26 year old thai male
nil past medical history

presents with atypical chest pain of 2 days duration
dull in nature, persistent, does not change with position or activity
no radiation
not relieved by rest or sleep or GTN patches
interferes with work and sleep

asw SOB and heavy breathing, although RR not increased.
ECG shows pathological J waves
CXR shows cardiomegaly

MX:
rest in bed
analgesia
keep INo2 more than 100%
KIV heart and brain transplant cm after team r/v

Think i handled this one really badly... back to my cave man... back to the cave we go.... till this ice age's past, and the world has run out of snow. Till the world's ending, n the need has past for us to stop shielding, hiding, defending.

Sometimes we are left with choices that we have to make, both of which may not be to our liking. But such is the nature of choice, you choose, not because you like to do so, but rather, because you have to.

Do i trust my friend and heed his advice, tho' i see no reason, no rhyme, and am totally blind? Or should i just go on my way, do wat i want, and risk fraying the bonds of friendship that has taken so long to weave together?

I chose to trust, but in doin so i am faced with a barrage of questions that i have no answers to, as well as a conscience that aches badly, for i have had to possibly let go of another friend.

Choices... i don't know wat to do. I don't know what to say, n i dun know if i can sleep. But i have made a choice, and have to face the consequences alone...

Max lay down on the corner of the lane that led down to the Castle. This was the Royal lane, the life-line of the city. All the important people went up and down this lane. Some conducted the King's affairs, others simply plied their trade, did business. Still others begged or tried to steal, and lil' child beggars pouted and cried for a chance of a good meal. At night, the courtesans would lure the young sailors and their captains with the promise of one unforgettable night.

Max felt the cool of stone pavement on his face. No one noticed him... they never did, and perhaps they never will. The pang of hunger hit him again, filling him with nausea, and he salivated at the wifts of fried bacon that has meandered its way through the turns and bends of the lane. Hunger pangsq lasts 20 minutes; but he decided he might not. So off Max went, scampering across the lane following the smell of fried bacon. Ducking a horse carriage and darting through the tangle of human beings, he reached what he was looking for.

Max was 3, never knew his parents, and had survived mainly because people found his innocent, wide eyes so captivating. His kind struggled for a living, and he has had friends who had been kicked around for fun, set on fire, and even beaten to death, then skinned and eaten. He will never forget the smell of his friend's burning corpse as he lay spitted just round the corner from the lane where he now stood.

Max looked up at a burly, sweaty man with a paunch, panting away from his lil' journey here. Blood-shot tired eyes met wide, bright, innocent eyes.

"What the hell do you want?"
Max kept quiet. He never spoke a word, and made a conscious effort not to stare at the bacon, but to hold his captivating gaze on that bald man's face. Time slipped away. Customers came and went, and the bald man tended to them. Max sat down quietly, and continued to stare at the man. The man raised his chopper and waved angrily at Max.
"Get out of here you stinking ..." That gutteral voice.. then a spit that landed next to Max. But Max knew the bald man wasn't aiming it at him. He was a good man, and it's just that he had to deal with situations like the one he was confronted with now dozens of times a day. Max continue to gaze unflinchingly.

The bald man bent down and tossed Max a relatively large piece of burnt bacon.
"Now get out of here before i gut you you hairball... and don't come back!"
Max lept up and licked the man on the face, drawing a half hearted protest. Then he scampered away, with that prize between his canines, saliva dripping down his grey beard down onto his paws that was covered by scabs.

Max rounded the corner and ran into Rose. Rose was 2, pedigree, flawless in features, a beautiful Alaskan. Max had always loved her since he had set eyes on her. She was one hot ahem... female dog. But he knew he had no chance. He was a mongrel, surviving in a tough world, with scars from fights with dogs bigger and meaner than him; and he knew that he would grow up to be like one of them one day. Rose belonged to someone, and was loved and cherished. She was smart, and classy. He loved her long silky hair, and the smell of the Dove dog shampoo whenever she walked past. He loved the way she looked when she was sleepy, and she had told him that she had trouble sleeping, so Max loved the way she looked all the time. Everywhere she went, there would be dogs howling to ask her paw in marriage. All manner of gifts would be given her... cat carcasses, the heads of sparrows, tails of 200 rats, the femur of a cow, the manhood of a poor blindfolded horse who was towing a carriage.....

But Rose still talked to him, befriended him. Though whenever she was around, he would not be able to say anything sensible, but would only make stupid suggestive comments as he tried to be cool. Damn, he was never this way with the other bitches. Then again, he never liked them that much either. She wasn't going out with anyone now, having broken up with a short lil' chihuahua about half a year ago. There is a big bulldog asking her out as well, and he was rich, made good conversation, and was more experienced in cutting up other dogs.

Max held his head a little higher, and spoke a bit more confidently. "Hi.." He barked. Then his mind was so full of Rose that he had nothing else to say. Without thinking twice he walked forward and lay that piece of burnt meat at her feet. His stomach growled noisily in protest. He had not eaten for the last 3 days.

"I couldn't take it..."
"No you must."
"But you look like you haven't eaten."
"Nah, i get deals like that all the time... cos i am so good looking." His sores suddenly itched.
"Ha ha... ok... but i am not so hungry."
"It's alright, take it, you might get hungry later."
"Ok, thanks. Anyway i gotta run."
"Sure, I gotta meet someone myself. No time..."

She hesitated, then picked up the piece of burnt bacon and sauntered off. Max walked away, then stopped pretending that he had to meet someone, and followed quietly after her. Rose went down the lane towards the river, her fur glowing an angelic white in the summer sun.

Under a sigamore tree, Rose met Dave, a dashing 4 year old Labrador, who was carrying a roasted duck in his jaw, with a tag saying "Peking". Max didn't know the meaning of that. Dave frowned in disgust at the burnt piece of bacon. Rose looked around and didn't see Max, and promptly flung the burnt bacon unto a nearby ditch, whereby a few large mean rats whisked it away before one could even go "woof woof".

Max howled in agony when he had found a quiet corner to do so. He had given up more than a lunch. But he also knew that if he was put in the same situation once again, he would have done the very same thing.

You know you like someone when you think about them all the time; you wake up imagining that person beside you. Your every thought revolves around them every minute of everyday.
You know you like someone when you can't think straight when you are with him/her, when you say the wrong things or can't say anything, when you keep tripping.
You know you like someone when you keep talking about them, regret talking so much when the whole world finds out, and then you carry on talking anyway.
You know you like someone when every love song seems to mean something to you once more, and every love story like a story you could relate to, though they had been simply entertainment before.


You know you love someone when you care their their needs and wants, and place their wishes hopes and dreams higher than your own.
You know you love someone when you don't mind getting hurt, as long as they are alright.
You know you love someone when you dun mind hurting the person, and having them hate you for it, when you know that ultimately, it's important, it's for their good.
You know you love someone when you open up yourself totally, wholly, without restraint, hoping for but not requiring reciprocation... when you are naked and vulnerable, handing your heart out on a silver platter, to be cherished or to be devoured, spat out and cast aside forever.

-I love someone

There exists a rule amongst the world of brothers... a rule cast in stone since time began... a rule passed on not with words as women would have it, but with that male intuition, powered by our God-given testosterone. Hurray!

That rule is....

If your friend is likes/liked a certain gal, you be nice and go fish elsewhere. But if you deem your friendship with that certain brother too shallow to be worth that piece of sheat that falls out of ur nostril, then please be my guest, go ahead and stalk her.

It's a rule i have lived by. And i think it's a pretty good rule. Treasure the male bonding rather than listen to the gonads, for they tend to lead you into temporary gain, but also a whole lot of trouble.

Note: Any semblance or inference to any person living or dead is purely coincidental.

Floaters:
It's hard to breathe
When i am near you
But it's harder to breathe
When i'm far from you
I toss and i turn
'Cos i pine and i burn
For you my love

My dawn
Awake fiery hot desires from within me
Color the darkness with your caress
and turn the dew into a field of diamonds

Vitreous:
Enough, friend
This be not the season
For wounds remain
and time has not revealed the fullest extent of the pain
That yet awaits me
6 winters chill i have been in love
6 months i have been out of love
My heart is not ready
Understand please
Friend

Floaters:
Summer rain kisses the flowers that bloom
Likewise i will pour out my love on you
Let your tears mingle with my own
Let me hold you as you sleep

Vitreous:
I speak to you as a friend
Or i will speak no more
For before me lies a door i cannot enter
A line i cannot cross
Push me no more
Dearest friend

Floaters:
Shall i await the day
When you conquer the army of confusion and fear that besieges you
Will such a day come?
When will that be
And how will i know
I don't want to wait here forever

Or i could take you and draw you near
Reach through the door and pull you through
Could i hold you close
Kiss away the sorrow from your eyes
Melt the cold sorrow with the passion within me
To hold you as you struggle
as you flail away
Against memories that stalk you
Against fears that taunt you
Could i brush my lips against yours
Run my fingers through your hair
Whisper "i love you"
"I will treasure you..."

Vitreous:
I will speak no more
You have a golden heart
But i have no need for such a heart
This spring song has been sung
Before winter has passed
You seek to awaken desire before its proper time
I long to be free
Yet with your love and passion
You seek to bind me

I would have you as a friend
But I do not want to torment you
With desires and dreams unfulfilled
So I bid thee farewell
Begone
You will find another lass
For whom you can compose another poem
Another song

Who knows what tomorrow brings
Perhaps love
Perhaps sorrow
Perhaps everything or nothing
Perhaps we will be together then
Perhaps we won't
Perhaps we will take turns bouncing grandchildren on our laps
Perhaps we won't
Who knows if tomorrow will even come

Floaters:
There are many fishes in the sea
And we are best, you and me
If i had met you in a different ocean, a different sea
I'd have pulled you through that door
Convinced you
And loved you for all eternity
But alas, this is not to be
I cannot pull you
I can only wait for you
And be happy
On my own

As little children we would pick up those lil' stamps or stickers that we found, encase them like jewels in ornate books, and pick at them ever so often, like they were the most precious things in the world. Back there and then, that was all that mattered. Our primary goal during free time, during shopping excursions, would be to seek out more of such rarities. Never mind the fact that they can be bought at NTUC, at the price of a couple hundred for $5, or that there will always be more stamps and stickers than we would ever be able to collect. And those first day covers... oh my goodness, they are so sexy i can't breathe.

Somewhere along the line we got bored... we got distracted by cute gals with long straight tresses, or cute guys with their floppy mops that passed off as hair. Somewhere along the line, more "important" things cropped up, and our childish treasures are chucked away into a corner, to be visited by us only when our soul is released, in our dreams... in which we were young and carefree again. Such dreams disappear like shadows with the break of dawn... and we forget... again.

Back in Waffles Institution, i remembered hanging out with the geeks of my batch as we went hunting for stamps in chinatown. We had $150 to spend, courtesy of donations from the Old Rafflesian Association, (so please dun ever donate to them). We sipped expensive tea in old musty buildings and gawked at stamps and splurged our $150. Then we kept the stamps in some books and left it in some room, in some corner of the school, never to be seen again. Yep, i am a geek... for about 2 weeks... haha.. got bored q quickly.

Stickers and stamps.... symbols of that childlike part of me... thot it was all left behind me. Then i realised that they never really disappeared... they had always been stuck to my behind. So burn baby, burn... with that enthusiasm and zest that sets the world aglow. You are more than you know.

Just returned from the first day of the houseman orientation programme. Learnt BCLS and all that stuff. Lectures were boring, but tried to keep awake cos i realise that i would need the knowledge in the future.

Can't believe that the dummy can be so zai... can tell me whether the depth of my chest compressions and the volume of ventilation that i was given is sufficient or not. Had to take 2 attempts to pass the 1 man CPR station cos i didn't fully relax when i was doing the chest compressions. But the tester was nice enough... a Mr Tan. Gonna try to take the effort to remember more names now... think it's nice to remember ur patient's names during the ward round or if u bump into them out there in the streets, not that i will hit the streets very often from now on anyway.

Any highlights of the day?:
1) My wacking my baby dummy's head loudly on the table when trying to save the bugger from choking
2) Was supposed to be paired up wif JS during the relief of choking demo... haha... of cos she refused to act the obese or pregnant lady. Wonder what would have happened if it was Chris instead of me.
3) Freezing in the auditorium beside lihua n leslie
4) eating rice cracker coated wif pork floss wif amelia n lihua and spilling crumbs all over my new polo T. Dun ask me if polo T is real. Me comin from thailand doesn't mean its 200 baht. It's actually 140 baht.
5) The soya bean drink was lovely... esp when it's cold.

Got some thinking to do... something that has got to be done at transition points in life.

Still sinking in... the fact that i am now qualified as a doc... still got a lot to learn tho... but at least i've made the first step.

What did i do today?

Jogged with zL at cheena garden.. did 4 to 5km and ended up with stomach cramps and felt like puking. Guess i am really getting out of shape. Spotted a fat swan tt would look pretty cool on my dinner plate. Saw 4 small komodo dragons with their long whip-like tail. Pretty cute, tho i dun dare to pet them cos i've seen what i think is mummy. And mummy is pretty huge, and moves pretty fast. Heard that their bite is deadly, and they then wait for the victim to die, n then they drag it to one corner to let it decompose as they slowly savour the acid taste of rotting flesh in their own time.

Saw lots of pink flowers on the ground. Did stuff bordering on being gay, like take photos of each other wif my cam phone. Then we whiled the afternoon away killing monsters on PS2.

Went for my best fren's bday at night... ate at Al dente at the esplanade. Pretty romantic place. My fren's fam was there, and so was the sister's boyfren n her 2 kids... real cute. Had trouble ordering cos the there were too many french words man... the boyfren is a TV producer and so i tried to get myself a date with Fiona Xie, but he said she was too busy. Guess it's too bad for her then... prob zap zap zapping her fu bu4 with the U-zap.

Most of my frens are busy with work or exams. Time to get a dog... or wait... even better... get 2 dogs.

It's nice to do nothing, to wake up at whatever time you want, and to feel bored with nothing to do, like back during the hols in pri and sec school. Bet i will miss this feeling.

Swam jus now... soaked in a bit of sun to get the needed Vit D, then watched another 3 episodes of LOst season 2. Wonder how it's all goin to end.

Apart from that, i fixed up my PPC and reinstalled most of the programs that i 'd lost jus prior to the MBBS exams.

Cousin's daughter still around. Think the mummy went back already. Thought i saw her cry, she's only 13. It must be quite a frightening experience stayin in another place by yourself when you're so young.

Think i will sleep earlier tonight in my attempt to live a normal life. Maybe i'll wake up and take a jog tomorrow. =)

ok so far i din kena the viva, even tho i was prepared to go for one cos my short cases for medicine and pediatrics were really bad.

it's already the 4th of april and i have some 15 days left before the orientation for HOship starts, and abt 6 days before the release of the exam results. Dun really know what to do. Want to travel but the ticket prices are q ex to London where my fren is staying... will come up to 1.2k++ for airfare alone.

Prob go somewhere else, somewhere closer, somewhere quieter to reflect and consolidate b4 embarkin on the nex phase of my life. I dun particularly like transition periods, but i guess everyone muz go thru them.

Juz passed my notes and gave tips to my lil counsellee whom i waited for 1 hour whilst she was sleeping upstairs. In the end i had to get my black hairy fren to get the house number for me cos the handphone wasn't working... At the 2nd call then she picked up with a dreamy
"Hello..."
"Oi4, XXX here. I am downstairs."
"I jus woke up... very sleepy... I slept at 2"
Looked at my watch... nb, it's 10.40. We were supposed to meet 9.30. And i slept at 2 too.... and i dragged myself out of bed cos i am a sooper zai counsellor.
"Oi4, faster come down."
"ok... coming"
Another 10 minutes to come down. No choice lor... made her buy me breakfast while i told her how her mbbs would be like and sip and all that.

Ok, back to thinking of where to go... what to do... sianz...

Before something good happens, there's always goin to be a bit of pain.

For many of us mugging for our final MBBS, it's goin to hurt for a while. But in the end, it's gonna be alright.

I'm not used to studying so much, seeing so many patients and sleeping little. Should have been more consistent and disciplined. 5 weeks left. Would go on a holiday after that except that i have $3 in my bank. So i guess i'd jus stay home and sleep a week or 2 or hang out with frens. That's surely something to look forward to. Ooh... and i can start finishing LOST season 1 and Naruto and Full Metal Panic before working life starts 2 weeks later. So sad i can't backpack to Iran and sip coffee with a terrorist or 2, and watch a nuclear fall-out in all its brillance.

All the heart sounds that i am hearing everyday are merging into one big throbbing headache. My ESM and PSM now sound the same... so it's not true that things get better with practice. Someone remind me to dig my ear before the finals. Also have to remember to pick the mushroms out of my stethoscope.

Livers and spleens and kidneys... we hunt them down in the wards if they are palpable. Then we harass the patients into letting us press here and there. Paiseh la ah pek... we got exams lar. We dun disturb you nex time how to be good doctor to take care of ur grandson?? Ok. ok... we wun do PR... or how about jus 1 or 2? No, never mind, it's ok... how about 1? Ok ok...

My christmas wish is that we will all forgive one another, without waiting for each other to change.

That we will spend more effort to love each other, and less time feeling angry. Life is too short for that. If i were to have one last breath, i would tell my loved ones to always forgive... and to keep at it.

Forgive me, my friend, for often times i know not what i do.

The ATLS teaching in the morning was not as effective as it ought to be. The first lecturer came an hour late, and smoked his way thru... hey, i could have done that! And i would have thrown in a few more gross pics along the way and describe some horrific accidents to get everyone's attention. At least the nex 2 speakers seemed to have done some homework.

Studied in the library today... resisted the temptation to go home... which wasn't all that difficult cos it was pouring and the car's parked at the satellite carpark which would guarantee a nice cold bath if i tried to make my way there.

Lost my PDA stylus, super sian... cos i kept telling myself not to lose it for the last dunno how long. I guess it's back to using my fingernail to write.

Been driving my dad's car the last couple of days... realised one thing... i rather be driven than drive myself. Haha... think i'll have to either make a lot more money, or jus make less money and let the driver of the double-decked mercedes benz drive me around.

Surgical SIP at CGH is pretty heavy compared to the other hospitals, thanks to the Head of Department there. That guy actually din allow students last year to sit for their final exams cos they decided to skip the less than useful posting. I mean, if you're tryin to educate us, then put a bit more effort in revamping the system. What sounds good in theory seldom is that good in reality. Now, we feel like lab rats in white coats scurrying around looking tired and PMSy or jus plain bored sleep deprived zombies.

Renal tutorial at SGH by that nice old prof was swell. Nice guy, i'd like to buy him a beer, though i dun think he'll like going to places where the air-con is not strong enough. Maybe we can have unlimited tutorials as long as we give him air-con. Better check the TSH...

Other than that, the only other frivilous detail is that i had a proper vegetable dish for dinner for the first time this week. Before this, it was mee pok and instant noodles at home and other unhealthy stuff that actually tastes better. Seems to me that the bad things in life often feels better than the good... like how i feel like goin to sleep now even tho i haven't been studying. Watched Final Fantasy VII Advent Children, Tifa is *drool* sibei chioh. Think i will jus marry her lah, and stop being so picky. Then again, i can't really speak Japanese.

ok ok ... got to go do the laundry cos every1 but bro is in Thailand, and bro has a life outside... sigh... freedom does come with a hefty price tag.

All good things have got to come to an end. Looking back i realise i kinda enjoy it. Tho i would enjoy it a lot more if i didn't have to think abt the MBBS nex March. The team that i am with now is really nice... and the nurses are nice, even the phlebotomist is nice. Man, it's a lot different from when i first came. I can imagine doing this for a living... tho the calls are a bit sianz cos it messes up the routine and ur body clock.

Made a few new frens here... on talking term with some others. I see dead people. Really... i see dead people. And i guess that i am not as numb to it all after all. I feel it, but usually a little later as usual cos my heart takes a while to catch up with my head nowadays. And i say a little prayer for their family and every person who i come into contact with during the day. That's the way i keep my heart kinda tender amidst the sobering issues of life and death that come my way. It'd hurt more, but it's good. I will not be jaded and apathetic.

Not studying much at all... no mood, no energy... got hatchet facies everytime i try... and i get Stoke Adams attack and find myself waking up to alarm the nex morn. Took to swimming everyday... a cure for every stress and pain in my body cos after that, I am distracted jus thinking abt how to get my runnin nose to stop.

Watching the prince turn frog on channel u. Love the silly sound effects man... never fails to crack me up. And find that ye tian yu gal kinda cute haha... good thing got subtitles.

ok nose killin me...

The last couple of weeks have been a real pain... cos SIP started. Kinda hate it when the school admin decide to use us as their guinea pigs in their attempt to make NUS Medicine world class. I do agree that there needs to be change. But some of the changes dun make sense. We dun need to get used to suffering as a HO. No need to make us go thru 2 months of SIP for that. Jus teach us what is necessary and let us go home and study... not waste our time. Or if you are going to make us do sai4 gang1, then at least give us a pay worthy of sai4 gang1 warriors tt we truly are.

Haven't studied much at all, and prob will fail if i take the exams now. But on the brighter note, i am more able to do the stuff tt nurses and housemen must do... like take blood from small tiny veins on patients who look like they dun really have all that much blood left to give.

Seen patients die in front of me. Getting kinda used to it liao. Doesn't bother me all tat much anymore.

The setting plug part bothers me more than seeing dead patients. Me think weirdz.. and tok Farnie... losing?? it#?? I get more upset abt causing patients pain when i bump a vein 1 2 3 4.. times than when i see them pass on. Prob becos i think tt that's better for them... a release from all these sufferings tt plagues their bodies while they are still here. There is no dignity in dying, no matter how we try to make it sound better. There is only dignity in living, and in death. The process of dying isn't cool at all. there is nothing glorious about having to have ppl change ur diapers, shower you, feed you. there is nothing nice abt having a brain wrecked by many many infarcts such that you no longer recognise those who are closest to you. You have dementia. You get depressed cos of the pain, and the many diseases that are feeding on ur body. You feel tipsy half the time and can't really get up cos of the side effects of the 10+ medications tt you have to take in order to prolong this "life".

Let them go when it's time, and delay not the passage. For the children that seek that delay will only the good of themselves, to appease that guilt striken conscience tormented by regrets of never having known their parents, or putting careers and material things above relationships.

Night calls, i love night calls.
The HO and MO i followed were super nice. Then again, i purposely follow those who are nice lar.
Did the usual: clerk cases, set plugs on juicy veins ooh... take bloods... do ECGs....

Met a hainanese ah ma who din want me to take her blood. Searched the ward to find someone who knew what she was saying... couldn't. Decided to go ahead anyway cos the bloods are to check her heart and it's pretty important.

Ah Ma, tam po4 tia hor! i hoped she understood a bit of Hokkien. She started shouting at me... the rest of the ward stirred. Everyone else was asleep liao. I din know what she was saying but it din sound v nice. Guess i dun want to find out. Then she started talking to someone behind me. I looked behind and saw no one... But she's looking at someone... oh man... oh man... not good. Let's get this over and done with...

Ah ma has low threshold for pain like some people i know. Screamed and pulled her hand away. Blood oozed out of the puncture wound i had made.

Ah Ma, mai4 ting tang!

Ah ma scolds me back and tells her invisible friend about me... i dun know what she is saying. I try again... another movement, another push, another hole to plug with that alcohol swab until the bleeding stops. I can't believe this... getting fed up liao...

Ah Ma.... i tried to look fierce to scare her. Used to work on other patients... but not this time. Ah Ma believes she and her friend can make enough noise to drive me away. They are wrong... cos i very stubborn one. And the bloods are for cardiac enzymes. Only thing i scared of is that she will have a heart attack.

After plugging 3 holes, i decide to use brute force and pin Ah Ma's hand down so she can't move it. She started crying... i felt bad... first time i force myself on a gal... shouldn't lar, even when it comes to Ah Mas. I sighed... and got down to taking the blood. Had to sayang her after that.

Apart from that interesting encounter, i also set a plug for a 150kg ship captain who jokingly threathened to pummel me if i dun get it right. He also said he knew it was a bit hard for me cos his skin is dark. And said tt the gal who last tried it went off crying. I jus took it as an exaggeration. Prayed really hard to get it right, and i did... amazing cos i usually cause a big hematoma haha... and this time it's like going in blind also cos can't see can't feel. Then he decided to chit chat with me and i din noe how to say no to a dude whose forearm was bigger than my neck. Listened to his stories abt sailing here and there, and abt his exploits with women from all over the world, tho he qualified that he's gotten married and have settled down already.

It seems that sick male patients love to talk abt their sexual prowess. Had another patient who had 22 children from 7 wives with ard 8 gathered ard him. He went on and on telling me abt the girlfriends he had from this district and that district in the most wonderful country in the world, where i come from. I think 1 is enough... too much headache la...

Last patient i saw had heart failure, bumped a vein ... *again* and saw darkness spreading... like some horror show.
Uncle, you taking warfarin ah?
Yah, i taking...
Oh sheeeeT!... i press the wound site for dunno how long. But it still looked real bad.
Sorry uncle.
Never mind.
And i felt even worse.

When do you know if your mole or that thing on your skin is bad?

A: asymmetry
B: border irregularity
C: colour variegation
D: diameter >6mm
E: elevation
F: fwah... Itchy.... Must scratch

Risk factors:
Congenital naevi >5
Multiple naevi
Dysplastic naevi
Heavy exposure to sunlight
Tanning
Family History
Fair complexion
Immunosupression

If you have this, dun get pregnant and dun take L-dopa.

Types:
Lentigo maligna: ah peh's face 10%
Superficial spreading 70%
Nodular 15%
Acral lentiginous 5%
Ocular
Only the nodular type spreads vertically.

2 classifications:
Breslow: based on LN
Clark's: based on depth of invasion.

Prognosis:
Female better
Trunk worse
Mets means you are confirmed dead. Mets to brains lymph nodes lungs. Can be non contiguous.
No spread means 70% survival at 5 years.

73 year old male, chinese known to have DN HTN and stroke, comes in with history of jaundice, pruritus, tea colored urine for 3days. Says he bruises more easily nowadays. No pale smelly stools that float up. No vomiting out blood or passing dark colored smelly stools. No SOB or feeling lethargic and faint.

No loss of weight or appetite. Says abdomen a bit more swollen but can't really say.

Risk factors: drinking 500ml of beer a day for the last 50 years, smoking 10 sticks for 50 years. No sex with CSW, no drug abuse with needles, no transfusion.

Med hx: left sided stroke that resolved leaving only a slight weakness that does not impair his function. HTN DM no high lipids.

Meds: warfarin, gliben, atenolol, amilopidine, famotidine.

Fam history: son has stroke.

PE:
Jaundice, no flap, no spider naevi, fetor hepaticus, no gynaecomastia, no visible veins.
mass in right hypochondrium 4 cm below costal margin. Firm not hard, smooth surface moves with respi, non tender. Abdomen distended but percussion note resonant throughout. No shifting dullness. No palpable kidney or spleen. No pedal sacral edema. Din check iguninal hernia or do PR.

DISCUSSION

Am quite a pock cos I couldn't tell the diff between a gallbladder and liver. This was a case of a gallbladder. No murphy's. The tell tale signs were all there. A liver that's causing such a jaundice would be cirrhotic, prob from alcoholism. There would be signs of portal hypertension and CLD too. In this case, the liver hardly felt cirrhotic at all.

This means that the jaundice must have come from an obstruction. Blood causes like ABO incompat and Thal would not give you a soft liver. And he was 73.

A cholestatic jaundice with an enlarged liver can mean some liver damage. The jaundice is for 3 days.

A cholestatic jaundice with an enlarged, non-tender gallbladder. This is bad news. Courvourseir's law. Stones dun give you large gallbladder cos it causes fibrosis, and the gallbladder can't enlarge.

Take home message: beware of a "liver" mass that feels otherwise normal in consistency in the presence of such a jaundice. The liver will not have a normal consistency if it is the cause of the jaundice. Always consider a lesion in the biliary tree... And remember that the gallbladder can get enlarged.

It was a cholangioCA. Risk factors would include choledochal cyst, onichorsis, primary sclerosing cholangitis.

Presentation is usually asymptomatic, or with jaundice, pruritus, plus or minus a murphy's. Special test includes CA19-9, PTC, MRCP.

Rx with biliary-enteric resection, lobetomy of liver. Distal lesions do a Whipple pancreaticoduodenectomy. Staging I in wall, II thru wall into surrounding, III in liver, gallbladder pancreas, IV main portal vein and in the common hepatic artery, duodenum, stomach, ab wall.

Prognosis:
10-30 % for curative resection of prox lesions.
30-50% for distal lesions.

Will put summaries from tutorials for the benefit of everyone. If you got anything to share, mail me! then everyone will benefit. Let's all work together yah?

Approach to the neck (medicine)

There is only one case that will overlap both medical and surgical tracts and that is thyroid.

Medical thyroid case is usually a diffuse goitre, whereas the surgical thyroid is usually a thyroid nodule.

Approach the patient from the front. Take off the shirt.

Look for:
-Fullness->is it symmetrical or asymm
does it cross the midline or can you still see the tracheal notch? If you can see the tracheal notch, then the bilateral fullness prob not the thyroid cos the thyroid will be in the midline.
-Scars
-Distended veins-> look at the location. Is it external jug or the internal jug? Look for waveforms. If absent, there is something in the svc within or without that blocks the transmission of the impulse from the heart. If it's present consider a pathology on the right side of the heart.
->check the patient's eyes and look at his fingers for tremors.

->nex check in case got thyroid by asking the patient to swallow and to stick out tongue.
->check for tracheal deviation first, then go on to the back.
->after you are done looking, feel the mass from the back, not the front or you will fail! Remember to describe site size shape surface sound(bruit?) surroundings(LNs) colour consistency mobility tenderness
->check LNs. one of the most common causes of SVC obstruction is enlarged LNs due to lymphoma. Know that hodgkin's is contiguous LNs and non Hodgkin's is non contiguous. So check the pattern of LN involvement and offer to palpate the spleen and other LNs.
->percuss for retrosternal thyroid, LNs, masses.
->auscultate the carotid or the mass if found.

Know what can give you svc obstruction: inside will be thrombus, outside will be stuff like LNs, retrosternal thyroid.

Differentiate between svc obstruction and thoracic inlet obstruction which will produce additional signs like dysphagia, SOB. Causes of thoracic inlet obstruction are many, and include Pancoast tumour, cervial ribs, mediastinal LNs.

Pemberton's sign actually exaggerates both svc obstruction and the thoracic inlet symptoms.
->if you suspect that is some svc obstruction or TI obstruction involved cos the dude looks plethoric, dyneic, sneak a look at the arms if you haven't already done so from the foot of the bed during that 15 sec of staring, and note the swollen hands. Also look at the dilated veins on the arms and the chest. Check the flow in the chest veins and say that it is downwards. Remember that it will be upwards in the case of portal hypertension.

I will try my best to remember my lines tho I still dun have the complete script! My pock indian fren sent me only half the script...

let's go umpa loompas!. It's our last year so we might as well go have fun make a fool of ourselves. Love the way we escort the contestants on n off the stage. n tweedle dee n tweedle dumb was hilarious as well.

Just got back from school not too long ago after dance practice and rehearsing my little short scene. Beat out tired as usual but I am beginning to enjoy the feeling. Think I might be weird or something.

My indian bro is as funny is ever... The one with thai blood that is... Though he wouldn't admit it. Cowol acts well too, a little fierce but tat suits the role well. Ewin is a farnie as ever... Damn natural at everything, and the cryng part is still the best. Aint seen anyone do it so well. I am supposed to be a smeagol like character, a bit psychotic and leacherous. Pretty easily to act... Yes, I have to ACT. Got one embrace seen wif ewin, hope they cut it out; dun wan to be taken advantage of, haha.. No la, jus feels weird. Last year last chance to get involved, and yet, my first time acting for the class play though I have done it many times in the past... Which is pretty long ago... Year 1... Wa that's kinda long.

Ok got round at sgh tomorrow. Better ong ong or I will feel like crap by morn.

No time, no time, no time... The previous week was like woo hoo! Hardly a breather anywhere as i tried to juggle neuromed and paeds, and ended it off on sat giving a presentation and singing in front of 200 doctors in the ballroom of Laguna golf and country club. Life doesn't get more exciting than this. But i really ought to get more sllep. And i am far far away from finishing Talley or Baliga. In fact, i only read thru the neuro chapter of Talley, and even then, briefly. No time to blog either... gotta go out for buffet.

We love Ian, but Ian only love 2 of us! 

I dun know where this came from... some1 kop4 my ppc to take... looks a bit like baby's underwear. 

A lonely nite studying in school.... 

Wa, that Dr BL og is back... really glad, cos i really missed the entries when it was gone. Worse, i dun like the fact that some hospital can shut down a blog whenever the CEOs or some1 with unresolved issues feels threatened by the content of the blog that was meant to be farnie.

Am running between KK and SGH again, trying to crash some paeds tutorials and get some knowledge into my head while i still can. I always ask for permission before crashing... tho i never really wait to see if permission is actually given. i mean, everybody loves me mah...

Man i am deluding myself... like how i think son ye jin talks to me every morning, and jessica alba is sending out secret messages in the crossword puzzles in the straits times everyday. But unlike John Nash, i dunnoe what's the message cos me IQ not as high as him... She is saying something she says she laughs/loughs knee/tee/hee/nee or something.

Also trying to settle the log book by the end of this week. Think it might be possible... jus maybe...

See the seniors around who are housemen/women liaoz.
On one hand i feel better about the exams when i see them: chey... they can i also can, since they seem jus as blur as me...
On the other hand, I feel being a doc q chum... really whole day bin chao chao... some look like they never eat cos the patients steal their food. Some look like the big bad menopausal nurses giving them a hard time. Some look like they are entering puberty again and their faces are erupting like volcanoes spewing out sticky gooey white lava. Then again, i might be imagining all of it, these are probably not the people i knew. They jus happen to look almost identical, and sound identical and have v v familiar names.

But i guess that when it comes to our turn to be housemen, it won't be so bad anymore. Cos thanks to some big shot's wife our class is now almost double the size it was some 5 years ago. That means more people to do the work and share the calls. Am i glad i am in this cohort!

A whole host of things seem to be happening to the people around me in church. Family problems and fights that require police intervention, deaths of loved ones, heart aches... I am not the only one. It's funny why it's all happening at once. It's as if we were about to embark on a new phase of our journey, an all-important phase, and some1 who's really bad doesn't want us to go anywhere.

Now, another earthquake in south Asia has just resulted in over 30,000 dead. Tough times. I wonder how many wake-up calls the world needs before people really start to live differently.

Ok, my agenda for this week:

1)Not worry about anything. Just do it!
2)Get my paeds logbook settled
3)Study finish Talley o Connor and Baliga... (there can be miracles, when you believe)
4)Start exercising again after resting for a couple of weeks for my arm to heal.
5)Settle the worship leading and the presentation for the christian doc's meeting this coming sat

Let's rock dude... it's you and me... we'll get thru this...

Funny how the people who are closest to you can end up hurting you the most. Then again, it aint that funny and it happens everyday, jus that ppl like me have been spared that painful reality for q some time that we forget. Eg. Ppl with alcoholic dad and mums; fave uncle who turns out to be a paedophile... nope din happen to me like that... my tale isn't tat tragic yet.

Now got a broken bedroom door to fix... wish i could say tt the damage was caused by some chio bu who was v v v eager to meet me and wouldn't take a "no" for an answer. Wish i could tell the whole world that i am sooper zai, got lots of self control and principle and wun take advantage of SYT-sweet young things who are lonely and find me sexier than brad pitt... but i can't... Wish tt i wasn't so delusional heh...

Door's broken, door-knob no longer works... and i realised that the material that was used to make the door is damn lousy. Break so damn easily after what... 2mins? Will get teak nex time in case someone tried to disturb me and my wife when we are making out. And teak transmits sound less heh heh...

Wood fragments are strewn across the tiled floor. Angry words splashed carelessly onto hearts that too easily soak it up, cos hearts have been waiting and longin for tt affirmation tt was slow in coming. And tt's why it hurts. That was why i stayed my hand and voice, and stilled my heart... where i would have bashed up the other guy on the soccer field.

Sticks and stones can break my bones but words can never hurt me.

The generation of kids who really took that bloody rhyme would have repressed all the Baaadd feelings and end up depressed, suicidal or homicidal. Or they would have done the worst thing possible to themselves and changed their gender back and forth a couple of times, or married a gal who cuts herself routinely for fun.... or they would have studied medicine to become surgeons so that they can cut up people and bleed them without getting charged in court for it.

Me? I just have a good cry 2 weeks to a year after a traumatic event, cos my emotions have a mind of their own haha... i dun understand either.

Wa very shiok... i got a week's break. If you can call it a break lar. Raining cats and dogs out there, and i get a cremasteric reflex all the way back into my abdomen when there is thunder. If it was any scarier i might cough them jewels out.

Fren came back from overseas... at least now i have an excuse to slack a bit more, dota a bit more, and eat a bit more haha. Feels nice to be a normal singaporean dude out somewhere in orchard window shopping and looking at ppl's galfren and trying to pick up a fight. But my right arm not back to normal so i wun try anything too farnie. maybe i should bully the small 15 year old punks whose ego is way bigger than er... nvm.

Really miss that man, hanging out... nex time only got the nurses, but i dun wan to bring my work home... so no nurse for me, tho some are quite cute...

my fren who was hospitalised before met his lil angel there. I not sure if the gal really as chioh as he said she was, cos when you are taking farnie drugs and jus came out of an op and have only the talk-non-stop ah peh to talk to, i think even the head nurse who weighs like a cow, and moonlights as a female bouncer at mohd sultan there can look soooper chioh.

Think i am in a funny mood. a bit guai lan.... need to beat something up... or maybe i jus need to sleep...