Wedding Invitation

Assalamualaikum, I am inviting you, my blog readers to my wedding reception. May your presence bring blessing to the ceremony. Thank you.

The adventure

Alhamdulillah, I have arrived at Malaysia on 7th December. Since then, I have been extremely busy managing all of my wedding preparations and greeting few of my relatives here.

My adventure at Melbourne has ended. I have changed the blog title and haven't decided what will be my next blog title.

Graduation day on 5th December was one of the happiest moment in my life. After 6 years of studying at medical school, finally my friends and I have managed to pass all the exams and celebrate the graduation day together. It was not an easy journey for all of us. Sometimes, when the challenge was too hard, few of us were thinking of quitting from medical school.

When I came to Melbourne 6 years ago, I don't have any idea what will I be in 6 years time. To get a place in a medical school is a challenge in its own right and to graduate as a doctor is another difficult hurdle too.Alhamdulillah, my journey is over.

The next chapter of my journey will be a test to measure my own capability to cope with continuous daily stress at workplace. Working as a young doctor and at the same time managing your own family will be an exciting adventure. Hopefully I will be able to be a good doctor and a good husband at the same time.

I will upload my wedding card in my next entry. Till then, I am inviting all my blog readers to come to my wedding reception on 26th December 2009 and 2nd January 2010.

Year One - The adventure begins

On January 2004, 20 students from Mara College Banting arrived at Melbourne for their one-month orientation programme. The orientation programme was filled with random activities comprising of lectures, PBL tutorials and orientation to the university and visiting the city of Melbourne.

Accommodation

Out of 20 people, 7 of them are JPA scholars and the rest are MARA. 7 boys and 13 girls. Before coming to Melbourne, JPA let us to find our own accommodation but will not pay for any accommodation above the monthly allowance. At that time, the monthly allowance was only AUD 637 and the average rent for accommodation around the university could reach up to AUD 300 per week.

The JPA scholars were stranded and at one point, we had to ask permission from Malaysia Hall at Melbourne for temporary accommodation. Alhamdulillah, few days before arriving, one of our friends from Monash University managed to find an accommodation for JPA scholars (only for boys though). As a result of this, our female friends were left stranded randomly hopping from one house to another house for the next few months.

p/s: I have been living in the same house for the last 6 years. I guess I'm too lazy to get involved in the hassle of moving house.

Bicycle

I bought a bicycle in the middle of the first semester and has been using it to travel from home to university. I think the distance is roughly 4km. It was a good form of exercise for me. Whether it is summer or winter, raining or extremely hot weather, I persevere to use my bicycle as my main mode of transportation around the neighbourhood.

Right in the middle of the winter holiday, four of us, managed to cycle to Monash University, Clayton. It took us few hours to cycle from Melbourne to Monash University since we choose a route that was full of steep hills. It was a memorable experience for me and it was exciting to think that we have enough stamina to cycle for a trip that was roughly about 20km.

Grandmother
My grandmother passed away during my first semester exam. I was pretty close to her since she has been looking after me when I was little. I think the hardest bit when we are separated from someone is  not having the chance to show how much we love that person. Occasionally, the memory comes back to haunt me since I've never got the chance to say goodbye to her. Al-Fatihah to her.

Blog

On 15th of August 2004, I started this blog. Alhamdulillah, I managed to persevere with blogging until today despite that I have been blogging less frequently in the last few years.

Fruit picking and packing
During my first summer holiday, my friends and I tried various jobs to earn a bit of cash. Initially we went all the way to Mildura looking for job. Mildura is right at the border of Victoria, roughly about 300km north from Melbourne. Having no luck looking for job overthere, we went to Cobram which is also along the state border. Alhamdullilah, after few days searching for job, we got a job in one of the big farms over there.

My first job was as a cherry picker, but I quit after few days. The salary was not that attractive compared to the workload. Next, we worked as strawberry pickers. This job is quite good but it won't be good for your back since you have to squat throughout the day to pick the strawberries. Again we quit from the job.

Next, we went home to Melbourne and try our luck looking for job at Yarra Valley, which is about 50km west from Melbourne. We managed to find a job as a cherry picker again and this time, we managed to persevere with the job until the end of cherry season (middle of January).

I've written a lot of posts about my working experience as a cherry and strawberry picker. Read these post below if you are interested to know more :)

Cobram 1
Cobram 2
Cobram 3
Cobram 4
Cobram 5
Cobram 6
From Cobram to...
Wandin East 1
Wandin East 2
Wandin East 3
Wandin East 4
Wandin East 5
Final Note

p/s: I'm not sure whether I still have the talent to write that kind of post anymore.

I think that is a pretty good summary of my first year :)

The Final Hurdle

As part of  my final year exam at University of Melbourne, I had OSCE and one long case in the last two weeks.

OSCE stands for Objective Structured Clinical Examination. It means that you spend roughly 9 minutes either taking history from an actor or performing a brief but concise physical examination in front of an examiner or interpreting radiological images such as chest x-ray and answering several questions.

Long case means that you are given one hour with a patient in the hospital. In that one hour, you need to know why the patient is in the hospital and to perform relevant physical examination and at the same time, think of appropriate management plan for that patient. You then present your history and examination findings to two examiners. The examiners will be either a general surgeon, physician or a general practitioner. The examiners will asks several questions relevant to the patient and test the depth of your knowledge based on your answer.


OSCE
I had two OSCE at two different location for two days. The first day OSCE was held at the medical faculty and the second OSCE was held at the hospital.

Medical Faculty

1. Patient presented to you with dizzy spell. It was benign paroxysmal positional vertigo. I was not sure what else to ask in this station and was asking weird and random questions towards the end of the station.
2. Interview patient who was referred from Emergency Department to Neurology Outpatient. The ED doctors felt that her epilepsy is not fully controlled. Again, I was not sure how should I approach this station. I have to read the question several times and in the end, running out of time to answer the questions from the examiner.
   
3. Pregnant women who is vomiting. Take history and discuss the differential diagnosis and the relevant investigation. Hyperemesis gravidarum is the keyword for this station. I totally forgot about the intravenous fluid therapy.
   
4. Interpret peak flow chart and teach good inhaler technique to asthmatic patient. Was running out of time in this station.
   
5. Radiology station. CT Brain: Haemorrhagic Stroke. Chest X-ray: Tension Pneumothorax. Interpret lab result: Nephrotic syndrome. I don't have enough time in this station.
   

Clinical School

1. Interview a patient who is feeling unwell. He had malaria. I think I did pretty alright in this station.
   
2. Interview a patient who had recurrent abdominal pain. It turned out the patient had acute pancreatitis. Need to know the differential diagnosis and the relevant investigation. Despite memorising all the causes of acute pancreatitis before the exam, I forgot all the causes due to anxiety attack.
   
3. Procedural skill station. Need to perform airway management and CPR. 
4. Perform cardiovascular examination on a patient who had a murmur. I think the murmur was mitral regurgitation. Not really sure about the murmur since I was pretty nervous thinking the differential diagnosis for both diastolic and systolic murmurs.
5. Perform relevant examination for patient who had right hip pain. Need to do gait, Trendenlenburg test and hip joint examination. After that, need to interpret the hip X-Ray (Osteoarthritis) and discuss the appropriate management of osteoarthritis.

Long Case

I had the opportunity to interview a patient who came in to the hospital with acute asthma attack in the background of nephrotic syndrome (I already had nephrotic syndrome as part of my OSCE).

I don't think I did well in my presentation and the examiners does not ask me any particular question related to asthma management. Instead they opt to ask me questions related to nephrotic syndrome. It was quite difficult since I haven't learned in detail about nephrotic syndrome. When they asked the type of glomerulonephritis causing nephrotic syndrome, I stumbled a bit and just said maybe diabetic nephropathy and rapidly proggressive GN. When they asked me to explain the mechanisms of hypercoagulability state in nephrotic syndrome, I guess this must be my limit. I'm not sure which clotting factors or proteins that will explain the symptoms. I mentioned several clotting factors, protein C and S and antithrombin. I don't know the real mechanism to explain those symptom.

Anyway, up to this point, they haven't asked me anything about asthma. If they were to ask me about asthma, I guess I could do a bit better in my long case.

Hopefully all my friends and I could pass the final year exam and able to graduate together on 5th December 2009.

Year Zero - Before Melbourne Uni

Back in 2003, when I graduated from Mara College Banting  (MCB) with a diploma in International Baccalaureate(IB) , I have roughly about 7 months of holiday before going to Australia. The IB programme was initially designed for students who are going to universities in Ireland and United Kingdom (UK). Therefore the IB programme in MCB finished in the middle of the year and gave their students 2-3 months before starting their studies in UK or Ireland. Most if not all universities, at Ireland and UK start their intake on August/September.

At that time, there were only two Australian universities available to MCB graduates, namely University of Melbourne and University of Monash. I am among the first batch from MCB  who are going to study at Melbourne Uni.

My friends who were going to study at University of Monash, Australia had their 3 months orientation programme starting from September that year. Their orientation programme is held at Melbourne, Australia. I guess at that time, I felt a bit disappointed to learn that my friends at Monash were having fun and getting allowance at the same time whereas I have an extra long holiday after finishing my study at MCB.

So, what did I do at that time? After few weeks discussing with our MCB principal, and confirming that I don't have any similar orientation programme similar to Monash Uni, thus began the era of me looking for various sorts of jobs.

I initially planned to work  in a factory but the working condition and the low salary immediately turn me away from the job. Then, I thought of working as a cashier in a nearby petrol station but the position was not vacant at that time.

My mom suggested to me to work as a substitute teacher in her school. So, I took the opportunity and immediately got the job. I had to teach the entire Form Four in the school from the topmost class to the last class in the Form Four. It was an interesting yet challenging experience for me.

The last class in Form Four were filled by students who were not motivated to study or even came to the school. They had to come to school because their family forced them to come. They don't have any insight on the importance of having education for their own future. Compare this situation with the topmost class students who were quite motivated to study and willing to do lots of homework to improve their knowledge.

I had to be flexible in teaching these students and need to adjust the level of teaching according to their level of interest and knowledge. It was certainly an eye opener for me to learn the skills to teach students who are not motivated to study in the first place.

After two months of teaching, I retired from the job when the original teacher came back from her maternity leave. Thus, I was jobless again. I had to look for another job but what could I do then at that time? I had only SPM certificate and IB diploma, and hardly anyone knows what is IB programme anyway.

If I'm not mistaken, I retired as a teacher on middle of September and I had few months to go before I started my study at Melbourne Uni. Waiting for my flight to Melbourne was certainly a lesson in patience for me. Doing nothing during an extra long holiday is not something that suits me. I need to do something interesting. Otherwise I will be extremely bored killing all those free time.

After early retirement from teaching those students, I had to stay at home and look after my two younger sisters. My youngest sister was only 3 years old and her older sister was only 5 years old. Early in the morning, I had to sent them to a neighbour who will be looking after them and pick them up in the afternoon. Both of my parents are working and no one is at home to look after them. I'm not qualified enough to look after young children :)

It was during those days that I had the chance to learn how to cook. I never cooked any meals before. Hmm, looking back at those days, it was funny to see how I approach cooking. I always think cooking as a chemistry experiment where you add few of stuffs together and boil them in a frying pan. To get the taste right, you need the right amount of stuff and this ingredients need to be balanced. I constantly tried to find the right chemistry equation for different type of meals but I failed miserably in the end :)  There are too many variables that need to be adjusted to get the right taste and it was certainly will take me ages if I were to write equations for all the meals. In the end, I had to use my own taste bud to adjust the ingredients.

This is an already long entry for Year Zero. I guess I will stop here and continue later whenever I have free time :)

Final Year

It has been busy, but it is expected. My final year exam will be in another two weeks and yet there are lots that I haven't revised. Speaking of revision, I don't think it should be called as revision in the first place since I pretty much forgot everything that I've learned so far. Hopefully I won't be extremely anxious when the exam comes in the next fortnight.

Apart from studying, I'm also in the midst of selling my first car. It is not easy to sell an old car and it has been a bit stressful for me. The experience of selling a car certainly taught me a lot on how to deal with potential car buyers. I'm also looking for cheap courier service to bring my stuffs back to Malaysia. Maybe I would do that after the exam.

And finally, I am also inviting you, the blog readers, to my home at the end of this year (to be exact 2nd January 2010) for a small ceremony :D   I am getting married at the end of this year. The wedding preparation has kept me extremely busy and I still haven't finished printing all the wedding invitation cards. Hopefully it will be done by next few weeks and I will be able put up the scanned wedding cards here in this blog.

Last but not least, I have already booked my flight ticket home. This time, the flight ticket is paid by my sponsor :) I will be going home few days after the graduation ceremony.

p/s: After 6 years living in Melbourne, it is sad to see how things will end. After reading my friend's blog, I think I should reminisce about the past 6 years.

Anaesthesia

Over the last five days, I have spend most of my time in theatre. As part of my surgical rotation, I need to do a week of anaesthetic.

Anaesthesia is defined as loss of bodily sensation with or without loss of conciousness. There are three main components of anaesthesia, namely hypnosis (being put to sleep), relaxing your muscles and sedation (this means that you lose your awareness of your surrounding).

As a specialty, anaesthetic is one of the toughest training program to get into. There are high level of competition for young doctors to participate in anaesthetic training. It is quite attractive to become an anaesthetist since there are wide range of skills being involved and in term of salary, it has one of the highest salary grade among specialist.

Over the last week, I had the opportunity to practice putting a laryngeal mask into few patients. I had the chance to sharpen my skills in performing intravenous cannulation. 

A laryngeal mask is a tube that is inserted inside your throat during an operation. The picture below shows how to put the laryngeal mask inside your mouth.

 Picture from Merck Manual.

Intravenous cannulation simply means of putting a needle inside your blood vessels. This link will describe in detail how you perform the procedure.

As a medical student, putting a cannula (needle) inside the blood vessel was initially a hard task to be performed. You have to overcome your anxiety of hurting the patient and develop a good technique to insert the needle into a blood vessel.

Anyway, back to my anaesthetic rotation, it was exciting to be at the other side of the theatre. I used to be helping surgeons with the operation and hardly have any chance to sit on the other side. The anaesthetist usually sit behind the curtain and will monitor the anaesthetist machine to ensure the patient is breathing appropriately and is comfortable throughout the operation.

It is interesting to see how the anaesthetist handle the emergency cases. I had several emergency operation throughout the week such as emergency caesarian and emergency laparotomy due to unknown abdominal bleeding. There was a patient who had laryngospasm at the start of the operation and the anaesthetist taught me how to handle this emergency. Laryngospasm is uncontrolled contraction of the muscles inside your vocal cord and will cause a person to stop breathing. This is certainly a dangerous situation since it will cause lots of damage to your organs especially your brain.

In summary, being anaesthetist is fun but at the same time, it is hard to get into their training program. My next four weeks will be in theatre assisting the surgeons with their operation. This will be my last four weeks in medical school.

p/s: I'm looking forward for graduation but at the same time, I've to study hard for the final year exam. Hopefully, I will get a good mark from the exam.

General Practice rotation

It has been 5 weeks since the last time I blog. A lot has happened in the last 5 weeks. Alhamdulillah, I have finished my general practice (GP) rotation.

This rotation means that you are spending time with doctors at their own clinic and observing how the doctors managing their own patient. You will be given lots of opportunities to interview the patient on your own and then presenting your findings to the doctor. It is a good practice for my final year exam.

This rotation gives you an insight on what are the most common illnesses around the community. Sinusitis is more common than temporal arteritis. Otitis media is more common than croup. Pneumonia is quite common but it is not that severe to warrant the patient to be admitted to the hospital.

Having been spending few years in the hospital, it certainly give me a bias perception towards finding out what is the most likely diagnosis. If I were to see a patient in the hospital, I'm more inclined to think of rare or life-threatening conditions rather than to think of more safer illnesses.

I did my GP rotation in rural Victoria and there were several opportunities for procedural skills. I managed to excise a skin mole and suture the wound. After 6 years of studying medicine, I finally performed my first PR examination on a patient. It was an exciting experience to learn how normal and abnormal prostate gland feels like. I managed to deliver a baby in the hospital which is quite exciting considering that the last time I delivered a baby was almost 12 months ago.

It is certainly an interesting rotation and it certainly boosts my experience in managing the more common variety of medical illness.

p/s: Since I hardly been able to use the internet in the last 5 weeks, there are a lot that I need to catch up with. My google reader is already been filled with few thousands of unread items.

General Practice

For the next 5 weeks, I will be spending time at General Practice (GP) clinic. This means that I will be having lots of opportunities to clerk patient individually and present the findings to the doctor. This will be the best time for me to get lots of procedural skills done.

During winter holiday, the medical school asked us to choose 10 places for our GP placement. Unfortunately, since many medical students choose city placements, not many were able to get their place of choice. In my case, my placement was not even in my list. I was given rural GP placement which is quite far and close to the border of Victoria. I might be celebrating Eid over there as well. There won't be any Muslims within 50-70km radius from my GP placement.Now, that is something that I would call as celebrating Eid'ul Fitr in a foreign land.

I don't think I would be able to get free internet access over there. Hence, no more blogging or even facebook-ing in the next 5 weeks. As this will be my last post before going to my GP placement, please forgive for all my wrongdoings and Happy fasting. Happy Eid in advance too.

Medical Rotation

Alhamdulillah, I have finished my medical rotation. After 5 weeks of spending time following a general medical team, there has been lots of stuff that I've learned yet at the same time, I managed to find out the limit of my knowledge. Clearly, after studying medicine for 6 years, there are still a lot that I don't know.

6 years of studying medicine does not really teach you how to works as a doctor. There seems to be a big gap on how to put all your medical knowledge into practise. Doctors do lots of paper works and referral. Medical school won't teach you how to fill in those paper works. You are supposed to observe it from the interns during this semester and learned it by yourself.

Referring patients to the other specialty is not an easy task to do. Interns are supposed to refer any suitable patients to the specialist for further management. The most difficult part of this process is to answer questions from specialist on reason for referral. I've seen how interns were scared to death when referring to the specialist. If you are not able to answer the questions from the specialist, the referral won't be accepted and you have to tell this to your own consultant.

Many patients who are admitted to the hospital require lots of medical imaging such as chest X-ray, CT scan and MRI. Radiology department is always busy and it is not easy to get a slot for your own patient. Somehow, the young doctor has to plead or find convoluted ways to get permission from the radiologist. Asking for permission to do medical imaging for your patient will always be one of the most difficult tasks for an intern.

Drug chart is one of the most common tasks that every young doctor will do. Yet up to now, I have never been taught formally about all of the doses of the medication. The university asks us to learn it by doing online course.

In the last 5 weeks, I have learned more on how to do my future job more efficiently than learning anything on medical knowledge. Hopefully, my next two rotations will be interesting :)

وَمَن يُشَاقِقِ الرَّسُولَ مِن بَعْدِ مَا تَبَيَّنَ لَهُ الْهُدَى
وَيَتَّبِعْ غَيْرَ سَبِيلِ الْمُؤْمِنِينَ نُوَلِّهِ مَا تَوَلَّى وَنُصْلِهِ
جَهَنَّمَ وَسَاءتْ مَصِيرًا (4:115)

If anyone contends with the Messenger even after guidance has been plainly conveyed to him, and follows a path other than that becoming to men of Faith, We shall leave him in the path he has chosen, and land him in Hell,- what an evil refuge!

[An-Nisa:115]

closer to the grave

Alhamdulillah, I have been blessed to be given 26 years to live in this world.

Whenever I went to the ward, the average age of the patient would be around 75 years old. 26 years seems not a long period to me. I gained lots of reminder each time I met an elderly patient. Looking at their face and thinking of what sort of experience they have gained in the past, it helps me to re-orientate myself to the reality of this world.

Every time you reach an anniversary of your life, you are one step closer to the graveyard. It may seem far for now, yet sooner or later, you will meet the judgement day.

Sometimes, I'm a bit hesitant to celebrate my own birthday. Maybe unconsciously, I'm afraid that I will realise that all this while, I have been wasting my time. I hope that in the past 26 years, I have done enough good deeds and repent for all my sins to Allah and for any wrongdoings to any human being that I have met in the past. Insha-Allah, I will try my best to be a better person and controlling all my negative attitudes.

I'm grateful for all the birthday wishes that I received. I hope that everyone will remain steadfast in Islam. Happy Ramadan.

5th Anniversary

This blog as of today, will be 5 years old. A lot has happened in the past 5 years. Let me tell you a little bit about my blog.

This blog was started as a personal blog. A place for me to jot down all the ups and downs of my life as a medical student. The initial title of this blog was paradigmshift and the initial url was hafiz_238.blogspot.com. I chose paradigm shift to reflect my motivation to be a better person and to be brave to face all of the challenges in the future.

Later, I changed the blog title to 'kembara di bumi Melbourne'. I think I have to change the title of this blog at the end of this year since I won't be living at Melbourne. Not sure which title I should choose.

I used to be blogging frequently. However, in the last few years, especially when I started my clinical years, I haven't been able to blog as frequent as it used to be. Perhaps, life has been busy or I don't have any inspiration to put my mind into writing. Nevertheless, I hope that I would be able to maintain this blog for the next few years.

Pergi tak kembali

Al-fatihah to Ustaz Asri. Read more.

Gen Med

Tomorrow will be my third week of doing rotation in General Medicine. So far, alhamdulillah, it has been fulfilling. The consultant expects the medical student to participate in the ward round everyday and try to admit patient and presenting on the ward round. The ward round usually lasts between 4-5 hours everyday. It has been busy, but that will be my life starting from next year. So, I guess I shouldn't be the one complaining.

I usually arrived at the hospital around 8am and only came back to home around 10pm. I like to do my revision at hospital rather than studying at home since it can save me lots of electricity bills and prevent me from wasting my time doing unnecessary things.

There are lots of things that I need to revise for this semester. I am still trying to find time to revise my Obstetrics and Gynaecology and Paediatrics since those subjects will be part of my semester exam. Hopefully I can find time to blog and visit other blogs as much as possible in the next few months.

Ok, that's all for now.

Semester 12

This will be my final semester at Melbourne. There will be three rotations during this semester (Medicine, General Practice and Surgery). Each rotation will be 5 weeks and at the end of 15 weeks, there will be 10 OSCE stations and 1 long case.

I am looking forward for this semester since it means that my 6 years of studying in Melbourne will end very soon. At the same time, I am feeling a bit anxious knowing that I will be working as a doctor in less than 6 months time. This will be my transition point from being a student to someone who will be looking after many sick people.

For GP rotation, we were instructed to choose 10 places that we would like to go and at least 3 of them have to be rural places. For this rotation, I was hoping to get somewhere close to home. Unfortunately, I got rural place for my GP rotation. It is so far that I don't think I would be able to return home every week. Hopefully, there will be internet access over there.

My first rotation will be medical rotation and it starts tomorrow. Despite being a final year student, I still believe that there are so many things that I didn't know and I am expecting a busy semester ahead. Hopefully I can survive this semester.

p/s: It is interesting to read what I have predicted 5 years ago. Read future predictions (In Malay)

Winter Holiday

I haven't been updating this blog regularly. Perhaps I am having writer's block which is perpetuated by the cold temperature of winter season. This condition might be precipitated by not having much interesting activities to be written on the blog. However, I believe there are few protective factors that will protect me from giving up blogging.

p/s: The paragraph above was written in the format of formulating a psychiatry history. Usually, you need to mention 4P (Predisposing, Precipitating, Perpetuating and Protective factors) at the end of your presentation

Swine Flu (H1N1) in Melbourne

In response to one of my commenters, I will try my best to illustrate what is happening in Melbourne regarding to the famous swine flu.

Up to 2nd July 2009, there have been 1691 cases in Victoria out of a total of 4568 cases in the whole Australia. Melbourne has among the highest swine flu cases per capita in the world.

However, this does mean that there is a widespread panic among people living here. Despite there were many school closed down and intensive media coverage, there were not many deaths associated with swine flu.

You should know that swine flu is not a dangerous disease. It is known to be extremely contagious but it is less likely to kill you. The normal seasonal influenza kills more people than the current swine flu.

Right now, I'm glad that the media has shifted their attention from swine flu and focus more on the death of an artist .

A frustating OSCE

I finished my exam yesterday. One of the main reasons I took a day to write about OSCE were that those OSCE were quite frustating.

There were 5 OSCE stations.

1. Take history from patient with symptoms of depression.
2. Take history from patient with bulimia nervosa. Describe the management.
3. Elderly women with Colles' fracture. Describe your findings in clinical examination and x-rays. Management of Colles' fracture.
4. Patient with advanced lung cancer, want to die at home. Has several issues. Medication, feeding, EPOA.
5. Elderly patient with side effects of medications (MS Contin and Naprosyn).
   

The first station I had, was the depressive patient. I had to exclude whether this patient has Major Depression. I almost forgot all the symptoms of depression due to anxiety. Fortunately, I'm able to remember few of the symptoms before the bell rang.

Bulimia nervosa again. This disorder has been featured in the previous written exams and I'm not sure why the medical faculty is so interested in asking medical students about eating disorders. During this station, I'm not sure what else to ask after eliciting all the DSM IV criteria for bulimia nervosa.

Colles' fracture. Hmm, I'm stumbled quite a lot in this station. When the examiner asked me to do physical examination of the wrist, I'm not sure how to neuro exam of the hand, so I quickly do a random examination of the hand. Hopefully, I can get enough points in this station to pass the ED station.

The last two OSCE stations were quite a puzzle. I'm not sure what else to say in patient with palliative care needs and not sure what are the side effects of those medication.

Overall , this semester which is made of RAPP (Rehabilitation, Aged Care, Palliative Care and Pyschiatry of Old Age), Rural rotation, Emergency Rotation and Psychiatry has been a frustating semester. Let us hope that all my friends and I could pass this semester exam.

p/s: Before the OSCE, we were given surveys for this semester to fill in. This was what I wrote for RAPP: The RAPP handbook is too painful to read.

Hopefully they will make significant improvement for RAPP :)

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV refers to a condition when you get dizziness on a certain position such as rolling in the bed or waking up from sleep.

While studying for this condition, I found out a nice claymation video showing Hallpike manouevre and Eppley's Manoeuvre.

Below is a nice diagram showing what is happening in the ear canal.

Credit to Merck Manual

SHR Written paper 2

Six 5 marks questions

1. Side effects of haloperidol
2. Football player hit at head. GCS 3. Describe assessment, initial management and investigation
3. Key features of delirium
4. Key features of obsessive-compulsive disorder
5. Describe 3 risk factors of fall and give example for each factor.
6. Elderly men with recent cognitive impairment. Given diazepam to treat his ‘nerve’ problem. Give comment on his diazepam usage.

Six 15 marks questions

1. Elderly Italian lady with mental impairment. Lives in Shared Supported Accommodation. Unable to speak in English. Has diabetes, obesity and history of falls. List 5 issues in this lady. Describe your management.
2. Men with paracetamol overdose and found with empty whisky. Slightly intoxicated. Describe initial management, investigation. Mechanism of paracetamol toxicity. Tool to assess paracetamol toxicity. Management of paracetamol toxicity and route of administration. [Guidelines for the management of paracetamol poisoning]
3. Elderly women with advanced lung cancer. Want to die at home and family happy to support her. Describe your discharge planning.
4. Women present to GP with symptoms of 8 years history of binge eating and purging. Normal physical exam. Describe management of this patient.
5. 40 year old women with MS. Work as a telephonist and need to access computer as part of her job. Describe clinical features of MS that may interfere with her job (4 marks). Describe your assessment on finding out what are available at work to overcome this issue (4 marks). Recommendations on how to cope with work difficulty due to her MS-related disability (7 marks).
6. Elderly men with long history of ischaemic heart disease and now presents with depressive symptoms. Describe the relationship between medical illness and depression.
   

In this paper, there were few questions asking on DSM IV criteria of several psychiatry disorders. DSM IV is the manual published by the American Psychiatric Association and covers all mental health disorders for both children and adults. It tells you how to diagnose any mental illness and describe the relevant differential diagnosis. Most, if not all, psychiatrist were able to recite the DSM IV criteria for any mental illness. So, it is necessary for medical students, to memorise the DSM IV criteria for major mental disorders.

I'm not sure how to answer the question on MS. It is asking for specific answers related to work-related issues. I randomly put anything that might be relevant in answering this question. Hopefully, I could gain at least several points from this question.

Overall, I'm glad that the written exam is over. Now, I could look forward for my OSCE and the short winter break after that

Update 27/9/2009: Thanks to Intan for telling me the other questions.

SHR Written paper 1

Six 5 marks questions and six 15 marks questions.

5 marks questions

1. List symptoms faced by an elderly widow, few weeks after the death of her husband.
2. Describe the differences between vasovagal collapse and syncope.
3. Describe anorexia nervosa
4. 5 causes of constipation in bed-bound cancer patient
5. 5 components of CBT in managing major depressive disorder
6. A young boy falls on outstretched hand. Presents with pain in anatomical snuffbox. Normal plain X-ray. Diagnosis, management and complication.
   

15 marks questions

1. Differences between acute, chronic and cancer pain. Answer in table form
2. 87 year old female, lives alone, presents with decline in function over the last 6 weeks. Has multiple co morbidities and lots of medications. Still driving. Has slightly reduced score in MMSE. Describe your management of this patient.
3. A young tourist poisoned by bright-coloured octopus. Presents to ED. Which organism (blue-ringed octopus), what type of toxin and mechanism of toxin. Initial assessment and management. Treatment and expected outcome
4. 38 year old women, previously well, presents to ED with back pain. Normal neuro exam and MRI. Has relationship problem with her partner but has resolved. 3 differential diagnosis. How to assess the different diagnosis in Hx and MSE.
5. 40 year old train driver, presents with history of frequent alcohol drinking. In the last few weeks, he had panic attacks while driving the train and this is alleviated by drinking alcohol. DDx (6 marks). How to assess him in hx and MSE (9 marks)
6. 40 year old policeman, presents with delusion and hallucination. He needs to do something to protect himself. Describe a thorough risk assessment (11 marks). Ethical principles faces by GP in this patient (4 marks)

Few of the questions were a bit difficult to answer. Those questions test the capacity of your memory.

The question on octopus was in a way interesting. I knew the type of the octopus but I didn't know the toxin nor its mechanism of action. In fact, I wrongly guessed the management in this question. There goes my 15 marks.

15 days later

The title refers the number of days this blog last updated. Lots of things has happened in the last two weeks.

1. Swine flu is now officially an epidemic. Malaysia currently has more 90 cases of swine flu and the reaction from the Malaysian newspapers has managed to over exaggerate the severity of the swine flu. In fact, many of my friends who are going back to Malaysia for winter holiday are quite worried that they will be under home quarantine too, since few cases of swine flu in Malaysia originate from here. Go read this; Swine flu's not that bad.
2. Riot in Iran. I wonder what will happen to Iran in the next few months. Hopefully, if there is any chaos in the future, it won't lead to lots of unnecessary killing among the citizens and disrupting the petroleum production. Petrol prices has already been increasing and we don't need another riot to push up the petrol price.
3. New operators for tram and train in Melbourne. Hopefully this will improve the quality of public transport in Melbourne in the future.
   
4. Exams. I have finished two written exams and will be sitting for OSCE next week. Will write more about those written exam later.
5. Firefox has released the third Firefox 3.5 release candidate. I am patiently waiting for the next version of Firefox . Read this; Firefox 3.5 memory usage, Top 10 features in Firefox 3.5

Update

It has been more than a week since I last updated this blog. Currently, there are about two more weeks before my semester exam.

At this time of the year, many medical students are busy applying for the intern job in Victoria or interstates. Most of my groupmates were having lots of stress and worries since it is not an easy process to apply for a job here in Victoria. They have to sit for many interviews and few of the interviews will be during the exam period. They have to balance between revising for the exam and preparing for the interviews.

As the only person in the group who is not applying to get a job in Australia, my role for the last few weeks has been to calm them down and help them with possible interview questions. Interestingly, we are doing psychiatry rotation and it has been useful to put all of those relaxation techniques into practice. I hope that all of my groupmates and my friends will get a job in Victoria.

In term of psychiatry rotation, I don't think it has been a useful rotation for me. It was not properly taught and most of the students are not really interested in choosing psychiatry as their future career.

Swine flu in Victoria has been infected many people in the last few weeks, and of last night, there has been at least 1011 persons infected in this state and the total number of swine flu cases in Australia is 1260. If the number of cases in Australia especially Victoria keeps on increasing, WHO might have to declare the swine flu as a pandemic.

Iklan 1960an

Sungguh klasik bahasa yang digunakan .

Disturbing radiology images

Warning: Viewer discretion is advised.




















From ABC News via [Kevin MD.]

Bizarre radiology images.

Part of being a medical student is the ability to be calm whenever facing a major trauma. Hence, we have been shown weird and traumatic images since first year. The ability to calm down is important since it can have a direct effect towards the patient.

Imagine your doctor being more anxious than you. How do you think that would affect the patient?

Swine Flu in Melbourne

VICTORIA has passed the point where the spread of swine flu can be prevented and should immediately close every school in the state for a week to slow the progress of the virus, a federal government influenza adviser has warned.

There were last night 209 confirmed cases of swine flu nationally, with 138 cases in Victoria.

Tasmania also reported its first case.

Although seven Victorian schools have been closed in steps to contain the virus and a further 27 identified as "affected", governments and health authorities insist the scale of the outbreak does not warrant wholesale school closures or cancellations of major public events. But Raina MacIntyre, an infections diseases expert and a member of Australia's Pandemic Influenza Advisory Group, said yesterday the time had come to consider more drastic steps.

"We're at the stage now in Victoria where a blanket closure of all schools and pre-schools should be on the agenda and a decision needs to be made quickly," Professor MacIntyre told The Weekend Australian.

Federal Health Minister Nicola Roxon conceded yesterday that the focus of Australia's pandemic response would invariably shift from trying to contain the virus to treating it.

Read more

It is interesting to see the number of schools that have been closed down around Victoria for the past few weeks. I have managed to mark all the schools that has been closed down (in red) and the schools that has been affected by swine flu but does need to be closed down (in blue).

The hospital that I'm attached to is right in the middle of the epidemic area. I might add that there is one railway line that is passing through all of those schools.

p/s: Having said that, I don't think we should be panic with the increasing number of swine flu in Australia.

Trials and Tribulations

Be sure we shall test you with something of fear and hunger, some loss in goods or lives or the fruits (of your toil), but give glad tidings to those who patiently persevere,

Who say, when afflicted with calamity: "To Allah We belong, and to Him is our return"

They are those on whom (Descend) blessings from Allah, and Mercy, and they are the ones that receive guidance.

[Al-Baqarah: 155-157]

Signs versus Symptoms

This post is written to clarify the difference between symptoms and signs.

When a patient come to see a doctor, the patient will usually tell what is wrong with him/her such as having fever, short of breath or chest pain. These are what the health professionals called as symptoms. Symptoms are the observations made by the patient.

On the other hand, signs are the observations made by the health professionals. For example, a doctor might notice that there is an abnormal breath sound heard using stethoscope. The doctor might used various medical terms to describe the abnormal breath sound. This is a sign that may indicate that there is something wrong with the chest.

In summary,

• Symptoms : any feature which is noticed by the patient
• Signs : any feature that is observed by any health professionals (Doctors, nurses, allied health professionals).
  

p/s: Sometimes, signs and symptoms are used interchangeably .

Electroconvulsive Therapy

I had the opportunity to observe Electro Convulsive Therapy (ECT) today. The indications for ECT are

• major depression, resistant to medication
• bipolar disorder
• mania
• schizophrenia
• Need exists for rapid treatment response, such as in pregnancy

The relative contraindications are

• brain tumour
• dementia
• delirium

ECT was performed by putting two electrodes next to your head and seizure is induced by passing electrical current through those two electrodes. You can do ECT unilateral (only one side of the head) or bilateral (two side of the head).

If you are going to do unilateral ECT, you usually choose the non-dominant hemisphere. Usually, right-handed people have their left side of the brain as their dominant hemisphere. More info on cerebral dominance.

To reduce the effects of the induced seizure, muscle relaxants need to be given eg Succinylcholine (Suxamethonium Chloride). The patient need to be under general anaesthesia and a short acting general anaesthetic agent is used. The one I saw used Propofol.

Some trivia about ECT.

• It was initially used by Romans by using electric eels and currently ECT is no longer practised in Italy.
• In modern age, it was initially thought that having seizure can cure schizophrenia. So, that's how ECT was started :)
• After more than 70 years of using ECT in modern time, doctors are still not sure how ECT works inside the brain.
• ECT is one of the last resort to treat major depression. So, once you are having ECT, it is possible that you need to have ECT for lifetime.

Symptoms

If you are ever had the chance to know how the psychiatric disorders are classified, you will be utterly shocked.

All psychiatric disorders are classified according to their symptoms. Let's say if you have symptom A and symptom B together, that will be called as a disorder 1. If you have the third symptom, symptom C, A+B+C = disorder 2. To make it more confusing, many of these psychiatric disorders are overlapping and if the psychiatrist are not able to categorise the disorder, they will simply called it disorder not otherwise specified .

The classifications for psychiatric disorders keep changing over time, and any disorders were subjected to whether they were perceived as abnormal by society. If a certain psychiatric disorder was no longer perceived as abnormal and the society is able to accept the condition, this disorder will be removed from the classification.

Homosexual used to be classified as a psychiatric disorder. However, due to the increasing number of people who are practising homosexuality and the acceptance by some society, being homosexual is no longer treated as a mental illness.

Read more.

We should treat the cause and not the symptoms. However, in psychiatry, many causes of mental illness still remain elusive and perhaps will take several centuries for it to be found. In the mean time, we have to depend on this classification based on symptoms, which is not accurate and can be confusing at times.

Psychiatry

Doing psychiatry as my last rotation seems to be the right rotation for me . There were not many lectures/tutorial that I need to attend every week and each person has their own individualised timetables. At first, the individualised timetable seems a bit complicated to understand. However, after reading it several times, it seems easy to comprehend.

I have lots of free time in this rotation. Having lots of free time is a great blessing for me. I can now start to revise for my coming semester exam, although I’m not really sure what will come up in the exam.

After doing nearly two weeks of psychiatry, I still haven't found anything interesting in this rotation yet. I hope I can find something useful in this rotation. Otherwise, psychiatry will not be an option in my future career list.

How much a young doctor earns?

Taken from The Star

lt starts at RM2.456.39 (Grade UD41, P1T6) as against those of other schemes of service. The initial salary takes into consideration the period of six years that an undergraduate takes to qualify as a medical officer.

Furthermore, the total takehome pay for newly-appointed medical officers is RM4,058.39 when all the monthly allowances and Incentive Payment for Critical Service (the highest compared to those of other critical schemes) are factored in .

In addition, medical officers als o receive the following allowances:

> On-call allowance at the rate of RM150 per night;

> Locum at the rate of RM80 per hour; and

> Incentive payment for specialist ranging from RM1,600 to RM3,100 per month, depending on the grade of the officer.

The ruling that will entitle newly-appointed medical officers to receive RM6,000 per month will take affect in 2010, after the current batch of medical graduates have completed their internship at a local government hospital.

To further advance their career prospects, the Government has improved promotion opportunities of medical officers by creating more promotional posts. At the same time, the Government has increased the number of scholarships for the Masters programme to 600.

------------------------------------------------------------------------------
Will this be enough to lure Malaysia medical students to work in Malaysia public hospital? Personally, I don't think this will be enough to keep doctors in public health care system. There are various factors that need to be improved such as working environment, more opportunities to do specialist training at overseas, opportunity to work in private sector and the Ministry of Health should conduct more surveys from junior doctors to capture the suffering and burden among young doctors.

Any opinion?

HAVE WE NOT opened up thy heart,
and lifted from thee the burden
that had weighed so heavily on thy back?
And [have We not] raised thee high in dignity?
And, behold, with every hardship comes ease:
verily, with every hardship comes ease!
Hence, when thou art freed [from distress], remain steadfast,
and unto thy Sustainer turn with love.

[Al-Syarh: 1-8]

Energy efficient of Google search

Taken from Google Blog

Activity	Google Searches
CO2 emissions of an average daily newspaper (PDF) (100% recycled paper)	850
A glass of orange juice	1,050
One load of dishes in an EnergyStar dishwasher (PDF)	5,100
A five mile trip in the average U.S. automobile	10,000
A cheeseburger	15,000
Electricity consumed by the average U.S. household in one month	3,100,000

read more

p/s: I found it funny to compare the number of Google searches with a glass of orange juice

End of rural

I finished my rural rotation last friday. For the last three weeks, I have been away from Melbourne.

After spending two weeks and a half at Heathcote, I personally think that rural rotation needs to be shorter in duration and Emergency rotation should be longer. There is not much to be learned during rural rotation.

You will be able to see how each health services are coping with limited resources in rural setting. Plus, you may be able to visit any interesting places around the town. If there are aborigines around, you can visit them and learn more about their culture and history.

Anyway, my three weeks of holiday in rural rotation has ended. Now, it is time for me to learn about psychiatry and hopefully my next rotation would be more interesting than RAPP and rural.

Heathcote

I have been spending close to one week at my rural placement, Heathcote. This place is 30 minutes away from Bendigo, which is a big regional town and 50 km from Kilmore which is a small town like Heathcote.

The population of Heathcote is around 2800 people and most of the people here are Anglo-Saxon. I hardly see any Asian people here . There are 2 doctors (GP) in the town and one small hospital. The hospital is run by one GP and that GP has resigned from the hospital last week. Now, the hospital is facing the dilemma of recruiting another GP.

This problem is a common scenario in any small town around Australia. There are not many doctors who like to work far away from major cities such as Melbourne and most of the doctors who work in rural, are being forced to work by the government.

Having said that, there are still doctors who love to work in a small community. There is one doctor, not far from Heathcote, who is still working to provide the necessary health care to the community, despite he is already 80 years old . It is something that amazes me.

Anyway, back to my rural rotation. I lived in a nice house next to my supervisor and it has wireless broadband internet connection. This place has a nice environment and I always saw kangaroos jumping around the neighbourhood. In fact, this morning, I already saw around 20 kangaroos alone .

Every medical student in University of Melbourne is required to spend 3 weeks in rural setting as part of their medical course. Rural rotations means that you are send to a small town, far away from your home and you have to learn what are the differences between rural and city health system. Some people were send to a place that is about 400km from Melbourne and close to the border of New South Wales. It is almost impossible for them to go back to Melbourne every weekend. Hence, they have to stay at that place for the next three weeks.

Not all accommodation has internet connection and I'm fortunate to be blessed with internet facility. Without internet, I would be stuck in rural doing nothing and getting bored.

This is my second week of rural rotation and I'm already looking forward for this rotation to end. There are not much that you can do here and I miss having superfast broadband connection at home .

Cultural Safety

On the third day at Dookie Campus, all of us have to travel to Rumbalara Football Club, Shepparton, which is about 40 minutes away from Dookie Campus. The main reason we have to travel to the football club is to learn about the cultural differences among many races and in this case, it was the Aborigines.

Aborigines in Australia have been abused for hundreds of years. They were isolated from their families and integrated into the white society to such an extent, they lose their own language. Australia has its own dark history.

Read more

There was an interactive session where the medical students were split up into two group and each group have to become a predefined culture group and follow all the rules. It was an interesting experience as each group culture is significantly different and each group has to find out what are the rules of the other cultures.

I find the session was useful to highlight the differences of cultures among human being. We are not that easy to accept any people who are different from us. Sometimes, deciding which one are good or bad rules in a community can be difficult since it is subject to various factors such as culture, faith and the global environment.

Dookie and cows

We spend three days at Dookie campus and most of the time there were lectures that we need to attend. Bear in mind that attendance sheet were distributed at each lecture and 100% attendance is required from all medical students.

At the end of the first day, we were given a tour on how to milk the cows. It was an interesting adventure for most of us since many of us were brought up in urban environment and hardly see any cows at a close range.

Seeing how the workers milk the cow was an exciting experience for all of us. Most of us took several pictures of the cow but at the same time, we have to beware of any unexpected things that could happen during milking.

The cows are milked from behind and the milking machine is attached to the udder. The machine will automatically stopped when it reaches a certain amount of milk. I'm not sure how much though.

Since we milked the cow from behind, the butt is facing our face and the cows can unexpectedly urinate or defecate at whim. There are two rows of cows during milking process and we stand in the middle. So, we have to be cautious on both sides .

On that day, several unfortunate people had the accident. It was not a nice experience to have that on your first day of your rural rotation.

Rural rotation

For the next three weeks, I will be doing my rural rotation. For the first three days, I will be at Dookie Campus, which is about 204 km from my home and it took me roughly 2 hours to get here. Right now, I am blogging from Dookie Campus using wireless network .

After this, I will spend the rest of my rural rotation at Heathcote, which is about 155 km from Dookie and the journey will take another 2 hours from Dookie. The journey from Heathcote to my home will be another 107km (1hr 27 minute travelling time).

The map below will show the locations that I have written in the above paragraphs.

Melboure to Dookie


Dookie to Heathcote


Heathcote to Melbourne

p/s: I might not be able to blog once I'm at Heathcote since I'm not sure whether the internet will be available at my accomodation.

Fascinating photo.

Can you think how this picture is taken? [Note: this is not achieved via any photo-editing software such as Photoshop or GIMP]

The answer.

p/s: It took me few minutes to understand the technique. Incredible shot .

Favourite Firefox extensions

These are my favourite Firefox extensions in Firefox 3.0.

1. Adblock Plus. I certainly recommend my reader to install this popular Firefox add-on. It blocks 95% of website advertisement and this also includes flash ads. It certainly helps me on having faster loading of any websites and have better internet surfing experience.
2. DownThemAll. A useful download manager. It contains download accelerator and help me to organize all my downloads.
3. IE Tab. I used this for any websites that stubbornly have to be displayed using Internet Explorer. This add-on is also useful if you are a web designer.
4. Web Developer. It helps me whenever I'm designing this blog layout. It also help me to gain further understanding on how each website works.
5. Greasemonkey. This allows me to customize the way a webpage displays using small bits of JavaScript.There are various JavaScript available to be used with Greasemonkey. It certainly useful if you would like to try various JavaScript available on Greasemonkey
   

Related: My favourite Firefox extensions [2007]

Perak piyor

Inspired from Sarah who took a quiz on loghat Pahang on Facebook

Hafiz took the istilah loghat perak yg anda faham quiz and the result is anda mmg perak piyor!

anda mempunyai pengetahuan luas dengan istilah2 yang digunakan diperak, anda mmg berasal dr perak kerana anda familiar dgn istilah2 yg sukar ini...dengan ini anda layak utk berkahwin dgn og paris, lambore dan kwsn2 yg sewaktu dgnnya!

Take the quiz on Facebook: Istilah loghat Perak yang anda faham

Time Lapse Videos

These were interesting videos showing changes over time. How clouds move according to the wind, how the sun bring brightness to the nature and how moon shone light upon darkness.

Definition of time lapse video:

Time-lapse photography is a cinematography technique whereby each film frame is captured at a rate much slower than it will be played back. When replayed at normal speed, time appears to be moving faster and thus lapsing. Time-lapse photography can be considered to be the opposite of high speed photography.

Shlino lake sunset time lapse from Timelapser on Vimeo.



Spitzmeilen - Swiss winter mountains in time lapse from Michael Rissi on Vimeo.


My way from Per Erik Sviland on Vimeo.



Pixel's Revenge timelapse showreel from David Coiffier on Vimeo.

More time lapse video: 1, 2

Emergency Medicine review

I have finished my three-week rotation of Emergency Medicine. This was one of the most interesting rotations that I've been so far. It is a rotation that I've been looking forward since pre-clinical years.

I have managed to refreshed my knowledge on various acute life-threatening medical problems and able to perform few simple procedures such as putting a cannula into a vein, making plaster or back slab, practising Advanced Cardiac Life Support and observing how to manage various fractures.

Three weeks seems a long period for many but it seems to me that I prefer longer time in ED. Perhaps another week in ED will be good for me .

Overall, in this rotation, it is up to you whether you would like to be busy or just enjoying lots of free time available. You have to be very proactive in approaching doctors and nurses to get an opportunity to do lots of stuff. Most of the staffs here in the hospital I attached to, have been very nice and helpful.

My advice to my colleagues who will be doing ED after this:

• The best time to see lots of patients will be after 5 or 6 pm. If you are in the morning shift, there will be few new admissions except if there is any major trauma happening in the local vicinity.
  
• Fast Track, a section of ED which handles Category 3 t0 5 will be a good place to get your procedural skills done.
• Make sure you get to see lots of common presentation to ED [Chest pain, SOB, headache and fractures]
  

Mnemonic for Delirium

Delirium is an important medical symptom and may pointing to an immediate medical emergency if not recognised early. Here is mnemonic to remember the causes of delirium

• Drugs
• Endocrine (diabetes, thyroid, parathyroid or adrenal dysfunction)
• Epilepsy
• Lung Disease (pneumonia, COPD, sleep apnoea)
• Infection (Encephalitis, meningitis, syphilis, HIV, septicaemia)
• Injury (Concussion, subdural, extradural haemorrhage, burns, general and cardiac surgery, #NOF)
• Intracranial (Tumour, raised ICP)
• Renal (acute and chronic end stage failure)
• Intestinal (Carcinoma, obstruction, ileus)
• Unstable circulation (Arrythmias, CCF, Myocardial infarction, Hypertensive encephalopathy, hypoperfusion, blood loss, shock)
• Metabolic (Hyponatremia, Hypokalaemia, Acidosis/alkalosis, hepatic failure, dehydration)

Adapted from Bloch and Singh, Foundation of Clinical Pyschiatry