COPD

COPD

- pathophysio

a preventable and treatable respiratory disorder largely caused by smoking, is characterised by progressive, partially reversible airflow obstruction and lung hyperinflation with significant extrapulmonary (systemic) manifestations1 (Level II-2) and comorbid conditions2 (Level II-3) all of which may contribute to the severity of the disease in individual patients.

due to a mixture of small airway disease (obstructive bronchiolitis) and lung parenchymal destruction (emphysema), the relative contributions of which vary from individual to individual. Airflow limitation, associated with an abnormal inflammatory reaction of the lung to noxious particles or gases, the most common of which worldwide is cigarette smoke, is usually progressive, especially if exposure to the noxious agents persists. 

diagnosis and severity assessment of COPD, a post-bronchodilator FEV1 /FVC ratio of < 0.70 and post-bronchodilator FEV1 measurement, respectively are recommended.

The pathological changes in COPD, 

which include chronic inflammation and structural changes resulting from repeated injury and repair - -

- due to inhaled cigarette smoke and other noxious particles, 

- are found in the proximal airways, peripheral airways, lung parenchyma, and pulmonary vasculature.

The chronic inflammation in COPD is 

- characterised by 

• an increase in the numbers of neutrophils (in the airway lumen), 
• macrophages (in the airway lumen, airway wall, and parenchyma), and 
• CD8+ lymphocytes (in the airway wall and parenchyma).

 The cells and mediators involved in the inflammatory processes in COPD and in asthma are different 

• differences in physiological changes, symptoms and response to treatment 

•  These pathological changes lead to 
• mucus hypersecretion, 
• expiratory airflow limitation 
• with dynamic small airway collapse causing 
• air trapping and lung hyperinflation, 
• gas exchange abnormalities, and 
• progressive pulmonary hypertension t
• hat may lead to cor pulmonale.
•  There is further amplification of the inflammatory response in the airways during exacerbations, 
• which may be triggered by bacterial or viral infections or 
• by environmental pollutants. 
• In general, the inflammatory and structural changes in the airways increase with disease severity and persist on smoking cessation.

PE:

Physical signs of airflow limitation and air trapping (barrel chest, loss of cardiac and liver dullness, prolonged expiration, reduced breath sounds)

Ix

Signs symptoms of exacerbation

- >2 cardinal symptoms

: increased dypsnea/sputum volume/sputum prevalence

if 2/3--> moderate to severe

risk factors: age>65, fev1<50,>2exacerbation/year, with u/l IHD/ HF

noctural cough : why?

- Patients with nocturnal asthma symptoms may have greater nighttime activation of inflammatory cells and mediators, lower levels of epinephrine and increased vagal tone

We can also use MMRC dyspnea scale and COPD staging to further improve our Management afterwards.

ddx: 

- bronchial asthma

- CHF

-pulmonary edoema,

pneumonia

-bronchiectasis

-pulmonary vascular disease

Outpatient management

- bronchodilators: beta agonist(salbutamol 2.505mg)/ipratropium bromide

- corticosteroids (fev1<50 30mg per day for 1week)

Types of meds

• Acute exacerbation: doxycycline 100mg/ amoxycillin 500mg QID
• CAP: ampicillin_ azithromycin
• severe: 
• wihtout beta lactamase inhibitor (piperacillin-tazobactam) /cefepime

• Gram positive: 
• staphylo, strepto, pneumococci, tb: cloxacillin, penicillin g,
• gram negative: 
• e coli, pseudomonas aeruginosa: aminoglycosides (gentamycin), cephalosporin(ceftriaxone), fluoroquinolones (ciprofloxacin)
• tonsilitis: amoxycillin
• meningitis: ceftriaxon + ampicillin

Heart Failure

Heart Failure(HF)

1. intro

2. pathophysio

3. Signs and Symptoms

4. Classifications: NYHA

5. Investigations

6. Management

HF is a structural or physiological abnormality of the heart resulting in its inability to meet the metabolic demands of the body or its ability to do so only at higher than normal filling pressure

Population:

EF <40% HFrEF

EF>50% HRpEF

EF: 40-50: HFmrEF

Pathophysio

Acute heart failure Signs and Symtoms

4 types of symptoms to show which type of HF belongs to. 

• warm and wet: adequate perfusion but congested (lungs/peripheral) - volume overload
• cold and dry - hypoperfuse, dehydrated - pump failure
• cold and wet - hypoperfuse and congested
• ward and dry - adequate perfusion and dehydrated - mild HF/ compensated stage of HF

what is reperfusion? The restoration of blood back into tissue

- Elevated jugular venous pressure 

• is a manifestation of abnormal right heart dynamics, mostly commonly reflecting elevated pulmonary capillary wedge pressure from left heart failure. This usually implies fluid overload, indicating the need for diuresis.

Left and Right sided heart failure differences:

NYHA: 

I- no limitation , 

II: slight limitation, comfortable at rest, activity causes fatigue 

III: dmarked limitation: less than ordinary activity causes sx 

IV: unable to carry out physical activity without discomfort.

Imvestigations (Ix):

• ECG
• - access HR, rhythm, 
• QRS morphology /durarion/voltage, 
• evidence of ischemia, LVhypertrophy/ arrthymia
• chest radiography: 
• pulmonary congestion, cardiomegaly , or other lung pathology
• Echo 
• to determine type of HF
  - assess LV chamber size, thicknesss
  - diastolic fx
  myocardial ischemia test: treadmill exercise, stress echocardio,
• invasive: 
• coronary angiography
• others: holter, pulmonary function test

Blood Ix: 

• FBC
• RP
• LFT
• CBS
• FLP
• HbA1c
• Natiuretic Peptides/BNP: 
• peptide hormones synthesized by the heart, brain and other organs. to reduce arterial pressure by decreasing blood volume and systemic vascular resistance

- the higher the number= heart could not pump the way it should

- release when cardiac myocytes are strained

- useful to rule out acute dypsnea

- NP can increase also when pt have AF/ CRF/ age/ obese/ ARNI

- significant if >400, age >50: >450, age 50-75 :>900, age>75: >1800

• CK: 
• inflammation of muscle, indicates level of damage or disease of skeletal muscle
• TFT
• infective screening
• iron study,
•  - to check Tsat: Fe/TIBC x100, if <20% : inadequate iron supply
• urine test: UFEME/ C+S
• blood gas:

- hypoxemia: paO2<60

- hypercapnia: PaCO2>50

- Acidosis: pH<7.35

Management(Mx): 

Acute HF:

1. stabilise hemodynamics
2. maintain o2 and perfusion of organs
3. relieve symptoms and signs
4. treat u/l cause or aggravating factors

Treatments:

1. non pharma, pharma

• Diuretics
• ACEI
• ARB
• Beta blockers
• MRA
• Statins

2. Surgery

3. Device therapy

- catheter ablation/pacemaker therapy

Common drugs used:

• dopamine: improve renal perfusion and promote diuresis / increase BP
• dobutamine: peripheral hypoperfusion n pulmonary congestion
• Ivabradine: slows the heart rate to allow more perfusion to the heart
• thiazides: hydrochlorothiazides: promote natiuresis and diuresis

ROF : 1-1.5L/day

To watch out for

- worsen symptoms, readmission rate

- increase in cardiovascular event rate

- increase in bleeding risk and stroke rate

- adverse effects due to pharmacotherapy

References:

1. Malaysia CPG for HF

ATLS overview (OSCE)

Definition: 

1. ATLS : life threatening with pulse
2. ACLS(cardiac): life threatening, no pulse

Common emergency cases:  (ATOMTC)

• Airway obstruction
• Tension pneumothorax - silent chest, trachea deviated

• Open wound

• Massive hemothorax

• Tracheobronchio dissociation/ fistula
• empysema
• crepitus, poor air entry
• corrective surgery
• do X-ray - is it hyperventilated?

• Cardiac tamponade - JVP, increase HR, muffled heart sound
• Pericardial effusion?

OSCE ATLS steps: 

1. What to do when the patient came in with emergency? (DR. AVPU)

1. Danger
• access the situation, ensure you are safe first
2. Response & role
• check for patient response and 
• ask someone around you(assistants)to help
• prepare airway apparatus +cervical support
• chest tube, needle tube, SP02
• IV line - for fluid & BT & crossmatch

    Check their response to... 

1. Alert
2. Verbal
3. Pain
4. Unconscious

2. If all above indicates emergency case signs proceed with   ABCDE

Airway       - jaw thrust - open the mouth and inspect for foreign substances (yonker suction could help 

                       removing them) - check for gag reflex - 

                   - cervical support - can be confirmed by using the NEXUS criteria 

                  

 https://www.grepmed.com/images/3860/management-clearance-algorithm-cervical-canadian-mnemonic-imaging

 (cervical spine evaluation in trauma)

             

Breathing   - ventilation,

• inspection: check for ATOMTC (common emergency cases, in first paragraph)
• palpation: trachea location, rib intact? fracture?
• percussion: hyper-resonance? dull?
• auscultation: Air entry? Heart rhythm, HR?                        

                    - check Respiratory rate

                    - intubate if needed

Circulation - bleeding

• IV 2 large bonula
• IL warm NS
• BT urgent panel
• inspect head to toe for bleeding
• EENT, abdomen (peritonitis), pelvis(spring fracture), genitalia (hematoma, scrotum, perianal bleeding, urethral)
• peripheral bleeding (fracture)

Disability   - pupil

• GCS scale!   
•       

Exposure    - environmental - do they need a blanket? (hypothermia?)

• log roll for back examination (examine the spine - stepping sign)/ rectoperitoneal bleeding / prostate high riding / pelvic injury / abdominal injury / thoracolumbar injury
• DRE? anal tone lac? 

Simple Management mnemonic:

2(CBD, NG tube)

+

2(X-ray : chest and pelvic)

+

2(drugs and analgesia IPTT)

+

2 investigation(ECG, FAST u/s)

other links:

https://www.researchgate.net/figure/ATLSR-algorithm-and-spine-trauma-assessment-In-Step-A-cervical-spine-C-Spine_fig4_24174239

USM Exam Part II Experience 2019

Examination for provisional registration

Date of exam                      : 3rd December 2019

Date of Intensive class       : 1st and 2nd December 2019

Duration                             : 3 days in HUSM

Transport                            : Flight from KL to Kelantan (around RM 500)

Exam Cost                          : RM 3000 for the exam, RM 1000 registration 

Utility Cost                         : Food RM100, USM Guest House RM 75/night (shared a double room)  

Past Year Question link      : USM 2019 Dec
Things to pack along          : Lab Coat, Stethescope, Pens, Snacks and sweets, Formal attire
                                              (pentorch, hammer will be provided if it is required in the station)

What happens after you pass?

So after you pass, you will need to wait for about 2-3 months before they give you a call to let you know the next exam date. DO NOT wait until they call to start studying, it will be too late >.<

After I receive the call, they send me the letter two weeks later (around 5th November). And we will need to:

 - confirm if we are going to take the exam

 - confirm if we are attending the intensive class

 - make payment

Letter Head of the Offer Letter

Part of the Letter

Accomodation

-They do not provide accommodation for us, so we call a few numbers below to ask for availability. If you know a friend who is taking the exam together, you can share a room with them. It helps to improve the atmosphere, or you will be nervous all the time, plus you will have a study partner too! 

After consideration, we choose to stay in rumah tetamu USM, it was more expensive but the room is bigger.

The double room we had even has a balcony and a pantry area.

I had a picture of the bed below, please ignore the mess we made. XP

Usm Guest House 

Itinerary

We reached one day earlier to settle in and get use to the place. It depends on you if you need it or not.

On the first day we are require to go to this pusat sumber pelajar for a briefing. It was in Hospital USM itself. Remember to bring a jacket, it is quite cold for me.

They also gave us a schedule of what we would be doing for the rest of the day, so we can get prepared. We are being reminded that this intensive course is not a class to teach medicine from A to Z, but a class to help us get use to how the osce is going to be done (such as the scoring, what they expect us to do in the exam venue, quick summary on what the examiner expect when you see them on the exam day). 

The intensive course was really useful, it help a lot to make us get use to the environment and the exam style. 

Intensive course Venue

Schedule for 3 days

Tutorial Hall

Practice Session
We are given some time to practice on manikins in a room (I am not sure what they call it)

Where is our exam hall? 

The pictures shared above is a sneak peak to where our exam was conducted. It was scary at first, but soon you will get use to the flow. I enjoyed the OSCE exam more then the theory, because it reminds me of my days as a student taking my final exam during my university years. So glad to be able to be one step closer to my dream after a year of waiting and studying!

If you want to know about how it was being conducted, check out this link.

Take Home Tips

- Read the questions properly. Think and try to recall the information you want to ask and present. 

- Always start with greeting, introducing yourself and wash your hands!

- Build good rapport and have eye contact with patient, respect the examiner as well.

- Take patient identification data! (name, age, marital status, occupation) follow by their chief complain

- Balance with open and close ended questions about the assessment. especially : mental assessment, suicidal risk, OCD criteria, trauma related. -- they are very important and often carry high points
- Always say thank you to the patient and also the examiner
- I know you will be nervous in the room, but try present your finding as organised as possible, so the examiner can understand you and it helps you with your diagnosis too!

I wrote a post on what came out on that day, you can learn more from here.

So try your best and have fun in the exam! You will meet a lot of new friends who are in the same situation. Get their contacts and keep in touch😁

Enjoy and pass the exam with FLYing colours!

USM OSCE - EPR 2019 Dec

Past Year Topics for USM OSCE - 2019 - Part I

Hi all, in this post I am going to share the topics they have on year 2019 for Examination for Provisional Registration-/EPR. (the year I took my exams😁Thank God I passed)

** EPR is a special exam where International Medical Graduates must take to get full licence to work in Malaysia. 

So I will provide more details on how the questions were asked and what I experienced specifically for the USM December 2019 session. However I won't be able to recall the questions fully word by word, but will try my best to explain what was being asked.
The other session for 2019 are USM-Feb  and IMU-July will be posted in another post.

Reminder:

You have 1 minute to read the questions outside the room and once the bell rang, you have 9 minutes to finish the station. the second bell will ring, and you will have to move to the next station quickly to read the next question.

USM (December 2019)

Emergency medicine
1. Patient involve in motor vehicle accident, access the patient and do immediate management
   - Emergency management of Pneumothorax
   - Name all the equipment needed in ED (we have to name the equipments shown on the table)
   - explain the safe triangle position in detail
   - perform the procedure from the safe triangle


Orthopedics
2. Patient involve in motor vehicle accident and have problem walking, you are require to do a lower limb PE
  -  identify short limb gait (at least that is what I think it is) ** real patient walking
  - so I proceed with full lower limb physical examination and LLD(Limb Length Discrepancy) diagnosis
  - Physical examination necessary to identify LLD

3. Hip X-ray with a problem, patient short history provided
   -  Describe the X-ray, give a diagnosis and explain your further management
   - identify all structures shown in the picture and explain their functions.

P/S: remember to check patient name and date


Internal medicine
4. Patient with chest pain and SOB, take the history and explain further management if needed
  - history taking and I suspect its AMI

5. Interpret chest X-ray and give diagnosis with treatment + physical examination of the chest
   - Tips: there is a mass in the chest x-ray

P/S: treatment plan must be specific***


Surgery
6. Patient present with mass at inguinal area, diagnose and focus physical examination
  - Inguinal Hernia - after history taking, ask for permission to do examination
  - physical examination is done on the manikin. (you can refer to this to understand the scoring)

** The examiner asked the differences of direct and indirect hernia physical examinations and their respective treatments.

7. Pneumoperitoneum - X- ray interpretation and management plan
  - management is specific

Tips: if you plan to have iv fluid, what do you want to do? (is it fluid bolus? how much you want to give? how long you plan to administer the fluid? etc.)


Pediatrics

8. Growth Chart interpretation
  - scenario given was about short stature. (explain the cause, QOL, management)

 Tips: calm the child down first so they can cooperate

9. Lumbar Puncture Consent from Parents
  - get the consent is the aim. make sure you explain all about lumbar puncture from the cause to the treatment values.
   - reassure the patient


OBGYN

10. Bimanual Examination
   - there is a huge mass in the manikin.
   - explain your examination specifically on inspection and palpation,
  - the examiner will ask for your diagnosis and your management plan for the patient

11. Patient complain is stomach pain and discomfort (a little aggitated)
  - After history taking, i suspect its a Placenta Abruption case.
  - the examiner asked for our diagnosis
  - present your case from history taking
remember to include: Gestational age calculation, GPO - all OBGYn necessary history
  - treatment plan

*P/S: I finish this station when the bell rang for us to leave the room. We only have 9 minutes to do all the above, make sure you manage your time well. 


Anesthesiology

12. Patient need to prep for surgery, as a junior doctor apply adequate oxygenation before anesthesiologist arrive.

  - full airway assessment and use the Bag valve mask (if  you observe well, you will see it lying on the table beside the manikin) -explain the indication and possible complications.

*P/S:   - the procedure was easy as i did a lot during my internship in china (finish smoothly in a few minutes), but the examiner asked a lot of questions and fully utilized the 9 minutes. Be ready to answer a lot of questions and make sure you know what and why you do what you have done.


Psychiatry

13. The patient is very sad and depressed. If you have good observation, you will see a plaster on her wrist.

 - The patient has history of suicide, so after accessing the patient and confirm it is related to suicide, I used the suicide risk assessment to confirm the diagnosis.
 - the examiner will ask how you come out with your diagnosis, luckily i still remember the specific components for the assessment. (the examiner asked how I get the score)


ENT

14. ASOM
 - acute suppurative otitis media

* I am very thankful to be able to work as a clinic assistant for an ENT doctor for almost a year. 
Really grateful I know how to use the equipment, give diagnosis, explain the cause, complication and management to the patient very quickly and specifically. I spend a lot of time sitting outside the station to wait for the next bell to ring.😄Thank you Doctor Koay! 


Radiology

15. Two CT was showed
 - I suspect it's a CT with Epidural hematoma and subdural hematoma
 - we are require to explain the CT in detail to support our diagnosis

 *P/S: this is the only station I don't know if what i did is right or wrong. because he is not satisfied with the answer i gave, and when I asked the other students, they say the same thing.. 
 Until now I still don't know what the doctor showed us, because I forgot how the CT looks like... (sad)


Community Medicine

16. Consultation on family planning
 -  asking for pregnancy advice and how to have a healthy

*P/S: the patient has diabetes after minutes of asking... So I have to quickly brief her the pros and cons on the complication of pregnancy while having an uncontrolled diabetes situation. 


If you have more questions can leave a comment below, I will try to reply as soon as possible.
Good luck!