The end is the beginning is the end...

I'd finally survived a spontaneous vertex delivery from medical school on Feb 28, 2008! No meconium aspiration in the process, it was a clear pass. No resuscitation required. Am receiving my birth cert called MBBS in May, with my surname "Doctor" imprinted on it! Aahhh... the air is so refreshing...

With my mates

Kumpulan Kongsi Gelap Anti-Sosial

With my group study members, "Kumpulan Gagak Hitam"

He said Dua, I say Diu!

The godfather of medicine Health Minister, Latok Chua announced yesterday that newly graduated medical doctors will have to undergo TWO years of hell-holeship housemanship compared to the previous one year! What pissed my willy off is that the salary will still be the same for the entire 2 years.

Today's paper said that those bargers will seek to promote doctors to the U43 Grade only AFTER housemanship. You and I know what "will seek" means in Malaysian context! In other words, for the first 2 years of fresh graduates' life, we need to eat shit to survive. They claimed the consolation for prolonging the housemanship for another year is that we can enjoy a RM500 pay raise (upon approval of "will seek") and be allowed to pursue further studies right after housemanship. Be realistic lah, we often hear stories in the past that people got into a postgrad program as early as during HO (the rule was 3 yrs after completing houseman). Why still need to "will seek this" and "will seek that" when you have confirmed the duration of housemanship? Just blardy confirm the salary lah! We are ready to give and take if the deal is right, don't make it so arbitrary ok latok?!

Footnote: Sigh... there goes my 4-year plan of replacing Latok Chua! Niamah...

Curbside.MD

This is a new search engine for EBM. In contrast to the other search engines which require the old school way of using keywords, Curbside.MD provides evidence-based answers to real medical questions! Forget the keywords, ask a question like you would ask a medical expert. Enter patient’s info, diseases, drugs, even paragraphs of information. The more the better. This is because Curbside.MD uses a technology called semantic fingerprinting, which essentially works quite similarly to geocoding.

Click here to read more on how it works, or go to the main page to start searching!

Mantoux Test

Mantoux test is a test for tuberculosis. The test involves injecting a small amount of tuberculin (an extract of the causative bacteria) into the forearm skin, and the skin reaction measured 72 hours later.

This is the staff nurse who administered my tuberculin injection.

The nurse said the injection itself is quite painful, and claimed that she was quite nervous administrating Mantoux test for a "doctor".

It's an intradermal injection, meaning the stuff is injected right under the skin.

The injection site is left untouched for 3 days; no soap around the injection site during shower. The site is inspected and interpreted by an experienced medical personnel after 72 hours.

The skin reaction on my forearm, 72 hours after injected with the tuberculin.

Simply put, the induration (the reddish hardening) on the skin is measured to arrive to the diagnosis of tuberculosis. An induration of 10mm or more in people with no BCG scar indicates a positive reading for tuberculosis. In most people who are vaccinated against TB and hence, a BCG scar is present, a reading of 15mm or more is needed to indicate a TB infection.

8mm!

My skin induration measured 8mm (and yes, I do have a BCG scar)! That means I don't have TB! Fuhhh... On why I did this test, that's a story for another day!

Subungual Haematoma

Haven't start training for Seremban Half Marathon yet, mainly due to my subungual haematoma (bruise under the nail, also known as runner's nail in this case) sustained from Penang Bridge Marathon. Not sure if I'm gonna train at all, with impending exam stress and the painless purplish toe I'm having!

Unlike tridoc who's going to Lumphini Park this Friday for a highly specialised training with the hope of gunning it under 2hrs for Seremban Half (LOL!), I'm lying low nursing my bruised toe!

Consulted my orthopaedic surgeon, Prof. H this morning, as I was contemplating of draining the clotted blood by poking a heated needle through my toe nail (the standard treatment for subungual haematoma). He advised me against it, as my bruise is not huge and it is painless. Most importantly I wouldn't want any bacterial infestation by creating a hole on my toenail. And the complications of onycholysis and what nots. Will try jog a little tomorrow. See how it goes. The blistering hot weather doesn't help at all!

My Middle Finger

This is actually a picture of my left middle finger. Notice the pinkish lesion? I've been having it for about 4 months now. It's mildly itchy at times, otherwise I don't feel a thing. I was hoping it would go away with time but it didn't! Let's have a closer look...

Can you guess what's that nasty-looking thingy that I'm having on my left middle finger? And no, I don't have a fetish for fingering stuffs.

Fellatio reduces incidence of Pre-eclampsia?

Fellatio, or "blow-job", is oral sex performed on the penis (as if you did not already know!). I was browsing the net and came across this journal that claimed fellatio with subsequent ingestion of semen reduces the incidence of pre-eclampsia.

But before you strip your partner's southern region naked, you must be wondering what the heck pre-eclampsia is. Pre-eclampsia is a condition of hypertension (high blood pressure of 140/90 mmHg and above) during second half of pregnancy, typically accompanied by proteinuria (passage of relatively high amount protein in the urine) with/without oedema (bodily swelling).The cause of pre-eclampsia remains unclear, although aberrant trophoblastic tissue and immune mechanisms have been implicated. Untreated pre-eclampsia can cause foetal death, maternal multi-system organ failure, vaginal bleeding, and seizure. Conventional treatment of pre-eclampsia is to admit the mother into a hospital, and medication given to control her blood pressure. Ultimately, the doctors would have to deliver the baby as delivery is the only way to bring the mother's blood pressure back to normal.But what if there's a way to prevent this from happening in the first place? No needles, no tablets, no surgeries, no pain, and most important of all, comes packed with erotic fun and pleasure with your partner!

The study by Koelman et. al. titled "Correlation between Oral Sex and a Low Incidence of Pre-eclampsia: A Role for Soluble HLA in Seminal Fluid" found that oral sex and swallowing of sperm is correlated with lower incidences of pre-eclampsia! Neat discovery aye?!Before you rush to get hold of that therapeutic fluid, the last line of the study abstract also stated that "An extension of the present study is necessary to verify this hypothesis". Ooops did the warning came too late?Bet you didn't know blow-job has health benefits (provided safe technique is observed). There's always a risk of sexually-transmitted infection, mind ya! You wouldn't want your oral cavity to look like our mate in the photo above, so say no promiscuity aight?! Should anyone wanna find out more on fellatio, you know, how to improve your fellatio prowess, there's a book written on it too:Imagine, if further studies verify that fellatio and sperm-drinking actually reduces incidences of pre-eclampsia, O&G specialists will go around telling patient "Give your hubby a blow-job and make sure you swallow his cum, twice daily for a fortnight before attempting conception". Or, "Drink a tablespoon of your husband's sperm everynight before going to bed". Eww, *shudders* I feel disgusted already.

Just in case the links to the study mentioned above didn't work, here's the study abstract by Koelman et. al.:

The involvement of immune mechanisms in the aetiology of preeclampsia is often suggested. Normal pregnancy is thought to be associated with a state of tolerance to the foreign antigens of the fetus, whereas in preeclamptic women this immunological tolerance might be hampered. The present study shows that oral sex and swallowing sperm is correlated with a diminished occurrence of preeclampsia which fits in the existing idea that a paternal factor is involved in the occurrence of preeclampsia. Because pregnancy has many similarities with transplantation, we hypothesize that induction of allogeneic tolerance to the paternal HLA molecules of the fetus may be crucial. Recent data suggest that exposure, and especially oral exposure to soluble HLA (sHLA) or HLA derived peptides can lead to transplantation tolerance. Similarly, sHLA antigens, that are present in the seminal plasma, might cause tolerance in the mother to paternal antigens. In order to test whether this indeed may be the case, we investigated whether sHLA antigens are present in seminal plasma. Using a specific ELISA we detected sHLA class I molecules in seminal plasma. The level varied between individuals and was related to the level in plasma. Further studies showed that these sHLA class I molecules included classical HLA class I alleles, such as sHLA-A2, -B7, -B51, -B35 and sHLA-A9. Preliminary data show lower levels of sHLA in seminal plasma in the preeclampsia group, although not significantly different from the control group. An extension of the present study is necessary to verify this hypothesis.

Intensive Care Unit

A panoramic view of Hospital Tuanku Jaafar's ICU. This week sees my first time stepping into an ICU. Full of mechanical gadgetry and sick people. Am posted there again tomorrow. Yawn!

Post Gynae Long Case Exam

My patient is a 54 year-old widow of parity 1, who presented with cyclical menorrhagia of 2 years duration with mild symptoms of anaemia. I wouldn't say it's a postmenopausal bleeding despite her age (mean age of menopause for Malaysian women is 50.7 years), as her menses were regular cycles of 40 days with duration of 7 days for the past 2 years. She's recently diagnosed to be hypertensive and on medication.

Dr. S: Are you ready?
Me: (Give it to me baybehh...) Err, yes...
Dr. S: Say you are the one who saw this patient for the first time, how would you investigate her?
Me: FBC to assess anaemia, PT/APTT to see if there's any coagulation defects, blood grouping and crossmatch in case she needs transfusion. Thyroid function test for hypothyroidism as she appeared sluggish. Then, a transabdominal or transvaginal ultrasound to look for uterine and pelvic mass. Followed by cervical smear, Pipelle sampling, and hysteroscopy for direct visualisation and directed biopsy.
Dr. S: What can be done during ultrasound examination to improve ultrasonographic view?
Me: ... ... ...
Dr. S: Distend the uterus with normal saline la. Do you think a renal profile is justified in her case?
Me: No?... err Yes, actually... given her age she may have diabetes...
Dr. S: Yes! And don't forget she has hypertension too! Now, they are going to insert a Mirena into her. What's Mirena?
Me: It's a levonorgestrel intrauterine system used to treat menorrhagia and dysmenorrhoea, and is also used as contraception. It releases the hormone levonorgestrel locally in the uterus in small doses for up to 5 years, making menstruation lighter, shorter, and less painful (lucky I curi the Mirena booklet from the clinic!).
Dr. S: Other than Mirena, how would you manage the patient, medically?
Me: I would prescribe her haematinics for her anaemia. Then, mefenamic acid and tranexamic acid to reduce her menstruation. Also, hormonal preparations such as Danazol, Gestrinone, GnRH analogues, and combined oral contraceptive pills (COCs). (Was basically regurgitating facts from textbook)
Dr. S: Do you think she needs COCs at her age?
Me: Oops, sorry, no COC for her.
Dr. S: And due to her age, we don't normally prescribe Danazol, Gestrinone, and GnRH analogues. What other management options would you give her?
Me: Surgical options, and these are divided into fertility sparing and non-fertility sparing procedures...
Dr. S: Why do you want to preserve fertility in this patient?
Me: Oh yeah, 54 year-old, suppose to be menopause edy... (sh!t... again!). Then the surgical option would be more radical, such as vaginal hysterectomy, transabdominal hysterectomy, and laparoscopic-assisted vaginal hysterectomy.
Dr. S: Riiiiggght... ok tell me the physical findings.
Me: On general inspection, she's overweight with BMI of 25. She has pallor of the conjunctivae but no jaundice, clubbing, oedema, or cyanosis. Blood pressure 160/90, pulse 60, respiratory rate 16 breaths per min, afebrile. Her lungs are clear. On heart exam, apex beat is not deviated, dual rythmn heard and no murmur detected. On abdomen exam, it's soft, non-tender, no organomegaly, no uterine enlargement and no mass palpable. If given enough time, I would proceed to pelvic examination.
Dr. S: What would you look for in pelvic exam?
Me: Starting with inspection of external genitalia, I'd look for any bleeding or discharge. On speculum exam, I'd look for any ulceration or exophytic growth on the cervix, and if there's any active bleeding. I'd do a bimanual palpation to assess mobility of pelvic organs, feel if the uterus is retroverted, if there's any adnexal pathology and palpate for pelvic masses.
Dr. S: Do you expect to find anything in this patient?
Me: Not likely.
Dr. S: What's your provisional diagnosis?
Me: Given her history, I would like to entertain the diagnosis of benign growth of the endometrium, such as endometrial polyps.
Dr. S: You're not wrong, but do you think she would be given Mirena if it's a polyp?
Me: No,... no Mirena if it's polyp.
Dr. S: What's your differential diagnosis?
Me: Malignancy, such as endometrial carcinoma.
Dr. S: Yes, don't forget about malignancy. Why do you think her cycles are getting prolonged?
Me: ... err... hormonal imbalance... the ovaries are failing...
Dr. S: What do you call that?... failing ovaries and cycles getting longer?
Me: ... anovulatory cycles?
Dr. S: Yea lah, why you so scared to say that? So what's your diagnosis for this lady now?
Me: (heh heh, actually I tembak oni...) Dysfunctional uterine bleeding!
Dr. S: (polyphonic ring tone blasting loudly) Ok la, thanks.
Me: (yeahh... balik tidorrr... Oh no... Dato' S. is still in the ward...)

Post SAQ Exam (Int. Med)

Just finished my 1-hour SAQ paper for the Internal Medicine posting. There are 6 questions all together, and here's my contribution to the infamous "IMU Past Year Questions" archive.

Question 1
A man came in with right-sided pan-systolic murmur, fever, breathless. Multiple venous puncture scar on arm hinting on IVDU. Chest X-ray showed multiple cavitating lesions. Diagnosis is right-sided infective endocarditis, involving the tricuspid valve with septic embolisation resulting in pneumonia. I find the question "Describe the chest X-ray findings" a bit confusing. Is it asking for the cause of the pneumonia, or is it asking for other possible causes besides pneumonia?

Question 2
Middle aged Indian man came in with jaundice, epigastric discomfort, ascites, oedema. Causes of hepatitis? Viral, drug-induced, alcohol, biliary diseases. A LFT is provided, increased ALT. Two probable diagnosis? And give eight physical signs of liver disease.

Question 3
Patient came in confused, dizzy, vomited. Bilateral leg oedema. A BUSE result was given, showing hyponatraemia. What is the cause of confusion and vomitting? Answer: Hyponatraemia. Pathophysiology? Cerebral oedema. How would you manage the electrolyte imbalance (3 steps)? Answer: fluid restriction, diuretics, treat underlying cause, etc.

Question 4
A male executive came in to check his BP. It was raised la. Smokes ciggies for 15 yrs 10 sticks per day. Height 1.75cm, weight 90kg. His dad had DM and died of CVA at age 60. Give 4 investigations for his general well-being (again non-specific, tibai anything also correct I guess). What are the risk factors for development of CVA/CVD in this patient (give 3)? What are the side effects of hydrochlorothiazide he was given (give 3 also)?

Question 5
Old lady, collapsed at home. Another BUSE result given (normal range not given!). History of DM for 10yrs on Metformin. Random blood glucose on admission = Read: 60mmol/L! Diagnosis clinched - Hyperosmolar Non-ketotic coma (HONK)! Pathophysiology? Four other investigations you would perform on her? Management.

Question 6
Esha's question. Female came in with right-sided hemiparesis, history of two abortions, joints swollen and painful, with characteristic facial rash. Diagnosis - Systemic Lupus Erythematosus. Give four complications associated with the underlying disease (again, what is this question asking for?? I wrote the other manifestations of SLE). A syndrome commonly associated with SLE? Anti-phospholipid syndrome. How would you investigate her.

That's it guys. Overall, quite an easy paper la, since I never study that much also can answer >60%. If study more than average sure score kao kao one. Chiao, gonna makan. Can't go back KL coz Sunday got marathon!