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.


Saturday, October 22, 2016


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

Multiple Sclerosis
Cerebral Palsy
Infection - HIV
Motor Neuron Disease

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

Hereditary Spastic Paraparesis
Tropical Spastic paraparesis
Bilateral Stroke


1. General inspection - cachexic, tachypnoea?, barreal shapped chest, inhalers devices or oxygen around

2. Observe the breath in and out - pursed lips breathing

3. Examine hand - tar stain, palmar erythema, flapping tremor

4. Pulse - Bounding pulse

5. Respiratory rate

6. Eyes - suffused conjunctiva

7. Mouth - Central cyanosis, pursed lips breathing

8. Neck - JVP

9. Trachea - Reduced cricosternal distance (less than 3 fingers), central?

10. Inspect the chest again front and side - barrel shape, hyperinflated chest (vertical > horizontal expansion

11. Feel Apex beat - displaced, or difficult to appreciate - emphysematous

12. Parasternal heaves, P2? cor pulmonale

13. Chest expansion - 3 places

14. Percussion - resonance? dull? Apical, 2 middle, 1 axilla

15.Auscultation - Breath sounds reduced or equal? Bronchial breathing? Prolonged expiratory phase, Inspiratory coarse crackles, Expiratory wheeze.

16. Vocal resonance

17. Swing to the back

18. Feel for lymph nodes

19. Expansion again

20. Percuss - apical, 2 middle, 1 axilla

21. Auscultation

22. Vocal resonance

23. Pedal oedema

Thank patient


I would like to end my examination by checking Mr ABC's temperature at the observation chart, doing a PF and looking into the sputum pot.

Mr ABC has the appearance of plethora, flushed looking and purse lips breathing. He is tachypneic at rest, with respiratory rate of 24 breaths a minute and usage of accesory muscles and intercostal recession.

On peripheral examination, there is finger clubbing, palmar erythema and nicotine stain. I found signs of CO2 retention with bounding pulse and asterixis.  On face and neck examination, he has suffused conjunctiva, but no jaundice or central cyanosis. His tracheal is centrally located.

Moving on the the chest, there is no scars noted. The chest looks hyperinflated with appearance of barrel chest. My chest findings are: Reduced chest expansion bilaterally throughout, resonance percussion, reduced air entry on the right hemithorax and coarse pan-inspiratory crepitations on the left lower zone which is altered by coughing. Vocal resounce is unremarkable. There is expiratory wheeze all over the lung fields with prolonged expiratory phase.

There is  no pedal oedema and JVP is not raised and there is no loud P2 or parasternal heaves.

Cervical lymph nodes are not palpable.

In summary, Mr ABC has emphysema on the right lung and left lower zone bronchiectasis with underlying COPD secondary to cigarette smoking. He is in respiratory failure. In the context of chronic lung disease, there is no signs to suggest cor pulmonale.

Saturday, October 15, 2016


I would like to end my examination by checking the genitalia of the patient and performing a per rectum examination.

Mr Ahmad is a young, thin and hyperpigmented gentleman with short stature. On peripheral examination, he has no stigmata of chronic liver disease. He has conjuntiva pallor and jaundice, with frontal bossing, prominent maxillaries and chipmunk teeth appearance. There is also sparse axillary hair.

Moving on to the abdomen, there is a scar at the left upper quarant, well healed. There is hepatomegaly, measuring 4 f.b, with smooth edges, non pulsative, non tender, and no bruit heard. Spleen is not palpable. There is no ascites, and kidneys are not ballotable. There is no cervical lymph nodes palpable, lungs is clear and no pedal oedema.

In summary, this young gentleman has signs of chronic hemolytic anemia with pallor and jaundice with underlying Thalassemia major and previously undergone a splenectomy. In terms of complications of the disease, he has signs to suggest hypogonadism and iron overload.

I would like to do a few investigations  namely blood test of full blood count to make sure he is adequately transfused Hb9-10, LFT is also required. I will also send ferritin level, transfusion related infection of Hep B/C/HIV serology, endocrinology work-up of thyroid function test, HbA1c/FBS and sexual hormones - LH/FSH/Testosterone/Estrogen.

Also, he will need to undergo cardiac MRI T2star for cardiomyopathy and Dexa scan for osteoporosis.