ALONE

i am alone today. mum, d, ana , ira all went o visit historical places in malacca. i bet they really have fun. but unfortunately, is is a one day visit, cause there was no hotels opened for reservation, so need to go back to kl. well im working on night shift today,, and yet i do not have anything ANTICIPATE

does singular cause behavioural side effect

Question: Answer: In April 2009, the Food and Drug Administration (FDA) finished its review of the clinical information regarding the possibility that Singulair (montelukast) is related to psychiatric side effects. Reported symptoms include agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor. This investigation was a result of reports of people attempting suicide while taking Singulair. While there were no reports of suicidality or behavioral changes involving 11,000 patients taking Singulair during the manufacturers' safety studies, there have been reports of these symptoms in people taking the medication since it has been marketed. The FDA announced its initial concerns in March 2008, and updated these concerns on June 12, 2009. As a result of these findings, the FDA has required the makers of Singulair (and related medicines, Zyflo (zilueton) and Accolate (zafirlukast) ) include a warning statement in their labeling regarding the possibility of psychiatric side effects. Patients are advised to contact their healthcare provider if these side effects occur, but should not discontinue taking Singulair unless directed by their healthcare provider, since the sudden stopping of Singulair could result in worsening asthma symptoms. Singulair is an allergy and asthma medication that blocks leukotrienes, chemicals released from mast cells and other immune cells that are involved in causing inflammation of the respiratory tract. Read More:

teachers day 2012

today is teachers day. well, i did wished mummy and dad. but i didnt wished it to my any other teachers. i had a post night shift today, since got back, ive been so short of breath and barely walk around my house, for sure i knew i have not taken my singulair for 2 weeks already since it has been out of stock well, then , i should read on singulair sudden discontinuation main effect

14 march 2012

14 march 2012

today is my birthday. its nothing unusual, its just a lame 14th march.
i worked am shift today, being left alone all day long, as another team of mine went to ot.
i am quite sick today, and it happens to be on my birthday

i had a flu shots (my yearly influenza shot) last monday during my respiratory clinic appoinment. it winded me up with a fever, a little bit of asthma exacerbation, and of course , and uncomfortable left hand.

was thinking what to wish for. now im turning 24, and yet i have no idea how much have achieved so far. what i knew was: i want to be healthy, i dont want to take any meds anymore, i wish never have to come to clinic appoinment seeing other doctors.

the fact is that i just hope and pray that i would not be sick for such a long time. need time to grow out of this sickness, and think carefully on what i should be doing in this life.

liver abscess. bargaining from mr azmi

liver abscess
-pyogenic, amoebic
-suspect liver absces
-do us
-in ultrasound: hypoechoic : if single : amoebic, if multiple locules: pyogenic
abx: size less that 6cm
size abscess more than 6 cm: percutanoues drainage
c/i for percuatneous drainage:
1. ruptured abscess
2. inacessible site, dome of liver
3. non liquiefied liver abscess
treatment: cefobid, flagyl (flagyl also cover amoebiasis)

i am a doctor , but i am different

i am not just a doctor, who go to work everyday, come back, and repeat the same rituals everyday. i am also a patient, and yet on the same time i am a doctor too. i had a lot of hospital admission, despite being a doctor. my nurses , knows me as not only their daily doctor, but also their occasional patient. i went through my final year in medical school not just like any other doctors, as i had to battle with my health as well. to some doctors, maybe getting a medical degree is just fighting with books and exam.

it's different for me, i had to battle with my health, i had to manage my own medications to keep me going, i need to take care of myself well and not to get sick at times when i cannot afford to be at. it's tough , and i would never have words to describe them. i don't even look at the doctors whom are my friends who get flying colors in their medical degree, as to me, they don;t have to fight against health and other issues as i am.

i am not a loser, for seeking help at time of sickness, for asking my own nurses to help me move on hospital beds, for asking my own college to take care of me and review my progress daily during every hospital admission, i am not a loser, i am a fighter .

i will always fight as long as i am alive. and to me , being a patient and also a doctor at the same time, makes me a different one, not just to say i understand how difficult it is to be a patient, but ive gone through almost all of it, that none of my patients can tell me that i don;t understand

a hectic night call day

inserted a second chest tube succesfully in surgical posting this early morning
it was hectic, 3 icb, where all are intubated, requring cp

didn';t sleep the whole night.
today, just happens to be the last night of surgery
hope it is uneventful
just need a rest today
had enough since yesterday night

cause we are out of intensive care beds already

grief

lend me a minute of your time, and please let me teach you on grief

this is not a lecture, or a boring factual thing, its just something that we all should take a minute, and think about it

the process of grief start with denial state. for example, a 28 year old pt of mine, who has acute leukemia, (has 95% of blast cells in peripheral blood) , took an AOR discharge and refusing chemo and bone marrow.
--> the thing is , he is not stupid, he is not selfless , or an idiot, he is jst in a state of denial, where he should be given some time, to think about it and learn.
he whom in a state of denial, thinks that this is wrong, this couldn't happen to me.

denial state is follow by anger. i was once had an episode of pulmonary embolism. it had left me with severe disability to do my daily chores. i was angry, full of remorse. i start to think,, what ive done wrong to receive such a bad situation as this, i was so angry, that i refuse anticoagulation, i refuse blood examination to find the cause of my unprovoked pul embolism. i was in an anger state. i start to blame people around me, i blame my mummy for not taking good care of me. i was angry with my doctors, to tell me what i should do.** i was lucky enough that my anger did not last long.**

anger state, once it resolved, is follow by acceptance, acceptance is when u accept and redha on what had happened and is happening on you.like for example, the boy with acute leukemia, finally accept chemo, like an SLE pt who had severe disease with sever vasculitis, accept that she should spent a whole lot of her young adulthood in hospital and wards, rather that at shopping malls , and parties enjoying with friends at the same age. While acceptance in me comes with : i began to realize that i need to be anticoagulated, and i start taking warfarin, i went for my vq scan appoinment, i had my blood withdrawl very often to check my INR. i also begin to realize that my
asthma is getting worst despite maximum medical medications for asthma. i accept the fact that sometimes , and oftenly, i need admission to the ward for acute exacerbation. i also do not mind if my friends and my colleague who are house officer like me , knows my complicated medical illness. i was never embarrassed, i don't care what they'll say( of course they are profesional enough not to say anything), and most of all i don't care what they will think. ( i learn to change my thoughts know, thanks to dr lazli and dr firdaus). well that is acceptance for me

thant is grief. i looks simple, but it is not as simple as it looks like, once you understand grief, you will learn not just how you react, but also how you think, and direct your thoughts to something right.

d-dimer

ive been reading few things regarding d-dimer

( by courtney et al. : sensitivity 93%, specificity 51%)
-d-dimer has a very high negative predictive value

-d-dimer also need to be clinically interpretated from pretest probability)
-in high risk pt( wells score >4: d-dimer has no role in diagnosis)
high risk pt should just be asses straight by imaging

-as aforementioned, low risk pt, with -ve d-dimer , can exclute VTE

false +ve d-dimer: elderly, infection, inflammation)
false negative d-dimer in pt with pre existing on warfarin , or any anticoagulant

exam with miss tan

1. Differentials of RIF pain
a. In male : acute appendicitis, torsion of testis, epidiymitis, cystitis, diverticulitis, mesenteric ischemia, cecal cancer with obstruction, constipation colic
b. In female: to add on PID(tuboovarian abscess), ectopic pregnancy, torsion of ovarian cysts
c. In peads: to add on mesenteric adenitis, age
2. Investigation: twbc, ufeme, upt for female, pt, inr if suspect coagulopathy, buse ( asses dehydration)
3. Others: radiological axr: fecal loaded, dilated small bowel in caes of i/o 2 cecal cancer, in female , us gynae esp if upt positive
4. Size of bowel dilated: small bowel: 3cm, large bowel : 6cm, cecum iis 8cm
5. In acute appenditis: do u give painkiller yes, because if pt have peritonitis, the pain is always there
6. In appedicectomy: what layers: skin, subcutaneous fat, sup fascia, deep faschia, ext oblique, int oblique, transversalis fascia, peritoneum
7. What is the area for op: 2/3 rd upper from the umbilicus to asis . mac burneys point, via the lanz incision
8. How the pain is like: paraumbilical(gen peritonitis) to rif ( local peritonitis)
9. What is rovsing sign: press thelif, the have pain at rif ( d/t reffered pain: T10 innervation)
10. Pr in acute appendicitis: can see if fecal loaded, can feel for tenderness of the lateral wall in cases of pelvic appendicitis

11. Diffential of epigastric pain: surgical , non surgical

a. Surgical-
i. Acute abdomen: panreatitis, cholecystitis, cholangitis, reffered pain?, acute diverticulitis, mesenteric ischemia, volvulus, peptic ulcer disease, h.pylori infection.reflux oesophagitis, deudenal ulcer, intestinal obstruction: colon carcinoma
b. Non surgical- right lower lobe pneumonia, myocardial infarction, dka, adisonian crisis, crest syndrome ( scleroderma)

12. How to investigate: x ray, chest erect, us abdomen
a. X ray: abdomen calcification of pancrease in chronic pancreatit, erect axr: step ladder sign in i/o
b. Erect chest: air ender diaphragm

13. Ugib, pt come to ed . how do u manage: ABC:airways, removed the dentures, suction any blood, and remove foreign body obstruction, head tilt, chin lift
14. B: breathing
15. C: circulation: crystalloids: ns and hartman,. Hartman may cause lactic acisdosis, but still can be used in resus as acidosis is a later complication
16. How do u divide hypovolemic shock: stage 1-4
17. What is the 5 parameters: bp, pr, rr, urine output, mental status ( the other 2: vol of blood loss and % of the blood loss)
18. If after resus: what u proceed : take blood, hb, correct coagulopathy
19. Ask his: taking nsaids, trad meds, dengue: look for heamoconcentartion, look at platelet(ITP, hemophilia, von wille brand disease), aspirin, on warfarin
20. Examination: crt, peripheries, pulse vol, bp, lungs: any crackels, cvs: any gallop, p/a: any tenderness, how is bowel sound, pr
21. In pr: fresh melena: marron calor, stale melena: black to dark green
22. Then , how do u proceed: with ogds, can inject adrenaline, clips, of if have varices banded
23. If varices cannot band: pt bleeding: put sensteken blackmore tumes
24. Explain about sengtaken blackmore
a. 3 ports, one suction, and the other 2 are ballons port. The re are two ballons, gastric ballon and oesophangeal ballon,
b. The is also a gastric aspirate
c. The gastric ballon is filled with: 250 cc air(water?)
d. The osephangeal ballon is filled with: air pressure 30-45 mmhg(never exceed 45 mmhg)
e. Leave the tube for maximum 24 hours
f. If still bleed, and cannot control by endoscopy: for sclerotheraphy or tips(transjugular intrahepatic postcaval shunt
25. How to insert it?
a. First , consent. Make sure pt intubated, or not must be sedated
b. Check patency of tube
c. Insert the tube via: oral or nasal until the 50 cm mark
d. Pump in air, and listen to the air sound to indicate tube is already in the stomach
e. Then , aspirate all the gastric content , to prevent aspiration
f. Inflate the gastric ballon with 250 cc air
g. Then apply traction
h. If still bleed, inflate the oesophangeal ballon
i. Connet the free end oesophangeal port with the manometer, and inflate the oesophangeal ballon to maximum 45 mmhg of air
j. Keep for 24 hrs. if fail: for scleroptheraphy, tips
26. Indication of sengsteken blcakmore tube:
a. While waiting for endoscopy
b. Fail endoscopic band ligation
c. While awaiting for TIPS
27. Mva: u are at casualt y, pt come gcs: 5/15, how u proceed: withABC initial resuscitation
28. D:
29. E: exposure , log roll the pt , to look at any other injury
30. How do u asses gcs
31. Then, : to proceed with ct brain: edh: lentiform, sdh: cresent, sah: lightening? Of sulci and gyri
32. What is the life threatening chest injury: tension pneumothorax, flail chest,injury of great vessels, cardiac tamponade, open sucking chest wound
33. What is flail chest: when 3 or more ribs fracture , and at least at 2 sides
34. How do u insert chest tube
a. Get consent
b. Use open technique, lie pt down
c. Prepare set, prepare underwater seal
d. Use lignocaine to infiltrate ( maximum lignocaine is 3 mg.kg)
e. Locate: at the safety traingel
f. Pect major, lattissimus dorsi, 5 th rib
g. Use blade to nick the skin
h. Use hand to open in up
i. Then use artery to separate the muscles
j. Then, u will feel a give awayin penumothorax (air), or water comes out ( in hemothorax)
k. Clamp the chest tube, the insert
l. Conncet to the underwater seal
m. Secure with purse string suture
n. Chest x ray post chest tube insertion
35. If chest tube too deep, can pull out, if too superficial, never push in, off the chest tube, and insert a new ones
36. How do u insert cvp?
a. Take consent
b. Decide: subclavian, internal jugular, external jugular, branchiocephalic
c. Subclavian
i. Location. Medial third of clavicle
ii. Easiet rt side, as the lobe of the rt lungs, lower than the right
iii. The subclavian arteries lies superior and posterior to the subclavian vein
iv. Insert the needle, at the medial third clavicle, aim towards the sterna notch
v. Insert the subcalavian line as usual
vi. Cxr post insertion
d. Internal jugular
i. At the between the sterna head and clavicular head of scm muscle
ii. The apex is the clavicle
iii. Aim the needle to laterally, carotid arteries lies medial to the internal jugular vein.
iv. When aiming needle , aim it towards the nipple line.
v. Once gush of blood, insert the catheter as usual
vi. Cxr post procedure.
e. External jugular
i. Easier in this people where the external vein are prominent
ii. Pulsation can beseen, but cannot be palpated
iii. Compress the clavicle , to expose the ext jugular to be distended
iv. In other words, can put pt in tredelenburg position: to prevent catheter embolus , and to distend the vein
f. branchocephalic
37. The use of cvP
a. Use for measuring central venous pressure
b. For tpn insertion
c. To give medication
d. To give inotropes
e.
38. How do you do you proceed with incison of drainage of an abscess?
a. Example of breast abscess
i. Do an incision below the breast nipple( good cosmetic reason)
ii. Take pus c+s , drain the abscess, if can , use curret
iii. wash with povidone iodine
iv. then , pack with povidone gauze
v. wound inspection cm, or as outpt
39.