Faithfulness Forever

Exactly 2 more weeks I gonna face my Professional 3 exam. Feelings of anxiety and uncertainty begin filling my heart. So much to study, so much to clinical examination to practice. I really dunno how this 2 weeks is gonna be, what the outcome. I wish I could just turn back time and start all over again, but tats of course impossible.
We can try our best to achieve anything but, we cant guarantee anything in life.
With this I put my all my hope and trust in God. Whatever the outcome of this Pro 3, I will still praise Him.
“Do not be anxious about anything, but I everything, by prayer and petition, with thanksgiving, present your request to God.” Philippians 4:6

Hospital Pasir Mas

Its been a few days since I was posted in Hosp. Pasir Mas. Life here was really different than that in USMKK. Arrived here on thursday, I found the scenery here rather peaceful and quiet. There were 17 of us, 6 guys and the rest girls, one house for each. Two dutch students from Holland came and join us in this district posting. Wow, our life here will be much more interesting with their presence. The house was dirty, so the first day was all cleaning and mopping. One good thing we found is that, the previous groups left a map of Pasir Mas in our house, showing those popular food restaurants in Pasir Mas. These restaurants were also rated, imagine that? How creative they were?

The next day, we set out to check out those ‘hot’ restaurants in Pasir Mas, but unfortunately most of the reataurants are closed on fridays. We wanted to eat the ‘Lian Hong’ Loh Mee, but it was closed too. So we just settle down with wan tan mee nearby. That day was also one of our coursemate, Zie’s wedding party. Including her, there were already 4 ppl in group who are married, one of them is already a mother! I am still single.:-( So jealous of them… Anyhow the bride was so beautiful tat day. She was always pretty, but tat day was just extraordinary beautiful. We had another lunch at the wedding party and then took photos with the newly wed couple.

On day 3 which was Sat, We spend the whole day online, chatting, downloading movies. The line here was quite fast, so our computers were on most of the time. I brought my keyboard along and Viki brought his guitar. I taught Toh Jeng, my coursemate to play ‘My heart will go on’ on the keyboard and he was diligently practising it since then. Occasionally his gf (who is also our groupmate) will drop by listen to him playing. How sweet…:-)

Yesterday, was just the usual briefing, running in the wards, doing procedures. We are supposed to go Barkas in the evening, to do some research on the water in Kelantan but due to technical error, the trip was postponed. Tis morning, I went to the Labour room, and there was this patient, 28 year old female, gravida 2, para 1, about to give birth to her second child. No painkiller was given to her. Her active phase of labour was long and she was having difficulty pushing her baby down. Possibly due to her short contraction pain. It took almost 1 hour before finally the the baby’s head came out. Here in Pasir Mas, unlike HUSM, they dont give painkiller to pregnant ladies in labour. Imagine the pain they go thru? I really salute these ladies who choose to deliver in Pasir Mas.

Life here is rather slow paced, unlike in HUSM. People here are more relaxed and not in a hurry. I dont feel so much pressured here.

Experiencing God in Christmas

Testimony by L. B. Liang

Hi brothers and sisters,
First of all, for those who have never heard of me, I am Lau Bik Liang, a 4th year medical student from Sibu, Sarawak.

Christmas night is coming soon. This is the biggest event for CF. I have been through three meaningful Christmas nights in USMKK that has brought me a lot of good memories.

In my first year, I was so excited about Christmas night that I wished to participate in a lot of performances. However I ended up with only joining choir. Haih… Maybe I really am not a talented person, haha! Never mind, I still enjoyed myself during that Christmas because I found something special about CF – love among brothers and sisters. CF had given me a sense of belonging and we are all like in a big family with lots of care and encouragement from each other. During that time, we spent a lot of time and effort in practicing choir. Despite feeling exhausted, we got support from each other. Besides that, many Christians who seldom turn up for routine CF meeting also came to help for Christmas night. There was a great deal of fellowship among us. It was a warmth Christmas night for me staying so far away from my family

The following year, I was surprised to be asked to take charge of Christmas night choir. In the beginning of our practice, we faced problems like a lack of musicians and song selections. We have a very limited number of musicians as compared to now during that time and most of the musicians were final year students who were very busy in their study. Thus, I feel quite stress at that time. Thanks to the Christmas night committee that year who prayed continuously for these matters and we finally got the musicians. I think God had answered our prayers and that’s why most of our problems were solved. Prayer is great!

Last year’s Christmas was a struggle to me, the most struggling, in fact. I actually felt bored after serving two years in Christmas night. However, David (our previous CF president) came to my room and asked me to become vice president for the Christmas night committee. At first I rejected because of my Pro 2 exam. I wished to focus more on my studies since that was my Pro 2 exam year. Previously we rarely see a Year 3 medical student taking such a heavy job in any CF event. Thus, that discouraged me in taking the position as the vice chairman for Christmas night. The thought of worrying about “others would have a chance to study much more than I do as they continued to stay in their room” had ruminated in my mind. Thank God that in the end, I did agree to become vice president and my results was considered good enough for me to enter my 4th year. Haha! I think this was the first time I struggle to participate in God’s work and I am glad that I had chosen the correct pathway

This coming Christmas, I wish I can continue to involve in the work of God and experience God’s work on me. For those brothers and sisters who still hesitate to help in Christmas night, please hurry to lend a helping hand. I am sure God will make this a special Christmas for you as He had made it for me in the past three years.

May God bless you all!!!

Tuesday with Morrie

Testimony by T. Liszen.

… a book that I read during early in my fourth year in University, I could recall not much of the book’s messages, but there is one chapter, one particular that keeps on lingering in my mind until now…and will once in a while pop out to echo loud in my mind. It is a chapter where Mitch, the author asked his old, bed-ridden professor, Morrie, who had been afflicted with a disease known as Amyotrophic Lateral Sclerosis or ALS, about his opinion of the Book of Job. I suppose Mitch was wondering how a suffering patient like Morrie would see God’s deeds on Job in order to test Job’s faith.

As a Christian who was very enger to know more about God then, I am ashamed to admit here that I was terrified when reading through the Book of Job.
Yes, I was terrified.
“If I were to give all out for God, will I be experiencing the same situation as Job?”
It was not the adversities to come in the way that I feared the most; It was the process of testing my faith to God.
I love God very much; at least that was what I thought I was then. “But will my faith survive all those adversities if I were Job?”
Despite all these thoughts, I could not help but try to learn to be a good servant of God, because without His salvation, I will not be here writing this. Hallelujah!
Hence I began my journey to learn to be a good servant since my Year 4 in University. And more often than not, I would be encountering helplessness, loneliness and being perceived as a weird person or hypocrite. I survived these and I said to myself. “Hmm, not bad…may be it is not as bad as I thought it will be. Yes, as long as I put my eyes on God, God will help me to go through all those trivial trials. He will be my strength when I am weak.”
I had been holding to that thought whenever I encounter difficulties, until a few months ago, I found myself too weak to even to think of that thought.
I was confused, bitterly in pain emotionally and physically, and worse, I blamed God for what had happened.
I blamed Him for giving me a problem that could not be undo, I blamed Him for allowing that incident to happen, I blamed Him for involving the people I care and love all this while, if all these were to help me to grow…why it could not be that I being the one and only who undergo it?
Then during the CF meeting when Mick came to preach about “Encounter”, he said about how job demands of God an explanation of his plight, and God said,

“Who is this that darkens my counsel with words without knowledge?
Brace yourself like a man;
I will question you, and you shall answer me.
Where were you when I laid the earth’s foundation?”
Those verses were like a slap on my face.

Who am I and what am I to question and to even blame God? Then I realized that I had been loving and worshiping not God, but rather God’s gift and blessings upon me. I love what God can bless me with, to the extent that I idolize the gifts, not the Giver. That is the reason, I suppose, I agonized so much when things gone so wrong in my eyes, and forgot that sometimes, humans will never be able to comprehend all of God’s ways. For God’s ways are higher than our way.

The recently, God put me through a serial of events to help me to seize the meaning of true faith in Him. I could not share with people I love what are in my mind, what are troubling me and why am I acting in such ways. It was indeed a true agony, when the people you love started to doubt you and you could do nothing to make them understand. Then I learned at that time, am I not the same? Putting God into such situation myself? I doubted Him so many times, while deep inside, I know He loves me, and He has always been there for me. It must have been very painful for God too, to have His child to doubt Him, when all the things He has been doing, are for the good of His child, just that it is beyond the child’s ability to learn the blessings behind. Thus, I know now, Father in Heaven, that I should keep on having faith in You, even if the situation looked terribly grim and messed up at that moment.
And at the end of that chapter, Morrie answered Mitch, “I think, God overdid it.”
Personally, I think, God was doing things in His ways, in accordance to His will.
Well, so now I am really grateful and praising God for the trials He has been giving me, and I think there are more to come…but thank you, Father in Heaven, for promising me that You will not give me burden that I cannot bear. And I would really love to end this by sharing with you all these verses.

“Consider it pure joy, my brothers, whenever you face trials of many kinds, because you know that the testing of your faith develops perseverance. Perseverance must finish its work so that you may be mature and complete, not lacking anything.” James 1:2-4.

Causes of respiratory distress in term infants

PULMONARY CAUSES

Common

Transient tachypnoea of the newborn – Caused by delay in the resorption of lung fluid and is more common after birth by C-section. CXR may show fluid in the horizontal fissure and additional ambient oxygen may be required. Condition usually settles within first day of life but can take several days to resolve completely.

Less common

Meconium aspiration – Meconium is passed before birth by 8-20% of babies. Rarely passed by preterm infants and occurs increasingly the greater the gestational age, affecting 20-25% of deliveries by 42 weeks. Asphyxiated infants may start gasping and aspirate meconium before delivery. Meconium is a lung irritant and results in both mechanical obstruction and a chemical pneumonitis. In meconium aspiration the lungs are overinflated, accompanied by patches of collapse and consolidation.

Pneumonia – Prolonged rupture of the membranes, chorioamnionitis and low birthweight predispose to pneumonia. In this kind of case, we usually start broad spectrum antibiotics early

Pneumothorax – May occur spontaneously in up to 2% of deliveries. May occur secondary to meconium aspiration, RDS or as a complication of ventilation

Milk aspiration – More frequently in preterm infants and those with respiratory distress or neurological damage. Babies with bronchopulmonary dysplasia often have gastro-oesophageal reflux, which predispose to aspiration

Persistent pulmonary hypertension of the newborn – This life-threatening condition is usually associated with birth asphyxia, meconium aspiration, septicaemia, or respiratory distress syndrome. As a result of high pulmonary vascular resistance, there is right-to-left shunting within the lungs and at atrial and ductal levels. Cyanosis occurs soon after birth. CXR may show pulmonary oligaemia. Most infants require mechanical ventilation and circulatory support in order to achieve adequate oxygenation. Inhaled nitric oxide, a potent vasodilator, is often beneficial. Extracorporeal membrane oxygenation (ECMO), where infant is placed on heart and lung bypass for several days, in indicated for severe cases.

Other rare causes

Diaphragmatic hernia, Tracheo-oesophageal fistula, Pulmonary hypoplasia, Airways obstruction, Pulmonary haemorrhage

NON-PULMONARY

Congenital heart disease, Intracranial birth trauma, Encephalopathy, Severe anaemia, Metabolic acidosis

Neonatal Examination

These are the few tips I learned today on neonatal examination…

1. Firstly we look at the child’s general appearance. See whether the child is in respiratory distress, discomfort, pain. Also we should observe the patient’s posture and movements. (For us to do this, the baby needs to be fully undressed)

2. Find out the patient’s gestational age. If we suspect the patient’s is a pre-term baby, use the Ballard score to assess his/her gestational age. (I will share on Ballard score later…). Also we should not forget to measure his/her birthweight, length and head circumference and plot the growth chart. Take note if the patient’s birthweight/ length or head circumference is below 5th percentile or above 95th percentile.

3. Palpate both anterior and posterior fontanelle. Feel whether is it tense or not. A tense fontanelle when the baby is not crying may be due to raised intracranial pressure and cranial ultrasound should be performed to check for hydrocephalus. Also we should palpate the sutures. The sagittal suture is often separated and the coronal suture may be overriding.

4. Observe the face. Look for any syndromic facies such as flat occiput, flat nasal bridge, hypertelorism, low set ears, unslanting of palpebral brigde, cleft lips, increase intercanthal distance, small jaw. etc etc. This features could indicate Down, Edward, Patau or Turner syndrome.

5. Also look at the face for any plethoric, cyanosis, jaundice or paleness. If yes, check the haematocrit to identify polycythaemia or anaemia. Central cyanosis is best seen on tongue. Jaundice within 24 hours of birth requires further evaluation.

6. Examina the eyes, checked for red reflex with an ophthalmoscope (cataracts, retinoblastoma and corneal opacity). Inspect the palate, including posteriorly to exclude posterior cleft palate.

7. Observe patient’s breathing and chest wall movement. Look for any sign of respiratory distress such as subcostal recession and chest wall indrawing. Confirm it by counting the respiratory rate. ascultate the heart for any murmur and count the pulse rate. The normal rate in babies is 110-160 beats/min, but may drop to 85 beats/min during sleep

8. Palpate the abdomen. Feel for any intraabdominal masses which most commonly is renal in origin. The liver normally extends 1-2 cm below the costal margin, the spleen tip may be palpable, as may the left kidney.

9. Inspect the genitalia and anus. In boys, look for presence of testis in scrotum. In girls, look for labia majora and labia minora. You should be able to differentiate between the two. Also look for any fistula or discharges.

10. Palpate for femoral pulses. Femoral pulses is reduced in case of coarcation of the aorta. This can be confirmed by measuring the blood pressure in the arms and legs. Femoral pulses is increased in case of patent ductus arteriosus.

11. Assess the muscle tone by observing limb movements and on sitting the baby while supporting the head. Most babies will support the head briefly when the trunk is held vertically.

12. Whole of back and spine is observed looking for any midline defects of the skin

13. The hips are checked for development dysplasia of the hips (DDH). This is left last as the procedure is uncomfortable.

Characteristic clinical manifestation of Down’s syndrome

Typical craniofacial appearance
- Round face and flat nasal bridge
- Upslanted palpebral fissures
- Epicanthic folds (a fold of skin running across the inner edge of the palpebral fissure)
- Brushfield spots in iris (pigmented spots)
- Small mouth and protruding tongue
- Small ears
- Flat occiput and third fontanelle
Othe anomalies
- Short neck
- Single palmar creases, incurved fifth finger and wide ‘sandal’ gap between toes
- Hypotonia
- Congenital heart defects (40%)
- Duodenal atresia
- Hirshsprung’s disease
Late medical problems
- Delayed motor milestones
- Moderate to severe learning difficulties
- Small stature
- Increased susceptibility to infections
- Hearing impairment from secretory otitis media
- Visual impairment from cataracts, squints, myopia
- Increased risk of leukemia and solid tumours
- Risk of atlantoaxial instability
- Hypothyroidism and celiac disease
- Epilepsy
- Alzheimer’s disease

Cerebral Palsy (CP)

Def : Disorder of MOVEMENT and POSTURE due to a non-proggresive lesion of motor pathways in the developing brain.

It is the most common cause of motor impairment in children, affecting about 2 per 1000 live births. In addition to disorders of movement and posture, children with cerebral palsy often have other problems reflecting more widespread brain dysfunction. These include:

- Learning difficulties (about 60%)

- Epilepsy (40%)

- Squints (30%)

- Visual impairment from errors of refraction and cortical damage (20%)

- Hearing impairment (20%)

Causes

- 80% is antenatal in origin due to vascular occlusion, cortical migration disorders or even structural maldevelopment of the brain during gestation

- 10% due to hypoxic-ischaemic injury at birth

- 10% postnatal in origin. Preterm infants are especially vulnerable to brain damage from periventricular leucomalacia (PVL) secondary to ischaemia and/or severe intraventricular haemorrhage.

Clinical Presentation

Early features of CP include

- Abnormal limb tone and limb and/or trunk posture in infancy with delayed motor milestone; may be accompanied by slowing of head growth

- Feeding difficulties, with oromotor incoordination, slow feeding, gagging and vomiting

- Abnormal gait once walking is achieve

- Asymmetric hand function before 12 months of age.

There are 3 main clinical types of CP, namely spastic (70%), ataxic hypotonic (10%), dyskinetic (10%) and mixed pattern (10%)

A. Spastic (3 main types)

Hemiplegia : Unilateral involvement of the arm and leg, with the face spared. Affected children often presented at 4-12 months of age with fisting of the affected hand, a flexed arm, a pronated forearm, asymmetric reaching or hand function. Subsequently a tiptoe walk on the affected side may be evident

Quadriplegia : All 4 limbs are affected, often severly. The arms may be affected more than the legs. The trunk is involved with extensor posturing and poor head control. This form of CP is often associated with seizures, microcephaly and moderate/severe intellectual impairment

Diplegia : All 4 limbs, but the legs are affected to a much greater degree than the arms, so that hand function may appear relatively normal. Walking is abnormal

B. Ataxic hypotonic CP

Signs are relatively symmetrical. There is early trunk and limb hypotonia, poor balance and delayed motor development. Incoordinate movement, intention tremor and an ataxic gait may be evident later.

C. Dyskinetic CP

Dyskinesia (fluctuating tone) leading to frequent involuntary movements (generally of all 4 limbs) especially evident with movement/stress. These involuntary movement may be…

Chorea : irregular, sudden and brief non-repetitive movements

Dystonia and athetosis : Simultaneous and sustained contraction of agonist and antagonist muscles involving the trunk and proximal limbs (dystonis) or distal part of the limbs (athetosis)

Ref : Illustrated Textbook of Paediatrics

Acute Asthma

I just finished my clinical exam with Prof. today. Got an acute asthma case. Couldn’t decide whether my patient’s acute asthma is mild, moderate or severe.

This is how we classify acute asthma as mild, moderate or severe in Malaysia.

	Mild (admission unlikely)	Moderate (may need admission)	Severe (admission needed)
Altered consciousness	No	No	Yes
Physical exhaustion	No	No	Yes
Talks in	Sentences	Phrases	Words
Pulsus paradoxus	Not palpable	May be palpable	Palpable
Central cyanosis	Absent	Absent	Present
Rhonchi	Present	Present	Silent chest
Use of accessory muscle	Absent	Moderate	Marked
Sternal retraction	Absent	Moderate	Marked
Initial PEF	> 60%	40-60%	< 40%
SaO2	> 93%	91-93%	<90%

I think I really got a nice bashing this time around. Feel kinda depressed now…

Tomorrow will be MCQ. Hope things gets better…

Remedial Paediatric Posting

Im back in campus, have to do remedial for paediatric posting. Still feel the tiredness in me after the 8 hours journey from Shah Alam, so much to study, so much to cover… I didn’t expect to fail my paediatrics, seems medical life is unpredicatable. Paediatrics was my last posting, I expect to pass it and continue my elective in Hospital Klang, but wat happen…

Im reali disheartened over it, sad and heartbroken. I have gone thru so many setbacks in 4^th year, yet another problem prop up. I’m losing my self-esteem recently, every posting I struggle to pass. I did once failed my ORL posting, but thank God I managed to repeat the exam with the next group and then passed it.

So many thoughts are going thru my mind now, I dunno wat gonna happen soon. How is my future going to be? Wil I be able to make thru medical school?

My dad once said, as a Christian, we will have to undergo trials and tribulations. Only thru this trials and tribulations, our hearts and soul will be moulded to be better and better. When problem arise, we can choose to be bitter, or choose to rise up above the challenge. It never easy to do the latter, tat is to rise up above the problem, that’s y we need to come to God

I dunno how this two weeks of paediatrics gonna be, we are going to go thru clinical sessions, oncalls, and lectures. At the moment, besides studying, there’s nothing I can do, except to put all my hope, faith, trust in the Almighty God. Only with God, I shall see my paediatrics through. I guess I won’t be writing any blog until my exam over (which is next week). I will do my best for HIM!