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...