Friday, August 31, 2007

end of Neuro

6 weeks of neuro, eye and ENT rotation is over. Overall, it was an interesting block which requires a lot of revision and practice.

What is contained in this block? Well, first of all, there are a lot of physical examination that need to be mastered theoretically by the end of this block. 12 cranial nerves, upper limb, lower limb, gait, checking the eye, nose, ear and throat. That is quite a big area to cover and not to mention there are a lot of diseases in the eye.

At the end of week 6, I think I know most of the physical examinations except the eye since I do not have the luxury of having an ophthalmoscope. The only gap that need to be filled quickly is the knowledge of major neurological diseases.

Two of the most common presenting symptoms that I feared right now is headache and back pain. There are many diseases that can caused back pain and headache. Some of those are mild and does not present any danger to the patient. However, the one that can cause severe disability to the patients are not to be missed and it is this category that requires me to be extra cautious.

An easier way is to ask the patients to undergo CT/MRI but this is not an option. Plus, the interpretation of radiology a.k.a the dark art :D is still not in my grasp yet.

erti kemerdekaan

Hari ini usia Malaysia mencecah 50 tahun. Kalau usia 50 tahun ini diterjemahkan ke dalam kehidupan seorang manusia, dia mungkin sudah mempunyai cucu dan memiliki pengalaman luas dalam beberapa aspek kehidupan. Kalau ditanya mengenai bentuk nasihat yang ingin diberi kepada generasi muda, mungkin dia mampu memberi beberapa nasihat yang penting.

Situasi Malaysia pasca merdeka masih mempunyai ruang untuk diperbaiki. Mungkin erti kesabaran dan perpaduan perlu diajar dengan lebih tekun kepada sesiapa yang bergelar warganegara Malaysia.

Ramai rakyat Malaysia yang kurang sabar apabila berada di atas jalan raya. Namun begitu, kalaulah ingatan saya masih utuh, Malaysia terkenal dengan rakyatnya yang bersopan-santun. Apabila tiba suasana perayaan, angka-angka kematian di jalan raya meningkat berkali-ganda dan mungkin boleh mengatasi jumlah orang yang mati kebuluran di benua Afrika atau jumlah orang yang terbunuh di Palestin.

Istilah perpaduan masih lagi merupakan suatu konsep yang sukar untuk diterapkan di Malaysia. Kita masih lagi memandang orang lain berlandaskan konsep bangsa dan istilah bangsa Malaysia adalah suatu istilah asing di halwa telinga kita. Ada banyak tembok yang perlu diruntuhkan untuk kita memupuk semangat perpaduan ini.

Rasanya cukuplah setakat ini celoteh saya di dalam bahasa Melayu :). Sudah lama tidak menulis dalam bahasa Melayu yang menyebabkan saya memerlukan masa yang lama untuk mencari-cari kata-kata yang sesuai. Kadangkala perlu berfikir di dalam bahasa Inggeris dan menterjemahkannya ke dalam bahasa Melayu untuk menulis. Secara perlahan-lahan, perbendaharaan bahasa Melayu saya sudah terhakis walhal saya dahulu sering mendapat A di dalam subjek Bahasa Melayu.

erti kemerdekaan

Saturday, August 25, 2007

week 5

Now, I have finished the 5th week of my rotation. Only one more week left. I guess I will try to practice neuro physical examination throughout the semester since it will take lots of practice to become familiar with those examinations.

Every medical student need to learn the steps in examining a patient and every system in the body has its own specific examination. What I mean by system is the division of human body for example brain, hand, leg, chest, breast, abdomen and genital. Each of the system has different steps involved which will help in diagnosing a specific disease.

Now, in my current rotation, I need to know how to examine eye, ear, nose, throat, specific cranial nerves , hand,leg and gait. Different diseases have different types of presenting symptom and I need to be aware of that. An example would be Parkinson's disease. There are a lot of diseases that can mimic Parkinson's to the point that many physicians/doctors misdiagnosed someone with Parkinson where in reality those people have another disease.

I was quite busy this week that I forgot the actual date of my birthday. To recap what I have posted on my birthday in the past few years, here are the links to my previous post.


I will end this post with this verse from al-Quran as a reminder for me.
For, Believers are those who, when Allah is mentioned, feel a tremor in their hearts, and when they hear His signs rehearsed, find their faith strengthened, and put (all) their trust in their Lord;

Saturday, August 18, 2007


I had an opportunity to attend a neurosurgery last week. The surgery was to remove a brain tumour which has caused the patient to have chronic headache in the past few years.

Prior to the operation, I changed my clothes to the surgical cloth. There were few people in the operating theatre: few surgeons and the supporting nurses. The tumour was meningioma which is a type of tumour that attaches to the surface of the brain (dura).

At the start of the operation, the patient was put under general anaesthetic. Since the tumour is located at parietal lobe, the patient's head need to be turned sideways. To ensure the head does not move during the operation, screws were attached at the front and at the back of the head. It seems painful to me to have screw put into your head, front and back for few hours and your head need to turn sideways throughout the operation. Anyway, general anaesthetic helps this situation.

To reach the tumour in the brain, the surgeons need to remove the layers of the scalp. There are five layers in scalp [Skin, Connective tissue, Aponeurosis, Loose connective tissue and Periosteum]. Each layer need to be removed separately. It was amazing to see the layer being removed carefully and you could see the brain beating according to the heart beat. Whenever the scalpel cut through blood vessels, blood spurts out and I think by the end of the operation, the amount of blood gushed out from the brain was around few cups of blood. It is not something that can be seen by someone who is haemophobia.

When all those layers and bone have been removed, we could see the tumour. It was big and it took quite a long time to remove the tumour from the brain. The surgeons need to peel off any attachment of the tumour from the brain. It requires strong concentration and stamina too. The operation lasts about 4 hours and I think only surgeons are capable to stand for more than 4 hours without moving a lot. I need to move around the operating theatre to prevent leg cramps from standing too long. I guess surgery will not be my future career :).

After the tumour has been removed, the surgeon connects the layers and the bone. The bone is connected using screws and the scalp is secured using staples. I am surprised to see the staples being used in the operation. I was thinking the surgeon will attach the skin back using sutures. I guess staples is a better option in this type of surgery.

This neurosurgery gave me an opportunity to refresh my knowledge on neuroanatomy and it was interesting yet tiring.

Saturday, August 11, 2007

of neurology

In this semester, we have three 6-week rotations. Each rotation introduces us to different specialty of medicine. We got to see different type of patients and how different disease affects the patient and the family.

Next week will be the fourth week of my neurology,eye & ENT rotation. I should theoretically know at least half about the related disease such as stroke, ataxia, Parkinson, epilepsy, macular degeneration, ear problems etc. To tell you the truth, I don't know that much yet. Still struggling to learn those diseases and I believe I will know the important disease by the end of this rotation :).

Part of tasks that I need to do is to interview and examine patients and learn about patient management. Sometimes this is not an easy task to do. Partly, I'm not that confident and forgot the relevant question to ask. Another contributing factor is most of the patients have some disability ranging from paralysis in one part of their body, language difficulty (aphasia) due to the problem in the brain, dementia and depression. It is not easy for patients to cope and understand the burden of their disease. It just reminds me of this television show which depicts the life of a patient with a disabling disease. It is sad yet good in showing how disease can impact life of the patient and their family.

Anyway, hopefully I will be able to grasp the important concepts from this rotation.

Wednesday, August 08, 2007

broken heart syndrome

Image taken from here

I attended case presentation by the registrar this morning. The meeting start at 8 am and free breakfast was provided. This is a weekly case presentation.

One of the cases that were presented was broken heart syndrome. The name is interesting and the clinical presentation fits the description.

This describes a situation when a person had a sudden onset of chest pain and it mimic severe heart attack [again, why do we always call severe heart attack instead of small heart attack or heart attack :) ].The investigation of the coronary arteries (this is the blood vessel of the heart) will be normal whereas in a heart attack, coronary arteries sometimes can be blocked. The left ventricle sometimes can be seen as bulging due differences in muscle contraction in ventricle.

Diagram of the heart. From Yahoo health

How this syndrome happens? This usually happen in elderly women who had severe emotional stress such as the loss of a loved one or receiving bad news.

How this is related to my neurology rotation? Apparently, stroke can cause broken heart syndrome too. Another name for this disease is Takotsubo. It means octopus trap in Japanese.

This disease does not usually leave permanent damage to the heart and usually patient can recover within few days. Although there is no physical damage to the heart, the person will be suffering from emotional damage. Now, how do you mend a broken heart?

Friday, August 03, 2007


Another tiring week. There are a lot of things to do. The biggest thing that I forgot now is the neuroanatomy. I can't exactly remember which foramen the cranial nerves travel into and the name of main muscles and related nerves in upper and lower limb. I think I will remember those by this weekend.

For non-medics, the term arm and leg are not sufficient to cover both hand and leg. The layman term of hand/arm and leg has different meaning in medicine :).


Kasyah has asked me to put my childhood pictures. I have combined these two pictures to show you how much my face changed. I cannot exactly remember when the pictures were taken.

I have lots of pictures when I was small but I think this should be enough :).