Short Case Internal Medicine

On the 27th of December, I had my short case exam for internal medicine. I left home early that morning, around 7.30 am, because I didn't want to be late, thinking that the exam starts at 8am. I reached the French Kasr el Ainy hospital around 7.40 am, the road was clear. To my surprise, I couldn't find any of my malay classmates there, not even Iqbal! It was weird, because usually, he is the first among us to get there. So I waited and waited, and I saw some of my Arab friends who were in the same group, that was a relief, at least I was at the right part of the building! I called Lina, she didn't answer, again, another wonder. Then it occured to me, maybe the exam starts a bit late, it's just that I wasn't informed about the time, I just assumed that it starts at 8am, as with the past surgery clinical exams. And yes.. the exams was supposed to start at 9.30am!

But it's ok. I enjoyed sitting with Tala and Ghaidaa, we discussed about the general examinations and later, Faaiqah came. She also didn't know about the time of the exam. Alhamdulillah, the weather was perfect, so it was really nice to sit on the bench outside the hospital. The weather was nice, not too cold, but the dust on Kasr el Ainy Street my face itch after an hour, I don't know whether it really was true, or it was psychological. :P

Then, at about 9.30 am, we went up to the 6th floor, by stairs! A GOOD EXERCISE! By the time we got to the 6th floor, we were all dyspneic, but still managed to laugh at ourselves for being so "fit" and still be able to talk in sentences with words separated by deep breaths. We had another quick discussion, mainly asking each other the important questions... later, we were called to wait outside the wards. When my number was called, I sat on the chair outside the ward, I thought that the other Malays who went in earlier had already gone in, but no, only Faaiqah has. Iqbal, Dzul and Izwan were still waiting outside the ward. I felt a bit nervous because I didn't know what to expect, even worse when some students came out and showed bad signs... some said that there were malignant doctors. I chose not to believe them. I didn't want to be affected by other people's opinion, because I believed, insyallah Allah will set the best for me. I am pretty sure that the students who said the exams went bad did very well, it's just that they have a very high standard and expectation so they consider not answering a few questions perfectly as not doing well.

I think I waited around 45 minutes for my turn. I just sat alone, I was the last person to go into the ward! When I went in, the professor (neurologist) showed the bed of my patient.

Patient 1

She was an old lady, lying comfortably in her bed accompanied by a middle-aged woman, I supposed she was her daughter. The paper above her bed wrote "Cardiology and Neurology" so this means that I had to examine both systems. So I thought I will start with Cardiology... not long after that, the professor who showed me the bed earlier told me to inspect the patient's apex and percuss the aortic and pulmonary area, then proceed to auscultation. So I did what he told me to do. The findings seems normal, even the heart auscultation, but her radial pulse was rather strong. I couldn't hear any murmurs, it took me long to confirm that her heart auscultation was normal because I didn't think that they would give you a normal cardiac case for the exams and tell you to examine the patient.. I was wrong, hihi! As I was about to put my stethoscope on her chest, all sounds murmurs appeared in my head! Alhamdulillah, her heart was normal, so the discussion would be easier.

Examiner: What did you find during the inspection of her apex?

Me: Her apical beat wasn't very clear, so I told her to turn on her sides and it was in the normal anatomical position.

Examiner: Which is?

Me: 5th Left intercostal space, midclavicular line.

Examiner: The character of the apical beat?

Me: Normal.

Then he told me re-percuss the patient's aortic and pulmonary area, so I did. But I forgot that when percussing, I was supposed to go from lateral to medial... I directly percussed on the area. The he asked me, "which way is your direction?" then I said, "oh yeah, I was supposed to percuss from lateral to medial." He laughed. Well, at least he didn't tell me off.. fiuh!

The next part was the neurological examination. He instructed me to test the reflex. When I tested her biceps reflex, her reaction was exaggerated but I didn't want to say it was hyperreflexia until I checked the rest. She was hyperreflexic for both side. Then when I tested her plantar reflex, she showed positive Babinski sign, so it was confirmed that this is hyperreflexia and most probably UMNL. I thought she was paraplegic until she moved her legs! So I tried to do a quick diagnosis (luckily for short case, we don't have to give the full diagnosis)... so I think her hyperreflexia was due to thyrotoxicosis, which also explains her rapid strong pulse.

Examiner: What did you find?

Me: The patient shows hyperreflexia.

Examiner: Which side?

Me: On both sides.

Then he told me to do the plantar reflex again as asked what the response was.. it was dorsiflexion which means positive Babinski sign.

Examiner: Causes of hyperreflexia?

Me: UMNL, thyrotoxicosis..... mmmmmm.....

Examiner: Sympathetic overactivity?

Me: Oh yes, sympathetic overactivity.

Examiner: Good, you can go.

That was all??? That was a bit short for 120 marks!

Patient 2

I moved to the next ward, so it was a different patient and I was being assessed by a different professor. The patient was an old male patient which a distended abdomen, it wasn't due to ascites, but obesity. The doctor asked me to palpate the patient's liver.

Although he said palpate the patient's liver, you always begin with tidal percussion, to detect the upper border of the liver first, this is to differentiate between a ptosed liver and an enlarged liver. After tidal percussion, then you proceed to the liver palpation.

Examiner: What are causes of enlarged tender liver?

Me: It could be due to congested liver as a results of right-sided heart failure, inflammation of the liver or malignancy.

Examiner. Ok, good. What if you find the patient's transaminase elevated and positive for HCV, what is your next step?

Me: I will do an ultrasound to check whether his liver is enlarged or cirrhotic.

Examiner: Good. Then what else?

Long silence, I was trying to think, what other investigations should I do? I can't do liver biopsy since this patient might have bleeding tendency.

Examiner: So, how will you treat this patient? --> I see, that was what he meant by "what else"

Me: I remember that there an antiviral named Lamivudine that was supposed to be added to a drug but I can't recall the name of that drug.

Examiner: It starts with alpha.

Me: Alpha interferon.

Examiner: Ok, you can go now.

Correction: I said the wrong answer. Lamivudine was for HBV. Ribavarin is the anti-viral drug for HCV. Luckily he didn't say anything about that!

Alhamdulillah, the short case exam wasn't so bad. I felt happy. Hopefully, I can be as happy for my long case exam this Sunday!

• UMNL = Upper Motor Neuron Lesion
• HCV = Hepatitis C virus

The Shift

Yesterday, I watched The Shift. It is a movie made by Dr Wayne Dyer. I was really moved by the movie and learnt so much things and I would like to share them with all of you.
Today, we live in the world where everyone is so focused on the materialistic world lead by human ego. What does ego teach us?

• I am what I have.
• I am what I do (achievement).
• I am what other people think of me.

If we go back to the basics of what Islam has taught us, all the 3 things mentioned above is not what has been preached. Owning a closet full of Louis Vuitton handbags does not mean that we are a great person. The human ego makes us chase the wrong thing and hence, leading a life in the wrong direction. Becoming a doctor does not mean that you are a great person. I just love how the movie made me think of what my life purpose is, the movie is very intense and spiritual. For muslims, it's even easier to understand because the values had been taught to us since we were babies.

Finding your life purpose is very crucial so that we will not loose hope and believe that Allah has set everything for us, and the things will appear in your life when the time is right. Now, I want to make a clear line between leaving things to fate and planning your life... well, being positive and believing that Allah has set everything for us should not make us lazy and leave everything to fate. From what I understand is, I should continue making plans for my life but, while doing that, I keep believing that everything will fall nicely into place according to what Allah wants to for me. One of the example that my mum gave me was, let's say I open a restaurant... if my priority was to get as many customers as I could, I will be stressed out, looking for new customers everyday... and think about how many profit I would make for that day. I would also put unhealthy ingredients as long as I make the most out of my sale. This happens, right? How many times have you been to restaurant feeling really pissed that the food didn't taste so good. Ok... now, I have shifted. I found my purpose of life and I know exactly why I wanted to open a restaurant in the first place... it could be that I want to serve good healthy nutritious food to my customers and keep them satisfied, I would focus more on the giving, focus more on service... surround everything with love.... it would totally a different setting, right? I don't have to worry about how much profit I make, but instead, I focus the service and hence, the profit will just follow along. There's a marked difference, right?

I think it is about time that the world changes.

Watch THE SHIFT.

I'm not lucky in love

Last Sunday, I went to a Spinning class at my gym. It's a group exercise where you cycle for about 50 minutes. It was very intense but I enjoyed it and I think I did quite well for a beginner. It was my first time. The instructor's name is Heba, a very nice lady, she was friendly, helpful and very welcoming. I particularly chose classes that was for the ladies only as it was my first time, I didn't want to feel uncomfortable with other men around. It can be a bit intimidating sometimes because the people there are so fit, especially the ones who come after 5 pm. When I got out of the spinning classroom, it felt like I was at an audition for Spartans! Get the idea? 

Anyway, the class was really good but the music was a bit too loud, luckily my bike was far from the speakers. What I like about the class was the fact that it's a group cardio workout, so you support each other, and you get motivated looking at the fit lady in front of you. It certainly made me feel motivated. I plan to go to the next class again and I will stick with Heba since she knows that I am a beginner. 

During the class, Heba helped us by making us visualize cycling outdoor, with the cool breeze blowing and bla bla bla... this part, I like. But when she starts increasing the resistance, I began to get pissed, hehe. And she said, "I know you all hate me for this, but I told you, I will take your breath away!." Once I got the hang of the new resistance, I liked her again. Anyway, she said she dreams of cycling all the time and it is one of the things that she really loves. Then someone from our group said, "well, later, you can start dreaming of the man in your life." Heba replied, "I do, I dream of him all the time but it's just that I am not lucky in love." 

I have heard this kind conversation before, in fact twice... at the gym. It's funny how people tend to be so negative about life. I know it is unfair for me to say this, but it made me think. Was she really unlucky or it's her perception that she is unlucky? I understand that sometimes, marriages don't last because of many reasons but it shouldn't make you feel that you're not blessed with luck because I truly believe that everyone is lucky in their own way and that Allah has so many great things set for us. I hate to listen to this kind of conversation as it can scare me, I cannot help but wonder how my life would end up being. BUT... I would shut off those negative feelings right away. It's not good to think of bad things, I have to be careful of what I think as it can shape my emotions and of course, my life. 

Before, I used to worry over small things, then as I began to read more about Law of Attraction, I could feel my life changing. Things remained the same but I felt happier. I used to think that happiness is something that you get, but in reality, it's just a state of mind that can be easily changed IF YOU WANT TO! After practising this kind of life for about 3 years, I certainly complain less, I am more optimistic and the best part is that more great things are coming towards me. Alhamdulillah, I got the support from my mum as she also practises the same lifestyle, so whenever I feel down or in doubt, she'd help me out. So our weekly phone calls would be about the manifestations of the positive vibration. It is really amazing. My mum has changed a lot, she was great before, but now, she's much much more optimistic and I just love her positive aura. Talking to her on the phone can keep in positive vibrations for a long time, and when I get stressed up about my exams, I'd get myself "recharged."

I hope all of you understand about the Law of Attraction. If you don't, do make time to google and study it. 

I have my long case surgery exams this Saturday! Bubbye for now.

Case: Ulnar Nerve Injury at the wrist level

Me: can I examine your left hand?

Patient: Give me some money for my tea then I'll tell you the positive findings?

Me: I'm so sorry but I have no small changes left. I had given them to the previous patient.

Patient: ok, I won't help you out with what I know about my case. (muka merajuk)

This is the story of chronic 'professional' patients. They can talk about their diseases like doctors. Can be helpful but can be painful if you don't spare enough small changes!

Nile

- Posted using BlogPress from my iPhone

Workout plan

I opened my small notebook that I take everywhere and I use it to write the things that I want to buy or do, just in case I forget. The last time I wrote in my small notebook was on the 16th September 2009, and it had a list of workouts I planned to do. Oh boy, has it really been that long? Sadly, YES!

The reason I opened that notebook was because I wanted to write what routines I planned to do tomorrow. Yes, I am a planner kind of person, I write every single that I want to do, it helps me get more things done, especially at the gym. What I notice is that, if I go to the gym, and just follow the flow, depending how my body responds, I'll be out of the gym after 30 minutes, well, maybe after an hour, but it's because of the long minutes in the steam room, hehe. Hence, a proper plan is needed since I workout on my own now, no more trainer. My contract with her has ended and I don't want to continue with her because of my exams, it is quite challenging to argue with my trainer when I have exams, she'll keep on calling asking when I can come. I don't blame her at all, she's doing her job. And most of the time, I feel obliged and go without wanting to go... actually, that is the best part, because I still get to go. When Rehab (my trainer's name) is around, I workout for 2 hours! Talking about her makes me miss her, I just hope I don't bump into her tomorrow, I don't want to see "that" look on her face, where she looks at me up and down, checking whether I put on weight or not. She still does that although she's not my trainer anymore, I guess she's just concerned because she knows how hard I worked before to loose the extra weight, and didn't want all the effort to be wasted. During the whole of working out with her, we developed a great friendship, sometimes, she gives me free sessions. How nice is that, right?



Ok.. so what I planned to do tomorrow:

• 45 minutes on the treadmill including warm-up, speed 5.5 km/hour, incline 2%. I'm going to start gradually, because I want to overwork my calf muscles. I should burn about 200 calories. Insyallah next week, I'll start jogging and running again.
• 30 minutes of abdominal workout on the matt.
• In between the matt workout, I'll do some quick cardio like skipping or quick run for 2 minutes, just to keep my heart rate high. According to Rehab, I'll burn more fat this way.
• End with 30 minutes on the EFX cross trainer.

Elliptical Crosstrainer

Hopefully I'll be able to update tomorrow with good news and feeling of satisfaction after being able to reach my goal! I am so excited, and I've also packed my gym bag so that I can leave as early as I could tomorrow morning, maybe around 7 am. One the main factor that makes me feel lazy to go is packing my gym bag, I cannot be bothered to do it, and it makes me not go.

Health is wealth! ;-)

Tumblr

I just created a new account at tumblr. It looked cool and I think from now on, I will continue from there.. Surely you're thinking.. oh no.. moving again??? Create an account there and you will see why I fell into the trap, it has cool features that are so simple to use.


The link is http://aniahazmi.tumblr.com

Pronioa

Pronoia is the opposite of paranoia. Instead of feeling that everything/everyone is against you, you feel that the whole world is favoring you.

I was inspired by an email I received a few days ago, about a person, who felt that the whole world is against her until one day, she decided to write a list of the people who were against her. Surprisingly, she could only come up with 3 names. So this leaves her with millions of people are willing to help her.


I just finished my written exams, and along the way of preparing for the exams and during the exam itself, I did face a few challenges, but somehow, I managed to face them really well. I chose to be in a state of pronoia, as always advised by my mom. I love talking to her, she always makes me feel better. Alhamdulillah I feel blessed thinking about how great my family had been towards me, especially during the times of stress. They were always there to help me out physically and emotionally.


Ok, my first challenge was I decided to change to a different surgery textbook as my reference for the finals at the last minute, which was 2 months before the exams. The thing is, I had always thought about changing the book, but I thought I was making the right decision all along.


The story begins like this… I had been attending private class (we pay extra money for the class, not part of the university tuition fee) by a surgeon, who was not part of the Cairo University faculty. Ok, let’s name him Dr W. Although he is not very popular among the doctors in my university, I still respect him for his knowledge and his enthusiasm in teaching us. He is indeed a great surgeon. In order to follow his lectures, it was best if the students read his books as the notes in there are in exact orders of his lectures. Many of us were advised to study from the textbook written by the department of surgery, but of course, I preferred Dr W’s book since I had extra notes that I added in during his lectures. I was doing fine with the book, I didn’t see anything wrong with the book except for the spelling errors, which is very typical if the book is written by Egyptian doctors. But I consider them trivial flaws, what’s important is the content, not the spelling because I can always make up what the word was supposed to be. Ok… so during my study leave, I began with Ischemia as the first chapter to start with. Then I referred to the department textbook, to see how the book explained about one of the investigations for lower limb ischemia. As you can guess, I felt like screaming, regretting for not opening this book earlier because it was way better than Dr W’s book. I was in a dilemma then, I couldn’t decide whether I should start referring to the department’s book or just continue with the Dr W’s book. I followed my instinct.. and changed book, and that left me with little to time to cover 700 pages. “Oh that’s good… ” I convinced myself. Because of the limited time, I got myself to rearrange my plans and planned to read 40 pages per day… and alhamdulillah I read everything on time and I really enjoyed myself. It didn’t feel like I had to force myself to read and understand. So I think there was a reason why Allah made me realize that I should read the department’s book, it was so that I get all excited about a new book! It was very exciting indeed. While I was deciding, I thought to myself, if I don’t read this beautiful book, I will never read it, because I don’t think I would have been bothered to study the book after I finish the exams, and the principles taught is very crucial to understand surgery!


The second challenge happened on the exam day, my second paper of internal medicine. I understood the instructions wrongly where I wrote my answers for Dermatology on a different paper when I was supposed to write it in the same booklet as the Internal medicine answers! This costed me 18 marks! After I handed in the answers for Internal medicine, I waited for the doctor to take my dermatology answers, then I realized, I got the instructions wrong. I ran and chased the doctor and told her what happened, and she took me to see the “big boss” and he said that he was sorry and nothing could be done. I admitted my mistake and begged him. So he took the paper that had my answer and put it in his pocket and he told me to see the dean, and the dean, Dr Nadia said that it was not a problem and the marks will be counted. But I had doubts, I doubted whether something was going to be done, I felt like Dr Nadia said that to make me feel better so that I can concentrate on my next paper. It was done and there’s no turning back. I can’t undo anything so I might as well focus on my Surgery exams. I did feel a bit pissed at the system because they gave the briefingduring the exams, and not before the exams. This is very typical of the Egyptians… the give you instructions during the exams, they go back and forth, shouting telling us where to answer… and I have to say, it is very distracting. But I cannot change that, I can change my reaction to it, which was to accept them they way they are and just be happy! Actually, I got used to answering exams in a noisy environment. If you were to ask any Malaysian students here, I am pretty sure they’d say the same!


So.. how did I change this event into something positive?

1. I reflected back at my goals of why I wanted to score for the finals… getting good marks is a bonus, but it’s the knowledge that was more important. Earlier on, I chose to study hard so that I could get as much as I could because I notice that if I aim low, I wont get as much, but if I aim high, I will work my ass off trying to remember and understand everything. And I believe that is the most important thing. To me, my goals were partially attained, I got what I wanted, which was to understand medicine and surgery! So that calmed me down, the marks was not as important as my understanding.
2. It’s just 18 marks out of 1000 marks! Only 1.8%!!! Why bother, right?
3. Something great is coming to me, that’s why Allah challenged me with something frustrating and hurtful like this. And I look forward to receiving the “gift” Allah has in store for me!

This challenge has also made me want to study extra hard for the Dermatology viva exams to compensate for the lost marks (just in case it wasn’t added in). To be honest, I didn’t really study for Dermatology, I started memorizing the points the night before the exam! Although the questions were quite straight forward and I could answer them, but the knowledge I had about Dermatology is very thin. Hope I do well in the viva exams.
On a different note, I am really enjoying myself right now. The weight on my chest has finally been lifted and it feels really good… and I look forward to the clinical exams. Insyallah I will get cooperative patients and helpful examiners, and not the malignant ones!
Have a phenomenal day!

One of the few pictures that make me smile ;-)