachment to pectoralis major, mass will become prominent).
3. Examine normal breast first, then the pathological one. Cover the other breast.
4. Ask patient to raise hand above head.
5. Lift up breast and look under breast for surgical scar (breast augmentation)
6. Palpate four quadrants + on nipple + below scapula
7. If there is a mass, describe it as usual - site, size, shape, surface etc.
8. Don't squeeze the nipple! Ask patient if she has any nipple discharge, if not then proceed. If yes, ask if she can demonstrate.
9. After examine both breasts, ask patient to sit down facing you. Check for axillary lymph nodes. Anterior, apical, medial, lateral and posterior. Check cervical and supraclavicular lymph nodes. Check spine tenderness (bone mets), percuss lung (pleural effusion, lung mets), auscultate lungs (reduced air entry, crepitations)
10. Ask patient to lie supine. Check for hepatomegaly.

STATION 4
Hernia - Mr. Islah

The patient was very willing to let us examine him, one person per group, that's a total of 9 students touching him....thank youu pakcik may Allah bless you!

Elderly man, lying comfortable in supine position. On inspection of abdomen, there is a midline laparotomy scar noted, with two transverse scars at right and left iliac fossa. There is an obvious right inguinal swelling, not extending to scrotum. There is no erythematous changes, no skin excoriation, no dilated veins, no punctum or discharge, no visible pulsation or peristalsis. Cough impulse is positive as the mass becomes obvious after coughing. 

On palpation, mass is oval in shape 5 x 4 cm, soft and doughy, has well-defined margin, non tender, not warm to touch, can get below and reducible. Occlusion test is negative. 

Genitalia examination is normal. Scrotum is well-developed. Both testis palpable, normal size. Normal spermatic cord, no bag of worms felt.

Since patient's swelling is completely reducible, I would like to ask patient to stand for further assessment. When patient standing, do transillumination test. It's negative.

I would like to complete my examination by doing per rectal examination, abdomen and respiratory examination.

How to do occlusion test?
Make sure swelling is completely reducible. Find landmark. Midway between ASIS and pubic tubercle (first bony prominence after pubic symphysis). Occlude opening with one finger. Ask patient to cough. If negative, ask patient to stand, finger still occlude the opening. Ask patient to cough again. 

Your complete provisional diagnosis?
Right recurrent completely reducible direct inguinal hernia with no complications such as strangulation, ischemia or incarceration.

How to know if its bowel or omentum?
- Bowel : Visible peristalsis on inspection, gurgling sensation on palpation and when you try to reduce it, initially it's hard and then becomes easy, bowel sound on auscultation

- Omentum : No visible peristalsis, soft and doughy on palpation and when you try to reduce it, it's easy initially but hard at last, no bowel sound heard

How to manage this patient?
Since this is a recurrent disease, I would like to take complete history and assess his risk factors (occupation, congenital, complications of previous operation, abdominal mass, urinary and bowel symptoms, respiratory problems, heavy lifting). After that, I would like to perform complete physical examination. Then, do pre-op assessment, optimize patient's condition, take blood for investigations, do CXR, ECG. Prepare patient for laparoscopic hernioplasty where we put in mesh to induce fibrosis and prevent hernia.

Advantages of laparoscopic surgery?
Small incision, less bleeding, less infection, faster recovery, reduced hospitalisation, reduced chronic pain

Disadvantages?
Need highly-experienced surgeon, longer operating time, risk of recurrence if surgeon is not experienced enough

Other options for surgery?
- Herniotomy : excision of sac after reduction, usually in children because they have weak and immature ligaments.
- Herniorraphy : reconstruction by using patient's own tissues

Type of open repair surgery that you know of?
- Lichtenstein : most common, flat mesh is placed on top of the defect
- Shouldice : four-layer reconstruction of fascia transversalis, difficult to perform
- Bassini : tension repair, edges of defect are sewn back together without any mesh 
- Desarda : simpler, faster, tension-free, mesh-free

Read more about Inguinal Hernia Surgery in this website.

Special types of hernia that you know of?
- Sliding hernia : an organ is part of hernia sac eg. colon or urinary bladder
- Pantaloon hernia (saddle bag hernia) : combined direct and indirect hernia
- Maydl's hernia : two adjacent loops of small intestine are within a hernial sac with a tight neck - double lumen.
- Richter's hernia : hernia involving only one sidewall of bowel
- Littre's hernia : hernia involving Meckel's diverticulum 

Read more about other types of hernia (there are a lot!) in this website.


STATION 5
Vascular - Mr. Ahmad Faidzal

The patient is a middle-aged Indian lady with varicose veins. We managed to feel defect in her veins. We did Doppler as well.

I have written about peripheral vascular examination last year, you can read it here. This is just a summary.

Remember : Inspection, Inspection, Inspection - Palpation, Percussion, Auscultation and Special Test.

Arterial system
1. Inspect for muscle wasting, colour, chronic signs of infection, arterial ulcer
2. Palpate for temperature, CRT, bone or joint tenderness, pulses (proximal to distal)
3. Ascultate bruit for AV malformation
4. Buerger's test - lift patient's leg and look at what angle it turns pale
5. Complete examination by doing ABSI, doppler, carotid pulse, cardiovascular, neurological and abdomen examination

What are the 6Ps of acute limb ischemia?
Pain, Pallor, Perishingly cold, Paralysis, Paraesthesia, Pulseless

Venous system
1. Inspect for calf swelling, lipodermatosclerosis, previous scar or healing ulcer, varicosity
2. Palpate the varicosity, tenderness (phlebitis), hardness (thrombosis), cough impulse
3. Auscultate bruit for AV malformation
4. Percussion is optional
5. Tradelenburg test and Multiple Tourniquet test
6. Complete examination by doing abdomen, per rectal, arterial system examination

Sooo... 10 stations COMPLETED!

Hope we can remember all of these points during exam!!

Hope all of us will pass the exam!! Amiiinnnn
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