Sobs sobs, so pack ! This is for the first 4 weeks out of 8 weeks of Internal Medicine Posting in Tanah Merah. First four weeks are the toughest week as it include the respiratory system, cardiovascular system, GIT system, haematology and cranial nervous system.  

The other remaining four weeks will be the endocrine system, renal system and miscellaneous. Mannnn, I need to study from the beginning as this posting required a lot of reading, memorize facts and understanding skills. *cry*

End posting exam is a week after raya puasa. How can I enjoy this year Hari Raya Aidilfitri? Still wondering which week should I sacrifice.. hehehehe..

F I R S T . D A Y 

First day of O&G posting kinda sucks. I woke up late and reached hospital about 8.50 am, but thank God my group still waiting the head of department to handover duty or something (not sure). So I'm actually not really late. Haha. And then we were introduced to each specialist of O&G. There were four of them and I only can remember two of them; Dr. Salwanah and Dr. Affendi.  Not only the O&G specialists, the staffs and nurses also seems nice and friendly. I love Dr. Salwanah as she taught us during seminar about Bleeding In Early Pregnancy and I understand all of it. So, I have Mr. Ken for surgical, Dr. Haila and Prof Safwat for paediatrics and Dr. Salwanah for O&G.

First day in O&G posting :D

Got this one lecturer that everyone fear off. He was so scary and I'm so nervous when he's around the college. Mann.. he asked us to submit the first case write up end of first week of posting! *sigh*





Oh well. Baru start posting ni, dah pack and busy! Unlike paediatrics or surgical postings. You need to work hard and study hard. I hope I can adapt with this posting well. 8 weeks of posting !
And now my group tetiba kena present in seminar assigned to Prof Che Anuar T.T


mentally drained

and Tanah Merah is so hot right now. Panas dia lain macam geng. Musim panas in Kelantan is so not fun at all. Sweaty and migraine. Aiyooo, cannot laaa like this. Bila hujan, sampai banjir jadinya. Bila panas, panas sangat. No in between !

Early development of baby milestones is marked by primitive reflexes - reflex actions that occur in response to certain stimuli. These primitive reflexes are important for babies to be able to cope alone after nine months being totally supported in the womb.

Primitive reflexes do not usually persist (except the parachute reflex) and persistence can be a sign that all is not well with the neurological system of the baby.

Causes of retain primitive reflexes:

¾    Low birth weight at birth

¾    Prolonged or premature birth

¾    Traumatic birth, suction, forceps, emergency C-section

¾    Severe illness, trauma or injury in infancy

¾    Lack of tummy time

¾    Decreased ability to explore environment in early months

¾    Too much time in bouncer, stroller, or car seat which restricts (if overused) developing motor patterns and pathways

¾    Missing crawling stage

(picture credits to artlog.liyeung.com)

This kinda useful for me while I'm in ward, clerking patient :)

Can read more at here.

So my patient was a 2 years 5 months old boy living in Rantau Panjang. He came due to fever and rapid breathing. I know you will be like - Ohhh, its a pneumonia case ! Not so fast gaisss!

Patient has history of on and off, non-productive cough for a week. Mother said it was a mild cough so she didn/t seek for any medication for that. - I forgot to ask mother when the cough got worsen, was it by day or by night..

7 days later he develop diarrhoea and according to mother it was more than 8 times/day. Mother described the diarrhoea was yellowish, watery and there was faulty smelly. Diarrhoea was not associated with abdominal pain, but there was vomiting up to 5 times/day. Vomiting was aggravated by meal and the contain of vomitus was food particles. There was poor food intake, but patient can tolerate liquid intake. Patient seems lethargic. - It was diarrhoea started first then only the vomiting. Diarrhoea was described as watery and yellowish - more to viral GE but there was faulty smelly which brought the case more to bacterial GE. Confusing huh? Hahaha.

Around 2 am on next day, patient develop high fever (according to mother). It was warm to touch but there was no documented temperature. Fever was associated with chills and rigor ,but there was no fitting. Mother gave syrup PCM, but only temporarily resolve about 8 hours. - Fever was high and associated with chills and rigor should be suggesting a bacterial GE right?

In the evening, mother noticed there was rapid breathing during patient was sleeping. So she brought him to ED. - Cough, fever and rapid breathing ? This is the Pneumonia Triad ! 

Otherwise, there were no rashes, no sick contact, not from dengue prone area, no recent water activity, no history of outside food intake and mother not sure about rodent in the house but she said she never see rodents before in her house. Patient is the only one having these symptoms in family.

This is his 5th hospitalization. 3 of it was due to bronchopneumonia and treated with nebulizer. His 4th hospitalization was due to leptospirosis in 2015.

There were no malignancy or chronic illness in in the family. His father is a smoker and mostly he smoke outside the house. Patient was delivered full term by normal vaginal delivery with 2.6 kg. 

Other history were uneventful. Upon admission, his temperature was 39 degree Celsius. His respiratory rate was 36. On auscultation on lungs, there is bilateral crepitation. No rhonci. 

Lab Investigations

• TWC is normal.
• Lymphocyte was 57.3% and Neutrophil was 29.7%.
• Platelet was 255.
• Liver function test; A/G ratio elevated and Alkaline phospatase was 266.79 U/L.
• Stool for rotavirus is positive.
• Stool culture and sensitivity: Negative
• Lepto rapid test was inconclusive.

Hmm, so what is your differential diagnosis gaisss?

C H I L D . WI T H . F E V E R . A N D . R A S H E S 

N O R M A L . D E L I V E R Y

Team for today 

Pathophysiology of Labour

---

Hormonal
Progesterone maintains uterine quiescence (suppress PGs, prevent Oxytocin release)
Oestrogen opposes the action of progesterone. 
Fetally produced cortisol may also contribute to the conversion of progesterone to oestrogen
Myometrium
Cervix

Mechanism of Labour

---

7 cardinal movements of labour:

Think of the following according to the 3 altered shapes of the pelvic canal:


1 Engagement- when the widest part of the presenting part has passed successfully through the inlet. Occurs in vast majority prior labour. If more than 2 fifths of the fetal head if palpable abdominally, the head is not yet engaged.

2 Descent- this is secondary to uterine action, helped by voluntary use of abdominal musculature and the Valsalva manoeuvre (pushing) in the active phase of the second stage of labour.

3 Flexion- happens as head descends into the narrower mid-cavity. Important in minimizing the presenting diameter of the fetal head and happens due to the surrounding structures.

4 Internal rotation- so that the sagittal suture lies in the AP diameter of the pelvic outlet (the widest diameter) on reaching the sloping gutter of the levator ani muscles. OP position persistence is associated with extension of the fetal head and possibly obstructed labour or need for Caesarean section.

5 Extension- the well-flexed head now extends and the occiput escapes from underneath the symphysis pubis and distends the vulva- ‘crowning’ of the head. The symphysis pubis acts as a fulcrum point as the bregma, face and chin appear in succession over the posterior vaginal opening and perineal body. This extension and movement minimize soft-tissue trauma by utilizing the smallest diameters of the head for the birth. This extension and movement minimize soft-tissue trauma by utilizin ghte smallest diameters of the head for the birth.

6 Restitution/External rotation- when the head is delivering, the occiput is directly anterior. The slight rotation of the occiput through one-eighth of a circle is called restitution.
External rotation- shoulders rotate into the direct AP plane.

7 Expulsion



The 3Ps:
Powers- uterine contractions, 3-5/10min
Passenger- size, lie, presentation, attitude (flexion etc), position, station, fetal abn
Passage