I felt young again last night, after some coaxing by Monty and Yx to do something utterly unimaginable - I drove out at 1 am all the way to Pasir Ris, just to grab newly-imported corals. Cheap, cheap, cheap!! Bought more than I expected I would, but they were really hard to pass up at that price and quality. Tonnes of photos coming up!
First off, miscellaneous photos before last night's trip:
Caulerpa sp. - a green seaweed
Purple sponge
Cup coral, Turbinaria peltata
Button coral, Palythoea sp. - containing palytoxin, *the* most toxic naturally-occuring substance. If you think fugu is bad, think again - people have gotten ill just by putting their hands into a tank containing this coral, and one reefer was hospitalised after he suffered progressive airway constriction after breathing in fumes after he poured boiling water over his rock (which had this coral on it) in an attempt to sterilise it.
Gross. In a sticky messy wet state now, been doing manual labour for the last 4 hours or so. Got some nasty cuts from a screwdriver, and blisters on hand. Really not cut out for this huh.
Here's some updates!
The hood that fell apart - quite literally! The original work was done many, many months ago - almost a year, actually - using wood glue and uncannulated nails.
Wenky's Territory. I took up the entire living room's walking area. Surprisingly, Dad didn't chide me for leaving all those tools out last night.
Muahaha .. you won't get a chance to fall apart again, you monster!
Got the wiring done for the new lights, and fixed up new parabolic reflectors. The old one's on the right.
Testing the circuitry. I ain't no electrical engineer, so that green plastic box lid was placed over the lamp, *just in case* it explodes. Wiring up an electronic ballast is truly idiot-proof! No capacitors or ignitors to deal with, just one end to the plug and the other to the bulb. I'm feeling a little upset though, it's personal practice to earth every single metallic component. However, this particular electronic ballast has an earth for the ballast itself, but only live and neutral wires on the bulb, which means I couldn't earth that new parabolic reflector. Yx, can you help here? Do you think I can use a wire to connect the 2 relfectors in the hood, so that they share 1 earth?
Whee! LOL, poor YX's getting fatigued by this period of frantic party-going. We went to Deb's house today to meet up with the Lindy people today, kinda like a pizza party. OMG, her house is sooo scary - 16 floors up! And she has 5 HUGE cats (one of which looks like he's bigger than Brownie) that roam the kitchen.
So, we had pizza and drinks and spent the night watching the old Lindy Hop Ensemble archive videos. All the stuff from 10 years ago etc. Hmmm .. little did we even guess what the real purpose of this party was, hah.
Just as Yx and I announced that we really had to leave, Debs and Xinyi produced this lovely cake, wow!
Ah. The induction into LHE. It's kinda odd. Some years ago, when I first started off learning the basics of Lindy, the LHE were like The Gods. Joining them was not even fathomable at that time, and I wondered if I'd ever be good enough. But when tonight came, I felt really weird. Dunno if Yx felt the same too, but I had slight reservations at that time.
Firstly because I'm already at a pretty nasty crossroads in my life right now, and there's this element of fear that I will disappoint - but yet on the other hand, regular exercise would really be very good for me. And partly too, because I couldn't help but feel very strongly that the LHE would have been great if they had stuck to their original feel that I saw in those 10-year-old tapes. Yx and I were never the types who could entertain dancing Lindy to anything but authentic Lindy music. Somehow, the nature and spirit of the dance can never shine through, however astounding the choreography may be. But yet - and it's not only the LHE - a lot of people are starting to dance Lindy to other forms of music, the most abominable of which would be pop music. I really did enjoy their old routines very, very much indeed, including our all-time most-hated Big Apple. IMHO, the dance is quite enjoyable enough and inherently funny without injecting even more clownishness into it.
In any case, we were given the very nice LHE T-shirts, haha ... although YX got the design that I wanted! To think that this all started when Yx saw this flyer for a Lindy Hop Basics course at YIH 5 years ago .. Anyway, time for shameless plugging now, lol - Here's LHE's website! We were pleasantly surprised and really pleased that the current Chairpeople of the NUS Lindy Club have handed down their position to a really enthusiastic pair of people. Here's wishing them luck for the next year (and hopefully more!) to come, we'll try to help out in terms of training as much as we can. After all, the new Chair must be able to dance well, right? Yx, we're both so old. These people are 2 generations down already, and we're still stuck on their backs like soddy newspapers. Reminds me of our Club Dinosaur, are we like that already?!? =p
Was utterly embarrassed when KC had to take measurements of my waist ("what waist??") and thigh girth for new costumes. Yx, time for drastic measures.
Right, off to try and do the tank hood, blearghh. Or perhaps I should give it a rest tonight?
As again, everytime I meddle with the tank, something falls apart. (Yes yes, you win, Yx) If you can remember, the last time I made my own lighting hood using plywood, I idiotically mis-calculated and ended up with 2 halves of a hood instead of the single piece I was thinking of. And the last time I meddled with the tank, the front half fell apart.
And guess what just happened?
The back half fell apart this time. After trying in vain to hammer and drill nails into the goddamned thing, I threw the entire load of tools aside and decided .. heck. I'm off to buy a lifetime's supply of L-brackets now, time to make a bullet-proof back half.
Had to meddle with the tank, since I'm in the midst of installing a new set of lights - the left lamp was 250W Radium while the right was 150W Iwasaki 20,000K which looked oddly lopsided, and in any case the Iwasaki is refusing to strike now. So I took a trip down to Reef Depot at Thomson Road and bought a new XM 20,000K bulb (Radiums were out of stock) and also an algae-scraper (another horror story, saving it for later). They only stock the IceCap e-ballasts, which way too extravagant for me ($300 for a bunch of metal??) so I made my way down to Janet's.
Phew, Janet saves the day! Got an Elbiru e-ballast for cheap, and bought a couple more supplies at the same time.
Just a short one, showing Mommy bird trying to arrange the nest nicely.
Anyway, definitely suffering from post-traumatic stress disorder now. It's been 2 days since the last exam, and I'm still waking up with dreams, reliving the exam again and again. Went out for a dinner last night, and met Ren Ci's CEO, who was trying to encourage me to take up geriatrics and psychiatry. Psy, yes .. but geri? Anyway, nice chap. Should have asked him for help regarding the PTSD. Then again, he might just sign Form 1 and send me straight to IMH for 3 days.
I think EW, Dopey and I almost puked while waiting for the viva list today, it was such a horrible wait. It looked like most of them were distinctions though.
Anyway, had a great time at Wala-wala at Holland V last night! A great bunch turned up, including Yx, Dopey, HypoC, Josh, Dopey's "Boss" and Joline. Plus we also bumped into Sharon & co, and also Casey & co. Nice nerd party! The band was excellent, I loved their rendition of "Chasing Cars" by Snow Patrol. I got a little thoughtful at some point though, dunno if anyone noticed I phased out a little. It's just that some weeks ago, I dreamed and dreamed of doing this EXACT same thing, during one of those dissociative episodes. Singing in a small cosy place like that, to a small group of appreciative fans. Nothing big, nothing glam, just appreciation.
Of course, there was a little drama at the end that the Early-Leavers (lol ...) missed out! Da Boss was eyeing this girl who was Sharon's friend, but even after repeated coaxing and bribing (Joline and I offered to buy him drinks to go talk to her!!) he was waay too shy. So ooooops ... someone must make the first move right? Miraculously (*wink* Miraculously, but with a little sms on my part), that girl and Sharon came over to our table. ARGHHHHHH I think the 3 girls were about to murder Da Boss .. he clammed up!!! Sharon was like, "What's wrong with your friend?? You'd better do something!" Seriously, we tried. Time to compile Karmasutra Lite I think - the fail-proof road to dating. Haha .. my apologies to Da Boss for springing this on him. Girls!! Work on him will ya? Don't worry, you're in good hands, those girls are the absolute relationship divas.
OK, time to let out a long sighhhhhhhhhhhhhhh and try to help YX out in her work.
Feeling extremely ill right now, just before going off to meet my old CG-mates. Always happens after exams, it's not unexpected, but I wish I didn't react this way - it takes the fun out of post-exam periods.
Bought 6 Bangai cardinals at a steal from Henry's! I can't believe I got them at $3 each, after being quoted $15 at other places.
On a very sad note, I just learnt that one of my reefing-idol's (lol, how pathetic is this??) fab tank crashed this weekend, due to some very unfortunate accident from an overflowing skimmer that was followed by a rapid water change of 200 gallons (my entire tank's volume is only 100 gallons!!). Click here to visit Steve Weast's reef tank site (Steve, hope you don't mind me posting this pic from your site!)
The day before my paeds exam, something really exciting happened right outside my window. A pair of hummingbirds were building a nest 1 metre away from my study table!
Spent a good hour or so in total just staring at them going to and fro, and the female bird doing her marvellous weaving. Apparently, the male goes round foraging for nest materials, then calls to the female who flies over to him and picks the stuff up. I'm feeling really good about this, since they were using a lot of material from my garden. They actually destroyed one of the coconut fibre pots I use for some of the Nepenthes, pulled out my poor Tillandsia usenioides (spanish moss) and used some bouganvillea bracts for some colour. And I believe I saw Brownie's hair too in that nest!
Took an hour's worth of videos, shall cut and join them and post a short snippet here soon. =) Can't wait for the babies to arrive! The last time I had baby birds in the house was when YX and I rescued a bunch of abandoned sparrow chicks, and my, that was fun! More fun than those 4 kingfisher chicks I had years and years ago in any case - those stank to high heaven from the fish I fed them with.
Vaguely thinking of building a bird table, lol. Yes, right outside my window. But chances are, it'll be filled with uglies like crows and mynahs instead of nice things. Why is it that our local fauna is so grotesque?
We taken to 2 cases by 4 female examiners, but they were exceedingly nice. The first 2 had rather strict faces though, although I had the impression that they were trying to look strict rather than being really strict. So here's my paeds cases:
1. Spastic diplegic cerebral palsy
Walked into the room to find a 17-year-old guy as my patient, and his mom sitting by his side. Oh WOW. Thanks so much, Mommy and Patient! Examiner said, "Please examine his gait, and proceed from there". Hmmmmm ... Duchenne's? CP? Spinal muscular atrophy? Spina bifida?
OK, I admit I got the gait wrong. The diplegic gait really looks like a waddling gait what! Redeemed it by saying that I didn't see Gower's Sign. Nods and smiles. The patient was wonderful. He did everything himself - walked to end of corridor, turned, came back, stood on 1 leg, squatted and stood up. Talk about good priming!!
It was only during the neuro examination that I managed to get my diagnosis in order. Heehee ... scored a little I guess, I noticed an ADULT tendon tapper on the table, so made a show of putting away my paeds tapper and using it instead, at which they smiled appreciatively and said, "Yes, use the adult one, that's right." Typical upper motor neuron signs with clonus, increased tone, brisk reflexes. Pretty proud of myself actually, for once I did the reflexes nicely and sleekly. Strangely though, he had a bit of proximal muscle weakness. Was about to do sensory examination when examiner 2 asked, "Why do you want to test for sensation?". Mentioned cord transection as another possible cause of diplegic spastic paralysis and that I can gauge transection level by dermatomal distribution. Nods and smiles. Okie! =)
"So what do you think he has?" "Mdm, this patient has spastic diplegic cerebral palsy as evidenced by the (blah blah blah blah) upper motor neuron signs. He retains good functionality as he has good gait and posture control, and does not need any ambulatory devices that I can see."
"What is the most likely cause?" Most commonly due to perinatal asphyxia, but went on to categorise into antenatal (intrauterine infection, placental insufficiency) and post-natal (non-accidental injury, trauma, intraventricular bleeding, meningoencephalitis)
"What kinds of intrauterine infections are you concerned about?" TORCH infections- TOxoplasmosis, Rubella, Chlamydia .. then faltered a bit for the "H" - FACK, it's Herpes simplex!! They looked amused at me faltering and decided to spare me.
"So do you think it might be TORCH infections in this case?" No, because the patient will also have accompanying deafness and blindness etc.
Bell rings, I went to the next case.
2. Cushing's Syndrome
Alas! OMG, I have never - NEVER - seen a Cushing's as florid as this. Remember purple abdominal striae? This young girl had striae on the arms and legs as well! Examiners were 2 women, 1 was Dr. L.Shek (score!!) and the other, a goodly elderly lady who had such a kind face I wouldn't mind her being my aunt at all. Just be nice and generous with the marks, can? It wasn't all that smooth and sleek, but for one wild moment I DID think of ichthyosis and other strange, rare skin disorders.
"Please look at this young lady's lower limbs, and proceed from there."
At first glance, my first (shocking) thought was ichthyosis! I dumped that thought and made a brash statement of "I see striae distributed blah blah blah" and they nodded, so I went on to describe the textbook stuff - central obesity, rounded facies, abdo striae, but no thin skin, no supraclavicular and interscapular fat pads. As I was looking at the back for the interscapular pads, the Nice Elderly Examiner (NEE) pointed to her neck, and I was like oooooh ... acanthosis nigricans! Also noticed some gingival hypertrophy, but I think the examiners missed that cos they actually came to have a look. Damn. I tried examiner-baiting by saying, "I also see florid gingival hypertrophy" and was waiting for them to ask, "what are the causes of gingival hypertrophy?". Grrr .. that never came.
"What do you think this girl has?" Cushing's syndrome, most likely cause being exogenous steroid use. (Although for one very, VERY heart-stopping moment I thought she appeared a little dark and thought ... holy ****!! Addison's Disease requiring steroid replacement????!???!?!!!? Then I realised ... Oh. She's Indian.)
"What else do you want to look for?" Frequent infections, oral and perineal candidiasis, skin wounds. "Please proceed" Nil. No candidiasis of the mouth, was told not to look at the perineum (Duh ..)
"Anything else?" I'd like to look for a reason why she's on such high-dose steroids. So I offered respiratory examination for asthma, and had to be prompted into systemic lupus and nephrotic syndrome. Noted some ectopic patches all over, so I brashly suggested that she may be using steroids for very severe dermatitis. Examiners' eyes bulged so much out of their sockets that they were in danger of falling to the floor, so hastily changed my tune and said that it is, however, highly unusual not to use topical steroids instead.
"So what do you think is the most likely cause?" Nephrotic, since:
1. No malar rash of SLE 2. No wheezing of asthma, and anyway it's very rare to use that much steroids in asthma
But mentioned there was no oedema at this time, it could be steroid-dependent nephrotic syndrome.
Then prompted into other things ... urgh. "She now says she can't see clearly .. so - " OOOOOOOPS. I'd like to check for cataracts. "How would you do that?" Using the fundoscope for loss of red reflex, and also a slit lamp biomicroscope to identify the type of cataract.
"So what would you be concerned about in the long term?" Shiiiiiit. Forgot height and weight. So said that long-term use can cause growth problems, offered to take height and weight, and insulin resistance, and osteopenia.
"What bedside tests can you do to screen for these?" Height and weight, urine dipstick, capillary blood glucose, blood pressure.
The NEE turned to Dr. Shek and whispered, "You have any more questions?" She shook her head, and I was herded out of the ward. To my shock and horror, I was extremely early. The bell hasn't rung, and I felt so insecure I asked one of the nurses if the other students in that room also took such a short time ... she reassured me that that's the case. Phew. Once again, massive diaphoresis, was offered drinks and tissue by the amused-looking nurse who repeatedly asked me to calm down.
****
In all, the 4 ladies were exceptionally nice, all of a sudden my fondness for paediatricians has increased somewhat. Done and over with, although very nasty rumours have been flying around about sigh ... nevermind. Just hope for the best! Slightly disappointed that I didn't get a cardiac or developmental assessment case, and that all the stickers, toys etc that I brought weren't put to good use. My patients were like 17 yrs and 13-14 yrs old!
Ah .. the final exam today. Petrified, of course, but can't help feeling some anticipation deep down. The end in sight, after months and months of preparation! Dearly hope it'll be alright, I keep telling this to myself night after night, lol. But wish me luck!
Feeling grossed out, and scared. Not exactly because of Sunday's paediatric shorts, but more like nervousness and anxiety about this entire exam. So much hard work, and honestly I did try hard. I'm sure most of us have felt this way at some time or another - that at times, trying hard just isn't good enough. I will probably take up to 2 days after Sunday to have the post-exam feeling completely sink in. The post-traumatic stress disorder from these exams is unbelievable. Never have I had consecutive nights' dreams about exams and reliving them again and again even during sleep. It's so surreal, the entire affair.
Ah well, back to slight relaxation for a while, before launching into the paeds books yet again.
I'm praying that it surely will be the last. No viva list for today's surgical long and short cases, so it's good. Anyway, surgical long case consists of taking history and examination from 1 patient for 30 minutes, then the examiners come in and blast your balls out for the next 20 minutes. The short cases consist of 4 patients, do examination and discuss the case in 4 minutes (SICK!).
Long case - Buerger's Disease aka thromboangiitis obliterans
OUCH. Ouch, ouch, ouch! Of all things, why Buerger's Disease?? I have never seen one, just read about it in books. Scenario - I rush into the ward cubicle to find my patient sleeping, and he had a surgical drape tied around his leg. First thought - OOOOOH, struck gold! Diabetic foot! All my medical information on diabetes started flashing through my head. Then the first blow came. He talked like he was still asleep, I was slightly rudish and had to ask close-ended questions. And the second blow? No diabetes. And he had MULTIPLE ulcers and TONNES of amputations everywhere - I mean everywhere - hands, legs, everywhere. No way this can be a diabetes. The ulcers took more than a year to heal ("Arterial ulcers??" shot through my head - damnit) but ah. He had classical signs of chronic arterial insufficiency - pain at night, needing to hang legs over the bed. Nice. Except that in my hurry, I actually forgot to ask for a history of vascular claudication and had to admit that to my examiners, while hurling obscenities at myself inside.
I won't even begin to talk about the examination. Having a diabetes case with 1 ulcer is something, but a patient with ulcers EVERYWHERE? Started with carotids, took pulse and listened for bruit. Then the arms, documenting all the skin changes and pulses. Then the legs, skin changes, Buerger's test and pulses. Then a cardiovascular examination, and was so totally put off already, when the Reg popped in, asked if I managed to get the diagnosis, gave me a wink and a thumbs up when I told him incredulously, "Buerger's Disease???".
Examiners came flooding in, 3 of them plus the Reg. Urghhhhhh. They looked mildly surprised that I managed to get the diagnosis. Questions:
1. Please present your history - blah blah blah 2. Have you examined the patient? - blah blah blah. Before I could finish, they asked for diagnosis (I wouldn't be able to finish the examination findings in 20 mins, I think!!) When I presented the ulcers as a punched out edge, OUCH. Apparently it was sloping edge. And pointed out that there was, in fact, some granulation tissue in the ulcer. Felt demoralised and wilted in front of them. So I changed my song and started describing some features of chronic venous insufficiency I saw, hyperpigmentation, loss of hair, pitting oedema, shiny skin etc. 3. What are your differential diagnoses? - Buerger's Disease (happy nods), atherosclerosis (nods), chronic venous insufficiency (some frowns, so i quickly said that it's unlikely since he doesn't have diabetic history), Reynaud's Disease (nods). 4. Why do you think it's Buerger's? - Young age, smoker, multiple ulcers even on upper limbs (excludes venous ulcers), involvement of lower limbs (excludes Reynaud's, usually on upper limbs and associated with connective tissue diseases like scleroderma), no history of diabetes or cardiovascular risk factors. 5. What investigations will you do? - Duplex scan for lower limb occlusion, ankle-brachial pressure index (was asked what it is, what the values signify - got stopped halfway, I think they know I know it ...). Totally forgot about angiogram until they led me to the computer and I saw from afar an angiogram and quickly suggested it before we reached the computer. 6. Arteriogram interpretation. LOL - you know what, they actually thought I could read it at first!! Quickly pointed out filling defect in the femoral artery, they looked mildly impressed and alas ... wrong move. Thinking I could read it, they dished out more and more slides until my ignorance finally got exposed. Apparently, you're supposed to see arterial beading as well. I remember this vaguely from lectures, but couldn't remember it. 7. Where is the dye injected from? - Femoral artery, at the inguinal area 8. Lower limb vascular anatomy. Shit. Could only tell them a few. Bad. 9. How to manage Buerger's? Ouch. Suggested thrombolysis in acute ischaemia, medical therapy with arteriodilators, and bypass grafting.
Short cases - F*CCCCCK
My examiners were kinda nice ... Please, please don't be mean to me!! Please be nice about the marks, I promise I'll be a better person.
1. Young lady who hitched up her right pants to show me her knee. Saw a lump on the medial aspect of the knee, proceeded to describe lipoma. Prof said, "Is there a similar lump on the other knee?" I said yes, and he told me that it's actually gravity pulling on the fat. "Go home and look at your mom's knees ..." he said. Huh? So he told me if I see anything else, I found a TINY patch of varicose veins near that same area. Asked me the distribution of the long saphenous and short saphenous veins, and what these are. Erm .. varicose? So asked me where varicose veins can be found - lower limbs, oesophagus, cardia of stomach, anus. He then told me, "Actually, they can be found anywhere on the body" - I died on the spot. So why is he asking me these?? I felt the patch of veins, they were warm. Got asked about differentials, I said arterio-venous malformation. Riiiiiiing. Urgh. Still dunno what these are. Obviously he didn't want me to look at varicose veins, cos there wasn't a bed for the patient.
2. Gouty tophi which were SO HARD, so fixed to the bone, and so not typically chalky that I said they were multiple exostoses. Had to be led into the diagnosis, and I seriously wasn't that convinced until he told me to feel one particular tophus at the elbow - "if you pull it hard enough it should move just a little". Felt that this one was unfair. It seriously felt like it was stuck to the bone. Got asked investigations, I said blood for uric acid, joint aspiration for crystals, he actually wanted X-ray. Bleargh.
3. Irreducible inguino-scrotal hernia. Crap lah, wasn't too good cos most hernias I felt were reducible, and I was slightly lost when the Uncle couldn't push this one in. Plus the testes were pushed to the back and top of the hernia so that for one wild moment I thought it couldn't be felt. "What will you be thinking of if you can't feel the testes?" Said hydrocoele, Prof smiled and nodded. "What's your management?" Said mesh repair, they were satisfied.
4. Another hernia! Paraumbilical, I claimed it was umbilical. It came through the umbilicus what, I'm sure of it. Sigh. "What is the defect in an umbilical hernia?" Said weakness of the linea alba. "What age do patients come with umbilical hernia?" - infants, usually, or very young children. "So what's the pathogenesis of an umbilical hernia?" - OMG, I actually launched into a treatise on the embryological development of the gut. Prof nodded and smiled though, I dunno if it's what he wanted. "How would you manage this hernia?" - gross. I actually said the wrong thing, conservative. Guys, DO NOT WAIT FOR PARAUMBILICAL HERNIAS. Repair asap, the orifice is small and it can strangulate. I suddenly saw the light, apologised for the wrong answer and told him I would want to repair it asap.
Sigh. Didn't go as well as I would have liked, but I suppose it wasn't all that bad.
Other cases that my friends got:
Breast cancer (long case) - ARGHHH!!! I WANT!!! Osteoarthritis of knee (long case) - ARGHHH!!! I WANT!!! Ankylosing spondylitis (long case) - as above Gastric caner (long case) - as above Diabetic foot (long case) - as above, lol. Lipoma (short) - as above Sebaceous cyst (short) - as above Frozen shoulder (short) - no thanks ...
Now for a short rest, I feel so drained from today. Definitely one of the most stressful exams, ever!!
As usual, all huddled around and doing last-minute revision with colleagues (which got everyone even more confused sometimes), and nurses bustling around trying to gut-feed us with ham sandwiches, fish fingers and milo (nurses are such sweeties during exams!!) and the usual prep talk by the exam coordinator who never fails to realise that we're all at the point of a major stroke.
"Don't be too worried, all of you. Your examiners will try hard to make you pass, and it is the responsibility of the School that you pass. There should be no reason why all of you have gotten into medical school and made it this far, and yet fail at this point. So if you do, it is not you who have failed; it is the school."
Applause for him, please!!
And now, time to make sure I do justice to my surgery exam and not falter at these last steps.
1 last major one to go (actually, it's THE last major one) and 1 last one that I just need to make sure I pass. Or better yet, score.
Today was the best I've felt so far about the exams, it was medicine short case. Guess what? No neuro!! =D
1) Abdo - Polycystic kidney disease
OMG, I fucked up my trump card, I totally can't believe it. (YX, you remember me wishing last night that I'd get a PKD??) Wanted to hurl myself out of the window after that. I prepared and prepared and prepared for PKD, and made a mess out of it. You know what? I actually forgot to measure the liver span and to auscultate for bruit! OMG! While presenting I think I turned green and hastily admitted that I'd have done those, but forgot to, and offered to do it NOW.
"Sirs, Mdm, my patient has hepatosplenomegaly with gross ascites and a fluid thrill. My - " Woman's face turned melanotic, nice guy examiner had a face that said "Shit!" and scary-looking guy examiner (who turned out to be ultra nice) gave me a look that said "No, nooooo!!!" Quickly retracted and said that I am not sure if there was also an enlarged kidney. I just wanted to die on the spot, since I already said I saw an arteriovenous fistula , made a show of feeling for thrill, and presented scratch marks on hands and legs.
Ended up re-examining the patient, OOOOOOOOOOOPS. It's a kidney with hepatomegaly. Oh come on, seriously, how good can this PKD patient be? Ultra-classic signs, complete with an arterio-venous fistula on the arm - and I messed it up ... ARGHH. Wanted to slap myself and squeeze my balls. So, the discussion session was centred around, "How do you differentiate a kidney from a spleen?" (can get above it, no splenic notch, band of resonance, ballottable etc.) and "What do you think caused the hepatomegaly?" (liver cysts) and "So what's your diagnosis now?" (PKD with end-stage failure on haemodialysis ... )
In a last-ditch attempt to score that extra mark and show them I knew all about PKD just that I mistook the kidney for a spleen, when the bell rang I quickly blabbered that I would also like to check for berry aneurysms in the brain. External examiner smiled and nodded. Should pass it, but a low one I think. Unless the woman is nasty.
2) Cardiology - prosthetic aortic valve complicated by aortic regurgitation
Ha .. this guy's my own patient! LOL. He doesn't recognise me (dozens of students rushed to see him while he was warded, when word spread that he had been listed for the exams) so I just went on. In all honesty, I only remembered he had a replacement, but not the details. Taken by 2 ang mohs, they were very, very nice. They let me present my song! Woot! Mixed up aortic regurg with aortic stenosis, but quickly remedied it within 5 seconds. Loved that phrase I picked up in Baliga - "Sir, I hear an audible metallic click even with the unaided ear."
Not many questions, maybe cos I pretty much covered all grounds - no complications of anaemia or over-anticoagultation and no diastolic murmurs heard ... except, "Why do you think he needed an aortic replacement?" - likely aortic regurgitation, because no evidence of heart failure which will be seen in stenosis. Dunno leh.
3) Respi - COPD +/- bronchiectasis + Cushing's
Gross. OK, 2 guy examiners were super-nice. You know, it's alarming when you get NO SIGNS except for hyperinflation and coarse creps. Forgot to mention hyper-resonant percussion sounds, and had to be prompted for that. Prompted into Cushing's as well. OK lah, I suppose if I had said ,"COPD on steroids, complicated by bronchiectasis and Cushing's syndrome" I'd probably have gotten distinction, so it wasn't that bad. A lot of things, you only recap and realise most-mortem.
Questions: "What are the other causes of fibrosi - ooops - crepitations?" - lol. he gave it away! So just expounded on the differences with fibrosing alveolitis and bronchiectasis without prompting, knew they'd ask that next anyway. Should have mentioned pulmonary oedema as well. Was a little disappointed that they didn't ask about the causes and treatment of bronchiectasis.
"Why do you think he has Cushing's syndrome?" - COPD on steroids, so most prob Stage III or IV. Should I have mentioned the possibility of asthma, or would that be grave-digging?
"What investigations, and what do you want to see on that?" - Spirometry, looking for reversibility and variability.
Now this is the odd question - "So for which kind, reversible or non-, do you give steroids?" - Wanted to tell him about GOLD guidelines using only FEV1 values to guide treatment, but decided not to antagonise examiner since obviously he isn't too familiar with GOLD, so I just gave it a go and said "Reversible" ... Was it a trick question? Well, they both nodded, so I guess that's fine.
Just a little note. You know how I have a problem with crazy sweating during short cases. Most examiners find it amusing, the HOD of anaesthesia at NUH remembers me specifically for profuse sweating while intubating patients. =\ At the end of Case 2, the 2 ang moh examiners offered me an entire box of tissues to carry around even though I had my own. By the time I reached my last case, the 2 examiners were visibly alarmed by my drenched shirt. Plus I almost buckled during percussion of the chest due to a very ill-timed exacerbaton of slipped disc. At the end, "Here, take these tissues .. get dry before you go out, or else everyone will think we tortured you in here!!" =D Smiled, thanked them profusely, and ran off.
Would have been a beautiful day, if not for that first case. Now, just 1.5 days for the WHOLE of surgery. Sick!!!
1) Counselling.Young patient with BMI of 26, he wants me to prescribe weight loss pills. Advice him.
Did ok for this one, forgot all about asking him to have family/social support, peer support groups etc.
2) Angry patient, father had a total knee replacement which resulted in tonnes of complications. Main issues for anger were father's disabilities, complications, costs, anxious that after downgrading to B2 ward he will have less care.
Pretty good, examiner was expressively pleased. *Thanks, YX!!!*
3) Consent for procedures. Patient (who was the examiner) had a pneumothorax, I need to put in a chest tube. Get consent.
So-so, and the nice examiner helped me out a lot! =) Was so engrossed in telling him what will be done that I almost forgot to go through the form. Killer question for this station: "When will you remove the tube for me?" And I wasn't really able to suggest alternatives ...
4) Breaking bad news. Patient came in with miscarriage, break the news to her, and tell her she needs an evacuation of the uterus.
So-so also. Was able to calm her down, and I forgot to offer her tissues (had plenty in pocket, fack!!). She came up with a sob story of how her husband wasn't around, I told her that her doctors and nurses will always be around for her - forgot to offer to call him for her. ARGHHH. The fascilitators were extremely surprised that I came out in like 5 minutes, shit. But the patient didn't have anything else for me what!!
5) Prescription-writing. 7-month-old boy with urinary tract infection, tell mommy that I need to give antibiotics. Then need to write in IMR the prescriptions for ampicillin and gentamycin, and maintenance IV fluid regime.
Not too good. Fack - forgot to educate her on the signs and symptoms of UTI and when to seek help. Reassured her that it's ok though. ALAS. ALAS ALAS ALAS!! I forgot to oralise the gentamycin!! But I guess I kinda salvaged that a little - after all, I *did* say that it's empirical, that the antibiotics may have to be changed after cultures come back. Mommy's question: "Can he just have antibiotics to eat?". Crap. Forgot to tell her that it's hard for 7-month-old to swallow tablets. When you have only 8 minutes to do a billion tasks, common sense evades you apparently.
6) Blue letter. Patient has biliary atresia, post-Kasai. Write to dental surgeon (OMG) regarding dental clearance for liver transplant.
So-so. But erm ... HELLO. I don't even know why the dental surgeon needs to see him! And didn't have enough time to write down all the investigations, and that HORRID piece of blue letter paper was so puny.
7) Emergency call. Pregnant patient with SLE comes in at night with breathlessness and haemodynamic instability. Call the registrar at 3am to come to hospital and see this patient.
So-so, examiner (who was on the phone) was very, very nice. Guided me through the entire thing, cos I had NO IDEA what was happening. SERIOUSLY, DO YOU EXPECT A MEDICAL STUDENT TO BE ABLE TO DEAL WITH DISSEMINATED INTRAVASCULAR COAGULATION AND PULMONARY EMBOLISM?? For us, SLE = renal complications. Was shocked, because I've always been taught that SLE gets better during pregnancy - not that we get much teaching on SLE anyway!
8) Anxious patient's daughter. Patient had chest infection causing frequent falls, and on warfarin for atrial fibrillation and coronary heart disease. Daughter demanded to know WHY he is still on warfarin, and is the warfarin too much, and rehabilitation.
Not good. Aspirin evaded my head until the very, very last moment. The very last. Well at least I touched on it. And the actress was mean!!! I mentioned AMK hospital for rehab, she insists she lives in Tampines and wants to know rehab places near there. Good thing is, examiner was my tutor last time and I think I made a sparkling impression on him while under his tutelage. Hope he'll be nice about the marks. =\
9) Procedures and prescription. Subcutaneous insulin injection, show how to do it, and fill in IMR for it.
F*CKED UP. BAD BAD BAD! I KNOW I failed this one, unless examiner is very very very nice (he is very nice, but whether v.v.v. nice .... ??) - I could have killed my patient, but remedied it in the last minute. I mis-read the instructions, and thought it was a subcutaneous insulin INFUSION. OMG. After I injected the insulin (wrongly), I forgot to cross out the prescription on the IMR. In my state of shock and hurry my mind registered a complete blank to stupid questions like "where will you inject it?" and "how often do you monitor my glucose?" Sad case of exam nerves getting the better of me.
One point though, the nurse in the room was EXCELLENT. She was a complete dear, and I MUST remember to thank her personally one day.
10) Another prescription - fill in IMR for something, can't remember.
So-so, not too good.
CRIPES. MUST buck up for the rest of the exams, I am definitely not happy at all with what's been happening so far.
Had a really bad night, filled with horrible dreams about the exams. Was very disturbed by yesterday, I think.
Today's exam will be odd, I'm really worried that some STRANGE issue will come out, which I won't know how to handle. Stuff like advice for leukaemia and perivalvular leaks (I can't for the hell of it find a single piece of information even online!!).
Will talk more about Yx's Oscar-winning performance later today. Too distraught by nasty dreams right now.
Oh dear, oh dear oh dear!!!! Did badly for the adult medicine case, I think. KT and I got the same case, and he came up with a radically-different - and much more sane - diagnosis than me. At least, he got to see the CXR. I didn't. I got asked a load of crap that I don't even know what they mean (some people need to learn how to ask questions properly). OK, you judge.
Elderly, obese man. Background history of VERY long-standing DM, HTN, hyperlipidaemia, CHD s/p CABG. Now presents with leg pain.
Immediate thoughts: Claudication DVT/cellulitis (less probable) Rheumato case
NOW. Leg pain has been there for 15 years, radiates up to knee. A/w joint swelling, pain and redness. Background of chronic pain, pain comes on when NOT walking. Man on crutches. No SOB/CP/orthopnoea/PND. Pain "spread" to both hands in last 2 weeks. Otherwise unremarkable.
O/E: kinda cushingoid. No striae though, but bilateral basal creps. No active joint disease, and NO MORE INFORMATION. (wtf ... they can't even give us proper significant negatives?!?!?)
My DDx was that of RA. OMG OMG OMG. KT said CCF. I feel so sad now, it was a total mess. Got asked possible reason for Cushingoid appearance (steroid Rx for RA?), how DM will affect him (possibly the reason for his CHD and CABG) and how the RA will affect him (WTF?!?!?? I said pain, disability with tendon rupture etc but it wasn't what he wanted apparently. Then he asked the SAME question at the end, I was like, "I'm not too sure of what you're asking", and he said pain and disability!!!! Exophthalmos ++++++++++) Totally fucked up, fucked up, fucked up.
On the bright side, I think I did pretty well for the paeds case though, it was a BA with jaundice 4 years post-Kasai, not listed for transplant. Plus progressive hepatic decompensation with thrombocytopaenia. Only thing was, I totally freaked out and was unable to tell her (OMG, I got D.Goh as examiner, wow!) the DDx of jaundice on D1, the definition of pathological jaundice, and TOTALLY forgot the values of bilirubin in a patient with BA. But was able to tell her possible causes of post-Kasai jaundice, and why Kasai patients are more prone to cholangitis. Phew! And other examiner (another nice neonatologist) asked about possible cause for thrombocytopaenia, said it was hypersplenism 2o to portal HTN. Feel quite ok. At least I got past Inx and Mx for this one.
Episodes of mild hysteria during studying, as you realise that anything - ANYTHING - can happen. Or even worse, you suddenly mix up the GINA and GOLD severity classification and treatment guidelines for asthma and COPD respectively, draw a complete blank when recalling the treatment of congestive heart failure, and mix up the Schwartz equation for glomerular filtration rate calculation with dosage calculation for potassium replacement. Please, please don't let it be Prof Yap. She remembers me as the guy who would admit a baby with dengue instead of her father. (BTW, the answer is the father - higher chance that he has been infected with a second serotype, with a risk of haemorrhagic fever and dengue shock. I was literally in shock that day, and she looked wildly entertained by my fervent explanations that a baby is more prone to haemodynamic instability etc etc etc while my other examiner giggled in the background. Wouldn't you, as a sympathetic human being, admit a baby instead?)
This is interspersed with long periods of catatonism and numbness as you sit there, totally drawing a blank.
Then the reality comes back to you and you get into sympathetic overdrive with dilated pupils, heart rate of 140 bpm and constricted, cold peripheries.
4 hours before exams:
Escapism as a maladaptive mechanism gets turned on once again, and you either blog about nonsense like this, or pray that you get some nice dove of an examiner today, or that you won't trip and keel over while running between the adult case and the paediatrics case later, or that you won't faint, get a heart attack/stroke, or baulk all over the examiner later. I vaguely entertained the thought of arriving with a cervical collar to gain some sympathy points.
Sympathetic overdrive is in full blast today. Sweaty palms, icy-cold hands and feet, mild tremors and extreme restlessness.
Please don't let me get acute confusion later, or have my voice stuck in my throat. After all, it's just 20 minutes with 3 very unknown examiners who may be out to murder you, but I'm guessing those 20 minutes will probably seem like an eternity.
To those who have already started on one of the most major of the last 5, hang on in there!
Today's paper was such a fiasco. I don't know if anyone anticipated those topics, but I was quite alarmed and had to dig into deep, deep, deeeeep memory to write something sensible.
Is everyone also starting to think that this upcoming surgical exam is quite, quite, quite impossible to finish studying for, or am I the only one?
I'm honestly just doing the bare essentials I think, going through notes that I so painstakingly wrote out months ago. But alas, looking at last year's paper, it seems that barebones just isn't enough. "Write short notes on Monteggia fracture-dislocation of the forearm, compartment syndrome of the leg, and osteochondroma". Ouch.
Made bouillabaisse yesterday on a whim, together with rouille and croutes.
Medicine theory - down. Now to cardiovert - or rather, cerebrovert - into surgical theory. OMG, it's so frustrating!! I revised surgery weeks and weeks and weeks ago, and I'm so sure none of that actually stayed in my head. 3 1/2 days to completely finish up general surgery, orthopaedics and obs & gynae is crazy. My head's swimming already.
This year's MCQs weren't THAT bad. Passable, I think, but definitely won't score at all.
Feeling a little down right now. I feel I deserve a break, but I can't. Shall make up by cooking up authentic bouillabaisse this weekend, but shucks - there's no way I can buy scorpionfish meat here, is there?
Update: Sick exam syndrome
I'm feeling quite burnt out, honestly. And I'm barely halfway through the entire month of exams! Maybe it's all that unaccustomed hard work - honestly I don't quite work hard enough normally - but I came home today, lapsed into a state of unconsciousness for 3 hours, and woke up with significant constitutional disturbances. And great. Now I have a bad tummy due to drinking too much milk today, it's all bloated and painful. Full of air.
Right. No more defeatist attitude. I'm going to finish up everything asap, I'm going to finish up this chunk of thyroid notes because I know that perhaps, at the end of Wednesday, I'll be bitterly wishing I had gone through these notes tonight.
On this new blog, anyway. Essay paper was mercifully OK, except for the strange question on what to do with a patient that has both rheumatoid arthritis and ischaemic heart disease. That, I totally bluffed my way through. But it was otherwise ok, and my wrist is feeling extremely sore right now, somewhat like post-econs paper.
Feeling slightly upset right now. I sneaked off for a snack of retail therapy today (meaning fish) and bought 2 GORGEOUS fish. One's a flying gurnard (YX, you're going to adore this guy!!) and the other - ALAS - a leopard blenny. I don't have pix right now, but here are some from the net:
Leopard blenny
Flying gurnard
I come home, search my trusty Reef Central and OMG. The leopard blenny eats exclusively small polyped corals!! I'm really shocked (and so were the people on RC actually), since blennies are mostly considered reef-safe and are in fact great at munching up nuisance algae. Fack. Now I have a coral-eating fish in my tank. He's still not out of the bag yet, I really should've asked about its diet first but I doubt I'd get a correct answer anyway. If it were Henry, then yes. But not where I bought these fish.
How?!? I only have one small polyped stony coral in my tank, and that's the beautiful yellow Porites that I love so much. There's no way I'm going to let that fish eat that coral, then die from starvation after he's killed it. =(
Plan now, is to put him in the sump I guess. Will try to acclimatize him to eating normal food like shrimp and teach him that there are tastier things to eat other than corals. This is bad. I'm going to stave off buying any more fish for now (not until something truly delightful pops up, anyway) - I'm very shaken by this coral-eating fish episode.
Lapsed into deep sadness last night and most of today. I know 230 other people are facing the same situation right now, but I can't help feeling all alone. When you know it's really up to you at this time, it's something you've got to face alone, but yet you're yearning for help - somehow, someone, somewhere. It'll be a boon; something unearned but appreciated, but you simply can't expect. What will it be then? Dreams, prophecies of revelation? For fate to be kind to a battered soul? Or sudden precociousness and expertise?
What can't be seen - the infernal battle raging on inside the head, trampling on grounds that were much earlier charred to the ground, reduced to dust, with the dull red glow of a dying sun.
I must be grateful.
Sitting in a darkened dungeon Silence humming, thickened air Can't breathe. Scattered pieces of paper and scribbles Speaking voices in the head Can't concentrate. Sudden realisation Seeing all but nothing Can't pull this off.
First total lunar eclipse of the year tonight! Well, technically tomorrow dawn, since we're only going to be in the umbra region but not in totality. The entire event starts with the moon sliding into the penumbra at 1900 GMT (3am) but the better show should start anywhere from 5.30 am to 7.30 am. The moon will be low down in the west at this time, so make sure you look at the right places! The moon will turn from the usual yellow colour into a deep pumpkin orange colour ... grrr. Hope I'll have the energy to wake up (or stay awake .. depending) and catch this one. Next eclipse near the end of the year I think.
OMG, this is a first! And I thought I've had it all with reptiles and scary animals. A Draco volans, or flying dragon, soared straight into my mom's room during today's storm! She thought it was one of those changeable lizards ("iguanas" as the ignorant primary school kids called them, no doubt the product of idiotic parents) but after I caught the creature up I was highly surprised. The poor thing was very shaken (heard Brownie barking at it some minutes ago) and didn't even struggle when I picked it up.
I've only ever seen 1 of these before, and it was at a good distance away, gliding from tree to tree. Did a quick Google on it, they are almost obligatory ant-eaters and captive breeding efforts have been dismal, so the poor guy will just stay for a picture, a freak show for YX and my sisters, and just 1 empirical try at feeding it, and then off it goes back into the wild tomorrow morning. I know I can't keep this baby alive.
Wish she (appears to be female) would lay some eggs before I let her go though, it would be such a sweet thing to care for the babies after the exams.
Yesterday was pretty gross - probably passable (Question 1 was exceptionally kind) but definitely nothing above 70%. Mark allocation for the 2 paeds questions were utterly idiotic though. 3/4 of the question took up barely 50% of the marks. And all of a sudden the patient with infectious mononucleosis develops difficulty walking - what is the likely diagnosis - and this took up 25% of the marks. Yes, just the diagnosis of something ELSE that happened. Grrrr. Quite grossed out. Paeds people are sick in the head.
