housemanship, SPM Malay, O Level Malay

I studied in Brunei, did my Olevel there. Hence, i do not have SPM Malay.

Since i am applying for Housemanship in Malaysia, one needs to have SPM Malay no matter what.

I have called VARIOUS government sectors about this. Well, here are some of the facts that you might need to know.

MQA has stated that Brunei O Level has the same standards as those of SPM. However, you need to confirm with the ministry that you are attached to whether they can accept the substitute.

KKM :
- since i'll be an employee of the ministry, they told me i need to have SPM Malay. I have 1 year after registration to do so.

So, what do i have to do? 

Once my housemanship starts, i need to refer to the hospital's admin and ask them whether they can apply the SPM Malay for me.

Lembaga Peperiksaan stated that i have to register in March as a private candidate. You are required to register with Lembaga Peperiksaan Negeri. Since i am going to Miri Hospital, i need to register there.

Since i do not have SPM at all, i will sit for November paper. However, some said u can skip this, and do the June papers; which are easier instead. I still need to confirm about this once i start working in Miri. The papers will be the same as those normal SPM paper.

I spent about 1 hour, just to get confirmation on this matter. I called MQA, JPA, SPA, KKM and finally, Lembaga Peperiksaan. I got directed to many numbers, having to say the same things all over again! At one point, i got pissed off about it!

Haish, why do they make things complicated?!?! As if we use perfect Malay in our everyday life anyway!

psychiatry related movie #2

since it was a break for me, i have been catching up some movies that i missed. i was surprised that this movie showed some elements of a psychiatric illness which lead the character to go through a tragic ending.

the reason why i watched this movie is because it has Leighton Meester and Gwyneth Paltrow. An easy going movie but with strong emotions displayed by each characters. An enjoyable movie to conclude it all.

I will not write its sypnosis or even explaining on the whole plots here since i am not the kind of person who likes to spoil a movie. So, to all the Psychiatrist wannabes, go and watch this!

MBBS Final Pro Exam - Medical Case

candidate : MS 33

Examiner :

1. Dr R (external examiner) - alpha female

2. Dr ??? Malay, female lecturer of CUCMS kot since she was wearing the labcoat. - didn't ask much. angguk2 for most of time 

Station : BBQ station of Medical - not my favourite. (NSTEMI)

My patient is a middle aged chinese lady who could not speak Malay properly! 

After about 5-10 minutes, i gave up and decided to inform the staffs for a translator. 

The admin took time to find one and in the end, i got another old chinese lady in wheelchair as the translator -.-;; better, but still had difficulty in translating some words to Malay and they took some time to talk to each other. 

-.-;;;;;;;;;

in summary,

Madam L, 58 y.o, Chinese lady

Day 8 of admission

Underlying DM for 17 years and HPT for 20 years

C/O : SOB 

• a/w central chest pain +  palpitation
• no failure symptoms
• no hyperglycemic symptoms
• compliant to medication and not informed of having any TOD during her regular follow up
• then, patient was admitted to the ward and she mentioned "tiga", "tiga". so i suppose 3-vessels disease lah right?
• Hx of gynaecological surgery at the age of 40. the translator mentioned CHIGONG CHIGONG, sakit sakit. have no freaking idea but patient got menopause after that. i suppose hysterectomy kot. 

physical : displaced apex beat but otherwise DRNM, presence of dressing at the femoral area (post angiogram), diabetic dermopathy changes (dry skin, hyperpigmented legs, loss of hair), all others seem to be ok. 

QUESTIONS : 

1. How was your patient? Did you have any difficulty? 

- yes, i experienced language barrier with her. 

2. Did you mention about this to the admin? 

- yes, i tried to clerk her but after 5 to 10 minutes i decided to just inform the admin.

3. Did u manage to get a translator? Is the translator provided for the patient or is it only just on the spot? 

- yes, they gave me another elderly chinese lady but i still had difficulty. i am not sure who she is but it could be one of the patients for the exams. 

4. It's okay. We will note that down in your marking sheet. So present your history. 

5. what is your diagnosis? 

AMI

6. Okay going back to your history, if you could clerk the patient properly, what else should you asked the patient about for the shortness of breath? symptoms of pulmonary embolism, PUD, pneumothorax

7. what is the different between the pain in pulmonary embolism and AMI? blur blur blur. she asked is it diffuse or sharp? 

i said sharp. "are you sure look" pops up. 

8. name me other types of pain that you know of? colicky, dull, burning, sharp, radiating pain, pleuritis

9. okay, what would be the kind of pain in PUD? worsened by food, hx of NSAID

10. how can you tell patient has good control of DM and HPT? 

- she said her dr didnt mention of any TOD

- i want to look at her HbA1c and BP trend 

* still tak puas hati lagi* you have already mentioned that in your hx.

*pause*

oh, she has been DM and HPT for quite some time but she is only on 1 type of OHA and anti HPT. *Yes. Good*

let's meet the patient

11. show me the relevant negative and positive finding. in the end, she asked me to show reflex at the lower limbs. 

- for ankle reflex, i told the patient to position her legs like the way i demonstrated to her.

E : shouldn't reflex be done in a passive manner?

Me : err.. 

E : what should be the condition of the muscles if you wanna do the reflex?

Me : relaxed

E : so, if you ask the patient to position herself, wat would the muscles be?

Me : contracting. she gave the "TAU PUN" face.

then, went back to discussion room

12. since you mentioned patient is big built, did u take her BMI?

- i did ask the admin for a weighing scale but instead, Dr M came in and said, no need. then she roughly estimates her (by the power of observation) as 60-65kg. 

Oh. so u did try to get the BMI?

yes, i did. 

13. ivx that you would like to order - ECG - to look for MI changes

14. How do you differentiate the symptoms between Unstable Angina and NSTEMI? answered ivx but she insisted in hx. 

(battery span at that time- 50%). she answered : well, it's quite hard to distinguish but there are some distinguishing fx.

15. causes of ST depression? *thought block* no idea

16. which one are u more worried of? ST elevation or ST Depression?

17. other ivx? 

FBC - to look for anaemia due to chronic HPT and DM. she wasnt satisfied and asked the relevance of anaemia in MI. answered : oh. anaemia can further precipitate her to get Heart failure. which patient is already at risk of due to MI.

*Yes, that is even better answer than saying anaemia of chronic disease*

18. Others ? 

cardiac enzyme - which ones? Troponin and CK enzymes. relevance? so that we can estimate how long patient has been experiencing MI and to confirm dx.

Coagulation profile - for thrombolytic therapy later on / heparin

Lipid Profile - risk factor

Renal profile - need to make sure electrolyte is balance so that it doesn't further worsen her heart condition, to look for renal /dm nephropathy

19. since you mentioned about timing of MI, what is the relevance?

- can decide whether patient needs thrombolytic therapy or PCI.

20. which is?

- door to needle time is 30 mins. 

21. where should you thrombolyse patient? 

- in cardiac unit?

22. only in there? - not sure. 

well, u mentioned that you thrombolyse the patient A.S.AP, so you can also do it in....? 

Red Zone, ED. yes. 

23. so how are you going to take care of patients before she undergo bypass?

- ensure the glucose and BP are controlled

- advise ambulation to prevent DVT

- ensure enough hydration

24. how about medication?

- Start on B-blocker, ACE-i, Statin and Heparin.

25. how about other non-pharmacological? 

- since patient does not exercise regularly, then i would advise her to do light activities e.g briskwalking for 30 mins if possible on daily basis.

- advice her to control her diet

26. how are you going to advice her on diet?

- erm, i would prefer to refer her to dietitian. 

E: Oh, you cannot simply do that without trying to explain to her something about it. 

- well, reduce carb intake, increase on fruits, vegetables and increase protein diet.

*times up*

PENGAJARAN : 

1. a straight forward case but due to the problem i had earlier on, i did not have time to prepare for the discussion. ended up mengelabah like Shhhh... especially when answering the questions
2. to the juniors, if you experience language barrier, please call for help A.S.A.P. it is possible u get to change patient. 
3. follow your instinct : quite fortunate, i studied CPG of AMI the day before. at least i wasn't that hopeless in answering the questions. 
4. cramping everything up 1 day prior to exam can make u experience thought block.

you have reached your destination

This post is supposed to be up last week but since i was away to Melbourne for a week, so here it is.

Praise to the Almighty, i am no longer a medical student. I have passed my final pro-exam and right now, waiting for the offer to start my housemanship.

I am supposed to get the title Dr, but i still feel i do not deserve it. That title comes with great responsibility that sometimes i doubt myself whether i can handle that.

For housemanship, i have applied to Hospital Miri, Hospital Kuala Pilah and Hospital Putrajaya. 3 different states but all with the same aim; to be a skillful doctor, a good learner and a patient employee.

As for now, i am still waiting for my SPA interview. Then, we all need to wait for the results and hopefully, we get the places that we want to.

Meningococcal disease fact

• The vaccine for those who are performing Hajj and Umrah contains vaccines against Meningococcus serogroup A, C, Y and W135. 
• For paediatric patients, the vaccine is against serogroup A. hence, we see the decline in this infection in paeds populations.
• If you want to go to Africa / Middle east, the vaccine must at least contains against serogroup A and C.
• Why don't we have vaccination against serogroup B? because it lacks the immunogenic polysachharide capsule that vaccines can act on. 
• In teenagers : most prevalent Serogroup C. In infant : Serogroup B
• Meningococcus (Neiserria Meningitides) spreads via nasopharynx secretions. Hence, risk factors include immunocompromised and overcrowding places. 
• Presentations can either be, septicemia, meningitis or focal lesion (septic arthritis, pericarditis or conjunctivitis)
• rash can be petechiae or purpura (non-blanching). 
• Meningococcal septicemia is not known to have neck stiffness, bulging fontanelle. abdominal symptoms, photophobia and the tests (kernig's, burudzski) are negative. This is the otherwise in meningitis.
• Kernig's sign (pain elicited with passive extension of the leg in a supine patient lying with their thigh flexed on their abdomen and their knee flexed)
• Burudzski's sign (passive flexion of the neck in a supine patient results in spontaneous flexion of the hips and knees)
• In meningococcal septicemia, IV/IM Benzylpenicillin must be given immediately. In meningitis, it is not urgent since the progress is slow.
• complication : distal amputations, lossof hearing, cranial nerve palsies, scars due to skin necrosis, cerebral atrophy, hydrocephalus, mental retardation can occur.  

source of BMJ Learning Module

MBBS Final Pro Exam - Surgical Case

Specialty : Thyroid Disease in Pregnancy (Surg + Obst)

Examiner : Prof S & Prof Z

Case Summary :

29y.o Malay Lady

G2P1 at 22/52

Presented with neck swelling currently for 6/12.

First notice 1/12 before went to seek treatment.

Swelling at the right neck, painless, initially size of a marble, gradual increase in size.

No compressive Symptoms

+ Hyperthyroidism – irritability, mood swing, heat intolerance, increase in appetite, proximal weakness

No Risk factor : no family hx, not from endemic area, no hx of radiation.

At the moment, she has done TFT. Scheduled for U/S and FNAC tomorrow. Not on any antithyroid.

1 month after noticing the lump, patient found out she was pregnant. Currently, at 22/52 of POA. No active complain other than morning sickness. MGTT once due to weight gain (2kg in 1 month). Result : unknown

Questions :

1.       Present your history and summarise it.

2.       Show me how you examine the thyroid. (how much are you going to expose patient?)

3.       Summarise your neck examination.

4.       What is your diagnosis and its differentials. (I said toxic adenoma. DDx – dominant nodule in MNG, thyroid malignancy)

5.       Why do you say toxic adenoma?

6.       How are you going to investigate the patient? TFT, U/S, FNAC.

7.       What do you expect in TFT? Primary hyperthyroidism, low TSH, high t3 and t4.

8.       If patient is euthyroid, what can be the diagnosis? Malignancy and benign thyroid

9.       What other biopsy can you do? FNAC and Tru cut. He asked ever heard of tru-cut in thyroid? Then I changed my mind to excisional biopsy.

10.   If it is malignancy, what can it be? papillary and follicular. The most likely? Papillary

11.   How are you going to manage if it is malignancy? My plan is to go for op which is total thyroidectomy, keep patient euthyroid by giving PTU since patient is pregnant.

12.   How soon? I dunno. A.S.A.P?

13.   Complications of thyroidectomy.

14.   What are the nerves that can be cut. Recurrent laryngeal nerve – unilateral hoarseness. Bilateral – stridor.

15.   What to do if patient has stridor? I answered dilate the vocal cord? Stenting?

16.   What antithyroid drugs that you know? Carbimazole and PTU.

17.   Which one cross placenta? I said carbimazole. PTU doesn’t. Prof said, both can.

18.   What are the things that you be worried of Hyperthyroidism to pregnancy? I answered IUGR, oligo. He said ok.

19.   What is the complication that can occur that will delay delivery? I have no idea. Answer : fetal goiter.

20.   Other complication to anticipate? I said hypertension in pregnancy. (OK). Others? Thyroid storm (after hinting)

21.   How are u going to manage thyroid storm? Steroid, iv hydration, antipyrexia, ptu and potassium iodide.

22.   Can you breastfeed her post-delivery? I said can.

23.   Does the antithyroid drugs be passed in the breast milk? I said no. answer is YES. The process is called weaning down since the mother has been on antithyroid throughout the pregnancy.

24.   If patient is 30/52 and you found out it is malignant, what is your plan? I said do op. he said yes, do C-Section. (HAHAHA padahal I meant thyroidectomy)

25.   If patient is 8/52? This is a controversial question. I said keep the pregnancy. But I think Prof Zainurrashid said, terminate it. Prof Shaker said, wait until 12/52 baru op patient. I am confused here.

TIPS :

1.       Request buku merah from the patient.

2.       Ask as many as you can from the patient. Even for the current plan. It may help you with the answer.

3.       I was lucky the fact that I only have to present neck examination and not the whole physical examination (though I did BP, reflex and all). 

1 DOWN, 2 MORE TO GO! WISH ME LUCK PEEPS!!