Long First Step

It has been a while and I know that I have to polish back my writing skill. Alhmadulillah I just finished my MBBS recently and completed my MMC registration. The process was hectic, but that was our lifestyle for the past 7 years ( 2 years in matriculation & 5 as undergrad). Ive been getting a lot of emails asking me to write more notes but I would like to apologize, many things happened in my family that I lot my focus on writing. Anyway, I'll definitely tell more on my professional exam and everything.

Today is my last day in Kuantan. Sad? I would describe it more like void, empty. Mixed feeling. I don't know. Feeling can't be described by any dimension, well I am not an astronaut but you tell me. The path was rough and tough but the ending is too sweet that you wish it remains that way longer. Whatever it is, life must goes on and I hope all of us will be successfully contributing back to the ummah.

So, first thing first. I am planning to write more on the graduating process for my juniors, tips for exam and maybe notes. Maybe. Since I don't think I will be working since I'll be staying in Qatar for a while. But I was planning to stay in Malaysia while waiting for my placement to work as a photographer or teaching for tuition though. But, my mom keeps objecting as handling people's child can be difficult. I actually wish she will support me to take the challenge. Maybe she's too worried because I have GERD and she thought it was due to stress during medical school. Hah, never mind. Letting your child to decide once in a while (even if it turns out bad) is good to boost self-esteem and confidence. But don't get me wrong I still love them. Family comes first, always.

Alright. Will be hearing mire from me soon.

Tumor in orthopaedic

Approach for orthopaedic tumor PART 1
Teaching Mr. ariff

History and PE : Aim to
1. Differentiate between soft tissue or bone

2. Differentiate between malignancy or benign or benign to maligancy transformation
-benign usually long standing
-malignant usually is fast growing a/w night pain or pain at rest?
-benign to maligant transformation - usually lipoma
Tengok balik buku. Cuba buat table

3. Any symptoms of metastases
-can be to mets from other site (5 tumors commonly mets to bone are lung, breast, thyroid, renal n prostate). So need to rule out those as well. would be useful if we can read the characteristic of those tumor...osteoblastic, osteoclastic or mixed. For example prostate tumor is osteoclastic in nature
-it can also be primarily from bone itself but mets to bone elsewhere.. bone usually mets to lung and other bone which is highly vascularized, which is the cancellous bone. Examples of cancellous bones are proximal girdle,hip, vertebral body, proximal humerus (but can only be seen radiologically once it spread to pedicle giving owl wink sign). Rarely mets to liver, unlike carcinoma. So, ask about any pain elsewhere, hemoptysis, sob...
-note that giant cell tumor (benign) has metastatic characteristic, but only to lungs. It is bacause it gets doslidged from the primary lesion. But unlike a real mets in malignancy, it can't transfer from lung to lung.

4. Anticipate complications  local or systemic
-local compression:
♧nerve - any loss of sensation, numbness
♧vascular - pulse, dilated vein, edema
♧muscle - weakness PNS
♧joint-effusion

- systemic
♧anemic sign n symptoms (ssx)
♧ssx of hypercalcemia (resorption-read more how it occurs)

5. obtain family history of malignancy. Apa tumor yg commonly ada genetic influence. X dpt kawab hari tu sbb x dtg seminar mr goh

6. Syndromic??? X dpt pick up sebab terspace out. Among important keywords : bone tumor boleh develop fibrous dysplasia...monostotic or polyostotic. and syndromes somehow related with endocrine punya features like thyroid pr pituitary. Good to know.

From mr shuk : causes of pain in malignancy
1. Compression to surrounding
2. Central necrosis
3. Stretch of pseudocapsule

Kwashiorkor vs Marasamus

Just sharing from what we hve learnt from dr muhd during bedsite teaching today.

Since today we hve examine ptn at 1yo with kwashiokor, here are some differences between kwashiorkor and marasmus

🐥Kwashiorkor
1.inadequate protein intake , good caloric intake
2.Pitting edema (lower ext > generalized in severe case + moon face)
3.reserved subcutaneous fat, marked atrophy of muscle mass
4.mentality : apathy , disinterest in eating
5.marked skin changes : hyperpigmented hyperkeratosis to macular rash (more common)
6.hair changes : sparse , easily plucked , dull brown/red/yellow white (more common)

🐣Marasmus
1.inadequate calories n nutrients , protein may not deficient
2.edema usually absent
3.loss of subcutaneous fat and muscle mass
4.mentality : irritable
5.skin changes : less common
6.hair changes (as kwashiorkor) : less common

New posting!

Now, it is already my second week of medical posting, the most feared posting. I don't sure how i feel when I started my first week. So many diseases need to be covered and clerking is wayyyy moreeeee detailed in medical posting. But, first, you need to know what are the spectrum of diseases especially the common ones in our setting for each system, and some  MOST diseases have systemic manifestation, everything is interrelated.

But fret not, first, master the PE, try to read through how it is done and possible causes which may lead to a particular complaint. I would suggest you guys to read oxford handbook. Or Talley for throrough reading, my fav so far. LOL. But yes it really is you bible in this posting.

Just got my surgical posting result, it was fine...hmmm....yeah fine. A bit disappointed though with my theory but shouldn't  because it was my own mistake, I procrastinate too much before the exam. But, Thank God, I passed :)

Medical posting is a hectic one, I can't deny that plus the ward is congested most of the time and the current weather was like, phewww...It seems like everyone is hyperthyroid like that. Will be starting to post the cases and discussion here soon. Sharing is caring, if no one is reading, fine, an alien would be interested then. It is for my own revsiion anyway. (-_-')

May Allah ease.

Lump, Bump, Groin Tutorials with Mr Nazli

Try to grab the histological structure of the skin with the appendages. Usually if the pathology occurs within the dermis, the lump or bump should be attached to the skin. For example sebaceous cyst, carbuncle, boil, dermoid (positive transluminance test). Not attached to the skin, you can actually pinch the skin, for example lipoma.

In examining the lesion, As usual we go with inspection, palpation, percussion if needed, auscultation, and some special test in distinguishing the lesions.

LIPOMA

http://www.lipoma.net/wordpress/wp-content/uploads/lipoma4-e1355211534412.jpg

• It is a benign tumor consist of mature fat cells, it is the most common for of soft tissue tumor
• mostly in upperlimbs, chest, neck, shoulder with size smaller than 1 cm commonly. It will have hemispherical or discoid shape, with smooth/ lobulated, may fluctuate with soft of firm in consistency. The edges usually irregular 
• most of the time painless, free mobility of overlying skin with normal temperature
• slips sign test should be positive
• transluminence test usually negative but can be positive if liquified
• it is not a precancerous lesion - less likely to develop into liposarcoma. But if there is liposarcoma, usually it develop de novo ( by its own)
• Prognosis of it 
• 2/3 not growing
• 1/3 growing
• Rx : excision

SEBACEOUS CYST

http://i.ytimg.com/vi/9xKYKyn3oMM/maxresdefault.jpg

http://health.tipsdiscover.com/healme/wp-content/uploads/2013/07/Sebaceous-cyst-%E2%80%93-Causes-Symptoms-Diagnosis-Treatment-and-Ongoing-care.jpg

• arise from hair follicle consisting keratin. If oily, sebum secreted by sebaceous glands.
• Usual sites are the hair bearing sites like scalp, shoulder, neck, scrotum, back
• Usually hemispehrical, with smooth surface, hard and solid, well defines. Attached to the skin hence not mobile
• Usually have one punctum or fistula
• can be complicated with infection, ulceration, calcification, so observe the skin changes suggestive of inflammation
• Rx : excision

DERMOID CYST

http://byebyedoctor.com/wp-content/uploads/2011/05/epidermoid-cyst-3.jpg

• It is "skin lined cyst" deep in the skin in subcutaneous tissue (attached to the skin)
• usually the site is central part of the body 
• shape usually is pherical, smooth surface and may fluctuate, 
• congenital : usually central part of body
• acquired : due to fusion of 2 abnormal layers
• positive transluminance test,
• painless unless infected
• Rx : excision

CARBUNCLE

http://www.millerfamilydermatology.com/wp-content/uploads/2013/05/carbuncle.jpg

• necrotizing infection in the subcutaneous tissue, with pus and slough formation
• multiple punctum
• can be widespread
• lost of skin appendages
• Rx : antibiotic, saucerization(remove layer by l;ayer)
• for saucerization, do dressing for wound healing and prepare blood transfusuion

GANGLION

http://vipplasticsurgery.com/wp-content/uploads/2014/01/ganglion.jpg

Acute Pancreatitis

Patient is 67 years old lady with no known medical illness. She presented with epigastric pain for 7 hours prior to admission with similar episode of pain in October.

The pain was at sudden in onset, constant and pricking in nature. The pain radiated to the back with no specific agrravating or relieving factors. The pain score was described as 7/10. It was associated with vomiting for 3 times already and vomitus consisted of food particles with no biles or blood seen. Oral intake was reduced. She denied chest pain or shortness of breath, no history of yellow discoloration, fever or changes in characteristics of urine and stool. No URTI Ssx.

On further questioning, patient admit that she had an episode of epigastric pain and had seek treatment for the pain. She was prescribed with rastritis medication and she admit she has ingested traditional Chinese herbs to relieve the abdominal pain back in October.

Prior to current admission, she came to Klinik kesihatan to seek medical attention and was referred to hospital as pain was not resolved.


There was no history of scorpion sting, insect bite and not preceded with trauma. She denied a
history of traditional Chinese herbs ingestion in October to relieve abdominal pain. She denied any consumption of alcohol and she is not a smoker. There was no history of eating outside and no similar problem in family. Her elder brother succumbed to cancer but she wasnt sure what type of cancer.

Physical examination, I lost the result. Hmpphhh...

Investigation

CXR erect...no cardiomegaly
no air under the diapghragm
ECG : sinus rhytm
no acute ischemic changes

ABG
FBC
amylase
LFT
RP
AST LDH
Ca
alb
coagulation profile
total bil
UFEME


PRovisional diagnosis
acute pancreatitis

DDxes
gastritis
peptic ulcer disease


Management

• Treat the cause/stop the possible insulting agent
• Resuscitate
• Anticipate complication

IMRIE score

Emergency Trolley

1. Injection : syringe, needle, medication which includes atropine, bla. bla

2. Things tu be used in intubation and torchlight

3. Endotracheal tube, branula, sterile gloves, stopper etc.

4. IV drip, mask