madDoc

2010-06-14T07:48:00.000+08:00

Case study

2006-08-14T20:35:00.000+08:00

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.

Choices

2006-08-13T19:42:00.000+08:00

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...

A little story: Max

2006-07-17T18:21:00.000+08:00

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.

How do you love someone?

2006-07-12T22:51:00.000+08:00

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

RULE

2006-07-05T23:16:00.000+08:00

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.

2006-07-04T21:05:00.000+08:00

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

A little story: of stickers and stamps

2006-07-04T20:39:00.000+08:00

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.

BCLS

2006-04-23T18:00:00.000+08:00

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.

ME DOCtor!

2006-04-13T00:29:00.000+08:00

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.

Slack slack

2006-04-11T23:31:00.000+08:00

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. =)

Exams over

2006-04-04T13:34:00.000+08:00

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...

Birth pains

2006-01-26T20:45:00.000+08:00

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...

Forgiveness

2005-12-21T21:14:00.000+08:00

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.

Study study

2005-12-05T20:56:00.000+08:00

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.

Zoom zoom

2005-11-24T21:10:00.000+08:00

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.

Fly away amidst some rain

2005-11-21T10:25:00.000+08:00

Dad flying off. i thought it was today... guess not, it's tomorrow.
Mum and sis flying off today to thailand to be his Fed Ex wrt to his
journals and books that have decidedly rooted themselves in the living
room, taking up > 1/2 the space there. I think with the luggage limit,
there will be an increase of less than 5% in floor space.

Raining now. Would be more pleasant if wasn't for the fact tt i am
unsettled by my dad leaving us to work in BKK. Would be more pleasant
if i could actually sleep. i couldn't... so ended up whiling the night
away trying to kill the Illythid on Neverwinter Nights-Kingmaker. Died
like >10x cos i was a wiz and he was immune to everything. Should have
been a monk or fighter. Should have stuck to the Sims. At least i will
have some progression in plot there ...

A bit cliche, but there's a storm brewing within me. I feel the need
to hide away lest i hurt someone by what i say or do. Need to find a
cave. There i'll await the virgin who will soothe my weary heart; or
i'll be slain by those who seek me out prematurely.

I say a lil prayer
For someone to hear
It's fetch up to the heavens
And replied with showers of tears

Why is this so
I don't know
What happens now
Anything goes
Won't you
Will you
How to
Love me
Love you
Help me
Help you
Seems like the path is closed
Answer is no.

Wondering if this will work

2005-11-20T12:18:00.000+08:00

Tryin to find out if i can blog via PPC. Cos my sis plays Neverwinter
nights and i dun get to use the com most nights haha...

Anyway, slept most of the weekend away as usual. Had a fun night out
with the guys on Fri when we did the only thing we knew how to do,
something that gals , well most gals shy away from. It involves some
percussing, some trichillomania (is that how you spell it?) You
guessed it.. it's DOTAing... the very thing tt is hitting singapore by
storm. NS boys and officers suddenly become best of friends in the
office and stay back late voluntarily every night, making bosses very
happy. Wives suddenly find that their husbands are away so very often
with meetings and start to wonder whether there is a 3rd party. well,
the only 3rd party hacker who came up with the no-cd crack.

Anyway it was a good time of dotaing, with the juniors joining us. Did
quite ok till we got a bit hao4 lian4 and randomed. Then got their
star player shanhan, and we died jia lat jia lat cos we all actually
play like 1x a month only.

I think that girls who want to get to know their boyfrens/husbands and
spend more time with them and are afraid of them straying shoud pick
up the game. They can play as the syllabear and summon the cute white
polar bear and walk the bear ard the firebush and the fountain, and
take excursion down to the secret shop wa ha ha... and stay at level
1. Just have to warn them not to walk into the neutrals.

ok... let's post this and see if it works.

SIP medicine is ending

2005-11-17T20:25:00.000+08:00

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...

SIP... busy busy

2005-11-10T18:52:00.000+08:00

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 call

2005-11-08T19:08:00.000+08:00

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.

Moley moley moley

2005-10-23T03:34:00.000+08:00

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.

a lesson from an abdo case

2005-10-22T01:47:00.000+08:00

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.

Approach to the neck

2005-10-22T01:03:00.000+08:00

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.

Playhouse

2005-10-21T02:30:00.000+08:00

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.

Smeagol???

2005-10-20T02:35:00.000+08:00

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.

Ending of a weekend

2005-10-16T17:04:00.000+08:00

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.

Where to go... where to go?

2005-10-13T19:08:00.000+08:00

Dunnoe where to go these 2 weeks... supposed to be at SGH but i really need some lessons on paeds so i am crashing KK. Feel a bit paiseh but what to do. NUH can crash also lar but think it's even more crowded than KK.

On the brighter note, i have managed to get most of my log book for paeds done up, and only need to look for one more doc in NUH before it's all done! Think i will pop down to NUH nex thurs when there is CTS, or when we got for the SIP briefing on Fri.

Cases i saw today... Duchenne's, one complex heart disease, one nephrotic syndrome with possibly ballotable kidneys (or i might jus be doing fluid thrills anteroposteriorly), one urticaria pigmentosa with hepatosplenomegaly. Not too bad for a day's work. Need to practise the examination.

Dr Tan Ah Moy's real nice.. asked her to fill up my log book for me, and she was like, "I remember you!" Waited for her to say more but she didn't, so i guess it might have been on TV via Weakest Link. She asked lots of questions like how long have i been here in Singapore, then told me "ok i write for you, hope what it says is true lar!" (Think she doesn't remember me after all.) Ha ha, i told her can lar, that i am quite a hardworking student and good student and very enthusiastic. Man, wish more docs are as friendly as her, then the medicine wun be so stressful.

Feel a bit bad not going to SGH, leaving ZL to shine there like a supernova, but i really need paeds... and he doesn't want to trouble the ppl here i think. Will go down tomorrow.

Going to put up more pics from now on... of actual people, and friends and whatever i come across with my PPC.

2005-10-13T18:45:00.000+08:00

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

2005-10-13T18:38:00.000+08:00

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

2005-10-13T18:26:00.000+08:00

A lonely nite studying in school....

Dr BL og is back! Looking at my seniors

2005-10-11T20:25:00.000+08:00

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!

Brave new week

2005-10-10T09:47:00.000+08:00

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...

It's funny anyhow

2005-10-05T21:27:00.000+08:00

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.

1 week Break!

2005-10-03T23:19:00.000+08:00

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...

Personality Test....

2005-09-27T22:43:00.000+08:00

Your Personality Profile

You are dreamy, peaceful, and young at heart.
Optimistic and caring, you tend to see the best in people.
You tend to be always smiling - and making others smile.

You are shy and intelligent... and a very hard worker.
You're also funny, but many people don't see your funny side.
Your subtle dry humor leaves your close friends in stitches.

For less than 10 sec of my time, it was better than i expected.

The World's Shortest Personality Test

Scary scary....

2005-09-26T22:36:00.000+08:00

Boom boom.... sound of the metal door shutting resonates thru the narrow corridor. You are in ward @#, the forensic psychiatric ward. The patients here have done something wrong and will be charged in court. You wait for security to clear you, and pass in thru the locked door. The cop brings you the patient for you to interview.

You nervously arrange yourselves in a horse-shoe around him... make the tentative small-talk and start the clerking. Midway, you notice the paper clip on the table and realise that small as it is, it can lacerate ur carotid. You imagine what might happen and signal to the tall friend on ur right to remove it from the table before the patient gets any farnie ideas. Then you realise that he can do the same thing with the pilot v5 pen that the gal who's right beside him is holding. Then you look at the size of that forearm and realise that he doesn't actually need a pen at all.

Then you look at your friend and try to remember what you like about her, and the 4+years of friendship that had developed... You recall with a bit of nostalgia the dissection of the indian dude in the anat hall as another colleague tastes that dead bit of flesh that accidentally gone flung off... You recall the times when you get scolded for not knowing this and that cos you happened to use a diff anat text from the Profs... You remember that you had to do stupid powerpoint presentations together for some picky anat tutor... You remember drawing blood and setting plug on each other and wasting a lot of AH's resources as you kop stuff from their store to figure out what they were used for.... You remember...

But actually there is little need to do so... The patients in there are sedated, and most are your average joes who suddenly develops a bad temper or hears voices telling them to run through a protected area to stop a tank or plane and ask for help from the ghosts that haunt them. The patient never feared the guns and turrets that were trained on him when he leisurely strolled through the army base. But i bet the guards must have thought that he was a suicide bomber or something and wet themselves.

Another dude who is 55 told us that he played soccer with 20 malay boys at the void deck, smoked with them but didn't drink. Police came cos there was too much noise and he was arrested after he got angry at a policeman who told his mum to go somewhere in chinese (ahem, his mum was not around). Got arrested cos he was 55 and the rest were under 16, and also because he was the only chinese there. I forgot to ask if this happened in Malaysia... oh wait... it was in Singapore! In the car, he told the cops that he could take their gun and shoot them even though he was handcuffed... so the cops got really really scared that the old man at the back might actually do it, and decided to give him the 2nd charge, the 1st being disturbance of public peace.

Had a history of going to the Bermuda Triangle to be a cook for one year. He said it was a british colony that had a lot of blacks. Had to return cos his brother who went with him got addicted to gambling. Said his relationship with his wife was good. No $ prob. Sleep only 5 hrs a day, felt more happy recently but no flight of ideas or pressure of speech or grandiose delusions, or easy distractibility. No family history, no medical or drug history. Never felt sad apart from over his dad's death some 30 years back.

I wanted it to be schiz cos that would be so cool... I wanted to find out what magic powers his 20 frens had, and whether he could still see himself as he entered the bermuda triangle... aren't there a lot of ship wrecks there? And ooh... did he really go with a brother? or is that brother the one that the rest of the family never talks to, never acknowledges, never ask about... has never seen... the one that always comes home with a bit of blood on the shirt... no, he says not him, it's the brother's shirt, his stains... (no, i am imagining it)

Turned out to be Bipolar.... the 20 frens and the triangle thing was actually real.. the sis said so... unless there is some fun family condition going on. There was separation from his wife, financial losses, 3 hrs of sleep a day, and the story of him giving treats to all his newfound friends... things we couldn't get from our history.

I wish to thank that cop out there for his help in keeping singapore safe from all the dangerous, handcuffed old men out there in the backseat of police-cars, and for having a sense of humour, and the common sense to realise that the old man was probably joking. Thank you for not venting your frustrations and taking your issues and repressed childhood feelings out on the old folks and and serving them charges. Thank you for overcoming the sense of insecurity and the fact that you never got hugged by your mum and dad. You are a wonderful cop. I wish you and your mum the best. Dun worry, i won't tell her to go anywhere... pls dun charge me.

A Little Story: Lil Babe

2005-09-23T20:37:00.000+08:00

What are the things that you remember when you were little? What were the things that you told yourself not to forget, and you still haven't? Those were the days when everything seemed vivid and clear, less clouded by the myriad of emotions that assault one's sense, and impair the registration of our sensory perceptions, and leave one unable to really remember anything, anymore.

I remember that i liked the nurse's voice better than my mum's when i was jus delivered. And i cried when they handed me back to my mum. But of course that sounds absurd... but i thought i remember it that way.

I remember that i was bored of staring up at the white ceiling in the room where i lived, and thus i decided to roll to the side to look around cos it's hard to look at anything when the pudgy neck gets in the way. And after i got tired of rolling from side to side, i decided to roll over till i was in the prone position so that i can take a better peek around from an elevated position.

I remember hating the feel of plastic against my skin. I needed some cloth in between, or the sweat and pee will get really icky.

I remember laughing at people holding up their mugs to their mouths cos they looked silly. And suddenly, there was that moment when you knew you were a thinking being... there was revelation that night. I realised that i drank that way too, and looked silly too. I didn't laugh when people were drinking after that day. I was 4.

There's so much trivia to dredge up... i will leave some for another day. =)

"Sianness..."

2005-09-22T17:06:00.000+08:00

Doing this posting makes me feel like i got a lot of issues man.

For one, i get sian everytime there is a test... the sianness is usually rather sudden in onset, and increases progressively over the course of the nex 1-2 weeks. Sianness is dull in nature, like a toad that's sitting somewhere on top of my head and i am afraid to brush it aside cos i am afraid that toad will turn to elephant dung the moment i touch it. It radiates into every facet of my life and i sometimes dun feel like studying, which is something that i usually enjoy very much. It doesn't affect my sleep, appetite or sex drive (i am still equally frustrated).

Aggravating factors for this sianness include life events like harbouring a growth or 2 in my anatomy, growing a new skin tag (no, it's not a wart and i am a poor candidate to ever get STD for obvious reasons), seeing an innocent young blackhead evolve into a nodular-cystic acne and then feeling the angst as i detonate that fragile structure only to live with a box-car type of scar some 2 weeks later.

Other aggravating factors include relational conflicts or the lack thereof, with dad... it's complex. Losing my logbook sure didn't help, nor did the hassle of runnig from department to department getting ready a letter to say that i had lost it. And the real drag of getting all the IC numbers and signatures of all the doctors hasn't even started yet.

Relieving factors include praying, reading Bible, and pontanging class to DOTA, and i have a good game.. which is quite hard since bloody HJ is so good at jugg. Other relieving factors include DOTA, DOTA, and DOTA... and DOTA. HA's solution of pcc tds would only temporarily assuage the sianness, n leave me feeling more sian after that. Swimming really helps, and i used to swim everyday, but now cannot... not for a couple more weeks at least. Ms YPL and LH's retail therapy works... but i got no money now cos my retail therapy usually involves me spending a whole lot of money at once buying some gadget... playing with the new toy would help, but that monster is sitting at the HP service centre right now... how not to sian?

I am wondering if i got dysthymia...
1)can't concentrate when studying
2)feel low
3)no energy

Can qualify? And since every posting also sian, and i have been in school for 4 years plus, so >2 years liao...

Gals! Gals! Gals!

2005-09-18T01:25:00.000+08:00

It's funny how ones tastes changes as one grows older. I had always been a sucker for gals with long hair, big eyes, long slender limbs, pouty lips and *ahem* who are adequately endowed tho' not overly so... I was into shy demure gals, then spunky quacky gals, then family oriented sorta gals, then now, not interested in gals....

Just kidding. =)

It was Winolda Ryder in secondary school, Faye wong in JC, then Zhang Ziyi, Faye wong, and more recently Jeon Ji Hyun, Son Ye jin...*drool* In school, well, there are the few that sometimes make me wish i was that textbook they are carrying...wa haha... I am not too good at spying and have been caught and sentenced to basement 13 in their version of hell liao, but the good thing is that i am not the only one in that basement. =) Got others who got there b4 me heh heh...

Now, things are a bit different. I guess i have changed. Sounds very cliche, but to me, looks are not that important a factor anymore. Notice that I did not say that looks are not a factor anymore, cos i still believe that i should be able to wake up next to some1 without going "Holy cow... what have i done???" and then spend the next half hour praying for supernatural power from above to love the person i am now stuck with for who they are, and not how they look like. I am not that zai a guy as to be immune to looks altogether... not yet anyway.

And i am pretty sure that i am not saying this because i am desperate and have decided to lower my standards. On the contrary, with (hopefully) 5 and a half months away from getting that MBBS, and new differin and retin-A cream to help my ok ok looks (by eradicating the evil cysts and nodules on me nose by preventing the comedones from ever forming in the first place), plus a pretty ok personality, i think i dun really need to worry lar.

So what's caused this change in my taste? Tt's in my other blog... cos the christian theme might not be for everyone.

Derm: end of another posting

2005-09-17T13:03:00.000+08:00

This must be my slackest posting ever... even more so than geri. Not that i should have been slack, but i had a couple of body parts to remove from my body so that meant that i had to skip some lessons. But the other stuff like going to see how warts are removed and how pimple scars are evened out with laser doesn't really interest me. And the docs in this posting... well, let's jus say that the community of dermotologists here at skin centre have a higher proportion of not-so-nice people who's moods seem to be associated with when their last cigarette smoking break was.

Example 1 The Father

It was our first clinic session. We go into the room, wait. He tells us nicely tt the ppl will come only in half an hour's time. We say it's ok we will wait. He leaves, i comment "wa, this doc v fatherly..."

Comes back... patient enters. Registrar with us gets up to take a closer look at the patient. We do the same. We kena scolded. "How would you like it if some1 jus walked up to you and looked at ur face without ur permission?" Muz agree with him that it's prob scary for ppl when i suddenly put my dao1 face right in front of theirs. But man... can say it nicely mah... and say it once lar... not go on and on.

Guess he didn't smoke that morning so he wasn't too happy. Maybe he din have time to polish the metal studs on his boots either. My fatherly doctor not so fatherly after all.

Example 2 Ice Queen

This lady is pretty cold. Din say hi... allowed us to join her only when we told her we've been scheduled to do so. Reminded me of FayeWong. But Faye was much prettier, and had a much nicer voice. This lady doc din say v much the whole session. Jus made me and me partner feel like we shouldn't be there cos we were wasting her time. She walked in and out of the clinic without saying a word. She didn't teach anything. And it was not because she was busy. The com was down and she sat ard in the room checking e mail and arranging some pics on power-point.

Makes me wonder why ppl do medicine if they din really love other ppl. And it was not jus us. She treated the patients v coldly as well. Think i should be dean of medicine with veto power over who can become a doc. Then the world will be full of female docs who are pretty and cheerful and really love their patients. =)
-------------

But all that said and done, there were also some nice docs. But i only met one really nice one, maybe cos i was on MC half the time, or on self-declared study break the other 25% of the time. Dr Lim gave me and my friend lots of free samples for Differin n some face wash. Differin is good stuff. Really clears up blackheads and whiteheads. I can hardly recognise my nose anymore. Gave me a prescription for retin A as well, cos i told her i got cysts that exploded on my face like every 2 weeks that was slowly shaping my nose into a mishappen object.

The most important lesson that i learnt from this posting is that whiteheads and blackheads lead to big red pimples that will result in scars. I wish some1 taught me this earlier. the best way to prevent big red pimples is to use the comedonolytic agents like differin or retin A. By the time you put Oxy, it's too late. But the reason why we can't buy Retin A over the counter is that it can cause birth defects if you're pregnant (i dun think i will get pregnant), and the mice that got this cream smeared over them kena skin tumours (tho no human reports abt this occuring yet). Another thing you should learn is that UV light deactivates the cream, so you muz use it at night.

I tried the night Differin, day Oxy regimen for me nose and i started having something like seb derm. Eyebrows shed... skin turned dry scaly oily and started flakin off leaving erthematous raw skin... but at least the blackheads and whiteheads fell off too, right... along with my nose and half my face.

Something beautiful

2005-09-13T20:33:00.000+08:00

Something beautiful is going to happen tomorrow. And i am thankful for it. If you know what's happening you may wonder why that is beautiful. It is beautiful not because i want it to happen. Nor is beautiful because it its pleasant. It's beautiful because i know that i can grow from it.

Choices... we all have choices. We all make choices. We can be crushed, disappointed, jaded, hopeless, angry at God, people, parents... or even ourselves. Or we can choose to grow, choose to mature. Choose the right attitude in order that we might be able to help others with the same problem in the future, who may need making the right choice as well.

Something beautiful is happening tomorrow. I may be scarred for life, or i may not. But the end result of tomorrow has already been decided tonight. I will be strong. I will live for more than me. I will live to help somebody breathe a little easier.

a little story: kindergarten

2005-09-11T12:48:00.000+08:00

Uprooting oneself from one country and going to another is never easy... especially when you can't speak the language, when you have no friends there, and when you are only 5 years old.

Amidst the nightmare of staying with a hot-tempered dad whom i met for the first time that i can remember, and trying to win the competition with my younger for my mum's limited attention and energy, I also had to go to k2.

Went to kindergarten at Xing Nan Pri School, now relocated to some place nearer to the rest of humanity. It used to be sited amongst pig and vegetable farms with a couple of graves here and here in the western part of Singapore. Used to be able to see soldiers doing their jungle bashing and ending up off course and in our lil playground.

Anyway, the time in kindergarten was a wonderful time for me, becos of the teachers and the friends. The first language that i learnt in Singapore was Hokkien, cos the people who sent their kids to the school were farmers, lorry drivers and other odd job labourers. Learnt normal words and a couple of flowery ones to impress my other friends, but of course not my parents who would not be amused if they knew what i was saying.

The english and chinese got picked up a little later, in about six months, and i managed to top my class for english... a pretty easy feat given the fact that no one else really spoke any english apart from the teachers.

In the first 6 months, since i couldn't understand anything that the teachers were saying, i jus spat and fought with the other guy in class who looked like a real crook. He tried to make friends with me by teaching me how to look at gal's panties while we were having a nap time in class, but i felt even at that young age that it wasn't right... so i saboed him, told the gal in chinese, who then complained to the teacher. We fought pretty often after that. But he got most of the punishment and caning cos my english and art n craft was better... haha... ter han i think, that's his name.

The gal whose modesty i preserved became my reason for studying hard in k2, cos she was the best student in the class and if i wanted to dance with her at the end of the year, i'd have to be the top in class too. So i made sure my drawings and colourings were super zai, and my writing super neat. Got to dance "A li san de gu niang" and a couple of other songs with her. We received our prizes together, and i gave her a flower... part of the dance... part of the dance.

But even at that young age, we knew it was not possible for us to be together. In all maturity, she told me that we were too young, and she was a year older, and it would be very hard cos her parents would never allow it. I had to agree with her. And so we parted ways. And since i was too stupid to ask for a home number, i lost all contact with her. I can't remember her name, which is not surprising since i forget people's names 30secs after i get introduced to them.

So I loved my kindergarten, enjoyed it a lot more than Primary school where the stupid syllabus really ruined creativity, and the teachers seemed too preoccupied with discipline to really befriend any student.

What's your kindergarten story?

Excursion

2005-09-09T21:36:00.000+08:00

It was a really educational day. Felt more like an excursion. I started by persuading my body to get out of bed in the morning, and it did so reluctantly, walking with a reeling gait towards the toilet, knocking into a couple of things along the way, stimulating the pain fibres that fired up the spinothalamic tract, kicking the reticular activating system into overdrive, waking me up somewhat rudely.

Walked the 15 mins to the MRT that i hated, cos i remember that later on during the day i would have to walk another 15 min back the other way. Met a couple of my groupmates at #$! MRT and we were transported back in time as we navigated towards the clinic. It's basically a clinic to diagnose and treat sexually transmitted diseases, and provide screening for commercial sex workers.

We made our way thru old foggies doing morning taichi and flea market vendors who were starting to set up their shops selling all sorts of articles... from dozens of remote controls to bicycle parts (hope none of them came from the 2 bikes i've lost over the years) to old tapes, cds, laser discs. Interesting... saw more of it all when we made our way back after lunch.

Sneaked into the place, made our way up to the women only section . Got a few stares from a few women who'd arrived early for their monthly checkup. Got a dao nurse who didn't really want us around, and dao women who didn't want medical students looking at how they were examined. This was something i found v strange since some of them service like 10+ clients a night.

Some of them were actually quite pretty, disspelling the myth that those who enter the trade cannot make it in terms of looks and have to ply their trade at night when it's dark, and hit on men too drunk to notice the difference. But from experience, it's hard to see who is really female and who is a transexual. So can't look too long or they will come and speak to you in a male voice so shocking that will activate a cremasteric reflex so strong that ur family jewels pop all the way back to beside ur kidneys where they plopped down from...

Went into the lab to see how tests were done, and then entered Dr T's clinic. An tall perky doc full of zest and funny stories to tell. Seemed familiar, turns out that we'd met in when i was in year 1.

===Decided it was not edifying and have modified this part of the blog, sorry if i stumbled any of you====
Washing hands

We learnt the importance of washing hands. The patients who come into the clinic usually have some discharge or ulcer or rash of some sort, and after handling their equipment, not one of them washed their hands. They all jus zipped their big brother up and proceeded to sit down on the chair, and they would have jus gone out of the room in the same way had the doc not asked them to wash their hands. Which means that the door handles and other materials in the clinic were probably crawling with gonococci and other bugs. Imagine you opening the door, and then scratching that itch in your eye... nice way to kena gonorrhea.

medicine

A Little Story: Biking with Lance

2005-09-07T19:59:00.000+08:00

We stared at each other. Sun had set, and most of the other kids at the playground (the sand-pit) had gone home, dragging their plastic spades and shovels with them.

I was 6. Lance was a year older. We were the fastest bikers around the neighbourhood on our bmx bikes. Mine was an ugly grey. His, a cool bright yellow one. We were equally brave and reckless, took the same bus, to the same school. Our bikes were equally scratched and banged up, and both our brakes didn't work properly anymore cos of all the braking we did down the slopes. We had to use our feet to stop the bike. The easier way to stop it would be to knock down a car or 2. The only thing that was obviously different was our size. He was like 2 feet taller than me, and had a much bigger build. I was so scrawny it was a wonder that i can even make it up the slope on Nanyang Hill (now called Nanyang View) where we lived.

We never liked each other very much. We always got into fights... and I'd always lost. We fought while waiting for the school bus to go back home. We fought on the bus over gals... (yah, a bit ridiculous to do that at that age) We fought over who was stronger ( i don't know why i bothered). But

Lance was the one who taught me the true meaning of manhood even at such a young age. Once, after they had shown American Ninja on SBC 5, we'd decided to try out some of the moves while waiting for our bus. To be fair, he suggested that we do one move on each other, taking turns. This way, he said, i would have a fighting chance. I agreed... trying to remember the killing, spine-breaking move that i had relished on TV the night before. Lance was so dead haha... i thought to myself. We got ready. Lance had the first move, since he was older (makes no sense, but i had to agree to the terms of the fight). I got into my Bruce Lee stance... pretty uptight. He jus stood there, pretty relaxed. Then he stepped forward... and kneed me in the groin. The rest of it you can imagine. He had a couple more turns. I never had the chance to make a move. Lance taught me manhood, made me realise that i was not a za bao4... that i had something down there that caused me to lose that fight.

It was a windy night... and i was eager to go on with the race, cos the mosquitoes from the nearby jungle would soon be out. We started cycling. The rules were simple. The first one off the bike loses. We started the kicking. We started punching. We kept cycling... riding into each other's way. No need to guess who won that race. I had to get my brother to go out and collect my bike for me. Left a bit of skin a bit of lip and blood on the pavement that day.

I didn't see Lance till 7 years later cos he went overseas. Met him again in RI when he came back. The Australian diet was amazing... he was already 1.8, and i don't think he was Marfanoid cos he was built. I wa ard 1.6, yeah, so thin that when i turned sideways, i could disappear, like a poker card. He stayed in my class for a while... but i had my lil gang then... and we weren't so frightened of him. He became a good friend, and a human sandbag that never broke. We beat each other up for fun, placed different classmates in boxes meant for recycling paper, crawled up the window grill at the side, and landed on the victim below. Did it till they stopped making noise... did it till the box broke. When it broke we took a 5 min break to tape it up again... then we continued. Lance was one of the nicer ones to put into the box. The others that made good cushions included Prem haha... Shaun was wonderful to land on cos of the irritating noise and comments that he tends to make.... " get me, get me!", "come on... why so slow?" Anyway, Lance had to go away again after sec 2. Last I heard, he had testicular cancer... no, i am kidding... last i heard, he was training to be a professional tennis player. May he do other guys in like he did me.

A little story: the beginning

2005-09-06T20:29:00.000+08:00

Grains of sand fall thru my fingers... disappearing into the currents that are tossing my leg hair about. Friendly fishes nibble on my toes, helping me get rid of my corns. Sunshine on my face from the setting sun... fresh air.... woah...

No matter what happens in life, one can always hope... always dream, always imagine. It is this gift from above that has allowed Man to survive and persevere, making it thru the storms of life... conquering seemingly insurmountable odds.

Nothing is as it seems. There is a story recorded, the synopsis of which is written in our eyes. The prose is engraved in the language of poetry, dancing like tow-kay on a musical score, sending the rhythm of life resonating within our souls. It's not a boring story. It's the type of story that made us lean forward at the edge of our seats as the storyteller (perhaps a teacher or a parent or a friend). Most of us don't really pay attention to the story that resonates within our souls with every lub-dub of our hearts. Most of us will only listen, when the body slows for one reason or another... when we're unable to just jump into things like we're used to.

And so i listened, pondered at the story that has been written thus far. I knew most of it, forgotten some of it, never thought much about the rest of it. It's not a perfect story. It's not without regrets for things done and things left undone. It's not without the tears and despair that makes one want to pull out hair (trichotillomania), knock down a car or MRT, or get a rush from seeing the ground rush towards your as you look down from atop a generic 25 storey HDB flat. But it's a real story, my story. And it's a good story.

A cool sunday

2005-09-04T19:43:00.000+08:00

It was a cool sunday. I got up, studied... felt sleepy, listened to wang xin lin to get me perked up... Then started grooving too much to the music so i turned that off. Felt sleepy again so i went to sleep. Ate lots of tuna sandwiches for lunch... cos my sis din like them. Studied... drank water... went to toilet... stared at my nice highlighting of the book... felt sian cos i dun remember anything.

Meanwhile my bro goes out and comes home with some new nike handbags to sell. $39. From some thai nike factory. Real price $80. Anyone interested?

And yah... mum asked me how i intend to get married if i dun go out. And asked me if i wanna go on holiday with her in december. Want to but cannot lar...

What i learnt tonight

2005-09-04T00:54:00.000+08:00

This post is not meant for non-medical ppl or those who have a life... go search for mp3s or photos of son ye jin instead. :) All information are compiled and i cannot say how accurate they might be hor3.

CNS Examination: Important stuff or things i always forget

To assess judgement, ask what the patient would do if he saw fire in his basket.
Cognitive function: As a rule, difficulty with immediate recall suggests depression, whereas difficulty with recall after 5 minutes suggests dementia.
Viewing the optic disc tells you a lot about the bodie's vasculature. Remember to offer to do it
Test hearing with high frequency tuning fork, and vibration sense with low frequency
To assess fine motor coordination, ask her to tap her thumb with each of the fingers on the same hand in succession
Screen for dorsal column dysfunction by the direction-of-scratch test, and do vibration if you find something. This is to save time.
Test pain. If got findings then test temperature by asking him to compare your finger and the tuning fork.
To tell between Parkinsonism and benign tremors, ask the patient to move. Tremors should disappear if it's parkinsonism. Essential tremors are also faster.

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Varicose Veins:

Main influences on the development of varicose veins:
Heredity:
Female sex
Hormones
Gravitational hydrostatic forces
Hydrostatic dynamic muscular compartment force

Heredity uncertain if dominant or recessive trait

Profound effect of female hormones in pregnancy on development of varicose viens:
70-80% appears in 1st trimester, often within 2-3 weeks of gestation
Indicates that do not develop because of size of a gravid uterus, increased blood flow or iliac venous occlusion

Two mechanical forces act on the heredity and hormonal substrate to produce the elongation and dilatation of the veins:
-Weight of blood column from right atrium to affected vein through valveless conduits of abdomen, pelvis and any incompetent valves of proximal limb veins-constant and called hydrostatic pressure
-Pressure exerted by contracting muscles on adjacent veins-hydrodynamic force: forces blood through open valves in deep veins towards the heart. Incompetence of deep perforators allows transmission of this huge force to unsupported superficial veins and venules.

Clinical Presentation
Asymptomatic:
Unsightly dilated, tortuous veins
Telangiectatic blemishes
Consultation sought by patient on cosmetic grounds
Symptomatic:
Aching pain usually in the calf all worsening as day progresses
Leg heaviness relieved by elevation & rest
Easy leg fatigue maximal on 1st day of menses

Superficial thrombophlebitis
External bleeding
Ankle hyperpigmentation
Lipodermatosclerosis
Venous ulcers

Over time, the elevated pressure in the venous system leads to edema, chronic inflammation, and ultimately sclerosis of the skin and subcutaneous fat. This sign of chronic venous hypertension is known as lipodermatosclerosis (LDS) and is most commonly seen in the lower medial leg, the "gaiter" area.

Acutely where the skin is warm, red, tender, and indurated with indistinct borders. The acute condition is frequently misdiagnosed as cellulitis, but patients with acute LDS are never febrile, and the skin eruption does not spread rapidly as does cellulitis. The proper treatment is external compression stockings, NSAIDs, and ambulation.

Chronically where the skin is indurated, sclerotic, and hyperpigmented, and fixed to the underlying tissue. There is usually no hair growth in these areas, and the induration is easy to distinguish from surrounding normal skin. The involved area may actually be concave due to fat atrophy. Chronic LDS can present as large confluent areas or small brown indurated plaques. The sclerotic skin is extremely susceptible to minor trauma, which can lead to rapid appearance of venous ulcerations.

Obvious varicose veins may or may not be seen in patients presenting with LDS

As a rule, LDS is much more common than cellulitis.

Chronic venous insufficiency :

worse late in the day, after prolonged sitting or standing, and in hot weather or during menstrual periods
Asw pain, itching, heaviness, tenderness, swelling, night-time leg cramps, throbbing restless leg syndrome, burning, and stinging.
Symptoms almost always improve overnight. If a patient's symptoms do not improve with rest and elevation, use stockings during the day for 2 weeks. Significant improvement in the patient's symptoms indicates a probable venous etiology.
Symptoms that do not improve with compression are unlikely to be connected to venous disease and may be Baker's cyst, arthritis, muscle strain, or diabetic neuropathy.
Varicose vein disease is frequently overlooked as a cause of nocturnal leg cramps or restless leg.
Disease symptoms are not always proportional to the size of the affected veins. Refluxing deep or superficial veins can cause symptoms in the absence of visible vein dilatation. A normal-appearing leg does not rule out vein disease.

Dilated veins means incompetence of valves above that level! Usually salphenofemoral junction in the groin.

PE:

Inspect: cutaneous signs. Lipodermatosclerosis... and examine the medial malleolus for corona phlebectatica, a classic sign of chronic venous insufficiency. This confluence of dark blue or purple dilated venules appears around the medial malleolus or instep and is highly suggestive of venous hypertension.
Palpate: pulses. No pulse? Then must do ankle-brachial index. Normal >1. Call a vascular surgeon if <0.5.>
Move: ankle. Is the calf pump working?
Tests: Medical Students only need to do cough tap and Tredenlenburg. Just mention the rest in general.

Cough test: Thrill felt with examining hand placed just below SF junction when patient coughs-signifies primary SF incompetence

Tap test: Thrill felt with examining hand placed over a bunch of varicosities as other hand gently taps GSV cephalad to examining hand. Basis for this is that the fliud thrill set up by taspping the GSV passes retrogradely through incompetent valves

Trendellenburg's test: For primary SF incompetence. Leg is elevated and veins drained by milking the leg from foot to thigh with patient in reclining position. Examining hand or a tourniquet is placed just below SF junction and the patient asked to stand up off the bed. The bunches of varicosities are examined-if they remain unfilled, then perforators are competent. If bunches of varicosities fill despite control at SF junction-perforators below SF junction and bunches of varicosities are incompetent. Watch as examining hand or tourniquet is removed-if bunches of varicosities fill, primary SF incompetence and incompetence of all valves along the GSV to the varicosities is present.

Modified Trendellenburg’s test: Can be used to determine level of perforator incompetence. In thigh Hunterian perforator mid-thigh; Dodd perforator approximately 1 hand’s breadth above knee. Below knee, Boyd perforator approximately 1 hand’s breadth below knee; then Cockett perforators 5, 10 and 15cm above ankle. Application of a tourniquet at each level just below perforator should control the incompetence and prevent filling of the bunches of varicosities if SF junction is competent or controlled. Removal of the perforator-controlling tourniquet will result in filling of the varicosities.

Fegan’s method (of demonstrating Boyd and Cockett’s perforators and perforator incompetence): with the patient supine and elevating the leg with one hand and running an examining finger along the medial border of the tibia-the position of below knee perforators will be easily palpable as sizable defects or depressions in the deep fascia in patients with chronic perforator incompetence. Finger-tip control with an examining finger will be possible and the modified Trendellenburg test can be performed easily.

Perthe’s test: To detect significant deep venous occlusion or insufficiency. If an tourniquet is placed just below the SF junction tight enough to occlude superficial venous drainage, the patient is asked to push him/her-self up and down on his/her toes for several minutes. If there is significant deep venous occlusion or insufficiency, there will be a bursting pain (as classically described) or tightness in the calf (“venous claudication”). This is because blood cannot be drained out of the leg through the tourniquet-occluded superficial venous system.

Investigate and Treat:

Doppler looking for:

Deep venous system:
Presence/absence of DVT
Competence of deep venous valves
Competence of perforators
Superficial venous system:
Competence of short and long saphenous vein junctions (primary sapheno-femoral or sapheno-popliteal incompetence)
Competence of valves along the long and short saphenous veins
Pharmacologic: Pentoxifylline (Trental), 800 mg tid, has been shown to be marginally effective in healing venous ulcers.
Stockings: Full length/below knee. Gradient highest in ankle and falls as it progressess upwards. Below knee same efficacy and less slippage so more compliance so better.
Operative:

Small incision over surface marking of sapheno-femoral junction in groin or marked junction of sapheno-popliteal junction (located by Duplex scanning as this junction can vary considerably)

Dissection of junction and ligation and division of all named tributaries (failure to do this is the commonest cause for recurrence)

Flush ligation, division and stripping of the long saphenous vein to the knee (unnecessary to strip below knee as this can cause saphenous nerve injury and does not increase benefit)

Stab incisions over marked varicosities and avulsion of these veins
Endovenous ablation therapy is indicated for saphenofemoral or saphenopopliteal reflux into incompetent great or small saphenous veins, respectively
Bulging or palpable varicosities are usually treated with ambulatory phlebectomy or sclerotherapy (Detergent substances, Hypertonic saline and glucose solutions, Chemical irritants or caustic agents). Nowadays, foam substances are preferred.

I hate skull x rays...

2005-09-03T11:18:00.000+08:00

Just got up... 11am... can't remember when was the last time i actually slept so much... muz have been during the hols. Got up, ate my tuna sandwich, got nagged at by dad for spending money on medical investigations that he doubts whether it's necessary... and wa la! the day has started. But it's a good day cos i didn't get woken up by the alarm on my sony ericsson k700i.

Crashed the A&E slots yester cos i missed my slot last week. One thing i concluded was that Singaporean parents are mostly quite paranoid about their kids, and more than half of them do not actually need to come to the A&E. A bit of flu and high fever won't kill you. Just go see ur downstairs that GP lar. Think every1 kiasi.

Also realised that there are some very good doctors out there who have both a head full of knowledge and a heart full of love. Hmm... maybe i want to be a physician afterall, instead of a butcher... Have to get more cerebral tho. Nvm, pass my exams first...

Went thru some x rays. And i realsise that i still hate ortho very much, and am only competent in CXR and AXRs.

Dr A: What do you see on this x ray?
Med students x 4: Er... this is a skull x ray of Mster Loo taken on ...er... 18 aug 2002. There is a patch of radio opacity over there.
Dr A: First comment on the views...
Med students x 4: Er... AP and lateral?
Dr A: What about this one?
Med students x 4: Er.. (silence for very long time till doc gets fed up)
Dr A: This is the occipital view
Med students x 4: Oh...
Dr A: How do you take this view?
Med students x 4: ... from the occiput?
Dr A: Yeah! Very good! (medical students felt sheepish)So what do you think it is?
Med students x 4: Er... otitis media with CSOM?
Dr A: ...
Med students x 4: Er sorry i retract my statement.
Dr A: What else can it be?
---silence---
Dr A: Let's go back to first principles since you have no idea. Infection what do you think of?...Neoplastic?

We struggled thru the differentials of a radio opacity on a skull x ray. Never knew that HSV causes diffuse calcifications, Sturge Weber tram-track ones, and CMV causes Calcifications-around-ventricles.

At the end of that 1 x ray we had spent so much time tt we couldn't go thru many other x rays.

2005-09-01T21:40:00.000+08:00

Really enjoyed the karaoke session on TV. Think Kelly is pretty with make-up... attractive... Bravo Kelly! Go Kelly go! Go Kelly go! I guess i won't really swoon when i hear your voice on radio. But i would definitely go to watch you perform in concert.... if you give me a free ticket.

陈伟联... dude... You got good voice, but lack the on-stage presence. But i guess that it's not fair lar... Hard to prim oneself and prance around and look cute in colourful costumes when one can't see. And that's what the audience wants to see when they see a lone figure on a huge empty stage. But i have to hand it to you dude. You came far, can sing better in your off days than me on the days i get drunk on honey water. And your appearance on TV didn't involve you being mocked by Asha Gills. And your fans and family love you. That's more than many can ever expect in their lives.

Thank guys and gals... for all the tears and laughter, and for letting the world know that 新加坡人也可以唱歌!

Beat the Cig!

2005-08-31T20:30:00.000+08:00

Never understood why people smoke. Tried it before.... and ended up with decreased ability to smell and taste. Not to mention that it is like a metacholine challenge test... end up wheezing like that ahpeh i saw in that outram 1 room flat when i did my ambulance call. Wheeze and wheeze and turn blue. Paramedic: "... aiyah... let's jus wait a while more and then repeat the chest leads lar, got straight line already then call police. Cos he so old already resus will still die very soon one lar... dun wan him suffer some more..."

Smoking drains stamina, causes cancer. Contrary to popular belief it does not really help you relief stress, and does not help you endure cold weather. It does not reduce the risk of airborne infection unless you intend to inhale through your cigarette all the time. Theoretically, the bugs will combust as they pass thru the lighted end... haha...

Cigarettes contain nicotine, tar and paper amongst a whole bunch of other carcinogens. And since it is so expensive to smoke nowadays, i suggest the following: get the nicotine from pesticides, lick the newly surfaced road to get your daily tar requirement, and burn a couple of pamplets or the stuff they burn in 七月... burn it and drink it down with some water. Cos that's more cost effective than smoking. And you harm less people in the process with your second hand smoke as well.

Dog tired...

2005-08-30T20:48:00.000+08:00

I wish i was swimming in Goa, India like 2 months back. Miss napping with my canine friends. We were a gang! But for now, the public pool will have to do.

Nose running... drank a some chlorinated water as usual. I swim q ok lar... faster than most of the people in the pool... mostly kids and aunties. But i still end up drinking some of the water leh... I dun noe what's inside, and i try not to think about what i had passed out of 2 of the orifices in my body into public pools when i was little and got a bit nervous.

I find it hard to swim without some1 banging into me. Kids are forgivable... they swim slow, dun collide too hard, and have soft bones that heal well so i dun worry about them. The ah mas i am more worried abt in case they drink too much water and get aspiration pneumonia or something.

The guys are the worst. They collide hard and fast, dun know how to swim in a straight line... and with all the testosterone in our bodies... everything ends up as a race. Tt's how my relaxing swim after a hard day's work came to an end.

Ooh... we got to buck up...

2005-08-29T21:10:00.000+08:00

The kid came in with not breathing and his heart was not beating. We all looked on in trepidation... not knowing what to do. By right we were all certified Basic Cardiac Life Support trained... which means that we were supposed to give a glimmer of hope to those who kena something that threatens their life.

That was in theory.

It reality, we were BLUR Poks... Can't remember what drugs to give or what dose to give. One of us started squeezing the reservoir bag instead of the ambu bag... and the size of the mask was wrong for the child in the first place. Nothing went right... and the kido desaturated...

Oh no, he din die lar... he simply wasn't alive in the first place. He was jus a doll. That was jus practice. We were just hopeless. Got to work harder. Now got excuse... can say we are mugging hard for psychomed so that we can diagnose psychotic conditions from a mile off. Nex time when we graduate we wun have such luxury, and the patient wun be a plastic baby...

Things i wish i didn't have to memorise

2005-08-29T00:41:00.000+08:00

1) The fact that too much Th1 causes autoimmune diseases, and too much Th2 causes lotsa atopies... and blah blah...

2) 27% of lil kids are allergic to birds nest... and can get asthma from it. The mechanism... cross-linkage to a mast cell by a multivalent hapten. Moral of the story... stick to simple stuff for the lil ones... dun waste money.

3) Allergies range from eczema to food allergies to asthma, to allergic rhino-conjunctivitis to anaphylaxis. If you sway sway kena one... you prob kena some more.

4) We pick out the above by pricking ppl's nice skin, by doing RAST which is not better than the skin prick and i dun noe stands for what... and lastly by making the lil kiddo take all kids of foods. We then watch the lil kid to see if his face and tongue swells so much that he can't breathe. Then we do a rescue with IV adrenaline and steroids... and anti histamines... of course we hope it doesn't come to that.

5) If you got eczema... pimecrolimus is good stuff. That's the good news. The bad news is that it's not available so i dun noe why i am memorising this!! Why is this in the notes!

6) SLE: Autoimmune disease that causes a butterfly rash on the face of gals that can look kinda cute. But to have SLE, they must also have 7 out of the following 11: malar rash, discoid rash, photosentitivity, oral/nasal ulcerations, arthritis, nephritis, CNS involvement, serositis, cytopenia, ANA positive and positive immunoserology... anti dsDNA +ve or anti SM +ve.

7) Treatment for SLE: NSAIds>hydroxycholoroquine for joints and skin>steroids>aZt,CSA,CPA.

Memories...

2005-08-28T17:21:00.000+08:00

Just thinking back on the last 4 years... how everything swam by so quickly, so fast. Remember that when i first stepped into Medicine, i looked at the seniors and thought that they were all pretty zai, pretty sure of themselves... muz be la... since they were about to be flung out to the deep blue sea filled with hungry consultants and hospital administrators with shark-like teeth.

But now tt i am like half a year from getting my degree, i feel q blur, like a sotong. The only consolation is that i can smoke a bit... but that only makes me a smoked-sotong.

Then again, i think back and i feel that life is pretty much like that. When i was 10 or so i looked at the ppl in university and went: Wah... so cool, so zai... got independence, got brains... all look pretty good...

Guess i always thot that the older foggies always got everything figured out. Most of them never really did... they jus drifted along in tt current... Some did... but they are the rare ones... the ones i'd like to emulate. Maybe, jus maybe, there might be some tt might want to follow in my footsteps... one day.
medicine

Weekend!

2005-08-27T12:49:00.001+08:00

Weekend at this stage in m5 means time to sleep a bit more so that we can spend more time during our waking hours sleeping. Lovely... Minus church and i wouldn't be going out at all.

Guys slightly older than me and gals younger than me busy procreating or taking steps so that they can procreate within the conventions laid down by this society. Well, the good thing is that people in Medicine NUS are less likely to get attached and married as compared to the normal human being. This means that i still got ppl to hang out with.

Stickerman

2005-08-26T13:29:00.000+08:00

Stickerman is a new friend i made at the hospital. He is paralysed from waist down, has no control of bladder and bowel, and has a bed sore that won't heal. It looks so bad that he says he's glad he never feels a thing. Bed sores are basically the same thing that did in the gal boxer in million dollar baby.

I looked for his bed in the wards after asking the HO for patients i can harass in order to become a better doctor. Ok, curtains are drawn.... i will come back later. He's probably answering some calls...

15 mins later... curtains are still drawn... I take a tentative peek. Stickerman is sitting on his bedpan. I ask if i can talk to him. He told me he's taking a crap, in case i didn't realise. I told him i didn't mind if he didn't mind. He didn't. I didn't, and so our conversation continued for the next hour with him on that bedpan.

Talked abt his family... how they abandoned him when he was little, and he's had to stay in a home. He knows other kids, and says that at least they have a family who cares for them. He goes to a sec school by calling a cab and moves around in a wheelchair. He's supposed to catheterise himself 6 times a day, but doesn't always do it. Now he's in becos of a headache... prob a blocked VP shunt. I felt truly sorry for him, but kept up my hearty smile and witty comments cos i knew that shedding tears over him will not make him feel any better. He'd prob think that i was gay.

He loves to digress... and that's why i spent close to one hour in that hot dreary cubicle. He asked for my sony ericsson k700 and started a video session of our conversation after finding the chinese mp3s not to his liking. He asked me why there were no pretty gals on my phone. I told him i din keep photos of pretty gals. He asked me why... i bo chup and thiam thiam. To be honest i would sneak a few pics of chio bus4 if my k700i cam didn't have to make that damn loud noise when i use it to take photos. And chio bu4s usually come with a tua jia4 guy so i dun wan to get beaten up.

Anyway, he told me he got friendster and got 4 galfriends whom he talks to very often and even writes long long letters to them. That's why he needs stickers.... to make cards for them. I gave him 5 winney the pooh stickers that i usually use to bribe the little kids so that i can get to hear some heart sounds and breath sounds and all that boring stuff. With a scary face like mine that makes children cry, i need all the help i can get. After talking to me about his 3 chinese and 1 indian galfrens on-line, he asked me how many i had. I said i haven't added many after i first started 2 years back so i only have 260. He said he couldn't believe it. I said i couldn't believe that he had not passed motion for 1 month either. Then he asked he whether i got galfren. I said no. He asked why. I thiam3 thiam3 again. He asked me what the hell i was doing with the 260 friends on friendster, can't be all guys right?

The nex time i saw him was in tutorial... he was happy to be examined by one of my pretty female friends and kept on smiling. He asked me to ask her for her number. She decided to give e mail. Hope they live happily ever after.

doctor

Tired... I love and hate MEdiCine

2005-08-25T21:09:00.000+08:00

So tired...man i feel dog tired... swam an hour, had a whole day of running around waking patients up and making them feel like lab rats. Tried to be nice about it but man, honestly i am still after the juicy signs that i can elicit! And now... 920pm... i got 3 hours left to study.Welcome to NUS Medicine... wonderful curriculum.

Attended the combined teaching on acute abdomen and the only thing i learnt is that there is a lot to learn. And if some1 came to me with a life-threatening condition, with a hole somewhere in his viscus or is bleeding so much that his abdomen fills with blood, the best thing i can do is to not send him for CT scan. Why? Cos there is no room in there to do any resuscitation.

So how? Do an x-ray, hopefully pick up gas under the diaphragm or funny looking loops of bowel and quickly dump him on a surgeon who would supposedly know what to do. Preferably do this in the middle of the night, just so that you can enjoy that moment of being able to tell some1 more senior than you to do something that he really doesn't want to do. heh....

Have to hit the library soon to chao mug!

Can't believe he said that

2005-08-24T12:58:00.000+08:00

Went to the clinic of a doctor strongly affliated to the PAP as part of our program. In walked a 14 year old gal the size of a sumo-wrestler. Weighing 100kg at a height of 150cm, she made her mother as well as me and my female friend seem anorexic in comparison. The chair groaned as the generously padded gluteous embraced/smothered the cushion. The doctor offered everyone a sweet as it was past lunchtime and he surmised that every1 mus be quite hungry and tired. Pudgy fingers reached it without hesitation.

So what can i do for you?
>Gal has "pimples at her groin" many times now, and wants the doc to do something about it
>Doctor examines her and the 2 medical students watched in horror as fats jiggled.... er... no underwear... and she'd shaved... er... a week ago?
>Medical students can't look on.

You have folliculitis, and that's because you dun wear underwear.
>Gal denies this and says she usually wears.
Anyway, you have fat thighs and they tend to rub and that can cause.. pimples.
>Gal looks at her hands and chews silently on sweet.
You need to lose weight.
>Gal and mum silent.
For most people i would advise a low carbo diet. But in your case I would recommend a no-carbo diet.
>Gal and mum stares at doc in disbelief. Medical students look on with wide eyes and dun think it can happen either.
If you dun lose weight, you won't be able to find a husband.
No one says anything.... deafening silence.
If you dun lose weight, it's very hard to have a baby.
Me and my companion dun quite understand. Does being fat make you more infertile? Perhaps hormonal imbal?
I mean, you know, if you are fat it's difficult for your husband to find his way in.

singapore