Jumping straight to conclusions

It is often happen when you see signs and symptoms that fit a typical disease, and you immediately assume that disease is the culprit.

One example would be when someone presents with inability to walk far and have associated features of shortness of breath and chest pain.

You might think this could be caused by either heart disease such as ischaemic heart disease (IHD) or lung disease eg chronic obstructive airway disease (COAD). It is true that both IHD and COAD can prevent someone from walking far. Hence, you would order CXR and ECG stat.

We need to think broad before wasting precious investigations. Is there other diseases that might cause someone unable to walk far?

One possible explanation that should be included in differential diagnosis would be osteoarthritis of knee or hip :). If you don't think this as one of the possible causes, you will look foolish in front of the patients and consultants.

Another example is shoulder pain. Pain in the shoulder joint can be attributed to the shoulder pain but there are other possible causes of shoulder pain.

My usual approach is to diagnose the causes systematically. Try to find out local causes, distant causes and referred pain.

Local causes

• rotator cuff (degeneration, tendon rupture, calcific tendonitis)
• subacromial bursa (calcific bursitis, polyarthritis)
• capsule (adhesive capsulitis)
• Glenohumeral joints (synovisitis, osteoarthritis, dislocation)

Distant causes

• head of humerus (tumour, osteonecrosis, fracture/dislocation)
• Acromioclavicular joint - osteoarthritis
• Sternoclavicular - synovisitis, osteoarthritis and dislocation

Referred pain

• Cervical spondylosis
• Cardiac ischaemia
• Anything that can irritate the phrenic nerve (liver, pancreas, pleura etc)

I find that this type of approach is useful and help me not to miss something important.

If you are stuck and unable to think of other possible causes of any symptoms, asking system review questions will help to buy time and hopefully reveal useful clue to the diagnosis.

Besides diagnosing medical condition, we tend to jump straight into conclusions whenever we met any strangers in life. We immediately judge someone based on their appearance, attitude or based on how other people perceive the person.

Anyway, the message that I would like to convey in this post is to think broad and collect enough evidence before making your own opinion towards anything in life.

24 years in a dungeon.

Human being is the only species who can be cruel to each other, even to their own children.

AUSTRIAN police have arrested a 73-year-old man accused of locking his daughter in his cellar for 24 years and fathering seven children with her.

A prosecution spokesman said Elisabeth Fritzl, 42, had accused her father, Josef, of "massive crimes".

DNA tests are being conducted on the woman and six surviving children.

It is the third time in recent years that Austria has been stunned by tales of children locked away by parents or adults they know.

According to police, Ms Fritzl told investigators her father put her to sleep with an anaesthetic on August 28, 1984, handcuffing her in a locked basement.

Officially, she was declared a missing person, with Interpol opening an investigation.

A letter was sent to her parents asking that they stop searching for her and local authorities concluded she had been seized by a religious sect.

She told police she spent years imprisoned in an underground chamber beneath the family home near the eastern town of Amstetten.

MS Fritzl told detectives she was "regularly abused" by her father and their incestuous relationship produced seven children.

All the children appear to have been born in grim captivity, but investigators said one child, a twin, died shortly after birth. Police said the body was subsequently burned.

All the children appear to have been born in grim captivity, but investigators said one child, a twin, died shortly after birth. Police said the body was subsequently burned.

Three boys and three girls, now aged between five and 20, survived. Mr Fritzl legally adopted two boys and one girl.

Mr Fritzl is said to have told his wife, Rosemarie, and local authorities that three babies had been left by Elisabeth on their doorstep, in different years.

Each delivery was accompanied by a letter purportedly signed by Elisabeth saying she could not support the child because she already had others to care for.

The trio went to school as normal, seemingly unaware that their mother and three other siblings (a girl of 19, and boys at 18 and five) were trapped underground.

Read more here.

studying hard

There are a lot to cover. At this point, I'm only revising the common and important diseases that I need to know as an intern. The rare diseases.... I leave that to the registrars or for the consultants :)

I started to come early to the hospital and went back late since the exam is less than two months away. The only reason is the library. Somehow, library provide conducive and warm environment to study. At home, it is a bit difficult.

However, I will not be able to do that in my next rotation. The next rotation will be at Northern which is a different hospital from the current hospital. It is further from home and the timetable is more packed. The time to travel will be longer.

Sometimes I think I'm studying too hard. I mean I revised to the point of full saturation and I get headache from studying. I have to stop for few minutes and then forcing myself to continue my revision again.

I'm blogging this as part of my break from my own revision. At least, this will bring back my focus towards reading my notes. Ok, good bye for now.

embarrassment

I was reading this sentence in a medical book when I found this word...

....if there are any signs of circulatory embarrassment, treatment must be prompt and uncompromising...

What does that mean? How does blood vessel becomes shy eh...I guess the word embarrassment here means occlusion :)

ANZAC day

Today is a public holiday for Australia. ANZAC which stands for Australian New Zealand Army Corps, fought on the first World War and many soldiers died in the battlefield. This special day is a special remembrance for those soldier who died during the war. I've written on this matter few years ago; Sejarah Anzac (ditulis di dalam Bahasa Malaysia)

Anyway, I should not waste this 3 days of holiday. I should revise. The exam is quite near already.

satisfaction

This morning we were discussing on acne and psoriasis with a dermatologist. It is part of our dermatology topic session. After the discussion, somehow our talk deviated to discuss on the treatment of acne that is available on the market.

The non-pharmaceutical company that sells the treatment for acne is quite dubious and they does not necessarily have proven track record. The dermatologist told us that most of the product advertised heavily on the newspaper, radio and television does not work at all and the products do not treat the cause of acne. At most, they only relieve the symptoms of acne temporarily.

Due to the nature of this topic, all female members of my group start asking questions on various products such as make up, moisturiser, sun screen and various treatments of acne. The conclusion is that many companies exploit the human desire to become beautiful who never satisfies at anything.

One striking example was that dark skin people like to have white skin whereas white people like to have darker skin. We will never become satisfy at anything. Once we get something that we desire, we want more and more. It will never stop.

Narrated Ibn 'Abbas: I heard the Prophet saying, "If the son of Adam (the human being) had two valley of money, he would wish for a third, for nothing can fill the belly of Adam's son except dust, and Allah forgives him who repents to Him."

[Sahih Bukhari, Book 76, Hadith no 444]

Bacaan tambahan: Cukup tampan, Cun dan Hensem :)

Number of posts

It seems that the number of posts in this blog has been decreasing. I guess this can be contributed to the number of hours I spend for revision. Clinical years is quite busy and sometimes the consultants expect you to know some stuff that you've never learned before. You have to study on your own and should not expect the consultants to teach you. Prior to the clinical years, you can always depend on the lecture notes given by the lecturer and now, there is even less lectures. You have to be independent and organised your own timetable and notes.

The conclusion from this chart is that I should write more often in this blog :)

Plastic surgery

It is often associated with cosmetic such as reconstructing face, nose and breast. After 3 weeks in this rotation, I learned that plastic surgeons do more than that. In fact, in a public hospital, it is less likely to see them doing surgery related to beauty purposes.

Many of the patients that come to see plastic surgeon were from patients who had fracture, had skin tumour removed, had serious trauma that is affecting their arms and legs and some serious medical problems that is affecting their function to live as a normal human being.

In fact, in a plastic clinic, the patients were totally different and sometimes unexpected. I could be asked by the plastic surgeon on anatomy of various part of the body. I've to be well prepared before coming to a plastic clinic. Fortunately, I've mastered the anatomy of upper limb, head and neck and abdomen :)

Learning the language

2 weeks into this rotation, I have learned various new vocabulary related to dermatology and orthopaedics. Dermatology lead us to become more aware of any skin lesions and to check for tiny details on the lesion that may help in diagnosis.

Several new words that I have learned so far: papule, eschar, purpura, ecchymoses, nodule, blister, sloughy, gangrene, naevus and comidone.

Instead of describing a normal skin lesion as a tiny dark spot on the skin, I'm now describing it as a dark brown macule lesion with a diameter of roughly 5mm with well-defined margin which may be consistent with epidermal melanocytic naevus.

See how long the descriptive word has become now ;). There are more descriptive terms that need to be used to describe any skin lesion.

walimah

Yesterday, I attended my friend's walimah. It is the first time for me to attend walimah at Melbourne. Both of the groom and the bride, Faiz and Marlina are my colleagues from the same batch.

The walimah was held in a mosque and it was only for male. Walimah for female was held at a different place. The ceremony started with recitation of the following verses from al-Quran.

O MANKIND! Be conscious of your Sustainer, who has created you out of one living entity, and out of it created its mate, and out of the two spread abroad a multitude of men and women. And remain conscious of God, in whose name you demand [your rights] from one another, and of these ties of kinship. Verily, God is ever watchful over you!

Hence, render unto the orphans their posses­sions, and do not substitute bad things [of your own] for the good things [that belong to them], and do not consume their possessions together with your own: this, verily, is a great crime.

And if you have reason to fear that you might not act equitably towards orphans, then marry from among [other] women such as are lawful to you - [even] two, or three, or four: but if you have reason to fear that you might not be able to treat them with equal fairness, then [only] one - or [from among] those whom you rightfully possess. This will make it more likely that you will not deviate from the right course.

And give unto women their marriage portions in the spirit of a gift; but if they, of their own accord, give up unto you aught thereof, then enjoy it with pleasure and good cheer.

And do not entrust to those who are weak of judgment the possessions which God has placed in your charge for [their] support; but let them have their sustenance therefrom, and clothe them, and speak unto them in a kindly way.

And test the orphans [in your charge] until they reach a marriage­able age; then, if you find them to be mature of mind, hand over to them their possessions; and do not consume them by wasteful spending, and in haste, ere they grow up. And let him who is rich abstain entirely [from his ward's property]; and let him who is poor partake thereof in a fair manner. And when you hand over to them their possessions, let there be witnesses on their behalf - although none can take count as God does.

[an-Nisa:4-6]

A lecture related to wedding in Islam was given and it touches on how to choose the right spouse while in the same time remind the audience the impact of Western civilisation towards Muslim view with regard to love and wedding. It also highlighted the effect of culture in organising walimah back in Malaysia.

The building block of any community begins with a family. A good family will contribute a lot to the society. Deciding who you are going to marry with will lead to large effect in the future and upon this, the talk reminds us again on the famous hadith on how to choose a wife.

The talk was refreshing and a good reminder for all of us.

After that, few of the boys performed nasyid dedicated specially for the groom. The next event was a bit unexpected which was having martial art show inside a mosque. Four people performed Malay martial art from silat gayong and silat cekak and it was quite entertaining. It reminds me of those days back in KMB when I was actively involved in silat gayong.

The food was delicious and it is certainly different from walimah back in Malaysia. Anyway, I think I need to do lots of exercise now to burn all the cholestrol I got from the food :).

Being in the same batch with the bride and the groom, the usual question of asking me when it will be my turn follows. There were several people who asked me this question and I quickly replied that I have not found the candidate yet. If I find the right person, I will get married as soon as possible :). Hopefully this answer will satisfy their curiosity.

So, out of 20 people in my batch, 5 are already married and I wonder who will be next...

....until proven otherwise

There are few diseases that are important not to be missed in any differential diagnosis. When you see any patient with signs and symptoms that may fit the condition, you have to do few tests and investigation to rule in or rule out few important diseases.

Off the top of my head, these are what I could remember...

• Fever in a returned traveller is malaria until proven otherwise.
• Broad complex tachycardia is ventricular tachycardia until proven otherwise.
• Nocturnal joint pain is tumour until proven otherwise.
• Monoarticular arthritis is infectious until proven otherwise.
• Iron deficiency anaemia equals to occult bleeding until proven otherwise.
  

I end this post with a quote I found from a dermatology book.

"The dermatologist's art is giving a disease a long Greek name...and then a topical steroid" :)

power blackout

I was having lunch and noticed that it was extremely windy outside. The weather forecast mentioned that today will be raining. After that, I went to the library and discovered that the light was flickering. Perhaps there was some short circuit somewhere, I thought.

Not long after that, the library went totally dark. An announcement was made that there was power failure in the entire hospital. This is the first time it occurs and it was rare to see total blackout in the hospital. Few of the surgeries were cancelled and the operating theatres had to use emergency generator.

Code brown which stands for disaster plan was activated. My tutorial had to be cancelled and having nothing to do, I went home.

The weather outside once I step out is extremely windy. Many small tree branches have fallen down on the road and traffic light was out. Fortunately, it is not peak time yet and the traffic is not that busy.

More related news.
Storm winds unleash chaos
Victoria's wild weather

It seems like a hurricane has descended on Melbourne.