~aku bukan parasit~ #004 Short case examination

May peace be upon us all

As promised, my supervisor's tips for the coming short case. *This may be incomplete and perhaps I mixed up some of my thoughts and understanding. Disclaimer: pleaese don't blame anyone is none of this is happening*

Firstly, you need to be able to know the diagnosis before you start examining. What? HOW? hehe. Not entirely true. What it really means is that you need to come up with your differentials based on the question alone. As the Dr says: typical cases. You then examine, get the signs, then it fits into a pattern-which confirms your thought and then you got your provisional and differentials:) In other words, it is the retrograde of your learning process. When we are learning, we get the signs, and then "oh, this must be this or that". Then we get to learn the etiology, pathophysiology, etc. honestly, I hardly do this. Seriously melalut? Let's move on. 


If you got hands examination, it is often scleroderma, RA, PsA. So if your question is "examine the hand", your differentials are at least these three. See? You have the differentials already. How to differentiate? You know better than me :) *A little bit on PsA: Look for pitting of the nails, sublingual hyperkeratotic, onycholysis, total nail dystrophy, psoriatic plaques(at the extensor surfaces[hand and legs], behind the ear, along the hairlines, periumbilicus).

Q: Examine the pulse. This is either AF or collapsing pulse. If this question, unlike CVS examination, palpate the pulse for 1 minute(you might miss slow AF if you palpate for only 15-30 secs). Your differentials: causes of collapsing pulse(5): AR/MR is common, A-V fistula, PDA, rupture of sinus valsalva. (other causes(including bounding pulse): APAMBATAF; aortic regurg; PDA; AV Fistula; MR; Beri-beri; Anemia; Thyrotoxicosis; Atherosclerotic aorta; Fever-bacterial endocarditis), causes of AF(refer the workshop :P)

Q: Inspect and proceed/ Look and proceed. The differentials: Cushingoid features[moon face], Parkinson[expressionless], thyroid[goitre or thyroid eye disease], *stroke[maybe unlikely for undergrad, the clue is Ryle's tube and reduced nasolabial fold]. It is going to be something obvious enough to be noted by undergraduates :D.

**if thyroid[if you notice goitre/neck lump], proceed to the neck first[due to time constraint]. After that only you proceed to the thyroid function status. Hands-fine tremor(kembangkan jari/spread the fingers), sweating, warm, AF; eye-lid lag, lid retraction, chemosis, ophthalmoplegia; reflex(don't forget!)- in hypothyroid=delayed relaxation --> ankle jerk!(don't know why) read this.;CVS and respiratory may have findings if patient is in failure but maybe not enough time for that.Note that presence of clubbing/thyroid eye ds/ pretibial myxedema is specific for Grave's ds. 


Skin: Psoriasis. Any other possibilities? Ulcer- unlikely bcoz they often in Surgery or Orthopaedics.


CVS: murmur-most common MR, VSD(can be in someone who is 40-50 years old), AR, TR(raised JVP but not tachypnoeic. Possible- AS, prosthetic valve(often have murmur as well- soft/ejection systolic murmur-this is normal, only if loud or diastolic murmur=the valve is failing). Uncommon: MS, ASD. CCF is even more uncommon because treated CCF does not have much finding and acute patient is not stable enough for exams. *just in case: CCF= raised JVP+tachypnoea


Respi: 

1. Pleural effusion (stony though you may still unable to diff btwn stony and dull dullness+reduced/absent breath sound/vocal fremitus)
2. Consolidation: (dullness+ increased vocal fremitus) - consolidation only have two possible causes - infection and malignancy. 
3. Collapse: may present in patient who has had lobectomy/pneumonectomy[any lateral scar?]
4. Generalised coarse creps: think of bronchiectasis
5. Only generalised fine creps/scattered: fibrosis

**according to Dr, bronchiectasis and fibrosis are very easy to get because they are under regular follow-up, so can contact them any time. 

also, please give full diagnosis. Eg: AEBA/AECOPD secondary to pneumonia. 

Abdomen:

-hepatomegaly

-splenomegaly

-hepatosplenomegaly

-polycystic kidney ds(look for fistula[run your hand over the pt's arm]/nephrectomy scar[very lateral])

**ballotable kidney: bilateral-PCKD, unilateral-renal cell Ca/obstructive uropathy/PCKD with one kidney removed already.

**transplanted kidney: unlikely for undergrad. Just in case, there is J-shaped/curved scar at the inguinal region with mass underneath. 

Neuro: (upper limb/lower limb/cranial nerve[not common but possible; facial nerve{VII} or eye{III, IV, VI}])
-stroke: Ryle's tube, facial asymmetry
-if one sided lesion+aphasia/dyspasia: consider stroke
-if both lower limb: spinal cord lesion (LMNL)

**don't forget peripheral neuropathy

footnote: This list is not comprehensive. Let us all learn to become a good doctor rather than just passing the exam. May Allah grant His blessings to those who strive and leave the rest to Him.

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~aku bukan parasit~ #003 Session with Prof 01

Assalamualaikum w.b.t.

Some recap on session with Prof, sorry for the limited info, hardly able to recall everything:

The case is about a HbE beta thalassemia complained of vomiting, etc.. (sori xingat, but in short, this pt is most like having food-poisoning with underlying anemia d/t thalassemia).

**HbE is a variant of abnormal Hb, a subset of beta-thalassemia since it is affecting the beta globin chain. please click here or here for more detailed information. Also, please note that HbE is the most common variant in Southeast Asia (epid medicine :D)

In anemia(pale/reduced Hb) case, it is important to ask about

• bleeding tendency
• relevant social hx [ i)diet hx- IDA, ii)hx of barefooting-percutaneous parasitic infx: hookworm(Necator americanus or Ancylostoma duodenale), iii) hygiene-feco-oral infx: most likely present with dysentery, caused by Trichuris trichiura), iv)auto-immune ds (SLE, RA)- auto-immune hemolysis]

Prof did touch a little bit on food-poisoning:

i) can the pt point out any food that s/he took that may be the culprit? is anyone else affected-if yes, does this person consume the same food?

ii) has the pt went out to eat? if yes, how is the hygiene of that place/restaurant/stall? its environment?

Investigation:

This pt has thalassemia, so the peripheral blood film would show hypochromic, microcytic, pencil-shaped erythrocytes[is this correct?-a little bit confused]. As for which investigation would you like to request: ask for electrophoresis first as beta-thalassemia is diagnosed by electrophoresis(since it is most common). If negative or not available, perhaps you may want to request for chromosomal analysis(alpha-thal)...

Other things:

• Prof asked about how many percent of myelocytes/myeloblast in peripheral blood film will be diagnosed as leukemia? @ >x% myelocytes/myeloblast=leukemia? - i couldn't find the answer, anyone knows?

• leukemoid reaction- there is leukocytosis with normal amount of myelocytes(may happen in severe infection/stress)

• Causes of macroglossia: B12 & folate def., Down Syndrome, acromegaly, amyloidosis, hypothyroidism.

• Collapsing vs bounding pulse... the term collapsing is used only when the etiology is of CVS problem, otherwise it is called bounding pulse... 5 causes of collapsing pulse: i) aortic regurgitation ii) Patent ductus arteriosus iii) arteriovenous malformation iv) arteriovenous fistula v)i forgot~ sorry!

• hypokalemia in ECG- i)prolonged QT interval ii)presence of U-wave(a camel hump effect next to T wave)- fusion of T and U wave cause QT interval to appear prolonged. Other features: ST-segment depression, reduced T-wave amplitude

• Comments on short case examination: i) Clinical is all about practise ii)During examination, you will be assessed on: speed, steps, smoothness, correlating signs and diagnosis... This shows that clinical skill is the major bulk of it, not your diagnosis... Most students are lacking in smoothness... You need to be systematic, confident and correct. Confidence but wrong is useless and so does vice versa.

• Recommendation from Prof: multiple short cases per day and all systems in each week. (to be honest, I am far from achieving this, please don't blame me if I don't achieve it, I am sharing this for your benefit:) *p/s: I don't want to be CaTakSeruKin...

Disclaimer: I am sorry if I posted the wrong info but at this point of time, I wrote only things that I know are correct(unless I mentioned otherwise). If any of you is able to point out the mistake/wrong info, please, please and please comment on it... you help is very much appreciated!

Mood: this posting is not easy but lots of nice things can happen too:)

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~aku bukan parasit~ #002 CVS examination

Assalamualaikum~

nk share skit psl CVS examination, sekadar yg tahu, mgkin ad silap ataupun salah, tlglah betulkan ye.

mcm biasa, PPD sntiasa diamalkn, introduce urself.

next, exposure, position(45 degree/higher if pt is uncomfortable)

sume da ok --> g end of the bed: General inspection(Dr ckp student slalu lupa tang ni, so tgkla sume2 ea, any branula/drips/infusion/oxygen mask/sputum cup/inhaler). ringkasnya, apa2 barang yg ad kt sekeliling pt tuh~ (klu neuro, mgkin leh tgk tongkat/walking frame). N kalau da nmpk tu, pandai2la describe, (mgkin site/type of drip/infusion).

Dr pun ad mention ttg venti mask. cmne nk bezakan face mask VS venti mask? ans: presence of venturi valve(yg warna-warni tuh). Xperlu hafal colour coding utk venturi valve, sbb lain hospital, lain colour coding yg digunakan(Dr ckp) tp make sure check bpe conc oxygen yg digunakn...

Ok, next section> inspection of the hands

firstly, tgk ad clubbing x? causes of clubbing: IE, congenital cyanotic heart ds(transposition of great arteries, tetralogy of Fallot). n tgk jgk stigmata of IE(clubbing, Janeway lesion, Osler's nodes, distal emboli, splinter hemorrhage). splinter hemorrhage ni can have other causes jgk. Cthnya: trauma(most common)n vasculitis.

pastu jgn lupa pulse(radial pulse). Pulse kene describe tiga benda:rate(bpm), rhythm n volume, character(eg. collapsing pulse).

**collapsing pulse: mula2, tny pt ad x sakit kt bahu(sbb kta nk agkt tgn dia, klu sakit n dia xbg agkt, xyah k?). pastu guna tpk tgn anda: use ur palm and feel for the pulse. then release it until u can no longer feel the pulse and life the patient's arm. If u feel the pulse/bounding pulse then there is presence of collapsing pulse. Nape name dia collapsing pulse? sbb korg dpt rasa pulse yg kuat pastu tetba hilang... hmm, xpernah experience tp dgr org ckp n bc definition, mcm tu la...

then check for radio-radio delay n radio-femoral delay

-> face examination

Eyes
look for signs of hypercholesterolemia(xanthelasma/corneal arcus). Tapi corneal arcus is common in elderly, so not necessarily that elderly pt has cholesterolemia if s/he has corneal arcus. But if u see corneal arcus in a young pt, then it is a sign of hypercholesterolemia. Check for anemia/jaundice.

Mouth
Oral hygiene(might be source of IE)
central cyanosis(under the tongue)
high-arched palate(use a torch, make sure u see enough palate to identify a high-arched palate)

->neck examination

Then check for JVP(jugular venous pressure)- refers to IJV; how to locate IJV? hmm, u need to know the course of IJV; it runs from the TMJ(temporomandibular joint) and its inferior end passes in between the sternal and clavicular heads of SCM(sternocleidomastoid muscle). So basically, tgk TMJ n the region btwn the two heads of SCM, make a perpendicular line, n look somewhere there(last sentence ni teori sy sndiri yg diadaptasi drpd teaching dgn specialist, xde mention dlm mana2 textbook, so klu xnk caya pun xpe). btw, IJV lies deep to SCM, so SCM ni kira a good landmark for JVP. pastu, to identify JVP, u need to know its characteristic, (it is visible but not palpable, double pulsation[bc blik physio nape double pulsation k?], positive hepatojugular reflux, the pulse obliterated by touch, decreases with inspiration). dlm stiap sume ni, msti ad sebab dia kn? so, back to basics-physio

***in case there is raised JVP, must palpate for liver!(According to Dr N)

-> chest

inspection: chest deformities, scar (e.g, midline sternotomy: CABG or valvular replacement), pacemaker(look at both left n right sides)and precordium: visible pulsation?

palpation: start with apex beat(start from most lateral and inferior). locate(normal position-5th I.C space, mid-clavicular line) and describe its character (normal, tapping, heaving, thrusting, double-pulsation).

**normal is normal, tapping is only in mitral stenosis(only mention it if u r sure there is murmur there), heaving is when there is increased resistance(stenosed/restricted outlet or systemic HPT), thrusting(volume overload. eg., mitral regurg, tricuspid regurg, CCF), double-pulsation(don't know the reason of this. anyone knows?)

However, you might not be able to palpate the apex beat. So what can be the causes? Anything that can prevent the transmission of the pulsation to your hand(obesity, pneumothorax, pleural effusion, pericardial effusion). You might want to ask the pt to move to left lateral position if you can't feel the apex beat.

palpate the thrills(over the area of each valve: mitral, tricuspid, pulmonary, aortic)- use the tip of ur finger
and also look for parasternal heave(use the heel of ur palm)

Auscultate!

start with bell(low-pitch) over the mitral area/apex to look for murmur radiating to the axilla. if nothing, then change to diaphragm, listen again and go to the next valve. usually the sequence is mitral-tricuspid-pulm-aortic. also, when u find a murmur, u need to perform the manoeuvre to accentuate the murmur and where it radiates to(i won't tell bout this coz im not yet sure myself). u also need to listen over carotid artery(both sides) for radiation of aortic murmur or perhaps carotid bruit(in case of carotid stenosis).

n ask the pt to sit up n auscultate the aortic area(right 2nd IC space)- a manoeuvre for aortic regurg(previously written as mitral regurg. sorry for the mistake). then, auscultate the base of the lung(bibasal creps) and check for sacral edema.

Last but not least, never forget pitting edema(and of course, always look at the patient's face!)

lupa lak nk ckp: Dr pesan, klu ad peripheral signs of IE, palpate for spleen!

n after u have finished ur examination, present everything in sequence. yg plg pnting: murmur(describe the site/radiation if any, type and grade), pt in failure or not, in sinus rhythm or not.

your finishing sentence: "this pt has the clinical evidence of ____________ (e.g, mitral stenosis, aortic stenosis, etc. )


in case u got exam question such as "palpate this pt's radial pulse", u still nd to do general inspection(at the end of the bed) n mention everything about the pulse~


All in all, Dr N ni mmg style~ jom kta sama2 doa dia dpt hidayah dr Allah...

**pt yg ad AVF(arteriovenous fistula- yg utk hemodialysis tuh) xdpt rasa radial pulse sbb da ad connection btwn artery n vein..



isu semasa: nk kuar study grup???

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~aku bukan parasit~ #001

~aku bukan parasit~

Cervical cancer may affect woman of any age, especially those who have been sexually active. Human Papilloma Virus has been shown to cause ~100% of this cancer which 70% is attributed to HPV-16 and HPV-18(there are up to 15 serotypes which can cause cervical cancer). Vaccination against HPV-16 and HPV-18 is now available. Despite vaccination, one still has to undergo regular PAP smear for screening purpose.

The recommended schedule for PAP smear: annually for three consecutive years and three yearly until the age of 54 and after that 5-yearly until the age of 65 (provided the smear shows normal result. If any of the smear is not normal, please do the necessary-proceed with further investigation)

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