Tuesday, August 30, 2016

Renal Transplant

Did very badly in today's practice. Missed not just one but two AVFs!

1. Wash hand, introduce and consent.

This renal transplant patient~!~!~~!

2. Exposed patient from waist up, and general inspection of surrounding, and patient as a whole. ?Cushingoid ?Pigmented ?Sallow appearance

3. "Is there any discomfort anywhere?"

4. "Can I have a look at your hands? Check for clubbing, leukonychia, palmar erythema, Duputrun's, Flapping tremor, tremor

5. Check for AVF on both upper limbs, if found, with three fingers to feel the thrill, and look for any recent puncture marks? Move up to see any tattoo, bruising, thinning of skin.

6. Check eyes - look up and look to the finger. Pallor, jaundice.

7. Check parotid swelling.

8. Open mouth for me, and stick out your tongue, show me your teeth, look for gingival hypertrophy.

9. Examine the chest - look for spide naevi.

10. Raise your arms to your head, and look at axillary hair

11.  Check gynaecomastia

12. Inspect for scar (RIF scar?) and Palpate abdomen - soft then deep. Noted a mass and a note its size, bean shaped, tenderness, firm, percuss on the top, listen just next to it for bruit.

13.Liver, palpate the percuss.

14. Spleen, palpate, then precussed

15. Tap on the midline for any fluid. No ascites. Check sacral oedema.

16. Ballot for kidneys

17. Check pedal oedema.

18. Sit up and check LN and then check for proximal weakness.

19. Cover up and present.


Mrs Lee has Cushingoid appearance with moon face, supraclavicular fat pad and dorsal humb. There are two AVFs on bilateral forearms with no thrills and recent puncture marks. Other examination reveals conjuctive pallor, hyperpigmented skin lesions on the left temporal measuring 2cmx1cm and gum hypertrophy.

Moving on the the abdomen, there is a scar at the RIF and a mass measuring 6x 4 cm beneath it which is firm and bean shaped. It is non tender, dull on percussion and there is no burit audible. The rest of the abdomen is soft, no hepato or splenomegaly. There is no ballotable kidneys. He has no ascites, scaral, pedal oedema.

In summary, Mr lee has a transplanted kidney for ESRF which is functioning well. Etiology for ESRF for this lady would need some further history as I could not find obvious signs of common causes such as DM, Hypertension, Glomerulonephritis or APCKD. There is no signs of fluid overload and uremic encephalopathy. In terms of immunosupression, she is likely to be on steroids and cyclosporin, with no lymphnodes palpable but there is a suspicious skin lesion on the left temporal which needs further work-up. Would like to end the examination by checking his urine dipstick and blood pressure measurement.

Tuesday, August 09, 2016


Doing postgraduate examination is such a humbling journey.

Without patients, we are nothing,

We learned from them more than anything else.

We should thank them rather than the other way round.

Ah, back to books.

TTM moments.

Saturday, July 30, 2016

Mitral Stenosis

1. Wash hand, introduce, consent.

2. General inspection - malar flush? expose - scar?

3. Can I examine your hands please? Peripheral stigmata of IE. Finger clubbing.

4. Just going to feel your pulse. Rate, rhythm - AF?, volume and character. Feel the other side, and then femoral. Feel the brachial. Then collapsing pulse.

5. Could you look slightly to the left for me, just going to examine your neck. Look for JVP - systolic v wave. raised?

6. Could you look up for me, just going to check ur eye, and look to my finger down there? Pallor, jaundice.

7. Could you open your mouth and stick out your tongue, and up to the roof? Dentition and peripheral cyanosis.

8. Going to examine your chest. Look for the scar - mitral valvutomy, left lateral.

9. I am going to feel your heart beat. Feel for 1. Character - tapping S1. Displacement. The parasternal heave, and thrills of TR.

10. I am going to have a listen, and feel the neck at the same time. Apex diaphragm, S1 - loud? S2. Then opening snap? Early in diastole. Any murmur? Radiation to axilla. Now turn to bell. Mid diastolic murmur? Turn to left lateral.

11. Proceed with LLSE, LUSE, RUSE. If murmur then proceed for accentuation.

12. Lung bases and pedal oedema.

13. Cover up and thank the patient.



Ms X is not breathless at rest. There is no peripheral stigmata of IE. Her pulse rate is 80 beats per minute, irregularly irregular, but with normal volume. The JVP is not raised. There is no malar flush.


Moving on to the praecordium, there is no scar. Apex beat is tapping, undisplaced. There is no heaves or thrills. On ausculatation there is loud first heart sound, and normal second heart sound. There is an opening snap in early diastole. There is also a mid-diastolic murmur at the apex, 3/6 in grade and accentuated by left lateral position with breath hold in expiration. The lungs is clear and no pedal oedema.


In summary, Mrs X has a mitral stenosis with no signs of IE and not in failure. There is no sign of overwarfarinisation for the AF. The most likely etiology for MS in her is Rheumatic Fever. I would like to complete my examination by looking at the temperature chart, urine dipstick and measuring her blood pressure. Thank you.


Aortic Valve Replacement

1. Wash hand, introduce, consent

2. General inspection. Expose - median sternotomy scar. Breathless at rest? Corrigans? (so as to look hard for collapsing pulse later)

3. "Can I look at your hands please?" Peripheral stigmata of IE 

4. "Just going to feel for your pulse". Rate, regular/irregular, volume. Check the other side for radial radial delay. Check brachial pulse as well.

5. "Do you have any pain in the shoulder? Ok, I am going to lift it up above your head". Looking for collapsing pulse.

6. "Could you turn slightly to the left, just going to check the neck". Looking at JVP and carotids. Feel for the carotids. 

7. "Could you look up for me, just going to check your eye, and look down?" Check for anemia and jaundice.

8. "Could you open your mouth for me and stick out your tongue" - look using torch. Check dentition and central cyanosis.

9. "Just going to examine your chest now". Look hard for other scar - mid sternotomy scar, valvutomy scar, palpate for pacemaker.

10. "I am going to feel for your heart beat". Palpate for apex beat, then parasternal heaves and any thrills. Count ribs. Displaced - likely AR, undisplaced 5th intercostal space, midclavicular line - likely AS. 

11. "Just going to have a listen and feel the neck at the same time". Apex - diaphragm - check for S1 and S2 (look hard for prosthetic click - time with the carotids) Bell. LLSE - diaphragm. LUSE - diaphragm. Listen hard for Early Diastolic Murmur !! then RUSE - diaphragm. Likely to have a ESM at aortic area.

12. "I am going to listen to the neck, could you take a deep breath and hold it" - radiation for ESM to the carotids

13. Could you sit up for me, lean forward, and big breath in and out and hold it for a second? - listen hard to EDM again!

14. Listen to lungs, and check for pedal oedema.

15. look for bruises, and harvesting vein at the legs and radial.

16. Thank the patient, cover him up and wash hand.


Mr X had undergone an aortic valve replacement for, most likely AS. 

There is no peripheral stigmata of IE. His pulse is 70 beats per minute, regular and normal volume. There is no collapsing pulse. JVP is not raised, and there is no conjunctiva pallor or jaundice.

On my examination of the praecordium, there is a midline sternotomy scar. Apex beat is not displaced. There is a normal first heart sound and a prosthetic click coincide with second heart sound. There is an ejection systolic murmur loudest at the aortic region, but no radiation to the carotids. I would grade it 3/6 with no palpable thrills. There is no early diastolic murmur or collapsing pulse to suggest valve failure, and lungs is clear with no pedal oedema to suggest cardiac failure.

In summary, this patient had an aortic valve replacement, most likely for AS secondary to degenerative calcification. There is no clinical evidence of valvular leakage, thrombosis or hemolytic anemia. There is also no signs of pulmonary hypertension or cardiac failure. There is no sign of IE or overanticoagulation. I would like to complete my examination by taking the BP of the patient, looking at his temperature chart and do a urine dipstick.

Monday, June 13, 2016


They say money will never be enough.

I read somewhere that do not ask a female her age.

Did not mention why.

and do not ask a male, his income.

But it mention why.

It is because 90% of his income is spent on others.


Friday, May 06, 2016

Parkinsons Disease

1. Wash hand, Introduce, Consent.

This looks like Parkinson?

2. "Hello Sir, can you me your name and your address?" - monotonous, low volume speech?

3. General inspection - "I am just going to stand here and have a good overall look first"
 Walking aid? Looking at the patient, Expressionless, mask-like face, reduced blinking

3. "Any pain anywhere?"

4. Tremor -
Put both hands on a pillow/lap - thumbs and indexs top and radial surface bottom - to show pill rolling more evidently. Is it symmetrical? Coarse? Pill-rolling?
"Could you close your eyes for me, gently and count backwards from 10 to 9 to 8 and so on...?
- distraction method to enhance tremor
"Could you lift up your arms and spread out your fingers like this?"
- rule out postural tremor

5. Rigidity -
"Just going to examine the muscles and movements of the arms and hands, Can you go floppy and soft, just let me take the weight of the arm, relax and soft, relax and soft..."
- Supinate and pronate, extend and flex elbow, extend and flex wrist, both sides
Look for lead-pipe rigidity at the elbow, cogwheeling at the wrist.
"Could I ask you to tap your knee with your other hand like this, keep going while I examining this side? and the other side
- Synkinesis would accentuate the rigidity almost instantaneously

6. Bradykinesis
"I am going to need you to do this movement like twinkle stars, as fast as you could and keep going keep going keep going:
- decreased amplitude and speed as it goes
"Can you show me your hands movement as if you are opening the water tap?"

(proceed with power and reflex)

7. Postural Instability
"Sir, do you think you would be able to take a few steps across the room and show me how you walk?" Can you walk over to the door and make a U-turn back here as you would normally?
- Look for difficulty to initiate movement of getting off the chair and start walking, stooped posture, hesitation, shuffling, narrow based gait, reduced arm swing, difficulty in turning with accentuation of pill rolling.

9. Function
"Can I get you to show me how you unbutton your shirt, just a few buttons? and can you put that back?
"Can you write your name for me?" - holding pen and write

10. Rule out PSP
"Just going to check your eye movements. Can you keep your head straight and still, and use your eyes to follow my finger? Keep going keep going... all movements
 Look for vertical gaze palsies, and nystagmus for cerebellar disorders
"Could you close your eyes and  keep your arms straight, palms nice and flat up like this?"
- pronator drift
"Could you form a pointer like this and touch the tip of my finger and then the tip of your nose?" and the other side
- check for cerebellar sign

I will complete the examination with full neurological exam, supine and erect BP, MMSE, swallowing test and writing.


Mr X is an elderly gentleman with Mask-like and expressionless face, monotonous and low volume speech. He has asymetrical tremor at rest, predominantly on the right side with characteristic pill-rolling movements of the thumb. The tremor diminished with usage of the hand, but accentuated by walking and distraction. There is presence of lead pipe rigidity at the elbow joint, cogwheeling at the wrist joint and both accentuated by movement of the contralateral upper limb. He has bradykinesia with reduced amplitude and speed of his fingers movement. He has difficulty getting up from his chair and initiating walking, with stooped posture. Once walking, he showed shuffling, narrow based gait, with lack of normal arm swing, and slow in turning.

Functionally, he can dress up himself, able to walk unaided.

He does not have features suggesting PSP. There is no sign of PSP such as impairment of vertical gaze. There are no cerebellar sign to suggest MSA, or sign of corticobasal ganglia degeneration such as pyrimidal signs or dystonic arm.

All in all, he has features in keeping with my diagnosis of Parkinsonism, and most likely  due to Parkinsons Disease with good preservation of function, and no evidence of dyskinesia at this point in time.