Lower Limb Amputation

1) Hemipelvectomy
     Also called hindquarter amputation, which involves the excision of part of the pelvic bone

2) Hip disarticulation 
    Which is the amputation of the limb at the hip level

3) Transfemoral amputation (Above Knee Amputation)

4) Knee disarticulation

5) Transtibial amputation (Below Knee Amputation) 

6) Syme amputation 
     Amputation at the level of the ankle joint, where the heel pad is preserved to provide 
     a platform for weight bearing

7) Amputation of the foot: 
    Amputation is performed at the mid-foot, it is called a Chopart 
    Amputation near the metatarsal is called a Lisfrance
    Amputation through the metatarsal bones is called a Transmetatarsal amputation
    Amputation of toe(s) plus part of metatarsal bone(s) is called Ray Amputation

8) Disarticulation of Toe(s)

Algorithm Management of Diabetic Foot Patient

* cut & paste from Malaysian Diabetic Foot CPG

Types of Brian Herniation

Supratentorial herniation

1-Uncal 

2-Central (transtentorial) 

3-Cingulate (subfalcine) 

4 Transcalvarial 

Infratentorial herniation

5-Upward (upward cerebellar or upward transtentorial) 

6 Tonsillar (downward cerebellar)

Proper X-Ray of Fractured Bone Must Have?

* Rules of 2

1) 2 View --> AP & Lateral View
2) 2 Joints --> prox & distal
3) 2 Limbs --> in children particularly
4) 2 Injuries --> exclude injuries elsewhere
5) 2 Occasion --> repeat 1/ 2 weeks later

Obstetric Ultrasound

1^st Trimester (10-14 weeks)

-          Viability

-          Dating scan (CRL)/ REDD (if diff > 7)

-          Gross anatomy – anencephaly, cystic hygroma, bladder outflow obstruction

-          Multiple pregnancy – chorionicity, amnionicity

2^nd Trimester (18-24 weeks)

-          Dating Scan (Biparietal diameter/ Head circumference)/ REDD (if diff >14)

-          Structural anatomy – brain, face, heart, kidneys, abdomen, spine, hands, feet, genitalia, bladder

-          Fetal growth – IUGR/PE/Oligo

-          Fetal Sex – 99% accuracy

-          Placental site – recheck @ 34 weeks

3^rd Trimester

-          EFW: FL, AC, BPD

-          Fetal Progression, well being, presenting part

-          Placenta Location (> 28 weeks) 

List Of Medical Problems in Preterm Baby

1) BRAIN
    - Interventricular Hemorrhage

2) EYE
    - Retinopathy of Prematurity

3) RESPI
    - ARDS
    - Pneumothorax
    - Bronchopulmonary Dysplasia

4) CVS
    - PDA

5) GIT
    - GERD
    - Jaundice

6) METABOLIC
    - Hypoglycemia
    - Hypothermia
    - Hypocalcemia
    - Malnutrition --> Need more
    - Anemia

7) IMMUNOSUPRESSED
    - Risk of Infection

HyperKalemia VS HypoKalemia

* Normal Serum  K⁺ : 3.5 - 5.0 mmol/L 

Contraindication of Tocolytic Agent

ABSOLUTE
1) Cardiac disease
2) Hyperthyroidism
3) APH
4) Chorioamnionitis
5) Cervix Os > 5 cm
6) IUD
7) Fetal Anomaly
8) Fetal Distress

RELATIVE
1) PE/ Chronic HPT
2) DM

FIGO STAGING: Cervical CA, Ovarian CA, Endometrial CA

* First need to remember this;
   Staging of Cervical CA by Clinical, Ovarian CA by Surgical & Endometrial CA by Histopathology

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In Gynae Malignancy, this 3 cancer are very important; thus need to have at least a basic idea of their   staging, because this will determine the management & prognosis of the patient 

Common Gynae Complaint & its Differentials

1) Dysmenorrhea 
    -  Primary
    -  Secondary
       1) Endometriosis 
       2) Fibroid
       3) Adenomyosis
       4) PID 

2) Menorrhagia
    1) Fibroid 
    2) Adenomyosis
    3) Endometrial Polyps
    4) Endometrial Hyperplasia
    5) Endometrial CA
    6) Hyperthyroidism
    7) DUB (dx of exclusion)

3) Bleeding Early Pregnancy
    1) Abortion
    2) Molar Pregnancy
    3) Ectopic Pregnancy

4) Amenorrhea 
    -  Primary 
        1) Kallman Syndrome
        2) Gonadal Dysgenesis: Turner Syndrome, Testicular Feminizing Syndrome
        3) Uterus: Mullerian Agenesis 
        4) Vagina Atresia, Imperforated Hymen
        5) Any Chronic illness of Childhood eg: Thallasemia, CF etc

    -  Secondary 
        1) Pituitary: Exercise, Stress, Eating d/o, Sheehan Syndrome, HyperProlactinemia,
                          Hyper/HypoThyroid
        2) Pregnancy (most common) 
        3) Menopause
        4) PCOS
        5) Uterus: Asherman's Syndrome

5) Post-Menopausal Bleed
    1) Cervical CA
    2) Endometrial CA
    3) Endometrial Hyperplasia +/- Ovarian CA (Hormonal Secreting)
    4) Endocervical Polyps
    5) Atrophic Vaginitis (most common)
    6) Bleeding Early Pregnancy
    7) Blood Disorder

6) Infertility/Subfertilty  
    1) Uterus : Fibroid, Endometriosis
    2) Tubal: PID (adhesion), Tubal Pregnancy
    3) Ovary: PCOS, POF
    4) Husband Related
    5) Unexplained Fertility

* Selamat Belajar*

Metabolic Syndrome

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I always forget the criteria to diagnose Metabolic Syndrome as I thought it is not much important, but nowadays... the incidence of Metabolic Syndrome is keep increasing as as result of Obesity and some other factors.... So you guys please remember this, I'm sure your lecturer going to ask about this quite often...

Digital Rectal Examination (DRE) : What to Examine?

1. No Contraindication for DRE:- Pt refuse/ any painful anal condition
2. Inspection of Anal region 
3. Insert Finger & check for anal tone
4. Intraluminal Examination - any mass, impacted feces etc
5. Extraluminal Examination ---> eg: Prostate
6. Removal Finger --> Any melenic stool/ blood etc

     * Painful Anal Condition

1. Anal Fissure
2. Anal Fistula
3. Prolapse/Thrombosed Hemorrhoid
4. Perianal Abscess  

* learnt from Mr Nazli credit to him 

Hernia Examination

INTRODUCE & Ask if any pain over the examination area

ON LYING SUPINE
1) Expose properly: Up to knee

2) Inspect: Testes & Groin
    - Testicular swelling/ redness/ loss of wrinkle/ displacement of median raphe/ scar
    - Groin swelling/ redness/ scar

3) Coughing Pulse
    - with b/L groin palpation --> if +ve (EXPANSILE)
    - then without palpation --> see the flow of swelling

4) Demonstrate inguinal ligament line
    - show the swelling above & lateral to the inguinal line

5) Palpation: Testis & Groin
    - Is the Testis separable, can get above the swelling, & feel for the cord
    - Feel for tenderness, temperature, consistency, surface, margin, translumination, compressible
    - Don't forget to measure the size of swelling/ or just estimate

ON STANDING 

    - Ask patient to put the swelling back in (REDUCIBLE) 

    - Upon standing, occlude deep inguinal ring (2FB above midpoint of ing ligament) 

       & ask patient to stand

    - Ask patient to cough & then release your hand

    - See again the flow of swelling ---> sausage shape/ go from inguinal to scrotum

    - Here probably can see the shape more clearly & can measure the size more accurately  

COMPLETE

    - Do Abdominal & PR Examination : Any evidence of Increase Intraabdominal Pressure

    - Examine the Lungs --> any Lung problem, chronic cough 

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Hernia Examination is very tricky, most of the problem student encounter is whether to examine patient on lying supine first or straight away ask patient to stand? the answer is it depends on patient position at the time, if patient is at the time lying supine & you test for coughing pulse & not really demonstrable, I think better you ask patient to stand straight away and start your examination from standing, but if the swelling very obvious o lying supine & coughing pulse is positive, you can just follow the examination flow I recommended here

Cushing Syndrome

* Clinical syndrome resulting from excess circulating glucocorticoid

Causes
1) Exogenous: Steroid Toxicity (Tx for Nephrotic, SLE, JRA, IBD) 
2) Endogenous : Adrenal CA/Adenoma, CAH, Cushing disease, Ectopic-ACTH

Head-to-Toe Examination ---> Mainly for Exogenous Cause (as a cause for CS)

1) General
    - Orange on stick appearance
    - Central Obesity
    - Hyperpigmentation (ACTH-dep)

2) Face
    - Moon Face, Plethoric Face, Acne, Hirsuitism, Frontal balding (female)

3) Eyes
    - Cataract, Papilloedema (funduscopy)

5) Oral
    - Candidiasis

4) Back
    - Dorsal fat pad, Vertebaral tenderness (osteoporosis)
    - Neck: Skin Infxn

5) Arms
   - Bruises, Thin skin, Skin Infxn (folds area), prox m/s wasting
   - Test for Prox Myopathy

6) Fingers
   - Bad ungual infection

7)) Abdomen
   - Central Obesity, Striae (purple/red), Scar (any reason)
   - Palpate --> Epigastric tenderness (>> steroid usage --> PUD)
   - Check for Ascites

8) Legs
    - Bruises, Thin skin, Thin limbs, Prox m/s wasting
    - Palpate for leg edema also
    - Test for Prox Myopathy

9) Complete with
    - BP --> HPT
    - RBS/ Dipstick --> DM
    - Weight & Height --> Growth Failure
    - Ask Hx of Long Steroid Tx
    - Any Bony pain/ patho# --> Osteoporosis

Graphic presentation of Cushing Syndrome

Principle Management of AGN

* In General NO specific Tx for AGN. The Tx is SYMPTOMATIC only

1) Confirm Dx of AGN (Send Ix)
    - BP (High) --> plot at BP centile 
    - UFEME & C+S --> RBC
    - BUSE --> Renal Fx
    - Ser C3($), C4 (n)
    - ASOT (>200 IU/mL)/ Throat/Skin swab & culture
    - FBC; Hb, TWBC

2) 10 days course of Penicillin
     - Initially IV C. Pen 30 mg/kg QID (1mg = 1667U)
     - Then change to PO Pen V 7.5-15 mg/kg QID

3) Tx Edema (d/t salt & water retention)
    - ROF & salt intake

4) Tx Hypertension (Diuretics/ AntiHPT)
    - T. Frusemide 1-2 mg/kg BD
    - T. Nifedipine 0.5-1 mg/kg BD

5) Tx Fever with Anti-Pyretics
    - PCM 15 mg/kg 4HRly (max 4g/day)
    * 1 Tab = 500 mg

6) Monitoring
   - Strict I/O Charting (plus urine colour)
   - Nephrotic Charting (daily albumin & BP target < 90th centile)
   - VSx 4HRly
   - RP daily ---> Renal failure

7) Monitor for Cx & Tx appropriately
   - HPT Encephalopathy -->
     c/o headace, vomiting, blurry vision, seizure, altered conscious
     * do Fundoscopy 
   - Acute Cardiac Failure
   - Acute Renal Failure (Oliguria < 300 mg/m²/day)
   - Progressive Glomerulonephritis 
   - Nephrotic Syndrome (Pro; nephrotic range 3+/ > 1g/m²/day)

8) Follow Up

   - For at least 1 year

   - Monitor BP every visit

   - UFEME & RP ---> asses recovery

   - repeat C3 6 weeks later if not normalised on the time of discharge 

9) Outcome

  - Short term: Excellent, mortality < 0.5%

  - Long term: 1.8% dev CKD; should referred to Paeds Nephrologist

 

Down's Syndrome Features

My CHILD HAS PROBLEM

Glemer tak adik nie.... hehe...

Congenital heart disease/ Cataracts
Hypotonia/ Hypothyroidism
Incurve 5th finger/ Increased gap between 1st and 2nd toe
Leukemia risk x2/ Lung problem
Duodenal atresia/ Delayed development


Hirshsprung's disease/ Hearing loss
Alzheimer's disease/ Alantoaxial instability
Squint/ Short neck


Protruding tongue/ Palm crease single 
Round face/ Rolling eye (nystagmus)
Occiput flat/ Oblique eye fissure
Brushfield spot/ Brachycephaly
Low nasal bridge/ Language problem
Epicanthic fold/ Ear folded & low set
Mental retardation/ Myoclonus

Down's Syndrome: H to T

Major Depressive Disorder: Major Criteria

SPACE DIGS:

• Sleep disruption
• Psychomotor retardation
• Appetite/Weight change
• Concentration loss
• Energy loss
• Depressed mood
• Interest loss
• Guilt
• Suicidal tendencies

Depression: Common among medical student (lagi2 dah nak exam nie..huhu)

Principle Management of Nephrotic Syndrome

1) Confirm Diagnosis
    - Fulfill the criteria: 
        > 1g/m²/day urine protein, Albumin < 25g/L, Gen Edema
    - Exclude secondary causes ---> 
        Infection (Hep B, HIV. Malaria), Malignancy (Lymphoma, Leukemia), CTD (SLE)


2) General Measures
    - Control Edema --->
       Normal protein & less salt diet, +/- Frusemide with caution  (ROF in Chronic Edema) 
    - Asses Hemodynamic (Hypo/Hypervolemia) --->
       Daily Nephrotic Chart & I/O Chart
    - Penicillin V Prophylaxis ---> Dose according to age

3) General Advice
    - Nature of disease -->
       Most will relaspe (85%-95%) - Consult Dr if Pro 2+ in 3 conseq days/ edema+
       Mostly idiopathic, Not affect renal fx
    - Home dipstick monitoring --> Once daily at early morning 
    - Tx option & its Cx -->
       Long Term Steroid, Cushing's, Immunocompromised (avoid infectious contact)
    - Immunization : Pneumococcal Vaccine -->
       Give during remission

4) Specific Tx for Primary Nephrotic Syndrome 
    - Long Term Corticosteroid or
    - Cyclophosphamide --> For frequent relapse/ Steroid dependent 
    - Steroid Resistant --> Renal biopsy (specific Tx depend on HPE) + supportive 

5) Manage Cx of Nephrotic Syndrome/ Cx of the Tx (if any)
    - Hypovolemia --> Tx: Human Albumin fast infusion
    - Spont Bacterial Peritonitis --> Tx: IV C. Pen + 3rd Gen Cephalosporin
    - Thrombosis --> Prophylaxis

    - Cushing's Syndrome --> Tx: Taper down steroid/ change to Cyclophosphamide 
    - Immunocompromised --> 
       Immunization, avoid infectious contact, fever come to hospital
    - Acute Adrenal Crisis --> when udergone stress TX : HCT/ Prednisolone 
    - Loosing protein --> Muscle Wasting Tx: advice on diet (high calorie) 

Salter-Harris Fracture Classification

*        Type I - fracture through the physis (widened physis)

*        Type II - fracture partway through the physis extending up into metaphysic

*        Type III - fracture partway through the physis extending down into the epiphysis

*        Type IV - fracture through the metaphysis, physis, and epiphysis -- can lead to angulation deformities when healing

*        Type V - crush injury to the physis

The 5 Ts of Right to left shunt

The 5 Ts

1. Truncus arteriosus (1 vessel)
2. Transposition of great arteries (2 vessels transposed)
3. Tricuspid atresia (3 =Tri)
4. Tetralogy of fallot (4 =Tetra)
5. Total anomalous pulmonary venous return (5 =5 words)

Clubbing: Causes

CLUBBING CAUSES:..................CLUBBING

• Cyanotic heart disease
• Lung disease (hypoxia, lung cancer, bronchiectasis, cystic fibrosis)
• UC/Crohn's disease
• Biliary cirrhosis
• Birth defect (harmless)
• Infective endocarditis
• Neoplasm (esp. Hodgkins)
• GI malabsorption

Sequence of Elevated Enzyme Post-MI

"C-AST-Le" (CASTLE):

• CK-MB.... first
• AST......... second
• LDH......... third
• *Also: can use the last 'E' for ESR.

Respiratory Failure

* mintak maaf kualiti gambar kurang memuaskan tapi yg penting still boleh baca kan....

Carpal Tunnel Syndrome : Causes

Mnemonic is MEDIAN TRAP

• Myxoedema
• Edema premenstrually
• Diabetes
• Idiopathic
• Agromegaly
• Neoplasm

• Trauma
• Rheumatoid arthritis
• Amyloidosis
• Pregnancy

Management of GAD/ Panic Disorder/ Phobia

* Manage as OUTPATIENT 

INVESTIGATION
1) BIO :
    TFT, RBS, FBC (Hb),
    Urine for Drugs,
    ECG

2) PSYSCO:
    Collaborative hx from relatives, colleague, employer etc (find the stressor)

TREATMENT
1) BIO
    SSRi (1st line) ----> (Panic 1/2 dose AD, GAD = dose MDD)
    T. Escitalopram (Lexapro) 10-20 mg OM
    T. Sertraline ( Zoloft) 50-200 mg OM
    T. Fluoxantine (Proxac) 10-20 mg OM ---> DOC OCD/ Social Phobia
    Anxiolytic (BDZ)
    GAD ---> T. Diazepam 5 mg OD (Long Acting)
    Panic ---> T. Alprazolam 0.25-0.5 mg PRN (Ultra short) ----> xcont > 2 weeks can cause dependent 
     +/- Beta Blocker


2) PSYCHOSOCIAL
    PsychoEducation (pt & family)
    - Reassurance --> not going to die/ be crazy
    - Nature of d/s ---> stress --> +CNS & increase adrenaline ---> phy symptoms
                                   if no stress ---> no symptoms
    - Important to identify the stressor & anticipate

    CBT
    - Cognitive : Modify & correct misinterpretation (catastrophic thinking)
                       eg: List down +ve VS -ve quality you have
    - Behaviour: Relax/Breathing technique
                       Distraction technique
                       Stress Mx: Share!!!
                       Problem Solving (table)

    PsychoTx (Dynamic) ----> only for PHOBIA
    - Systemic Desensitization (with relaxation)
    - Gradual Exposure
    - Flooding

3) SPIRITUAL
     - Pray & Read Quran ----> can find piece (go back to your God)
     - Good deeds that you have ---> utilize it
     - I will pray for my patient

Management of Suicidal Patient (guide by Dr Kartini)

1. Admit the patient


2. Restrain patient

    - physical: patient will become traumatized by this method

    - chemical: best choice!

3. Put the patient in "strict suicidal caution"

    - in the ward, there is a "suicidal chart"

    - the patient will be observed hourly on some aspects:

      i.  sleep, appetite, interaction with others, 
          self hygiene: marks will be given

     ii.  tendency to attempt suicide (yes or no)

4. Assess the cause 
    (if it is due to psy problem, have to tackle them..eg: secondary to hearing voices or 
     delusion of guilt, etc..)

5. First line treatment: oral medication

    - but if the patient is catatonic or stupor, then only we can consider giving ECT 
      (but not on the day of admission-->give on second day)

6. When the patient is stable, plan for psycho-social management.

~I took this from Puteri, so credit to her for this~

Preparation for Blood Transfusion

* Patient already agreed for blood transfusion 

1) Prepare blood product: make sure same blood for same pt
2) Put patient on large branula
3) Give N/S 1st - to check the patency of branula
4) VSx check : esp Temperature & BP (pre-tx)
5) Get Transfusion set (w/out filter)
6) check VSx again (post-Tx)
7) Stand there for 10 mins to monitor any:
        Acute Tx Reaction (Fever, Hypotension, Flushing, Urticaria, dark urine)
        Mx: Stop transfusion, give IV HCT, Anti-Histamine, once resolve cont transfuse slowly
8) Give diuretics in between 1 pint to another 1
9) Repeat FBC post-Tx   


~credit to Dr Muna~

Ectopic Pregnancy

DIAGNOSIS
1) Hx: Bleeding Early Pregnancy, UPT +ve, Abd pain, Shoulder tip pain (d/t peritoneal irritation)
2) RF: Hx of Gynae surgery, PID, IUD
3) O/E: Shock, Abd pain, Cervical Excitation
4) TV U/S: No IUGS, Fluid @ POD
5) Ix: Ser Beta hCG (monitor every 48 -72 HRs) - (kat HTAA leh buat mase office hr je)
6) Lap Exploration : suspected Ectopic (cannot rule out)

MANAGEMENT
1) Surgical Mx
- Hemodynamically stable : Lap approach
- Hemodynamically unstable : Laparotomy (Open)
- Tubal Pregnancy: Salpingotomy/ Salpingectomy
- Post-Op Mx:
    Pain Mx (T. Synflex), rpt Post-op Hb, TWBC, send t/s for HPE, WI D2,
    Monitor VSx 4HRly, Encourage orally & ambulate, TCA x 2 week to review HPE

2) Med Mx
- Suitable women: hCG < 3000 iU/L, min symptoms
- IM MTX (75-95 mg) as a single dose
- Ser hCG D4 & D7
- Explain :
     Possibility of need for future Tx &
     SE of Tx (eg: Abd pain, Conjunctivitis, stomatitis, GIT upset)
- Advice:
    Avoid SI dur Tx, drink well,
    Use effective contraception x 3 months after give MTX (Teratogenic)

3) Expectant Mx (for preg unknown location, pt stable)
- b-hCG < 1000 iU, No IUGS
- Monitor conds (sx/syms), b-hCG every 48-72 HR until < 20 iU/L


* Anti-D 250 iU (50 microgram) is given to Rh -ve women 

Management of Breech

1) Confirm the date (if early, still can wait)
2) do US:  to type the breech & find possible causes
3) Offer pt ECV @ 37 weeks POG

1. Criteria
• No Contraindication
• EFW < 3.5 kg
• Adequate liquor
• Flexed Hd
2. Prepare for ECV
1. Consent
2. Explain: Procedure, Risk, NBM 6 HR, put IV line
3. Ix: 
• FBC, GSH, Rh Status (give anti-D to Rh-ve Mother)
• CTG: 1 HR before & after (check Fetal HR)
• US: favorable
• ECG: before & after (detect arrhythmia)
4. Cx of ECV:
• Mother: PROM, HPT, PA
• Fetus: Rh Isoimmunization, Fetal distress, Cord prolapse, Pre-Term labour 
5. Max: 3 attempt 
• 2nd attemt can give Tocolytic agent (but do ECG 1st) 
6. If Fail:
• Counsell regarding LSCS or
• Breech Vaginal delivery 

Management of DVT

1) Diagnosis of DVT by:

1. Clinical Probability (Hx, PE)
2. U/S Doppler
3. D- Dimer 

2) Management of DVT (Hep-Warfarin Therapy)

1. Exclude Pul Embolism; Clinical: Hemoptysis, Tachycardia, Ix: ECG, CXR, ABG, CTPA
2. Blood Ix (for DVT) : FBC, PT/APTT, baseline INR & APTT ratio, Thrombophilia Screening 
3. Start Heparin
• UFH - Loading dose 5000 U bolus, then 1000 U/HR by IVI, Monitor APTT ratio 6 HRly aim 2-3 (and change accordingly)
• LMWH - No need monitoring (give S/C)
4. START Warfarin D2 (aim INR: 2-3)
5. STOP Heparin when INR > 2 x 2 consecutive days (Combination of Hep-Warfarin at least 5 days)
6. Take DAILY INR for 1st week
7. Maintenance Dose Warfarin ~ 2-10 mg/d
8. Duration of Warfarin:

• Idiopathic: 6 month
• Recurrent: 6 month - 1 yr  

3) Find Underlying Causes 

4) Combined with Mechanical Tx of DVT

• TED Stocking : minimize post-thrombotic event 
• PhysioTx/ Encourage Mobility