Fear is the only thing that will deter people from stupidity. Hit your children more often. -HypoG

My Fun Short Stint In Medical


Warning: Super Long Entry for Nobody to Read!

After four months of truckin’ in Medical, it came to a conclusion, and if there’s only one word I can use to describe it, it’s fun.

Medical, as a first poster, can be extremely difficult, and it can be excruciating if you go through it in a hostile environment. Of course, the hospital in which you work would play a pretty significant role in what kind of challenges you will face, but at the end of the day, if you have an easy path on the way up, it’s gonna be extremely easy to trip all the way down, as you trudge on without any care.

I can still remember my first day in the ward, it was an absolute disaster. I felt like a fish out of water, like I was completely out of my element. I didn’t know what was going on, and I felt like everyone was moving on such a fast pace leaving me behind. If I was to be all dramatic and use words a prolific author might use, “I am suffocated and lost when I have not the bright feeling of progression.”

The first week is absolutely brutal, because, as you run around as a headless chicken, you spend all your time trying to learn everything, as you will soon come to realize, you know nothing. You will at times feel that you’d just like to quit your job, and you’re done with this shit, and that my friends, is an absolute indication that you’re doing your job correctly.

As a first poster in medical, you’re to tag for two weeks, with a possibility of tagging extension. You’re given a tagging log which you’re supposed to fill up and complete within the two weeks. You will soon find out that you won’t have the time to even fill it up and will even forget about its existence.

As someone who spent 99.95% of his free time gaming, I must say I have absolutely no regret. It appears, even if you had spent 99.99% of your time studying, when you start here, you’re gonna be on even footing, no matter how good you think you are. So if you’re feeling holier than thou than all those chumps you see gaming all day, and wasting their time, take another good look at all those faces. This is gonna be the faces of the people who are going to be better than you. Unfair? Blame God.

Anyways, lets stop digressing and get to the crux of the matter. I know (inevitably so) many of you are feeling depressed and worried about how Eastern European graduates are being looked down upon. Just relax and take a chill pill. It just so happens that a very few rotten apples make it look bad for everybody, and with the advent of social networks and social media, these isolated incidents are published far and wide making it look like a common occurrence.

Let me put it to the rest, It doesn’t matter where you graduate from, it only matters if you keep harping on it. In HTAR, the Dengue wards, and MOPD is practically run by a Ukraine Graduate M.O. I’ve seen SPECIALISTS present cases to him to ask for his management opinion. When he is on off, another Ukraine Graduate M.O. runs the MOPD. Once, when both of them were on off, the MOPD was a mess, and when the usual 200 patients are seen by 12 p.m. went well into the afternoon.

Back to my first day, I knew that I knew shit, I knew that I’m doomed, but I knew one thing for sure, the same shit my mom told me before starting med school, “Any idiot can become a doctor.” So it hit me, hey, you’re an idiot, you can do this too.

On my very first day, I went through most of the tickets in the ward, to find out what were the common cases we were treating. Uncontrolled HPT, Uncontrolled DM, ACS, URTI, AEBA, AECOAD, ACUTE ON CKD, ARF, and the such. I went through the management of all these cases, and compared it to the Sarawak handbook, I wrote down my findings in a small pocket note book.


Blood Transfusion for patient –Unknown!

Then, I started clerking cases, and since I am Jonah, getting new admissions is not a problem, at all. During my first few clerking attempts, it was really horrible, and I was not systematic. I was all over the place, it was a complete mess.  Naturally, the MO reviewing the case gets so pissed, and says, “The fuck is this shit”. Afterwards, I note all my mistakes, and try to understand what is expected and develop from there. Initially, considering the bad clerking, the MO will tell me to write a new entry and will dictate his findings and management.

Having learnt this, I will learn the proper management, and the reason why it is managed as such. I continued clerking as many cases as I could and continued presenting, and now the response is a bit better. Now they are fine with my clerking, and are okay with the management, but feel that it needs a bit more optimization, and they add/omit/modify whatever I’ve started.

Continuing this path, I learnt what and how I could expect a drug to react. This eventually led to me experimenting with my own management style. Of course some were utter rubbish, but others were interesting to note, that they worked. To quote you an example, patient already on amlodipine 10mg OD, defaults for 1 month, comes back with bp skyrocketed at 180/100. Common sense dictates, using the long acting amlo is not sufficient, and furthermore, just using one antihypertensive won’t be enough either. So here I have literally a shitload of drugs I can add, but what to choose? Begin the experiment with alpha channel blockers, beta-blockers, ace-inhibitors and see what works best. Of course every patient is a subjective individual, but for the most part, everyone unless contraindicated respond as expected.

Finally, by the time I got off tag, reviews were now smoother, with most MO’s simply saying, ok just write Seen By me. Usually meaning they completely agree with your management, and may choose to add/omit some, or usually nothing. Boy does that do wonders for your confidence. It even got to the stage where I played with my own Insulin Sliding Scale, and conjure one from memory Smile. Of course now a new specialist has tried to standardize the sliding scale, by distributing a more systematic one for the ward, but sometimes, its easier to just write down your own sliding scale than to look for the ward specialists version.


The next big thing is procedures, and this was a big thing for me. I’m not into the whole reading and gaining knowledge nonsense. I’m hands on, and doing procedures was awesome, and as someone interested in surgery, it felt like the training I needed prior to getting to the good stuff. Personally, I only wrote down procedures I performed myself, assisted, or observed into the log book. This proved to  be good, cause I could gauge which procedures I needed more exposure into and which I was confident enough to do whilst listening to music (true story bro).

As a first poster, you will come quick to notice that MO’s will not trust you to do any procedures, and rightly so. Mainly because, if you screw up, and if something goes terribly wrong, the patient is going to be affected, and in the worse case scenario, might perish! The key here is persistence and confidence but don’t be overconfident!

On my fourth day of tagging, there was an abdominal tap being done. Me, being naïve and shit thought, hey, a rare procedure (needless to say, you’ll be seeing at least 3 patients that need a tap every day in the ward) and quickly went to observe. I observed the procedure, and was keen to do the next available one. Surely enough, by the time I was done in medical, I had two pages of abdominal taps performed, so much so till the gastro MO noted, You must be hating me since I’ve ordered most of these taps. I smiled and told her, I enjoy doing procedures boss, any other taps to do? Smile.

Anyways, taps are pretty minor thing, there are other procedures that carry a higher risk.


I observed two stab peritoneal dialysis and found the procedure interesting, and challenging. I decided I was confident enough to try it. Surely enough when there was one PD available, I asked the MO if I could do it. After going through the usual, WHAT YOU’RE A FIRST POSTER, NO WAY BRO thing, and after a bit of convincing (basically she asked me what is the procedure and I verbally told her what I planned to do) she agreed and warned me saying, if you cause peritonitis, you’re gonna die Smile with tongue out

Just a bit of confidence, and knowing my limitations told her please supervise me, and I went towards it. She corrected my techniques here and there and I successfully did my first PD. The feeling was mixed. I was excited that I have completed this complicated (sure felt like it at that time) and delicate (lol, it’s called stab PD, how delicate?) successfully but at the same time, the patient that needed it was a 20 year old young man with ESRF. Eventually it got to the point of having done quite a few PD’s, a few without supervision, but each as exciting as the first one. My thinking on the matter is simple, if I don’t do this shit now, and learn it well, when I am an MO, how the fuck am I to do this shit?


My most cherished moments in medical was doing procedures, it was honestly the most exciting part. However, the best part of medical was the process of learning. I had amazing MO’s who taught me well and MO’s who taught me how not to be an MO. I had specialists who conducted teaching during their rounds and specialists who did tornado rounds, where there were little to no learning. Of course I understand why specialists rush through their rounds, they have so many patients to cover, but it honestly is up to you to figure out why they did what they did. If you really can’t figure it out, just ask a senior HO or the MO, who more often than not, will be happy to help.


With Medical done, especially in HTAR, where everybody knows how it is, I’m happy for everything attained, the good, the bad, and the ugly.

Now to head into the the world of O&G. Wasn’t exactly my most favourite subject in Med School, but lets just call it a necessary evil. Abilash and Shorty were both in this department in their first posting. Abilash made the department sound really tough, but he’s been known to exaggerate. Shorty, who is in Kelantan, is understandably having a difficult time there, because, as I have come to understand it, people in Kelantan reproduce like rabbits.




Wish me luck bitches!


P.S. Before I end this terribly long article, let me just leave a video behind for you. This video was played during my last day in medical, during a Palliative Care CME. It has had the most profound effect on me, a heartless bastard, perhaps it will do you some good?

Profound And Shit

P.P.S. Yes, I know, this is the same HypoG that bunked so many classes and lectures during med school attends CME’S and shit. There is no hope in this world anymore.

The art of Clerking; When Copy Paste Won’t help :(


So you spent the past few years taking photos of patients history files and copy pasted your friends work with minor tweaks? Well, when you start your career, you’ll feel like an idiot, and will most probably perform like an idiot clerking patients and subsequently reviewing them. Clerking is really simple. It’s simple enough even an idiot could do it {i.e. Me}, so all you smart kids shouldn’t have any problems.


Just follow 3 simple rules, concise, relevant, and accurate.

Concise: Don’t write an essay, get to the point.

Relevant: If patient comes in for APO, don’t order BFMP investigation.

Accurate: If for example a patient comes in with fever, it is vital to know the exact date of onset.


There are plenty of other nonsense but I’m sure you get a rough idea.


Before we begin, it’s important to identify our patient.

Since I’ve been recently working in the dengue ward, I’ll just use a Dengue Case as an example.

28/01/2012 @ 6.00 PM

30/M/F  K/C/O HPT

30 years old Malay Lady, Known Case of Hypertension


Next to get the chief complaint;

Fever x 4/7

Proceed to full clerking.

+Fever x 4/7

– A/W Chills and Rigor

+ Vomiting x 2/7

  – 3 Episodes Today (Induced by eating food)

  – Food Particles

  – 0 blood

+ Diarrhoea x 2/7

– 4 Episodes Today

-Brownish-Yellowish Stool

– 0 Blood

+ Arthralgia/Myalgia

+ Lethargy

+ Bleeding Gums x 1/7

– Occurs after brushing teeth.

0 Retro orbital pain

0 Headache

0 Abdominal Pain



+Tolerating Orally Minimally


Last PCM Intake: Today at E/D at 4.00 PM

0 H/o of IM Injections

0 h/o Jungle Trekking, Waterfall, or other such activities (TRO Leptospirosis)

+Lives in Dengue Endemic Area, Recent fogging.

+Menses started today, usual course 7 days, 2-3 pads a day, claims used 5 pads today.


0 Surgical H/o

Insignificant family h/o of hereditary disease.

0 Non Smoker / Alcohol Abuse



O/E Alert, Pink, Answers in Full Sentences, Full GCS, Fair Hydration

0 Pallor, 0 Ankle Oedema, 0 Jaundice

BP 130/86

PR 135 (Good Volume)

T’C 37.5

Lungs Clear, A/E Equal


CNS Grossly Intact

CRT < 2 Seconds

PA : Soft, Non-Tender. No Organomegaly

Diagnosis: Compensated DSS In Febrile Phase Day 4 with warning signs (Persistent Vomiting, Lethargy, Bleeding Tendencies)





Dengue IGM


Serum Lactate



DXT : 7.0 mmol/l



1) Notify Dengue

2) Ideal Body Weight (45.5 + 0.91(152.4-ht)). If difference between IBW and Real Weight is huge, just add IBW + Real Weight, divide 2, and take that value.

3) Run 10 CC/kg/hr NS for 1 hour, and review. (Compensated DSS)

4) T. Provera 10MG Stat then BD

5) IV. Maxolon 10mg stat then TDS

6) Encourage Orally

7) Tranexamic gargle TDS/PRN

8) ORS Per Purge

9) Pad Chart

10) Hourly Vital Sign Monitoring

11) Put in Acute Cubicle

12) Inform MO

13) Trace IX and Review

14) Withold Antihypertensives

15) IV Omeprazole 40mg BD

16) I/O Charting


That’s roughly the gist of how you clerk a patient. Probably not the best clerking ever, but it’s good enough to survive. So now we’ve got this patient on a bolus, it’s time to do a post bolus review.


28/1/12 @ 7.20 p.m.

<Post Bolus R/V>

30/M/F K/C/O HPT

Compensated DSS D4 in Febrile Phase with Warning Signs (Persistent Vomiting – Resolved) (Lethargy) (Bleeding Gums – Resolving)

C/ Completed 10cc/kg/hr NS x 1 hr

+ No more vomiting / No Nausea

0 Abd Pain

+Resolving Gum Bleed

0 Other Active Complaints


Blood IX

HB 13.0 WC 1.42 PLT 87 HCT 43 LACTATE 1.9 PH 7.33 HC03 22 CK 300

Noted Carditis

O/E Alert, Pink, Answers in Full Sentences, Full GCS, Fair Hydration

BP 120/80

PR 115 (Good Volume)

T*C  38.8

Lungs: Clear A/E Equal


PA : Soft/Non Tender. 0 Organomegaly

CNS : Grossly Intact

CRT < 2 Seconds


P/ 1. Cut down IVD to 7cc/kg/hr, and review in 1 hour

    2. Blood IX, FBC, LACTATE, VBG

    3. Trace IX




This would be a simple review. A patient that was running a 10cc bolus due to Compensated DSS, is now tapered down to a 7cc bolus as she is responding. You trace the 10cc bolus bloods and review the patient again in an hour and check all her parameters, if you like what you see, taper down your bolus again, if you don’t, restart a bolus.

As always, be careful when running bolus. Don’t wanna overload the patient, always auscultate the lungs for the dreaded bibasal crepts!


That’s all for now, I’m too tired. Bye kids! Hopefully this update isn’t incorrect, I’m as sleepy as hell while typing this.