10th Batch MBBS IIUM Blog

For those yg tak dpt attend.. this are just stuff i found interesting, not the whole thing cos blaja je... any corrections bgtau

1) Recent Advancement in DM control by Dr. Alexander Tan

- Hypoglycaemia increase risk of CV event (highest compared to other risk factors)
- Benefit of glycaemic control is seen longterm (>15 yrs)
- Glycaemic control depends on individual…. For example a 25 y.o we can reduce HBA1c <6.5, but if a 75 y.o with hx of stent/bypass and poor control, reduce <8… coz aggressive reduction predispose to hypoglycaemia which in turn increases risk of CV event…

Based on intensive glycaemic control in the ACCORD and ADVANCE trial…

link : http://www.nejm.org/doi/full/10.1056/NEJMe0804182 New approach= incretin (baca la sendiri ye..)

2) Battle against Obesity – Dr Adie Nuar

Just to remind revised BMI for asians
Underweight : <18.5 kg/m2
Normal :18.5- 22.4 kg/m2
Overweight:23 -27.4 kg/m2
Obese : => 27.5 kg/m2

3) Approach to joint pain – Dr. Ainon Mohd Mokhtar

Diognostic Criteria for Gout (2 or more)
a- clear hx of at least 2 attacks of acute severe joint pain with complete resolution in 2 weeks
b- clear hx of podagra
c- presence of tophus
d- rapid response to colchicines within 48 hours
Definite – crystals of monosodium urate in synovial fluid sample

Indications of hyperuricaemic drugs i.e. Allopurinol
a- Frequent and disabling attacks of gouty arthritis (3 =>attacks/yr)
b- clinical or radiographic signs of erosive gouty arthritis
c- presence of tophaceous deposits
d- urate nephropathy
e- urate nephrolithiasis
f- impending cytotoxic chemo/radiotherapy for leukaemia/lymphoma (tumour lysis syndrome)

ATTN! new criteria for RA diagnosis… yg the usual seven tu dah tak pakai sgt sebab that criteria will detect late stage RA… the new criteria is better to detect early RA… but I think for exam purposes.. remember the old but mention ada new... nak hafal mampos la.. ada score2...

ACR/EULAR rheumatoid Arthritis Classification Criteria 2010

Link : Skip to page 6 for the criteria… http://www.rheumatology.org/practice/clinical/classification/ra/2010_revised_criteria_classification_ra.pdf

4) Per-rectal bleeding – AP Dr Mohd Zailani

Perrectal bleeding- MANDATORY endoscopy
<40 yrs =" flex">40yrs = full endoscopy

Specific IX
-upper lower endoscopy
-Nuclear scan technetium 99 tagged RBC scan – sensitive but not specific.. detect bleeding of 0.1 ml/ hr (MCQ pernah kuar kan?)
-Angiography – less sensitive but specific.. detect bleeding of 0.5 ml/hr (again.. MCQ penah kuar)
-capsule endoscopy

HTAA gonna start a direct access to scope rooms for Primary care J

5) Diabetic retinopathy – Dato’ Dr Vasanth

Recap pathophysio…. Leakage + occlusion

Leakage -> macula oedema -> stretching of the nerve fibers and receptors -> ineffective impulse transfer -> scarring

Occlusion-> increase VEGF -> angiogenesis ->at disc + iris(iris rubiosis) ->bleeding ->scarring ->retinal detachment

Frequency of eye examination
<30 y.o (type I) – 1st exam 5 yrs after onset – repeated annually
>30 y.o (type II)- 1st exam at time of dx- repeated annually
DM complicating pregnancy – unsure (sapa sempat .. tak dgr la yg nie)

6) Tinnitus – Prof Din Suhaimi Sidek

Tinnitus + bleeding postnasal discharge =>rule out NPC(common gak in Msia kan)

7) Management of asthma – Prof Roslina Abd Manap

Untreated asthma causes reduce lung function long term! Caused by subepithelial fibrosis

So, ICS is important, safe to be used long term…

Treatment still ikut the one in GINA.. yg stepwise tu

Adding a LABA is better than >=2x increase of ICS..but must not be used alone, causes increase mortality.. with ICS

New treatment => combination treatment (formoterol +budesonide)..can be used for maintenance and rescue i.e. symbicort (diorg sponsor kot.. haha)

How to increase compliancy? since pt will say that they are asymptomatic and refuse to cont… instead of saying like ‘yes, I know but u still need to use it’ which is so not convincing kan?…use the asthma control scoring, afew recommended by GINA…. So say like ‘look here, yes u might feel asymptomatic but according to this score u r ?? and we need to reach ?? so u still need to cont the med’.. ok of course gentle2 la :P

8)Hep B – Dr Tee Hoi Poh

HBV carriers with increase risk of HCC
-Asia male >40 y.o, female >50 y.o
-Hx of chirrosis
-Hx of HCC
- Carrier with increase ALT or increase HBV DNA lvl > 2000 IU/L

Now ALT upper normal limit is 19 U/ml

Indication for Rx (Ada 3 study tp I only take the asia pacific…)
- ALT 2x upper normal limit and persist after 3-6 months
- HBV DNA >20 000 IU/L if HBeAg (+)
- HBV DNA >2000 IU/L if HBeAg (-)

Indication for Liver biosy
- ALT 1-2 x upper normal limit
- HBV DNA 2000-20000 IU/L
- Age >40 yrs old

Difference between =(acute hepatitis B) /(chronic hepatitis B with flare)
IgM core antibody = (+) / (-)
HBV DNA = (reduce)/(increase)
HBeAg= (reduce)/(increase)

Targets of Rx (descending pattern)
1- HBsAg Seroconversion – hard to achieve
2- HBeAg Seroconversion – the next best thing
3- HBV DNA suppression
4- Normalisation of ALT
5- Histological improvement


Rx
1) Peg-IFN alpha 2a (immune modulator ) – cannot be used in chirrotic
2) Nucleos(t)ide analogue

DESIGN 1

Dr gave me the EDD and asked for POG… the pt’s was 35 weeks…

I was asked to examine pt generally….

Me: This is a lady in her..mid 20’s? medium built, conscious and alert. Hydrational and nutritional status fair. Not pale (no signs of anaemia sucha as angular stomatitis, atrophic glossitis)nor jaundice, no parotid, no thyroid swelling. No pedal oedema. Oh.. and the abdomen is distended…

Prof : *smiling* y do u think I bring u to this patient? What do you think I want tou to pick up?
Me: *slams my forehead* oh.. the patient has rashes found all over her face, forearms and legs *I’m so dead I thought*

Prof : remember hielmi, don’t be so caught up with the negative findings.. these rashes are obvious..
Me: Yes Prof

Prof : so describe the rashes…
Me: it is found most prominently on the face, multiple 2-5 mm, hyperpigmented, keratinized, looks healed… there are a few at the forearms and legs tho they look more healed?

Prof: what else do you want to do?
Me : I would like to check the trunk and with seeing the progression of the healing maybe can tell whether the pattern is centripetal or centri….*ak lupa dowh masa nie..prof pandang je lama plak tu*.. fugal?

Prof: good *phiuhh* what do u think is the cause?
Me: Varicella zoster?

Prof: ok, now examine the abdomen

The abdomen finding was uneventful… other than more rashes…. However halfway thru.. uterus contracts, so timing was done… prof prefers running commentary

Prof : so whats ur dx?
Me: seeing that she has contractions at 35 weeks, my dx is preterm contraction secondary to varicella zoster infection. However I need to complete my examination with VE and bishop scoring to see if she is in labour.

Prof: if I give u one chance… only one.. to ask a single question to the patient… what will it be? Do it…
Me: Puan, bila puan dapat ruam2 nie? Trimester pertama, dua, tiga?
Pt: baru je 2 minggu…

Prof: Ok, y that question?
Me: due to the complication it carries based on trimester.

Prof: elaborate..
Me: 1st trimester carries risk of teratogenicity…

Prof: but this pt got it at third so?
Me: hmmm.. the baby will be a carrier?

Prof: no… what do we worry bout? 10 days post delivery?
Me: fulminant manifestation of the dx on the baby..

Prof: elaborate..
Me: hmm… skin eruptions?

Prof: ok… skin infections.. anymore?
Me: lung infections?

Prof: ok pneumonia… one more we worry bout…
Me: *masa nie cuak.. mula pikir all the organs dalam badan…* brain?

Prof : so.. what brain? Be specific..
Me: hmm.. meningitis?

Prof: that is just the covering…
Me: owh encephalitis..

Prof: Yes… now one more chance to ask a question to patient..
Me: Puan ada makan ubat? Ubat apa? Tau nama ubat?
Pt: ada, antiviral tp tak tau nama apa.

Prof: but u know I believe… what is it?
Me: Acyclovir

Prof: how do u prescribe acyclovir for her?
Me: I’m sorry prof, I do not know.

Prof : ask the patient now, u will remember forever…
I start asking the pt and was told its 800mg 5 times a day for 5 days.. ak tak cek lagi…

Prof: will the treatment cure her?
Me: not entirely, the virus will remain dormant in the nerves ganglion and will resurface if the patient will undergo stress or immunesurpressed..

Prof: so whats the long term complication for this patient?
Me: it could resurface during next pregnancy and causes 1st trimester infxn and for the patient.. shingles..

Prof: what is shingles?
Me: the virus causes rashes along the dermatomal region it resides while remain dormant. Painful pustules.

Prof: which shingles are we afraid of?
Me: lumbar?

Prof: why? Its just the abdomen..
Me: owh, trigeminal nerve shingles… ocular complication leading to blindness?

Prof: yes… How do you think the patient get the disease?
Me: through contact with someone with the disease..

Prof: ask the patient…*basically one of her kids got it first*… what do u mean contact
Me: fomites? Touch? Clothes? Its not airborne..

Prof: what?*mata terbeliak* Are u sure its not?
Me: *ak degil ckp tak gak.. sebenarnya ya* hmm.. the virus resides in the pustules and contact with it causes spread of infxn..

Prof: hmmm… ok.. have u ever been infected?
Me: yes..

Prof: when?
Me: when I was 7

Prof: will u get infected now by her?
Me: no because one, I’m immune and secondly she is beyond her infectivity period because it has been 14 days..

Prof: so explain y she have it only now?
Me: she has never been exposed, this is her first infxn and also because she did not take the vaccination which at her time wasn’t in the immunization programme.

Prof:*asking the pt* pertama kali ked pt demam campak?
Pt: a’ah.. nie kali pertama..

Prof: you can go now
Me: thank you

Prof sgt2 baik.. tolong je… masa bincang ak atas kerusi while dia duduk atas katil..

CC

A 38 y.o, Malay lady, from Felda Panching, G5 P1+3, a k/c/o PCOS with 14 yrs hx of subfertility, recurrent abortions dx with anti-phospholipid syndrome(APS) and valvular heart dx with LNMP 15/6/10 SOD, no contraception but irregular menses with benefit of early scan 10/52 confirm her EDD at 22/3/11 making current px at 37/52 presents 3 days ago for 3 days history of reduced fetal movement.

Dr: so in conclusion u have a very complicated case *smiles*
Me: Yes..huhu... but i will try my best Dr

HOPI

This is a very precious pregnancy.
Suspected when missed period, UPT done positive.
1st trimester symptoms = only breast engorgement.
No episodes of PV bleeding or abd pain during 1st trimester

Booking at 8/52 POA
-Obese = BMI 35
-normotensive, blood group cant remember, rheses +ve
-blood test = nonanaemic, VDRL, HIV. Hep B non-reactive
-urine = no glycosuria or proteinuria

Due to her dx of APS, given aspirin 75mg from 10/52-37/52. Self-administered s/c clexane given from 28/52.
Due to heart dx, visit MOPD and was told can cont with pregnancy and does not need combine care.
Due to obesity, MOGTT indicated, done 3 times @ 15, 24, 34 weeks.. all normal.

So far 13 followups(biweekly) at HTAA due to her probs, all uneventful.
Scans done on every visit – singleton, healthy, no congenital abnormality, normal growth, AFI good, placentation normal with no obvious calcification.

Quickening felt at 16/52. ATT completed.
Started on FKC at 34/52.
3 days ago, reduced fetal movement(do not complete 10 in 12 hrs), did not seek medical attention because of an upcoming followup. On followup, fetal movement returned normal but warded just to make sure.

Currently no sign and symptoms of labour, no PV bleeding, FM good.

On further questioning, denied rashes of face or anywhere else, no joint pain, no easy bleeding, no jaundice, no SOB, no calf tenderness.

Past Gyn + Obs (I decided to just combine the both to have smoother chronological flow)

Attained menarche at 12, regular till age 21 when turned irregular (every 1-3 months around 3-5 days) nor dysmenorrhea.

Was married for 14 yrs however conceived first child after 6 years of trying in which she got help of two cycles of clomiphine citrate (without any complication of OHSS) and an ovarian drilling. Dx with PCOS, other than the subfertility and irregular menses does have hirsutism(moustache), was on metformin.

Her first child was born full term 9 yrs ago with weight of 2.3 kg via elective LSCS due to oligohydramnios. On further questioning, no cause was found, she denied LL, GDM, PIH or congenital abnormality. No other cx antenat,intra,post-partum. Breast fed for only a week due to migraine.

Subsequently 3 miscarriage (2006(required D+C), 2008, 2009), investigated, dx with APS.
None of the pregnancy after the first was helped with induction.
Last papsmear 3 yrs ago – normal

Medical/surgical Hx
No significant hx

Family Hx
3/8 siblings. Both parents alive and healthy. Two other sisters have similar problems of subfertility.

No other significant drug hx. No allergy

Social Hx
Housewife, SPM holder. Live with hsband and daughter. Husband mechanic making RM1500.No high risk behavior.

PE

VS BP = 130/75 mmHg, PR=80bpm, RR=18bpm, T= 36.7oC
BMI= 42
Not pale, not jaundice, hydrational fair, No pedal oedema
Respi, thyroid normal.. denied breast examination
Heart = systolic murmur of the mitral region, radiating to the axilla, grade 3… no raised JVP.

Abd : distended due to gravid uterus. Pfannenstiel scar 20 cm, no scar tenderness, SFH 37cm, singleton, longitudinal lie, fetal back on maternal right, cephalic presentation , 4/5th palpable, adequate liquor with EFW of 2.8-3.0 kg. Can’t hear fetal heart due to thick abd.

Would like to complete with VE and bishop scoring…



Discussions

List the patients problems…

What is your concern now ?
Fetal wellbeing

How do you check for fetal well-being now?
Hx-FKC, PE-serial SFH(not relevant in this case), Ix- US and CTG.

Tell me bout FKC…

Tell me bout CTG and inteprete the pt's CTG….

What is APS? korang baca la ye sendiri pasal APS

How does it cause recurrent abortions?

What is done to this patient to maintain the px? How does it help?
Aspirin n clexane..bla2 ets

How wud u manage this patient?
-Seeing that the FM carry on till 38 weeks

Y c-sec? – very precious, dun wanna take the risk of vaginal delivery.

What risk? – untried scar, risk of rupture, no previous SVD before, so there is probability of CPD… again I stress it’s a precious pregnancy.

But is she contraindicated for SVD? No

How wud u monitor if pt keen on SVD?... S+Sx of impending rupture, prolonged active/2nd stage…

How wud you prepare this patient for C-sec: Ix : FBC, GXM, PT/APTT….Make sure anaes team comes… fasting… stop clexane on the morning of surgery.. bla2 ak goreng lagi ;P

What is the cx of the c-sec? anaes[mendelson(px)? Diff intubation(obese+px)? Difficult epidural(obese)], Hge, injury to other organs, bla2 etc….

After delivery, does she still need the anticoagulant? Yes, eventhough if the delivery is successful, she is still at risk of thromboembolism due to her obesity and APS…

So when do u wanna start? 6 hrs post-surgery..bolus 5000u and maintenance 1500u

What if tomorrow she complains of reduced FM? Put on cont CTG and if there is any sign of fetal distress EmLSCS..

thank you, u can go now

Seperti biasa, di akhir-akhir posting, biasanya medical students bertungkus lumus memenuhkan logbook i.e. mengambil darah, memasang branula, memasang CBD, etc. Lebih-lebih lagi bila FNAC tak berkesempatan nak tengok, scope pun sikit, jadi kenalah compensate dengan blood-related procedure ni.

Bagi yang jujur dan yakin setiap perkara akan dipertanggungjawabkan, mereka akan berusaha mencari procedure sendiri sehingga stay sampai malam atau weekends. Tapi bagi yang kurang peduli apa yang bakal dijawab di depan Allah esok, mereka akan menipu dengan pelbagai cara, termasuk meminta H.O. sign ‘blank cheque’ agar dia boleh isikan procedure yang sebenarnya tidak ia lakukan.

Beberapa hari terakhir posting surgeryku, aku meng-hunting procedure sampai ke wad IM. Jam menunjukkan pukul 6.40pm. Seorang H.O. sedang bertugas dan agak teruja mempersilakan aku membantunya mengambil blood C&S, FBC, VBG etc. Selesai habis procedure, aku kembali ke kaunter utk mendapatkan sign H.O. tersebut. Dengan mask yang masih melekat di muka, tiba-tiba dia bertanya kepada staff nurse di sebelahnya,

“Eh, kat wad ni boleh solat tak? Aku tak solat Asar lagi ah”

Aku melihat jam sambil berpandangan dengan temanku. 7.00pm. Tak solat Asar lagi?

Aku pun dengan rela hati menawarkan “Dr, saya boleh hantarkan specimen STAT ni semua. Saya boleh tunggu kat bawah, Dr tak solat lagi kan,”

“Oh, baiknya ko. OK, FBC ni semua takyah tunggu, ko tunggu VBG je. Thanx eh”

Aku pun bergegas ke bawah utk hantar specimen. Jam sudah pukul 7.15pm. Syukur golongan wanita Allah kurniakan MC setiap bulan, jadi aku tak risau pasal solat maghrib waktu tu. Sedang aku menunggu di lab, tiba-tiba muncul kelibat H.O. tadi, dengan cemasnya panggil lab assistant,

“Kak, boleh tolong trace tak result patient ni? Potassium dia high, 8.2 ni. Tolong checkkan balik boleh?”

Aku melihat jam. 7.20pm. Eh Dr ni dah solat Asar ke? Aku cuba berbaik sangka, mungkin tadi dia dah solat kejap sementara aku turun dan tunggu result patient. Tapi... alahai, masknya masih melekat di muka...

Aku cuba bayangkan. Nanti H.O., takkanlah takda masa langsung sampai solat 5-10 minit pun tak sempat? Seorang temanku, H.O. di Hospital Serdang nasihatkan, “Jadi H.O. ni kena selalu berwudhu’”

Rasanya bolehlah disimpulkan, hendak seribu daya... mungkin ada masa-masa emergency yang betul2 tak sempat, e.g. kalau kita tinggalkan patient utk pegi solat, patient boleh mati... Tapi itu mungkin situasi terpencil, kenalah jama’ maybe. Tapi kalau kebiasaannya, kitalah yang kena pandai curi masa. Kita kan tak tahu bila emergency tu akan terjadi, mcm tadi, tetiba potassium patient high pulak, jadi kalau ada masa yang ‘tak emergency sangat’, cepat-cepatlah tunaikan solat... Kalau dari awal dah ‘lenient’, tak set pun dalam mind masa utk solat walaupun 5 minit, kononnya sbb “Aku kan H.O., akulah yang paling sibuk dalam dunia”, jadi dengan mindsetting mcm ni, mungkin mudahlah utk seseorang tu tinggalkan solatnya...

Na’uzhubillah, semoga Allah pelihara kita... semoga kita semua menjadi hamba-hamba yang sentiasa cuba utk taat dalam menunaikan hak Tuannya, dalam situasi apapun jua...

Part 1 – perkenalkan diri

• Sebutkan nama & IC
• Tempat lahir ibu, tempat lahir bapa
• Di university masuk persatuan apa, main sukan apa
• Lulus tak exam, pernah dapat distinction tak
• Dah kahwin belum
• Mintak di hospital mana? Kenapa?
• Kenapa tak minta di KK, Kuching?
• Kalau dapat di Sabah macamana?

Part 2 – kenegaraan

• Siapa menteri kesihatan? Address FULL JAWATAN, termasuk YANG BERHORMAT DATO’ SERI, etc
• Siapa DG? Kenal tak rupa dia? If he comes in with slippers & jeans, would you be able to recognize & greet him?
• Apa rukun Negara? Pilih salah satu dan kaitkan dengan profession seorang Dr

Part 3 – technical (tapi Alhamdulillah interviewer KKM tak dtg, syukur...)

• What are the jobspecs of a house officer?
• What are the qualities that you have to be a good Dr?
• Hypertension & stroke, berapa reading SBP & DBP, apa Sx. Kalau low blood pressure berapa reading, apa Sx
• You know becoming a H.O. you’ll be in a lot of stress, habis tu kenapa ramai your colleagues masih ramai yang complain? (manalah saya tahu Dato’...)
• How do you manage stress?

Ini interview dengan Dato’ Abdul Rahman, bilik C. Sebelum tu ada yang kena soalan tentang fever & cough, how you approach. Dia baik sangat2, don’t worry.

Ada juga yang dapat dengan interviewer lain, ada soalan2 spt:

• TB – Mx
• Dengue – How do you Mx
• Pernah fail exam tak sebelum ni?
• Dah kahwin? Ada perancangan nak kahwin dalam masa terdekat? Dah tunang? Dengan orang mana
• Maybe dia nak consider tempat/hospital yg kita mintak kot...

Sekian... Semoga Allah mempermudahkan kalian semua esok... insyaAllah, semua interviewer baik2 belaka, buat penat je takut =) Don’t worry, Allahumma yassir...