A box of sweets

Ee needs to present the case of the lady with colloid goitre in the ward to one of the consultant surgeons tomorrow morning. A case which I had presented during a bedside teaching session yesterday.

According to her, she didn't have the opportunity to clerk the patient due to time constraints. What a lame excuse, I thought. Hence, I had to lend her my clerking sheet.

After coming back from watching Tron : Legacy, I had to trudge reluctantly to the cafeteria a few blocks away to pass my clerking sheet to her. And she caught me by surprise by giving me a box of sweets as a repayment.

Yes, I was astonished. It's so sweet of her. Really.

Ee and I aren't really close. In class, she's kinda obscure. I'm not trying to sound egoistic and complacent here. But, there are always people in your class whom you know won't pose any threat to you academically or in any way. And I guess she's one of them. 

Well, the point I'd like to highlight here is, when you lend someone (whoever the person may be) a helping hand, without any expectation of being repaid, you never know what's in store for you.

I was actually kinda touched. As if I was embraced by a blanket of warmth and infused with a lingering sensation of sweetness. Something I hadn't experienced in a while.

Thanks, Ee.

Life's impermanence

When I first met her, her entire right breast appeared grotesque with an ulcer with blood-stained serous discharge, peau d'orange sign and satellite nodules. The prognosis was really bad, with the presence of ipsilateral axillary and supraclavicular lymphadenopathy, lymphoedema, malignant pleural effusion and liver secondaries. 

It's painful to see her wither away with such an advanced breast cancer. Really. As I listened sympathetically to her history, I was also angry at her ignorance of her painless right breast lump which had been there for 4 years. I was incensed by the gross stupidity of the traditional medicine practitioner who gave her the misleading advice that it wasn't malignant. Shouldn't these people know that a painless breast lump in a middle-aged woman is cancerous until proven otherwise?

Sometimes, I close my eyes, and ask myself, "What if she's my mom?"

Immediately, I can envision my entire world crumbling down on me. I can imagine myself consumed with anger, cursing destiny for its paradoxes and injustices. I can visualize myself sitting forlornly at a corner, ensnared in self-pity and a devastation unfathomable by others. I can picture myself swimming aimlessly across the ocean of depression with the heartbreaking awareness of mankind's mortality.

Mom called a few times to ask if I'd be going back to hometown after my exam, an idea which I'm ambivalent about. The only thing holding me back is the astronomical price of the return air ticket.

On one hand, I was thinking that I could use the money saved to buy myself a new suit so that I could look stunningly gorgeous presentable during my brother's wedding next February. On the other hand, I really do miss Mom. The approaching exam and my innumerable trivial personal problems, coupled with my impending obesity, are giving me a considerable amount of stress.

Life is impermanent. Certain things ought to be cherished before they vanish forever. I wanna spend as much time as I can with Mom when I still can, even though, inevitably, this means having to come up with a plausible explanation of why I'm still single.

You might want to diagnose me with dependent personality disorder. But, I guess I just miss my mom. And I'm getting very agitated now because, most probably, I'm not going back during my break after the exam.

AirAsia, please have mercy!

I'm only human

I'm sure all of us have heard stories of how people exploit their clients or customers for mercenary purposes. Lawyers. Pharmacists. Promoters. Businessmen. Insurance agents. And even hawkers. They have a variety of unscrupulous ways to manipulate their clients for their personal gains, legally, of course.

Nonetheless, if a doctor is involved in the aforementioned misconduct, he is deemed unethical and despicable. You're not even supposed to order uncessary investigations, say, for instance, obtaining the coagulation profile of a lady with fibroadenoma as a pre-operative assessment if you haven't found anything significant in her history that would suggest the presence of a bleeding tendency.

I've attended numerous lectures on ethics, so much so that, even speaking impolitely to a patient when I'm PMS-ing feels like a total breach of ethics.

Most patients are very understanding and kind. They have faith in my clinical acumen despite the fact that I'm just an obscure medical student. They contribute a lot to my learning experience and have deeply touched my heart in many ways. I wonder if I'll ever have the honour to repay their generosity.

Understanding human behaviour is prerequisite to developing a good rapport with a patient. The rule of thumb is to be polite, and smile genuinely. And never judge a patient. Whether he's an affluent businessman or a peasant with a minuscule monthly salary of RM 300, he can always tell if you're judging him. He can sense it in your nonverbal actions and will clamp up, hampering you from attaining a detailed history and diagnosis. And if this happens during your exam, you're as good as dead.

Unfortunately, there's a minority of patients who really really drive me crazy. It'll take forever to elaborate on how they irritate me. You can always sense it when they really want you to fuck off. After all, they're not the only ones with the ability to interpret nonverbal messages. By right, I'm not supposed to feel the least annoyed. Because medicine is a noble profession. Because, ethically and morally speaking, it's wrong. Because it makes me seem unfit for the profession.

But then, I'm only human.

All I can do is put on a bogus smile and hope my resentment goes unnoticed.

It's that gentleman with a bleeding peptic ulcer complicated with severe anemia and his wife that made me write this. I felt really upset and angry. They were really mean. I remember walking away without even saying thank you. There's only so much you could expect from a barely educated patient, I silently scoffed.

I feel apologetic and conscience-stricken now. But, I'm only human. I will learn to handle such a situation more professionally in time to come.

I went to the pool that afternoon. Swam 40 laps. Shopped to my heart's content in the evening and ended buying clothes even though my wardrobe is already overflowing with them.

This is probably unrelated. But, yes, I'm a rather messy person. I simply don't have the patience to fold my clothes. A major turn off I guess. Yet, it's not like I'm going to meet my potential boyfriend on blogosphere. :)

Twinky male nurse

I did a suture on a patient this morning. He had a cut on his right ankle. I never enjoy doing it on a conscious patient, or worse still, a child. I'm still not very adept at suturing and my lack of confidence is apparent whenever I seek the nurses' help.

The patient was watching me closely I made every stitch with worries and extreme care. I was under a lot of tension and afraid that something would go wrong and he'd shout at me. Yet, with the assistance of a cute male student nurse who patiently guided me almost throughout the procedure, I guess I did quite a good job. At least, the patient didn't display any sign of impatience or dissatisfaction.

By the way, the male student nurse is such a twink. Ritchel caught my attention the first day I started my posting here. Fair complexion. Short. Slim. Looks like a Chinese. And clad in white from head to toes and always puts on a angelic smile. Yummy!

How high is the possibility of a male nurse being gay? JY told me it's 99 %. I so am going to seize every chance to establish an eye contact with him tomorrow, just for the sake of confirming he's gay. Hopefully, it'll last more than 5 seconds. Hehe.

I don't think it makes me a slut doing this, right? So, wish me luck.

Caesarean section

I've just returned from the ward. Last night was action-packed.

I got the opportunity to observe a Caesarean section (an operation performed to deliver a baby via the transabdominal route) which started at 11.35 pm. The procedure was indicated as the patient had premature preterm rupture of membranes (PPROM) and the amniotic fluid index (AFI) was low. Besides, the baby had a breech presentation, meaning that the foetal buttocks (instead of the head) occupied the lower part of the uterus and this would complicate normal vaginal deliveries.

CW and KH accompanied me. It was our first time entering an operating theater (OT) and watch a surgery. Needless to say, we're ecstatic and jubilant. We're required to change into the blue suits ( I don't know what they call them. Surgical gowns?), masks and green caps provided. Even that was enough to make us exuberate. Our laughter permeated the entire changing room. Heh.

The surgeon made a transverse suprapubic skin incision and cut open the abdominal wall, layer by layer. The urinary bladder was reflected inferiorly and the uterus incised. Finally, the baby was taken out. The procedure was much simpler than we thought. It looked kind of quick and easy to our untrained eyes.

It was enjoyable being in an OT for the first time. The 3 of us took tons of pics before changing into our formal attire (at 0035).

Cholecystitis

Chronic cholecystitis with cholelithiasis


Rushed to the male surgical ward right after a boring lecture on bedside manners and decorum. Haih. The environment has forced me to become 'kiasu' these days. I can't help it. I just want to survivie.

Found a case on cholecystitis (inflammation of the gall bladder) caused by cholelithiasis.

Acute cholecystitis follows stone or sludge impaction in the neck of the gall bladder (GB), which may cause continuous epigastric or RUQ pain referred to the right shoulder, vomiting, fever, local peritonism or a GB mass. If the stone moves to the common bile duct, obstructive jaundice and cholangitis may occur.

I was able to palpate a mass in the epigastrium of this particular patient. Tried to elicit the Murphy's sign too. I laid 2 fingers over his RUQ, asked him to take a breath, which I knew would cause pain and arrest of inspiration as his inflammed GB impinged on my fingers. Well, his face did crumple up. Yet, I wasn't sure if what I saw was a Murphy's sign.

Gallstones are the notorius cause acute and chronic cholecystitis. Other complications of gallstones in the GB include biliary colic ( occurs when gallstones become symptomatic with cystic duct obstruction or by passing into the common bile duct), empyema, mucocoele and carcinoma. Whereas, gallstones located in the bile ducts may lead to obstructive (acholuric) jaundice, pancreatitis and cholangitis.

Inguinal hernias and cute MO

SureClerked a patient with right-sided reducible inguinal hernia today.

Basically, hernia refers to any structure passing through another and ending up in the wrong place. Indirect inguinal hernias pass through the internal inguinal ring and if large, out through the external ring. During the embryonic development, the testis is led down from its original position in the posterior abdominal wall into the scrotum by the gubernaculum. Hence, if the connection between the peritoneal cavity and the tunica vaginalis fails to close behind the testis, there'll be a patent processus vaginalis. It's through this that an inguinal hernia occurs. Indirect hernias are more common (80%) and chances of strangulation are high as the external inguinal ring is very narrow.

Whereas, direct hernias push their way directly forward through the posterior wall of the inguinal canal, into a defect in the abdominal wall. Predisposing conditions include chronic cough, constipation, urinary obstruction, heavy lifting, ascites and previous abdominal surgery ( damage to the iliohypogastric nerve during appendectomy).

To distinguish a direct from an indirect inguinal hernia, reduce it and occlude the internal inguinal ring (mid-point of inguinal ligament) with 2 fingers. Then, ask the patient to cough or stand -- if the hernia is restrained, it is indirect. If it pops out, it is direct.

Hmm. A medical officer talked to me in the surgical ward. Dr. Aarron. A pleasant surprise. He's kind of cute. I'm not sure of his race. He took the first move to talk to me thrice. I literally tagged along him while he was doing his ward round. I'm gonna linger in the surgical ward tomorrow!!!