Sharing and caring

I started this blog few month ago with high spirits. To share my limited knowledge and offer some guidance to my colleagues taking internal medicine.

I've always wondered why despite 3 postings(180 people) who have taken medicine, less than 10 is willing to share. Like i've always said, We need to complete each other, not compete with each other. Holding on to this, I tried my best to offer guidance to my colleagues, whoever interested.

But it seems that i overlooked the dangers of teaching, especially in a medical faculty. Different people have different styles and these people always say other methods are wrong except for their own.

Therefore, my opinion may differ from other people. Although i am 101% positive i am right, how am i going to argue with an MMed or MRCP's opinion?

and some not so nice comments also passed from mouth to mouth that I am being "too free". The irony is, i am in O&G. So i think i must be very brilliant such that someone noticed me of being too free in this hellish posting.
Some wind told me about getting arrogant, from my style of walking etc etc

Come on.....some times i walked a little fast and maybe limping to one side because i have chronic back pain of unknown origin(possibly due to my mattress contour). Not trying to look like a consultant or something. And most of the mistakes i corrected is MY mistakes. In every little advice i give, i was hoping the receiver will be far far above me in the exams by not repeating every little stupid mistake i make.

If you think its useless, you can just assume i am singing a very lousy song. If you think i'm being too fussy over small small mistakes, trust me, the consultants you will be meeting will be far more fussy than i am. If i don't know an answer to a question you asked, i will say i don't know, i will offer a possible explaination, i will ask you to look it up and up to you to prove me wrong! If you choose to swallow whatever i said, then whose fault it is?

So the best thing in my mind now is, don't ask me anything, go find from books. Any questions from now onwards will meet a same universal answer from me -->"I don't Know".

And 1 most irritating things going around is that i only share with my "gang". Whoever is my "gang" i don't know, but so far, i think i've never turned down any request for advice or guidance.

Some people find it irritating for me to question them. They want everything to come out from me for me to absorb. But believe me, questioning is a method to know where you stand. If i do not ask the questions that had been asked in short and long case, how are they going to know what to expect? Sometimes, i may ask some quite "unimportant" questions, this is to scare you into studying so that you will excel......not to,like yi hui put it, "berlagak" that i know the thing in front of you!

Sometimes, i overestimated people's level and sometimes, i underestimate. Trust me, this is disastrous.

In my medicine posting last time, how i hope that someone will offer some guide to me. How i hope someone will show me what short case is like. How i hope to know how long case feels like. Luckily, i have a very dedicated supervisor and registrar who did just that, with liberal amount of tachycardia, of course. Which is why i wanted to give exactly the same thing to my colleagues, without the tachycardia.

But i just seem to create a not so nice environment for myself. Feel weird that people don't even smile at me when i pass through the corridors in the Medicine wards. Really, i am 190 cm tall, its not that hard to saw me isn't it?

Back in my form 6 days, i used to generate a wonderful bond with all my friends in our Biology study group. I tried to apply the same idea here, unfortunately the early results seem to fail quite miserably. My style is terrible and incompatible here

therefore, my point is i am not giving any more teaching or guide to anyone anymore. It's not worth sacrificing my image for it.

Before i get labelled as a Consultoid (Yew yew teach me this term haha) by other people, i'd better quit now:)

PPD component
I learn that medical students are just too smart to be cared for :)

Ashamed,,,,,

in response to kuan yew's blog Times when I am ashamed to be a chinese. -不管别人瓦上霜

This is my comment

I agree!! Sometimes chinese people just don't give a shit about what happen around them.
They think that to care about their surrounding is a stupid thing to do.What happen is, when they are in trouble and nobody help them, they start making so much noise!! Complain to DAP,complain to MCA, complain here complain there, government not good la, dis la, dat la...sometimes quite insensitive to other people's feeling.
I've got 2 excellent examples here:1) In front of my house, last few months, a 50++ year old woman have her necklace snatched and this cause her to fell off her motorcycle. My neighbours saw it happen because they tengah menyibuk. But they did not help the poor lady at all! They straight away cut short their menyibuk session and go into their home and shut the door,because the victim is a malay lady!
2) when jo ee visited melaka, i was waiting for him at a famosa when a road bully(CHINESE) is bullying a female driver(ALSO CHINESE). I intervened and the bully threatened to hentam me as wel. A whole lot of CHINESE kepoh chees are looking but they couldn't be bothered. At last, before i start wrestling with that fat guy, a MALAY lady shouted and called the police and the bully fled!And the worse part is the female driver just go off, without even a word of thanks!
Tun Dr Mahathir said, Melayu mudah lupai say,

I said, Cina takkan lupa, kerana cina tak pernah ingat :(
Wake up people...

Syabas!!

Syabas to HUKM docs and nurses

Viva Cardio team ! :)

All the best!!

to all my friends going for Medicine shortcase on wetnessday....
Just relax and hope for the best!

Everybody will do fine. Why do i say that? Greet the patient and ask for permission to examine, you got 2 marks out of 12 already. Just conduct the examination step by step and you got 4 marks. Now, that's 6 out of 12, pass already: ) During discussion, even if you are making up stories, do not look as if you dont know. Look at the examiner in the eyes.

To kuan yew, soon hooi, alex and gang, i'm sure you all will score one! Just be confident :)

Who say people Malaysia no clever speaking the England?(Siapa kata orang malaysia tak pandai cakap Inggeris?)

This is the most atrocious English I've ever imagine i could encounter in this life. What's more, it comes from a Government office website!! Kudos to Department Registration Country (direct translation of Jabatan Pendaftaran Negara) for giving me, and the whole world a good laugh.Keep up the good work!(and we will soon be down the drain)



. I’m 17 year old, when should I change my identity card replacement?
A person whose had got first-time identity card namely during old 12 year, are required change again his identity card when have reached the age 18 year. If this change made within life time 18 - 25 year, no any penalty imposed.

2. I already 25 year old and still not have my own identity card. What shoul I do?
To them not yet own identity card although already aged more 16 year are advised to come to any nearby NRD to apply identity card past record. Applicant and promoter must showed up together to be interviewed, bringing with together following documents:-Applicant Born Certificate / AnakAngkat’s Certificate / W’s Form OrApplicant Enter Permit / Confirmation Form National Standard(if concerning)Promoter Identity Card

3. I a foreign citizens and have gotten permit of entry from Jabatan Immigration Malaysia. Whether I qualified to apply identity card? What is conditions for I apply identity card.
You qualified to apply identity card with permanent resident status(Red). Applications requirements is bringing with permit of entry and passport and copy both of them and application fee as many as RM 40.00. Applications can be made in NRD Putrajaya Headquarters and NRD Branches only.

4. Is there any payment am being imposed in case happened damage for chip in my identity card.
Chip damage who is not due to purposely destroyed, misuse and others within one year from the date of submission card is give replacement by free, and if card period has been held by the applicant exceeding one year, payment as many as RM 10.00 imposed.

5. How many payment am being imposed if I loss identity card?
Lost identity card would be charged follow loss number. Please see payment schedule.

6. How long MyKad’s application period can be completed?MyKad can be completed within 24 hours as applicant whose opted to take MyKad in NRD Putrajaya headquarters.
For applicant opted to take MyKad in any NRD branches office in Peninsula of Malaysia, then MyKad would be completed within 10 working day while 30 working day for applicant opted to take MyKad in any NRD branches office in Sabah, a Sarawak or Labuan. MyKad’s charter completed this only involve applications from Warganegara Malaysia and prayer not problematical only.

7. Could I change address without change my identity card? If I can how many rates imposed?Yes. With payment RM2.00 and new address information would be updated inside chip. If you want change identity card one time, the charge is RM10.00 .

8. Is it NRD receive payment other than cash ?
Yes, NRD comply accept payment electronically namely via credit card, card debit and MEPS.However, there were limit minimum sum accept to payment via credit card

Actually, there's many many more of these garbage in the website, but i think the more we read, the more we feel ashamed of ourselves. If this type of english is allowed on a government website, then i doubt we could ever achieve Vision 2020,3030,4040 or 5050. How can this happen? Hopefully the ministers(especially Minister of Education) will be able too see this and make appropriate changes to our education system. I will use a Malaysian quote to describe this english. "The stage of england in Malaysia half eye cannot see la..."(Taraf Bahasa Inggeris di malaysia, sebelah mata tak boleh tengok)

The effect of Onania

Another interesting read..

Tissot’s scientific aims extended to the mental effects of masturbation.
Following the third law of Newton on action and reciprocal reaction, Tissot theorized
that orgasms were spasms of extreme nervous activity that necessitated an
equal and opposing depression of the nerves. This dampening of the nervous
activity caused permanent derangement when it occurred too frequently,
making the individual more susceptible to apoplexy, paralysis, insanity, and
other nervous diseases (17). This idea contributed to the 19th century notion
of “masturbatory insanity” caused by permanent brain damage due to constant
irritation.

Therefore, according to Tissot, masturbation denuded the body of blood
and, thus, gave rise to grave physical and mental consequences. Included
among these were weakening of the digestive system, loss of or excessive appetite,
vomiting, indigestion, breakdown of the respiratory system, general debility
and lassitude, as well as damages to the faculties and memory. The consequences
to women were even more grave, because masturbation led to hysteria, “vapeurs
affreuses,” incurable jaundice, stomach cramps, prophase and ulceration of the
womb, and clitoral rashes, for example. The young were particularly vulnerable,
as the loss of “precious liquid” stunted their natural physical development and
contributed to feeblemindedness (14,17).

By providing a pathological model of masturbation rooted in the seemingly
scientific and secular domain, Tissot’s book sparked the 19th century
medico-scientific masturbation phobia in the United States. Masturbation
was transformed from one of the many forms of seminal and excretory
loss into a sexual practice potentially fatal to individuals and society alike

Late onset of Hypogonadism

This is an article by Prof Zul regarding Hypogonadism.......interesting read :)

Shrinking willies

What i'm planning next week

1) Go labour room observe vagina.....NO!! i mean observe delivery
2) Go medicine ward, slaughter anyone who want to be slaughtered in short case
3) Go watch madagascar II
4) ?go back melaka for a day or 2
5) Go......go.......aiya where else a.....go.....whatever la..

Gender Poser

Gender uncertainty....looks like there's many things which need research......Paktorlogist sekalian...please take note haha

Gender Poser

Sorry, this have nothing to do with Medicine..Just to pen my thoughts..

Yoga is Haram for muslims, says NFC

So i don't know what the fuss is. everyone is politicking this issue to make it sound as if Hinduism is banned in malaysia.

Why in the blue hell the non muslims must worry about this ban? Why they keep criticising the ban? The ban only applies for muslims. Any objections, should come from muslims la! I don't see why the non muslims should go on critisising one of the highest muslim authority in malaysia! Dont be so kepoh la.....they ban that's their problem....tak kena mengena with you all one!

National Fatwa council say that yoga should not be practiced by the muslims......only the muslims...understand? That's their law, we should respect although we may not agree with their reasons. After all, again i would like to reiterate, it only applies to muslim!! Non muslim want to practice yoga, go on practicing till become dhalsim oso nobody will disturb you!

Sometimes, i think that somehow, people of malaysia really DO forget the Federal Constitution. or maybe the newer generation don't know about Article 153 of the federal Constitution....Maybe should make Pengajian Am compulsary for form 1 students onwards. After all, i learn more useful things from 1 year of Pengajian Am compared to 5 years of Sejarah

For the sake of unity, stop the squabble la.....Do not question something you don't know...
small small matter want to make big big....nothing better to do ah?

Does size matter?

Important for life ok!:D

Concerns about the size of genital organs are often unwarranted.
MOST humans are concerned about the size of objects. For many, big is beautiful up to a point after which, it may become ugly. For others, small is beautiful again up to a point after which, it becomes unacceptable. Only a few of us have no views on size.
As it is with inanimate objects, so it is with the human body. Many adults are concerned about the size of their genital organs, particularly its relationship to sexual performance and satisfaction.
The paucity of information in the public domain, the gaps in consumers’ medical knowledge, misinformation and advertisements in the print and electronic media and the reluctance of many doctors and health care professionals in discussing such matters have contributed to misperceptions.
Men’s size
The male is fascinated with the penis from an early age. As boys become adults, many become convinced that it would be better if the penis is just a bit longer. Information from friends and advertisements reinforce the perception that there is a relationship between penile length and manhood.
Most females cannot understand this fascination or obsession. There are reports that chance remarks about small penile size, particularly in the bedroom, have led to impotence (erectile dysfunction).
When a male sees his penis, it is at an angle, which makes it appear to be shorter than it really is. But when he sees another male’s penis, there is no such foreshortening effect, so it appears that the other’s penis is longer.
One should remember the facts about penile size. Wessells and his colleagues reviewed publications on penile length in 1996. The average length of a flaccid penis, measured from the base to the tip, is 8.85 to 10.7cm while that of an erect penis is 12.89 to 15.5cm. During an erection, the shorter flaccid penile length of a male will increase more than that of another with a longer flaccid length.
It should be remembered that the vagina can accommodate any penile size as it is distensible because of its capacity to increase in length if an object is introduced gradually. There is no relationship between race, height and penile size. Neither is there a relationship between penile size and sexual performance and satisfaction. Some men have bigger penises than others, just as some men are taller or of bigger build than others but penile size is no indicator of virility.
Concerns about sizes
If one is unhappy about his penis size, it is advisable to consult a general practitioner or urologist. In most instances, reassurance that the penis size is normal is all that is necessary.
Many people advertise their claims of methods of increasing penis size. The expert opinions on the methods are:
Pills or patches – a complete waste of time
Penile enlargement exercises – probably futile
Penile suction devices – probably of little use
Penile enlargement surgery – uncertain value with risk of bleeding, infections and deformity. Surgery may lead to the flaccid penis appearing longer but it makes no difference to the size at erection. There are reports of some modest improvement in length with penis stretchers (expanders). Some men may want to reduce the penis size. Although this can be done, there are risks of bleeding, infection and deformity. A urologist should always be consulted prior to the use of devices or surgery.
Female size
The vulva is the visible part of the female genital organs. It includes the clitoris, labia and urethral opening. It is not uncommon for women to be concerned about the size of their vulva and vagina as it plays a major role in their sexuality. A common myth is that a large vagina is associated with excess sex. This is incorrect as the frequency of sex has no impact on vulval and/or vaginal size.
Braun and Kitzinger in their publication Culture, Health and Sexuality put it succinctly: “With the construction of women’s genitals as problematic, the ‘private’ female body becomes a site for potential improvement. Socio-cultural accounts of vaginal size in the West construct a tight (but not too tight) vagina as desirable, and a ‘loose’ vagina as undesirable. In women talk, we found a curious pattern: women identified the cultural desirability of a tight vagina, and noted negative uses to which this is put (such as the positioning of women with ‘loose’ vaginas as promiscuous).
“However, when women described their personal concerns about vaginal size, these were couched in terms of anxiety about being too tight. We argue that constructions of vaginal size are problematic because they create another site of bodily concern for women, and are used to control and abuse women. We suggest that they also reflect a disregard of women’s sexual pleasure, and a lack of familiarity with the functions of the vagina.”
Weber and his colleagues studied the relation of vaginal anatomy to sexual function and concluded: “Vaginal anatomy measured by introital calibre, length and vulvo-vaginal atrophy does not correlate well with sexual function, particularly symptoms of dyspareunia (painful intercourse) and vaginal dryness.”
If a woman has not given birth, there is no way that her vulva or vagina is too big. However, childbirth affects vulval and vaginal size. The more babies delivered vaginally, the more likely the size will be increased. This is because the vaginal muscles and its supporting tissues are damaged during childbirth, particularly when labour is prolonged or difficult.
The increase in vulval and vaginal size can be prevented by adherence to pelvic floor exercises for six months after delivery. This involves tightening up the pelvic floor muscles, like trying to stop passing urine, holding the contraction for 10 to 15 seconds, relaxing for 10 to 15 seconds, repeating the contracting and relaxing for five to 10 minutes and doing the exercises three to four times a day.
Too big
The effects of too big a vagina include less than satisfactory vaginal intercourse for the female and/or male, air and/or water getting into the vagina and descent (prolapse) of the vagina, uterus and other pelvic organs in later life.
There are different treatment methods. Intensive pelvic floor exercises described above for six months will lead to improvement. Working at vaginal muscle developers for some time can also improve matters. A pelvic floor repair done by a gynaecologist brings together and tightens the weakened pelvic floor muscles and tissues.
Many women are concerned that the vulval lips (labia) are too large, too long or protrude unequally. If there are such concerns, a gynaecological consultation will be helpful. In most instances, reassurance that one is normal is all that is necessary. If there is a genuine abnormality, it can be corrected surgically.
Sometimes, a female may feel that her vulva and vagina are too small. They are statistically very rarely correct. A small vulva and vagina may be the result of surgery to the vulva and vagina. Too small a vagina can occur when there is a vaginal septum, which may lead to a double barrel-shaped vagina. The symptoms include inability to insert a tampon, pain on vaginal intercourse or total inability to have intercourse.
The vast majority of women with these symptoms have a normal sized vagina. However, many of them suffer from sustained contraction of the vaginal muscles whenever there is an approach to the genital organs (vaginismus). An internal examination will provide the answer to questions about smallness. A vaginal septum is easily treated surgically. The treatment of vaginismus is challenging and requires an expenditure of time and effort by both patient and doctor. If the vulva and vagina are genuinely small, it can be corrected surgically.
Whenever there are concerns about the size of the genital organs, it is advisable to consult a doctor. To do otherwise is risky and to have an untrained person do the job is to court disaster.

Important Must Knows

Cardiology
Presentation of cardiac pathology
Angina-types
Angina-MI difference
STEMI and NSTEMI and how to differentiate them
Complications of MI
Principle of management of MI and Angina
CCF-at least know the 3 most common cause i.e. MI,dilated cardiomyopathy and systemic hypertension, others such as congenital heart disease, valvular heart disease and cor pulmonale is additional
Types of CCF
Effect of CCF on CXR and ECG
Complications of CCF
Heart block-ECG changes(may be asked in long case)
Atrial Fibrillation-causes, effect and management. For causes, i use the mnemonic I SMART CHAP, there are other mnemonics such as CVS HaRUS CePat etc...use whichever 1 convenient

I=inflammatory condition such as pericarditis and pleuritis
S=sick sinus syndrome, in old people where there is idiopathic fibrosis of the sinoatrial node
M=Medications such as verapamil, levothyrosine
A=atherosclerosis of the vessels leading to ischaemia
R=Rheumatic heart disease
T=thyrotoxicosis
C=congenital heart disease
H=systemic hypertension
A=alcohol
P=pulmonary causes e.g. pulmonary embolism and pneumonia

Infective endocarditis- Memorise the Duke criteria inside out,aetiologic agent and appropriate antibiotics is extremely important.many neglect this
Rheumatic heart disease-The bacteria involve, involve what valve, what is the extracardiac features(Duckett Jones criteria)

Dont forget the drugs used to treat cardiac disorders.

I think this is enough to cope for now kua.....respi, neuro and gastro and others next time tell la..

SFI did it,again:)

Being an alumni of SFI, i felt proud that again, SFI have made it to the news again, after a while:)
Congratulations to the team and Mdm Cheong! You're the best! : )

BOYS DO MALACCA PROUD AT THIRD ASIAN YOUTH FESTIVAL

Neurology

Neuro examination is always considered hard, with its many localising signs to remember. However, it is not that hard if you've practiced well in the 8 weeks

I'm lazy to write about neuro exam here, because there;s too many of them. If you want to learn, learn it from your supervisor, seniors, or our colleagues who have done their medicine previous semester. They should be able to guide.

But the most common mistake made is the use of the word normal. e.g. "the muscle power is normal" or "reflexes are normal". This is really contraindicated in short or long case, as the word normal denotes nothing but ignorance. Muscle power must always be expressed in "5/5" form,5 is maximum and 0 is minimum. Reflexes is expressed in +,++,+++, or ++++ with ++ and +++ considered normal.

If demonstration is needed feel free to ask. :)

Respiratory Examination

Respiratory examination need to be done fast because it involve examination of the chest and the back.



Important points to ponder

1) NEVER FORGET the RESPIRATORY RATE. --> common killer in short cases

2)Do the asterixis properly. Do not look like you have never done it before.

3) Hypertrophic pulmonary osteoarthropathy is peculiar to chronic pulmonary disease. So, in the exam, say HPO instead of clubbing, which is not specific, as it may be caused by some gastro and cardiac problems.

4)BCG scar --> impress some lecturers with this inspection, annoy others with it.

5) face, don't forget Horner's,nasal polyp, nasal septal deviation,central cyanosis, pharyngitis etc.

6) Neck--> Trachea(be gentle) and lymph nodes(do it fast, don't waste time here)

7) Trunk--> examine front and back except when told otherwise. Chest expansion, do properly. Ur thumbs should go away from each other when the patient INSPIRATE. Make sure ur thumbs are opposed when the patient expirate. To do this, cekik the patient chest during expiration. Ask any previous medicine posting ppl to demonstrate this.
Vocal fremitus is described as equal bilaterally, reduced on what site. DOnt say vocal fremitus is normal.
Percuss at least 8 spots on the chest including the base, which is in the MID axillary line.
Auscultate all ZONES, not lobe. There are 3 zones of the lung, while there is 3 and 2 lobes. Always describe breath sound as being vesicular(normal), bronchial(lobar pneumonia) etc. Do not say breath sound is normal. If crepitation is present, describe it. Pan inspiratory or mid inspiratory, coarse of fine and at which zone. E.g. bibasal mid inspiratory fine crepitation.

dont forget pedal edema :)

Gastrointestinal and Abdominal Examination

I'm not going into detail step because i'm sure everyone can do GIT examination. What i'll do is highlight the signs which may be present but frequently overlooked

Hands- Koilonychia, leuconychia, Plummer's nail(partial detachment of the nail from nail bed
Dupuytren's-alcoholism, excess use of the hand as in carpenter,NOT a sign of chronic liver
disease
Asterixis-->always forgotten
scratch marks-obstructive jaundice causing pruritus
jaundice, anaemia
mouth-leucoplakia, erythroplakia,stomatitis, glossitis, Pigmentation as in peautz jegher polyposis,
neck-virchow nodes and troisier's sign
chest-differentiate between venous stars,spider naevi and campbell de morgan's spots
abdomen inspection- cullen's and grey turner(discoloration)
abdomen palpation-sister mary joseph nodule, differentiate from fat hypertrophy in chronic insulin injection
Auscultation-renal bruit, differentiate from portal hypertension bruit by compression(portal vein bruit disappear on compression)

Signs that can be elicited for fun, but not compulsory:
Murphy's sign-> who dunno dis can go hang themself
Boas sign-> who dunno dis can also go hang themself
Rovsing sign-->erm...here we go again.who dunno dis can go hang themself
Psoas sign--> in acute appendicitis, attempt to extend a flexed knee will result in right iliac fossa pain
Cartnet sign--> if the pain is visceral, palpation of the abdomen after the patient sitted 45 degree with arm cross over the chest will not cause pain, because the pain is inside, not the abdominal wall.
The sign of hippocrates--> if gastric outlet obstruction, after warning the patient what is about to happen, the patient is rocked from side to side with the stethoscope diaphragm on the stomach. If there is GOO, succusion splash is heard.

CVS examination for Internal medicine

Cardiovascular examination

Examine the patient lying down at a 45 degree angle. Exposure of the chest(take off the shirt if possible)


Begin Examination by inspection of the general condition of the patient

“The patient is lying comfortably at a 45 degree angle. He appear ?alert, ?concious, ?not in any immediate pain or in any respiratory distress(describe what you see, don’t memorise script). Count the respiratory rate.###IMPORTANT

Examine the fingers for signs of clubbing, peripheral cyanosis, splinter hemorrhages, and Osler nodes.
Examine the hands and look for Janeway lesion.
Check the pulse for rate, rhythm and regularity. Compare the radial radial pulse (indicate subclavian artery stenosis due to aneurysm), and radio-femoral delay(indicate coarctation of aorta).--> Some doctors say radial radial delay is due to coarctation of aorta, but my logic and my findings find no reason to support such claims. No literature said that radial radial delay is due to coartation. If you find one, please let me and others know

Check for collapsing pulse which indicate aortic regurgitation,arteriovenous fistula, Patent ductus arteriosus, arteriosclerotic aorta or hyperdynamic circulation due to anaemia, pregnancy, thyrotoxicosis etc.(Remember all the pulse character such as plateu pulse, pulsus bisferiens, pulsus alternans, pulsus paradoxus and what they indicate)

Examine the face for flushing or grayish discoloration (mitral facies) suggestive of mitral stenosis.
Examine the eyes and periorbital area looking for corneal arcus and xanthelasma.
Check for jaundice and anaemia.
Examine the mouth for hydration, central cyanosis and oral hygiene.
Next, examine the neck for JVP
Use the right external jugular vein, look for sustained increase on inspiration which indicate constrictive pericarditis or cor pulmonale(Kussmaul’s sign)
Hepatojugular refluxà when abdomen is compressed, JVP elevate for less than 4 second in normal person. If elevated more than 4 second, indicate heart failure.
Use torch light at an angle, look at the shadow produced.(Datin Norella style)
If cannot detect, it is not elevated and hence normal.
** Difference between JVP and Carotid pulse should be fingertips by now J

Now examine the precordium. Look for scars from previous CABG or other thoracic surgery. Look for any visible pulsations.
Next, palpate the apex beat. Feel for the character(e.g. tapping in mitral stenosis), position and regularity of the apex beat.

Once apex beat is felt, proceed to palpation of the tricuspid area. Feel for thrills and heaves( Once felt will never forget, dun worryJ). Proceed to pulmonary and aortic area feeling for the same thing.

Percussion is not significant in CVS examination except for estimation of the heart border, which is rarely done.

Auscultation for heart sounds.
Begin at the apex using the bell of the stethoscope. Listen for low frequency murmur. If murmur is soft, ask the patient to lean to the left and listen for accentuation of the murmur.
Still using the bell, listen at the mitral area, listen for pansystolic murmurs which radiate to the axilla.( Mitral regurgutation)
Listen at the pulmonary and aortic area. Any murmur end diastolic murmur indicative of aortic or pulmonary regurgitation should be heard. Accentuated by sitting the patient up, deep breath and hold in mid expiration while listening to the murmur.
If a ejecion systolic murmur is heard, listen to the carotid artery for carotid bruit.

** in atrial fibrillation, pulse deficit can be elicited by counting the number of auscultated apex beat and radial pulse in a period of time. Any difference between apex beat and radial pulse of more than 10 indicate deficient pulseà atrial fibrillation.

Lastly, examine the leg for pedal edema. Examine the ankles and Achilles tendon for tendon xanthomata.

***I wanted to upload this, actually its in Words format, but being the Buta IT person that i am i dont know how.

Essentials of 3rd year Internal Medicine

1)Basic medical knowledge, especially anatomy, pharmacology, physiology and pathology
2) Ward bed side learning--> learning how to take a complete full history, do physical examination the right way and stimulating the brain to think critically.
3) Group study-> conducted IN the ward, not at night in the cafe. Exchange patients, prepare for short cases and prepare for any question that is posed to you by ur colleague, as well as prepare relevant common questions for your colleague.
4) Learn and read at night. Night is a time for self study, not group study. Only when you self study the night before can you contribute to group study the following day. If not, you will be a "blur parasite", not even knowing what you are learning in the group.
5)Do not compare compare yourself to others. If they have different method, let them be. Knowledge should be complete, not used to compete.
6) In approaching a patient, if the patient doesn't entertain you, make an appointment with them. After you have succesfully clerk and examine them, don;t stop there. Visit them regularly and be friends. This way, they will not feel they are being used by you..

Hello

Purposely start this blog, hopefully it will act as a guide to those who will be taking Internal Medicine this sem.

Firstly, i would like to suggest several books that NEED to be read before starting the posting(or after if you've already start it). The suggested sequence are:

1) Nicholas Tally and simon o connor: Read and master all the signs and physical examination technique of all 4 main systems :CVS, Respiratory, GIT and Nervous system.
2) TheECG made easy--> make sure u can interprete the 9 ecg given at the end of the book
3)HEart sound made easy(use stethoscope to hear, not your bare ears)
4) CHest X ray made easy**
5) KUmar and Clark (small one is enough, complement with Papa Robin)

Other miscellaneous examination such as rheumatology can be learn later after you have learnt about the disease.

**Important chest X rays that must be mastered is 1)pneumothorax 2) pleural effusion 3)pneumonia 4)tuberculosis 5) pulmonary edema 6)bronchiectasis 7) COPD

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