tag:blogger.com,1999:blog-32537237021171586912024-02-21T17:17:47.410-08:00Education of a KnifeJoin me as i venture through the hostile world of medicine.Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.comBlogger64125tag:blogger.com,1999:blog-3253723702117158691.post-21097272065313297822012-03-31T15:53:00.002-07:002012-03-31T15:54:16.519-07:00The History is the Patient telling us the Diagnosis, The Physical Examination is the Body telling us the Diagnosis.<div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong>Written by Professor Dr Wong Yin Onn The Start of a Diagnostic Process The History</strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong></strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">History taking is the foundation of the Clinical Art and the heart of the diagnostic process in Medicine. The medical history is the grand centerpiece, the big picture that provides a panoramic overview of the patient's entire illness - how it originated, how it grew and developed, and how it is at present. </div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">It is primarily the medical history that tells the doctor which specific signs to look for, and what other subsequent investigations are needed to obtain the information he seeks. All other methods of diagnosis can be seen as auxiliaries to the medical history, which is the principal, or core diagnostic method. </div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">Prof TJ Danaraj demanded a highly detailed history from his students, and a sloppy history will be met with a severe reprimand. Prof KK Toh recalled how a student who did a particularly poor job will be exiled from the Bedside teaching until he has personally apologised to the teacher and each student in the group, for he has wasted the precious learning time of the entire group and himself; and insulted the patient. </div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">TJD will typically draw a long line across the blackboard with his chalk; the student will be asked as to describe in detail what happened on the Day1 when the first symptom appeared and then Day2 etc etc. Then what brought the patient to hospital, that precipitating event which made the patient seek admission, and subsequently what happened Day1 of admission, etc all the way to the present day.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">We must pay close attention to the <strong>time course</strong> of the symptoms. How has symptom complex changed over time? </div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">The natural history of the illness, its progression is of utmost importance in diagnosis. Today I am saddened that most students take lightly this "History of Present Illness (HPI)". In this era of instant coffee and maggi mee, the students compressed all this HPI into a few brief statements, losing much that it tells us. Always remember that <strong>The History is the Patient telling us the Diagnosis!</strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong></strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong><img fbid="10150698032520798" hmac="ATpgbZgxpZX1yz-U" src="https://fbcdn-photos-a.akamaihd.net/hphotos-ak-ash3/532705_10150698032520798_532130797_9270893_212586087_a.jpg" style="border-bottom-width: 0px; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px;" /></strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong></strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong>I tell my students to at the very least think of 5 common conditions that can explain for the Chief Complaint and HPI.</strong> For eg if the Complaint has been Chest Pain, then at the very bare minimum, think of 5 Common or Important conditions that can cause or fit the HPI. The Common include Ischaemic Heart Disease, the NOT TO BE MISSED include Acute Myocardial infarct, Aortic Dissection, Pulmonary Embolism, and Pnemothorax. The long list of others from GERD to Oesophageal spasm to Zoster is at the back of our minds. With this we review the Systems and LOOK at each system one by one comprehensively for possible symptoms and disorders that may not be spoken of by the patient in the HPI. In the HPI the patient volunteers his data, in the systemic review we enquire!</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">The focused <strong>review of systems</strong> bring out information that supports a certain diagnosis or helps gauge the severity of the disorder, or exclude the likelihood of a pathology.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">Today, the systemic review often consists of mindlessly repeating a few lines that goes.... "Patient does not smoke, drink or take drugs of abuse. He has no sexual indiscretion". This is one extreme.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">Any book on Clinical Methods will have a list of symptoms that comprised the definitive "Review of Systems." Some students actually memorized this list. This is the other extreme! But the Mindless recitation of this list is rather stupid: "I know that you are having chest pain, but I need to know if you have ever had an extra marital affair." </div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">I smile to myself everytime I hear such well parroted lines at the wards, and realise that the student still has Not grasped the Art.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">The Diagnostic process is time honoured, refined by the passage of time,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">a distillate of Medical wisdom.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">History taking and Physical examination remains the pillars of sound practise,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">no matter how the machines have advanced.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">The human touch, both the spoken word and the touch of the hand is as important as the pharmacopeia.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">Even if the superb diagnostician may not need it, the suffering man does.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">he consults a doctor, not a machine,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">he seeks help, not the beeps of computers.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">On complicated machines we now rely,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">and use ear, tongue, eye and hand far too little.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">We scan and sound everything,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">and await with pious resignation the decree of the computer.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">Clinical methods we tend to damn,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">and the doctor now becomes a stranger to the patient.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">The modern doctor is at ease with ECHOs and Scans,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">but he forgets the symptoms and signs of diseases,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">the patient now a nameless collection of body parts to be referred to organ specialists,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">where once on a clinician's skills the matter rests.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">But we have yet a machine that can measure Human pain and distress,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">nor a computer that can counsel and relieve.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">What ails a man from the symptoms and signs, a clinician can tell,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">at the bedside he truly shines,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">his conversation reassures the patient that he is the most important suffering being to this doctor,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">his touch a soothing balm to the aching body.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">TJD warned us that we are Doctors, NOT Technicians; and unless we continue to act as Human Doctors healing the sick Human being, the Technician will take over!</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">The History is the Patient telling us the Diagnosis,</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">The Physical Examination is the Body telling us the Diagnosis. </div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">Both must be Complete.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong>The History is in a language both the Doctor and Patient understands,</strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong>The Physical Examination is in a language only the well trained doctor understands.</strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong>The Mathematics of Diagnosis is the Mathematics of PROBABILITY; what is the probability of disease A causing the symptom complex of this patient?</strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong>In the OSCE system of evaluation of our medical students at the end of the year, the student is asked at the end of his history taking... "What is your Provisional Diagnosis and Differential Diagnosis at the end of this interview?"</strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong>Effectively we are asking, what is the Probability of the diseases causing this illness from the highest to the Lowest! </strong></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"> Some symptoms provide us with valuable clues to the diagnosis, for eg</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><strong>Fever, Chills, and Rigors! </strong> People! pls give me 5 important common causes.</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">One of my students saw a patient come in with Fever, Chills and rigors with abdominal discomfort and unilateral flank pain. From the history, he was able to quite accurately localise the source of infection which took the attending doctors a CT Chest and Abdomen to diagnose! The history and physical examination should give us a Working Diagnosis based on which we order the appropriate Investigations. It should not be that we do the Investigations to give us the working diagnosis!</div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;"><br /></div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">The medical history and dialogue between the patient and his doctor is the heart of the doctor - patient relationship. It is here that the doctor establishes a rapport with his patient, and communicates to him/her his sincere caring and commitment to their recovery. This caring in itself has great therapeutic value. </div><div style="background-color: white; color: #333333; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 11px; line-height: 16px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: left; white-space: pre-wrap;">The cold impersonality of modern medicine is anti-therapeutic, and dehumanising.</div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com2tag:blogger.com,1999:blog-3253723702117158691.post-55065324110666048372011-09-15T02:59:00.000-07:002011-09-15T03:50:07.998-07:00Sleeping a little too much?<div style="text-align: center;"><br /></div><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; line-height: 14px; background-color: rgb(255, 255, 255); "><span class="Apple-style-span" >One of the patients that I encounter this morning during the Psychiatric Liaison round. 41 year old gentleman was referred to the PSY team for methadone replacement therapy. He is an ex heroin addict presented with 2 days history of altered consciousness and excessive drowsiness. The wife claimed that he was unusually sleepy and tired over the few days prior to admission. There were no documented fever, seizures, limb weakness. Systemic reviews of the cardio, respi, genitourinary system were unremarkable. FBC was normal with total WCC of 6x10^9. Comment on the CECT findings and I will post up what was reported by the radiologist.</span></span><div><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; line-height: 14px; background-color: rgb(255, 255, 255); "><span class="Apple-style-span" ><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglNzIT1UqinHD0Z6M2HIOT1-YfCWBZRPPHpGZEAs4vUt9pfx3LBRMxtXe0ASG7umQHnuHA3vaRly63NarPd1pQlo0RUW9DQDaTivCqLA-TFLTlp9KEqlmcVAB0R2C9-7O0T_hADJ2A6Xl_/s400/T.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 283px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5652525163686465554" /></span></span></div><div><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; line-height: 14px; background-color: rgb(255, 255, 255); "><span class="Apple-style-span" ><br /></span></span></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-78748098956748197912011-07-08T20:54:00.000-07:002011-07-08T21:27:10.922-07:00Causes of 3 figure ESR<div style="text-align: center;"><br /></div><div style="text-align: left;">I was taught by my prof that there are 5 common causes of a 3 figure ESR:</div><div><br /></div><div>1) Multiple Myeloma</div><div>2) Polymyalgia Rheumatica/Temporal Arteritis</div><div>3) SLE</div><div>4) TB</div><div>5) Advance Malignancy</div><div><br /></div><div>Though these are common causes, they are not definite or exhaustive. I have actually came across a lady with rhrumatoid arthritis having an ESR of 120mm/hr. </div><div style="text-align: center;"><br /></div><div>This gentleman presented with 1 year history of chronic back pain that worsened over the past 4 months. His condition deteriorated 2 weeks prior to admission and he was unable to ambulate independently without the aid of crutches due to the pain. Multiple X-rays were taken and showed</div><div><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgg_QTzVti_7wvN4zEgWezAyXMsRujOqk5zggJero9xq4n7p58HbM25gf7j_ak5XTfv0ip1C1tppwhjS39y5tNnbK78OhjaMSv_f3g6hlWe7fQn0fl3PnZY8T6WqmTuxtPCmHQ2usG-Q06g/s400/IMG_0696.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5627202099102010482" /><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEJIMb6yy6x2_NakLaAZkjUjPeQFwJM0eEvYnU6bJsrfyajWP3JjGBe_D0epmfaOKoWgqdJvW0RxehnLICkzJLogbfksJ836HwLbEpxb-eYVds42GEjeGR8wUHycHwvo6chAXf_w9z8fH3/s400/IMG_0697.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5627202717234640034" /><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTI1GRsHc4CVUY6cnT1QNbsw4m2CjhRHuguzIWJOz_-OW2jDMtm_w3AetLEgJqW_Pvpq7USKOho4cE5eX_pJWU_AQwV7IEQ8yGgAznHZRxrIMS6SmhTfasYyBMU3I5tmsMnrsGMDjTozHV/s400/IMG_0701.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5627203032163284850" /><div style="text-align: left;">His ESR was 114mm/hr. What's the diagnosis?</div></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com2tag:blogger.com,1999:blog-3253723702117158691.post-56538046815018010932011-04-26T05:35:00.001-07:002011-04-26T05:47:33.745-07:00Rash?<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiplDN6zB10njU98fCzWadg0nCqZ3RlUtvYiShEXO3qDT-hx34rvP1OtOYgZGwulUxRSIOQn8eKc1sMslZaimUkyqGFW2hHn5AB8HQfBaW2R9zDo28NZr1yAlzJ2xzJ1XDBjJPeuhK6Q4c4/s1600/IMG_0585.JPG" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiplDN6zB10njU98fCzWadg0nCqZ3RlUtvYiShEXO3qDT-hx34rvP1OtOYgZGwulUxRSIOQn8eKc1sMslZaimUkyqGFW2hHn5AB8HQfBaW2R9zDo28NZr1yAlzJ2xzJ1XDBjJPeuhK6Q4c4/s400/IMG_0585.JPG" border="0" alt="" id="BLOGGER_PHOTO_ID_5599870953575600178" /></a><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbWeVj1olrlJKl6WnqdvaoerX4xBXqBoFKBwYZbKJbgAY4-HdZCOjAs3utbhdP8xmpzUqyTZdX4CPoqLENZ4C4IxfHf8I6VKAU-2xqUCk3gvcFXOL8pJAhUBWe-VEpZhTGe5IWxJH_bru6/s1600/IMG_0583.JPG" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbWeVj1olrlJKl6WnqdvaoerX4xBXqBoFKBwYZbKJbgAY4-HdZCOjAs3utbhdP8xmpzUqyTZdX4CPoqLENZ4C4IxfHf8I6VKAU-2xqUCk3gvcFXOL8pJAhUBWe-VEpZhTGe5IWxJH_bru6/s400/IMG_0583.JPG" border="0" alt="" id="BLOGGER_PHOTO_ID_5599870603620085154" /></a>8 year old boy presented with arthralgia, abdominal pain, maculopapular rashes and renal impairment.Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com1tag:blogger.com,1999:blog-3253723702117158691.post-76401921888641331212011-04-15T20:15:00.000-07:002011-04-15T20:18:49.447-07:00Myelomeningocele<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiYRybTiBlDeUZbOtzid-9cIzqyBs9SfED4ZEtLJMXf8aX3mDG8x2DFLLY04N9F1gVU4hkZ8yZH0boiRE29RlR4huqNK1q6kZ-Qn18r4yk3BC3mmKInxet25kYNvZOGw5IfhWP17O8XF2F/s1600/Spina+Bifida.jpg"><img style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 396px; height: 283px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiYRybTiBlDeUZbOtzid-9cIzqyBs9SfED4ZEtLJMXf8aX3mDG8x2DFLLY04N9F1gVU4hkZ8yZH0boiRE29RlR4huqNK1q6kZ-Qn18r4yk3BC3mmKInxet25kYNvZOGw5IfhWP17O8XF2F/s400/Spina+Bifida.jpg" alt="" id="BLOGGER_PHOTO_ID_5596015598553669794" border="0" /></a><br /><div id="div_learn_r" style="display: block; overflow: hidden;"><span style=""><br />亲爱的</span><span style="">宝贝</span>,<span style="">再撑一下</span></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-20057673200037164492011-02-21T22:30:00.000-08:002011-02-21T22:57:55.244-08:00Acromegaly<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkMUOiMNUMuz3WdeGeMVI0F2gft58T0gXRBZNawT1zk2lVYNjc0IrcvvpsLegTVKBp0W6wKEN5-QJf8DFe7tcGhTeg_ULhqbo7M9rdXIDhzP1FXXnZEGH8SoksZZz0DeAzv3kifpgbMSjv/s1600/IMG_0561.JPG"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkMUOiMNUMuz3WdeGeMVI0F2gft58T0gXRBZNawT1zk2lVYNjc0IrcvvpsLegTVKBp0W6wKEN5-QJf8DFe7tcGhTeg_ULhqbo7M9rdXIDhzP1FXXnZEGH8SoksZZz0DeAzv3kifpgbMSjv/s400/IMG_0561.JPG" border="0" alt="" id="BLOGGER_PHOTO_ID_5576400550733897618" /></a><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZ6czPflpjhjOpC1gRM0L5Mww5cfe2nRciHQmX4x4_8ypQRfGDHSLquDm6kaiPxo6Iu4KBsFHxSKWF6pMx0K91TTs-SwqE8n2b-LJUO8HSMkFjUu6vcesOhZiPxpHTrfdY0kAiBONukb7U/s1600/IMG_0562.JPG"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZ6czPflpjhjOpC1gRM0L5Mww5cfe2nRciHQmX4x4_8ypQRfGDHSLquDm6kaiPxo6Iu4KBsFHxSKWF6pMx0K91TTs-SwqE8n2b-LJUO8HSMkFjUu6vcesOhZiPxpHTrfdY0kAiBONukb7U/s400/IMG_0562.JPG" border="0" alt="" id="BLOGGER_PHOTO_ID_5576399841613183410" /></a><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhx3-NDbC5d7suk-wk78LLTCckkcHuJKGU8mHCuEftJjj1fkG1pKfTE-evj5dtUET9gwktiQetssqOXMsSd7vUhq97VB4R_K4C2z5xCEmqCnsrqTCTTd_1VrMROAUiuID-8oxovw2-cornU/s1600/IMG_0563.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhx3-NDbC5d7suk-wk78LLTCckkcHuJKGU8mHCuEftJjj1fkG1pKfTE-evj5dtUET9gwktiQetssqOXMsSd7vUhq97VB4R_K4C2z5xCEmqCnsrqTCTTd_1VrMROAUiuID-8oxovw2-cornU/s400/IMG_0563.jpg" border="0" alt="" id="BLOGGER_PHOTO_ID_5576398960448078274" /></a>Courtesy of Dr Fadzli, Endocrine MO<div><br /></div><div>1)Spend a few seconds in general inspection</div><div>2)Start off by examining the patient's hand, you notice that he has spade-like, sweaty hand, the skin is thickened and doughy.</div><div>3)Check for carpal tunnel syndrome(Phalen and Tinel Test)</div><div>4)Look at the face-check for prognathism(causing malocclusion of jaw), prominent supra-orbital ridges, wide inter-dental spaces and macroglossia</div><div>5)Offer to look for skin tag(molluscum fibrosum) at axilla</div><div>6)Look at lower limbs for pitting edema to suggest cardiac failure, look for evidences to suggest osteoarthritis of the knee, thicken heel pad</div><div>9)Check for proximal myopathy by asking patient to squat down</div><div>10)Assess the visual field to look for bitemporal hemianopia(acromegaly tends to be due to macroadenoma)</div><div><br /></div><div>After eliciting all the positive signs, suggest to examiners you would like to complete your physical examination by</div><div>1)Check the blood pressure which is an indicator for active disease process</div><div>2)Check urine for glycosuria</div><div>3)Check fundus for DM/HPT changes</div><div>4)Examine the cardiovascular system for heart failure, neck for goitre and abdomen for hepatosplenomegaly</div><div><br /></div><div>Questions</div><div>1)How do you confirm the diagnosis?</div><div>2)What are the modalities of treatment available?</div><div>3)How do you monitor treatment response?</div><div>4)Any endocrine syndrome which is associated with acromegaly?</div><div><br /></div><div><br /></div><div><br /></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com3tag:blogger.com,1999:blog-3253723702117158691.post-73169363475684264222011-01-05T21:18:00.000-08:002011-01-05T21:42:12.208-08:00Liver Atlas and Casebook<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjVNyBaJh6K5GeGT_64XGq_Kq4uACiyj1hZxI8E8ToC_eQ9yR-FKLujP8YDc-yg1UMiFf75SCrcWd4oNPqoW0c5UanvLY735eC81LlXalddZj8gr89Gk1OX9wgFSNIeC2llgRH-b91Z-OEu/s1600/04012011847.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjVNyBaJh6K5GeGT_64XGq_Kq4uACiyj1hZxI8E8ToC_eQ9yR-FKLujP8YDc-yg1UMiFf75SCrcWd4oNPqoW0c5UanvLY735eC81LlXalddZj8gr89Gk1OX9wgFSNIeC2llgRH-b91Z-OEu/s400/04012011847.jpg" border="0" alt="" id="BLOGGER_PHOTO_ID_5558938474281360146" /></a><p class="MsoNormal">Was browsing through the book collection in the HDOK library and came across this book titled “Liver Atlas and Casebook” edited by our very Malaysian Director General of health, Dr Ismail Merican himself. I highly recommend this book for students like me out there as it highlights important concepts pertaining to the diagnosis and management of common diseases that affect one of the largest organs in our human body- the liver. On the other hand, this book compiles a number of complex cases, which were managed by the highly specialised team in our very own hepato-biliary excellence centre- Selayang hospital. Overall rating of 8/10 with high resolution pictures of specimens for an in depth understanding of the pathology of most liver diseases. Some of the important facts that I’ve gathered after finishing ¾ of the book.</p><p class="MsoNormal"></p><p class="MsoNormal" style="margin-left:18.0pt"></p><ul><li>The text book triphasic CT characterisation of HCC</li></ul><p></p> <p class="MsoNormal" style="margin-left:54.0pt">Arterial enhancement as HCC derives its blood supply from the hepatic arterial circulation</p> <p class="MsoNormal" style="margin-left:54.0pt">Complete venous washout</p> <p class="MsoNormal" style="margin-left:18.0pt"></p><ul><li>HCC usually causes thrombosis of the portal vein and its branches. Jaundice is not a common presenting feature of HCC.</li><li>Diagnosis of HCC rarely depends on liver biopsy due to potential tumour dissemination that may convert a resectable lesion into a non resectable disease.</li><li>Among the common presentations of HCC is abdominal pain/discomfort usually felt as a dull sensation, awareness of abdominal mass/constitutional symptoms of appetite and weight loss. Jaundice and ascites develop in later stages of the disease, when present contraindicates surgery.</li><li>Serum AFP may be normal in up to a third of patients with HCC</li><li>Text book CT characterisation of FNH(Focal Nodular Hyperplasia)</li></ul><p></p> <p class="MsoNormal" style="margin-left:54.0pt">Hyperdense vascular enhancement with central hypodensity (stellate scar)</p> <p class="MsoNormal" style="margin-left:18.0pt"></p><ul><li>FNH usually does not require intervention unless patient is symptomatic/ uncertain and suspicious for malignancy</li><li>The most common benign liver lesion-hepatic haemangioma that is usually picked up incidentally.</li><li>Leptospirosis is caused by “Leptospira Icterohaemorrhagiae”. Rats are common source of human infection. It can also infect cattle shoes and swine. Incubation period takes about 10 days (average)</li><li>Adolf Weil was the first person to document this disease and thus severe form of leptospirosis is also called Weil Syndrome.</li><li>Jaundice and haemorrhagic manifestation are not uncommon, hence the name “Icterohaemorrhagiae”</li><li>The leptospires, directly/through immune mechanism damage blood vessels, cause centrilobular necrosis of the liver, renal tubular dysfunction by causing interstitial nephritis and acute tubular necrosis. Diagnosis is based on serology with 1:800 being diagnostic.</li><li>Liver abscess usually shows up as a hypoechoic area with some debris within it. ( On ultrasonography)</li><li>K.Pneumonia has emerged as one of the most common pathogen responsible for liver absvess</li><li>Metastatic infections are commonly seen in patients with K.Pneumoniae liver abscess. They are</li></ul><p></p> <p class="MsoNormal" style="margin-left:54.0pt">Enopthalmitis</p> <p class="MsoNormal" style="margin-left:54.0pt">Septic Pulmonary embolism</p> <p class="MsoNormal" style="margin-left:54.0pt">Pulmonary abscesses</p> <p class="MsoNormal" style="margin-left:54.0pt">Cerebral abscesses</p> <p class="MsoNormal" style="margin-left:54.0pt">Purulent meningitis</p> <p class="MsoNormal" style="margin-left:54.0pt">Otitis media</p> <p class="MsoNormal" style="margin-left:54.0pt">Osteomyelitis </p> <p class="MsoNormal" style="margin-left:54.0pt">Prostate abscess</p> <p class="MsoNormal" style="margin-left:54.0pt">Psoas muscle abscess</p> <p class="MsoNormal" style="margin-left:18.0pt"></p><ul><li>In a patient with abscesses in multiple sites, K.Pneumonia infection should always be considered as a possible cause</li><li>Polycystic disease of the liver is a benign condition which usually presents as an incidental finding or abdominal discomfort/pain/mass</li><li>Occasionally an infected cyst would present with pain and fever</li><li>In a patient with abscesses in multiple sites, K.Pneumonia infection should always be considered as a possible cause</li><li>Polycystic disease of the liver is a benign condition which usually presents as an incidental finding or abdominal discomfort/pain/mass</li><li>Occasionally an infected cyst would present with pain and fever</li></ul><p></p> <p></p><p></p>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com1tag:blogger.com,1999:blog-3253723702117158691.post-28000499148538500082010-12-29T23:28:00.000-08:002010-12-29T23:41:44.580-08:00The land below the wind<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGneCfoVAYlIbcfCBjVbSBMg4u6tOZJhSOiJXUNmjjg4jfepYziMWubjY9aqb0CPACKiQKazgeEWQ-R2oMLYu-OtQ5e2euejQn8GsJVs6ZRiuAo_VEb0W88QPu9IHmHI5b63_4TN5dePwo/s1600/sabah-map-fun.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 305px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGneCfoVAYlIbcfCBjVbSBMg4u6tOZJhSOiJXUNmjjg4jfepYziMWubjY9aqb0CPACKiQKazgeEWQ-R2oMLYu-OtQ5e2euejQn8GsJVs6ZRiuAo_VEb0W88QPu9IHmHI5b63_4TN5dePwo/s400/sabah-map-fun.jpg" border="0" alt="" id="BLOGGER_PHOTO_ID_5556377240824467346" /></a><br />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.<div><br /></div><div>The SUN, SEA and SICK PEOPLE. The 3S of a successful elective posting. SANDAKAN here I come!</div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com1tag:blogger.com,1999:blog-3253723702117158691.post-5523181433365312412010-12-25T21:16:00.000-08:002010-12-25T21:38:06.058-08:00Wonderful Tonight<span class="Apple-style-span"><span class="Apple-style-span">Classical love songs by </span></span><span class="Apple-style-span" style="font-family: arial, sans-serif; font-size: 20px; color: rgb(51, 51, 51); font-weight: bold; line-height: 25px; ">方大同</span><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 20px; line-height: 25px;"><b><br /></b></span></span><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 20px; line-height: 25px;"><b><object width="480" height="385"><param name="movie" value="http://www.youtube.com/v/1gwMWrc2xxc?fs=1&hl=en_US"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/1gwMWrc2xxc?fs=1&hl=en_US" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="385"></embed></object></b></span></span></div></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 20px; line-height: 25px;"><b><br /></b></span></span></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 20px; line-height: 25px;"><b><object width="480" height="385"><param name="movie" value="http://www.youtube.com/v/2yR7_2-M9Hc?fs=1&hl=en_US"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/2yR7_2-M9Hc?fs=1&hl=en_US" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="385"></embed></object></b></span></span></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 20px; line-height: 25px;"><b><br /></b></span></span></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 20px; line-height: 25px;"><b><object width="480" height="385"><param name="movie" value="http://www.youtube.com/v/dtkvg1LFxW4?fs=1&hl=en_US"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/dtkvg1LFxW4?fs=1&hl=en_US" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="385"></embed></object></b></span></span></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 20px; line-height: 25px;"><b><br /></b></span></span></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 20px; line-height: 25px;"><b><span class="Apple-style-span" style="font-family: arial, sans-serif; font-weight: normal; line-height: normal; font-size: 24px; ">好听</span></b></span></span></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-56569924419066319312010-12-15T19:17:00.000-08:002010-12-16T22:30:42.074-08:00TB<div style="text-align: center;">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:</div><div><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjx8kRWxkDbJedVMSqv8VS5WYcXJh4tLEbzizc5zY0Oe6uzVuN66TGoJww2uW8lbL__MtwWWc6IzJZk3iV5FeIZIv2pj9F0Y6Nnf1ylaezL1JjOBCDPuIdWhcT5hxWRob7qZFV3e2w_AGVh/s400/ssss.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5551122159292401666" /><div style="text-align: center;"><br /></div></div><div>1) Chronic productive cough x 6/12 associated with </div><div>-Exertional dyspnoea</div><div>-Multiple episodes of hemoptysis worsened over the past one month</div><div>-Greenish sputum</div><div><br /></div><div>2) On and off low grade fever associated with night sweats chills and rigors x1/12</div><div><br /></div><div>3) Significant weight loss with decreased oral intake due to poor appetite</div><div style="text-align: center;"><br /></div><div>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.</div><div><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1kLjsnW0uQAzLGR0GI021ZaEd7HlyIhEpy1ye4uVyGsIuPr5Ht8Wtp6yMq_t7RbhWb7uszuGaQ88lbl4CPXEv5An_UzyliX_LDStWj2chyphenhypheno_vOEGXXts8o6EsM6yv2EpUc2ODB-H4aD4A/s400/17122010841kkk.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5551529483798483362" /></div><div>Chest X-Ray of another patient with active PTB. Note the cavitation. consolidation and deviated trachea(mediastinum) due to scarring. </div><div><br /></div><div>Yes, you are right, he was having active pulmonary tuberculosis.</div><div><br /></div><div>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:</div><div><br /></div><div>R.I.P.E.S</div><div>Rifampicin-<span class="Apple-style-span"><b><i>cholestatic jaundice, orange urine</i></b></span>, thrombocytopenia, enzyme inducer( OCP less effective)</div><div>Isoniazid-<span class="Apple-style-span"><b><i>Peripheral neuropathy</i></b></span>, hepatitis, <span class="Apple-style-span"><b><i>pyridoxine deficiency, drug induced lupus!</i></b></span></div><div>Pyrazinamide-hepatitis, <span class="Apple-style-span"><b><i>hyperuricemia</i></b></span> (Gout)</div><div>Ethambutol-Optic neuritis</div><div>Streptomycin-ototoxicity and nephrotixicity</div><div><br /></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 11px; line-height: 18px;"><br /></span></span></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-91623604407407742052010-12-06T06:10:00.000-08:002010-12-06T06:49:33.625-08:00Zap those female anopheles!!<p class="MsoNormal"><span style="font-size:12.0pt;line-height:115%;font-family: "Arial","sans-serif"">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?”<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:12.0pt;line-height:115%;font-family: "Arial","sans-serif"">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.<o:p></o:p></span></p> <p class="MsoNormal"><span class="apple-style-span"><span style="font-size:12.0pt; line-height:115%;font-family:"Arial","sans-serif";color:black">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.</span><o:p></o:p></span></p><p class="MsoNormal"><span class="apple-style-span" style="line-height: 18px;"><span class="Apple-style-span"><!--copy and paste--><object width="446" height="326"><param name="movie" value="http://video.ted.com/assets/player/swf/EmbedPlayer.swf"><param name="allowFullScreen" value="true"><param name="allowScriptAccess" value="always"><param name="wmode" value="transparent"><param name="bgColor" value="#ffffff"> <param name="flashvars" value="vu=http://video.ted.com/talks/dynamic/NathanMyhrvold_2010-medium.flv&su=http://images.ted.com/images/ted/tedindex/embed-posters/NathanMyhrvold-2010.embed_thumbnail.jpg&vw=432&vh=240&ap=0&ti=853&introDuration=15330&adDuration=4000&postAdDuration=830&adKeys=talk=nathan_myhrvold_could_this_laser_zap_malaria;year=2010;theme=the_creative_spark;theme=new_on_ted_com;theme=not_business_as_usual;theme=what_s_next_in_tech;theme=tales_of_invention;theme=design_like_you_give_a_damn;theme=a_taste_of_ted2010;event=TED2010;&preAdTag=tconf.ted/embed;tile=1;sz=512x288;"><embed src="http://video.ted.com/assets/player/swf/EmbedPlayer.swf" pluginspace="http://www.macromedia.com/go/getflashplayer" type="application/x-shockwave-flash" wmode="transparent" bgcolor="#ffffff" width="446" height="326" allowfullscreen="true" allowscriptaccess="always" flashvars="vu=http://video.ted.com/talks/dynamic/NathanMyhrvold_2010-medium.flv&su=http://images.ted.com/images/ted/tedindex/embed-posters/NathanMyhrvold-2010.embed_thumbnail.jpg&vw=432&vh=240&ap=0&ti=853&introDuration=15330&adDuration=4000&postAdDuration=830&adKeys=talk=nathan_myhrvold_could_this_laser_zap_malaria;year=2010;theme=the_creative_spark;theme=new_on_ted_com;theme=not_business_as_usual;theme=what_s_next_in_tech;theme=tales_of_invention;theme=design_like_you_give_a_damn;theme=a_taste_of_ted2010;event=TED2010;"></embed></object></span></span></p> <p class="MsoNormal"><span class="apple-style-span"><span style="font-size:12.0pt; line-height:115%;font-family:"Arial","sans-serif";color:black">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.</span></span></p><p class="MsoNormal"><span class="apple-style-span"><span style="font-size:12.0pt; line-height:115%;font-family:"Arial","sans-serif";color:black">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.</span></span></p><p class="MsoNormal"><span class="apple-style-span"><span style="line-height: 18px;"><iframe frameborder="0" width="480" height="320" src="http://www.dailymotion.com/embed/video/xditk7?width=480&theme=default&foreground=%23F7FFFD&highlight=%23FFC300&background=%23171D1B&start=&animatedTitle=&iframe=1&additionalInfos=0&autoPlay=0&hideInfos=0"></iframe><br /><b><a href="http://www.dailymotion.com/video/xditk7_kobe-surgery-japanprobe_webcam">kobe surgery [japanprobe]</a></b><br /><i>Uploaded by <a href="http://www.dailymotion.com/jdx459">jdx459</a>. - <a target="_self" href="http://www.dailymotion.com/channel/webcam/featured/1">See video of the biggest web video personalities.</a></i></span></span></p><p class="MsoNormal"><span class="apple-style-span" style="line-height: 18px;"><span class="Apple-style-span">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". </span></span></p><p class="MsoNormal"><span class="apple-style-span" style="line-height: 18px;"><span class="Apple-style-span">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.</span></span></p>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-47699378407700010682010-11-24T01:51:00.000-08:002010-11-24T02:17:41.655-08:00Holiday<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwQXR6qOmcSR10sqid4j48dYa8RUpmA8xJwUR6Ypm6NTmwQew4x-pw3otvZqWkMxtDR5C5ev99dJMG0UFtU-XL1X9RiHt-3zg6y8EppE6oXWuHtVcjxc2f9swfPxG6q-Lmu5fVfCmoMczw/s1600/aaa.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 245px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwQXR6qOmcSR10sqid4j48dYa8RUpmA8xJwUR6Ypm6NTmwQew4x-pw3otvZqWkMxtDR5C5ev99dJMG0UFtU-XL1X9RiHt-3zg6y8EppE6oXWuHtVcjxc2f9swfPxG6q-Lmu5fVfCmoMczw/s400/aaa.jpg" border="0" alt="" id="BLOGGER_PHOTO_ID_5543057756021586050" /></a><br /><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; color: rgb(51, 51, 51); ">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.</span><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 13px;"><br /></span></span><div><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; color: rgb(51, 51, 51); ">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.</span></div></div><div><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; color: rgb(51, 51, 51); "><br /></span></div><div><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; color: rgb(51, 51, 51); ">2) My outstandingly dedicated tutors!</span></div><div><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; color: rgb(51, 51, 51); "><br /></span></div><div><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; color: rgb(51, 51, 51); ">3) Specialists and consultants from both the surgical and medical department</span></div><div><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; color: rgb(51, 51, 51); "><br /></span></div><div><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; color: rgb(51, 51, 51); ">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.</span></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 13px;"><br /></span></span></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 13px;">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!</span></span></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 13px;"><br /></span></span></div><div><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: 13px;">Take care and hopefully we will meet each other again next year in my subsequent postings.</span></span></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-89867200042567522072010-11-15T02:05:00.000-08:002010-11-15T02:26:44.812-08:00Running out of water<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKalfuTcMPm3ZKu2dA5yrmCVO-NQIprDaZdsgqOH1l-vqrf8wmjYOaZnTMmZSupiSrakrFoK8rLRtrXYSaHZwwgB-UIz-SZXcw8jUcXsLP2062BJTqLuTVq51EJc8m67J9jHaHOWvClFAq/s1600/fish_out_of_water.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKalfuTcMPm3ZKu2dA5yrmCVO-NQIprDaZdsgqOH1l-vqrf8wmjYOaZnTMmZSupiSrakrFoK8rLRtrXYSaHZwwgB-UIz-SZXcw8jUcXsLP2062BJTqLuTVq51EJc8m67J9jHaHOWvClFAq/s400/fish_out_of_water.jpg" border="0" alt="" id="BLOGGER_PHOTO_ID_5539720928669199186" /></a><br />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!Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-39612583833851998862010-11-04T19:24:00.001-07:002010-11-04T20:31:57.794-07:00Spot Diagnosis?<div style="text-align: center;"><br /></div><div style="text-align: center;"><br /></div><div style="text-align: center;"><br /></div>Courtesy of C.S.Lee<div><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-TmOcYn1MpbrPdM-eAkR6ZQD41ydVBErbSBoZny9LGQZa1DVE8KL-6156ZAyjreV6an8IPAj6q7e0hMWCmAsRF8QiYSnvX7kwtHcjki5bzZ4LsAAua9Avt-2nB5oP1RzQifZpqG0NWPTR/s400/DSC04139.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5535902750131083810" /><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSN3dEXUxbZaFZJfNj29DKTCiFQXW00cipVsNFnVDulaiAmd9pSG9EP7vm3iAlSjFwNGvevGySE8LiunRrNZhDIVszWKm9NQrhzHUmZNXO9DSnlNHKRzPTDWhk8YOWWiZTQ40VPeIUfpbe/s400/DSC04138.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5535886248499150466" /><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGmzz-BzKwRLqwz6gG-At-Ohl7iqKqbTa_IOwTLHANbZJan8hLvr7yCyYjvoPYeapuqgpqdFDSnBbzgC3ziEs1uAWPULxhQDuPKG4PbFLL3ER0HM3GLj1FT_k5P9BNE_nKmOQaYdR0FwAo/s400/DSC04141.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5535903130025171698" /><div style="text-align: center;"><br /></div></div><div style="text-align: center;"><br /></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com3tag:blogger.com,1999:blog-3253723702117158691.post-81754905852250327892010-11-04T03:58:00.000-07:002010-11-04T04:28:44.361-07:00Thoughts for the day<div><img src="http://www.adoptadrugaddict.co.za/assets/images/heroin_spoon.jpg" /></div><div><br /></div><div><br /></div>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! <div><br /></div><div>2) A drug addict taught me that heroin can be used in 4 ways</div><div><span class="Apple-tab-span" style="white-space:pre"> </span>I) Injecting it</div><div><span class="Apple-tab-span" style="white-space:pre"> </span>II)Smoking it</div><div><span class="Apple-tab-span" style="white-space:pre"> </span>III)Snorting it through the nose</div><div><span class="Apple-tab-span" style="white-space:pre"> </span>IV)Inhaling it-Chase the dragon</div><div>Smoking and chasing is safer as compared to the rest as it reduces the risk of OD.</div><div><br /></div><div>3) Commonest cynotic congenital heart disease is still Eisenmenger's syndrome</div><div><br /></div><div>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.</div><div><br /></div><div>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?</div><div><br /></div><div>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.</div><div><br /></div><div>7) Met a few patients with haematological disorders. APLS, thalassemia and AIHA. Heamatology is quite a fascinating field I think.</div><div><br /></div><div>8) Observed a bone marrow aspiration and trephine biopsy. The doctor that obtained the consent must be very persuasive!</div><div><br /></div><div>9) A pericardial rub sounds like a systolic murmur</div><div><br /></div><div>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. </div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-4128898985320452302010-10-31T02:01:00.001-07:002010-10-31T02:16:06.081-07:00Reflections..<p class="MsoNormal">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.</p> <p class="MsoNormal">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. </p><p class="MsoNormal">A few things that I’ve learnt to appreciate over 12 months being posted in different departments:</p> <p class="MsoNormal"><span class="Apple-style-span"><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: x-large;">Respect patients</span></span></span></p> <p class="MsoNormal">All students should ask yourself, “Who taught me medicine?”</p> <p class="MsoNormal">“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?</p> <p class="MsoNormal">Then who taught us medicine? Obviously the patients.</p> <p class="MsoNormal">Patient came in with wheezing to show us the signs of asthma.</p> <p class="MsoNormal">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.</p> <p class="MsoNormal">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.</p> <p class="MsoNormal"><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: x-large;">To wish</span></span></p> <p class="MsoNormal">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.</p><p class="MsoNormal">"Healing occurs when you let another human being know that his suffering and fears matter to you"-Anonymous</p> <p class="MsoNormal">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</p> <p class="MsoNormal"><o:p> </o:p></p> <p class="MsoNormal"><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: x-large;">Be less intimidating</span></span></p> <p class="MsoNormal">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. </p> <p class="MsoNormal">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?</p> <p class="MsoNormal"><span class="Apple-style-span"><span class="Apple-style-span" style="font-size: x-large;">Duties</span></span></p> <p class="MsoNormal">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. </p> <p class="MsoNormal">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.</p> <p class="MsoNormal"><span class="Apple-style-span" style="font-size: x-large;">And finally <span class="Apple-style-span">Attitude</span></span></p> <p class="MsoNormal">“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.</p>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-58613062938466456572010-10-20T02:00:00.000-07:002010-10-20T02:28:53.560-07:00Spot Diagnosis?<div>A few of the patients that I've seen over the week..</div><div><br /></div><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0KFrqkSsaSk_nuMkLE3iIqKOZXitAcY8xAS3NnW9m9icH6-3dXT_7FNJMVGKnG47pPzqiQ50n1P32GsA5hh99m46wm32CMI3XftSctuTGDqjfoeBQi9TtDD2dkXBv1Ga1Lzr344SuRIoU/s1600/DSC03160.JPG"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0KFrqkSsaSk_nuMkLE3iIqKOZXitAcY8xAS3NnW9m9icH6-3dXT_7FNJMVGKnG47pPzqiQ50n1P32GsA5hh99m46wm32CMI3XftSctuTGDqjfoeBQi9TtDD2dkXBv1Ga1Lzr344SuRIoU/s400/DSC03160.JPG" border="0" alt="" id="BLOGGER_PHOTO_ID_5530054790707499266" /></a><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuOsPgbbYNdOqIyyzXjWwh1bpEawNeXozLfxKkbbBDeKQlsDLl27xYRXnB_3o0pCkurdfjQEi42tDnmvRiPM5suT_fo-vgoFCVGblh9KRkJKA8mZEHwQ-AXqfyuNgNZtP4QMOmbpXhI4C9/s1600/DSC03159.JPG"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuOsPgbbYNdOqIyyzXjWwh1bpEawNeXozLfxKkbbBDeKQlsDLl27xYRXnB_3o0pCkurdfjQEi42tDnmvRiPM5suT_fo-vgoFCVGblh9KRkJKA8mZEHwQ-AXqfyuNgNZtP4QMOmbpXhI4C9/s400/DSC03159.JPG" border="0" alt="" id="BLOGGER_PHOTO_ID_5530054358751745938" /></a><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhX8aW3NLVN0kJRxZD4CnMTuQDM3DvzW6MRs4pH389M8Yin1yiS3L0HauUlrOojvZBCnW3_V9XYR2S2OFY3gokjcDyRogDq5fd_3r_JsaHqk6zJD5KvQ6cb6LPiuSaAVXd3lJHBxsFwfyK1/s1600/DSC03154.JPG"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhX8aW3NLVN0kJRxZD4CnMTuQDM3DvzW6MRs4pH389M8Yin1yiS3L0HauUlrOojvZBCnW3_V9XYR2S2OFY3gokjcDyRogDq5fd_3r_JsaHqk6zJD5KvQ6cb6LPiuSaAVXd3lJHBxsFwfyK1/s400/DSC03154.JPG" border="0" alt="" id="BLOGGER_PHOTO_ID_5530053086907931730" /></a><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1zINzClwZFj6YYufJtEQkgT0eaZL2PJNQl7ekjX4yCEOI15MmtBvl8sYgfPK_DV73bzszHP4DxlPZmAHLelNOvaiXUc7C2XVbKknexByIiiUwfWQKBB2byK5RgV80QdxV23ylc6o8KWIP/s1600/DSC03156.JPG"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1zINzClwZFj6YYufJtEQkgT0eaZL2PJNQl7ekjX4yCEOI15MmtBvl8sYgfPK_DV73bzszHP4DxlPZmAHLelNOvaiXUc7C2XVbKknexByIiiUwfWQKBB2byK5RgV80QdxV23ylc6o8KWIP/s400/DSC03156.JPG" border="0" alt="" id="BLOGGER_PHOTO_ID_5530051844638053010" /></a><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dwpPTfKSmn2N_v-cSevsIHmcPs7CfQv_B3v7fFpCmhIXbuQ_CQZFSFLTK_GsthMyQ5i2n9yrths_SN0haWaYg' class='b-hbp-video b-uploaded' frameborder='0'></iframe>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-54954381995733070082010-10-15T05:39:00.000-07:002010-10-15T06:31:05.396-07:00The mad house<img src="http://blog.camera.org/archives/hospital.jpg" /><div>Just some random thoughts for the day<div><div><br /><div>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...</div></div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>4)I love the ECG machine in D2, it is printed in A4 size, no more long messy ECG strips laying around.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>7)Lung cancer and PTB is so prevalent in this region. </div><div><br /></div><div>8)Ascultated my first carotid bruit, and realized that clinical examination is way more superior as compared to sophisticated imaging investigations.</div><div><br /></div><div>9)Every complaint from the patient is genuine.</div><div><br /></div><div>10) And in medicine, what ever that happens after 5 actually makes you better.</div></div></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-61538075541243862152010-09-13T02:57:00.000-07:002010-09-13T03:09:56.095-07:00Clinic Cafe<div style="text-align: left;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', Arial, Verdana, sans-serif; font-size: 13px; color: rgb(51, 51, 51); line-height: 20px; ">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. </span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', Arial, Verdana, sans-serif; font-size: 13px; color: rgb(51, 51, 51); line-height: 20px; "><br /></span></div><div><span class="Apple-style-span" style="font-family: 'Trebuchet MS', Arial, Verdana, sans-serif; font-size: 13px; color: rgb(51, 51, 51); line-height: 20px; "><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj02pOYxAXAO2OXvVNyFnEIJJ8NOKPoYK2eJekD_DhxLQrlavHgj1fmlEYF4CO4ZosSnnjH_Vi9JHnCD4Ecxma04twsBTGvuE7FEJl5R1F5vLb6FuZJdEd32p-V9DvrY-WxWSdR1_T6bPg5/s400/DSC00019.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 400px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5516335873236382178" /><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8eKqQArYotGFdGDafx8QwJjoNI2jEwa1xi1Y6-exyVthAUBqu3hUhUaUzTS5ZFXzMaqMLrRwyDZ90lvCMNwitVOcnM-h48Ov2VVHsnA7wuaffYQ_O1toEaZwo6gRQeVb85qAB3vAbMDAj/s400/DSC00021.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5516335703290551714" /><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNmXrMPnanPGMo-5oBioIWFHf4DWEUoIzSHV900j9gV0_zLcmPNE85rMoY012b4ptGJcQsIp_FOVG3Wj47s5q6pGBsLDIgg7AdUZAklfA4wY_Md9rEZgvnULjPMIXkq_u_Ys1anydQVbK0/s400/DSC00022.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5516335476239258466" /><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixA-bOmOWRxdfD94zw8d0vvv9TrFbJIuNxJfGYFcgo4DJv9CZJUGkgJpyrjuEmrvgMsoGPV9aJfmfu1XvoAf-ILMdcq7D7TS26AjDLXZl6SP36EliQPj4L_GYrtqOvcJ2cP2yhfYfCak1a/s400/DSC00026.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5516336128136498290" /><div style="text-align: center;">Cool huh? Overall, it would be quite a nice place to chill out, decent atmosphere, service was good. However, food was just average.</div></span></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com2tag:blogger.com,1999:blog-3253723702117158691.post-62924890181808009972010-08-21T08:00:00.001-07:002010-08-21T09:08:52.815-07:00Yellow discolourationThe pathologist reported<div><blockquote><div>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.</div><div><br /></div><div>Impression: Adenocarcinoma, poorly differentiated, infiltrating</div><div></div></blockquote><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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. </div><div><br /></div><div>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. </div><div><br /></div><div>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. </div><div><br /></div><div>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.</div><div><br /></div><div>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</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>I do hope she's doing fine up there, surrounded by lovely people!</div><div></div></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-3028073977785295462010-08-07T03:46:00.000-07:002010-08-07T05:20:28.652-07:00A good cry<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhStQmzUhEQ5IH10v4yVnqN4udQhmlWDHORtLwEWbIHCyRHntWEKv2VtJpQYpsJCjyILga4KzFBLRt6k8I647beNEI-OLQnQxuW5zXx-7EcNLHEpSgOacZVvhF0Vol8OOGkUVNNDQJsykSn/s1600/images.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 260px; height: 194px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhStQmzUhEQ5IH10v4yVnqN4udQhmlWDHORtLwEWbIHCyRHntWEKv2VtJpQYpsJCjyILga4KzFBLRt6k8I647beNEI-OLQnQxuW5zXx-7EcNLHEpSgOacZVvhF0Vol8OOGkUVNNDQJsykSn/s400/images.jpg" border="0" alt="" id="BLOGGER_PHOTO_ID_5502634611580079058" /></a><br />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.<div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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".</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div><br /></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-89156727744725026052010-07-30T20:17:00.000-07:002010-07-30T21:10:32.628-07:00Necessity is the mother of invention<div style="text-align: left;">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:</div><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8BudXHIFjybBjE48zafHLJZeg-dD2bvmqSoCNxp_8-YqxQwvSiwg3vUT-VWy-nSCKR3JiKEKUCSSOSEJnVrYUp5iroGOK6uzjraX0NR2uQ0t4nhDTSldcgQSlN_ClNF-t8BSGAv8rbUnT/s400/DSC03110.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5499913433247260530" /><div><div style="text-align: center;">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.</div></div><div><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2UZ8gdTv0JhQDDWbpDLjr6uv0OaXYzUDyeI8KGxwOnjr8P6KWrP3p3NkspAk5blJTukHBsMfEDbWuRqj7lIgMK8IfdkMuqgVpRt_fNKqTYnJuX4CIn4lqytWtdspKRGB8DiipynBPtRsS/s400/DSC03111.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5499914689515727666" /><div style="text-align: center;">He's on Casodex, an androgen receptor antagonist that give rise to gynaecomastia.</div></div><div style="text-align: center;"><br /></div><div>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!</div><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiaxt_YDKi5xbcuoolrmgvHSS_t0wWl6We1vgaLn_ZkHMRwsgIG3b4L3RBLrLv36GGn2P3KGTucmtyIfXoWAac8mKzexKpobWdCFzbMawHHE24WJQVdVLuXVnZHHG1oGVEn_IuNnMZwWYJZ/s400/DSC03105.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5499915780224540994" /><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEip75LUdPteHs2__86W_CR7hk2GCTJu8zTcAE4TLG9s19cX4ulgF5mIwpedr07m3aaEutuGIlFPmK42SZIq8YAMAFyLYd4k54c9-pcstltmowYd_0UCDfGdD39M3RxBPYvsF9Iv1IjXiVkq/s400/DSC03104.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5499915356121267730" /><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeKTs6DFLtqrqJVqKgTFQgHekYyRH8AXbrPUZbkcETcpCTVxTpORYoPPYJQLvblDE8LRxtz4VDj-bwyeSF19HYV89igm3TEgWzCAKcZK1F3SuftdBboGcswNHj2HfDxcrGzriMz6d-dzvz/s400/DSC03106.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5499916170729562722" /><img src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPlkn1cTtEuKjbJFnMjBc440d3Tbx8VqX16BEGi5O60J1-2N2oppcZ6TZ_YAjodFXrSttuPPa3KWnAywhUJxsFql1JlZT-vunY_QmZZ3cI3FeKUKHrBxTmF1zj1E74vOcT8imWs7Zk4X6T/s400/DSC03107.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 300px;" border="0" alt="" id="BLOGGER_PHOTO_ID_5499916724018929522" /><div style="text-align: center;">Give it a guess, I'll buy you a drink if you manage to guess it right.</div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com1tag:blogger.com,1999:blog-3253723702117158691.post-82951760264846809822010-07-01T22:02:00.000-07:002010-07-01T22:55:51.801-07:00What's Surgery Like<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6rrLdtVUV6qTBV1IrhvWkN-c1e0p-SWiUFdOuzlWNGQ28xt36NBYW5CMfS8-6Q9dUPiWsebncJMItXgOp1yqD3TImL5OlWwXGKkIwHukuMGtCFjWyCVnsOs8tkJT-wkDyXi9iNnmUJYgi/s1600/Untitled.png"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 400px; height: 225px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6rrLdtVUV6qTBV1IrhvWkN-c1e0p-SWiUFdOuzlWNGQ28xt36NBYW5CMfS8-6Q9dUPiWsebncJMItXgOp1yqD3TImL5OlWwXGKkIwHukuMGtCFjWyCVnsOs8tkJT-wkDyXi9iNnmUJYgi/s400/Untitled.png" border="0" alt="" id="BLOGGER_PHOTO_ID_5489183536730704802" /></a><br />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.<div><br /></div><div>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.</div><div><br /></div><div>"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.</div><div><br /></div><div>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.</div><div><br /></div><div>1) Nephrotic syndrome</div><div>2) Felty's syndrome</div><div>3) Kaplan's syndrome</div><div>4) Carpal Tunnel syndrome</div><div>5) ?? Ish..</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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</div><div>1) Fingers of a Lady</div><div>2) Eyes of an Eagle</div><div>3) Heart of a lion</div><div>4) Stomach of a Camel</div><div>5) Legs of a horse</div><div><br /></div><div>I'll see whether I could acquire any of the above at the end of the posting, HAHA!</div><div><br /></div><div><br /></div>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com2tag:blogger.com,1999:blog-3253723702117158691.post-74796483088675031462010-06-30T21:01:00.000-07:002010-06-30T21:54:00.346-07:00Career Choice: Ambition Vs Family by Lucia Li, Medscape Student<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIT6gCy_TDOu058ALn5xdUzzrmCfDvzqGIIU2Rg7m-tWInl1lsA4f1cpqIYPDQnw_hGxJFQG_M17Er0MhMTX7i6NvVA7bRJfuEQbRWmk5b0nzBW0eGicVNvcvjXKMOMCSF1hPP4slhENYP/s1600/images.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 183px; height: 275px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIT6gCy_TDOu058ALn5xdUzzrmCfDvzqGIIU2Rg7m-tWInl1lsA4f1cpqIYPDQnw_hGxJFQG_M17Er0MhMTX7i6NvVA7bRJfuEQbRWmk5b0nzBW0eGicVNvcvjXKMOMCSF1hPP4slhENYP/s400/images.jpg" border="0" alt="" id="BLOGGER_PHOTO_ID_5488796485416187554" /></a><br /><span class="Apple-style-span" style=" ;font-family:arial, sans-serif;font-size:13px;"><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; "><em><b></b></em></p><blockquote><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; "><em><b>People take different roads seeking fulfillment and happiness. Just because they're not on your road doesn't mean they've gotten lost.</b></em></p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">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.</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">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. <b><i>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.</i></b></p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">But the whole point is we live in a free society in which we can choose our mode of happiness. <b><i>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.</i></b> Least of all, women should not criticise other women for that choice.</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">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.</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">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. <b><i>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'.</i></b></p></blockquote><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; "><b><i></i></b></p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">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:</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">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.</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">Dad: Ok, but if you see any good candidates(girls) along the way, just approach them and be friends.</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">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.</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">Dad: Ya la, I know, but don't wait too long.</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">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)</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">Dad: That's not success, no matter what, don't put it on hold for too long!</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">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. </p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">I don't think its impossible to achieve a great career and family, because at the end of the day, <i><b>you make your own time</b></i>. And I believe, one will never be too busy for his/her love ones. </p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">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.</p><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; ">Be the best doctor you can be, make time for what you love, the rest are just excuses.</p></span>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0tag:blogger.com,1999:blog-3253723702117158691.post-77775812434916795962010-06-19T04:23:00.000-07:002010-06-19T04:29:34.133-07:00Abstract for Endocrine Society of Australia annual meeting.<h1 style="text-align: left;"><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;">Expression and cellular activation of peroxisome proliferator-activated receptor γ in granulosa cell tumours.</span></span></h1><div><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><br /></span></span></div> <h6><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;">Simon Chu, Chee Yong Chuan, Maria Alexiadis and Peter J Fuller</span></span></span></h6><h6><span lang="EN-AU"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-size:medium;"></span></span></span><span class="Apple-style-span" style="font-weight: normal; font-size:16px;"><span class="Apple-style-span" style="font-family:arial;">Prince Henry's Institute</span></span></h6> <h1 style="text-align:justify;tab-stops:177.65pt"><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">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. </span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">Nuclear receptors (NR) are well defined targets which have a central pathogenic role in endocrine malignancy. They are potential targets for therapeutic intervention.</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;"> </span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">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 (PPAR</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">g</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">) had greater than 10 fold absolute expression when compared with </span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">either the NCBI tumour or brain reference RNA pools</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">. </span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">PPAR</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">g</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;"> agonists are regarded as potential therapeutics in the treatment of inflammatory diseases and certain cancers. Given the high expression levels of PPAR</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">g</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;"> in GCT, we investigated whether the use of PPAR</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">g</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;"> and/or retinoid X receptor (RXR) agonists or antagonists have an effect on GCT-derived cell lines. We observed that the PPAR</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">g</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">/RXR agonists and antagonists had no affect on cell proliferation, cell viability or apoptosis. Although the use of PPAR</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">g</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;"> agonists is unlikely to be of use in treating GCT, a combination of therapies involving knockdown of NF-</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">k</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">B 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-</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">k</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">B signalling pathway. We are currently investigating whether PPAR</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">g</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;"> is transcriptionally active in these cells using a reporter construct specific for PPAR</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">g</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;"> and whether the non-responsivness to PPAR</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">g</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;"> agonists or antagonists </span></span></span><i><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">in vitro</span></span></span></i><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;"> is due to NF-</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">k</span></span></span></span><span lang="EN-AU"><span class="Apple-style-span" style="font-size:medium;"><span class="Apple-style-span" style="font-family:arial;"><span class="Apple-style-span" style="font-weight: normal;">B transrepression.</span></span></span></span><span lang="EN-AU" style=" font-weight:normal;mso-bidi-font-weight:boldfont-size:11.5pt;"><o:p></o:p></span></h1>Yong Chuanhttp://www.blogger.com/profile/00802779720847282977noreply@blogger.com0