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Malay in the wards - 16/4/2017
updated Blood pressure examination - 23 August



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Saturday, 20 May 2017

The books I use (or used) in medical school

I've always hated reading the lecture notes (because I believe the essence of lecture lies not in the lecture notes itself, but the delivery) or the study material my university prepares for us.

Also I like the feel of books, so this is why I bought (like everyone else) books of my own, to aid my studies.

There were some books that I never touched even though I bought them - I have omitted them here.

Let me introduce the books I have ACTUALLY utilized during my medical school days. - in the order of frequency of use maybe.
I've put Amazon links because you can actually go there and look at OTHER PEOPLE's reviews. I think it's a good idea to get as many opinions as possible!

Macleod's Clinical Examination 




My university follows this book very closely for our OSCE sessions, and this book is great because it is very comprehensive, and filled with diagrams that are easy to understand. if you're going to buy ONE book for OSCE, be it this one - one could buy Talley's if you like to have explanations for everything you do.

Oxford Handbook of Clinical Medicine 



I really love this book because the information that we need per illness is nicely pressed and packed in this small book. It also has a bit of humor in it so it is a fun read as well. This is a book that is actually worth reading front to back. If you're getting ONE book in medical school, maybe it is this one. 

Oxford handbook of Clinical Examination and Practical Skills 



You may be asking "why do I need a second book for Clinical Examination?" but I like to bring a small book in my pocket in my white coat rather than holding a big book in my hand... and Oxford handbooks are really great looking things. I did read them quite a lot thanks to its portability 

Oxford Handbook of Surgery




Okay now, you might be thinking Oxford handbook again!? but ... well I think they're good. deal with it.
When I got to clinical years, I had to find one book to read from for surgey - as it was a new concept and I didn't know where to start. this book set my mind straight. it is also very concise and simple to read.

Harrisonn's Principles of Internal Medicine




this book is like the epitome of Medical Reference books. The reason why I like this book is because it is very comprehensive, and very intimidating. It is also very heavy, so you could probably knock someone unconscious in the event that someone is noisy in the library.
Jokes aside, I feel that this is the ultimate book to read up if your burning desire to know more about an illness isn't satisfied by either lectures or internet searches.

Netter's Clinical Anatomy 



Anatomy is ONE area of medicine that doesn't change over a few centuries, and therefore you won't be wasting your money by getting one book. If I were to choose ONE anatomy book to read from, for me, it was this - because it is more colourful, it is simple, and it is clinically oriented.

I never really enjoyed anatomy back in my first couple of years, but when I re-visit them after I have done my clinical years, I started to see how important it is. So currently I enjoy reading anatomy - back then, not so much. Tell me if you find a book that could INTRODUCE people to anatomy...

Clinical Microbiology made Ridiculously Simple




this book saved my life back in year 2 because (like everyone else) when I started microbiology, I was completely stunned at the amount of bacteria / virus we needed to be accustomed to (and the microbiology lecturer was like... "come on guys, you should ALREADY know this" - which wasn't the most helpful comment. I was feeling like I don't know where to start, UNTIL I read this book.

this book is filled with ideas to remember the multitudes of microorganisms, and it is presented in such a way that it is almost a storybook. Definitely a must, if you think microbiology is hard. Move on to other books if you have a good grasp of microbiology.


...So far, that's all I can think of! believe it or not, you can learn quite a lot of stuff online and therefore I only utilized a small number of books.... I think. 

Friday, 19 May 2017

(Alternative) Ways to study medicine

Today I'd like to talk about how I bring variety to my own learning by doing lots of different methods of learning.

because I am not a very patient nor hardworking person, if I were to limit myself to a single study method, (e.g. in my university, the "best" way or the most popular one was to just read from the lecture notes and MEMORIZE EVERYTHING) - I would just die. I mean, I would lose that interest and my brain would stop producing endorphin and dorpamines and all the feel-good substances that I need to sustain my healthy mental health.

I like to have variety in learning because...

  1. It makes studying less boring and hence I can study longer
  2. I would be able to find out what's best for me
  3. I can be like hey check out my new way to study (like right now)
  4. By employing other ways in which I learn, I can provide an alternative viewpoint - who needs another boring medical student who studies like everyone else?
and the list goes on. I want to study differently, so I study differently. 

Now, if you're a.... say, a third year student, you might already know those following ways to learn because you've gone through that "I would rather die than read another page of notes" and turned to other ways to study. 
So, perhaps this blog entry would benefit the more junior students more than the seniors. anyways here goes!

other ways to study!

watch youtube videos
Youtube has plenty of stuff that are both informative and fun to watch. some channels in Youtube are dedicated to provide quality information FREE OF CHARGE. Basically, there are people who want to learn medicine all over the world and we face the same pains. So might as well learn from them!
here are some youtube channels I follow!

Armando Hasudungan  - He draws a very comprehensive schematic diagram with which he describes basic medical facts. Some of his videos are really great at understanding basic concepts that you may need to straighten out before you get to the specifics in 10 minutes or less. here's an example - Overview of Immunology - great introduction to immunology and an overview of what immunology is all about. 

Geeky Medics - These guys make this blog an embarrassment because their OSCE guides and demonstrations are far easier to understand and refer to, than the text format I provide. They provide really good quality OSCE demonstrations. here's an example - Cardiovascular Examinations  - a straightforward examination of CVS. 



OnlineMedEd - This channel would be very useful for senior students OR current doctors whom (surprise surprise) are studying for exams. They are fully-fledged doctors trying to provide quality medical education to people, apparently their videos are free but with some cash, they'll teach you how to pass exams and most importantly, to be "a better doctor" - their slogan. here's an example - Antibiotic Ladder - It requires that you have some knowledge about drugs and microorganisms, but this tutorial is great for 3/4th years. 



Teach other students

You can offer to teach your friends or your juniors - the great thing about teaching is that the moment you teach, you win - teaching is one of the best ways to integrate information in your mind so that you can make it your own and answering exam questions would be a piece of cake. Teaching is hard,  but if you're able to teach so that other students can understand, that means you have really grasped the essence of the topic you're trying to cover, and this is my personal opinion but doctors should all  be teachers as well - to the peers, patients, and themselves. If there's some information to be learnt, it might as well be presented in forms that are most easily digested. Teaching will make you realize some things you needed to know, but didn't know you didn't know at that moment. 
If you're good, people would start paying you even! Which is not uncommon in medical school - some students can afford it!

Form a study group

Who does study group nowadays? Nobody! I think this is because everyone assumes that either you can manage to learn everything by yourself, or that everyone else has no time for group study. Which I beg to differ because group studying is one of the best ways to study - as evidenced by the fact that most medical schools now employ group learning sessions like PBL / TBL system. 

What is important about study group is that you're forced to output information more than you input - of course you listen to your peers, so that's an input, but when you need to present your ideas and facts to your peers, It requires that you fully understand what you're talking about.... either that or you develop a skill to beat vigorously around the bush until you bang onto something relevant - which is also a useful skill to have - but don't rely on it! Ultimately we want to be safe doctors, not politicians. 
here's me making the most out of group discussions. 


Take tests 

I like this method because it does two things - it forces me to get used to be tested, and it makes me realize what information I am missing out. Sometimes I go ahead and test myself before I read up anything about the topic so I can vaguely understand what may come out and what seems to be more important. 
It is best to take tests where the answers are properly provided on the back of the page or elsewhere. 

taking tests and checking the answers stimulate our brain more because of that pressure of answering questions, getting it wrong, and the "ahhhhhh" moment when you look at the answers. when you go  "ahhhhhh" that's when the information sticks. because memory tend to stick with emotions. 

here's me checking my answers. 15% correct...!? fffffff


Keep things at your fingertips

... and what are near your fingertips by default? YES - your smartphone.

I use apps which makes it very easy for me to readily refer to good source of medical information.

here are some example - 

Medscape  - Medscape is a website with a great deal of good quality medical information. It is also free (I think) with registration. Whenever I need to look things up, I can refer to this for a solid back-up of facts. Perhaps if i spent more time on this and less on Instagram, I could have been an A student. 

as you can see I can refer to drugs, conditions and procedures any time - even with 30% battery remaining.

but lastly....

don't study too much. get some rest. 

I personally don't need to choose where to rest. every floor is a bed. Chair is a pillow. 

Teamwork in medical school - assignments


Introduction

In medical school, we will be doing tasks which are sub-divided in a group, so a maximal amount of work is done with less effort.

for example, in a PBL (Problem-Based-Learning), there may be several learning issues - no doubt the best policy for maximal learning for each student is "Reading everything", but realistically speaking, you probably will not be able to learn everything in the desired depth, and thus a need for teamwork arises. (also, I believe one of the points of PBL is nurturing the teamwork abilities)

the most typical situation in these kinds of PBL is where students will allocate / select their tasks, become the "content expert", and present their findings 2 days later and so forth.

now, to the main topic of this post -

How do we yield maximum gain from shortest amount of time?

set a good division of task. Delegation is KEY

you need to breakdown your tasks (during your group meeting) so that it is;
  • fair in amount of time needed to read-up
  • fair in terms of content difficulty
  • make sure there is no over-lap of tasks. 
  • ensure satisfaction by members over the tasks given. Always ask for feedback before giving them another similar task to do
  • if the assignment / task is graded, we need to make sure it is of good quality - check everyone's work! make a draft at least a day ahead of presentation / meeting.
  • ask for clear direction from the lecturer / facilitator 

set priorities of given tasks immediately

  • what is the most needed facts? what kind of information would benefit us best?
  • where can I get the information?
  • Will I be able to present the findings better with use of graphs / illustrations? 
  • how much deeper should I go?
  • how long do I have to present / talk?
those are the questions you would be asking yourselves when you set yourself learning issues. 

ask for feedback of performance

Once you've done a certain group assignment, it is always nice to get some feedback for your own performance. It would be a blessing to know where you can improve, so next time you can actually work on that particular aspect. If there is no feedback, it would be more difficult to identify the problems that you may be facing as a group - it would be an idea to do a debriefing to do things better next time. 

lastly.... no hard feelings!

the people you divide work with, are your friends. In the end, grades matter but so does your friendship. If someone in the group is not satisfied, talk about it. if you're not satisfied and feel like you're doing all the work, also talk about it. Don't go bitching to other parties before you actually discuss with your group members because... well because that's what assholes do. Don't become one. 

In in the event shall you fail an exam

This is the topic nobody wants to talk about.

What should you do when you fail an exam?

first of all, you should realize that failing isn't that rare AT ALL in medical school. It SEEMS rare, because nobody talks about it.

You don't notice the people who disappears after a semeseter or two.
You don't realize your friends who had to resit for exams.
You don't talk about friends who had to leave because s/he failed.
You don't tell everyone that you have failed.

There are many reasons why it would seem that failure isn't common place.

So the very first step to take in every failure, is to accept it. 

Everything worth doing is difficult, so it makes sense that exams in medical school is made to be difficult. but just because it is difficult, doesn't make it impossible.

Second step to take after failing an exam, is Reflection.

The solution is very easy, if you have reflected back and thought hmm. I spent at least 4 hours daily on games and 4 hours weekly on studies. The answer is to study more, and that isn't very difficult.
But the problem comes if you've been studying 4 hours daily (not counting the times you're in university sitting in classes) and sacrificing your sleep, friendship, relationship and health.

you need to think - what made you fail?

a simple trap everyone would fall into is telling yourself "I am just too stupid" - well, it could be true. but you were admitted into medical school, and admission itself must have been tough. Its easy to say you're dumb. you just have to say you are! but it is the most lazy way out as well.

don't start by assuming you're stupid. one question to ask is "did I take the wrong method?" - everyone learns in a different manner. some are more auditory learner so they may learn best from listening. some are kinestetic learner - they learn best when it is hands-on. You need to re-evaluate youself and work to change your learning habits to suit none other than yourself.

Third step to take after failing is Communicate.

This may be hard, but I personally think it is important to have someone know that you're struggling.
That person may be your trusted friend. (If you don't have one... I am sorry for you. there must have been circumstances that you can't make one. You might have to skip this step)

The reason why you should communicate, is because this would motivate you. if you choose the right person to communicate with, that person would help you motivate you, and get you study material, get more help from other people etc... Afterall, nobody can live alone. Humans are social animals and we need someone to rely on, and to be relied on.

fourth step - is Execution

now most people think this is the hardest step - for some people, it may be. but it isn't has hard as the world paint it to be. Once a person starts doing something, the effort to continue is significantly less than the effort to start something. so take the first step! the rest would be much easier.


and lastly, I wish you all the best. It is difficult because it is worth doing. Make this experience a positive one by learning from it! I have seen many people who have failed but pushed themselves back and they always come out better than before in many ways.

Sunday, 16 April 2017

Malay in the wards

okay, this post is more to benefit myself - because I need to increase my prowess in Bahasa, I shall try and note useful terms in malay I could use in the Hospital wards in Malaysia.

I am a foreigner studying in Malaysia, so I had to slowly build on my malay - so I was wishing there was an easy reference to which I can refer to - but mostly I learnt from observation.

its going to be a long list, so i suggest using Ctrl+F to navigate yourself :)


Introduction

Hello, (good morning / good evening) My name is  -----, I am a medical student / doctor
Salam.(Selamat pagi / petang /) Nama saya  -----, saya pelajar perubatan / doktor

I wish to discuss about your condition/illness with you. is that okay?
Saya ingin membincangkan tentang keadaan/penyakit anda (encik / cik / puan / tuan). Boleh kah?

if you're comfortable with  it
kalau anda selasa.

Why did you come to visit us?
kenapa anda melawat kami?

Why did were you admitted here?
kenapa anda masuk ke wad ini?

how many days
berapa hari

how long
berapa lama

can we/I examine you?
bolehkah kami / saya periksa anda?

time-scale words -

satu - 1
dua - 2
tiga - 3
empat - 4
lima - 5
enam - 6
tujuh - 7
lapan - 8
sembilan - 9
sepuluh - 10
dua puluh - 20

hari - day
hari-hari - days
minggu - week
bulan - month
tahun - year

semmingu - one week
dua minggu - two weeks
sebulan - one month
dua bulan - two months

pagi - morning
petang - afternoon-evening
malam - night

----------------------------------------------

illness-words

Cardiovascular

sakit dada - chest pain
peluh - sweat
susah nafas - difficult breathing
nafas bersulit - difficulty breathing
batuk - cough
bangun - wake (from sleep)
bantal - pillow
jantung- heart
sakit jantung - heart disease
Darah tinggi - hypertension

Gastrointestinal

sakit perut - abdominal pain
muntah - vomit
angin - abdominal discomfort / bloatedness / pain (its a very vague word meaning "gas")
sendawa - burp
makan - eat
swallow - menelan
buang air besar - defecate
berak - poop (simple term)
tandas - toilet
sembelit - constipation
susah nak berak - constipation (simple term)
kencing manis - diabetes (literally - "sweet urine")
hati - liver
usus - intestine
dubur - anus

Respiratory

batuk - cough
kahat - sputum
bunyi - sound
nafas - breath
bunyi pernafasan - respiratory sound
asma - asthma 
rokok - smoking
paru - lung
tekak - throat
hidung - nose
selsema - common cold

CNS

Pening - dizzy
kepala - head
kepala sakit - headache 









... to be continued!
------------------------------------------------------

the following text is unrelated to medical education.

The "BERAT" story

I would like to share a story about my misunderstanding in malay, since you've stuck around till the end. 

I used to travel to and fro from Kuala Lumpur to Seremban weekly, using the private bus that departs from the Pasar Seni (sentral market) LRT station to the Seremban bus station. 

During the 2 years of stay in Seremban, I became increasingly efficient at using the public transport and bus journeys - there are several things that we need to take care in order to have a safe journey - but the topmost in my list is the control of my bowels and gastrointestinal conditioning. 

This is the story which lead to me learning this, the hard way.

about 2 months into my Seremban - Kualalumpur routine journey, when that faithful day happened. 

in the afternoon of my day in KL, I think I ate something bad - perhaps the egg in the Nasi Lemak was a bit off... but anyway I was clutching onto my lower abdomen while I was riding my LRT towards the bus station. 

once I reached the bus station, the first thing I would do is to check if the bus is there or not. Sometimes if the bus is there, if you would run towards it, the bus driver would kindly wait for me to alight. So I did the usual and looked for the bus-

and it was there - ready to depart. At that moment, I forgot about my large intestine which was getting a bit hyperactive, I ran towards the bus before it would drive off and leave me waiting for 30 minutes or more at the hot bus station, looking at passerbys. 

Thankfully (or not!) I arrived in time and the bus departed as soon as I was on it. 

once I sat down, I had to come to my senses and came face-to-face with the most pressing sense - literally as i felt something was pressing from the insides of my guts. 

I attempted to use shallow breaths, so that my lungs would not expand onto my abdomen - any more pressure onto my large intestine and it would need to find an exit for its contents... 

I also tried focusing on something else - the greenery alongside the highway, but everything seemed to aggravate my gastrointestinal earthquake and the tsunami of colic that would come and go. The blasting music in the bus also seemed to make matters worse too. 

The private bus usually does not make stops. It would just depart, and it will not be stopped by anything till it reaches its destination - even if it ran over a cow, donkey or perhaps even a man, and definitely not to relieve the passengers of its rectal content. (That was what I assumed with my panicked state of mind)

I began looking into my bag for a plastic bag, and around to see if i can ask the other passenger to move away as I use the plastic bag (I was VERY desperate), but I still had some pride in me to not do that while I fight with the thirteenth colic wave that washed over me.

but when the fourteenth wave came, I slowly stood up and began walking down the aisle, plastic bag in my hand. I decided nope, there are too many people in the bus, and the windows of the bus is bolted shut so I can't throw the plastic bag out the window after my deed is done.

I have to do it - so I hobbled towards the bus driver -

"encik, saya nak BERAT"

(Berat means "heavy" in malay - I meant to say "Berak" which is poop)

the driver, who looked at my facial expression which was a mixture of purple and maroon from withstanding my labor pains, seemed to understand the situation.

"HAH!? OHHHHHH YOU NAK BERAK!!!!"

and I am sure everyone in the bus heard it even over the blasting tamil music in the bus. I was clutching onto the driver's seat until the driver prompty went into the rest-area. I thanked all the Gods there is in the universe, and controlled all my sphincters in my body towards the toilet.

This story has a happy ending.

nobody got hurt, and there were no shit-stained bus seats, nor horrified bus passengers, or a poop-filled plastic bag clinging onto the car frontscreen.

Most importantly my Colons are now calm and happy. It was very satisfied by itself for the job that it has done - which is to transport waste material smoothly outside.

I walked into the bus, apologizing to the driver and the passengers. Everyone knew what was going on.

.... So this is how I have learnt the word "berak" and "berat",  It has then since been engraved, deeper than the  groove that the middle meningeal artery sits on the inner surface of the skull. 
I have also learnt to manage my bowels before any journey. 

Thank you for reading this far, I know it was a waste of time, but I hope you had fun. 


Wednesday, 1 October 2014

Tips for Final Exam

I have graduated from an MBBS course recently, and I thought I would put together some thoughts to help people gain confidence in getting through yet another "bump" before graduation - that is the final exam.

tips to prepare for the final exam

  1. you have made it this far -  which is hardly blind luck, so have a lot of faith in yourself, your study methods that carried you thus far, and your luck!
  2. find out what exactly is the style of your final exam. imagine the situation well, and apply that situation in your everyday work. time yourself and give yourself exactly how much you will have (or slightly shorter) on the day of exam. 
  3. find out the kinds of cases you would get during the exam. go through it, write reports of those cases. 
  4. practice your physical exam religiously - while imagining the exam situation. 
  5. consistently do 1 2 3 and 4 - imagination is key.
it's simple, mostly because if you are reading this, you probably have what it takes to pass - there is no reason why you should make it till the final semester without the sufficient knowledge, even if you feel like you know nothing (it is normal to feel that way, especially in medicine. it would probably never go away - and it is a good thing) 

now on the day itself, you won't have to worry because if you have done the above consistently, there is no way you are going to be nervous - you have done it in your mind a hundred times! 
lastly, believe in yourself. I know there will be doubts, but having doubts in itself, is a good trait of a good doctor. always doubt yourself, but have confidence that you will rectify it. 

Sunday, 25 August 2013

AV fistula Examination

there are several purposes of examining patients with AV fistula.
  • assessing function of present AV fistula.
    • the diameter and flow of fistula
    • where is the fistula? 
      • radiocephallic
      • brachiocephallic
      • transposed cephallic 
    • presence of other vascular access (which suggests previous AV fistula failure)
      • central venous access
      • peritoneal access
      • graft
  • looking for possible complications of AV fistula
    • infective / inflammatory changes 
    • aneurysm
    • hematoma
    • thrombosis
    • central vein stenosis
    • ischemia / steal syndrome
    • outflow stenosis of fistula
  • assessing adequacy of dialysis and renal failure
    • uremia
    • peripheral edema
    • anemia of renal failure
    • assessing complication of dialysis itself
      • common non-serious side effects
        • headache
        • itching
        • muscle cramps
      • cerebral oedema secondary to osmotic change (disequilibrium syndrome) \
      • hypertension
      • hyperkalemia 

inspection

inspection may involve the hands, arms (with the fistula), head, chest and abdomen with main focus on the fistula itself.
  • hands
    • check for signs of ischemia or steal syndrome distal to AV fistula
      • temperature
      • pulse volume 
      • capillary refill
      • pitting edema
  • head
    • check for anemia in conjuctiva (ESRD patients commonly have anemia due to Erythropoietin deficiency)
  • chest and proximal to AV fistula
    • difference in size of upper limb between left and right (central stenosis)
    • look for a scar for central vein catheterisation (subclavian site)
  • abdomen 
    • look or scars of peritoneal dialysis
    • scars of nephrectomy
  • legs
    • pitting edema (fluid retention)

inspection of the fistula

  • assess the location of the fistula
    • radiocephallic
    • brachiocephallic
    • transposed cephallic 
  • look for evidences of failed / old AV fistulas distally
  • look for complications seen on the fistula
    • infection / inflammation 
      • redness
      • swelling
    • aneurism
    • hematoma / bruising

palpation

  • lightly palpate over the fistula for;
    • increased temperature 
    • tenderness 
    • thrills (this is normal)
    • pulsation (this is not normal - suggesting outflow obstruction)
  • arm-elevation test for outflow stenosis
    • elevate the arm with the AV fistula - the fistula should flatten if there is no outflow obstruction.
    • sign is positive when AV fistula stays bulging
    • more signs suggesting outflow obstruction;
      • prolonged bleed after dialysis
      • loud systolic murmur (discussed later)
  • augmentation test to test for inflow stenosis
    • occlude the outflow by pressing onto the proximal arm along the vascular pathway
      • the thrills should become a strong pulsation- if not, there may be inflow obstruction
      • the extent at which there is a pulsation - whether there is strong or weak pulse, may be an indication of inflow patency

auscultation

  • on the fistula AND along the vascular pathway up till the chest
    • there should be a systolic murmur (low-rumbling) throughout
    • a harsh, high-pitched sound may suggest a stenosis somewhere along the vascular pathway.

Also check.... 

  • check the condition of overall vascular health - so one may see the lower limb for signs of Periphiral vascular disease to assess if more proximal AV fistula is worth placing, if the current one isn't doing well.
  • abdomen for evidences of previous / current CAPD - Continuous ambulatory peritoneal dialysis. Patient may have tried it, and then changed to AV fistula. 
  • The most common cause of sudden death in patients with ESRD is hyperkalemia, which is often encountered in patients after missed dialysis or dietary cause. Check the pulse rhythm - just in case! do ECG if you can afford the time.