I Define Myself

Pioneered Dynamism

2012-01-10T21:06:00.012+08:00

I elatedly cry out of my heart,

to leave and learn the state-of-art.

There's nothing less than patience,

to remedy the young nation;

As all the tainted lungs sob,

I'm about to follow the footsteps

of the education that molded me;

not just to vacuum but to be a pioneer

that I've no fear to be here,

and see the paws of mine,

not limited in the land of mine.

The oath sworn three years back,

is about to see action.

Religion and race not to mention,

I'm prepared to kick racism out.

The blessings I prayed for,

to ride through the purple patches,

with faith and dynamism to hatch.

He's listening to the theme song of DAP for the GE 08 "Just Change", lyrics by YB Tony Pua. He's a strong believer that he will return home one day and prove to the world that no other country is better than his fatherland as depicted within :- All races will stand as one & Forever! Malaysia must come first!

Engineered Move to Australia

2011-12-31T21:24:00.005+08:00

Like any others, just about to step into a brand new year, I am writing this post. It always goes this way where people pen about their regrets of the year and new year resolutions.

What makes this post more valuable is that for whatever that I write would be based on the ups and downs toiled through in the motherland. For the next decade of life, it's going to be an entire different journey to be walked. Time zone will still be the same with only occasional daylight saving of an hour difference. But the people, the culture, and the language spoken will all be alien to me.

Yes, I engineered this move to Australia. But why? It is all due to the incapability of my beloved country to offer at least on par education and job opportunities that would shape my career as compared to foreign countries. I know my friends share the same values that we will return home one day to serve our country.

I remember reading an English poem way back in form two, citing about acquiring knowledge abroad and return home proud one day. That's very motivating.

I have not looked back of what I have not achieved. Instead, I am satisfied with my hard work in polishing my clinical skills. I had the chance to exchange views and ideas about medical education with a Malaysian student who entered directly into the University of Tasmania. She's a 3rd year med student that has gone through a year of clinicals. I know I am not too far behind.

My uncle recently has become my first ENT patient for BPPV(of posterior semicircular canal). I am elated that I managed to brainstorm the diagnosis based on the history taken and provide the appropriate diagnostic test of Dix-Hallpike and treatment by Epley's maneuver.

Life's wonderful in the sense that you will never know the results of every minute ahead till you have gone through it. Tireless and enthusiastic commitment have since become a trade embedded in me. I don't mind going hours extra to learn.

Even the simplest things like gloving and putting on the sterile gown may seem like some petty issues in the eyes of some. But that's what I called them the basics. The confidence exchanged is priceless.

I want to do my best, at least be on par with the levels of those that directly entered UWA. My elder sister has recently graduated as a doctor; she will be the goal I want to surpass!

My heartfelt congratulations to my sister; you have made us proud!

Neoplasm, So What?

2011-12-16T20:30:00.005+08:00

I am privileged to be scheduled for a half a year break due to the commencement date of Australian universities. Never I thought I would spend 95 percent of my time working in a health care set up till today; it's almost five months plus to be exact.

I started off with Lam Wah Ee hospital (LWEH), the place where I first did my elective in a private hospital and absorbed paramount experience as compared to the nightmare I had in Penang General Hospital one year ago. I am very grateful to the following consultants, Mr Khoo ST, Dr Ng HH, Mr Khaw KT, Mr Leong WS for their delicate teaching in their respective fields. The staffs were very pleasant to meet. You would somehow feel respected though you are only a medical student. Friends met in the OT, clinics, and A&E were wonderful as well.

I have to commend LWEH despite being a non-profitable Hospital, they are able to cater the needs of the majority of the patients. Every hospital is there to serve a different class of patients.

I limited my time to three months plus in LWEH as I felt I needed to see some much higher profile cases to further improve. You can't be seeing the same cases for months. So I thought it was timely to go over to Island Hospital, a so-called tertiary regional referral private hospital.

It was true. Hereby, I am extremely thankful to the following consultants, Dr Aaron Lim BK, Dr H'ng PK, Dr Hwang YC, Dr Francis Lau, Dr Goh HK, Mr Goh TM, Mr Badrul and Prof TJ Wong. The learning curve with each consultant was challenging. My mind has to be armed with the perfect acumen to pop up with probable diagnosis, differential diagnosis, investigations, pathophysiology and so on at anytime.

The time at the I-Sports Centre to acquire knowledge about the management of Sport injuries was fairly good. It was an eye opener in terms of the perplexed anatomy of the knee. For instance, the Anterior Cruciate Ligament as easy as it sounds is much more complex that I first thought. I came to realize the emergence of physiotherapy in the conservative treatment of various orthopaedic problems. Most importantly, they do help relieve the pain!

The best time comes with Prof TJ Wong where I was given the opportunities that would only arise out of a blue moon to assist in most of his cases, be it a minor or a major surgery. And his keen interest in fighting against malignancy further strengthened my belief in becoming a world-renowned Reconstructive & Oncosurgeon one day. Don't ask me why I have much interest in tumors; it comes naturally.

Believe it or not, I have assisted in major cases such as Whipple's Op, Hepatectomy, Anterior Resection, Total Gastrectomy, Roux-en-Y reconstruction and so on and so forth.

The art of liver secondaries is beautiful. The tagline of "Neoplasm, so what?" has crossed my mind after witnessing the stories of the survivals.

I had the chance to attend various lunch time lectures to keep myself embedded with the latest happenings. Lectures like Enteral Nutrition, Procalcitonin, Phacoemulsification are pretty useful.

Some consultants were shocked when I told them that IMU provides the students with only two hours of lectures per day since day one. I was lucky to be sufficiently adept at the level I am supposed to be to. Hard work is the only word used to define this self-perceived brilliant type of education I have received.

Last but not least, I would want to remember the wisdom conveyed by Prof TJ Wong :-

Surgery is all about searching for the right planes.
Impossible is only about taking a longer time...

Once again, many thanks to all the consultants, staff nurses, paramedics and hospital staffs that coloured my second half of 2011.

Penang Cardiovascular Conference

2011-11-28T20:09:00.005+08:00

Thanks to Servier for sponsoring me to the Penang Cardiovascular Conference!

It was a wonderful two days in terms of learning and keeping yourself updated with the latest happenings revolving around the field of Cardiology.

New drugs have come about quickly to remedy the flaws of the previous ones. I remember reading much about how effective Plavix (clopidogrel) as compared to Aspirin just one year plus ago. And now Brilinta (ticagrelor) is cited to have replaced Plavix as the front runner for post angioplasty.

That tells how paramount it is to make oneself to adhere to the adage of Lifelong Learning.

The debate of CABG Vs Angiography where the Protagonist Dr Hafiz Law, Consultant Cardiothoracic Surgeon and the Antagonist Dr Ng Swee Choon, Consultant Cardiologist was a good one. Both presented well with supporting facts from various studies. Well, in the end of the day, the decision still lies upon various factors. Nevertheless, it depicts the willingness to correct the flaws and come up with better solutions like from the first generation of stents to the third generation of stents now.

I came across new scoring systems :- [1] Syntax Score [2] Euroscore

And I met Johari from LWE and a few other SNs from the Island Hospital. "Everyday's a Learning Opportunity"

Daring to Be Aggressive

2011-11-27T22:22:00.007+08:00

A simple surgical set of instruments can make wonders.

I have embedded "Daring to Be Aggressive" as my personal theme as an add-on to the Dynamism, I Envisage.

My ultimate aim has never swayed from achieving something extraordinary in the field of Reconstructive & Oncosurgery one day. It is going to be limited to resection & reconstruction of the diseased organ.

Many parts of the organs are often non-resectable when the patient comes in presenting to you with an infiltrating tumor or for some other reasons.

Many of times, the solutions are vividly surfaced on top of your table but due to high risk pre-op assessment, the patients are often being turned away. Or citing reasons that since it's a stage 4 disease, why still spend huge sums of money just for a palliative care that does not change much of the quality of life.

I am inspired by Prof TJ Wong's work on liver secondaries. His ability to convert the disease stage to a R0 (no residual stage) is encouraging. However, currently there are still limitations to certain parts of the organs for instance the small intestine, where you cannot afford to remove all.

But thinking about it, why not create a 'pipe' that mimics the small intestine to connect the stomach to the large colon? Change of mindset I call it.

It requires a gigantic courage to transform yourself to adapt to a situation that you can practise the core value of aggressiveness in the surgery without compromising the safety of the patient.

Orthopaedic Surgery [Week 2]

2011-09-17T21:47:00.003+08:00

1. 60 yr F c/o pain at L Hip (1/7). H/O falling down while sleeping the floor. O/E: tenderness at L greater trochanter w/ mild swelling, active & passive movements restricted. X-ray showed # L Intertrochanter

Evans' Classification (1949) :- Type I-Undisplaced 2-fragment #; Type II-Displaced 2-fragment #; Type III-3-fragment # w/out posterolateral support; Type IV-3-fragment # w/out medial support; Type V-4-fragment 3 w/out posterolateral & medial support; Type VI-Reversed obliquity #
Boyd & Griffin's Classification (1949) :- Type I-Linear intertrochanteric #s (w/out comminution); Type II-Intertrochanteric #s w/ comminution; Type III-Intertrochanteric # w/ Subtrochanteric extension; Type IV-#s of the trochanteric region & the proximal shaft (# in 2 planes)
Dynamic Hip Screw Fixation (! to check radiographically AP and Lateral planes to ensure the Screw goes through the middle)

2. 30 yr F c/o pain at central buttock region (2/52). no H/O trauma except falling down on a sitting posture. O/E: no swelling or obvious deformity, tenderness at central buttock region. X-ray revealed slight # at saccral-coccygeal region.

Rx: Conservative Treatment

3. 6 yr F c/o L tip-toe walking since 4 yrs. Wanted to try physiotherapy initially, but failed. O/E: stiff Achilles tendon w/ permanent dorsiflexion. Unable to passively plantar flex.

Percutaneous Z-plasty to lengthen the Achilles tendon
Pt lying prone & resting positions noted:- ankle is dorsi-flexed (normal), when knee is flexed, ankle is supposed to be able to plantar-flexed 30'.
3 positions to incise - Medial, Lateral, Medial then manipulate to plantar flex.
plaster cast for 6 weeks
Complications if surgery not done: [1] osteoarthritis of lower limb joints [2] Limb-length discrepancy [3] Muscle wasting

4. 59 yr M c/o L Hip pain for months. No radiation from back, no pain at other joints, H/O locking screws across neck of Femur due to # 10 yrs ago. O/E: no obvious deformity or swelling, tenderness noted at L Hip, no loss of movements. X-ray of pelvis: avascular necrosis of L Head of Femur + erosion of L acetabulum, 2 screws were not parallel.

L Total Hip Replacement

Orthopaedic Surgery [Week 1]

2011-09-07T21:47:00.001+08:00

1. 80 yr F c/o falling down 3 days ago. O/E: tenderness, swelling noted at R hip, and externally rotated R hip. D/D: [1] # R Femoral Neck [2] # R Intertrochanteric [3] # R Subtrochanteric

X-ray showed # R Femoral Neck, Stage 4

Garden's Classification - Stage I: Incomplete fracture; Stage II: Complete Fracture w/out displacement; Stage III: Complete Fracture w/ minimal displacement; Stage IV: Complete Fracture w/ marked displacement
Singh's Index
! Avacular Necrosis due to the blood supply
Bipolar Hemiarthroplasty - Anterior, Lateral, Posterior Approaches
Lateral Approach (Liverpool's/Haldinger's Approach):- # Neck incised, drilled through the medulla, semen poured, implant inserted, H2O2, Bipolar Head

2. 23 yr M presented w/ obvious deformity at R arm. H/O MVA Car vs Bike. O/Eb: deformity at R mid arm w/ tenderness, radial nv not affected w/ functions intact. X-ray showed # R mid shaft of Humerus.

Open reduction & Internal fixation (ORIF)
Anterior approach:- biceps brachii retracted, cautious of radial nv (!wrist drop), reduced the #, 6-hole plate w/ screws, drainage w/ tubing

3. 50 yr F c/o MVA w/ direct concussion of R knee. O/E: tenderness at R patella, # pieces felt, weakness of quadriceps. X -ray showed transverse # R Patella.

types of #: Undisplaced, Transverse, Lower or Upper Pole, Comminuted Undisplaced, Comminuted Displaced, Vertical, Osteochondral
Rx available: [1] Patellectomy [2] Circlage wiring of Martin [3] Figure of 8 tension band wiring [4] Interfragmentary Screw Fixation w/ combination of above any
Tension band wiring done:- vertical incision, damaged capsule seen (+/- damaged muscles), drill 2 wires parallely through the 2 parts, K-wire used

4. 70yr F c/o weakness of L limb. Unable to actively extend R knee. H/O failed tension band wiring in Indonesia + L Patellectomy w/ reconstruction of quadricep tendon here 3 months ago. O/E: no swelling, gap seen between, no active movements, only passive movements

Dx: snapped quadricep tendon

The Surgeon, The Baby, The Angels

2011-09-05T22:19:00.004+08:00

The perceived disdainful impression,

instigates all the feared tension.

The cries of him being heard,

as all that it hurts.

Pacing through the busy footsteps,

we are here ready to stab.

The dark blues painted the air,

the sobbing continued to flare.

Diathermy, rubber bands, forceps please,

the boss ordered for impatiently.

The oozing blood paled the faces,

the angels wandering impatiently.

Exultant chuckling filled the spaces,

Wong-Baker Faces worked the wonders,

from Ten to Zero, from Zero to Hero,

gliding back with the smiling faces.

[Inspired by a case where the one year old baby suffered from laceration of the Left Middle Finger accidentally, the parents and the surgeon]

ENT - Head & Neck Surgery [Week 4]

2011-09-05T22:14:00.009+08:00

1. 50 yr M c/o R parotid swelling X 3 days. H/O L parotid tumour Dx to be suggestive of Warthin's Tumour(Adenolymphoma) due to the lower pole and well-circumscribed appearance on CT Neck. O/E: R parotid-diffusely enlarged, tender, redness, warmth; L parotid- Lower pole well-circumscribed, mobile, lower pole tumour felt, non tender. Oral Ex showed no signs of deviation of the medial walls on both sides. CN vii normal on both sides.
IV Antibiotics suggested for R parotitis
Warthin's Tumour can be left as there's no risk of turning malignancy.
! never do Excision Bx for Parotid Tumours as run the risk of injuring the CN vii
Only Pleomorphic Adenoma has a risk to become Pleomorphic ex Ca. Warn pt!

2. Sjogren Syndrome

systemic autoimmune disorder attacking the exocrine glands esp lacrimal and parotid glands
presents w/ dryness of mouth(xerostoma) and eyes.
Dx by Schirmer's Test, Rose von Bengal dye, autoantibodies against Ro(SSA) & La(SSB) antigens
variant: Mikulicz Disease [Triad of symmetrical enlargement of all salivary glands, narrowing of palpebral fissures due to enlargement of lacrimal glands, parchment-like dryness of the mouth]

3. Kimura's Disease

benign rare chronic inflammatory disorder
presents as subdermal lesions in the head or neck or painless unilateral inflammation of cervical LNs.
Unknown cause.
HPE:Lymphoid infiltration w/ eosinohilia present

4. 25 yr M c/o blocked nose for months. O/E: deviated nasal septum, bilateral hypertrophy of turbinates, enlarged tonsils, mild obesity noted at neck. Frequent snoring and frequent apnea noted by wife. Tiredness in the day time.

suggest a Sleep Study to measure AHA Index (apnea-hyponea index)
Friedman Staging for Obstructive Sleep Apnea
Epsworth Sleepiness Score, Berlin Questionnaire
high AHA Index; Severe OSA
Plan [1]septoplasty [2] B turbinoplasty [3] B tonsillectomy [4] Uvulopalatopharyngoplasty [5] weight lost [6] Continuous Positive Airway Pressure (CPAP)
repeat Sleep Study post-op
! OSA can lead to heart diseases

5. Autoimmune Inner Ear Disease

rapidly progressive Bilateral sensorineural deafness
could be Idiopathic or assoc w/ other systemic autoimmune diseases like Sjogren Syndrome, Systemic Lupus Erythematous, Rheumatoid Arthritis
Rx: high-dose prednisolone, methotrexate, cyclophosphamide (! hemorrhagic cystitis, CI in children), plamapheresis

Type 1: Organ (ear) Specific

Rapidly progressive bilateral SNHL
All age ranges, although middle age is most common
No other clinical evidence of systemic autoimmune disease
+ve Otoblot (western blot 68kD or HSP 70)
-ve serologic studies (ANA, ESR, RF, C1q binding assay)
>50% response rate to high dose corticosteroids

Type 2: Rapidly Progressive Bilateral Sensorineural Hearing Loss with Systemic Autoimmune Disease

Rapidly progressive bilateral SNHL
Hearing lost often worst with flare of autoimmune condition
+ve (SLE, UC, PAN, Vasculitis, RA, Sjogren Syndrome)
+/- ve Otoblot
+ve serologic studies
Corticosteroid responsive + managed w/ targeted therapies

Type 3: Immune-mediated Meniere's Disease

Bilateral, fluctuating SNHL w/ vestibular symptoms that my predominate
+ve Otoblot
Corticosteroid responsive, may need long term Rx due to relapses

Type 4: Rapidly Progressive Bilateral Sensorineural Hearing Loss with Assoc Inflammatory Disease (Chronic Otitis Media, Lyme Disease, Otosyphilis, Serum Sickness)

evidence of profound drop in hearing w/ long-standing chronic otitis media
may show inflammation of ear drum + perforations
hearing loss progresses despite Rx of infectious agent
-ve Otoblot
Corticosteroid responsive + may need long term Rx

Type 5: Cogan's Syndrome

recurrent inflammation of front of eye(cornea) & often fever, fatigue, wt loss, episodes of dizziness & hearing loss
sudden onset of interstitial keratitis and severe vestibuloauditory dysfunction
-ve Otoblot for 68kD; +ve Otoblot for 55kD antigen
responsive to high-dose corticosteroid; resistant over long term
atypical form - Logan Syndrome

Type 6: Autoimmune Inner Ear Disease-Like

Young
Severe ear pain, pressure & tinnitus
-ve Otoblot & serologic studies
?unrelated, nonspecific inflammatory event that instigates ear disease
not responsive to immunosuppressive drugs

*Reference: Ballenger's Otorhinolaryngology

ENT - Head & Neck Surgery [Week 3]

2011-08-12T21:45:00.005+08:00

1. 36 yr M presented w/ Ca Tongue and has undergone Chemo & Radio Rx. O/E: Anterior 40% of tongue has been eroded w/ involvement of floor of mouth. CT Neck revealed eroded Anterior Tongue, otherwise normal.

Suggest Total Glossectomy w/ Pectoralis Major Flap reconstruction

2. 60 yr M c/o epitaxis due to a papaya ~1kg hitting the nose. Epitaxis is of on and off. O/E: nasal septum deviation to L. Plane X-Ray of nose showed: [1]Septum deviation (trauma) [2]Haematoma in maxillary bone [3]Fracture in other parts

Decompression must be w/in 1 week post-trauma

3. Carotid-cavernous fistula

! to be asked especially post trauma as it forms after that
presents w/ epitaxis

4. 55 yr M c/o severe blocked nose unresponsive to medications.

D/D: [i] Deviated nasal septum w/ Chronic sinusitis
Operative findings were suspective as the bones were friable when FESS was done. HPE was carried out and reported back by the Pathologist as Vasculitis.
Surgery to correct the air passage was successful. On follow-up, the healing was much slower that expected. Pt now c/o multiple itchy papules around the abdo, thought to be allergic to some medication.
Systemic manifestation thought, suggestive of Wegener's Granulamatosis. Referred to Dermatologist for opinion. Skin Bx done. Reported as Vasculitis.
cANCA w/in normal range
All specimens and blocks sent to another Pathologist for 2nd opinion. Reported as Extranodal Lymphoma, Nodal Type and NO Vasculitis.
Wegener's Granulomatosis: Triad of 3 systems [a]Upper & Lower Respi tract [b]kidneys, presenting as glomerulonephritis [c]vascular, presenting as necrotizing vasculitis
Rx: cyclophosphamide, methothrexate, rituximab
! D/D: Churg-Strauss Syndrome

ENT - Head & Neck Surgery [Week 2]

2011-08-08T21:07:00.003+08:00

1. Pt c/o tenderness around R postauricular area and noted redness extending till R SCM for 2 days. O/E:- features are consistent with Varicella-zoster oticus (shingles).

Rx: Acyclovir 5 tabs 800mg/day for 5 to 7 days.
Ramsay-Hunt Syndrome type I (Ramsay Hunt Cerebellar Syndrome)
Ramsay-Hunt Syndrome type II - of interest where pt presents with Acute Otalgia, herpetic, vesicular rash, and facial paralysis. Can affect other CNs = Herpes Zoster Cephalicus (CN auditory, vestibular, trigeminal, glossopharyngeal, vagus !anatomy @ brainstem) Poorer prognosis than Bell's palsy. Rx: combination of antiviral agent w/ steroids [!Surgical decompression not recommended due to skip regions and diffuse neuritis as compared to Bells' Palsy]
Ramsay-Hunt Syndrome III (Hunt's Disease/Artisan's Palsy) - occupationally induced neuropathy of deep palmar branch of ulnar nerve.

2. Pt c/o double vision(diplopia). O/E:- H Test done, concluded w/ L Lateral Rectus Palsy ( CNvi). CT Scan revealed sphenoidal lesion w/ erosion and communication w/ intracranial cavity.

Skull-base tumor; suggest biopsy through skull-base approach

3. 3 yr F c/o recurrent preauricular abcess despite IV antibiotics given x 2 weeks. O/E:- preauricular sinus opening and abscess adjacent to it noted.

Rx: IV antibiotics as 1st line, if failed, Surgical Intervention.
[1] Excision of sinus [2] Saucerization of abscess
! methylene blue injected into sinus prior as a guide, if leaks, indicates excision w/out clear margin
Branchial-oto-renal Syndrome (BOR Syndrome)
Lachiewicz Sibley Syndrome

4. Pt presents w/ hoarness of voice. Laryngoscope revealed L vocal cord nodule.

Suggest Bx by Endoscopic Laryngoscopic Microsurgery (ELMS), excised the nodule for HPE.
D/D: [1]Singer's nodule [2] CIS of Larynx [3] Amyloidosis of Larynx (Dx by Congo red Stain)

ENT - Head & Neck Surgery [Week 1]

2011-07-29T21:17:00.007+08:00

1. 70 yr F c/o dizziness upon lying down esp on the R. Dix-Halkpike maneuver (Nylen-Barany test) done; looked for rotatory nystagmus and provoked vertigo. Benign Paroxysmal Positional Vertigo diagnosed, Rx w/ Epley maneuver.

! pt is able to give the perfect Hx for a clincal Dx.

2. M pt c/o of discomfort upon chewing + swelling on the L angle of jaw. O/E: a mass was seen on the floor of mouth adjacent to the frenelum of tongue; Bimanual palpation confirmed Dx as Plunging Ranula.

Rare!
Mucocele of the Submandibular gland (or unlikely Sublingual gland). Normally known as Ranula unless involves the to the angle of jaw.
Plunging Ranula = Cervical Ranula
Rx: [1]Marsupialization [2]Excision of gland + cyst

3. Allergic Rhinitis. O/E: engorged turbinates + deviated nasal septum

Medical Rx as 1st line
often concurrently have Sinusitis (severe can lead to pansinusitis) otherwise Maxillary and Frontal sinuses most commonly affected.
Surgical Rxas 2nd line :- Septoplasty + Turbinoplasty (no longer practising Turbinectomy)

4. 23 yr F c/o L ear tinnitus, partial deafness for the past 1.5 mths. O/E: no inflammation, no perforation, tenderness of tymphanic membrane, all normal. PHx: Hep B vaccination last month, otherwise normal. Audiometry showed 50% reduction in L ear. MRI is normal as well, no lesions at the cnVii&Viii.

?viral-induced deafness
?S/E of Hep B vaccination (!extremely rare in literature)

5. 50 yr M c/o difficulty of swallowing. O/E: tongue deviated to R; Laryngoscope done, normal findings. PHx: NPC Dx previously & has undergone Radio Rx concurrently w/ a dose of CH Rx but defaulted then. Recurrent NPC noticed.

R cnXii affected by the Recurrent NPC

General Surgery [Week 4]

2011-07-24T11:24:00.004+08:00

1. 78 yr M c/o abdo distention, unable to defecate, urination clear. O/E: generalized distention and tender abdo; on DRE, nodular surface of the prostate felt (? Ca prostate), otherwise no mass felt. CT Scan revealed obstructed Distal Ca Rectal w/ dilated proximal large bowels, prostatomegaly & ? Liver mets (focal nodules)

O/O: Ca Rectal w/ multiple tumours noticed in colon; Stony Gallbladder(?Ca); Pyloric stenosis w/ enlarged paraaortic nodes.
Surgical Intervention: [1] Colostomy at proximal end of Ca Rectal [2] Gastrojejunostomy

2. 45 yr M c/o change in bowel habits, tenesmus. O/E: nodular mass (napkin-like) constriction felt at anal region corresponding to the external sphincter + bleeding. CT Scan showed Ca Rectal w/ bone mets at the bone adjacent to the SI joint + multiple lung nodules (?canon ball mets). Blood test: markedly increased CEA, CA 19.9, otherwise normal.

Conoloscopy to determine type of Ca (SCC responsive to Radio Rx);
Neoadjuvant Rc to shrink down tumour;
Resection of tumour

3. 72 yr F presented w/ change of bowel habits; constipation for 1 mth; urination clear. O/E: distended, non tender abdo, no mass felt. CT Scan showed [1] a tumour apx 5cm at R colon [2]?peritoneal deposit [3] Liver mets [4] 1 nodule in Lung (?mets). Blood test: Chronic Anemia

R Hemicolectomy + removal of peritoneal deposit;
Adjuvant Ch Rx

4. Laparoscopic Repair of Incisional Hernia

! mesh used is pertinent as complications like seroma can occur.
If the pores of mesh are large enough, the fluid that enters will be able to flow out.

Carcinoma Colon - Look for These

2011-07-19T21:18:00.001+08:00

Adapted from SRB's Manual of Surgery, 3rd Ed.

General Surgery [Week 3]

2011-07-17T20:43:00.002+08:00

1. 78 yr F c/o generalized abdo pain since last night, constipation (3/7), vomiting. Admitted. AXR showed air bubbles trapped in subdiaphragmatic space (MO Dx bowel obstruction). O/E: no fever, generalized tenderness at abdo, tissue saturation & BP dropping. PHx of Tripple Vessel Disease, ARF(oliguric) and on Plavix (clopidogrel). Lasix challenged no response.

?PGU; Laparotomy planned KIV Proceed.

2. 57 yr M c/o difficulty in swallowing (dysphagia) accompanied w/ pain (odynophagia). O/E: noticed wt lost.

OGDS showed ulcerating mass at 32-39cm at distal esophagus; Bx and small benign looking nodule at greater curvature of gastric, otherwise normal.

Dx: Ca Esophagus. Planned for CT Staging for further management

3. 57 yr F c/o swelling at R neck. O/E: the R thyroid nodule moves up w/ deglutition, non-tender. U/S showed a partially cystic mass.

R Complex Thyroid Cyst
Endoscopic Thyroid Lobectomy:- three-hole surgery w/ 1cm horizontal incision above R&L areola & at midsternal. Landmarks; Sternalcleidomastoid muscle. !Recurrent Laryngeal Nv

4. * (Orthopaedic Surgery) Henry's Anterior Approach to the Radial Shaft.

5cm medial incision parallel to flexor carpi radialis tendon w/ torniquet prior. No major structures other than radial artery, superficial tendons, otherwise safe till bottom. Needs to split quadrator muscle before radius can be visualized.
Reduction & Fixation, followed w/ T platting screws done for distal fracture of the radius.

General Surgery [Week 2]

2011-07-10T10:34:00.003+08:00

1. 26 yr M presented w/ a swelling in R scrotum & is tender. U/S findings are suggestive of abscess due to TB or other infections. Antibiotics given, not solved. Blood Test showed markedly increased AFP, otherwise not significant. CT Scan done, showed Lung mets.

Testicular Carcinoma (?Yolk Sac Tumour)
R Total Orchidectomy done w/out paracolic LNs clearance (since Stage 4) + Ureteric Stenting.
Next up, CH Rx or Radio Rx.

2. Breast Reconstruction:- LD Flap/ TRAM Flap; Nipple Creation; Areola Pigmentation in sequence sequence

3. TURP for PBH; risk of Bleeding, TUR Syndrome

4. Angiomyolipoma. Benign tumour of Kidney composing of Blood vessel, Muscle cells, Fat Cells. Occur most commonly in Kidney followed by Liver. Other places possible but rare.

5. PPH3 Haemorroidectomy w anoscope & purse-string Anoscope. Best indicated for haemorroids within 3rd degrees. Piles of 4th Degree needs Conventional Method. Less pain experienced for the staple-method.

Stitching the piles to the mucosa before stapling'd provide better results; followed by inserting PPH3 and pulled the stitches before firing. Hold for 5 mins before releasing. May need bipolar for the bleeding cases.

General Surgery [Week1]

2011-07-03T09:44:00.007+08:00

1. Early 30s w/ a lump and found to be T2,N1/2,M1[?](hypodense lesion in Liver on CT Scan); seems that the epidemiology of CA Breast is getting younger.

Doxorubicin (Adriamycin) X4, Cyclophosphamide X4; Paclitaxel (Taxol) X4 - CH Rx for CA Breast

2. Vague S&S of abdo pain, abdo fullness, vomiting on feeding; on OGDS - a typical umbilicated tumour (?Ca Gastric/GIST); CT Scan reported w/ intussusception at mid-jejunum w/ obstruction, gallstones, multiple pancreatic cysts. Past Hx of Myoepithelioma of Breast.

5cm R paramedian incision :- [1] Intussusception (partially reducible) visualized w/ tumour, multiple diverticula, black-brown tumours at further sites (?Melanoma) - 15cm resection of jejunum w/ anastomosis w/ staples. Multiple mesenteric LNs - unable to do total clearance, fearing the compromising of blood supply of remaining small bowel [2] Wedge resection at greater curvature of gastric.

3. 29 yr old Indon presented w/ S&S of lower abdo pain, chronic diarrhoea w/ blood. on DRE, no significant findings. CT Scan reported w/ a large tumour measureing 66.9mm w/ obstruction at the sigmoid colon & paracolic nodes enlarged, otherwise normal; Is the epidemiology for CA Colon getting younger as well?

! Lynch Syndrome (HPNCC) - Amsterdam Criteria I/II or Bestheda Guidelines

4. 29 yr old Indon complained of pain at the upper inner quadrants of bilateral breasts, would normally present before periods and subside later on. Significant F/H: Mother passed away last year due to CA Breast. O/E: no mass felt, non tender.

Mastalgia due to Fibrocystic Disease.
try w/ Danazol first but advise annual checkup. !Danazol should not be consumed if pregnant.

5. 25 yr old Indon complained of slight difficulty of breathing due to a mass felt at R supraclavicular since 8 months ago. O/E: ~2.5cm in Diameter mass felt, non tender, smooth surface, mobile. Blood test: ESR increased markedly; X-ray: Lungs clear; 4kg lost of weight noted. Suggest Excision Biopsy to confirm TB Lymphadenitis.

6. 50 yr old Female noticed swelling of neck upon usual follow-up of Bilateral Total Knee Athroplasty. O/E: L thyroid is markedly enlarged w/ multiple nodules and moves with deglutition, R thyroid has a few slightly enlarged nodules. U/S reported w/ the aforesaid & retrosternal extension, causing the trachea to be deviated to the R.

Yes, It's Really Done!

2011-06-20T16:22:00.009+08:00

Part of my collection of Medical books used so far. From Right to Left :- Netter's Atlas of Human Anatomy, Robbins' Basic Pathology, A Practical Approach Orthopedic Medicine, Surgery of the Injured Hand, Snell's Clinical Anatomy by Systems, Robbins & Cotran Atlas of Pathology, Kumar & Clark's Clinical Medicine, Otologic Surgery (v I & II), Essentials of Orthopedic, An Illustrated Colour Text of Haematology & Neuroanatomy, Ten Teachers' Gynaecology & Obstetrics, Netter's Clinical Anatomy, Vascular Surgery, Robbins & Cotran Pathologic Basis of Disease. From Top to Bottom: - Apley's Concise System of Orthopedic & Fractures, Atlas of Postmenopausal Osteoporosis.

Yes, it's really done! I passed my End-of-semester (EOS) 5 examinations, so it's full stop in IMU now! While waiting for the release of the results, I pledged myself to the sharing of knowledge and experiences with a few groups of juniors from semester one and three.

"Which sem are you in, student?" asked the CSU sister.

I basically spent my last two weeks in IMU by stepping into the Clinical Skills Unit (CSU) early in the morning daily. I had a few sessions to cover, each would take around an average of two hours. I got to admit that it made no sense in terms of refreshing my own memory since it was just only days after my finals - everything was still vivid in mind! Nevertheless, I have learnt to be more patient in teaching when juniors raised some seemingly easy questions but yet tough to them. Patience is a virtue.

I am glad that I have developed my own methods and ways of conducting the sessions. Instead of blindly following the past year questions of OSCE passed down by the seniors, I came out with my own questions based on my clinical experiences gained with Mr Khoo. The questions were meant not only to polish up their clinical skills, also to link their basics of diseases to the clinical scenario, trying to strengthen their basics.

Apart from Sem 3 juniors, some Sem 1 juniors have approached me for advice. To me, it is down to individual hard work and the willingness to sacrifice. Yes, no doubt that some people managed to do well without toiling hard, but do remember luck will not always be with you! I am saddened with the attitude of some seniors when they 'advise' juniors not to study that much. I mean, think about it, without a strong foundation how are you going to comprehend the pathology of diseases, especially those perplexed ones that involved not only anatomy, but also physiology and so on and so forth. It's just utterly stupid!

Anyhow, best of luck I would like to convey to my dear sem 1&3 juniors, especially those I have interacted with and Farook, for your USMLE exam. And thanks to my dear batch mates/friends -Thamotheran, Jie Ming, Ahmad Mukhlis and Farook for the wonderful time we have had for the past two and half years. Last but no least, not forgetting Hwei Jene's effort in guiding my physical examinations of the MSK module.

Semester Five, So Far

2011-06-04T18:37:00.006+08:00

My second home in Library & with Dr. Vijay Singh

Should I be saying Semester Five, So Far since it has ended virtually, provided that I pass my End-of-Semester (EOS) examinations? Two and half years are pretty fast, always as it is when you look backwards. Remembering I was just a newbie in studying medicine, now I am half way through, at least for the MBBS degree. Will I miss IMU? some asked. Probably I will, especially the wonderful lecturers that I have had interacted with and my mentor, MR Joachim Perera for sure. He is one of my inspirations for the surgical field. And not forgetting Dr. Vijay Singh, the pathologist whom cultivated the seed of interest in oncology to grow.

Now that I have half a year break before continuing my phase two clinical training in the University of Western Australia (UWA), I am looking forward to the Orthopaedic Surgery and Urology electives and not forgetting General Surgery with MR Khoo once again. I want myself to be well-equipped with the necessary clinical skills and if possible venture more into the fields of interest and orthopaedic surgery will definitely be one of them. You will always want to be at least on par if not excel ahead of the students in overseas.

In my humble opinion, going to the most prestigious university does not mean that you will be some great doctor one day. It is all down to the individual, his hunger and aspiration. I just do not understand why some are making a big fuss about getting only their second choice of university instead of first choice. Another matter to note, the matching process has brought great pain to many in terms of betrayals seen even among the closest allies. I have understood this much earlier, don't you?

Before moving back to my dear hometown, I would be here for few more weeks to try to lend a helping hand to semesters one and three juniors from the aspect of theories and clinical skills. I was once a junior struggling to get the accurate techniques. Now I aim to make it as simple as possible for them without compromising the core of the contents. That's what we strive for in medicine - to learn and to teach, both an art?

Rhomboids

2011-04-24T00:10:00.006+08:00

To love is not to love,

The compassion painted is not the passion wanted.

The rhomboidal robs the blissful,

A multi-cornered fight envisaged.

I walk with pride and with silence,

To displace my sketched soul.

To be your slave, I am not afraid;

not to be erased, I sincerely pray.

Thanks, MR Khoo!

2011-03-27T18:55:00.002+08:00

The direct and indirect learning during the attachment with MR Khoo was hugely beneficial. I find that I have improved tremendously especially when it comes to the physical examination of the breast and performing digital rectal examination. Other systems' physical examinations have also been stepped up, notably from the aspect of showing more empathy.

Thank you MR Khoo!

Surgical Elective [the Remaining Days]

2011-02-09T09:49:00.004+08:00

with my Consultant General & Laparoscopic Surgeon, MR Khoo Saye Thiam

I haven't got the time to do the daily updates partially due to the time spent in the operation theater and I was lucky to be able to do some urology under the Consultant Urologist, MR Leong Weng Seng. I have to say thanks to my consultant for teaching, guiding and allowing me to perform the physical examinations that I normally would only be able to practise on the models. It has been a fantastic experience, enabling me to be wiser from the sense of clinical management and surgical curative and corrective procedures.

Behavioural science wise I managed to pick up some vital skills during the breaking bad news session, where Breast Carcinoma and HIV being the two most deeply embedded in mind.

For the remaining interesting cases seen, I will do my write-up one by one.

Surgical Elective [Day 9]

2011-01-19T23:40:00.006+08:00

First and foremost, I would like to say thanks to all who have wished me Happy Birthday. It has come a long way to say it's finally time to sink BN! My wishes are pretty straight forward, viz:

have a great year ahead in terms of academic, health and family bonding.
hoping that Yong Vui Kong who celebrates his 23rd birthday on the same day as well to be pardoned by the President of the Republic of Singapore.
the patients that I have had managed directly or indirectly to recover as soon as possible.

I spent half of my day in the OT, observing new procedures and techniques. It started of with Laparoscopic Appendicectomy which was quite a quick one. The tip of the appendix was visualized to be erythematous, believed to be congested. The base was normal. Hence, it was not a complicated case like those of perforated appendicitis where drainage and so on have to be done. In complicated ones, either McBurney's incision or Lenz incision needs to be done.

The next case was about an infected sebaceous cyst, just medial to the scapula. Also a simple saucerisation was done. The wound was left open and daily dressing is needed. It would eventually heal from inferior to superior.

The last case took around three hours. During the induction period, I was given the opportunity by Dr Swaran, the anesthetis, to set up the IV Cannula and to do the intubation, first by inserting the laryngoscope. Have you ever heard of Endoscopic Thyroidectomy [1] [2] instead of the conventional open sugery right across the neck? Basically, it requires three small ports, each nearing the right and left nipples and the last being at the middle of sternum. Though this endoscopic procedure would leave the patient scarless at the neck but the subcutaneous tissues will well be sacrificed for the routes towards the thyroid gland. The landmark will be the sternocleinomastoid muscle.

Surgical Elective [Day 8]

2011-01-18T23:06:00.002+08:00

Adapted from Zollinger's Atlas of Surgical Operations, 9th Edition, 2011

Tomorrow there will be a case indicated for thyroidectomy, subtotal, I may have a chance to observe transaxillary endoscopic resection! So currently I am reading up about the conventional methods. The risk of anterior jugular vein damaged during surgery is air embolism!

As Chinese New Year draws nearer, the number of patients reduces. Today, basically I was doing breast palpation for a few patients coming with complaints of breast lump. I had a discussion with Mr Khoo regarding the post-operative treatment for breast carcinoma where ER/PR positive or Her-2 positive would seem to provide a better option where drugs like tamoxifen, transtuzumab (herceptin), lapatinib (tykerb), arimidex and so on are effective in terms of prognosis. For triple negative carcinomas, the options available are cut short to chemotherapy. The hormone therapy drugs are much well tolerated that chemotherapy which has major side effects like hair loss.

Triple Negative Carcinoma:

Found more frequently in women younger than 50 years.
10 - 17% of all breast carcinomas
more common in premenopausal women
Gross Pathology: Tumors are of relatively large size and have pushing borders
Histopathology: mostly are of a basal-like phenotype (tumors with basal cytokeratin, myoepithelial and epidermal growth factor receptor expression) and are high grade ductal carcinoma of no specific type.
have high grade nuclear features, high mitotic rate and geographic necrosis
Immunohistochemistry: [1] Cytokeratins 5/6, 14, 17 positive [2] EGFR positive [3] SMA& p63 positive
D/D: some tumors may mimic large cell lymphomas
Favor haematogenous spread with metastatic deposits to lungs and brain and less to axillary nodes and bones.
Tumors may show objective response to neoadjuvant chemotherapeutic regimens, but lack complete pathologic response implies poor prognosis.

Surgical Elective [Day 7]

2011-01-17T18:52:00.005+08:00

It's an usual day in terms of the number of patients and number of surgeries. As usual, I did a breast examination on the patient and felt a mass at the periareolar region. The thing to note is the areolar region is easily missed, must be much more careful.

Last week I mentioned about the Berg's Levels for the axillary lymph node clearance in the event of radical mastectomy. In the current practice, the sentinel lymph node (SLN) concept has started to gain popularity but due to the lack of facilities, we are not practising it yet.

Adapted from the Zollinger's Atlas of Surgical Operations, 9th Edition, 2011

According to the British Journal of Surgery, there was an article published that reclassified the Berg's Levels to look into the most probable lymph node to be affected so that the morbidity rate of lymphoedema as a post-operative complication can be reduced by clearing only the affected ones instead of up to Level III clearance which is beyond the pectoralis major muscle.

The other case seen was piles. Not all patients are fit for the staple haemorroidectomy, especially the patients that present with internal and external haemorroids. One important thing to note is the conventional way of haemorroidectomy when done, must only repair the troublemaking fella instead of all as it will cause stricture to the anal canal and problems like fecal incontinence will then arise.

And finally, I learnt about Goodsall's rule for the anal fistula tract.