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updated Blood pressure examination - 23 August
Approach to Anemia - 5 June 2012

Wednesday, 1 October 2014

Tips for Final Exam

I have graduated from an MBBS course recently, and I thought I would put together some thoughts to help people gain confidence in getting through yet another "bump" before graduation - that is the final exam.

tips to prepare for the final exam

  1. you have made it this far -  which is hardly blind luck, so have a lot of faith in yourself, your study methods that carried you thus far, and your luck!
  2. find out what exactly is the style of your final exam. imagine the situation well, and apply that situation in your everyday work. time yourself and give yourself exactly how much you will have (or slightly shorter) on the day of exam. 
  3. find out the kinds of cases you would get during the exam. go through it, write reports of those cases. 
  4. practice your physical exam religiously - while imagining the exam situation. 
  5. consistently do 1 2 3 and 4 - imagination is key.
it's simple, mostly because if you are reading this, you probably have what it takes to pass - there is no reason why you should make it till the final semester without the sufficient knowledge, even if you feel like you know nothing (it is normal to feel that way, especially in medicine. it would probably never go away - and it is a good thing) 

now on the day itself, you won't have to worry because if you have done the above consistently, there is no way you are going to be nervous - you have done it in your mind a hundred times! 
lastly, believe in yourself. I know there will be doubts, but having doubts in itself, is a good trait of a good doctor. always doubt yourself, but have confidence that you will rectify it. 

Sunday, 25 August 2013

AV fistula Examination

there are several purposes of examining patients with AV fistula.
  • assessing function of present AV fistula.
    • the diameter and flow of fistula
    • where is the fistula? 
      • radiocephallic
      • brachiocephallic
      • transposed cephallic 
    • presence of other vascular access (which suggests previous AV fistula failure)
      • central venous access
      • peritoneal access
      • graft
  • looking for possible complications of AV fistula
    • infective / inflammatory changes 
    • aneurysm
    • hematoma
    • thrombosis
    • central vein stenosis
    • ischemia / steal syndrome
    • outflow stenosis of fistula
  • assessing adequacy of dialysis and renal failure
    • uremia
    • peripheral edema
    • anemia of renal failure
    • assessing complication of dialysis itself
      • common non-serious side effects
        • headache
        • itching
        • muscle cramps
      • cerebral oedema secondary to osmotic change (disequilibrium syndrome) \
      • hypertension
      • hyperkalemia 


inspection may involve the hands, arms (with the fistula), head, chest and abdomen with main focus on the fistula itself.
  • hands
    • check for signs of ischemia or steal syndrome distal to AV fistula
      • temperature
      • pulse volume 
      • capillary refill
      • pitting edema
  • head
    • check for anemia in conjuctiva
  • chest and proximal to AV fistula
    • difference in size of upper limb between left and right (central stenosis)
    • look for a scar for central vein catheterisation (subclavian site)
  • abdomen 
    • look or scars of peritoneal dialysis
    • scars of nephrectomy
  • legs
    • pitting edema (fluid retention)

inspection of the fistula

  • assess the location of the fistula
    • radiocephallic
    • brachiocephallic
    • transposed cephallic 
  • look for evidences of failed / old AV fistulas distally
  • look for complications seen on the fistula
    • infection / inflammation 
      • redness
      • swelling
    • aneurism
    • hematoma / bruising


  • lightly palpate over the fistula for;
    • increased temperature 
    • tenderness 
    • thrills (this is normal)
    • pulsation (this is not normal - suggesting outflow obstruction)
  • arm-elevation test for outflow stenosis
    • elevate the arm with the AV fistula - the fistula should flatten if there is no outflow obstruction.
    • sign is positive when AV fistula stays bulging
    • more signs suggesting outflow obstruction;
      • prolonged bleed after dialysis
      • loud systolic murmur (discussed later)
  • augmentation test to test for inflow stenosis
    • occlude the outflow by pressing onto the proximal arm along the vascular pathway
      • the thrills should become a strong pulsation- if not, there may be inflow obstruction
      • the extent at which there is a pulsation - whether there is strong or weak pulse, may be an indication of inflow patency


  • on the fistula AND along the vascular pathway up till the chest
    • there should be a systolic murmur (low-rumbling) throughout
    • a harsh, high-pitched sound may suggest a stenosis somewhere along the vascular pathway.

Assessment of Diabetic Patient.

Assessment of Diabetic Patient

This is going to be a wide topic - but let me try.

the examination of Diabetic foot ulcer will be discussed separately.

Things to keep in mind while assessing Diabetic Patients

we like to look at diabetic patients, largely for 4 things;

presence of acute modbid conditions associated with Diabetes
presence of possible causes of diabetes
co-morbidities present
complications of diabetes

  • acute presentation of diabetic complications
    • hypoglycemia 
      • confused, sweating, anxious, hungry, trembling, dizzy patient 
    • Diabetic Ketoacidosis 
      • deep, dapid breathing, flushed face, abdominal pain, fruity odour, nausea and vomiting. 
  • presence of possible etiologies of current diabetes
    • Metabolic disease and lifestyle habits
    • pancreactomy 
    • PCOS (ladies)
    • Cushings, Thyrotoxicosis, 
    • Drug-induced 
      • phenytoin, Diuretics etc
  • presence of possible co-morbidities
    • hypertension
    • dyslipidaemia
  • presence of possible end-organ damage due to direct effect of diabetes
    • diabetic Eye disease 
      • background retinopathy
      • proliferative retinopathy
      • maculopathy
      • cataracts
      • rubeosis iridis*1 -> glaucoma
    • diabetic Nephropathy
    • diabetic Neuropathies
      • peripheral neuropathy
      • autonomic neuropathy
      • radiculoplexus neuropathy (diabetic amyotrophy) *2
      • mononeuropathy - focal neuropathy *3
      • cranial neuropathy (mostly 3rd nerve) 
    • Cardiovascular Disease & peripheral vascular disease 
      • CAD
      • PVD (claudication)
      • cerebrovascular disease 
      • TIA 
    • altered immunologic response and hence, infection
      • skin infections
        • cellulitis
        • erysipelas
        • lymphangitis
        • inguinal skin infections (mostly fungal)
      • lung infections
      • some infections are found almost exclusively in diabetics such as;
        • malignant otitis externa
        • rhinocerebral mucomycosis
        • emphysematous pyelonephritis 
      • UTI
keeping the above in mind, we would like to assess a diabetic patient.

Assessment of Diabetic Patient

history taking

  • hyperglycemic symptoms
    • polyurea, 
    • polydipsia
    • weight loss
    • recurrent infection
  • hypoglycemic symptoms
    • palpitations
    • tremors
    • sweating
    • dizziness
    • syncope
  • complications of diabetes
    • chest pain
    • oedema
    • shortness of breath
    • blurring of vision
    • parasthesia
    • numbness / weakness
  • risk factor assessment
    • smoking
    • sedentary lifestyle
    • alcohol

General Assessment

firstly during history taking, some questions may be asked to specifically rule out hypoglycemia and
  • Mentation - ruling out Diabetic Ketoacidosis / hypoglycemia 
  • Vital Signs
    • Blood Pressure
    • Pulse
    • Respiratory rate
  • hydration state
  • Lifestyle assessment (if non-acute)
    • BMI
    • waist circumference 
    • Waist-hip ratio
    • orthostatic Blood Pressure

Locoregional Assessment (head to toe)

  • Hands
    • pallor 
    • capillary refill
    • fungal nail infections 
    • tinnel's sign, phalen's sign - for carpal tunnel syndrome
    • dupuytren's contracture - associated with Diabetes. 
    • pallor (anemia of chronic diabetic renal disease)
  • arms
    • uremic frost - renal 
    • scratch marks
  • Head
    • eyes
      • anemia
      • cataracts
      • rubeosis iridis and glaucoma
      • fundus examination
      • visual acuity
      • xanthelasma
      • pupillary light reflex
    • nose
      • sinus tenderness
    • ears 
      • any discharge, lymphadenitis (malignant otitis externa)
    • mouth
      • oral health
      • gum hypertrophy (gingivitis)
      • periodontitis  
      • candida
  • Neck
    • carotid pulse
    • carotid bruit
    • thyroid
    • acanthosis nigricans 
  • Chest
    • cardiovascular examination

  • Abdomen
    • surgical scars 
      • pancreactomy
      • kidney transplant
    • complications of insulin injection
      • lipodystrophies 
    • renal artery bruit
  • Pelvis
    • signs of fungal infections
    • UTI
  • Legs
    • skin changes
      • lipodermatosclerosis 
      • necrobiosis lipoidica diabeticorum*4
  • Foot
    • diabetic foot is a whole new chapter. 

neovascularization around the iris - the newly formed vessels may evantually fibrose, to close the angle, causing increase in intraocular pressure to cause "neovascular glaucoma". 
Radiculoplexus neuropathy (diabetic amyotrophy) 

radiculoplexus neuropathy affects nerves in the thighs, hips, buttocks or legs. Also called diabetic amyotrophy, femoral neuropathy, or proximal neuropathy, this condition is more common in people with type 2 diabetes and older adults. Symptoms are usually on one side of the body, though in some cases symptoms may spread to the other side too. Most people improve at least partially over time, though symptoms may worsen before they get better. This condition is often marked by:
  • Sudden, severe pain in your hip and thigh or buttock
  • Eventual weak and atrophied thigh muscles
  • Difficulty rising from a sitting position
  • Abdominal swelling, if the abdomen is affected
  • Weight loss
Mononeuropathy involves damage to a specific nerve. The nerve may be in the face, torso or leg. Mononeuropathy, which may also be called focal neuropathy, often comes on suddenly. It's most common in older adults. Although mononeuropathy can cause severe pain, it usually doesn't cause any long-term problems. Symptoms usually diminish and disappear on their own over a few weeks or months. Signs and symptoms depend on which nerve is involved and may include:
  • Difficulty focusing your eyes, double vision or aching behind one eye
  • Paralysis on one side of your face (Bell's palsy)
  • Pain in your shin or foot
  • Pain in the front of your thigh
  • Chest or abdominal pain
Sometimes mononeuropathy occurs when a nerve is compressed. Carpal tunnel syndrome is a common type of compression neuropathy in people with diabetes.
Signs and symptoms of carpal tunnel syndrome include:
  • Numbness or tingling in your fingers or hand, especially in your thumb, index finger, middle finger and ring finger
  • A sense of weakness in your hand and a tendency to drop things

*4appears as a hardened, raised area of the skin. The center of the affected area usually has a yellowish tint while the area surrounding it is a dark pink. It is possible for the affected area to spread or turn into an open sore. When this happens the patient is at greater risk of developing ulcers. If an injury to the skin occurs on the affected area, it may not heal properly or it will leave a dark scar.

Wednesday, 26 June 2013

prezi 2

I have made another Prezi Presentation - Antibiotic types and uses, based mainly on what I have learnt during one of the plenary session.


Thursday, 13 June 2013

Prezi Presentation

I learnt of this new presentation software called "Prezi", which can make presentations actually fun to create and watch at the same time.

I'm bored of powerpoints, so it's quite refreshing for me to be able to make some interactive-looking stuff easily with a click of a mouse.

Made an elective posting presentation using this software;


its most useful for conceptual presentations, i think.

Tuesday, 26 March 2013

methods of anesthesia

mode of anaesthesia
  • General
    • induction
      • intravenous
      • inhalation
    • maintainance
      • intravenous
      • inhalation
        • spontaneous breathing
          • classical LMS
          • Facial Mask
        • mechanical ventilation
          • Endotracheal Tube
          • Proseal
    • arousal
      • with reversal agent
      • without reversal agent
  • Regional
    • Central Nervous Block
      • epidural
      • spinal anaesthesia
      • CSE
    • Periphiral Nerve block
      • upper limb
        • bracheal plexus block
      • lower limb
    • local anaesthesia
      • infiltration
      • topical anesthesia
      • intravenous (bier's block)

Sunday, 2 December 2012

How Do I PASS pre-clinical exams?

An issue every Medical / Dental student face is theory exams.

the pre-clinical exam involves more of a memory-based factual theory exams, rather than clinical vignettes or diagnosis / management examination. 

I would like to suggest ways to improve the efficacy of learning, as the students would realize at some point of their university life, that learning in a university is different from studying for high-school examinations.

First message I would like to give to my juniors is to Be Realistic.

first thing to know about examination in medical university is that you don't have to blame yourself for not having a distinction or a gold medal. the chances are that most of the students in your university was a high-achiever in primary, secondary, and high schools. in the midst of high-achievers, is it understandable that you have a few gifted students whom would achieve double with half the effort? 

most of us have to realize that Passing in a medical / dental institute is an achievement, and aiming for distinction should come only if passing is a breeze for you. for most students, it is NOT! the important thing here is to do your best, and not kill yourself in the process.

how can we improve the efficacy of learning? 

  1. concentrate when you're studying.

    this applies to every aspect of the learning process. whether you are in class, during group projects, or studying by yourself, it is better to concentrate for an hour than studying with half the concentration for 2 hours.

    I don't suggest playing music when trying to retain facts - especially music with lyrics. classical music may help you relax while studying when you're too tense (I will talk about stress shortly)
    You may listen to music however when you're trying to pull out information from your mind - i.e. when doing past year papers.

    One suggestion to make such concentration possible, is to time yourself while studying. try to achieve the maximum amount of learning in the shortest time possible - this skill of mental sprinting will also be useful in the future, when there is literally no time to waste.
  2. control the amount of stress, and use stress to your advantage.
    Everyone gets stressed out before exams - but not everyone knows that stress can be beneficial!
    Stress and task performance follows an inverted U-shape according to a psychological research (1) [yes, this blogpost has references!] which means, you should have an optimal amount of stress for you to perform maximally. If you're feeling too sleepy or relaxed, drink a coffee or think about failing, If you are having palpitations because you are too stressed, accept the fact that you won't function so well, and go talk to your classmates, joke about something, or go for a drink.
    try to be at the middle of the curve (the part that says "optimal arousal") or a little right of the curve, so that you will recognize your stress and slowly move your stress-managing capability.
  3. recognize that learning involves input AND output
    memory has no use, if you cannot output it from your mind. therefore, you need to make conscious efforts to practice on out-putting what is in your mind... through writing, ( like exactly what I am doing right now!), teaching others, and doing essay-based past year questions.  It takes practice to put concepts into coherent sentences, but it really does promote learning because when you try to put things into words, you realize that you need to recall the facts, and link the facts together when doing so.
  4. Do past year questions
    Past year questions are your strongest allies when tackling exams. every examination has its own trends, and you should make every effort to attempt past years - sometimes multiple times. not only to recognize the trend of the questions, but to realize which areas are your weaknesses, so you can revisit them.
  5. Plan your learning early
    why do we have to plan early? various reasons. One - we have to allow ourselves some time to fail. if you set your plan too stringently, say, 5 repetitions of a particular topic over 2 months and you figure out that you can probably do only 3, you need to readjust your plan accordingly. Two - it is always better to study a little everyday, than to study for the whole day for a day in a week. early planning will enable you to spread out your learning so that studying everyday would be a breeze. Victory loves preparations!
  6. Find your own studying methods
    everyone has a different strengths in cognition. some people can remember better when they read things aloud, and some others remember better when writing things down. try to find how you study best, and stick to it. when it is not working, change it! try many methods to find the one best suited for yourself.
    This blog is partly an attempt by me, to test out studying methods - as you can see, I have made several mind-maps! 

how do we improve our memory and recall?

  1. Memory improves with emotional involvement.
    we remember things better when we FEEL something when we try to retain facts. therefore, try to make opportunities to link emotions to facts - a good way to link them is through humour. try to make jokes out of facts. the sicker the joke is, the better, because that sense of disgust will also enhance memory. Have friends with a sense of humour around. they're usually good at turning everything into jokes.
  2. Memory improves with associations

    When we are young, we can remember facts as it is, but as we get older, we tend to remember more when it is associated with other information.

    for example if you were foreign to English language, and to remember the word... say, "ubiquitous" - if you were 5years old, you would probably be able to recall next week. if you were 55, you most probably will not. but if I were to explain the meaning of the word, that it means "Being or seeming to be everywhere at the same time" and because this 55 yearold man is a religious man, I tell him - "like god and his holy presence, it is ubiquitous", he may be able to remember this word not only for a week, but his whole life.

    try to relate everything you have learnt, to each other, and to something you known previously -which brings us nicely to my next point.
  3. Don't just study all the time.

    I just mentioned that people remember better when things are associated together. this means that your ability to memorize things will increase proportionally to your current memory of various things.

    If you have spent your whole life studying in your room, you won't be able to easily relate things together - simply because you have a lack of retained facts to link together! this explains why people who does lots of sports, and has lots of hobbies seem like they have less trouble remembering new things.

    having lots of things to do, is good for your hippocampus. what is that you say? it is the part of the brain responsible for remembering new facts. you can memorize new things thanks to this organ in your brain. In a nutshell, doing new things in life will stimulate your hippocampus, therefore making your ability to memorize more powerful.

    Having hobbies will be hugely beneficial in relieving stress. doing extra curricular activities in university will help you find friends whom you can turn to. the list of benefit is endless. when in university, join at least one extracurricular activity. Trust me, it is worth it.
  4. Teach people!

    Teaching is a highly complicated task that requires a lot of skill! but when we actually attempt to teach someone else, we are forced to search into our minds into our retained facts, and summarize them and output them as coherent words so others can understand. this will make us realize parts of our memories that are lacking, so that we can go back and learn them again, and train us in the terms of output. the person who benefits the most from teaching, is actually the teacher him/herself!
    This blog, including this post is the embodiment of my attempt to use this technique of memory and recall. I remember most things that I have written on this blog, because I had to crack my head over it. I am helping myself more than anyone else.
  5. More to be added!

1 - Yerkes RM, Dodson JD (1908). "The relation of strength of stimulus to rapidity of habit-formation"; Journal of Comparative Neurology and Psychology 18: 459–482.