Posted by medik-ukm on Monday, June 28, 2010
Kerley’s A lineAn essentially straight linear opacity 2–6 cm long and 1–3 mm wide, usually situated in an upper lung zone, that points to the hilum centrally and is directed toward but does not extend to the pleural surface.These are longer (at least 2cm) unbranching lines coursing diagonally from the periphery toward the hila in the inner half of the lungs. They are caused by distension of anastomotic channels between peripheral and central lymphatics of the lungs. Kerley A lines are less commonly seen than Kerley B lines. Kerley A lines are never seen without Kerley B or C lines also present.Kerley’s B lineAn essentially straight linear opacity 1.5–2 cm long and 1–2 mm wide, usually situated in the lung base and oriented at right angles to the pleural surface with which it is usually in...
Posted by medik-ukm on Monday, June 28, 2010
MNEMONICA - Alveolar Edema (Bat's Wing)B - Kerley B lines (Interstitial Edema)C - CardiomegalyD - Dilated prominent upper lobe vesselsE - Pleural EffusionThanks to Dr Shahul for asking this question during ward round.A115...
Posted by medik-ukm on Sunday, June 27, 2010
Lateral Medullary Syndrome is covered already.Medial Medullary Syndrome/ Dejerine SyndromeCauses :Stroke of-Anterior spinal artery-Basilar Artery-Vertebral ArteryClinical features:-ContralateralPyramidal Tract -> hemiparesisMedial lemniscus (dorsal column) -> LO concious propioception, LO discriminative touch, LO vibration-IpsilateralHypogossal nerve -> deviation of tongue to the AFFECTED SIDE (weakness side)Need help with this, very confusing. If the tongue deviates to the right, meaning the stroke is on right medial medullary ?Extra : Locked-In SyndromeCauses :Stroke in Basilar ArteryPresentations:-quadriplegia-cannot speak (vocal cord is not paralysed, but voice and breathing is not coordinated well, hence reduced ability to speak)-Retain full consciousness & cognitive function-Eye...
Posted by medik-ukm on Saturday, June 26, 2010
Q1 : What to look for in chronic liver disease during PE ?Signs of hepatic failure- Jaundice ( skin + sclera + mucous membrane, conjugated + unconjugated bilirubin ) + scratch marks- Hepatomegaly ( due to extramedullary haemopoiesis)- Anaemia- Purpura (coagulopathy - factor II, VII, IX & X)- hypoalbuminaemia -> Ankle edema, +\- ascites, nail changes (Leukonychia, Muehrcke's Line), oedema- Finger clubbingSigns of hyperestrinism (Hyper-estrogen-ism) - because liver cannot breakdown estrogen and cannot synthesize estrogen binding protein- Spider Naevi- Pectoral alopecia- Female : Breast atrophy (dun ask me, tak tahu kenapa. xD)- Male : Gynecomastia,...
Posted by medik-ukm on Saturday, June 26, 2010
CAUSEPosterior Inferior Cerebellar Artery (PICA) occlusion(lead to brainstem infarction)FEATURESdysphagia, dysarthria (IX and X nuclei)vertigo, nausea, vomiting, nystagmus (vestibular nucleus)ipsilateral ataxia (inferior cerebellar peduncle)ipsilateral Horner's syndrome (descending symphathetic fibers)loss of pain & temperature sensation on ipsilateral face (V nucleus)loss of pain & temperature sensation on contralateral limbs (spinothalamic tract)NO limb weakness (pyramidal tracts are unaffected)Thanks to Dr Ngiu for showing us patient with Wallenberg's Lateral Medullary Syndrome.A115...
Posted by medik-ukm on Saturday, June 26, 2010
An elderly chinese gentlemen with a background hx of parkinson disease come to the A&E with dyspnea, fever and reduce counciousness since 2 days ago.On examination he was dyspnoeic with RR of 28 + use of accessory muscle + course crepts + bronchial breath sound + pleural rub over the left upper zone.What is your differential for pleural rub? - one MO ask...pleurisy - secondary to pneumonia or pulmonary infarctionrare - pleural malignancy, spontaneous pneumothorax, pnemodyniaDescribe the pt's tone (UL exam)cogwheel / plastic / leadpipe rigidity - ↑ tone with interrupted nature → muscle give way → jerksdue to exagerated stretch reflex interrupted by tremorAssess the pt's GCS scoreeye - 4motor - 1verbal - 1= 6A114...
Posted by medik-ukm on Saturday, June 26, 2010
A 42-year-old woman is brought to the emergency room by ambulance for altered mental status. The glucose level by fingerstick monitoring was below the measurement capabilities of the monitor (<40 mg/dL). After 2 ampules of 50% dextrose, the patient’s fingerstick glucose remains at 42 mg/dL. She remains unconscious and had a 1-min seizure while in transport. She has no history of diabetes mellitus. Her family denies that she has been recently ill, but recently she has been depressed. She works as a registered nurse on a medical floor of the hospital.
Which of the following tests would confirm an overdose of exogenous insulin?
A. Plasma glucose <55>18 pmol/L, and plasma C-peptide levels undetectable
B. Plasma glucose <55>18 pmol/L, and plasma C-peptide levels >0.6 ng/mL
C....
Posted by medik-ukm on Saturday, June 26, 2010
A 54-year-old female presents to the hospital because of hemoptysis. She has coughed up approximately 1 teaspoon of blood for the last 4 days. She has a history of cigarette smoking. A chest radiogram shows diffuse bilateral infiltrates predominantly in the lower lobes. The hematocrit is 30%, and the serum creatinine is 4.0 mg/dL. Both were normal previously. Urinalysis shows 2+ protein and red blood cell casts.The presence of autoantibodies directed against which of the following is most likely to yield a definitive diagnosis?A. Glomerular basement membraneB. Glutamic acid decarboxylaseC. PhospholipidsD. Smooth muscleE. U1 ribonucleoprotein (RNP)The answer is A.A variety of autoimmune diseases may cause pulmonary/renal disease, including Wegener’s granulomatosis, microscopic polyangiitis,...
Posted by medik-ukm on Saturday, June 26, 2010
oculosympathetic pathway involved in Horner's syndrome:fibers from the hypothalamus go to the ciliospinal centre in the spinal cord at C8, T1 and T2.synapse.second-order neurones exit via the anterior ramus in the thoracic trunk. synapse in the superior cervical ganglion in the neck.third-order neurones travel from here with the internal carotid artery to the eye ( the pupil, the levator palpebrae) and the sweat glands of the face. A lesion at any site along the pathway can produce Horner's syndrome.Causes of Horner's syndrome:1. carcinoma of the apex of the lung ( usually squamous cell carcinoma)2. neck - malignancy eg. thyroid - trauma...
Posted by medik-ukm on Thursday, June 24, 2010
Abnormalities of the abducting eye in internuclear ophthalmoplegia reflect an adaptive process that helps overcome the adduction weakness of the opposite eye.This response operates under the constraints of Hering's law of equal innervation: any attempt to increase the innervation to a weak muscle in one eye must be accompanied by a commensurate increase in innervation to the yoke muscle in the other eye.Source : http://www3.interscience.wiley.com/journal/109677683/abstractThanks to Dr Ngiu for asking this question after showing us patient with Right Internuclear Ophthalmoplegia today.A115...
Posted by medik-ukm on Thursday, June 24, 2010
When a person looks to the side opposite the affected (right) eye, the following happens: The affected (right) eye, which should turn inward, cannot move past the midline. That is, the affected eye looks straight ahead. As the other eye (left) turns outward, it often makes involuntary, repetitive fluttering movements called nystagmus That is, the eye rapidly moves in one direction, then slowly drifts in the other direction.May have double vision. Internuclear ophthalmoplegia (INO) is a manifestation of intrinsic brainstem disease.It is caused by a lesion involving the medial longitudinal fasciculus between the abducens and oculomotor nuclei.Typically INO results from conditions which produce ischemia or demyelination in the brainstem.The chief clinical features are an adduction deficit in...
Posted by medik-ukm on Sunday, June 20, 2010
RESPIRATORYPleural effusionPulmonary fibrosis in RAConsolidationBronchectasisCOPD(when desperate)Pneumothorax (never,bcoz is acute!)CARDIOVASCULARHeart failureMurmursProstetic clickEbstein anomaly w TR(beware of this pt,we may see him in Pro exam)NEUROLOGYBulbar PalsyParkinsonismStrokeCN IIICN VIISpinocerebellar ataxia(this pt come to our Pro exam every yr!!)GASTROINTESTINALBallotable kidneyhepatoslenomegalyENDOCRINECushing'sGraves/TMN goiteracromegalyMISCELLENOUSPsoriatic athropathySLEScleroderm...
Posted by medik-ukm on Sunday, June 20, 2010
How old M.I ?? Cardiac enzymes FABP + + + - - Myoglobulin - + + - - CKMB - - + + - Troponin T/I - - + + + 30min-3h 3h-6h 6h-24h 24h-48h 48h-14days thanks to : dato' jeya, ...
Posted by medik-ukm on Sunday, June 20, 2010
Question during oncall at A&E PPUKM :In head trauma patient, why there is bradycardia + increase blood pressure?CUSHING REFLEX The Cushing reflex is a hypothalamic response to ischemia, usually due to poor perfusion (delivery of blood) in the brain. The Cushing reflex consists of an increase in sympathetic outflow to the heart as an attempt to increase arterial blood pressure and total peripheral resistance, accompanied by bradycardia. The ischemia activates the sympathetic nervous system, causing an increase in the heart's output by increasing heart rate and contractility along with peripheral constriction of the blood vessels. This accounts for the rise in blood pressure, ensuring blood delivery to the brain. The increased blood pressure also stimulates the baroreceptors...
Posted by medik-ukm on Saturday, June 19, 2010
causes of chronic aortic regurgitation:rheumatic heart diseasecongenital (eg. bicuspid valve; VSD - an associated prolapse of the aortic cusp is not uncommon)seronegative arthopathy (esp. ankylosing spondylitis)aortic root dilatationmarfan's syndromeaortitis (sero -ve arthropathies, RA, tertiary syphilis)causes of acute aortic regurgitationinfective endocarditismarfan's syndromedissecting aneurysm of the aortic rootSeverity of ARpositive LR indicate that the presence of a sign is likely to occur that much more often in an individual with the disease than in one without it. the higher the positive LR, the more useful is a positive sign.negative...
Posted by medik-ukm on Saturday, June 19, 2010
NO.1 RULE : Talk about everything you know. Don't be scared to impress your examiner, but only say things that you sure you know how to answer.No.2 RULE : Try to answer in a way that you can "drag" the examiner into your world. Lead them to ask the questions that you know how to answer ! Impress them !Source : Dr. Siva & Dr. ParasSituation :- Chinese Male- Middle age- Presents with chronic cough for 2 months- Initially cough with sputum, which is whitish in colour- For recent 2 weeks, associated with blood streaks- a/w SOB & fever these 2 weeks- Went to GP before for treatmentRandom Fact 1 : Pleuritic chest pain includes CHEST PAIN ONLY DURING COUGHING. Thus, pleuritic chest pain means chest pain during inspiration or coughing. (Source : Dr Siva from A&E)Question : Tell me how...
Posted by medik-ukm on Saturday, June 19, 2010
Tetralogy of Fallot is treated surgically. A temporary operation may be done at first if the baby is small or if there are other problems. Complete repair comes later. Sometimes the first operation is complete repair. Placement of a BLALOCK-TAUSSIG SHUNT (BTS) is a 'closed-heart' procedure performed as a first stage to correct TOF. Placement of a shunt is usually a temporary measure designed to alleviate symptoms until such time that the patients is in better condition to undergo complete repair.
BTS (An incision is made on the side of the chest under the arm, extending up towards the scapula).
The significant problem in TOF is REDUCED blood flow into the lungs. This results in reduced oxygen delivery to the body.
The operations designed to increase blood flow into the lungs are called SYSTEMIC-PULMONARY...
Posted by medik-ukm on Saturday, June 19, 2010
click on the image to enlarge itThanks to Dr Ngiu for asking us the question on assessment of severity of aortic regurgitation.Source : X'press Revision in Short Cases, Aids to Undergraduate MedicineLearning issue : List down the peripheral signs of aortic regurgitation.A115...
Posted by medik-ukm on Friday, June 18, 2010
INSTRUCTION FOR USETake one dose at a time.Remove the cap and shake the inhaler several times.Sit upright, hold head up and breathe out.Place inhaler in mouth and seal lips around mouthpiece.Breath in, press the canister down (The canister should be pressed just after the start of inhalation, not before) to release the drug and continue to take a deep breath in.Remove inhaler and hold breath for as long as possible up to 10 seconds.Then expire through nostril slowly.Recover (how long?) before taking the next dose, replace cap.*this MDI + spacerSources of information : Oxford Handbook of Clinical Examination and Practical SkillA115...
Posted by medik-ukm on Friday, June 18, 2010
CHECK THE BP SETThe key to the reservoir should be turned openThe mercury meniscus should be at zeroThe calibrated glass tube must be clean – a dirty tube can cause inaccurate readings.CUFF SIZEThe bladder length should encircle at least 80% of the circumference.The width should be at least 40% of the circumference of the arm.Too small a cuff will give a falsely higher reading and vice versa.INFLATION-DEFLATION BULBThe following may indicate malfunction of the device:# Failure to achieve a pressure of 40 mmHg above the estimated SBP or 200 mmHg after 3–5 seconds of rapid inflation.# The inability of the equipment to deflate smoothly at a rate of 1 mmHg per second or at each pulse beat.AUSCULTATORY MEASUREMENTPatients should be adequately rested and seated with their arms supported.The cuff...
Posted by medik-ukm on Friday, June 18, 2010
EVIDENCE OF BARREL CHESTIncrease antero-posterior diameterLoss of cardiac and liver dullnessReduce space between costal margin and ASIS (usually can place 2 hands)Liver ptosisAt rest, ribs are not in oblique but persistently in horizontal positionReduce space between trachea and suprasternal notch (normally can insert 2 fingers)Thanks to Prof ShahrirThanks to commentator below for correcting the facts.Learning issue : What are the differential diagnoses for barrel chest?A115...
Posted by medik-ukm on Friday, June 18, 2010
Differential ClubbingClubbing limited to upper or lower limbs alone.Clubbing may be limited to the upper limbs in chronic obstruction of veins of the upper thorax.A common cause is phlebitis of the upper extremities as seen in IV drug usersDifferential Clubbing In the Lower Limbs OnlyIt may be associated with cyanosis of the lower limbs.It is classically due to PDA with reversal of shunt( Eisenmenger PDA).It is also seen in in infected abdominal artery aneurysm.Thanks to Dr Ngiu for asking us these questionAnswer from this website.Learning Issue 1 : what is the grading for clubbing?Learning Issue 2 : what are the differential diagnosis for clubbing?A115...
Posted by medik-ukm on Thursday, June 17, 2010
CLINICALabdominal pain / tendernesspersistent vomitingclinical fluid accumulationmucosal bleedinglethargyrestlessnesshepatomegaly >2cmLABORATORYincrease haematocrit concurrent with rapid decrease in platelet countsource : HKLlearning issue : what does warning sign indicate?A115...
Posted by medik-ukm on Tuesday, June 15, 2010
Chest Pain with Low BP and High HRHow to manage this patient?1Inotrope (e.g. Digoxin)to stabilise blood pressure first2 (a) B-blocker (e.g. propranolol)to reduce heart rate2 (b)(if B-blocker contraindicated e.g. in asthmatic)Calcium channel blocker which act centrally (e.g. diltiazem, verapamil)to reduce heart rateOthersACEi / ARBDiureticCredits to Kanit and Asilah's group for teaching me.* Learning issue : why the patient who take ACEi presented with cough as side effect?A115...
