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.  

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!

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...

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.

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.

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.

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

source http://dizzyzizzy.blogspot.my/2015_06_01_archive.html?m=1

i should be more concise

salam.  because of too tired, class from morning till evening today.  i slept at 9.30pm and woke up at 2am. end up i cannot sleep after that because of thinking about the things that i cannot figure out after clerking my patient. she has infective endocarditis. she was diagnosed after taking 3 blood culture taking at different site and after 30 minutes of each.

just imagine. a patient come to you. she is pregnant. coming to hospital because she was referred from maternal health centre due to low haemoglobin level which was 7.6 g/dl.
5days prior to admission she also had loss of consciousness for 30minutes and after regain consciousness  she did not directly seek for medical attention.

the problem is she was referred because of  low haemoglobin level. she did not reveled her LOC as the main complaint at the hospital. . as you know, infective endocarditis, patient will come with history of fever. however when the first time im clerking my patient, she had history of fever. at the first trimester of pregnancy and she just told you that it happened at time of having symptoms of pregnancy...  patient was not concerned about the fever. for her that fever is not the chief complaint for her.  she also had history of cardiac problem a the age of 15 years and completed medication treatment for 1 year. however, she do not know the diagnosis and the treatment she had.

just imagine. if she come to general practitioner in private clinic... then complaint of fever... just treated with paracetamol. and just imagine again... in private clinic they dont have enough time to check you from A to Z. which it private clinic. they just check certain systems only base on your complaint like general examination and respiratory system they might auscultate your lungs but not doing full examination for your cardiovascular system. they got a lot of patients waiting outside.

alhamdulillah, this patient admitted to the ward. i ward doctor have plenty of time to review you 24 hours. all systems were examined. and this patient found out that she had pansystolic murmur.

but i am so sad, because i just got to know that her problem earlier at th age of 15 years old. she had fever  for a week then resolved... then fever come again for  a week and resolved again. i just got the point when im clerking for the second time by using straight forward question. initially you just asked any fever before? that question is not enough because patient might think that the proble is not concern her enough. so you need to justify her,that time whether she frequently developed fever ?
make the things clear, so that she can recall the symptoms that she had.

another thing that make me sad because of myself. for the first time i do CVS examination on her. i am only heard pansytolic murmur . and when i checked her hand i only found she had clubbing.

but i met her for another time and do cvs examination again. it was found that she had janeway lesions but i miss it because it just a little point at the palm... and she said that , there is more lesions like that before and it disappeared after the treatment. and another thing i didnot look properly is that se had corrigan;s sign. and after ausculatate her heart for the second time it not just a pansystolic murmur at the mitral area but she also had end diastolic murmur at aortic area. and she also had collaapsing pulse. oh god. i just realized that i miss all those important signs because i that time, when the first time i came to her. i clerking her for half and hour and do CVS examination by just auscultate the heart and not doing proper from general, checking for the collapsing pulse, JVP and all tose menuver after detectiong the murmur, timing for murmur wheter it is the systolic or diastolic. and yes the reason is i want to finish my examination earlier as i need to cover another 2 patients within 2 hour that night. and i miss all those important signs.

so the thing is. after this i will make sure asking patient properly, giving direct questions to rule out all my differential diagnosis and not just asking open ended questions just why you come here and end up my conversation, anyting you want to tell?any symptoms tht you had? bcause patient sometimes not concerned with the symptoms they had and sometimes they did not realized it.

yes i need to buck up!! especially in the way of taking good history and finding relevant positive and negative signs in patient. read more and learn more. from patient i learn more.

alhamdulillah pass.

assalamualaikum, hye. i'm just back to school. for the second last posting.

last block holiday, i am restless. waiting for paeds result whether pass or fail. i know my long case was the worst one in my life. i just presenting my chief complaint, then dr directly ask me the diffrential diagnosis. i got bronchial asthma case, 3 year old girl. giving the chief complaint  with the sentence of "with underlying bronchial asthma" is one of my mistakes as the examiner asked me how confirm you are that she is having asthma? then i gave my points for for the diagnosis and dr said, if this is not broncial asthma? now, i got the point, dr dont want me directly to support the previous diagnosis, she want me to broaden my thinking to rue out many3 causes... i gave viral wheeze, multiple trigger wheeze, foreign body aspiration... all were rejected by the examiner. i was very blurred that time. thinking of heart faailure? but usually they will come with failure to thrive, interupted feeding, prolonged feeding... so i dont want to throw it as my thinking....then i cannot think anymore after she throw her last words " i give you last chance, this is your passing mark, what is the other possible diffrential diagnosis, i'm stuck.  probably it is not bronchiolitis as she is 3 years old. yeahhhhhh my last chance! i cannot think anymore as i was scolded all along the long case duration,.. so sad. and she  left me. she stood up, went to the door, open it. and said, where is your cardiac asthma? where is your loafler syndrome?

my teary eye just sent her leaving me alone in the small room....

i know im gonna fail my long case. the worst long case in my life. i did not present my history. just presenting my chief complaint... did not answered well for my diffrential diagnosis. you know, you will fail if you just achieve that level. usually youknow that you pass your long case if you able to discuss the case up to the management... but me..... even the first level of the questions,  failed.

then waiting for my short case. i was redha... i might fail. i know it. i was depressed that time. all the things that i have study, is useless. all the things that come out during my long case. i did not perform it even i have struggled to read many2 topics before the exams. but it happened like this. very sad.

suddenly, prof nasser called my name. he took me for my short case. i was very lucky to have him. he is very kind. i should perrform my shortcase very well. even my feeling was disturbed that time. i m trying presenting and performing the examinations properly. i got a child with purpuric rash over the both lower limbs. it was palpable, raised,red,painless rash... after examine the child. the discussion startrd. alhamdulillah. i managed to answer up to complication of henoch scholein purpura. however i got wrong answer for my investigations... i was very worried. but dr corrected me, during the exam, he still doing his duty teaching me and correct my answers.


becuase of that, during holiday..  i became restless... hope that my shortcase marks would cover my long case... i just pasrah. if im fail this posting, i need to buck up for the last 2 postings...
alhamdulillah, Allah is the MOST Merciful,ARRAZZAQ.  i PASS!!! alhamdulillah. alhamdulillah...

today, i got the marks for my lond case. yes, i fail my long case. but i got very high marks for my short case.... prof was so kind... his words always remind us towads Allah and Raullullah. during teaching also, he is very struggle to make us understand in the things that he teaches in the class.. he even did our revision class at night up to 1.30 am... its hard to be like him. he is very patience in delivering the knowldge to his students. it hard nowadays to find a teacher like him. i am praying that Allah will always bless him,,, and stay healthy all the time...  jazakallahukhairan kathiran walada walana insyaAllah fil jannah..inshaALLAH FIL JANNAH...... may Allah bless you prof nasser from department of paediatric IIUM...