The land below the wind

Wednesday, December 29, 2010

I will be flying off to Sandakan in less than 24 hours to do my month long elective attachment with the boys in Duchess of Kent Hospital, department of Internal Medicine. I am feeling quite excited as I've never been to that part of the world yet. 4 of us will be doing some travelling around Borneo as well so do wait up for pictures of proboscis monkeys, sea turtles and orang utans.

The SUN, SEA and SICK PEOPLE. The 3S of a successful elective posting. SANDAKAN here I come!

Wonderful Tonight

Saturday, December 25, 2010

Classical love songs by 方大同



Wednesday, December 15, 2010

This is the chest X-ray I saw in the general medicine ward of a 30 year-old man who presented with the following complaints:

1) Chronic productive cough x 6/12 associated with
-Exertional dyspnoea
-Multiple episodes of hemoptysis worsened over the past one month
-Greenish sputum

2) On and off low grade fever associated with night sweats chills and rigors x1/12

3) Significant weight loss with decreased oral intake due to poor appetite

Physical examination revealed decreased chest expansion over the upper chest. Percussion over the chest revealed dullness over the right upper lobe with apical crepitation on auscultation. Several enlarged cervical lymph nodes were present as well.
Chest X-Ray of another patient with active PTB. Note the cavitation. consolidation and deviated trachea(mediastinum) due to scarring.

Yes, you are right, he was having active pulmonary tuberculosis.

Tuberculosis is one of the common topics that can be tested in an undergraduate exam (obviously not in Monash) and questions are commonly asked about the treatment and its side effects. The first line medications for TB and their associated adverse drug effects are as follow:

Rifampicin-cholestatic jaundice, orange urine, thrombocytopenia, enzyme inducer( OCP less effective)
Isoniazid-Peripheral neuropathy, hepatitis, pyridoxine deficiency, drug induced lupus!
Pyrazinamide-hepatitis, hyperuricemia (Gout)
Ethambutol-Optic neuritis
Streptomycin-ototoxicity and nephrotixicity

Zap those female anopheles!!

Monday, December 6, 2010

A few days ago, a close friend of mine who is also a final year engineering student approached me and asked: “I’m currently trying to come out with an idea for my final year project and I am thinking of integrating engineering into medicine. What do you think? Any ideas?”

Well, since it’s the end of year holidays now and I barely have anything intellectually stimulating to do, I decided to help him with some information gathering. Below are some interesting video clips that I have come across.

Nathan Myhrvold and team's latest inventions -- as brilliant as they are bold -- remind us that the world needs wild creativity to tackle big problems like malaria. And just as that idea sinks in, he rolls out a live demo of a new, mosquito-zapping gizmo you have to see to believe.

From designing a device that could prevent breaking the cold chain of vaccines to diagnosing malaria infection by just looking into your eyes/nail beds, if only more geeks would put their skills to use like this, the bright future that we long for is definitely not far away. Who needs to learn how to do a BFMP(Blood Film for Malaria parasite)? Diagnosing malaria is going to be a no brainer! And since this gadget could specifically exterminate the mosquitoes other than some other harmless insects with wings, I believe Dengue fever/DSS all can be put to a stop.

Next, how about using an I pad during a surgery to view high resolution CT/MRI scans? A team of surgeons in Kobe University Japan actually put this device into good use. The touch screen seems to be working fine although it is covered by a sheath of sterile plastic film and the surgeon has donned on his gloves.

kobe surgery [japanprobe]
Uploaded by jdx459. - See video of the biggest web video personalities.

Not a big fan of these products(I-phone/I-Pad) tho, just another over-rated, highly glorified mobile phones around. One of my housemates once told me:" The sole reason of me getting an I-phone 4 is just to impress the chicks, nothing else".

Anyhow, we all have to admit that advancement in the field of medical technology has certainly improved our quality of life and revolutionized how medicine is being practiced today.


Wednesday, November 24, 2010

Exam has finally ended. Time to rejuvenate and reward myself back at home-the pearl of orient. I would like to extend my sincerest thanks and appreciation to all the people who made this year a memorable one.

1) The patients. Without them, I wouldn't have acquired any of the skills and knowledge that I have thus far. And most importantly -the art of medicine.

2) My outstandingly dedicated tutors!

3) Specialists and consultants from both the surgical and medical department

4) MOs and all the HOs that I've had the pleasure working with! Gratitude is extended to Dr Fadzli for being so accommodating and for all the feedback, direction and assistance when I needed them. Not forgetting the house officers from D2, PP1, W4 who have indeed enriched my learning experiences.

5) Ward sisters and staff nurses!- Thanks for showing me that nursing has a very special place in the health care system. And you guys are indeed indispensable!

Take care and hopefully we will meet each other again next year in my subsequent postings.

Running out of water

Monday, November 15, 2010

It is incomprehensible that while our beloved country is planning on building a 5 billion ringgit 100-story sky scrapper.On the home front, HSA has run out of normal saline infusion solution. All the patients are now on either dextrose solution or half saline regardless whether they are diabetic or the fluid replacement therapy is apparently inadequate!

Spot Diagnosis?

Thursday, November 4, 2010

Courtesy of C.S.Lee

Thoughts for the day

1) You're in deep shit if you have a pneumonia caused by staphylococcus aureus. A knowledge on how heroin is taken could possibly lead you to the diagnosis!

2) A drug addict taught me that heroin can be used in 4 ways
I) Injecting it
II)Smoking it
III)Snorting it through the nose
IV)Inhaling it-Chase the dragon
Smoking and chasing is safer as compared to the rest as it reduces the risk of OD.

3) Commonest cynotic congenital heart disease is still Eisenmenger's syndrome

4)You need 2 medical students, 2 house officers, one ward sister and another staff nurse to insert a branulla in an emotionally unstable patient.

5) The chicken and egg story in a 28 y.o hypertensive patient. Hypertension causes the CKD or the CKD causes the hypertension? A thorough search for secondary causes of hypertension warranted?

6) You need extreme patience to be an infectious disease physician. Day in day out, you deal with resistant bugs, patients who defaulted their treatment and among others.

7) Met a few patients with haematological disorders. APLS, thalassemia and AIHA. Heamatology is quite a fascinating field I think.

8) Observed a bone marrow aspiration and trephine biopsy. The doctor that obtained the consent must be very persuasive!

9) A pericardial rub sounds like a systolic murmur

10) Saw Dr Liu today in the ward. He asked: Why are you still here. You like this place so much? What's wrong with you? I winked at him. He tapped on my shoulder and said: Better come back and serve.


Sunday, October 31, 2010

Another year has zoomed past and we are almost at the end of third year medical training. Time flies as they say. The end of another year is always the time when one looks back and reviews our achievements, what we did well, what we did not do so well and then look forward to set goals to rectify them.

Year 3 has been uneventful to me so far in the sense that life practically revolves around texts and patients. With the end of year exam approaching soon, I am starting to spend more time hitting the books instead of roaming around the wards acting like a house officer. Now don’t get me wrong, it’s not that I am better or comparable to them, it’s just the method of learning that I have adopted since the beginning of the year. Osler once said: To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.

A few things that I’ve learnt to appreciate over 12 months being posted in different departments:

Respect patients

All students should ask yourself, “Who taught me medicine?”

“Prof A is really good, he taught me this and that. He even printed notes for us!” one of my colleagues answered. At the end of the year, most students will be going around, knocking the doors of their lecturers to thank them for making them a better doctor. But how many actually pondered whether these individuals really taught us the art of medicine? Did they develop heart failure to teach us what an elevated JVP looks like? Did they suffer from cyanotic congenital heart disease just to show us clubbing of the fingers?

Then who taught us medicine? Obviously the patients.

Patient came in with wheezing to show us the signs of asthma.

Patient came in with a myocardial infarct taught us what are the ECG changes that you could pick up in an acute coronary syndrome. Without these patients we would never have learnt. Yet there are students who are capable of performing examination without even obtaining consent just to satisfy their hunger for good physical signs. They come, they strip, they auscultate and they leave.

Our parents taught us to always respect our teachers. That’s the reason why we should have utmost respect for our patients-Our great teachers. And not treating them like dummies for you to practise on.

To wish

Make it a habit to wish the patients and their family members when you clerk them. You’ll be surprised to see how cooperative and pleasant the patients become when you wish them. Always be polite to patients irrespective of their socioeconomic status, education level, ethnicity, language, culture and religion. I’ve learnt tremendously from drug abusers, inmates, people from the lower socioeconomic background throughout the year. They never fail to make me realise that I am indeed so lucky and blessed to be living in such a comfortable life and to pursue what I like in life.

"Healing occurs when you let another human being know that his suffering and fears matter to you"-Anonymous

Choose your friends by their character. Choose your socks by their colour. Choosing your socks by their character makes no sense and choosing your friends by their colour is unthinkable-Anonymous

Be less intimidating

Always stand or sit at the same level with patients when you clerk a new patient. If you are standing and patients are lying down, it can be very intimidating for them. Pull up a chair and sit beside the bed if necessary. Try to calm them down especially during bedside teaching sessions. I learnt to routinely shake/hold their hands while introducing them to my colleagues and teacher before each session starts. Trust me, this will ease their nervousness tremendously. Thank them before you leave, not because they have been cooperative but for the fact that they have imparted some knowledge in you.

Refer to them by their names, and not “cases”. They are not experimental subjects and don’t you think it’s rather dehumanizing to be referred as such?


Never do things half heartedly. What you do now will definitely reflect who you are going to be next time. Clerking without examination is unacceptable and it just shows that you are not interested in learning. It sucks to be the group leader in the sense that you are directly responsible for the group’s learning progress. Inevitably you will meet people who clerk a patient 15 minutes before bedside and expect the tutor to show them the clinical signs and to finish up all the remnants. Excuses like “The patient was eating when I wanted to examine” or “ Patient was not in bed when I wanted to examine” are commonly given as they fail to step up to their responsibilities. Be responsible when you carry out your duties. If you don’t know or haven’t done it, just admit it and remember to do it properly next time. You must be responsible towards yourself and your colleagues.

However, I’ve learnt to accept and adapt. Confucius once said: If I am walking with two other men, each of them will serve as my teacher. I will pick out the good points of the one and imitate them, and the bad points of the other and correct them in myself.

And finally Attitude

“Attitude , not aptitude determines altitude”. It is the attitude in learning that makes all the difference. Although you can argue that why take things so seriously? You'll get the same degree anyway, since you still call the person who ended up last in medical school -Doctor. It is up to us to decide whether or not to be a 99% doctor or a 50% doctor.

Spot Diagnosis?

Wednesday, October 20, 2010

A few of the patients that I've seen over the week..

The mad house

Friday, October 15, 2010

Just some random thoughts for the day

1) The medical ward in hospital Sultanah Aminah is indeed a mad house. You'll have patients screaming, yelling, crying even swearing from time to time. It's stressful to work in such environment, the workload is unreasonable with tonnes of blood to take, lab investigations to review, cannulae to be inserted. Worse still when you have a 10 year old dengue patient who is afraid of needle being admitted...tds FBC..argh...

2) I entered the ward when the sun has not yet risen and I went back home when the day has gone dark. Extremely exhausted to the extend that I lost my appetite for dinner.

3)I poked an elderly man 3 times, one for an ABG, inserted a branula and withdrew blood and lastly a blood CNS under strict aseptic technique. I'm sorry.

4)I love the ECG machine in D2, it is printed in A4 size, no more long messy ECG strips laying around.

5)The hospital is so poor that they ran out of reagents for TROP T, creatinine and serum calcium. This is a tertiary referral center and I believe the patients should receive tertiary specialist care.

6)My fasting blood sugar after morning round is about 3.2 mmol/L. This is the value after going around looking at 40 patients without taking a single sip of water or breakfast.

7)Lung cancer and PTB is so prevalent in this region.

8)Ascultated my first carotid bruit, and realized that clinical examination is way more superior as compared to sophisticated imaging investigations.

9)Every complaint from the patient is genuine.

10) And in medicine, what ever that happens after 5 actually makes you better.

Clinic Cafe

Monday, September 13, 2010

If you are feeling sick and not well, you need to visit a clinic to get some medication. How about if you are feeling hungry and thirsty, can you visit a clinic? The answer is YES-Clinic Cafe.

Cool huh? Overall, it would be quite a nice place to chill out, decent atmosphere, service was good. However, food was just average.

Yellow discolouration

Saturday, August 21, 2010

The pathologist reported

Sections show fragments of gastric mucosa with sheets and nests and occasional glands of malignant epithelial cells invading the stroma. The tumour cells are pleomorphic, have increased N/C ratio, vesiculer nuclei and eosinophilic cytoplasm. Abundant mitotic figures are seen.

Impression: Adenocarcinoma, poorly differentiated, infiltrating
This is an elderly woman in her seventies, who was warded 4 months ago with the chief compliant of yellow discoloration of her eyes and skin. I remember this particular patient vividly as she gave the medical team a hard time figuring out what is wrong with her.

When she was admitted, she was grossly jaundice. It wouldn't be difficult to spot her in a sea of people. The semester one student nurses were pretty curious with her presentation and some of them asked me what's wrong with her.

It's pretty simple when you have a patient presenting to you with jaundice which is actually yellow discolouration of the mucous membrane and skin due to excessive bilirubin deposition. In our Malaysian setting, an underlying liver pathology/gall stone disease is usually the culprit.

However, upon detailed history taking, we couldn't elicit anything related to an underlying chronic liver disease. No weight loss, appetite was fine either. Crepitations at both lung bases were picked up and the legs were minimally edematous as well. She has no risk factors of viral hepatitis infection but of course a full jaundice workup was done including hepatitis serology.

An ultrasound was subsequently ordered to look for evidence of liver cirrhosis that could explain her presentation. I scratched my head when the report came back, everything was fine other than the enlarged lymph nodes compressing the porta hepatis. Liver was homogenous in terms of echogenicity, no evidence of cirrhosis.

To cut the long story short, a full battery of investigations were performed and we finally hit the jackpot when an OGDS found a fungating mass at the body of the stomach. A biopsy was taken and the result as mentioned above. Bile flow was obstructed due to external compression by the enlarged lymph nodes. Prognosis was not good. Management was then to relieve the obstruction by stenting, the rest are just palliative.

I followed her up for almost two and a half weeks, trying to understand the disease progression. Every afternoon before lunch time, she'll definitely ask me whether I've had my lunch. And if I say no or later, she will start lecturing me on how I should take care of my own health, and how eating late is bad for health. She was a very cheerful lady and even the student nurses enjoyed chit-chatting with her. They call her "po po"(grandma). After the stent was put in, she was allowed to be discharged

Today while I was doing my groceries in Giant, I bumped into her daughter. We started talking and I asked about po po. "She passed away 2 weeks ago, in peace, without any pain" her daughter said. " Thanks for asking doc" she added.

I can't remember her exact full name. But other than that, I can remember every single thing she told me before she passed away. I spent quite some time telling stories, listening to stories, laughing with a woman who would not survive the year.

I do hope she's doing fine up there, surrounded by lovely people!

A good cry

Saturday, August 7, 2010

She looked outside the window and started crying. Her tears welled up in her eyes, rolled down her chicks and then subsequently she broke into a full out sob. She tried to suppress the urge to cry, wiping away the tears with her tudung.

I excused myself from the team of doctors doing round, went over and gave her a gentle tap at her back and said:" I'm sorry Mak Cik, is there anything else we could do for you?". I knew she had no choice, your mind overrides any effort to suppress the need to cry, I told her it's fine to let it all out, because i know when you hold your tears back, you are only amplifying the emotions your body is trying to release through crying. She took a deep breath and said: Thanks for the pineapple cake young doc, and asked me how I became a doctor at such young age.

Her husband is a 65 year old malay gentleman with a known history of type 2 diabetes mellitus under the follow up of one of the district clinic. He presented with the chief complaint of dysphagia(difficulty swallowing) that was progressively getting worse. It started off with solid food especially bolus of rice and subsequently followed by fluid. Prior to admission this time, he could only tolerate 3 spoons of whatever food before regurgitating. Vomitus was free from billous substances and the fact that he could pin point the level of obstruction above the nipple line strongly suggest a mechanical obstruction at the distal oesophagus. With the significant weight loss of 20kgs in one month with anorexia, any sound reasonable competent doctor will give the the provisional diagnosis of a malignant space occupying lesion anywhere along the oesophagus causing the above symptoms. And yes, the was the provisional diagnosis of adenocarcinoma of the lower oesophagus was agreed by the specialists and the rest of the MOs and HOs. The plan of management at that time was to get an urgent OGDS for diagnosis and probably a tissue biopsy of histopathological evaluation.

Looking at him, he was lying on his bed, propped up with the wife and a wheel chair beside him. He has not been ambulating well according to the wife, and probably it is due to his poor oral intake i said to myself. A quick glance at him reveals a man in his 60s, emanciated with temporal wasting looking quite pale probably with a haemoglobin level of 8 or 9. He's not in pain, comfortable under room air without any oxygen supplementation. Did a quick examination on him and found nail bed, conjunctival pallor, distended abdomen with positive fluid thrill and bilateral pedal edema up to the mid shin. From auscultation, there was reduced air entry bilaterally with bronchial breathing just above it suggesting some degree of pleural effusion. After palpating the abdomen quickly, I concluded that his physical findings were consistent with the provisional and probably there is liver metastasis to the liver causing a hypoproteinemic state.

When I went back to the ward after class that day, I was confused as the OGDS did not show any intraluminal obstruction, but instead 4 large oesophageal varices occupying more than 1/3 of the oesophageal lumen with red cherry spots indicating stigmata of recent hemorrhage. Something was not right, from the history itself, there was nothing to suggest an underlying liver disease. No previous history of jaundice, distension, tea coloured urine and pruritus. Stool was normal as well. I traced his liver function test and found myself even more confused with the LFT being relatively normal. Serum albumin was on the lowish side, serum bilirubin and the other liver enzymes were normal. Nothing at all that suggest a primary liver pathology. Coagulation profile was not prolonged as well. I doubted my skills in history taking at that point, did I make a mistake? But I am very sure that the patient's complaint upon admission was "Susah nak telan".

During the A.M round the next day, an abdominal ultrasound was done and serological investigations to detect Hep B/Hep C infection were dispatched. The report from the radiologist came back stunning all of us- a large heterogenous hypoechoic lesion over the left lobe of the liver suggesting hepatocellular carcinoma! The liver was mildly cirrhotic and there is no clear fat plane between the mass between the body of pancreas, suggesting local infiltration. This is not a good news at all, his wife asked me about the radiological report, I said I am not in a position to give any comments and the consultant will be a better person to talk to. To cut the long story short, a 3 phase liver CECT was done and subsequently found multicentric lesions over the liver with invasion into the main and right hepatic veins and distortion of the IVC. Everything make sense now, the portal hypertension was not due to cirrhosis of the liver, but instead thrombosis in the main hepatic veins with anatomical distortion of the IVC. Budd-Chiari syndrome.

I put the CT films down and rush to the patient, I asked for permission to examine him. By then, the abdomen is grossly distended with the umbilicus everted. Shifting dullness cannot be any more clear, even with such an amount of fluid in the abdomen, when I laid my hands over the epigastrium, I noted a firm mass with an irregular boarder, covering half of the epigastrium. HOW CAN I MISS THAT from the initial physical examination? I flipped open the case file and found out that it was missed by the HO who first examined him as well. This is a retrospective finding, nothing to be proud, but definitely something to be ashamed off. All my tutors were right, even the consultant was right, medicine is still an art that cannot be replaced even by the advent of sophisticated imaging technology.

She looked outside the window and started crying. I asked whether I could do more although I do know that as a student, I can do nothing. The wife and the family members decided to bring him back. There's nothing that can be done here in HSAJB for him, only palliative management. I spent some time talking about a few things that could possibly go wrong after discharge, asking him to come back if ever he finds himself passing black stool or experiencing any symptoms of anemia from UGIB. The ascites will only get worse, and I reminded him to come back for a peritoneal tap if he finds himself having difficulty breathing from all the fluids in his lungs and the restrictive effect imposed on the lungs by the large abdomen. I thanked both of them for all the teachings and bid goodbye.

HCC without the background of cirrhosis, alcohol binging and chronic hepatitis infections. Something different from the pathology that I've learnt previously. Looked up the patho textbook that night itself, and found that a variant of HCC can occur without cirrhosis/ hepatotrophic viral infection- Fibrolamelar carcinoma of the liver. I hope that the mass could be a benign one like an adenoma or focal nodular hyperplasia. But from the aggressiveness of the mass as reported, and the fact that is has infiltrated the major hepatic vessels and distorted the IVC, its unlikely that it is benign, a tissue biopsy is still mandatory for confirmation.

Too bad, I've lost all the notes that I've taken for this patient. Must have misplaced it. From the history, daily reviews and even investigations, all gone. Ahh, what a waste, but he taught me so much throughout his stay in the hospital that I can still remember that his serum bilirubin level-it was only 29.

Necessity is the mother of invention

Friday, July 30, 2010

I had an interesting encounter with a 75 y.o gentleman who was admitted with the chief complaint of passing black stools for the past 2 days. Upon clerking him, I found out that he has a number of pretty nasty co-morbids that require him to be on a long list of medication. When I requested for the medications that he is on, he showed me this:
A mini pharmacy. And he's such a good patient that he can tell you what is medication for, the dosage just off his head. I like the fact that he's such an organised person, obtaining the drug history can never be easier.
He's on Casodex, an androgen receptor antagonist that give rise to gynaecomastia.

Upon physical examination, I found this device attached to a part of his body. Upon questioning, this device is in fact his own creation. Speaking about the latest medical invention, this man could probably win himself an award or something!
Give it a guess, I'll buy you a drink if you manage to guess it right.

What's Surgery Like

Thursday, July 1, 2010

5 months in the Department of Medicine, Hospital Sultanah Aminah JB, was undoubtedly the best experience I've had so far in my medical schooling life. I owe it to the fantastic team of people in the ward I was assigned to. Because of their teaching and guidance, I am actually quite functional and versatile in terms of ward duties. I've done most of the procedures so far including a pleural tap, assisted in several peritoneal dialysis and peritoneal tapping. Venepuctures and IV cannulations were so frequently done that they call me a vampire.

But now, everybody is everywhere. The MO has been posted to some other ward, some of the HOs are doing their minor posting either in haemato/chest/ ID department. I miss those days where I was so gung-ho spending more than 12 hours in the ward, studying while waiting for the staff nurses to call me if there is any blood to be taken or any branullas to be inserted. I would wake up early just to join the morning rounds with the MO, caused that is the time I will get grilling for not knowing stuffs.

"Chee, kepala u kosongkah?", the MO will say when I fail to examine the hands properly. "Can't you see, the joints are swollen!". "Now tell me 5 syndromes that are associated with Rheumatoid arthritis". " Sorry Dr F, I know only 2". " Tell me 5 reasons why patients with RA develops anemia" "Tell me about all the organisms that cause atypical pneumonia, which one causes haemolytic anemia?". LOL. Then he will walked away feeling pissed, but I know he is not, he was just trying to act stern.

Patients, although they are sick will try to console me by saying its ok, and offered to let me examine them again after I've read. Having said that, I tried to recall the syndromes associated with RA and yet i am still missing 1 of them.

1) Nephrotic syndrome
2) Felty's syndrome
3) Kaplan's syndrome
4) Carpal Tunnel syndrome
5) ?? Ish..

Anyway, I will be spending my last weekend her before I head back to JB. Surgical posting is next and I wonder what is in store.

When you hear about surgery, do you think of TV dramas like "Grey's Anatomy?" But in reality surgery is not always so glamorous or so dramatic. I was told by some of the surgeons back in Sunway that surgery is challenging, exciting, varied and very rewarding.

I think what attracts me to surgery over a lot of other specialities is the hands-on approach. The directness of treatment is something very lacking in other areas of medicine. And Yes, the feeling of actively "fixing" someone is hard to resist when that could mean the difference between life and death.

But at the same time, surgery for me lacks alot of the cerebral diagnostic element that I love so much about internal medicine. In the medical ward, knowledge is the only thing that sets you apart from the others. In surgery, its more to skills and technique. As long as you can be a good assistant in the OT, you are considered to be a good surgical HO. Besides that, I find that the medical consultants are more gentle, in the way they approach their patients. Surgeons on the other hand are always called the butchers.

Anyway, I do keep an open mind. I'll need to have adequate knowledge in both the field of surgery and medicine before I can proceed any further. I remembered how I miss a gastric outlet obstruction secondary to post op adhesions in a pt with chronic renal failure who just underwent an exploratory laparotomy because of bacterial peritonitis. From the abdominal X-ray, the stomach was obviously distended and yet I could miss it. And the best part is, when she asked me what's wrong with her tummy I said everything is fine. See! It's dangerous to talk without knowledge.

I'm all hyped up for the coming posting. Besides, I've heard that I've got pretty good tutors. 5 Essential Features of a top surgeon
1) Fingers of a Lady
2) Eyes of an Eagle
3) Heart of a lion
4) Stomach of a Camel
5) Legs of a horse

I'll see whether I could acquire any of the above at the end of the posting, HAHA!

Career Choice: Ambition Vs Family by Lucia Li, Medscape Student

Wednesday, June 30, 2010

People take different roads seeking fulfillment and happiness. Just because they're not on your road doesn't mean they've gotten lost.

I am ashamed to admit that there used to be a time when, if a colleague told me he/she wanted to be a GP, my first thought would be "you're only doing it because you want to have a family." I was harsher on my female colleagues because I somehow felt that the only proper execution of modern-day feminism was to work hard. I would feel a little sense of masochistic pride that my own ambitions were a little more time-consuming. Now I look back and think how foolish, patronising and downright idiotic those thoughts were.

The concept that medicine, to many others of my colleagues, was simply an interesting and satisfying way to make a profitable living was alien to me. The concept of medicine being a way to pay the bills hadn't even featured on my radar. I guess, somewhat naively, I had looked upon medicine as a calling. I hoped, and still hope, to contribute in a big way to our knowledge about disease and treatment. In the specialty I hope to pursue, I have found a real passion. To me, medicine will never just be a job.

But the whole point is we live in a free society in which we can choose our mode of happiness. No-one should be criticised for wanting to spend more time with family or even for wanting to give up a career to raise one. Least of all, women should not criticise other women for that choice.

The specialty I wish to pursue is not what anyone would call family-friendly. It's a long, hard slog. It's a competitive arena. Because of this, people seem to respect this decision. However, those people wanting to do family-friendly specialties, even if their decision is motivated by genuine interest, may come across derision from people who see it as ‘slacking off' or a ‘cop-out'. I can't help but wonder if this sort of attitude is borne of the need to justify their own sacrifices; they have sacrificed their own family lives for their career and, in moments of self-doubt over whether these sacrifices were worth it, their frustration manifests in ridicule of others.

I confess to being a little bit daunted by how much I may potentially have to sacrifice of my personal and family life in order to be successful in my chosen specialty. Nevertheless, I have my heart set on it, I genuinely believe it will make me happy. And that choice, the choice of what will make you happy, is what is worth celebrating, irrespective of why you chose it. ‘Ambition' is not a dirty word. And neither is ‘family'.

Even as a medical student, I often contemplate on the family vs career dilemma. And yes I'll have to admit that at this stage, career is still prevailing. However by saying that, it's easy to be young and say " I will work my ass off, providing the best for my patients, and I shall put my family planning on hold." But when you are no longer a gung-ho 20 year old medical student or a 25 year old senior medical officer, seeing your colleagues going into a less competitive field, living comfortable lives, will make you think twice about the decision you have previously made. I had a conversation with my dad recently in the car:

Me: I'll be graduating in another 2 and a half years. After completing my housemanship in Malaysia I'll try to further my studies as soon as possible. And perhaps after that join one of the university's medical center for practice and academic teaching.

Dad: Ok, but if you see any good candidates(girls) along the way, just approach them and be friends.

Me: Haiya, no time la. Besides, it's hard for me to settle down. I might get posted to some rural areas in the inner Sabah/Sarawak. Who knows? And I can't afford to be distracted. The amount of money you are paying for my degree should produce an outstanding doctor, not mediocrity.

Dad: Ya la, I know, but don't wait too long.

Me: Don't worry la, some of my tutors get married pretty late as well. Dr Y completed his MRCP at the age of 35 and when he returns to Malaysia, he's still single. Dr K too, he just got married last year. I even know of a professor who dedicated his life to medicine, now still single(trying to scare him)

Dad: That's not success, no matter what, don't put it on hold for too long!

I'm not blaming my dad, I guess he's just a little worried that I will become too career minded. Medicine can be like a jealous mistress- These words were spoken to me by a few wise tutors. I listened to them but still could not fully appreciate the gravity of my chosen career. I'll just let maturity and experience change my views on things.

I don't think its impossible to achieve a great career and family, because at the end of the day, you make your own time. And I believe, one will never be too busy for his/her love ones.

Everybody has their own interest and it's important to respect them. "Ambition" as what the author mentioned is not a dirty word. I admire people who dedicate their life to medicine, serving the Rakyat who really need them. Afterall it is an honor and privilege to be called doctor. This is why I want to have a MBBS after my name. That is why we are allowed to handle life and death situations. That's why we don't mind staying up late in an operation theater for our patients. It's a life, a calling, not a business. And I seriously couldn't imagine how hard it is to do that all, if you do not possess the heart and passion.

Be the best doctor you can be, make time for what you love, the rest are just excuses.

Abstract for Endocrine Society of Australia annual meeting.

Saturday, June 19, 2010

Expression and cellular activation of peroxisome proliferator-activated receptor γ in granulosa cell tumours.

Simon Chu, Chee Yong Chuan, Maria Alexiadis and Peter J Fuller
Prince Henry's Institute

Granulosa cell tumours (GCT) of the ovary are rare, hormonally-active neoplasms characterised by endocrine manifestations, an indolent course, and late relapse. Chemotherapy and hormonal therapy have proved to be of limited efficacy. Nuclear receptors (NR) are well defined targets which have a central pathogenic role in endocrine malignancy. They are potential targets for therapeutic intervention. NR have established roles in granulosa cell biology but their roles in GCT remain largely unexplored. In order to more systematically examine the NR family in GCT, we used ABI Low Density Array microfluidic cards to analyse 14 GCT and two GCT-derived cell lines for expression of the 48 NR. The levels of expression were remarkably consistent across the GCT. We found that peroxisome proliferator-activated receptor gamma (PPARg) had greater than 10 fold absolute expression when compared with either the NCBI tumour or brain reference RNA pools. PPARg agonists are regarded as potential therapeutics in the treatment of inflammatory diseases and certain cancers. Given the high expression levels of PPARg in GCT, we investigated whether the use of PPARg and/or retinoid X receptor (RXR) agonists or antagonists have an effect on GCT-derived cell lines. We observed that the PPARg/RXR agonists and antagonists had no affect on cell proliferation, cell viability or apoptosis. Although the use of PPARg agonists is unlikely to be of use in treating GCT, a combination of therapies involving knockdown of NF-kB signalling may be of benefit. We have previously observed that several other members of the steroid receptor family are transrepressed due to constitutive activation of the NF-kB signalling pathway. We are currently investigating whether PPARg is transcriptionally active in these cells using a reporter construct specific for PPARg and whether the non-responsivness to PPARg agonists or antagonists in vitro is due to NF-kB transrepression.

When the HOs are desperate

Saturday, April 10, 2010

A fancy way of doctors saying that they have absolutely no idea what is causing the fever is PUO- Pyrexia of unknown origin or more commonly termed FUO, Fever of unknown origin.

When doctors come across patients who were admitted for evaluation of PUO, they were forced to put on their thinking cap, generating differentials that could suggest a cause for the patient's on going chronic fever. In reality, they know just as much as the patient at that point of time and I do admit, it takes hell of a gut for a doctor to admit that he doesn't know what is wrong with you or what is causing the fever.

This 24 y.o female patient was referred from the OPD for evaluation for her 2 week history of unsettling fever. The HO is indeed stressed out to find out the exact cause by looking at all the tests he/she ordered

Pleural Effusion

Just this week, I've come across 2 patients with massive pleural effusion. Thought of sharing with my fellow colleagues since this is indeed a popular topic for bedside discussion or even exam.

This 80 y.o patient presented to the A&E with 2/7 progressive SOB and subsequently an AP CXR was taken
A 55 y.o patient with a known history of DM and HPT presented with generalized edema, ascites, peripheral upper and lower limb swelling and facial puffiness.

Pleural effusion can be divided into unilateral or bilateral.
1) What are the common causes for pleural effusion
2)What is the difference between transudation and exudation. What is the Light's criteria?
3)What are the clinical signs of pleural effusion
4)What are the investigations that you would order for the above patients to find out the underlying aetiology.


Saturday, March 13, 2010

Patient came in c/o light-headedness , provisional diagnosis of uncontrolled DM was made.

MO to HO: Ask the patient whether he has erectile dysfunction

HO to Me: You ask then

Me to pt: Uncle, nak tanya sikit, jangan rasa terhina k, soalan routine saje ok? Bendera boleh naik ar uncle?

Pt to me : Walaupun sudah 66 tahun, bendera masih boleh naik, no problem!

Me to HO: No erectile dysfunction

My patient died

Wednesday, March 3, 2010

When I saw him going into cardiac arrest, and subsequently his death announced, I had a sense of futility, then sadness. I was just talking to him yesterday, asking him whether he felt better, eating well and ect. It was as though he just disappeared.

I had seen somebody die. Some willing, others were not. Some were expected to die and some not. Some died of natural causes and other deaths were iatrogenic. It does not get easier for me. On the other hand, if death became easier for me, I would lack empathy. I want to be the sort of doctor that, 20 years down the line, when any of my patients die, I will still feel sad, and sorry for them.

This type of learning, with the rare opportunities for open dialogue abt death and dying is unique. In the hidden curriculum of medicine, where learning about death comes from seeing it on the wards, there is little time and often doctors are unwilling to discuss death and emotions relating to it. A personal education from a willing and honest patient is invalueble.

I am still clueless about the process of dying, my role in it and my response to it.


Saturday, February 27, 2010

No doubt this is the biggest I've seen.

C/O: Penile Swelling, unable to pass out urine, bilateral pedal edema


CCF secondary to non compliance to fluid restriction, with MR+MS secondary to rheumatic heart disease complicated by AF.


The reason why I make it a point to drop by my designated ward everyday(at least for the morning) is not only to clerk patients for my learning, learn new procedures and etc, but also to experience bizarre incidents that could really baffle and puzzle my mind as a medical student. I often walked out from the ward smiling, telling myself I've enjoyed my day.

While I was doing my routine tasks in the ward this morning, I get a whiff of something burning. The cubicle was quiet as the visiting session has just ended. At first I thought I was having some problem with my olfactory bulbs and thus having some "smell hallucinations". But when it got stronger, I turned around and saw the bed of a patient burning in flame. Relax, it was just a small one at the side of the bed, not to the extend of burning the patient alive.

I alerted the nurse and she passed me a jug of water, I then splashed it on the bed to put it out. The climax is when the HO came to interrogate to find out who was the culprit. The nurses found a cigarette box underneath the pillow of the neighboring patient. But he denied. The nurses got upset and asked me to give his shirt a smell, LOL!

One of the housemen then came and threatened that they are gonna collect saliva samples from the cigarette butt found on the floor and determine whose DNA it belongs to. But still, her effort was futile as both the patient and his neighbor denied all the way.

Thank god he didn't smoke near the oxygen supply, I might not come out from the ward alive.


Friday, February 12, 2010

My clinical training started officially and I will have to admit that this week has been the best week throughout my medical training so far. Had the opportunity to auscultate 2 pan systolic murmurs in a 15 year old kid with VSD and another 70 year old uncle with a mitral valve prolapse complicated by infective endocarditis. Although it is physically and mentally exhausting at the end of the day, i know that the more patients i see, the more i learn.

Clerked a 65 year old man who was referred for evaluation of his shortness of breath and chest pain. He is known to have hypertension diagnosed 3 years ago with previous history of ischemic heart disease. He was unable to ambulate himself due to the shortness of breath(NYHA class III) and was then put on oxygen therapy. Spoke to his son and managed to obtain a comprehensive history.

This is a classic example of textbook heart failure in which the heart is unable to pump out enough blood to sustain the body's demand. I thought this was an interesting learning opportunity for the group and hence decided to present to Dr W during bedside. However, throughout the session, the patient seemed rather uncomfortable with 12 of us surrounding him, talking in some odd jargons that he himself could not comprehend. The son and son in law weren't that happy with our presence as well. While presenting the case to my tutor and my fellow colleagues, i feel very bad for disturbing him, making him a subject of study for the 12 of us. Throughout the session, I was not paying full attention to what Dr W was saying, I was instead concerned about how the patient is feeling. Periodically, I will take a peep at him, or ask the son whether everything is ok. I adjusted the window beside the bed so that more fresh air could ventilate the already stuffy ward. The session ended in an hour and i thanked him before i leave.

Medical students should ask themselves a pertinent question, " Who taught me medicine?" Many would respond " My professor, my consultant, MO, lecturers" and so on. When they graduate, they will go knocking on the doors of their profs and lecturers to thank them personally for making them a good doctor.

If you come to think about that,
Did the professors really teach us the art of medicine? Did any of them developed heart failure and atrial fibrillation so that i could palpate an irregularly irregular pulse for the first time? Did they suffer severe shortness of breath to show us the cardinal sign of heart failure?

The ans is so obviously no. No doubt that they did facilitate our learning, guiding us along the way. They teach us the correct technique of physical examination not forgetting sharpen our skills in critical thinking which is utmost important in reaching a definite diagnosis. Mind you, they were heavily paid to teach us(in monash at least), but did the patients receive any monetary gain by teaching us? NO!

Parents taught us to respect our teachers, that's the reason why we should have utmost respect for the patients. They are our TEACHERS, and will continue to be one, throughout our career, until the day we decide to stop practicing medicine. Without them, we would never become doctors.

So now as students, and future doctors, what we could do is to at least respect them. They are not "cases". Quoting Dr W, a pencil case? or a brief case?

Show sincere care

A wise physician said to me, " I have been practicing medicine for 30 years and I have prescribed many things. But in the long run I have learned that for most of what ails the human creature, the best medicine is CARE."

"What if it doesn't work" I asked

"Double the dose" he replied.


Attitude not aptitude, determines altitude =)

SurgeXperiences 315

Saturday, January 23, 2010

Thanks for dropping by. Welcome to the 15th edition of SurgeXperiences, the only Surgical Grand Rounds that is devoted to the best surgical related posts!

Without further ado,

Dr DJ, a surgeon from Mumbai, India who blogs at “Dr DJ’s Surgical Adventures” brings us two great posts. First he chronicles about a difficult situation where things are not in their expected places.

“The doctor doing the CT suddenly yells, “Where is the doctor that managed to do this”. The intern accompanying the patient almost had a fit”

Read on to believe it for yourself!

Medical practice is not universal, medical customs and indications differ widely between countries and indeed patients’ expectations differ even more. The second piece of literary from Dr DJ sheds some light on how cultural differences between doctors and their patients are common and may have important clinical implications for clinical encounter.

“I would love to have a middle ground and say it is our duty to inform the patient that a complete medical examination is required, but how many would agree to strip down completely just for a fever?”

Next up, ER Doc over at “Tales from the Serenity Now Hospital” shares a story of complete lack of common sense.

“I try to educate my patients as much as possible on things. I don’t always do a good job when its really busy. But this time I was sure to explain what milking the prostate really is”

Over at “Two weeks on a trolley” is a post titled Dr Ima Toilet that explores the worst things that could happen to you on the wards. Read on to discover how he was peed directly into his eyeballs during a delivery, drenched in liquid poo after inserting a tablet into a child’s bottom, not forgetting an encounter where a patient approached him from behind and urinated on the back of his legs. Poor guy!

There is also a mention about a med student who gulped a piece of cadaver adipose tissue and eventually became a surgeon. Read on for a good laugh!

Romana, a plastic surgeon in Little Rock, AR reviews a journal article about “Histologic Relationship of Pre-auricular sinuses to Auricular Cartilage”. [Read Here]

With the number of injured casualties continues to escalate, MSF’s surgical units in Haiti continue to work around the clock, providing relief and treatment despite having limited staffs and resources. However as the death toll in Haiti continues to climb, frustration appears to be overwhelming as relief efforts are seemed to be slow and disorganized. [Read Here]

Over at the “Forensic Scientist Blog” that covers the life, times and interests of a real life forensic science technician, he explores how forensic scientists use body parts to identify and perform criminal examinations of the deceased. He highlighted the role of prosthetics implanted by surgeons as well as scars from routinely performed operation such as appendectomies are indeed handy in aiding the process of identification.[Read Here]

Though I strongly believe that everyone should have access to a good defense, even I wondered how some lawyers can help defend people who have done horrendous things. When lawyers help killers and child molesters off the hooks my finding some legal loopholes, you got to ponder if they’re really upholding the legal system or merely just thinking about monetary gain and their ego.

Bongi a south African surgeon who blogs at “Other Things Amanzi”(my all time favourite) mourns over the death of his patient and rants about why he hates lawyers.

And that’s it for this edition of SurgeXperiences, please send submissions for the next edition via this form. Also , for anyone who wishes to join the ever growing family of SurgeXperiences, do not hesitate to contact Jeffrey who runs the show.

SurgeXperiences 315-Call for submissions

Thursday, January 14, 2010

Thank you for paying a brief visit. SurgeXperiences is the one and only blog carnival that assorts the best surgery related posts in the medical blog sphere today. It was pioneered by one of my esteemed counterpart, Jeffrey Leow of Monash Medical Student who is adventurous enough to open up new areas of thoughts and bringing something new to the surgical blogging community.

SurgeXperiences was first started on 1st July 2007 and it is hosted by various hosts ranging from surgeons, anaesthetists, radiologists, students and even to patients. It is published fortnightly and each season lasts approximately a year.

The current edition, SurgeXperiences(314) is up at Suture for a Living. Yours truly will be hosting the upcoming edition (SurgeXperiences 315) on the 24th of January for the first time.

Being a fresh 3rd year medical student with minimal surgical experience, knowledge and background, it is my fervent hope to still be able to contribute to this carnival by attempting to produce a succinct post that will hopefully satisfy readers' likes.

It is an uneasy but apprehensive experience for me since this is my first post and I certainly do not want to disappoint the readers, so please bear with me while I accustom myself to how to system works.
Submissions can be done here.
Dateline : 22th of January, Friday

Here are all the previous issues of SurgeXperiences for your reading pleasure and do not hesitate to contact Jeffrey who masterminded this remarkable blog carnival-SurgeXperiences-Where we share our surgical experiences!

Tremendous experience, Summer Vacation Research Scholarship

Wednesday, January 13, 2010

Even as the academic year winds down, I was preparing to meet a new challenge: 8 weeks in a laboratory that will hone my scientific skills and prepare me for a possible career in research. I was fortunate enough to work in the Steroid Receptor Biology lab in Prince Henry’s Institute of Medical Research as part of the initiative supported by the Cancer Council of Victoria.

Such programs give students a chance to immerse themselves in cutting edge medical research in tertiary research institutions. For an international student like me, it is a pivotal experience that helped me decided whether to pursue a career in research, and to consider a possible career of being a physician-scientist.

Throughout my placement here, I realized researchers/clinicians who bridge the gap between clinical medicine and basic science are in a unique position to exploit the expanding knowledge of human genome and other recent advances to make remarkable discoveries that will benefit the human health.

The range of possible research areas that I was exposed to is immense. Emerging areas include identification and use of markers to allow early detection of ovarian cancer, gaining an in depth understanding about the exact pathophysiology and discovery of new molecular targets for possible therapeutic agents spearheaded by the steroid biology receptor group over in PHI.

Upon completion of this program, I truly recognize the increasing importance of science and research for practicing physician. I probably didn’t have any idea that I am going to do research before this experience. This journey down under really does build up the excitement, but even if I decided not to pursue research somewhere down the line, I am undoubtedly better prepared for 21st century medicine after working in the lab.

By immersing myself in the project looking into the “Pathogenesis of Granulosa Cell Tumour”, I am proud to say that I have mastered a few key techniques in laboratory research. Among the techniques are cell culture, plasmid purification, bacterial cell transformation, mammalian cell transfection, PCR, Western Blotting and many more.

Personally, I have the impression that research is more tedious and meticulous compared to clinical medicine. Moment to moment awareness is crucial to avoid to avoid making mistakes that could jeopardize the whole experiment. Techniques such as cell culture are indeed demanding requiring strict adherence to sterile practices to prevent unwanted contamination.

Besides learning core techniques, one of the most valuable lesson I have gained from the people here is to be analytical in science. I was taught by my supervisor to think critically when things go wrong in science. Critical skills in investigate thinking do provide a basis for better medical practice, better assessments of evidence for that practice that will change rapidly in my generation of physicians and a better foundation for new biology of medicine. Spending time to search for answers as well as fixing problems that arise truly intrigues my inquisitive mind.

Although the results for my experiments are not conclusive, I have indeed benefited tremendously as in PHI there has been a great focus on understanding the aspects of translational research, a valuable experience for medical students beginning their careers, By having done an independent study project, I have gained insights in how things move from the lab bench to patient bedside.