SURGERY finale 'runaway' 2012

Long Case (Prof.Saufi)

Mdm.N.S/59yo/M/Lady/Housewife/Jerantut/kco treated Rt renal stones 4yrs ago/presented with abdominal pain for 3d and postprandial vomitting for 2d prior to admission

i) Abdominal pain -S=flank
                             O=sudden
                             C=dull ache
                             R=sometimes radiated to back
                             A=associated with mild fever
                             T=continuous
                             E=not aggravated by movement and relieved by vomiting
                             S=5/10

ii) Vomitting - postprandial = 2-3 min after eating or drinking
                   - contained mucus + food particles
                   - no sore throat, hemoptysis or coughing

Both symptoms preceded by urinary incontinence associated with, frequency, urgency, dysuria, dribbling and so on. The patient noticed to have mass at Lt side of flank.
 
O/E - Ballotable Lt kidney

Questions

1) Analyze symptoms and what do you think the system involved?
2) what is your working diagnosis? why?
3) In this patient where is the level of obstruction?
4) Causes of unilateral and bilateral urine retention??
5) If caused by colon, where?? what are the parts of colon?
6) Investigations?Why and components to look at??
7) Compare between abdominal x-ray and KUB?? and how do you prepare for both (NBM, clean bowel etc)
8) what do you look in ultrasound??
9) If the patient has renal stone, what is your choice of treatment?? (nephrostomy, ESWL, antibiotics, etc)

Short Case (Mr.Zailani)

Examine the abdomen (pt of invasive breast ca with mets to pubic bone and femur)

1) Your positive findings??(mass at pelvic region) describe it?
2) what do you think the mass is that? why?
3) other causes??
4) Relevant imaging?? what to look for?? (u/sound, AXR. CXR, etc.)

Lesson for today:
- learn more about investigations (blood, urine, imaging) in detailed.
- don't merely send it if we don't know what to look for

Ya Allah..berikanlah aku PASS..ameenn
tiba masa tuk fokus kat ramadhan and mak ayah pulak
(apa pun rezeki yg tertulis untuk aku, aku terima seadanya).. Good luck kawan2 yg nk exam esok !!!

ALLAH knows best !!!!

(",) I LOVE SURGERY !!!

Bismillahirrahamnairrahim...

Alhamdullillah and praise to Allah for giving me another ideas to write another chapter in my e-book so called WONDERFUL-LIFE-MAYBE and hopefully it will be a great masterpiece someday. I wish it would be benefit not only to others but at least going to be a lullaby story for my little caliphs in the future. I love my life a lots. Sometimes i felt like experimenting with what myself need to go through, seeing a great person's doing their great noble job would make me think where am i standing at,what have i been through and who really i am. For sure meeting this legendary creature will inspire you for what you are going to do as the time flies.

My best time in OT (HOSHAS)

Talking about the determination will never be lasted until your body is buried and returned for good. Life is not only to be inspired but it is more to be an inspiration to others. Once you have reached that level, then you will really know and think about what is one's life supposed to be. I am still in the process of learning and of course it will never stop me until I really appreciate how much the people surround me are meant to.

Currently, I'm in 4th posting which is the last posting for year 3 before moving to the next phase,year 4. Alhamdulillah, i have done with Internal Medicine, Obstetric&Gynaecology and Paeditarics (where we have to get PASS at least 3 postings to move to year 4). Now, time to boost myself for surgical posting which i guess, the best posting among all. I know it is not an easy posting but at least i can put some enjoyment for me to learn and prevail it. For this moment, i want to say that I do love SURGERY !!!


P/s: Alhamdulillah, i got a chance to assist the doctor in OT since the HO was not around...
       [ i have a shaky hands, i need to do something if i want to continue with surgery in the future :(( ]

PAED finale 'runaway' 2012

LONG CASE (Dr. ABG Nagi)

My patient adik AS/3 years old/Malay/girl presented to HTAA with complaint of 1 episode of seizure prior to admission.

• witnessed by her mother
• sudden in onset (during sleeping)
• generalized and lasted about 10 minutes
• occur once only within 24 hours
• associated with uprolling of eyes, stiffness of limbs and vomiting of milk
• no post-ictal complications 

preceded by fever, runny nose and diarrhea

• fever was 38 degree celcius noted at home
• diarrhea occured 3 times with no foul smelling
• in contact with sick people at home

P/E: noted only febrile (38) and tachycardia (148 bpm)

provisional diagnosis : Simple febrile seizure secondary to viral fever/AGE

Questioned ask by Dr.ABG Nagi :

1. Definition of high grade fever
2. Cut point for tachycardia and tachyponea in this age
3. Prognosis of simple febrile seizure
4. Why did you mention viral fever not bacterial?
5. Signs of meningeal irritation
6. Definition of Kernig's and Brudzinki's signs?
7. Classification of seizures (maybe yg ni Dr nak based on ILAE)
8. Definition of simple and complex febrile seizure
9. Comparison of management between simple and complex febrile seizure (yg ni aku ckp xthu)
10. Complication of complex febrile seizure
11. If patient presented with complex seizure what are the investigations you would like to send
12. Management of status epilepticus
13. Examples of anti-convulsant (diazepam, phenytoin, phenobarbitone...etc)
14. If patient with seizure was given all types of anti-convulsant but the seizures still occur, what you want to do (inducing coma)
15. etc..

SHORT CASE (Dr.Aye Aye)

Adik SNF/ 6years old/ facial puffiness

Please inspect this patient, DON'T TOUCH

Questioned asked by Dr.Aye Aye:

1. Is this moon face? Why? (prolonged used of steroid)
2. Examples of diseases that treated with steroids?
3. What are steroid toxicities?
4. What do you think the disease that the patient had? NS
5. Patient has already performed renal biopsy, what are the indications for renal biopsy?
6. What are the types of nephrotic syndrome? and what do you think about this patient?
7. What is the prognosis of focal segmental glomerulosclerosis (FSGS)?

p/s:

- Dgn yaqeennye duk present dalam bilik ber-aircond sempat pulak Dr. ABG Nagi tidur dgr presentation aku....hampehhhh

- Masa session CP ngan Dr.ABG Nagi aku present kes sama simple febrile seizure, alhamdulillah dpt jgk idea mcm mn nk buat ayat dan prepare soalan yang bakal Dr tanya...tp balik2 dia p pusing soalan laen...mak aihh

- Patient nephrotic tu aku dh clerk last week, so nsb bek la ad jgk idea nk present...

aku bermonolog sendirian sebelum keluar pergi exam:

[Allah dah tetapkan rezeki aku, walau apa pun terjadi jgn sedikit pun pertikaikan rezeki Allah]

Muka2 DR kesayangan (termasuk yg xde dalam gambar, Dr.Nargis, Dr.Taufiq & Dr.Fadzillah)
haha..gambar aku pun masuk!!!

InsyAllah mudah-mudahan apa yang aku usahakan hari ini menjadi bukti untuk hari yang akan datang.. Doa dan tawakal kepada Allah semoga ilmu yang diperolehi mendapat keredhaan-NYA.

Semoga mendapat PASS untuk paed posting..ameen

(',) Me, Myself and My Life

Assalamualaikum..

           Alhamdulillah masih diberi rezeki oleh Allah untuk bernafas walaupun terasa diri ini begitu jauh dari Sang Pencipta dan bukan semua rezeki itu mampu dilihat dengan mata yang terlalu kerdil ini kerana segala apa yang diberikan oleh Allah adalah tersirat biarpun ia sekadar ingatan yang tidak langsung.

           Akhir-akhir ini, diri ini amatlah sibuk dengan hanya 1 minggu lagi yang masih berbaki sebelum memberi laluan untuk peperiksaan akhir untuk posting ke-3. Walaupun dah hampir penghujungnya, masih terasa hanya secebis sahaja ilmu yang ada untuk dibawa, InsyAllah masih belum terlambat selagi ada usaha dan tawakal yang sentiasa istiqamah diabdikan untuk Si Dia.

           Penghujung minggu lepas berkesempatan menghadirkan diri untuk 1 program BAKTISISWA anjuran batch kami, 13th Legacy dengan kolaborasi Felda Chini Pahang. Alhamdulillah, tidak menghampakan sebab dapat belajar banyak benda yang bukan sahaja tersurat malah pengajaran yang tersirat yang saya rasa cukuplah untuk membuat saya duduk termenung memikirkan apa suratan disebalik penciptaan diri yang serba kekurangan ini. It changes my life a lots..~~

Beberapa gambar yang sempat di-snapkan:

Tahniah kepada pemenang cabaran tembikai hantaran dan xlupa kepada Miss Daily Dose dan temannya yang cukup kreatif menyiapkan gubahan. (walupun mata meliar tengok gubahan sebelah..haha)

Menunggu untuk menaiki van aka mini-lori menuju ke Tasek Chini.

 Siapa itu?? hehe..inilah 'artis' batch kami Mr. Syahmi Fikri mengambil peluang bergambar di Pusat Jualan Tenun Felda Chini

Menyelongkar keindahan dan misteri tersimpan di Tasek Chini.

           Sepanjang meng-k.i.a.s.u-kan diri di Wad Melur 2, HOSHAS selama 8 minggu, wad kanak-kanak ini banyak menginsafkan diri mensyukuri keupayaan diri yang boleh dikatakan sempurna untuk dibandingkan dengan adik-adik yang lebih tabah dari apa yang dapat dilihat dari mata kasar. Hati tersentuh melihat ibu-ibu begitu gigih menjaga anak-anak yang terpilih ini. Pada minggu terakhir ini, membawa hati yang sedih pulang dari Chini ke Temerloh sambil memikirkan masa depan dan kelemahan diri yang perlukan sokongan. Tapi dengan kehadiran adik-adik yang begitu ceria walaupun sakit dan juga group-mate yang supportive sekurang-kurangnya mampu mengukirkan senyuman dan tuntaskan perkataan syukur kepada Allah.

           Masa jalan kaki di depan kiosk hospital, hati tersentuh melihat satu naskhah buku yang saya rasa tajuknya begitu masyuk dengan situasi yang saya alami, tanpa berfikir sejenak..terus buku itu dimiliki untuk men-semangatkan diri yang mana semangatnya kian pudar. Apa yang dapat dicoretkan, diri ini cuba berubah untuk jadi insan yang lebih baik, mudah-mudahan Allah permudahkan jalan..ameen

"Visi untuk hati yang terluka"

p/s: Biarlah apa orang nak cakap sekalipun, they will never feel it unless they are in our shoes.
      Kepada Adik Taufiq (pt CP kat HOSHAS), mudah-mudahan Allah bagi kekuatan kepada kamu ye adikku dan tabahkanlah ibunya melayari hari-hari yang mendatang..ameen

          Groupmate yang D'bomb... haha, berseri2 semua!!

O&G finale 'runaway' 2012

LONG CASE

- Mdm.Z./ 27 years old/ G1P0/ 37 POA/ EDD = 8-3-12
- k/c/o Bronchial asthma for 20 years on MDI last attack was October last year
- p/w signs and symptoms of labour.
- o/e cervical os was open 3cm and the leakage during admission was not liquor.

Questions asked by Dr. Kamarul Bahyah ( korang cari sendiri la ye !!)

1. Type of asthma treatment that the patient used, what are medications used for asthma that you know?
2. Do you think the leakage is liquor?? i said no.. Your differential diagnosis ?? LL, urinary incontinence, ... etc
3. How to confirm it is liquor?? (aku bagi tau semua test untuk confirm liquor, pastu doktor perli aku balik, semua sekali ke awak nk buat?? then doctor asked me, in our center (HTAA) what is the test used? )
4. If patient came with PPROM (don't use short form masa present ye!!), what do you worry about??
5. How do you monitor patient with leaking liquor in the ward?? --> Pad chart
6. What are components that you monitored in pad chart?? colour, quantity, ... etc
7. Induction of labour ?
8. Methods of IOL?
9. What are complications of oxytocin? UHS, uterine rupture
10. If patient with PPROM, what are vital signs that you will monitor? (dr suruh guna medical term, dr xnk guna eg: temperature --> increased, high or elevated.. cakap je febrile/tachy/...etc)
11. If liquor is continuously leaking, what do you worry about?? what is your plan??
12. Continuous leaking + blood pressure drop, what do you think?? hypotensive shock
13. For this patient, when do you want to deliver her?? within 24 hr
14. etc...

" Okay Afizul, you go back and read regarding PgE, Oxytocin ...etc, because you'll be seeing this again in year 5... unless Nauzubillahuminzalik, if you repeat this again "... then Dr said, ok dah bleh tarik nafas dah.. 

Hahaha..nak berair mata cheq na.. Satu ward dengar suara Dr !!

Actually, i did one case presentation with Dr.Kamarul Bahyah in her room during 2nd week of the posting.  and during the presentation she bombarded me with a lot of questions.. Sampai satu tahap tu, i shed my tears.. pastu Dr cakap, xpe biar depressed sekarang, this is how you learn.. Banyak sangat Dr bg semangat masa tu, sampai je bilik terus nangis (mahalnya harga sebuah air mata, ingat senang ke aku nk nangis) .... InsyAllah, mudah2an I'll be a good and safe Dr..ameenn..

SHORT CASE ( Prof. Hamizah)

- EDD = 8/2/2012, so 

- Please examine this patient 

Pastu aku buat la satu2 sampai habis...Yaqeen giler aku wat (sebab dh banyak practice palpation kat pregnant mother..haha)

Pastu Prof cakap, Afizul, how do you improve your technique of measuring fundus height clinically, can you show me once again?? --> Alhamdulillah, banyak teknik yang Prof refine (but i'm worried because, our SC exam for 3rd yr is assessed from the technique not the findings)

1. POA = 41w (hari xm 15/2/12) --> Postdate
2. If patient came with postdate, what are the signs that you want to look for?? signs and symptoms of labour
3. What do you want to do?? Bishop Score assessment
4. Components of Bishop Score and Total score??
5. Then, Prof gave me the table of Bishop score and she asked me to calculate. I got 5/13 and i said it is not favourable.
6. What is your plan?? Induction of labour
7. Methods of IOL?

Okay, tq..you may go now..

p/s : kalau bleh masa session dgn Mentor, jgn suruh dia evaluate ap yg kite buat tp suruh dia observe btul2, btul ke teknik yg kite buat tu.. kdg2 kite dh rasa yaqeen..laen Dr laen diorang punya teknik and evaluation kan?? so, prepare more is better than less..

InsyAllah, mudah2an..apa yg aku belajar hari ini jd satu semangat untuk aku usaha pada hari2 akan datang.. ameen.. Ya Allah, aku dh usaha sebaik mungkin, segala apa yg akn berlaku, aku redha dgn rezeki-Mu Ya Allah..

(",) Dihambat kontroversi yang tak sudah...

Bismillahirrahmanirrahim...

       Alhamdulillah..buat kali pertamanya berpeluang membuat naskhah ramadhan untuk blog kali ini walaupun ia bakal menginjakkan ke pengakhirannya tatkala menghitung hari untuk menutup tirai.. Apa khabar iman kita kali ini?? Semoga apa yang diusahakn dari awal Ramadhan mendapat tempat disisiNYA..InsyAllah

        Rasa syukur kepada Allah s.w.t sebab tahun ini berkesempatan menghabiskan sepurnama Ramadhan disisi keluarga tercinta...satu nikmat yang teman rasa begitu bermakna setelah nikmat ini diragut tatkala teman menempatkan diri di asrama pada tahun 2005 dan semestinya semenjak itu, berbuka dan bersahur kebanyakannya dihabiskan bersama kawan-kawan teman yang setia dalam satu titipan perjuangan yang sama..

         Dikala sedih dek Ramadhan bakal meninggalkan kita, teman berasa sedikit gusar bercampur teruja kerana pengakhiran Ramadhan pada tahun ini merupakan titik tolak bakal berakhirnya nikmat cuti yang teman rasa begitu sukar untuk diperoleh pada masa akan datang dan ia juga merupakan penanda aras dimana bermulanya agenda sebenar latihan dan didikan diri yang perlu teman dan kawan-kawan teman ambik dalam mempersiapkan diri menghadapi liku-liku kehidupan yang sememangnya insan yang bakal bergelar doktor patut belajar. Gusar sebab segala pembelajaran teman dan kawan-kawan teman akan datang melibatkan 100% nyawa insan yang terduga oleh Allah dan teruja sebab dapat melangkah ke satu lagi anak tangga untuk mengait bintang yang selama ini teman cari.

          Menyedari saat itu bakal bermula tidak lama lagi, mulut teman tidak pernah berhenti memohon kepada Allah s.w.t disamping mengambil kesempatan mood Ramadhan yg penuh barakah ini.....agar:

• Dipermudahkan segala urusan teman dan kawan-kawan teman serta tunjukkanlah kami jalan
• Dibukakan pintu hati untuk mudah menerima ilmu disamping diberi ketenangan diri
• Diberi keupayaan untuk teman menolong kawan-kawan teman dan diberikan keupayaan kepada kawan-kawan teman untuk menolong teman serta dijauhkan sengketa antara kami
• Berkatikanlah ilmu yang kami perolehi 
• Jadikanlah teman dan kawan-kawan teman seorang yang rendah diri dengan segala ilmu yang kami perolehi
• Permudahkanlah lidah teman dan kawan-kawan teman tatkala berkomunikasi dengan pesakit

Ameenn..Ameenn..Ya Rabbal Alaminn...

          Teringat teman SMS seorang guru kimia teman tatkala meninggalkan dunia ASASI di Petaling Jaya, "Hidup biar ikut resmi padi, makin berisi makin tunduk" Mdm.Wan Mazlita...... InsyAllah segala tunjuk ajar puan kami dokong sampai ke tanah balik kami jadi... Sudah banyak teman berdrama rasanya tatkala pena 'cursor' tidak berdakwat ini kian letih mengisi ruang kosong yang teman rasa tak terkira banyaknya dengan jari..Mudah-mudahan Allah kurniakan kepada teman serta kawan-kawan teman kesabaran yang tinggi menghadapi ujian kami pilih ini...

(",) Who should be blamed??

Assalamualaikum !!! pag ibig mo ang lahat..

       Have a nice day... and my tagline for today is "to feel good is to look good". Absolutely, be optimistic is another option which may give you a different dimension of confidence trick disregard to what the people feel towards you...you seem to create your own world by ignoring any negative perception on you.. and of course you rock your own life...but mind that, optimistic solely is not enough because sometimes put a little hypocrisy may help you better to prevail any difficulties... In short, jgn terlebih sudah.. ermm.....

        Actually, i have another true story whereby i kept from last week before jotting it down here...and before that, Prof Ariff (our best anaesthetist) never misses this in his lecture.. Try to learn, unlearn and relearn. So, xdela nk buka aib org..just learn from it.

        Last Saturday, there was a mother around 60's (org kg aku jgk) came to my house and told something to my mum. And for your information, my mum is another good reason because we have a small shop which supplies keperluan2 dapur, lebih kurang retailer la....She opened her mouth describing about her current family conditions...and honestly, i didn't expect a mother to dishonour her own children (mungkin dah habis ikhtiar kut)

         Okay, senang citer....Briefly, her husband is suffering from heart problem and is advised for not to do any heavy work...Diorng pun bukan dari keluarga yang senang...sekadar bergantung harap dengan anak2 yang dah bekerja je la.....one of her daughter dah terlanjur  ngn her BF and it is a forced-marriage since she was detected of being pregnant.. then she told about her son who involved with drug abuse..xclap  aku methamphetamine (pil kuda)..Dah la bdk tu tak bekerja,dan pil tu bknnye murah...It's truly a sad sad story (kalaulah korang boleh tengok sendiri dpn mata seorang ibu tua dengan penuh ekspresinya bercerita)...yela kan ibu mana tak sedih anak yang ditatang dan dijaga akhirnya menjadi tak seperti yg diharapkan..Mudah2an hari2 yg mendatang ditempuhi dgn penuh tabah dan cekal..ameen..

okaylah guys...belajar dari kesilapan sendiri dan berdoa supaya Allah permudahkan lagi urusan kita..ameenn

P/s: ermm...dah macam rojak dah bahasa aku..k aku cuba ubah untuk post akan datang (seruan kerajaan banggalah dgn Bahasa ibunda)