Tuesday, July 03, 2018

It has been awhile!

Received emails from Blogger for some advert/spam comments.

Realised I haven't blogged anything for damn long already.

So many things happened past 1 year.

I passed my paces in uk somewhere in nov last year.

Got married in may this year.

LOL.

That's all peeps.

Saturday, January 14, 2017

Rheumatology Hands

That day failed my paces - grrrr

Have to restart the whole cycle of revising again and practicing.

Station 5

History

1.Joint pain and swelling - symmetrical, chronology and extent, ADLs - cooking, dressing, showering, and lastly complications - CTS

2. Early morning stiffness - symmetrical, severity in duration (>60 mins, affecting ADL?)

3.Treatment - previous treatment, tolerability, SEs, complications monitoring.

Examination

Look - Feel - Move

- Symmetrical Deforming Polyarthropathy affecting small joints of the hands, sparing DIPs
- Ulnar deviation of the MCP
- Boutonniere's and swan neck deformity
- Z-thumb

- Piano key ulnar head

- Rheumatoid nodules, elbows/any pressure points

- Surgical scar - CT decompression

- Extraarticular manifestations :
Hematological - pallor, splenomegaly (Felty, with neutropenia)
Skin - nodules, vasculitis, pyoderma gangrenosum
Eye - scleritis (more severe, painful compared to epi-), episcleritis, scleromalacia perforans
CVS - valvular disease, pericarditis, CAD, myocarditis, heart failure
Lungs - pulmonary fibrosis (lower zones), pleural effusion, lung nodules, bronchiolitis obliterans
Renal - amyloidosis
Neuro - peripheral neuropathy, mononeuritis multiplex, compression neuropathies such as cervical myelopathy (atlanto-axial subluxation), CTS, ulnar neuropathy

Function

Power grip
Undo button
Pick up coin

Investigation

Blood test -
Inflammatory markers - ESR, CRP
Blood counts - Anemia of chronic disease, Low WBC in Feltys
Rheumatoid Factor - a/w severe disease, 80% RA has it
Anti CCP - cant do in active TB, very specific

Xray - look for reduced joint space, periarticular osteopenia, erosion, deformity

CXR - pleural effusion, pulmonar nodules , HRCT

Treatment

Multidisciplinary approach involving physiotherapy, OT, dexterity aid and modification of homes
Mainstay pharmacological treatment is DMARDs - MTX, Sulphasalazine, Leflunomide, Hydrochloroquine. Pain management - NSAIDS and COX2 inhibitors
Lastly, Biologics - TNF blockade - infliximab, adalimumab, golimumab

Sunday, October 23, 2016

Fortis Atque Fidelis

Forgot to post about this.

In the midst of my exam preparation, I have no regrets spending one whole half day in the grand old lady.

I might not be the best of the student that came out from the school, I still share some of my most memorable moments of pride, disappointment, fun and excitement in the PFS.

This is the place I learnt the values of sportsmanship, with the big field we had almost daily football using some unwanted plastic bottle on the friday afternoon.

At that time, I didnt know what is pancit, energy seems boundless and the only reason we stop running is because it is sadly the time for the computer period at 2pm.

This part was written on 21 October 2016 morning and it is the school speech day. I have not missed any of the speech day, and to this date my parents have not been to any of the speech day despite their son winning best subjects prizes every year (haha, good old days of academic excellence) as they were scared of teachers complaining their son being mischievous and always wear unironed clothes to school after being summoned once to my primary school for that reason.

Hope the next generation of PFS will keep the  spirit flying high.

FortisAtqueFidelis.

Saturday, October 22, 2016

ILD

I would like to end my examination by checking the temperature chart, doing a peak flow meter and looking into the sputum pot of the patient.

Mr X has a diagnosis of interstitial lung disease, currently not in respiratory failure.

On general examination, he is not tachypneic, with respiratory rate of 16 breaths a minute. He has finger clubbing with no signs of carbon dioxide retention. There is no jaundice or pallor and no central cyanosis. His tracheal is centrally located.

On chest examination, there is no scar or deformities noted. My findings are confined to the bilateral lower zone, with reduced chest expansion, dull percussions, reduced breath sounds with fine-end inspiratory creptitations not altered by coughing and normal voval resonance. The JVP is not raised, no displaced apex beat or loud P2 and there is no pedal oedema. There is no palpable cervical lymphadenopathy.

In summary, Mr X has findings in keeping with a diagnosis of interstitial lung disease and currently not in respiratory failure. In the context of chronic lung disease, there is no sign of cor pulmonale. The likely etiology would be idiopathy pulmonary fibrosis. I would like to offer a few differentials of lower zone fibrosis such as connective tissue disease induced - rheumatoid arthritis, SLE and dermatomyositis, drug induced fibrosis - amiodarone, methotrexate and nitrofurantoin and radiation induced fibrosis.

Friday, October 21, 2016

Communication Station

5 minutes preparation:

1. Decide need to ask for family members/friends to be in the room? - Bad news vs the rest

If bad news....

2. Warm up: How is the patients since last seen?

3. Current understanding - What is the level of understanding? -  of the condition of patients/ relatives/ of the test done - reasons)

4. Perspective - What do the patient think is the problem? What is the expectation?

5. Shoot - warning shot, silence and shoot the news, and silence.

6. Tissue.

7. Permission to continue.... Explain the diagnosis/ ever heard before / anyone in family/friends had it?

8. Expect patient to ask - why me? - Usually unknown.

9. Expect anger - why no picked up early? - Not entirely sure what has transparent between you and the GP, it seems to be this is reasonable time line. Difficult to diagnose with non-specific symptoms. etc etc. Goreng.

10. Investigation further. Referral to specialist team

11. Treatment modalities

12. Outlook.

13. How are you feeling about this news?

14. What is going through your mind?

15. Anything I can help?

16. Probe social history - talk around the family/plans to tell them/offer appointments together and discuss with family members together. Information leaflets. Society to talk to.

17. How to go back? Offer taxi.

18. Next appointment. See consultant. Ask more questions.

Monday, October 17, 2016

Spastic Paraparesis

Spastic Paraparesis

Young:
Multiple Sclerosis
Cerebral Palsy
Trauma
Infection - HIV
Motor Neuron Disease

Old:
Trauma
Transverse myelitis
Infection of HIV, TB and Syphilis
Motor Neuron Disease
Spinal Cord Tumour
Syringomyelia
Anterior Spinal Artery Infaction
Subacute Degenerative of the Cord

Others:
Hereditary Spastic Paraparesis
Tropical Spastic paraparesis
Bilateral Stroke