Chronic oral ulcer in patients with rheumatoid arthritis is a diagnostic challenge in primary health care. The possible causes include the disease itself, side effect of treatment, malignancy and infections. This is a case of a 63-year-old woman with underlying rheumatoid arthritis presented with chronic solitary oral ulcer. She was on oral methotrexate (MTX) and high dose folic acid for five years with good compliance. Tissue biopsy showed marked inflammatory cells infiltration and nuclear hyperchromatism with no evidence of malignancy nor infection. The ulcer was resolved after completing antifungal treatment for six weeks following failure of improvement after empirical antibiotic, elimination of possible trauma and discontinuation of MTX. The fungal staining was negative. There are possibilities of false negative results, thus broadened diagnosis with repeated and further investigations are recommended in cases who did not respond to conventional treatment.

Introduction: An aberrant carotid artery has distinct terms and may exhibit a submucosal mass in the posterior pharyngeal wall. While it is primarily asymptomatic, an extreme aberrancy doubles the risk of dissection, a cerebrovascular accident (CVA) and an injury intraoperatively. Case Report: We report a case of ‘kissing carotid artery’ in a 65-year-old lady who presented with a foreign body sensation felt in the throat for one week. A finding of flexible nasopharyngolaryngoscopy (FNPLS) showed a bilateral paramedian retropharyngeal pulsating mass. Radiological examinations, including Computed Tomography (CT) of the neck and an angiogram, revealed an aberrant course of bilateral carotid arteries. In view of no malignancy and vascular malformations, there was no further intervention done, and the patient was subjected to yearly surveillance. Conclusion: Retropharyngeal carotid arteries are clinically significant anatomic variants. Such anomalies are potentially life-threatening and a risk factor for a severe hemorrhage during the simplest and commonly performed transoral surgeries. Thus, thorough perioperative assessment with accurate imaging techniques and studies are required to evaluate these anomalies and may avoid any disastrous complications.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become one of the most disastrous health crises of the present world. The COVID-19 pandemic imposes unprecedented challenges for medical education globally. We describe how the pandemic has disrupted the medical education landscape from the students' perspectives and how medical students from a public higher institution adapted to the changes made to comply with the various government agencies' guidelines to contain the spread of COVID-19 while fulfilling the course requirements. The utilisation of numerous innovative online applications enabled the students to participate in numerous teaching and learning activities (TLA) with more flexible scheduling of the classes, participated in a series of online case-based discussions, clinical practice guideline (CPG) discussions, case presentations and objective structured clinical examination (OSCE) simulations. Students also joined TLAs conducted by other institutions both locally and abroad. In addition, students had collaborated among themselves and students from other institutions to conduct online peer-teaching activities. Perhaps, the main challenges for online classes were being unable to perform medical procedures and technical issues, commonly the poor internet connectivity. In regard to physical examinations, students performed it on members of their household instead of real patients. Learning medicine from a distance also gave us an opportunity to taste telemedicine which may be the future of medical practice. Students and academics should be adaptive, resourceful and resilient in facing these changes together. The institution needs to look at all stakeholders' perspectives to respond to the changes in the medical education landscape.

Retropharyngeal abscess is life-threatening with potential airway emergency. A 53-year-old lady with diabetes mellitus presented with diffuse painful neck swelling for a week and difficulty in breathing with stridor. Video laryngoscopy done in operating theatre showed edematous laryngeal inlets with bulging posterior pharyngeal wall. Patient was tested positive for COVID-19 infection. The management was taken with high precautions, careful planning with unconventional and multidisciplinary approach. Management included airway protection, antibiotic, surgical drainage and correction of hyperglycaemia besides the compliance to COVID-19 SOP. Prognosis is good if identified early, managed aggressively and complications are avoided albeit the comorbidity and COVID-19 infective status

During the pandemic, diagnosis of COVID-19 infection must be excluded in patients presenting with respiratory features, especially in the area where the incidence was high. This case report highlights a man who came with respiratory infection symptoms and the chest radiograph suspicious of COVID-19 pneumonia; however, his swab test for RT-PCR was negative for COVID-19. Later he was found to have a positive anti-HIV antibody and developed advanced HIV infection by multiple opportunistic infections. A 45-year-old man presented with chronic cough and dyspnea for three months which worsened five days before the presentation. It was associated with diarrhoea, dysphagia, weight loss, left lower limb weakness, with bowel and urinary incontinence. Chest auscultation revealed generalized crepitations. The first chest radiograph showed bilateral reticular opacities extending to the lung peripheries when the suspected diagnosis of COVID-19 pneumonia was made. The nasopharynx swab for RT-PCR for COVID-19 was negative, and the sputum was positive for Pneumocystis jirovecii. The contrast-enhanced CT (CECT) brain revealed changes consistent with brain abscess. The cerebrospinal fluid (CSF) examination was consistent with cryptococcal infection. He was initially treated in the Severe Acute Respiratory Infection (SARI) ward because of the initial impression of COVID-19. He was tested positive for Human Immunodeficiency Virus (HIV) rapid test and PCR, RPR and TPHA for syphilis. He was diagnosed with Pneumocystis jirovecii pneumonia, cryptococcal meningitis, brain abscess, oral and oesophageal candidiasis and syphilis. He was treated with co-trimoxazole, Amphotericin B, flucytosine, fluconazole, penicillin G and Nystatin. He initially improved upon treatment but later succumbed to his illnesses. Given the current situation of COVID-19, any patient with acute respiratory symptoms must be tested to rule out COVID-19 pneumonia. However, in a newly diagnosed advanced HIV patient presented with respiratory infection symptoms and extrapulmonary symptoms, opportunistic infections should be excluded along with COVID-19.

The COVID-19 pandemic has caused the clinical attachment for medical students to be deferred in ensuring reduction of viral transmission. Patients encounter was near impossible, thus suspending medical students’ clinical skills on real patients. Despite this, the final examination had to be conducted. Hence, appropriate planning was made to ensure candidates were well prepared. A paradigm shift was made by Universiti Sains Islam Malaysia (USIM) with regards to the medical education delivery and the final undergraduate examination organization. The traditional in-person teaching and learning sessions were converted to video conferences and small group discussions to ensure social distancing. Objective structured clinical examination (OSCE) consisting of sixteen manned and twenty unmanned stations were introduced to replace the conventional one long and three short cases clinical examinations. The pandemic became the biggest obstacle for the final year medical students physically and psychologically. Familiarisation with the new format of learning and examination has to be made within three months. Online learning materials became resourceful during revisions. Simulated OSCE conducted by the lecturers, were advantageous to the students in ensuring familiarity to the new examination technique. Role-plays involving students’ family members and colleagues as patients, aided the candidates to rehearse their physical examinations and history taking techniques. The intensive teaching and learning sessions have enabled the candidates to be equipped with the new examination requirement. Reflection: Generally, candidates favour OSCE over traditional clinical examinations. This preponderance was due to OSCE capability in assessing the entire aspects of knowledge and skills in variable rotations throughout medical school.