Medicine End Posting Bedside Examination

Date: Today (24/2/2011)
Examiner: Dr Anoop
Student: Me
Patient: A Bangladeshi guy (who Dr Anoop can speak fluent Hindi with)
Question: Do the General Physical Examination. ( which include examination of hand, pulse, eliciting collapsing pulse, peripheral pulses, anatomical landmark of dorsalis pedis artery, popliteal artery)
Homework: Anatomical landmark of popliteal artery (Exam also got homework ek?? Got...with Dr Anoop only)

The course of the upper part of the popliteal artery is indicated by a line from the lateral margin of Semimembranosus at the junction of the middle and lower thirds of the thigh, obliquely downward to the middle of the popliteal fossa; from this point it runs vertically downward for about 2.5 cm. or to the level of a line through the lower part of the tibial tuberosity







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Witnessing 'DEATH"

Innalillah Wa Inna Ilaihi Raajiuun...

Yesterday 21/2/2011 was the 1st time in my life I saw and experiencing a man who is dying.
B4 that, in the morning as usual I was clerking a patient who was beside his bed. That time I could see he was in an intolerable state of breathelessness. Though his wife was there with him, but the pain that he was suffering cannot be described with words. An immediate lesson that I gained that time was, breathlessness can range from very mild to the one that the pak cik was suffering.

After having a Cardiovascular class with Dr Sushil under the topic of ACS-Acute Coronary Syndrome, as I was walking back (returning to hostel), I could saw the same Mak Cik (the wife of the suffering Pak Cik) crying. At that point of time, I didn't have the 'guts' to walk and go back from the hospital. There, inside an intensive room, I saw the MOs, HOs were struggling to resussitate the Pak Cik. Drugs such as Adrenaline, Dobutamine have been used.They countered the acidosis with Sodium Bicarbonate Infusion and CPR was also done. That time I was standing at a corner and felt so hopeless. Even the student nurse also was doing something to help that old man, and what is my contribution as a Medical Student? Nothing. I was a hopeless 'amoeba'. That old man was dying.

Suddenly I heard the MO incharge shouted at me- "Hey Medical Student, wear your glove and mask, come here and do CPR! Hurry!" At that time, I was so surprised and cannot believe that something I could do and contribute. Quickly I rushed off and those things and jumped on the bed and performed the CPR. Slowly, I told the Pak Cik to recite the Holy Sermon " La Ilaha Illa Allah"

Pupillary reflex was absent as I checked his eye. His BP continued to drop inspite the ionotropic agents that was given earlier. His pulse was irregularly irregular possibility of ventricular fibrillation. His extremities started to feel cold. The doctor sent a form to the Mak Cik to be signed. It indicated that 'the time' has came for the Pak Cik to meet his God, our God, The Empire of The Universe. I went and met the Mak Cik and told her to be brave, patience, stay strong and reminded her that all of us came from Allah al-Mighty, and to Him also, we shall return. I gave a kiss to the Pak Cik's forehead and walked out from the ward. I knew that, one day, we shall meet again, but for surely, in another world, World Of Justice.

Life has to move on. But definitely there will be a time, that its our turn. Maybe now, next 2 minutes, next week or next year.An 'Alim' person had told me that the interval between life and death is as same as the duration between the Azan and Iqamah.

Before I end, let us together recite the Ummul Kitab Al Fatihah, for those who have past away before us and all the Muslimin Muslimat, Mukminin Mukminat entirely.

Al-Fatihah...




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MasyaAllah...Egyptians' Victory!!!

I am pretty sure that all of us knew that Husni Mubarak's regime has been teared into pieces. But I'm not sure whether most of us knew that Syeikh Yusuf Qaradhawi has returned to his homeland for the 1st time in 30 years! What a massive reception for him! He lead the Friday(18/2/2011) prayers as well reciting the Friday sermon(khutbah)! Nearly 2 millions of Muslims were there at the Tahrir Square! MASYAALLAH!!! ALLAHUAKBAR!!!






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Perak FA & Hamburg SV

As many people know that I am a fanatic fan of Perak FA, just wanna share something intresting here...Just now, as I was surfing the internet, I just realized that there is ONE similarity between these 2 clubs...BOTH OF THEM HAVE NEVER BEEN RELEGATED!!!
It means, since the inception of the Malaysia Football League-previously known as Liga Perdana Malaysia, now Liga Super Malaysia/Malaysia Super League, Perak FA has never been relegated! Congratz!!!
The same happen to Hamburg SV, there have never been relagated from the top-tier of the German Football- currently known as 'Bundesliga'. Credit to them also!
I wonder how top Giants teams like Bayern Munich, Werder Bremen, and Schalke 04 have 'tasted' relegation???


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Aortic Regurgitation

Sometime, I use this 'fancy' word --> aortic 'regurge'

Clinical signs include;

* Hyperdynamic apical impulse displaced laterally and inferiorly may be associated with an ejection click.
* Decrescendo diastolic murmur is heard best while the patient is leaning forward on deep expiration.
* Apical middiastolic rumble
* Austin-Flint murmur
* Pulsus bisferiens; increased pulse pressure; visible, forceful, and bounding peripheral pulses (water hammer)
* Corrigan pulse - Quickly collapsing pulses
* Corrigan sign- dancing carotids,prominent carotid pulsation in the neck
* Musset sign - Bobbing/nodding of the head with each systolic pulsation
* Quincke sign - Capillary pulsations of the nail bed (alternate flushing and blanching of the nail bed)
* Hill sign - Systolic pressure in lower extremity greater than systolic pressure in upper extremity by at least 100 mm Hg
* Traube/ Pistol shot sign - Loud systolic sound over femoral arteries
* Duroziez sign - Systolic-diastolic murmur produced by compression of femoral artery with a stethoscope

Usually all these sign can be appreciated in chronic cases.



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Horner's Syndrome

Horner's syndrome or Horner syndrome is a clinical syndrome caused by damage to the sympathetic nervous system.
A classiccal triad of;
1. miosis (ie, constricted pupil)
2. partial ptosis(which is drooping of the upper eyelid from loss of sympathetic innervation to the superior tarsal muscle, also known as Müller's muscle) and
3. loss of hemifacial sweating (anhidrosis)

others->Enophthalmos (the impression that the eye is sunk in) loss of ciliospinal reflex and bloodshot conjunctiva may occur depending on the site of lesion

The clinical features of Horner's syndrome can be remembered using the mnemonic, "Horny PAMELa" for Ptosis, Anhidrosis, Miosis, Enophthalmos and Loss of ciliospinal reflex.

Usually examiner will ask, the relationship between Horner Syndrome & Bronchogenic Carcinomo of the apex of lung.
Bronchogenic Carcinomo of the apex of lung (aka Pancoast Tumor-mostly a non small cell cancer)-->Sympathetic Ganglion Compression in the cervical region--> Horner Syndrome





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Jugular Venous Pressure ( JVP)

The jugular venous pressure (JVP, sometimes referred to as jugular venous pulse) is the indirectly observed pressure over the venous system. It can be useful in the differentiation of different forms of heart and lung disease. Classically three upward deflections and two downward deflections have been described.



The upward deflections are;
- "a" (atrial contraction)
- "c" (ventricular contraction and resulting bulging of tricuspid into the right atrium during isovolumic systole) and
-"v"= atrial venous filling

The downward deflections of the wave are;
-"x"(the atrium relaxes and the tricuspid valve moves downward) during early right ventricular systole
-"y" descent (filling of ventricle after tricuspid opening)

In Exam, all the above will be asked, as they are the basics that all medical student should now, and after succeding in answering them, this they (the examiner) might asked;

# Large 'a' wave (increased atrial contraction pressure)

* tricuspid &/ pulmunory stenosis
* Right heart failure/ Right vntricular hypertrophy
* Pulmonary hypertension

# Cannon 'a' wave (atria contracting against closed tricuspid valve)

* Atrial flutter
* Premature atrial rhythm (or tachycardia)
* third degree heart block
* Ventricular ectopics
* Ventricular tachycardia

# Absent 'a' wave (no unifocal atrial depolarisation)

* atrial fibrillation

# Large 'v' wave (c-v wave)

* Tricuspid regurgitation

# Slow 'y' descent

* Tricuspid stenosis








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Hooray!!! Its weekend again!!!

HAha...its Friday! and the best part of it--> Its weekend!!!
The question right now will be, how should I manage my weekend? Just no my brother called me, asking whether I am interested in going to Paroi Stadium to watch Perak Fa VS PDRM...I don't think so, as I am having exam next week!
My plan are as below;
1.Study for End of Posting Examination
2.Exercises/ Work Out
3.Study for End of Posting Examination
4.Study for End of Posting Examination
5.Finish my Medicine logbook
6.Study for End of Posting Examination
7.Finish 2 Medicine Case Sheet
8.Try to go hospital for Study for End of Posting Examination
9.Study for End of Posting Examination
10.Study for End of Posting Examination

Arrghhh!!!!!-->Study for End of Posting Examination


Huhu..No more 'Hooray' =(



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Dream Car ( As for now~)

When I was playing futsal with my teammates (usually, there will be Arif, Abbas, Dinbo & the others- we usually play at Cheng Sport Planet) something that always attract me beside the talents that the futsal players already have in them (such as Arif~) is nothing but CARS (berlambak parking dekat futsal court)!...

Logically thinking, people who play futsal usually fall under medial to upper class group in Malaysia. There I could see them using from 'Protons'(which include all models of Proton) & 'Produas'(mostly Kancil and MyV) to cars like Toyota Vios, Honda City, and if I am lucky enough; Toyota Corolla Altis & Honda Civic. Very hard to see Mercedes, BMW (old BMW ada laa), and all the upper class cars.

Suppose I am working with 'sufficient' income, these are my preference;
1. Peugeot 308- The lowest price; RM 100k on the road!


2. Mitsubishi Lancer- around RM120k OTR!


3. Toyota Vios the lowest price is around RM 72k OTR...(My last choice as it is the cheapest among the 3 and being manufactured by Toyota)


Actually I wanna opt for Lancer, but to mahallaa...Peugeot 308 kinda 'ok' with its price and performance...but still log way to go. By the time I start working, there will be plenty of new cars in the market. Really hope the price will not be so expensive in the future (Malaysia will 100% follow the AFTA)...
But as for now, its just angan2 Mat Jenin...

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Trigger Finger

What is trigger finger?? The word trigger finger may be taken from the action of a policeman (most likely) pulls the trigger of a gun.
It is also known as-(by right its scientific name is) Stenosing tenosynovitis. It is an inability to extend a flexed finger. It occurs when one of the flexor tendons does not slide smoothly through the pulleys at the metacapophalangeal joint. Patients will present with a flexed finger that must be forcibly extended using the other hand.








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