Saturday, July 30, 2016


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 brachial.

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 at my hand, and down? Pallor, jaundice.

7. Could you open your mouth and stick out your tongue? 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. 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. On 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 hard sound, followed by 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 she has mitral stenosis with no signs of IE or pulmonary hypertension.


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 at my hand, and 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 - valvutomy, 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 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.

I wouldlike to complete my examination by taking the BP of the patient, looking at his temperature chart and do a neurological examination for stroke.

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.

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.

2. General inspection - "Just going to 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 20 to 19 to 18 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 spread out your fingers as if you are playing the piano?"
"Can you show me your hands movement as if you are opening the water tap?"

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.
" Can I get you to start straight here, I want to test how stable are you, but I will stand right behind you so dont worry about falling. I will give you a little pull to the back, and just try to stay stable as much as possible"

8. Higher cortical function
"Just to test how are your speech - can I get you to tell me your name and your date of birth?
Look for dysarthria
"And how about your writing - can I get you to write for me your name and follow by ur address?
 Look for micrografia - and his function

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 I get you to show me how you drink a cup of water? Any difficulty swallowing?

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, AMT (swalloing, writing and speech if not done)


It is a pleasure to examine Mr X. He 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 dystonic arm or alien limb syndrome.

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.

Saturday, January 23, 2016

Belleview and Property Purchase

I bought my first property rather inexperiencedly, i admit.

Well, I must say that buying property is a very steep learning curve. I would put it as equal as choosing a life partner, because, you are going to be with this commitment for life (oh well, unless you are speculator, or you are damn rich person)

I would like to write this entry just to make sure somewhere someone who read this will think twice when you buy a property.

1. Property Construction Company.

Serious, BELLEVIEW GROUP is a total disappointment. When I first saw the apartment that I bought in a fair, i googled BELLEVIEW GROUP. It seems like a good, trustable, oldie in this field.

Wrong, very wrong. But it is a good learning opportunity. Not only the worksmanship is less than shoddy, the way they treat us post sales is deplorable. No way that I will buy another property with Belleview Group of Companies.

My experience dealing with them and afterwards with other companies and contractor and other buyers chitchating - best trustable names are still IJM, SETIA, BSG, Ideal. Ya. Dont transact with Belleview, unless it is absolutely bargain, oh well, I wont still.

2. Lawyer

Now, I worked as a medical officer in a busy government hospital (time of purchase). I have very little knowledge in legal process of purchasing a property. As a medical person, I see logic in every step in whatever we do. For example we do a CXR before starting biologics treatment to avoid having a patient with TB on biologics. But why are we paying the lawyers so much money for a stack of photostated agreement?

I have only spoken once with her, during which I made the full payment of the legal fees (approx my one and half month salary), for 15 minutes.

And the rest of it, I only see her clerk (a very junior officegirl) whereby I signed all the documents. And I knew it was merely clerical photostated because, it was the similar ones, with different names, number of unit, and dates when I accompanied my good friend to the office - he bought the nearby unit of the similar apartment with me.

I cant help but asking - what is the value adding in this transaction?

I still not knowing what is my rights, nor what I should do in unsatisfactory transaction with the seller. None.

(*the reason of my rants is that I cant imagine the same done by a doctor to a patient, imagine you paying me one month salary and I let my junior nurse talk to u for a procedure I do for you when u are asleep...cannnot right, because we are doctors right? Can feel my sarcasm?)

******************To be Continue**************when I am free. Sorry, need to attend to my patient, for an exorbitant  fee of rm20/consultation of 10 minutes me talking to the patient face to face and take the liability of being a cheater if the symptoms worsened.

Friday, January 22, 2016


Wanted to buy a stethoscope and so was searching online to compare prices.

Remember the first time you were holding the stets?

Oh, that light green colour stets, my first stets, I wonder where you are.

It was the beginning of second year medical school, i remembered at that time I still brought the box with me in the bag.

When the GP says we are going to listen using stets, I took out the box and take out the new, brand new stets.

Haha! Fast forward...about 8-9 years already.

I lost that stets in the first year of h.o ship. Dont know which scumbag stole it. Grrrr

Going to buy a good, cardio stets this time! With my name!

Okla, one post every quarterly, to maintain this blog.

Have a good day people!

Saturday, November 28, 2015

What I Learnt from Phase 1 Conference?

I always feels that international conference is very much different than local conference, in the sense that the talks and speeches are on their work, unlike local ones which sometimes talk on the textbook content.

And so with a bit of luck, I had the chance to go to ICPOEP - International Conference on Phase 1 and Early Phase Clinical Trials in Hong Kong.

All the way from Seberang Jaya at Grand Hyatt Hotel, TST defined Phase 1 as studies that are usually conducted with healthy volunteers and that emphasize safety. The goal is to find out what the drug's most frequent and serious adverse events are and, often, how the drug is metabolized and excreted.

Of course, the obligatory photo as a traveler in Hong Kong
This conference is organised by Clinical Trial Centre, University of Hong Kong. As you can see, their's is a bit different setup from ours in Clinical Research Centre, Malaysia. They are part of the university and their hospital is part of the university.

There is a section displaying their trial set up. There is a large picture of the view from clinical trial ward. The hospital which houses the trial ward is overlooking ocean view of Hong Kong. They make the subjects feel that they are on Holiday rather than coming in for Research. Basic amenities such as soaps, shampoos, slippers are Hotel-like, and menu of the food there is extremely attractive!

Each of them given this starterpack. Note that there is an IPAD with entertainment, something like flight entertaiment concept.
Macam Hotel
Menu. Ganas.
The talk started right on time. Good organisation I would say. The list of speakers were impressive. Mostly were Chinese names based in overseas, renowned medical centres, like Ninewells Dundee, NUS Singapore, Imperial London, Uni of Toronto Canada, Harvard just to name a few.

I took pictures of almost all slides to keep me awake throughout the sessions, and for the purpose of this entry, for my goldfish memory. I'll share some slides which are very interesting, at least to me.

Let me start with this Prof Gail Echardt's talk on challenges and opportunities in early phase trial. She was given an award lecture in Drug Development in this annual conference. She is a very established early phase researcher from Colorado, USA. She shared her experience in organising her Phase 1 centres, particularly her strategies in nurturing new researchers and going away from MD-driven hierarchy. 

I particularly like this slide. She showed that there is a disease specific team leader and coordinator which oversees the Phase 1 study, specifically on that disease, and they typically follow through as the study progresses to Phase 2 and 3. 
Let me just say that in this slide, the last sentence is the killer!
I think I will not be able to go in depth in all talks. 

Let me move on to my favourite speaker, Prof Lee M Ellis. His CV is long, but for the sake of his speech, suffice to know that he is a journal editor. He talked about research integrity. 

He talked about increasing occurrence of fraud and dishonesty in research conduct. He feels that this is all because of academic pressure which is unnecessary. He gave examples of Japanese Riken scientists and Anil Potti in Duke. 

I think it is very relevant to us, in Malaysia whereby the push for publication is high, but without proper mentoring. There is a very high pressure on us to perform. In that process, it is important to keep in mind that we do not sway from good research integrity, attempted plagiarism, sloppy reporting, dishonesty and academic bullying.

I would think most of us are Sloppy, but hopefully we dont Fabricate.
I have nothing to publish in CNS. LOL
It is funny when some proposals I was told that was rejected previously because it has been done. Our top level needs to know the importance of reproduciblity of any research to test the hypothesis repeatedly. We learnt to do more, as we done more.
I would love to see this kind of fresh talk in NCCR.

OK, lets move to a intellectual talk. This Prof Mak Tak-Wah, is extremely funny man. I think he is damn old, probably in his 70s and his job is just travelling around the world giving speech. Despite his age you see, he is given a topic - Future Oncology Targets, just to show how big is his name in advanced research of Oncology. He basically went through from historical perspective on how unsuccessful our endeavors in coming out with new oncology drugs, mainly because we had the wrong conception. But right now, there are many new targets being pursued, which his lab is working on, and he even shared a slide of which it has just been published on that day itself.

New targets, note the footnote. The conference was on 19/11/15 - it was just published today
Warburg is a Nobel Prize winner who said Cancer is not caused by Virus or genes, both very wrong. But we progress not because scientists changed their minds, but because they die. Scientists - sometimes, over-believed their science.
Note that Prof Mak is the main author!
Other interesting speakers and slides:

 This was Prof Swanton's talk on  Cancer Evolution and Implications to research. Oncology which have seen past 12 years of research producing 72 FDA approved drugs with 52 new targeted approaches but only producing meagre 2.1 months of improved overall survival. 
How stagnant is our research progress and yet we we think we have progressed very much.

I think this is an exceptionally good topic. Prof Plesner gave a talk of his entire journey with Daratumumab, a new therapy for Multiple Myeloma. He was there in the Phase 1 trial in his Hematology Unit and Clinical Research Unit and all the way right up to Marketing. Such a complete research story to share.
Dr Chan Wing-Kai is a very outspoken person. He gave a brief outline of clinical trial in Taiwan. More like an advertisement type of talk, he told us the strength of Taiwan Clinical Research. But I took one point from him very deeply, is that if you want to be the boss, you must have gone through the entire process, A to Z, and keep youself involved in the entire process, and then you can be the BOSS. Taiwan is very far ahead of us in Clinical Trial, mainly because they have such competitive character like Dr Chan.
From Singapore, we have Danny Soon, well known figure in the field of clinical research South East Asia. Very straight to the point and motivated person, he is an example why Singaporean soars in every field they put their foot into. We can see from this one slide how far ahead is everyone else in terms of Phase 1 studies.
I checked with NMRR, we have two Phase 1 studies in this country as of today.

All in all, I enjoyed the conference very much, it shows me how behind is my exposure to current world and we need super flying speed to be catching up with the rest of the world.

Perhaps we should start with nurturing good research attitude and research culture. 

and pray.

Thanks for reading.