Chorus That I Need To Sing;P

MRCP- It teaches more than it tests

This is the quote that I find most inspiring and it really holds true as you venture along the path of being a 'mrcpian'.

Singing the 'songs' after the end of each examination would better be termed singing the 'choruses', as each of these would invariably be repeated for tonnes of times before one would sit for the exam:)

I would like to complete my examination by...



1) CVS: AR
BP for wide pulse pressure
Peripheral signs for AR
Signs of IE if suspected

2) CVS: AS
BP for low systolic/narrow pulse pressure
Signs of IE if suspected

3) CVS: TR (functional or structural)
(Of course, you'd have found a PSM at lower LSE best heard at inspiration along with a promivent v wave to say this:)
Examine the abd, in particular, to look for a pulsatile liver

4) CVS: Severe MS +/- pulm HT
BP
Signs of IE if suspected
Examine the lungs to look for bronchial breathing at left middle zone (collapsed consolidation of left middle lobe d/t enlarged left atrium compressing on the left brochus)
Talk to patient to look for Ortner's syndrome (hoarseness of voice secondary to left recurrent laryngeal nerve palsy from left atrium enlargement)

5) CVS: prosthetic valve(s)
Midline sternotomy scar is present...there is a metallic click which coincides with the 1st HS best heard over the mitral area...and there is no evidence to suggest leakage of valve...and clinically there is no evidence to suggest overwarfarinisation.

6) Abd: CLD
Scrotum for testicular atrophy
PR to look for malaenic stool (if pallor present)
...there are signs to suggest CLD as evidenced by the presence of... Therefore, I think this pt has CLD, but there is no sign to suggest that he is in hepatic encephalopathy. The possible etiologies I'd like to consider are...

7) Abd: APKD
Examine the BP to look for hypertension.
Dipstick the urine to look for proteinuria & haematuria
Examine the CVS in particular to look for MVP.
...previous peritoneal dialysis scar noted at the infraumbilical region... I think this patient has adult polycystic kidney disease in ESRF requiring haemodialysis. No signs of fluid overload. No signs to suggest that this patient is in uraemic encephalopathy.

8) Abd: Hepatosplenomegaly d/t myeloproliferative disease
Examine all the lymph nodes to look for generalised lymphodenopathy

9) Respiratory: Pleural effusion
Examine the sputum macroscopically, in particular, looking for haemoptysis
Dipstick the urine for evidence of gross proteinuria
....the etiologies I would like to consider are mitotic lesion of the lungs as evidenced by finger clubbing, cachexia and heavy nicotine stains; mycobacterium infection of the lungs and the remote possibility of a parapneumonic effusion of the lungs.

10) Respiratory: AECOAD
Examine the sputum mug to look at the sputum macroscopically, and to do a bedside PEFR for the pt.

11) Respiratory: Bronchiectasis
Examine the sputum mug to look for foul smelly copious sputum and haemoptysis
CVS- dextrocardia (if suspected Kartegener synd); loud P2 with left parasternal heave to suggest pulm HT

12) Respiratory: Dullness/consolidation apex
Examine for wasting of the 1st dorsal interossei of the ipsilateral hand, and to look hard for ipsilateral Horner's synd.

13) Neuro: Parkinson disease
Examine the standing and lying BP, examine for coordination to look for cerebellar signs and to check patient's upward gaze. I also would like to look for any evidence of long tract signs by carrying out a full upper limbs and lower limbs neurological examination.

14) Neuro: Unilateral facial nerve palsy
Examine for cerebellar signs, checking patient's ant 2/3 of the tongue for taste & sensation. Further examine the 8th CN by doing Rinne & Weber's test and to do a full otoscopic examination.

15) Fundus: DR with maculopathy
Examine pt's visual acuity (& to plan for an urgent ophthalmology referral; esp when there is significant VA impairment)

MRCP; Membership of Royal College of Physician- They only give that to the crowned heads of the world:)

Homage To Traube;)

My dear friend emrcpian had recently posted a blog on abdominal examination and had mentioned about the use of 'traube's space'.

It remains as elusive as it was back in my student years whereby conflicting opinions prevail till these days.

I had done some 'click and research' via the net. Would like to share :)

About Ludwig Traube, the original guru who described the Traube's space:
"Great merits and fame earned Ludwig Traube by establishing of the experimental pathophysiological research in Germany (e.g. he did animal experiments in the 1840th in his Berlin flat in the Oranienburger Str.) He improved the physical-medical methods like auscultation and percussion and was a taxonomist of the medical documentation. (e.g. inaugural of the temperature-pulse-frequenz of respiration-curve into clinical praxis). He investigated the pathophysiology of the respiration and the regulation of the body temperature, and gave a scientific basis to the digitalis therapy. The narrow coherencies between heart and kidney diseases have been well demonstrated. He worked together with Rudolf Virchow (1821-1902), they substantiated the „Beiträge zur experimentellen Pathologie“."

Wikipedia:
"Traube's (semilunar) space is an anatomic region of some clinical importance. It's a crescent-shaped space, encompassed by the lower edge of the left lung, the anterior border of the spleen, the left costal margin and the inferior margin of the left lobe of the liver. Thus, its surface markings are respectively the left sixth rib, the left anterior axillary line, and the left costal margin. Underneath lies the stomach, which produces a tympanic sound on percussion (medicine). If percussion over Traube's space produces a dull tone, this indicates splenomegaly. Assessing this may be more difficult in obese patients. The normal human spleen measures about 125mm in length, and splenomegaly is an important clinical sign. There are 2 possibilities to evaluate splenomegaly in the clinical examination: percussion and palpation. Percussion can be done in Traube's space, as described by his pupil in 1868. Another method was described by Donald O. Castell in 1967 (Castell's sign)."

Conclusion:
I think the percussion of Traube's space is both a non-sensitive and non-specific way of assessing for splenomegaly. As you can see, anatomically, it's bounded by the lower left lung, anterior border of the spleen and the left lobe of the liver. Hence theoretically, any enlargement/effusion of these structures could obliterate the space and hence would cause 'dullness' upon percussion.

As alluded earlier in Ludwig's biography, one of his main interests was in respiratory medicine. Hence it's not surprising that he had originally ascribed the dullness to pleural effusion instead :)

"Look out for the original papers decades back describing the eponymous syndromes or signs, and you'll be surprised how much they have evolved/changed through the years." -My neurology clinical mentor

A Little Untoward Event

An interesting event happened couple of days ago.

One colleague of mine paged me on my on call day, seeking for opinion on the management of a patient with unstable angina who had developed one episode of transient bleeding while he was on LMWH. From what I’d gathered over the phone it occurred to me that the patient was rather stable with minimal chest pain. I suggested him to switch to conventional unfractionated heparin instead, with careful monitoring, keeping in view of potential rebleeding. He thought the half-life of UFH was 6 hours. I corrected him by telling him that it was only 90mins (hence easier reversal and less prolonged bleeding should the patient bled again). Probably, this was what tickled him off ;P

I have always wanted to know (and get acquainted to) as many as possible of my medical colleagues elsewhere in the vicinity. Basically it’s for the sake of easier understanding among one another, as well as mutual sharing of clinical experience and knowledge.

As a friendly gesture, I had enquired him regarding the year of graduation and the university that he had graduated from, for I wanted to quote some names of my close friends of his batch. (We lead a rather small community in the medical line in our country, and eventually we tend to meet back one another rather soon!)

I was totally taken by aback when he accused me of being arrogant and that I had tried to insult him by asking his year of graduation. I eventually ended up half-apologising-half-pacifying him over the phone. Tough job indeed!

From this little untoward incidence, I could gather a few points of thoughts:

• Asking the year of graduation (and hence implies his seniority) would not be a good idea after a ‘skewed’ consultation. The other party would think that you’re trying to patronize him
• Over-the-phone consultation is both not specific and not sensitive (at least, the other party wouldn’t be able to pick up some visual cues that could have saved the misunderstanding)
• The referred party needs to be extremely cautious, as the referring party is easily sensitized by some unintentional audio cues, which is strongly influenced by the often imbalanced senior-junior relationship and is relentlessly driven by a hidden sense of inferiority complex among the juniors. Things could be quite different, if he were the senior :)