Whatablog!!

Bloodline

2020-10-09T06:45:00.002+08:00

The true meaning of family is not by bloodline.

But bloodline, does constitute a valid birth right.

There may be some blessing in disguise that I was born and raised poor.

It makes me what I am, what I feel, what I do today.

As I always said, the best gift I ever had from my parents was the raising me with willingness and easiness to live poor.

I hope my child/ren would be granted the same, although he/she/they may be much more comfortable than me.

2020 - Year of The Rats

2020-07-31T08:43:00.001+08:00

Blogspot had sent an email for some random comments dropped by some bots I think. Iklan yang bodoh-bodoh, again.

Today is last day of the month of July, Year of 2020. We have another 5 months to go before the end of 2020.

Despite the lockdown, 2020 remains a happening year for yours truly.

Past 2 years I had been quite involved with oncology research. Our site did very well with lung cancer biosimilar study. It is far from scientific breakthrough level of research but it did exposed me to the field of cancer.

A lot of my friends do not understand why I did not pursue clinical medicine, as I obtained the MRCP in 2017. I think I just dont have the balls anymore to do medical oncalls to be honest. Deep down I feel I am doing disservice to patients. Overthinking maybe but I cant help it.

Supposed to go over to Sg in March, but MCO.

Then May, but CB there.

Then July, borders not reopened yet.

and Now, it seems that if I can go there, I might not be able to come back often to see my fellow Penangite.

Which is quite, concerning. Haha.

All right peeps.

Adios for now. Good to be back talking to the world in writing.

It has been awhile!

2018-07-03T21:19:00.001+08:00

Received emails from Blogger for some advert/spam comments.

Realised I haven't blogged anything for damn long already.

So many things happened past 1 year.

I passed my paces in uk somewhere in nov last year.

Got married in may this year.

LOL.

That's all peeps.

Rheumatology Hands

2017-01-14T20:41:00.000+08:00

That day failed my paces - grrrr

Have to restart the whole cycle of revising again and practicing.

Station 5

History

1.Joint pain and swelling - symmetrical, chronology and extent, ADLs - cooking, dressing, showering, and lastly complications - CTS

2. Early morning stiffness - symmetrical, severity in duration (>60 mins, affecting ADL?)

3.Treatment - previous treatment, tolerability, SEs, complications monitoring.

Examination

Look - Feel - Move

- Symmetrical Deforming Polyarthropathy affecting small joints of the hands, sparing DIPs
- Ulnar deviation of the MCP
- Boutonniere's and swan neck deformity
- Z-thumb

- Piano key ulnar head

- Rheumatoid nodules, elbows/any pressure points

- Surgical scar - CT decompression

- Extraarticular manifestations :
Hematological - pallor, splenomegaly (Felty, with neutropenia)
Skin - nodules, vasculitis, pyoderma gangrenosum
Eye - scleritis (more severe, painful compared to epi-), episcleritis, scleromalacia perforans
CVS - valvular disease, pericarditis, CAD, myocarditis, heart failure
Lungs - pulmonary fibrosis (lower zones), pleural effusion, lung nodules, bronchiolitis obliterans
Renal - amyloidosis
Neuro - peripheral neuropathy, mononeuritis multiplex, compression neuropathies such as cervical myelopathy (atlanto-axial subluxation), CTS, ulnar neuropathy

Function

Power grip
Undo button
Pick up coin

Investigation

Blood test -
Inflammatory markers - ESR, CRP
Blood counts - Anemia of chronic disease, Low WBC in Feltys
Rheumatoid Factor - a/w severe disease, 80% RA has it
Anti CCP - cant do in active TB, very specific

Xray - look for reduced joint space, periarticular osteopenia, erosion, deformity

CXR - pleural effusion, pulmonar nodules , HRCT

Treatment

Multidisciplinary approach involving physiotherapy, OT, dexterity aid and modification of homes
Mainstay pharmacological treatment is DMARDs - MTX, Sulphasalazine, Leflunomide, Hydrochloroquine. Pain management - NSAIDS and COX2 inhibitors
Lastly, Biologics - TNF blockade - infliximab, adalimumab, golimumab

POSITIVE!

2016-10-24T16:24:00.001+08:00

Fortis Atque Fidelis

2016-10-23T19:41:00.001+08:00

Forgot to post about this.

In the midst of my exam preparation, I have no regrets spending one whole half day in the grand old lady.

I might not be the best of the student that came out from the school, I still share some of my most memorable moments of pride, disappointment, fun and excitement in the PFS.

This is the place I learnt the values of sportsmanship, with the big field we had almost daily football using some unwanted plastic bottle on the friday afternoon.

At that time, I didnt know what is pancit, energy seems boundless and the only reason we stop running is because it is sadly the time for the computer period at 2pm.

This part was written on 21 October 2016 morning and it is the school speech day. I have not missed any of the speech day, and to this date my parents have not been to any of the speech day despite their son winning best subjects prizes every year (haha, good old days of academic excellence) as they were scared of teachers complaining their son being mischievous and always wear unironed clothes to school after being summoned once to my primary school for that reason.

Hope the next generation of PFS will keep the spirit flying high.

FortisAtqueFidelis.

ILD

2016-10-22T15:27:00.001+08:00

I would like to end my examination by checking the temperature chart, doing a peak flow meter and looking into the sputum pot of the patient.

Mr X has a diagnosis of interstitial lung disease, currently not in respiratory failure.

On general examination, he is not tachypneic, with respiratory rate of 16 breaths a minute. He has finger clubbing with no signs of carbon dioxide retention. There is no jaundice or pallor and no central cyanosis. His tracheal is centrally located.

On chest examination, there is no scar or deformities noted. My findings are confined to the bilateral lower zone, with reduced chest expansion, dull percussions, reduced breath sounds with fine-end inspiratory creptitations not altered by coughing and normal voval resonance. The JVP is not raised, no displaced apex beat or loud P2 and there is no pedal oedema. There is no palpable cervical lymphadenopathy.

In summary, Mr X has findings in keeping with a diagnosis of interstitial lung disease and currently not in respiratory failure. In the context of chronic lung disease, there is no sign of cor pulmonale. The likely etiology would be idiopathy pulmonary fibrosis. I would like to offer a few differentials of lower zone fibrosis such as connective tissue disease induced - rheumatoid arthritis, SLE and dermatomyositis, drug induced fibrosis - amiodarone, methotrexate and nitrofurantoin and radiation induced fibrosis.

Communication Station

2016-10-21T00:19:00.002+08:00

5 minutes preparation:

1. Decide need to ask for family members/friends to be in the room? - Bad news vs the rest

If bad news....

2. Warm up: How is the patients since last seen?

3. Current understanding - What is the level of understanding? - of the condition of patients/ relatives/ of the test done - reasons)

4. Perspective - What do the patient think is the problem? What is the expectation?

5. Shoot - warning shot, silence and shoot the news, and silence.

6. Tissue.

7. Permission to continue.... Explain the diagnosis/ ever heard before / anyone in family/friends had it?

8. Expect patient to ask - why me? - Usually unknown.

9. Expect anger - why no picked up early? - Not entirely sure what has transparent between you and the GP, it seems to be this is reasonable time line. Difficult to diagnose with non-specific symptoms. etc etc. Goreng.

10. Investigation further. Referral to specialist team

11. Treatment modalities

12. Outlook.

13. How are you feeling about this news?

14. What is going through your mind?

15. Anything I can help?

16. Probe social history - talk around the family/plans to tell them/offer appointments together and discuss with family members together. Information leaflets. Society to talk to.

17. How to go back? Offer taxi.

18. Next appointment. See consultant. Ask more questions.

Spastic Paraparesis

2016-10-17T13:26:00.003+08:00

Spastic Paraparesis

Young:
Multiple Sclerosis
Cerebral Palsy
Trauma
Infection - HIV
Motor Neuron Disease

Old:
Trauma
Transverse myelitis
Infection of HIV, TB and Syphilis
Motor Neuron Disease
Spinal Cord Tumour
Syringomyelia
Anterior Spinal Artery Infaction
Subacute Degenerative of the Cord

Others:
Hereditary Spastic Paraparesis
Tropical Spastic paraparesis
Bilateral Stroke

COPD

2016-10-17T11:53:00.000+08:00

1. General inspection - cachexic, tachypnoea?, barreal shapped chest, inhalers devices or oxygen around

2. Observe the breath in and out - pursed lips breathing

3. Examine hand - tar stain, palmar erythema, flapping tremor

4. Pulse - Bounding pulse

5. Respiratory rate

6. Eyes - suffused conjunctiva

7. Mouth - Central cyanosis, pursed lips breathing

8. Neck - JVP

9. Trachea - Reduced cricosternal distance (less than 3 fingers), central?

10. Inspect the chest again front and side - barrel shape, hyperinflated chest (vertical > horizontal expansion

11. Feel Apex beat - displaced, or difficult to appreciate - emphysematous

12. Parasternal heaves, P2? cor pulmonale

13. Chest expansion - 3 places

14. Percussion - resonance? dull? Apical, 2 middle, 1 axilla

15.Auscultation - Breath sounds reduced or equal? Bronchial breathing? Prolonged expiratory phase, Inspiratory coarse crackles, Expiratory wheeze.

16. Vocal resonance

17. Swing to the back

18. Feel for lymph nodes

19. Expansion again

20. Percuss - apical, 2 middle, 1 axilla

21. Auscultation

22. Vocal resonance

23. Pedal oedema

Thank patient

Presentation:

I would like to end my examination by checking Mr ABC's temperature at the observation chart, doing a PF and looking into the sputum pot.

Mr ABC has the appearance of plethora, flushed looking and purse lips breathing. He is tachypneic at rest, with respiratory rate of 24 breaths a minute and usage of accesory muscles and intercostal recession.

On peripheral examination, there is finger clubbing, palmar erythema and nicotine stain. I found signs of CO2 retention with bounding pulse and asterixis. On face and neck examination, he has suffused conjunctiva, but no jaundice or central cyanosis. His tracheal is centrally located.

Moving on the the chest, there is no scars noted. The chest looks hyperinflated with appearance of barrel chest. My chest findings are: Reduced chest expansion bilaterally throughout, resonance percussion, reduced air entry on the right hemithorax and coarse pan-inspiratory crepitations on the left lower zone which is altered by coughing. Vocal resounce is unremarkable. There is expiratory wheeze all over the lung fields with prolonged expiratory phase.

There is no pedal oedema and JVP is not raised and there is no loud P2 or parasternal heaves.

Cervical lymph nodes are not palpable.

In summary, Mr ABC has emphysema on the right lung and left lower zone bronchiectasis with underlying COPD secondary to cigarette smoking. He is in respiratory failure. In the context of chronic lung disease, there is no signs to suggest cor pulmonale.

Thalassemia

2016-10-15T21:23:00.003+08:00

I would like to end my examination by checking the genitalia of the patient and performing a per rectum examination.

Mr Ahmad is a young, thin and hyperpigmented gentleman with short stature. On peripheral examination, he has no stigmata of chronic liver disease. He has conjuntiva pallor and jaundice, with frontal bossing, prominent maxillaries and chipmunk teeth appearance. There is also sparse axillary hair.

Moving on to the abdomen, there is a scar at the left upper quarant, well healed. There is hepatomegaly, measuring 4 f.b, with smooth edges, non pulsative, non tender, and no bruit heard. Spleen is not palpable. There is no ascites, and kidneys are not ballotable. There is no cervical lymph nodes palpable, lungs is clear and no pedal oedema.

In summary, this young gentleman has signs of chronic hemolytic anemia with pallor and jaundice with underlying Thalassemia major and previously undergone a splenectomy. In terms of complications of the disease, he has signs to suggest hypogonadism and iron overload.

I would like to do a few investigations namely blood test of full blood count to make sure he is adequately transfused Hb9-10, LFT is also required. I will also send ferritin level, transfusion related infection of Hep B/C/HIV serology, endocrinology work-up of thyroid function test, HbA1c/FBS and sexual hormones - LH/FSH/Testosterone/Estrogen.

Also, he will need to undergo cardiac MRI T2star for cardiomyopathy and Dexa scan for osteoporosis.

Renal Transplant

2016-08-30T00:54:00.002+08:00

Did very badly in today's practice. Missed not just one but two AVFs!

1. Wash hand, introduce and consent.

This renal transplant patient~!~!~~!

2. Exposed patient from waist up, and general inspection of surrounding, and patient as a whole. ?Cushingoid ?Pigmented ?Sallow appearance

3. "Is there any discomfort anywhere?"

4. "Can I have a look at your hands? Check for clubbing, leukonychia, palmar erythema, Duputrun's, Flapping tremor, tremor

5. Check for AVF on both upper limbs, if found, with three fingers to feel the thrill, and look for any recent puncture marks? Move up to see any tattoo, bruising, thinning of skin.

6. Check eyes - look up and look to the finger. Pallor, jaundice.

7. Check parotid swelling.

8. Open mouth for me, and stick out your tongue, show me your teeth, look for gingival hypertrophy.

9. Examine the chest - look for spide naevi.

10. Raise your arms to your head, and look at axillary hair

11. Check gynaecomastia

12. Inspect for scar (RIF scar?) and Palpate abdomen - soft then deep. Noted a mass and a note its size, bean shaped, tenderness, firm, percuss on the top, listen just next to it for bruit.

13.Liver, palpate the percuss.

14. Spleen, palpate, then precussed

15. Tap on the midline for any fluid. No ascites. Check sacral oedema.

16. Ballot for kidneys

17. Check pedal oedema.

18. Sit up and check LN and then check for proximal weakness.

19. Cover up and present.

Presentation.

I would like to end the examination by checking his urine dipstick and blood pressure measurement.

Mrs Lee has Cushingoid appearance with moon face, supraclavicular fat pad and dorsal humb. There are two AVFs on bilateral forearms with no thrills and recent puncture marks. Other examination reveals conjuctive pallor, hyperpigmented skin lesions on the left temporal measuring 2cmx1cm and gum hypertrophy.

Moving on the the abdomen, there is a scar at the RIF and a mass measuring 6x 4 cm beneath it which is firm and bean shaped. It is non tender, dull on percussion and there is no burit audible. The rest of the abdomen is soft, no hepato or splenomegaly. There is no ballotable kidneys. He has no ascites, scaral, pedal oedema.

In summary, Mr lee has a transplanted kidney for ESRF which is functioning well. Etiology for ESRF for this lady would need some further history as I could not find obvious signs of common causes such as DM, Hypertension, Glomerulonephritis or APCKD. There is no signs of fluid overload and uremic encephalopathy. In terms of immunosupression, she is likely to be on steroids and cyclosporin, with no lymphnodes palpable but there is a suspicious skin lesion on the left temporal which needs further work-up.

Intensive 60 days

2016-08-24T22:04:00.002+08:00

TTM

2016-08-09T21:56:00.002+08:00

Doing postgraduate examination is such a humbling journey.

Without patients, we are nothing,

We learned from them more than anything else.

We should thank them rather than the other way round.

Ah, back to books.

TTM moments.

Mitral Stenosis

2016-07-30T20:49:00.002+08:00

1. Wash hand, introduce, consent.

2. General inspection - malar flush? expose - scar?

3. Can I examine your hands please? Peripheral stigmata of IE. Finger clubbing.

4. Just going to feel your pulse. Rate, rhythm - AF?, volume and character. Feel the other side, and then femoral. Feel the brachial. Then collapsing pulse.

5. Could you look slightly to the left for me, just going to examine your neck. Look for JVP - systolic v wave. raised?

6. Could you look up for me, just going to check ur eye, and look to my finger down there? Pallor, jaundice.

7. Could you open your mouth and stick out your tongue, and up to the roof? Dentition and peripheral cyanosis.

8. Going to examine your chest. Look for the scar - mitral valvutomy, left lateral.

9. I am going to feel your heart beat. Feel for 1. Character - tapping S1. Displacement. The parasternal heave, and thrills of TR.

10. I am going to have a listen, and feel the neck at the same time. Apex diaphragm, S1 - loud? S2. Then opening snap? Early in diastole. Any murmur? Radiation to axilla. Now turn to bell. Mid diastolic murmur? Turn to left lateral.

11. Proceed with LLSE, LUSE, RUSE. If murmur then proceed for accentuation.

12. Lung bases and pedal oedema.

13. Cover up and thank the patient.

Presentation.

GENERAL

Ms X is not breathless at rest. There is no peripheral stigmata of IE. Her pulse rate is 80 beats per minute, irregularly irregular, but with normal volume. The JVP is not raised. There is no malar flush.

MAIN SYSTEM

Moving on to the praecordium, there is no scar. Apex beat is tapping, undisplaced. There is no heaves or thrills. On ausculatation there is loud first heart sound, and normal second heart sound. There is an opening snap in early diastole. There is also a mid-diastolic murmur at the apex, 3/6 in grade and accentuated by left lateral position with breath hold in expiration. The lungs is clear and no pedal oedema.

SUMMARY (DIAGNOSIS - ETIOLOGY - FUNCTION - COMPLICATION)

In summary, Mrs X has a mitral stenosis with no signs of IE and not in failure. There is no sign of overwarfarinisation for the AF. The most likely etiology for MS in her is Rheumatic Fever. I would like to complete my examination by looking at the temperature chart, urine dipstick and measuring her blood pressure. Thank you.

AVR

2016-07-30T20:32:00.002+08:00

Aortic Valve Replacement

1. Wash hand, introduce, consent

2. General inspection. Expose - median sternotomy scar. Breathless at rest? Corrigans? (so as to look hard for collapsing pulse later)

3. "Can I look at your hands please?" Peripheral stigmata of IE

4. "Just going to feel for your pulse". Rate, regular/irregular, volume. Check the other side for radial radial delay. Check brachial pulse as well.

5. "Do you have any pain in the shoulder? Ok, I am going to lift it up above your head". Looking for collapsing pulse.

6. "Could you turn slightly to the left, just going to check the neck". Looking at JVP and carotids. Feel for the carotids.

7. "Could you look up for me, just going to check your eye, and look down?" Check for anemia and jaundice.

8. "Could you open your mouth for me and stick out your tongue" - look using torch. Check dentition and central cyanosis.

9. "Just going to examine your chest now". Look hard for other scar - mid sternotomy scar, valvutomy scar, palpate for pacemaker.

10. "I am going to feel for your heart beat". Palpate for apex beat, then parasternal heaves and any thrills. Count ribs. Displaced - likely AR, undisplaced 5th intercostal space, midclavicular line - likely AS.

11. "Just going to have a listen and feel the neck at the same time". Apex - diaphragm - check for S1 and S2 (look hard for prosthetic click - time with the carotids) Bell. LLSE - diaphragm. LUSE - diaphragm. Listen hard for Early Diastolic Murmur !! then RUSE - diaphragm. Likely to have a ESM at aortic area.

12. "I am going to listen to the neck, could you take a deep breath and hold it" - radiation for ESM to the carotids

13. Could you sit up for me, lean forward, and big breath in and out and hold it for a second? - listen hard to EDM again!

14. Listen to lungs, and check for pedal oedema.

15. look for bruises, and harvesting vein at the legs and radial.

16. Thank the patient, cover him up and wash hand.

Presentation.

. I would like to complete my examination by taking the BP of the patient, looking at his temperature chart and do a urine dipstick.

Mr X had undergone an aortic valve replacement for, most likely AS.

There is no peripheral stigmata of IE. His pulse is 70 beats per minute, regular and normal volume. There is no collapsing pulse. JVP is not raised, and there is no conjunctiva pallor or jaundice.

On my examination of the praecordium, there is a midline sternotomy scar. Apex beat is not displaced. There is a normal first heart sound and a prosthetic click coincide with second heart sound. There is an ejection systolic murmur loudest at the aortic region, but no radiation to the carotids. I would grade it 3/6 with no palpable thrills. There is no early diastolic murmur or collapsing pulse to suggest valve failure, and lungs is clear with no pedal oedema to suggest cardiac failure.

In summary, this patient had an aortic valve replacement, most likely for AS secondary to degenerative calcifications or chronic rheumatic heart disease. There is no clinical evidence of valvular leakage, thrombosis or hemolytic anemia. There is also no signs of pulmonary hypertension or cardiac failure. There is no sign of IE or overanticoagulation

90%

2016-06-13T18:26:00.000+08:00

They say money will never be enough.

I read somewhere that do not ask a female her age.

Did not mention why.

and do not ask a male, his income.

But it mention why.

It is because 90% of his income is spent on others.

LOL

Parkinsons Disease

2016-05-06T22:48:00.003+08:00

1. Wash hand, Introduce, Consent.

This looks like Parkinson?

2. "Hello Sir, can you me your name and your address?" - monotonous, low volume speech?

3. General inspection - "I am just going to stand here and have a good overall look first"
Walking aid? Looking at the patient, Expressionless, mask-like face, reduced blinking

3. "Any pain anywhere?"

4. Tremor -
Put both hands on a pillow/lap - thumbs and indexs top and radial surface bottom - to show pill rolling more evidently. Is it symmetrical? Coarse? Pill-rolling?
"Could you close your eyes for me, gently and count backwards from 10 to 9 to 8 and so on...?
- distraction method to enhance tremor
"Could you lift up your arms and spread out your fingers like this?"
- rule out postural tremor

5. Rigidity -
"Just going to examine the muscles and movements of the arms and hands, Can you go floppy and soft, just let me take the weight of the arm, relax and soft, relax and soft..."
- Supinate and pronate, extend and flex elbow, extend and flex wrist, both sides
Look for lead-pipe rigidity at the elbow, cogwheeling at the wrist.
"Could I ask you to tap your knee with your other hand like this, keep going while I examining this side? and the other side
- Synkinesis would accentuate the rigidity almost instantaneously

6. Bradykinesis
"I am going to need you to do this movement like twinkle stars, as fast as you could and keep going keep going keep going:
- decreased amplitude and speed as it goes
"Can you show me your hands movement as if you are opening the water tap?"

(proceed with power and reflex)

7. Postural Instability
"Sir, do you think you would be able to take a few steps across the room and show me how you walk?" Can you walk over to the door and make a U-turn back here as you would normally?
- Look for difficulty to initiate movement of getting off the chair and start walking, stooped posture, hesitation, shuffling, narrow based gait, reduced arm swing, difficulty in turning with accentuation of pill rolling.

9. Function
"Can I get you to show me how you unbutton your shirt, just a few buttons? and can you put that back?
"Can you write your name for me?" - holding pen and write

10. Rule out PSP
"Just going to check your eye movements. Can you keep your head straight and still, and use your eyes to follow my finger? Keep going keep going... all movements
Look for vertical gaze palsies, and nystagmus for cerebellar disorders
"Could you close your eyes and keep your arms straight, palms nice and flat up like this?"
- pronator drift
"Could you form a pointer like this and touch the tip of my finger and then the tip of your nose?" and the other side
- check for cerebellar sign

I will complete the examination with full neurological exam, supine and erect BP, MMSE, swallowing test and writing.

----------------------------------------

Mr X is an elderly gentleman with Mask-like and expressionless face, monotonous and low volume speech. He has asymetrical tremor at rest, predominantly on the right side with characteristic pill-rolling movements of the thumb. The tremor diminished with usage of the hand, but accentuated by walking and distraction. There is presence of lead pipe rigidity at the elbow joint, cogwheeling at the wrist joint and both accentuated by movement of the contralateral upper limb. He has bradykinesia with reduced amplitude and speed of his fingers movement. He has difficulty getting up from his chair and initiating walking, with stooped posture. Once walking, he showed shuffling, narrow based gait, with lack of normal arm swing, and slow in turning.

Functionally, he can dress up himself, able to walk unaided.

He does not have features suggesting PSP. There is no sign of PSP such as impairment of vertical gaze. There are no cerebellar sign to suggest MSA, or sign of corticobasal ganglia degeneration such as pyrimidal signs or dystonic arm.

All in all, he has features in keeping with my diagnosis of Parkinsonism, and most likely due to Parkinsons Disease with good preservation of function, and no evidence of dyskinesia at this point in time.

Belleview and Property Purchase

2016-01-23T12:55:00.002+08:00

I bought my first property rather inexperiencedly, i admit.

Well, I must say that buying property is a very steep learning curve. I would put it as equal as choosing a life partner, because, you are going to be with this commitment for life (oh well, unless you are speculator, or you are damn rich person)

I would like to write this entry just to make sure somewhere someone who read this will think twice when you buy a property.

1. Property Construction Company.

Serious, BELLEVIEW GROUP is a total disappointment. When I first saw the apartment that I bought in a fair, i googled BELLEVIEW GROUP. It seems like a good, trustable, oldie in this field.

Wrong, very wrong. But it is a good learning opportunity. Not only the worksmanship is less than shoddy, the way they treat us post sales is deplorable. No way that I will buy another property with Belleview Group of Companies.

My experience dealing with them and afterwards with other companies and contractor and other buyers chitchating - best trustable names are still IJM, SETIA, BSG, Ideal. Ya. Dont transact with Belleview, unless it is absolutely bargain, oh well, I wont still.

2. Lawyer

Now, I worked as a medical officer in a busy government hospital (time of purchase). I have very little knowledge in legal process of purchasing a property. As a medical person, I see logic in every step in whatever we do. For example we do a CXR before starting biologics treatment to avoid having a patient with TB on biologics. But why are we paying the lawyers so much money for a stack of photostated agreement?

I have only spoken once with her, during which I made the full payment of the legal fees (approx my one and half month salary), for 15 minutes.

And the rest of it, I only see her clerk (a very junior officegirl) whereby I signed all the documents. And I knew it was merely clerical photostated because, it was the similar ones, with different names, number of unit, and dates when I accompanied my good friend to the office - he bought the nearby unit of the similar apartment with me.

I cant help but asking - what is the value adding in this transaction?

I still not knowing what is my rights, nor what I should do in unsatisfactory transaction with the seller. None.

(*the reason of my rants is that I cant imagine the same done by a doctor to a patient, imagine you paying me one month salary and I let my junior nurse talk to u for a procedure I do for you when u are asleep...cannnot right, because we are doctors right? Can feel my sarcasm?)

******************To be Continue**************when I am free. Sorry, need to attend to my patient, for an exorbitant fee of rm20/consultation of 10 minutes me talking to the patient face to face and take the liability of being a cheater if the symptoms worsened.

Stets

2016-01-22T14:17:00.000+08:00

Wanted to buy a stethoscope and so was searching online to compare prices.

Remember the first time you were holding the stets?

Oh, that light green colour stets, my first stets, I wonder where you are.

It was the beginning of second year medical school, i remembered at that time I still brought the box with me in the bag.

When the GP says we are going to listen using stets, I took out the box and take out the new, brand new stets.

Haha! Fast forward...about 8-9 years already.

I lost that stets in the first year of h.o ship. Dont know which scumbag stole it. Grrrr

Going to buy a good, cardio stets this time! With my name!

Okla, one post every quarterly, to maintain this blog.

Have a good day people!

What I Learnt from Phase 1 Conference?

2015-11-28T00:54:00.000+08:00

I always feels that international conference is very much different than local conference, in the sense that the talks and speeches are on their work, unlike local ones which sometimes talk on the textbook content.

And so with a bit of luck, I had the chance to go to ICPOEP - International Conference on Phase 1 and Early Phase Clinical Trials in Hong Kong.

All the way from Seberang Jaya at Grand Hyatt Hotel, TST

Clinicaltrial.gov defined Phase 1 as studies that are usually conducted with healthy volunteers and that emphasize safety. The goal is to find out what the drug's most frequent and serious adverse events are and, often, how the drug is metabolized and excreted.

Of course, the obligatory photo as a traveler in Hong Kong

This conference is organised by Clinical Trial Centre, University of Hong Kong. As you can see, their's is a bit different setup from ours in Clinical Research Centre, Malaysia. They are part of the university and their hospital is part of the university.

There is a section displaying their trial set up. There is a large picture of the view from clinical trial ward. The hospital which houses the trial ward is overlooking ocean view of Hong Kong. They make the subjects feel that they are on Holiday rather than coming in for Research. Basic amenities such as soaps, shampoos, slippers are Hotel-like, and menu of the food there is extremely attractive!

Each of them given this starterpack. Note that there is an IPAD with entertainment, something like flight entertaiment concept.

Macam Hotel

Menu. Ganas.

The talk started right on time. Good organisation I would say. The list of speakers were impressive. Mostly were Chinese names based in overseas, renowned medical centres, like Ninewells Dundee, NUS Singapore, Imperial London, Uni of Toronto Canada, Harvard just to name a few.

I took pictures of almost all slides to keep me awake throughout the sessions, and for the purpose of this entry, for my goldfish memory. I'll share some slides which are very interesting, at least to me.

Let me start with this Prof Gail Echardt's talk on challenges and opportunities in early phase trial. She was given an award lecture in Drug Development in this annual conference. She is a very established early phase researcher from Colorado, USA. She shared her experience in organising her Phase 1 centres, particularly her strategies in nurturing new researchers and going away from MD-driven hierarchy.

I particularly like this slide. She showed that there is a disease specific team leader and coordinator which oversees the Phase 1 study, specifically on that disease, and they typically follow through as the study progresses to Phase 2 and 3.

Let me just say that in this slide, the last sentence is the killer!

I think I will not be able to go in depth in all talks.

Let me move on to my favourite speaker, Prof Lee M Ellis. His CV is long, but for the sake of his speech, suffice to know that he is a journal editor. He talked about research integrity.

He talked about increasing occurrence of fraud and dishonesty in research conduct. He feels that this is all because of academic pressure which is unnecessary. He gave examples of Japanese Riken scientists and Anil Potti in Duke.

I think it is very relevant to us, in Malaysia whereby the push for publication is high, but without proper mentoring. There is a very high pressure on us to perform. In that process, it is important to keep in mind that we do not sway from good research integrity, attempted plagiarism, sloppy reporting, dishonesty and academic bullying.

I would think most of us are Sloppy, but hopefully we dont Fabricate.

I have nothing to publish in CNS. LOL

It is funny when some proposals I was told that was rejected previously because it has been done. Our top level needs to know the importance of reproduciblity of any research to test the hypothesis repeatedly. We learnt to do more, as we done more.

I would love to see this kind of fresh talk in NCCR.

OK, lets move to a intellectual talk. This Prof Mak Tak-Wah, is extremely funny man. I think he is damn old, probably in his 70s and his job is just travelling around the world giving speech. Despite his age you see, he is given a topic - Future Oncology Targets, just to show how big is his name in advanced research of Oncology. He basically went through from historical perspective on how unsuccessful our endeavors in coming out with new oncology drugs, mainly because we had the wrong conception. But right now, there are many new targets being pursued, which his lab is working on, and he even shared a slide of which it has just been published on that day itself.

New targets, note the footnote. The conference was on 19/11/15 - it was just published today

Warburg is a Nobel Prize winner who said Cancer is not caused by Virus or genes, both very wrong. But we progress not because scientists changed their minds, but because they die. Scientists - sometimes, over-believed their science.

Note that Prof Mak is the main author!

CVS

2015-10-13T08:54:00.001+08:00

Arghhh..still struggling to get the pace to settle the review of CVS.

Actually it is an easy task to do, as in everything is just in the computer, but I have too many distractions.

Need to step up and gear up!

The plan is to settle it within 1 month, get it published, and then move on to other papers I already can write it up.

Come on Ang!

Review!

2015-08-06T09:44:00.000+08:00

20% progress....since started in Bukit Fraser

Oh why write-up so slow...why....

Must settle in 2 weeks!!

Come on Ang Choon Seong!

- A REVIEW OF CORONARY ARTERY DISEASE RESEARCH IN MALAYSIA

Age

2015-07-24T01:17:00.002+08:00

Semua nak menang, siapa nak kalah?

As I ages, I starts to understand the heavy meaning of the above seemingly light sentence