kembara di bumi Melbourne

Swine Flu (H1N1) in Melbourne

2009-07-04T22:17:00.002+10:00

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

2009-07-01T15:30:00.004+10:00

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.

Take history from patient with symptoms of depression.
Take history from patient with bulimia nervosa. Describe the management.
Elderly women with Colles' fracture. Describe your findings in clinical examination and x-rays. Management of Colles' fracture.
Patient with advanced lung cancer, want to die at home. Has several issues. Medication, feeding, EPOA.
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)

2009-06-28T19:14:00.004+10:00

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

2009-06-27T18:32:00.003+10:00

Six 5 marks questions

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

Six 15 marks questions

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.
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]
Elderly women with advanced lung cancer. Want to die at home and family happy to support her. Describe your discharge planning.
Women present to GP with symptoms of 8 years history of binge eating and purging. Normal physical exam. Describe management of this patient.
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).
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

2009-06-27T15:49:00.001+10:00

Six 5 marks questions and six 15 marks questions.

5 marks questions

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

15 marks questions

Differences between acute, chronic and cancer pain. Answer in table form
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.
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
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.
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)
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

2009-06-26T20:00:00.003+10:00

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

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.
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.
New operators for tram and train in Melbourne. Hopefully this will improve the quality of public transport in Melbourne in the future.
Exams. I have finished two written exams and will be sitting for OSCE next week. Will write more about those written exam later.
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

2009-06-11T14:13:00.006+10:00

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

2009-06-03T19:23:00.002+10:00

Sungguh klasik bahasa yang digunakan .

Disturbing radiology images

2009-05-31T14:14:00.004+10:00

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

2009-05-30T10:04:00.005+10:00

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

2009-05-30T08:16:00.001+10:00

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

2009-05-28T11:18:00.003+10:00

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

2009-05-27T11:04:00.001+10:00

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

2009-05-26T18:05:00.005+10:00

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

2009-05-19T22:54:00.003+10:00

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?

2009-05-15T15:54:00.002+10:00

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.

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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?

2009-05-15T08:06:00.001+10:00

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

2009-05-13T21:56:00.002+10:00

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

2009-05-10T20:56:00.003+10:00

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

2009-04-29T16:01:00.003+10:00

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

2009-04-26T21:40:00.005+10:00

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

2009-04-25T17:32:00.003+10:00

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

2009-04-20T08:40:00.004+10:00

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.

2009-04-17T22:08:00.003+10:00

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

2009-04-14T11:21:00.001+10:00

These are my favourite Firefox extensions in Firefox 3.0.

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.
DownThemAll. A useful download manager. It contains download accelerator and help me to organize all my downloads.
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.
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.
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