Medical PBL

Case Files 12: My Last Breath - SOLVED

2013-04-09T14:00:00.000+08:00

A 24 years old lady with a history of HbH thallasemia with post splenectomy 8 years ago on frequent blood transfusion presented to ED with a history of shortness of breath. This patient frequently defaulted treatment and had been non compliant to medication. A month prior, she was admitted into medical ward for decompensated cardiac failure due to cardiomyopathy as a result of iron deposition.

She was seen gasping and was able to speak in few words at best. What was noticeable was her leg swelling was worsening and was tender on palpation. Her jugular venous pulse was strong and reaching her earlobe. She was put on high flow mask and a baseline ECG was recorded as below.

Do you recognize any particular pattern in this 12-lead ECG?

Answer:
The 12-leads ECG showed a variant of the SI QIII TIII of pulmonary embolism. Noted that there is right axis deviation with a prominent S wave in lead I (hence SI), and T wave in lead III. (TIII). There is no Q wave though in lead III (QIII). Another distinctive pattern seen was T wave inversion of V1 - V3 as well as P pulmonale (tall tented P waves) seen esp in lead II.

The patient had been having DVT from prolonged immobilization and US Doppler revealed significant DVT over the right lower limb. CT Pulmonary Angiography confirmed the diagnosis with multiple scattered areas of embolization in the lungs. The patient was started on unfractionated heparin infusion and overlapped with warfarin. Her condition improved after 1 week of admission. She was discharged with warfarin, however, knowing that her prognosis is guarded in view of her condition and prolonged non-conpliance to medical therapy.

A week after discharge, the patient was readmitted into ED red zone with another spell of shortness of breath. It was another episode of pulmonary embolism with pulmonary hypertension with biventricular failure and the patient was intubated and admitted into CCU but did not make it through after 2 days there. The parents were counselled of the prognosis and they did not wish for active resuscitation in view of her deteriorating condition thereafter.

Case Files 11: My Heart Skipped A Beat - SOLVED

2013-04-07T16:00:00.000+08:00

A 68 years old lady presented to the ED with productive cough for the past 3 days. She was brought today in view of her complains of generalized lethargy and weakness. Prior to further investigations, a baseline ECG was done. She was initially sent for green zone fast track, but was subsequently uptriage to yellow. What are your findings?

Answer:
This is a rare pattern of atrial bigeminy. While most are familiar with the easy-to-spot ventricular bigeminy with a wide QRS complex, this can be rather confusing as one may thought of Mobitz type II or 2:1 block. However, a closer look will reveal a few things:
1) The QRS complex exhibits grouped beating, being regularly irregular
2) There are presence of P waves prior to each QRS complexes
3) All P wave have an associated QRS complexes
4) The 2nd P wave have slightly different morphology than the 1st P wave, suggestive of 1st P wave originated from the sinus focus whilst the 2nd P (premature atrial contraction) may originate from another focus.

Atrial bigeminy, as a manifestation of premature atrial contraction, is a harmless rhythm in the proper clinical context. Most people with atrial bigeminy do not have organic heart disease, albeit the fact that it is more common in people with heart disease than those without. There are certain factors linked to the occurence of atrial bigeminy, such as caffein intake, emotional stress, smoking, alcohol use and fatigue. One things is of concern is that patioent with atrial bigeminy may not have the 2nd QRS wave transmitted into a pulse, which had caused this patient to have a pulse rate of 50-60 despite a heart rate of 100-110.

In this patient, no identifiable cause was found despite the alert and uptriage to Red Zone initially. Repeated ECG 1 hour later showed resolution to sinus rhythm and her pulse rate returned to 80-90 beats per minute. Nevertheless, the patient was admitted for community acquired pneumonia with a high CURB-65 score.

Case Files 10 - My aching stomach - SOLVED

2013-04-06T12:00:00.001+08:00

A 53 years old Malay gentleman with no known medical illness came to ED complaining of worsening epigastric pain for the past 3 days.He had earlier seek treatment from a GP 2 days ago and was treated as gastritis. He was discharged with syrup MMT and oral ranitidine. He claimed that the symptoms improved after taking the medication, albeit not completely.

However, today, the pain worsened and became rather severe, hence the reason he made a trip down to the ED. He was given syrup MMT and ranitidine and a baseline ECG was done. Routine blood investigations was done and it was noted that cardiac enzymes were normal as well.

2 hours later, the patient was noted to be sweating. He looked lethargic and pale. He still complained of epigastric pain. A repeat ECG was done in view of the patient's discomfort.

Normal 12-lead ECG

Posterior lead ECG

Inferior ECG

What would be your intepretation? Is there any bedside test to confirm your diagnosis? Any further blood investigations that can be taken?

Answer:

The 12-lead ECG showed significant ST - elevation over the inferior leads II, III, aVF whilst the lead V1-V3 showed ST depression. In a case of inferior MI, it is prudent to do a right sided ECG and posterior lead ECG The reason being is that inferior segment of the heart is supplied by the right coronary artery, which also supplies the right and posterior aspect of the heart. An occlusion at the right coronary artery that affects the inferior aspect may affect the other 2 as well. Of coursem other signs may include bradycardia and subsequent hypotension, as a result of sinuatrial node involvement, which is also supplied by the right coronary artery.

The right sided ECG showed no ischemic changes over the right aspect of the heart, but a quick look at the posterior leads showed significant ST-elevation as well.

Hence, this is an acute inferoposterior myocardial infarct. A bedside ECHO can be done and for this patient, there is hypokinesia over the inferoposterior region, correlating with the ECG findings. Cardiac triple test (bedside rapid test) was done for this patient. Myoglobin and CKMB was positive whilst TnI was negative, suggestive of recent onset basis. (Kindly refer to Malaysian CPG for acute coronary syndrome to have a quick review of the peak and through of the cardiac enzymes).

The patient was started on streptokinase fibrinolytic therapy in view of no PCI in the center. 1.5mU Streptokinase was given in 100cc normal saline over 1 hour (there are 2 other recommended regime). The streptokinase was witheld once midway as patient developed hypotension (side effects of streptokinase therapy) and restarted slowly once BP picked up after 1 pint of NS was given. Repeated ECG showed good resolution of the ST elevation and the patient was sent to CCU for close monitoring and management.

CPG 2012 - Management of Tuberculosis, 3rd edition

2013-04-05T16:31:00.000+08:00

The latest CPG on tuberculosis is out. Among all, this is one of the most comprehensive CPG, covering almost all aspects of the management of TB.

Management of Tuberculosis 3rd Edition- 2012
Download Links: Box.net | Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG Cardiovascular Updates - AF and Stable Angina Pectoris

2013-04-04T15:42:00.004+08:00

With the recent updates from MOH, the CPG guidelines for atrial fibrillation and stable angina pectoris is out. Here is the link to download the respective files. We hope that these CPG's will be put into good use to aid all medical practitioners in managing the conditions mentioned.

Management of Atrial Fibrillation - 2012
Download Links: Box.net | Mediafire

Management of Stable Angina Pectoris - 2012
Download Links: Box.net | Mediafire

Source:
1 )National Heart Association of Malaysia
2) Academy of Medicine of Malaysia

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

Malaysia Clinical Practice Guidelines and Consensus (Last update: 4th April 2013)

2013-04-03T14:00:00.000+08:00

Below is the subsection for the available CPG in Malaysia. All CPG are valid for 4-5 years unless stated otherwise. Older CPG are stored for archiving and reference purposes and should not be held liable for any differences in management.

For search purposes, it is recommended to use the browser's search function, "Find" through this list of CPG's. For example, Firefox or Chrome users can use the function "Ctrl" + "F" and type in the keywords in the designated search box. This will lead to the targeted keywords/ text on this list.

Pharmacological Guidelines

Malaysia National Antibiotics Guidelines 2008
Download Links: Box.net | Mediafire
Insulin Therapy Guidelines 2011
- Practical Guide for Insulin Therapy
  Download Links: Box.net | Mediafire
- Quick Reference for Insulin Therapy
  Download Links: Box.net | Mediafire

Cardiovascular CPG:

Management of Atrial Fibrillation - 2012
Download Links: Box.net | Mediafire
Management of Stable Angina Pectoris - 2012
Download Links: Box.net | Mediafire
Management of Ischemic Stroke (2nd edition) - 2012
Download Links: Box.net | Mediafire
Management of Unstable Angina/ Non-STEMI (2nd Edition) - 2011
Download Links: Box.net | Mediafire
Management of Pulmonary Arterial Hypertension - 2011
Download Links: Box.net | Mediafire
Prevention of Cardiovascular Disease in Women - 2008 (1st Edition)
Download Links: Box.net | Mediafire
Management of Hypertension (3rd edition) - 2008
Download Links: Box.net | Mediafire
Management of Heart Failure - 2007
Download Links: Box.net | Mediafire
Management of Acute STEMI - 2007 (2nd Edition)
Download Links: Box.net | Mediafire
Management of Ischemic Stroke - 2006
Download Links: Box.net | Mediafire
Management of Unstable Angina/ Non-STEMI - 2002
Download Links: Box.net | Mediafire

Respiratory CPG:

Management of Chronic Obstructive Pulmonary Disease (2nd Edition) - 2009
Download Links: Box.net | Mediafire
Treatment of Tobacco Use and Dependence - 2003
Download Links: Box.net | Mediafire
Management of Adult Asthma -Revised 2002
Download Links: Box.net | Mediafire

Hematology CPG:

Management of Transfusion Dependent Thalassaemia - 2009
Download Links: Box.net | Mediafire
Management of Anemia in Pregnancy and Chronic Kidney Disease (?Draft) - 2007
Download Links: Box.net | Mediafire
Management of Immune Thrombocytopenic Purpura - 2006
Download Links: Box.net | Mediafire
Diagnosis and Management Chronic Myeloproliferative Disorders - 2004
Download Links: Box.net | Mediafire

Nephrology CPG:

Management of Chronic Kidney Disease in Adults - 2011
Download Links: Box.net | Mediafire
Diabetic Nephropathy - 2004
Download Links: Box.net | Mediafire

Endocrine/ Metabolism Disorder CPG:

Management of Dyslipidemia - 2011
Download Links: Box.net | Mediafire
Management of Type 2 Diabetes Mellitus (4th Edition) - 2009
Download Links: Box.net | Mediafire
Management of Diabetic Foot - 2004
Download Links: Box.net | Mediafire
Management of Dyslipidemia - 2004 (The previous 2003 was a draft)
Download Links: Box.net | Mediafire
Management of Obesity - 2003
Download Links: Box.net | Mediafire
Consensus Statement on Androgenetic Alopecia - 2003
Download Links: Box.net | Mediafire

Dermatology CPG:

Management of Acne - 2012
Download Links: Box.net | Mediafire

Infection CPG:

Management of Tuberculosis 3rd Edition- 2012
Download Links: Box.net | Mediafire
Guidelines for the Diagnosis, Management, Prevention and Control of Leptospirosis in Malaysia - 2011 Download Links: Box.net | Mediafire
Guidelines for Clinical and Public Health Management of Melioidosis in Pahang - 2011
Download Links: Box.net | Mediafire
Management of Dengue Infection in Adults (Revised 2nd Edition) - 2010
Download Links: Box.net | Mediafire
Management of HIV Infection in Pregnant Women - 2008
Download Links: Box.net | Mediafire
Management of HIV Infection in Children - 2008
Download Links: Box.net | Mediafire
Management of Dengue Fever in Children - 2004
Download Links: Box.net | Mediafire
Adult Vaccination - 2003
Download Links: Box.net | Mediafire
Childhood Immunisation - 2004
Download Links: Box.net | Mediafire
Control and Management of Tuberculosis 2nd Edition - 2002
Download Links: Box.net | Mediafire

Neurology CPG:

Consensus Guidelines for Parkinson's Disease (2nd edition) - 2012
Download Links: Box.net | Mediafire
Consensus Guidelines on the Management of Epilepsy- 2010
Download Links: Box.net | Mediafire

Vascular CPG:

Management of Acute Variceal Bleeding - 2007
Download Links: Box.net | Mediafire
Management of Non-Variceal Upper Gastrointestinal Bleeding - 2003
Download Links: Box.net | Mediafire
Management of Venous Tromboembolism - 2003
Download Links: Box.net | Mediafire

Orthopedics & Rheumatology CPG:

Management of Osteoporosis (2nd edition)- 2012
Download Links: Box.net | Mediafire
Management of Gout - 2008
Download Links: Box.net | Mediafire
Management of Osteoporosis - 2006
Download Links: Box.net | Mediafire
Management of Osteoarthritis - 2002
Download Links: Box.net | Mediafire

Ophthalmology CPG:

Screening of Diabetic Retinopathy - 2011
Download Links: Box.net | Mediafire
Management of Primary Open Angle Glaucoma - 2008
Download Links: Box.net | Mediafire
Management of Post-Operative Infectious Endophthalmitis - 2006
Download Links: Box.net | Mediafire

Otorhinolaryngology (ENT) CPG:

Management of Otitis Media with Effusion in Children - 2012
Download Links: Box.net | Mediafire
Consensus Guidelines on URTI - 2009
Download Links: Box.net | Mediafire
Management of Sore Throat - 2003
Download Links: Box.net | Mediafire

Women's Health CPG:

Hormone Therapy During Menopause in Malaysian Women - 2010
Download Links: Box.net | Mediafire
Management of Anemia in Pregnancy and Chronic Kidney Disease (?Draft) - 2007 Download Download Links: Box.net | Mediafire
Management of Menorrhagia - 2004
Download Links: Box.net | Mediafire

Pediatrics CPG:

Management of Otitis Media with Effusion in Children - 2012
Download Links: Box.net | Mediafire
Guidelines on the management of Cow's Milk Protein Allergy in Children - 2012
Download Links: Box.net | Mediafire
Management of HIV Infection in Children - 2008Download Links: Box.net | Mediafire
Retinopathy of Prematurity - 2005
Download Links: Box.net | Mediafire
Withholding and Withdrawing of Life Support in Children - 2005
Download Links: Box.net | Mediafire
Rational Antibiotic Utilisation in Selected Paediatric Conditions - 2004
Download Links: Box.net | Mediafire
Management of Jaundice in Healthy Newborns - 2003
Download Links: Box.net | Mediafire
Management of Postnatal Corticosteroids For The Prevention of Chronic Lung Disease In Preterm Infants - 2003
Download Links: Box.net | Mediafire
Management of Febrile Fits - 2000
Download Links: Box.net | Mediafire

Mental Health CPG:

Management of Schizophrenia in Adults - 2009
Download Links: Box.net | Mediafire
Management of Dementia (2nd Edition) - 2009
Download Links: Box.net | Mediafire
Management of Attention Deficit Hyperactive Disorder in Children and Adolescent - 2008
Download Links: Box.net | Mediafire
Management of Major Depressive Disorder - 2007
Download Links: Box.net | Mediafire
Malaysia Consensus Statement for the Treatment of Bipolar - 2007
Download Links: Box.net | Mediafire

Cancer CPG:

Management of Breast Cancer (2nd Edition) - 2010
Download Links: Box.net | Mediafire
Management of Cancer Pain- 2010
Download Links: Box.net | Mediafire
Management of Cervical Cancer - 2003
Download Links: Box.net | Mediafire
Management of Breast Cancer- 2002
Download Links: Box.net | Mediafire

MOH Paediatric Protocols for Malaysian Hospitals, 3rd edition

2013-02-25T23:58:00.004+08:00

MOH Paediatric Protocols for Malaysian Hospitals, 3rd edition

by Hussain Imam Hj Muhammad Ismail, Ng Hoong Phak, Terrence Thomas

Format: PDF (~5MB)
Download Link:

Box.net | Mediafire

Finally, I'd got my hands on the 3rd edition. This book is worth RRP RM25 (At the time of this entry) and can be purchased at the MPA office at Jalan Raja Muda Abdul Aziz. MPA claimed that they do offer delivery service at RM5 per book. So, that's RM30 for you guys who prefer delivery service due to logistics issue.

To get your fresh copy of book, just drop by their office or call them for their delivery service. If you plan to drop by, The soft copy of this edition is also readily available in their MPA site.

Paediatric Association
3rd Floor (Annexe Block),
National Cancer Society Building,
66, Jalan Raja Muda Aziz,
50300 Kuala Lumpur.

Tel: 603-2698 9966/ 26915379
Fax: 603- 26913446
Email: info@mpaweb.org.my
Website: http://mpaweb.org.my/

*The Peds protocol 3rd edition had the copyright belonging to MOH. As a responsible organisation MPA decided to print the book as part of their contribution to paediatrics in the country and has done so from the first edition. They are selling the books at cost price and for the 3rd edition they have forked out quite a hefty sum to print out the books.

Guidelines on the management of cow's milk protein allergy in children 2012

2013-01-09T12:08:00.000+08:00

Guidelines on the management of Cow's Milk Protein Allergy in Children - 2012
Download Links: Box.net | Mediafire

Source:
1 )Malaysian Society of Allergy and Immunology
2) Malaysian Paediatrics Association

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG: Management of Otitis Media with Effusion in Children

2013-01-08T12:17:00.000+08:00

Management of Otitis Media with Effusion in Children - 2012
Download Links: Box.net | Mediafire

Source:
1)Malaysian Society of Otorhinolaryngologists - Head and Neck Surgery (MSO-HNS)
2)Academy of Medicine Malaysia

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

Consensus Guidelines for Parkinson's Disease 2012

2013-01-07T11:00:00.000+08:00

Consensus Guidelines for Parkinson's Disease (2nd edition) - 2012
Download Links: Box.net | Mediafire

Source: Malaysian Society of Neurosciences

Support Affiliation: Malaysian Parkinson's Disease Association

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG: Management of Osteoporosis (2nd edition)

2012-09-30T14:51:00.002+08:00

Management of Osteoporosis (2nd edition) - 2012
Download Links: Box.net | Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG: Management of Ischemic Stroke (2nd Edition)

2012-09-08T22:45:00.002+08:00

The 2nd edition of CPG for Management of ISchemic Stroke is out after a long wait.

Management of Ischemic Stroke (2nd edition) - 2012
Download Links: Box.net | Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

Paediatrics for beginners

2012-09-02T12:16:00.000+08:00

Its been a while since I last taught anybody anything, being busy preparing for exam and working. Thus I think it is appropriate to just share something during my rare free time, just for the benefit of medical students.......Okay I admit I'm bored.

Its a common perception : Paediatric cases in exam has high mortality rate. Here are some tips for medical students in dealing with those freaking squealing things called a child. Following this steps may reduce mortality rate in exams.

Why do medical students "die" in Paeds?
1)They thought children are "small adults" and treat them as such
2) they cannot tolerate crying babies and child
3)They panicked once they think they fail to follow so called "steps" when examining the child
4) They are too focused on the child, not realising that the caretaker(most of the time, the mother) is the Mouth of the child.

Prepare the following before your exam : A good pair of eyes, a calm and clear mind, playful character, selectively deaf ears, gentle pair of hands, flexible skill(with no hard and fast "steps" but complete) and small TOYS(after all, all the toys in the world are created for kids except for sex toys.)

There is a term in psychiatry called anticipatory anxiety(AA). Anticipation is a must in planning anything, but add the other A and it becomes pathological. Thus, in dealing with paediatrics (as well as other fields of medicine) anticipation is a must, but never be anxious in dealing with them, as they can sense you and make your life more miserable.

Things to anticipate with paediatric patients

1) CRY- This is the thing that you must be able to bear and handle before succeeding in any paediatric cases. Most students returning from the exam will tell their fellow students "Shit la, get paeds case, that child cry cry cry I also dunno what I'm doing."
Please be aware that a Crying Child is a good thing, it means the child is still alive. I personally would be very afraid if a mother come and tell me that the child had not cried for the past 1 week! Or if the labour room called and inform me that the newborn is not crying. Cry is the only means of communication for younger infants, a way to convey the message that they are unwell but still able to "talk".
So don't get panic when a child start crying when they see you. You can even comment on the cry and earn some extra points for good observation. The reason they cry:

I) You look big and formidable in your white coats!(trust me I know this all too well, standing at 1.90meters)
Solution:a) Ask for permission to remove white coat, and squat down, kneel down, sit down, whatever it is to make yourself look smaller and non threatening. A smile won't hurt either.
b) Have a lil bit of developmental regression, start playing with the child. Bring some small toys.Act cute, whatever. After all, the child won't remember that "when i was 2 years old a trainee doctor pretended to be cute in front of me". Perhaps the mother and examiner will laugh, let them. After all, laughter is the best medicine.

II) They are anxious of strangers.If you don't know what stranger anxiety means, its time to read up on Developmental paediatrics. Normally it appears at around 7 months of age.
Solution: a)They are anxious, you don't be anxious la. I know that there is this formidable Consultant Paediatric so-and-so watching your every step, let her/him! Have this in mind: Paediatricians are people who love kids and dedicate their life to take care of sick children, how bad and evil can they be? If they are then they might as well be paedophiles instead of paediatrician.
2) Anxious of strangers, so if you turn yourself into :non stranger then everything will be fine. Sometimes its hard to do in 10 minutes but try doing so. At the end if you failed its okay, just comment "the child is having stranger anxiety, thus he must be at least 7 months in terms of development" Extra points!

III) They are unwell. Fretful is the term. A fretful child sometimes cannot be consoled even by the caretakers. This is one of the most common reasons for visit to hospital (and most common reason medical students thought they already failed the exam): "Don't know why this few days he cry non stop" Can it be colic? Can it be some CNS infection? Can it be UTI? It is our job to find out what is causing the child so much distress.
Solution : If a child is fretful and you are unable to control, ask for help! Obvious help is right in front of you(No, not from Prof Madya SO and SO). Ask help from the caretaker! You don't need a Professor to pacify a child. If even the caretakers can't pacify the child, how can the examiner assume you can?
So if you came across a fretful child, do all you can, ask help from the mother, if still fretful, just say the magic word The child is FRETFUL. (saying this before attempting to pacify the child will invite weird questions like "so, what are you going to do?") ATTEMPT is important.

2) Unexpected behavior
A child is not a smaller version of adult (small size adult is called a dwarf, achondroplasia). In adult patients(normal one) we can anticipate that they will listen to our instructions -that make life easier. How do you instruct a child to breath in breath out while auscultating? Which is why, a pair of sharp eyes and a clear mind is essential. Be opportunistic. Do whatever you can. The small bugger wont listen to you anyway, just do what he allows you to do.

3) Questions on growth and development
Is the child's development appropriate for his age? Is he thriving? After all, if there is one thing that differentiates paediatric patients from adults, its growth and development. A child who can't grow(failure to thrive) or develop(developmental delay) may have some serious biological, psychological or social problems. Which is why a knowledge on Developmental paediatrics is very essential. We may miss lots of things(sometimes lethal) by not knowing inside out about the two terms highlighted above. So, if you don't have time to "read finish" your Sunflower, read on this 2 things.
After all, when you come to think of it, failure to thrive and developmental delay are the complications of almost all chronic diseases in paediatrics.

4) Questions on Genetics
Some of the most common questions in exams like thalassaemia, muscular dystrophy, Down's syndrome are all genetic diseases. It is easy to see why genetic is so important in paediatrics, most of them manifest either at birth or early childhood. You don't need to know how to interpret Fluorescen in situ hybridisation, just know the common ones (as listed earlier) and how to diagnose, what are the complications.

5) Scary Examiners
As I had said earlier, you may meet a Senior Paediatrician who had wrote 30 books and published 12 papers. Thus it is considered normal to be apprehensive when facing such people. So change your mindset "In 10 years I will be like him too". Some examiners are well known to fail people but I'm sure the number of people they passed is far greater than those he failed. Why are you so sure you will fail?
(the same applies to exams in other fields such as O&G)

The hardest thing is to comment on something you see. Sometimes we tend to haveBroca aphasia in exam, we know what we are looking at but we could say it out! We can practice this actually. Saw that fat lady in that awful dress at the supermarket? Describe what you see!
(while staying at A-19-7 in Prima Setapak, I used to describe what I saw from the balcony--> Petronas twin tower (Giant Japanese metal chopsticks), the KL tower and all other wonderful things I saw from up there)

Have fun dealing with kids. Its very satisfying. :)

CPG: Management of Acne

2012-05-08T22:57:00.000+08:00

Of all CPG to start the year of 2012, we have the clinical practice guidelines for the management of acne. Nothing fanciful, but useful for perhaps those with the condition (quite common after all).

Management of Acne - 2012
Download Links: Box.net | Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG of Infectious Disease: Melioidosis and Leptospirosis

2012-02-22T21:44:00.000+08:00

Here are the latest addition of CPG's in MedPBL's collection.

Guidelines for Clinical and Public Health Management of Melioidosis in Pahang - 2011
Download Links: Box.net | Mediafire

Guidelines for the Diagnosis, Management, Prevention and Control of Leptospirosis in Malaysia - 2011
Download Links: Box.net | Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

Case Files 9 - Hypertension in Pregnancy, or was it?

2011-11-27T11:46:00.001+08:00

Case submitted by Dr Jefrrey Lee on 15th Nov 2011

This is an extremely rare case. just would like to share it for academic purpose.

A 38 year old primigravida at 22 weeks POA was referred from MCH for stabilisation of severe hypertension in pregnancy

(BP=220/120 on 2 separate occasions).

No previous known history of hypertension but there is a family history of hypertension.
She is asymptomatic for preeclampsia, urine protein trace.
Routine PET workup taken shows that she is extremely hyperkalaemic (serum potassium =8.9).
Creatinine and other PET workup was normal and ECG does not show any changes suggestive of hyperkalaemia.
She was given cocktail, serum potassium improved to 4.5 but again increase to 7.8 a day later. - Sample was not lysed.
ABG was taken shows a compensating metabolic acidosis. She was otherwise asymptomatic with normal urine output.

The diagnosis is beyond our level as it is made by the Physician. But it is worthwhile to consider this when we cannot explain why a patient remain hypertensive, with asymptomatic hyperkalaemia and metabolic acidosis.

Ready for the diagnosis? --> Gordon's syndrome or type II pseudohypoaldosteronism. Nice to know, nice to forget too : )

Case Files 8 - Oh My Urine - SOLVED

2011-11-26T14:52:00.000+08:00

An elderly bed bound lady in her early 70's, was found to have urine as of such in her CBD bag.

Given that this is the first time the patient developed this condition,
1) What would your differential diagnoses be?

Purple Urine Bag Syndrome - Although the name suggests more of urine discoloration, most of the time, the catheter and the bag are more markedly stained by the pigment.
Porphyria - less likely, but still possible

2) What do you think are the risk factors for such condition?

Before we identify the risk factors, it is prudent to know how it is formed. Tryptophan in the food gets metabolized in the intestines into indoles. Enterohepatic circulation converts it into indoxyl suplhate which is then detoxified by the liver into indoxyl. These are excreted into the urine, which would be metabolized by colonizing bacteria(in alkaline environment) in the CBD into indigo (blue) and indirubin (red). The blue and red pigments when mixed, of course, gives you the purple hue from where the name originated from.

Risk factors, of course are bedridden female elderly, alkaline urine, chronic constipation(to allow tryptophan metabolism and enterohepatic circulation metabolism to occur), long standing indwelling catheter(for colonization of bacteria in the CBD).

3) How do you treat this condition, should there be a need?

There are many advocates for different treatment, including:
i) Urinary sanitization - by replacing the indwelling urine catheter and ensuring proper catheter hygiene, the urine condition will slowly but surely to improve
ii) Constipation management - Since constipation is a risk factor, it is prudent to help the patients to move their bowels, hence preventing or reducing the formation of indoxyl.
iii) A short course of antibiotics - Treatment of the UTI can be done, although it should not be the sole treatment. The above mentioned methods should also be practiced, otherwise there would still be recurrent infection!

CPG: MAnagement of Pulmonary Arterial Hypertension + Management of Breast Cancer

2011-11-12T09:24:00.000+08:00

Here/s the latest 2 Clinical Practice Guidelines. I'm pretty sure that the Management of Breast Cancer was recently uploaded as I would have noticed it by then if it was issued online last year. Nevertheless, feel free to update yourself with the last guidelines regarding Management of Breast Cancer and Pulmonary Arterial Hypertension.

Management of Breast Cancer (2nd Edition) - 2010
Download Links: Box.net | Mediafire

Management of Pulmonary Arterial Hypertension - 2011
Download Links: Box.net | Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG: Management of Dyslipidemia, 4th edition - 2011 + Guidelines for Insulin Therapy

2011-10-23T12:02:00.001+08:00

The latest guidelines to the management of dyslipidemia is out. Do check out the guidelines if you're interested in it. :)

Management of Dyslipidemia - 2011
Download Links: Box.net | Mediafire

And also, the guidelines for Insulin Therapy, a complementary to the latest CPG for management of Diabetes Mellitus, by Malaysian endocrine and Metabolic Society(MEMS) with MOH, in view of the rising trend of insulin users among diabetic patients.

Insulin Therapy Guidelines 2011
- Practical Guide for Insulin Therapy
  Download Links: Box.net | Mediafire
- Quick Reference for Insulin Therapy
  Download Links: Box.net | Mediafire

For a view of other CPG's, kindly do refer to: ==> HERE

Gearing for MD Professionals

2011-10-11T11:55:00.000+08:00

Preparations are never too early, but they can always be too late. In view of this, this section is created to aid future medical students, in particular UKM medical students and other Uni students sitting for similar exams to gear for their professionals. We do hope that this would be of great help, as some of these here are recollection of the past years question. We do hope that those who are still there would be able to continue to contribute to this site to expand the question banks for the benefit of the rest.

Professionals:
MD UKM Professionals Exam 2010 - A joint recollection --> Downloads: Box.net
MD UKM Professionals Exam 2011 - A joint recollection --> Downloads: Box.net

Surgery:
Year 3 Exams 2009-2010 --> Downloads: Box.net

O&G:
Year 3 Exams Sem 1 2009-2010 --> Downloads: Box.net
Year 3 Exams Sem 2 2009-2010 --> Downloads: Box.net

JKM:
Year 3 Exams Sem 1 2010-2011 --> Downloads: Box.net

Internal Medicine:
Year 3 Exams Sem 2 2009-2010 --> Downloads: Box.net
Year 3 Exams Sem 1 2010-2011 --> Downloads: Box.net

Year 4 Full Set Sem 2 Questions 2010-2011 --> Downloads: Box.net

Triad (ENT, Ophthalmology, Anesthesiology):
Dr Aida Ophthalmology OSCE Slides --> Downloads: Box.net
Ophthalmology Revision Questions --> Downloads: Box.net
ENT Revision Questions --> Downloads: Box.net
Year 4 Exams Sem 1 2009-2010 --> Downloads: Box.net
Year 4 Exams Sem 2 2009-2010 --> Downloads: Box.net
Year 4 Exams Sem 1 2010-2011 --> Downloads: Box.net
Year 4 Exams Sem 2 2010-2011 --> Downloads: Box.net

Psychiatry:
Year 4 Exams Sem 1 2009-2010 --> Downloads: Box.net
Year 4 Exams Sem 1 2010-2011 --> Downloads: Box.net
Year 4 Exams Sem 2 2010-2011 --> Downloads: Box.net

Orthopedics:
Year 4 Exams Sem 1 2009-2010 --> Downloads: Box.net

Year 4 Exams Sem 1 2010-2011 --> Downloads: Box.net
Year 4 Exams Sem 2 2010-2011 --> Downloads: Box.net

Pediatrics:
Pediatrics Long Case Template
(Seizures/ Epilepsy, Cerebral Palsy, Asthma, Thalassemia, Diabetes, Spina Bifida
Download Links: Box.net
Year 4 Exams Sem 1 2009-2010 --> Downloads: Box.net
Year 4 Exams Sem 2 2009-2010 --> Downloads: Box.net
Year 4 Exams Sem 1 2010-2011 --> Downloads: Box.net

CPG: Screening of Diabetic Retinopathy

2011-10-06T21:40:00.000+08:00

The new Clinical Practice Guidelines for Screening for Diabetic Retinopathy is out. So, there's no longer any reason not to refer to the eye specialist for diabetes eye problems right? :P

To download this file, kindly proceed to the CPG Downloads Section at: ==> HERE

CPG: Management of Chronic Kidney Disease in Adults

2011-09-14T14:30:00.001+08:00

The new Clinical Practice Guidelines for Management of Chronic Kidney Disease in Adults is out. For a soft copy of this CPG, you can head to MOH web or the link below to the CPG download section on this site.

To download this file, kindly proceed to the CPG Downloads Section at: ==> HERE

Malaysia National Antibiotics Guidelines 2008

2011-08-31T10:22:00.000+08:00

Just in case if anyone is looking for the Malaysia National Antibiotics Guidelines, here's the 2008 edition. Hope it could benefit all, while we await the latest guideline! :)

I've also included it in the "Malaysia Clinical Practice Guidelines and Consensus" Section.

Malaysia National Antibiotics Guidelines 2008

Download Links: Box.net | Mediafire

CPG: Management of Unstable Angina and Non-STEMI

2011-08-02T19:43:00.000+08:00

The latest clinical practice guidelines for management of unstable angina and non-STEMI is out. Hope this benefits all of us who's going to be working in Malaysia particularly.

To download this file, kindly proceed to the CPG Downloads Section at: ==> HERE

Case Files 4 - Emergency/ Int Med: Dying From Within

2011-07-01T19:59:00.000+08:00

Case Submission by Dr Jeffrey Lee (July 1st, 2011)

A 17 years old teenage boy was admitted to the wards after allegedly ingested 2 cups of Paraquat. Upon admission, he was vomiting profusely and multiple oral ulcers were seen upon inspection.

On investigation, his creatinine levels were raised from 168 μmol/ L on admission to 694 μmol/ L and >1000 μmol/ L over a week. The chest radiograph shows progressive changes suggestive of massive fibrosis.

Some questions to ponder:

What is your immediate management of this patient should you be the House Officer attending to this patient?
Give your full medical diagnosis of this patient from the information given.
What are the other signs and symptoms you should look out for?
What are the other complications you should be cautious of?
What are the investigations need to be done, particularly for monitoring purpose?

Upon admission, a nasogastric tube was inserted and NG Fuller's earth and Mist Alba was administered STAT with adequate hydration till diarrhea. Activated charcoal was also administered and the boy was being considered for peritoneal dialysis should his blood urea raises to a critical level.

A new protocol from the Sarawak General Hospital advocates the use of immunosuppressive agents. The agent recommended was IV Cyclophosphamide and pulse therapy of Dexamethasone. These agents presumably modulate the immunoresponse and have a reno-protective effect. These therapy was commenced on this patient. While the renal function improved with 2 or 3 cycles of immunosuppresion, the lung could not be saved as fibrosis has started to set in.

Further questions:

What are the dosage of the treatment given?
What are the indications for the use of immunosuppresive agents? Should we use them for all paraquat poisoning?