Hari ke 11
4/30/2009 12:58:00 PM | Author: fadzly
Today Dr Sajar was to busy to have a class. Raffiq today gone with the wind.. He went to the GP earlier to get a medical check-up for his headache. He sent me a sms, he said his BP was high and his Cholesterol was also high. It might be the cause of the headache. But after that he's gone nowhere. I think he went back to JB, and later goes to Kelantan to meet his ehem ehem..

Today job was to be with Dr Nawar's wife..Dr Wan Noor Azlin.. hehe.. She was so friendly to us, and we manage to present some case to her. I presented DM case today. I managed to do peripheral neuropathy examination, ophthalomoscope examination and do RBS. Zawati presented some unknown diagnosis.. haha.. oldfolks always like this. They always anxious that something serious might happen to their body. Today cases are mostly pain on musculoskeletal, and some of them, Dr Noor managed to get an Xray done, and some of them also referred to Orthopaedic..

We went back at 12pm, then i met our old friends Adlisan coming from Kelantan using Air Asia. hehe, i'm smiling. Mangsa sudah datang.... Apa lagi, ask him to blanja me makan Pak Ali la.. hahahaha... I ask him makan pak li, later after eating, i buat2 forgot that i didn't bring my wallet.. muahahahah... So why did he come anyway?? Syafiq is getting married this Saturday. That's y he come, in order to ask syafiq to do the same for him the next week! Gothca!
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Pegawai Perubatan Siswazah..Terlepas..
4/29/2009 10:18:00 PM | Author: fadzly
Haha.. The title doesn't mean i regret or watsoever of not passing my exam. It just the current story of the HO that 'terlepas' from getting an action of getting caught by the minister.. haha.. This time, our health minister back them up..

Article from UTUSAN

Aduan doktor 'curi tulang' tidak benar - Liow

PUTRAJAYA 29 April — Siasatan terhadap dakwaan kononnya pegawai perubatan di Jabatan Kecemasan Hospital Kuala Lumpur (HKL) ’curi tulang’ mendapati dakwaan itu tidak benar, kata Menteri Kesihatan Datuk Seri Liow Tiong Lai hari ini.

Beliau berkata doktor yang dikatakan ’membaca akhbar dan melakukan kerja peribadi’ di wad kecemasan itu sebenarnya merupakan Pegawai Perubatan Siswazah dan baru selesai memeriksa pesakit terakhir.

“Semasa menunggu kad rawatan pesakit seterusnya yang belum dihantar ke biliknya, doktor itu sekadar menyelak akhbar yang ditinggalkan seorang pesakit atas sebuah troli dan hanya mengimbas tajuk utama akhbar,” katanya kepada pemberita di sini hari ini.

Beliau berkata dakwaan kononnya ada 20 pesakit yang sedang menunggu di Zon Kritikal juga tidak benar kerana siasatan mendapati hanya lapan pesakit yang sedang menunggu, selebihnya adalah waris kepada pesakit.

“Tiga pesakit sedang menunggu untuk dirawat dan lima lagi pesakit asma sedang mendapatkan rawatan,” kata Liow.

Ahad lepas, Timbalan Menteri Wilayah Persekutuan Datuk M. Saravanan mendakwa dua doktor di jabatan kecemasan HKL membaca akhbar dan melakukan kerja peribadi, bukannya merawat lebih 20 pesakit yang menunggu dalam kesakitan untuk mendapat rawatan.

Saravanan berkata peristiwa itu berlaku kira-kira 10.30 pagi apabila beliau pergi ke hospital berkenaan untuk melawat seorang pelajar universiti yang cedera selepas dilanggar kereta yang dipandu oleh pemandu beliau (Saravanan).

Take that u saravanan. Konon jadi hero tapi.... Don't judge a book by it's cover
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The 10th day of my 6 months
4/29/2009 05:47:00 PM | Author: fadzly
Woke up early?

So? What i do today? Got up early in the morning. i mean not early, 9.10 am.. In my timetable given by department, class start at 9.30. I'm not in a rush anyway, because hospital was just nearby my college. Then later when i came, Dr Sajar was there. She claims that she was there waiting us at 8.00.. owh.. so pity.. we all except Syud was coming at 9.30am. Then the dept get one of our phone number so that in case of something happen, they will call us.. Sorry Dr Sajar, she was so busy this week because of the ongoing Master's Exam now. That's why a lot of unknown people in the college currently.


This time she managed to get us a past year questions.. It seems to be simple, but i thought it was challenging. There is 3 scenario question, basically all of them can be in the paper, OSCE or long case. Ok i managed to get the question in my note, roughly let see the question!

Question One

Mrs Tan 38 years old teacher present to the clinic with a 6 months history of lower abdominal pain, bloated, increased flatulance and diarrhoea. She stated that she can pass up to three loose bowel movement per day. There is no fever loss of wt(LOW) and loss of appetite(LOA). She was recently diagnose to have diabetes melitus and is on regular follow up and treatment.

1) What futher hx would you elicit and give reason? (8 marks)
2) Give 3 differential diagnoses (3 marks)

On physical examination, she looks well, in pink, not febrile and not in pain. Her height is 163 cm, and her weight is 67 kg. Abdomen was soft and there was very mild generalized tenderness.

3) What other physical examination and investigation would you like to do? (7 marks)
4) She has went to 4 different GP for the past 6 months and on antacids and antibiotics for her current condition. She request for a scope to be done. How do you respond to her request? (4 marks)
5) Outline the management for this patient (8 marks)


This is a typical question in paper 1 for PCM every year. It just so typical that the question will start by asking, what futher hx u would elicit and what are the differentials?

So how to answer?

Read the questions first! Patient having chronic diarrhoea for the past 6 months. What do u think in your mind? Although the first question is what futher hx you want to take, but i usually start the 2nd question. So it will be easier for me to answer the 1st question, isn't it?

The DDx in mind are:
Irritable Bowel Syndrome (IBS)
SE of drugs such antibiotics, antacids, acarbose

So the next things is to elicit history from the DDx above, rite?
Just answer like Steps on History Taking so you wouldn't miss a thing.

History presenting Illness
1) Characteristic of the stools, is it watery, mucous, blood, malaena, soft stool?
2) Any aggravating/relieving factor such as food stressor?
3) Any associated symptom such as nausea or vomiting
4) Patient malnurish? Assess the symptom of hydration status such as cramps, very weak or lethargy, thirsty, reduce urine output.
5) Symptom of thyrotoxicosis such as heat intolerance, increase appetite, reduce weight, eye problems

Then go to past medical and past surgical hx.
DM, HPT? any thyroid surgery - past hyperthyroidism

Drugs Hx
DM- what type of drugs? acarbose, metformin can cause diarrhoea
Antibiotics? Antacids? - can cause diarrhoea also

Dietary Hx?

Family Hx - any GI malignancy in the the first degree relatives?

Social Hx - any stress event occur? such as financial prob, increase workload as a teacher? - stress can induce diarrhoea

So basically, it complete. eventhough u might miss something, but hey, the above answers already make u have 8 out of 8.

Ok 3rd question.

The question already done Abdominal, take her BMI(overweight skit). What other PE?
Hehe.. simple la.. Same principle. Start with vital sign. Temperature, BP, pulse. Then do the Hydration status such as reduce capillary refils, skin turger, sunken eye etc..
Thyroid examination jgn lupa aaa..- Goiter, thyroid eye disease, pulse - AF, thyroid acropathy, proximal myopathy and etc.
Per rectal examination!!
and because patient has DM - check the eyes, peripheral neuropathy
Investigation such as - stools for culture, ova and cyst!!
then DM - we do, urine dipstick, UFEME, renal profile etc.
Haha.. 7 marks already~!

4th question.

4 marks means 4 point to be inserted... This question basically testing your generals knowledge. Even a layman can answer it.. If you meet this type of question, it means, it is a PCM question.

TIPS: PCM will always ask about this and the answer will always rejecting the patient request! The answer should be basically like this:

Firstly i would like to like to assess the patient consern about why she want to do scope? What does the patient thinks? Did she thinks about GI malignancy?
I would tell her that currently patient is not indicated for scope yet.(be in mind what are the indications for endoscopy)
Tell her about the complication if she done the scope such as bleeding, perforation etc, and it is costly wasting your money
But, if after stopping the antibiotic and antacid, patient still having diarrhoea then we can discuss about doing the scope later

Nice isn't it? If you have another type of answer pls do not hesitate to give it at the comment section.
Last.. Outline the management.

Outline management means make it simple. First of all address the issues that the patient having now.
Issues are Diarrhoea, DM, Overweight, Stress, Multiple GP, anxious about malignancy

Diarrhoea can be settle by non pharmaco and pharmaco. Non pharmaco such as stop triggering factors and takes care of her diet and takes plenty of water. Anti-diarrhoea can be given to her.
DM - Compliance to medication, healthy lifestyle, reduce intake of sugar, fats, eat a lot of fibres, reffered her to dietician.
Overweight - Lose weight, excersize regularly 30 minutes and 3 times a week.
Stress - Reduce stress by plan management, sleep adequately.
Reassure again that this is not due to malignancy and give simple explanation about symptom of GI malignancies.

That its.. Penat menaip.. 2nd and 3rd questions will coming.. later.. i nak eat first...

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Starting my diary with Vertigo?
4/29/2009 12:52:00 AM | Author: fadzly

Yesterday was the beginning of my 2nd week posting of my Primary Care Medicine and i've clerk one patient with a c/0 of dizziness. Ususally, i'll be given an hour to clerk. because i got this patient late, i have such a short time to clerk this patient. Patient is 38 malay lady works as a kindergarden teacher. She complaint of having dizziness for the past two weeks that are worsoning. However the dizziness have been there for the past 5 years already. But this time it was the worst and not relief by medication. At first i was thinking of Benign positional proxysmal vertigo (BPPV).

As a typical noob medical student, when we have a target, we cant think of other disease. I do manage to think other disease such as anaemia causing vertigo.

Time up! owh damn. i havent finish clerking and i didn't manage to do any of physical examination. my lecturer ask me to present the case. So as usual, i present in the way that i usually present. (haha). Dr ask me what the diagnosis. So i tell her the BPP

V and also the anaemia. As always, a typical lecturer will do is to ask alot questions regarding the history. haha.. i terkena so badly today.


Did you ask about anaemia? Did u ask about other things apart from lethargy, SOB etc? Owh damn... i forgot and blank.. then i ask what dr? lolz.... we shouldn't ask like that! kene lagi!

You need to ask about menstrual hx. Do u ask that? Do u ask about any cause of anaemia? Do u ask anything about bruises, jaundice, diet hx, etc2.. owh then i got it.. it's just the cause of anaemia.. Lolz. Of course i knew it, but then again, i cant relate it with the hx i take.. how pathetic..

Then the dr ask the patient to come in. This time dr take the 'proper hx'. The patient claim that she's having it since the day she delivered her last child. It was also associated with tremor, palpitation. and she said it again and again. She claim the dizziness also come during when she needs to see the principle, or need to get infront giving speech to the students. So what do u think the diagnosis now? Hehe.. wait till the end of the post..

So we do the maneuver to detect nystagmus to rull out BPPV, we do CVS also. But we didnt do any CNS examination. At the beginning, i was shock, but deeply in my heart saying thank god that the lecturer didn't ask me to do the worst examination ever - CRANIAL NERVE EXAMINATION.. haha.. Anyway we make it simple, dr have the diagnosis already. The lect says 'u all should think of Psychosocial also u know'. Immediately i think, what on earth vertigo related to psychosocial. So i took my oxford handbook and got to my vertigo page. (7th edition page 454). Now i know that vertigo can be true and false! aiyooo.. Oxford says, what is not vertigo is faintness may be describe as dizziness but often due to anxiety with associated palpitation, tremor and sweating. lolz.. i've study for 2 years and i still didn't know that vertigo(i meant dizziness) can be due to anxiety!! HAHAHA.. That's might be the case that i need to study extra 6 months..


Just forget about it, it's happening already. So the diagnosis was Panic Disorder and we managed her by doing FBC, thyroid function test, and gave her anxiolytics which is benzodiazepine. Because my lecturer was so afraid of giving this drug due to the SE (addicted) she only dare to give her the drug for 3 days, lolz... Nevermind then, a psychiatric will give her more.. muahaha..


So in summary, dont think that vertigo is just due to the inner ear problems only. think generally such as anaemia, heart disease, thyroid and put the tumour at the last last last last part of differentials or the best is dont ever say it and try think of psychiatric.. hehehehe..

Just want to share some readings materials in the web about anxiety. Nice to read, really. The site shows ways to tackle your anxiety. http://www.treatment-for-anxiety.org/

Till we meet next time, nite..


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Does it really makes money?
4/29/2009 12:48:00 AM | Author: fadzly
Next things to do is having nuffnang in my blog.. i see alot of ppl having their nuffnang in their blog and i thinks it not a prob for me to try it..i'm still long way to go anyway.. haha..
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Starting while i'm extended 6 months..
4/28/2009 10:50:00 PM | Author: fadzly

I'm thinking of starting a blog now for this 6 months when i see so many ppl now are blogging.. haha..

ok i will tell abit what would be in my blog. first of all, it will be about me, my life, my frens during this 6 months and also the things that i learn during this 6 months. Hope this will be a note or a diary that will help alot of ppl out there who are struggling in their life. Hope in future also this blog will help to those who are in a stage of failure, i mean specifically to those who extend 6 months during their MBBS or MD in Malaysia.. haha.. no la.. i wish no one will fail during their study. what ever.

But i need to start with something anyway. So, happy surfing and blogging. may be the best in our future. amin..


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