Extracardiac Compression of Right Atrium by Hepatic Cysts in ADPKD

What is the impact of growing hepatic cysts in patient with polycystic kidney disease? We reported a rare complication - the cysts have caused extracardiac compression of right atrium resulting in impaired filling. Patient is at risk of refractory hypotension in the presence of significantly impaired right ventricular filling. Beside this, hepatic cysts burden has been reported to cause inferior vena cava compression, hepatic venous outflow obstruction and portal hypertension. Therapeutic options for symptomatic patients include cyst aspiration and sclerotherapy, cyst fenestration, transcatheter arterial embolization, or surgical intervention including cyst resection and liver transplantation.

Full Text:
KG Lee, SH Teo, H John, KWQ Guo, JL Kwek. Extracardiac compression of right atrium by hepatic cysts in a patient with polycystic kidney disease. Kidney International 2016; 90:230.

If you're interested in updates in ADPKD, a position statement by European ADPKD Forum can be read here.

Outcome of AVF Creation, Effects of Preop Vein Mapping and Predictors of Fistula Success in Incident Hemodialysis Patients

This single-centre study reported arteriovenous (AVF) outcomes of incident hemodialysis patients with 19,450 patient-month follow-up, successful AVF maturation was achieved in 78% with 1-year cumulative patency rate of 74%. Routine pre-operative vein mapping was not necessary if veins are suitable on physical examination for AVF creation.

Full text:

KG Lee, TT Chong, N Goh et al. Outcomes of arteriovenous fistula creation, effect of preoperative vein mapping and predictors of fistula success in incident hemodialysis patients: A single-centre experience. Nephrology (Carlton) 2017; 22:382-7.

 

SCE Nephrology Exam Questions Writing

I am glad to be invited for authoring questions for SCE Nephrology Prep Course and all the questions were accepted. The guidance provided in authoring MCQs and replies from Editors are enlightening. Overall a good learning process!

Read more about the SCE Nephrology exam:

http://darrenmagic.blogspot.my/2012/04/sce-in-nephrology.html

Hyperkalemia - Principles of Management

Nice animation of ECG changes during hyperkalemia - this shows clearly that time is life when dealing with severe hyperkalemia.

5 essential principles of management, in simple terms:

1. Protect the heart - IV Ca Gluconate/ Ca Chloride (note contains 3x more calcium) to antagonise the cardiac membrane excitability thereby protect the heart against arrhythmias;

2. Shift K into cells - Insulin/ glucose infusion, nebulised Salbutamol (unlikely to work for patients on non-selective beta-blockers), Sodium Bicarbonate (not for routine use, comes with risk of Na and fluid overload);

3. Remove K from the body - Cation exchange resins (Resonium/ Kalimate, new agents: Patiromer, Zirconium), hemodialysis;

4. Monitor K level - do monitor for rebound hyperkalemia which is common;

5. Prevent recurrence - Do not walk away without knowing the cause of hyperkalemia and to stop further K accumulation, stop ALL potential offending drugs immediately.

Read more at:

CPG of Treatment of Acute Hyperkalemia

Rivaroxaban and Topical Miconazole - Do Not Mix

1. Direct oral anticoagulants (DOAC) are being increasingly use. Rivaroxaban is metabolized via CYP3A4, with in vitro studies supporting the involvement of P-glycoprotein as the responsible active transporter in renal secretion of rivaroxaban.

2. Antifungal imidazole derivatives have been shown to demonstrate significant inhibition of CYP450. Miconazole, a combined p-glycoprotein and strong CYP3A4-inhibitor, can potentially cause significant drug interaction and increased rivaroxaban concentration.

3. Interference of topical miconazole with warfarin has been reported, but not with DOAC. Systemic absorption appears to be enhanced when miconazole is applied under occlusion on large surface, close to mucous membranes or in cases of intertrigo skin lesions.

4. In summary, the use of topical miconazole may have significant drug interaction with rivaroxaban resulting in adverse event from over-anticoagulation.

The prescribing clinician should be aware of this possible interaction and exercise close monitoring if simultaneous use is indicated.

The interaction has been highlighted previously as a short communication (http://journals.sagepub.com/doi/pdf/10.1177/201010581502400209), and it was cited in Reactions journal as the first report of such interaction (https://link.springer.com/article/10.1007/s40278-015-4084-y).

Full text:
KG Lee, DL Jennifer. Increased bleeding tendency from interaction between rivaroxaban and topical miconazole: Case report. Proceedings of Singapore Healthcare 2015; 24:121-2.

Star Fruit - No Good for Kidneys?

Star fruit is not safe for any patient with chronic kidney disease.

1. Star fruit is a popular fruit in tropical and subtropical countries and its consumption is high in Asia. Multiple case series have reported its nephro-and neurotoxicity in CKD patients as well as in people with normal renal function.

2. The amount of fruit ingested which causes toxicity is related poorly to severity of symptoms. In cases of moderate to severe intoxication, neuropsychiatric manifestations can occur and may progress rapidly to coma and refractory status epilepticus, resulting in death.

3. Star fruit nephrotoxicity is believed to be due to its high oxalate content which could cause acute obstructive tubular nephropathy. Prompt treatment with intensified hemodialysis and hemoperfusion, close monitoring and supportive care has been propsed as an effective therapeutic approach.

I have highlighted this previously in a letter to Clinical Medicine (RCP Journal), and it was cited in a review for kidney toxicity due to herbs and dietary supplements in Food and Chemical Toxicology journal.

Full text:
KG Lee. Star fruit intoxication with acute kidney injury. Clinical Medicine 2012; 12:494

Duplicate SVC on Arteriovenous Fistulography

"Left SVC persistence, a rare but important congenital vascular anomaly with a reported incidence of 0.3% to 1.3% in the general population, results when a left superior cardinal vein fails to regress during gestation. Left SVC drains into the RA through the coronary sinus with no major hemodynamic effect and patient is usually asymptomatic...However, there are practical implications when the patient is subjected to endovascular interventions...in which the procedure may be made difficult by the anatomic variation and serious complications including arrhythmia and coronary sinus thrombosis have been reported."

Full text:
KG Lee, RY Tan, VA Chidambaram, SC Pang, CS Tan. Duplicate superior vena cava on arteriovenous fistulography. J Vasc Surg Venous Lymphat Disord 2017; 5:739.

Frank's Sign

 

"First described in 1973, Frank’s sign, also known as diagonal earlobe crease (DELC), was observed to be an aural sign of coronary artery disease (CAD). Since then, there has been much interest in examining this unique association. This may occur as a result of age- or disease-related weakening of dermal and elastic fibers in the ear lobes, making it a dermatological predictor of an underlying coronary vessel insufficiency. Over the years, more insights were gained from studies showing the association of DELC with significantly increased prevalence, extent and severity of CAD, independent of traditional CAD risk factors, with good sensitivity and positive predictive value. Recent studies have also demonstrated DELC’s independent association with increased carotid intima-media thickness as well as cardiovascular events (CVE) comprising not only coronary, but ischemic cerebrovascular and peripheral vascular diseases, suggesting that DELC may be a marker of generalized atherosclerotic disease. Wong et al. in a study of 558 consecutive patients (445 patients had CAD on coronary angiography), found that the presence of DELC is independently associated with 5-fold higher risk of CAD. Of note, there has been proposed classification of DELC based on the characteristics of length, depth, bilateralism and inclination of the crease. Although bilateralism has been shown to have good specificity for CVE association, the significance of the characteristics needs to be further studied."

Full text:
KG Lee. Frank's sign - A dermatological link to coronary artery disease? Med J Malaysia 2017; 72:195-6.

Nephrology Board Exam M'sia

I somehow feel that my Nephrology journey is filled with exams, one after another. After my MRCP and USMLE, I did my SCE Neph exam (UK) in 2012 in preparation to enter the Singapore Renal Fellowship (Senior Residency) program. During the 3-year training, there is annual US in-training exam (ABIM exam in Nephro), and additionally at second year an ACGME-I Graduation Exam, and finally at end of third year there was a Singapore JCST Board Exit Exam as completion of training and for Specialist Board Accreditation.

As now I have returned to home country for family, I was required to obtain the certificate of M'sian Nephro Board Exam, and I'm glad to share that I have successfully completed it.

Pursuing Nephrology has been my dream and passion. Having been exposed to different examination format (UK/ Singapore/ US/ M'sia), I would like to share on a series of Nephrology topics and hope these help if you're also preparing for any Nephro exams:

Nephrology Foundation

Nephrology Guidelines

Nephrology Updates 2017

Nephrology Resources

And many more to come!

Studying Nephrology - The Resources

Continuing from the previous post on "The guidelines", this post is about some essential and useful resources when you want to study about Nephrology.
 

 

ASN (American Society of Nephrology) tops the list. ASN is actively leading the fight against kidney diseases by educating, sharing new knowledge and advancing research. In the website, you can access the learning center and their excellent Nephrology self-assessment program (NephSAP), reading their official journals of JASN and cJASN, and subscribing to their Kidney News as well. Membership is free for any Nephro trainees.

 

 

 

ISN (International Society of Nephrology) Academy is an interactive e-learning platform and mobile app providing access to latest knowledge and updates in nephrology. By being a member, there is access to ISN's official journal - Kidney International which is one of the most premier Nephrology journals.  

ISPD (International Society for Peritoneal Dialysis) has been introduced in the previous post. Besides the guidelines, ISPD also provides free access to PD curriculum which cover important PD topics such as PD prescription, adequacy, techniques, ultrafiltration issues and PD complications etc.

Other resources are as follow:
1. HDCN (Hypertension, Dialysis & Clinical Nephrology)
2. SSN (Singapore Society of Nephrology)
3. MSN (M'sian Society of Nephrology)

SCE in Nephrology

Sat for Specialty Certificate Examination (SCE) in Nephrology of RCP (UK), or unofficially regarded as "MRCP Part 4 exam" last month - to be honest it was a tough one, as expected. Exam was very clinical based, and lots of renal biopsy images which are testing the histology knowledge. The details of the exam can be found on RCP website - it's essentially an exam for UK trainees during their penultimate year of subspecialty training, but it's open for oversea candidates as well.

I had an unusual experience I must say. During the day of exam, to my biggest surprise - the test center has encountered technical problem - which it never happened before, and the test has to be delayed to 7.30pm. The test took total of 7 hours - which means, yes, it finished after 2am! That was really my first time ever sitting for an exam across the midnight! And what's more, I had to be on-call the next day!

Anyhow, the crazy experience and weeks of anxiety were over. I have just got the result few days back and I'm glad that I made it. Besides the family support, I'm deeply grateful for the daily registrar teaching by the department - it really helps substantially in my preparation.

So it's time to have a bit of rest now, and perhaps a little celebration. ;)



My PACES Experience (2)

Ya, as promised, this post is about case presentation in PACES exam, in my humble opinion. There are more than plenty of resources on approaching this exam, hence I won't really elaborate too much. I'd just like to share a "format" that I think is "safe" and can be used even when you're in a panic state (Well, at least it works for me).

Let's just take an abdomen station as an example, and renal transplant case is one of the common ones. Upon completing your examination, you turned to the examiner,

1. General physical findings

"Mr Smith (always use patient's name instead of "this gentleman") is comfortable at rest. He has sallow complexion, conjunctival pallor and I noticed that he has finger prick marks and half-and-half nails, with an arteriovenous fistula at his left arm with no recent needling marks. I also noticed that he has gingival hyperplasia as well as fine tremor of his hands."

2. Main System

"...Moving on to his abdomen, there is a scar at right iliac fossa, with a firm mass beneath which is non-tender and dull on percussion. There rest of the abdomen is soft, and there is no hepato or splenomegaly. The kidneys are not ballotable. There is no ascites, and he has no sacral or pedal edema. "

3. Summary (The most important part - score at this point!)

Always go by - Diagnosis -> Etiology -> Function -> Complication (from disease & Rx)

"In summary, Mr.Smith has a transplanted kidney, which is functioning well, for his underlying end-stage renal failure, which most likely was due to diabetic nephropathy. He has features suggesting that he is on immunosuppressive treatment, most likely a calcineurin-inhibitor. He has no signs suggestive of fluid overload or uremic encephalopathy. There is no lymphadenopathy or any suspicious skin lesion."

Easy? Let me break down the important tips for you:

First of all, spot that this is a renal failure patient (The fistula is obviously the tell-tale sign), then switch on your brain engine and the visual survey, looking for:

1. Other signs of renal failure - as mentioned in textbooks, PLUS the evidence of previous dialysis (neck scar of catheter insertion, abdominal scar for peritoneal dialysis, failed fistula at other sites etc);

2. Possible etiology of the renal failure, e.g
- Finger prick mark - diabetes mellitus. If young patient, suspect Type 1 DM and look also for scar of pancreas transplant (usually done together with renal transplant);

- Nephrectomy scar - trauma, hemorrhage from angiomyolipoma, polycystic kidney, obstructive uropathy etc;

- "Gaunt facies" - lipodystrophy due to underlying Mesangiocapillary glomerulonephritis (Easily missed!);

- Autoimmune features - SLE malar rash, scleroderma, or even just skin vitiligo - could be associated with Type 1 DM - think broadly! ;)


3. Graft function status

Clinically by looking (carefully) at recent needling marks, graft tenderness, and signs of fluid overload/ uremic encephalopathy.

4. Side effects of Immunosuppressive treatment

Steroid: Cushingnoid features (long list)
Calcineurin inhibitor: Tremor, gum hypertrophy, hirsutism
And others (azathioprine, MMF, sirolimus etc)

5. Malignancy - Important!

Mentioning lymph node examination and skin lesion shows that you're aware of the risk of malignancy in post-transplant patient - most important ones being skin cancer (SCC/ BCC) and lymphoproliferative disease.

6. Lastly, mention about blood pressure. It shows that you're aware that cardiac death is the most important cause of deaths in post kidney-transplanted patients, which all cardiovascular risks need to be aggressively controlled. Besides, it could also be the etiology of his renal failure (Hypertensive nephropathy) or as a side effect of cyclosporin/ steroid.

So that's about it. Remember, it's a postgraduate exam so you need to look for "more things" so that you can make the impression. A holistic approach will be essential.

Good luck!

Related posts:
My PACES Experience (1)
PACES Case Sharing

My PACES Experience (1)

Finally I received my formal result. A pleasant surprise indeed. I scored 93/100. The passing mark this time is 75%, and the passing rate for this diet is 38%, for UK/Non-UK candidates. I'm glad that the hardwork did pay off and in my next few posts or so, I'll be sharing some of my thoughts about this exam (a.k.a my worst nightmare of the year, really!).

If you ask me what is important in the preparation, broadly speaking, I think there are 3 components - REMEMBER, these are EQUALLY important:

1. Knowledge

You might have heard that PACES is about practising. But believe me, if you do not have the core knowledge, you'll have hard time interpretating signs and correlate them together and bear in mind that this exam you are under direct observation and face-to-face oral Q&A, without adequate (or more than adequate) preparation and reading, "thought-block" and "verbal constipation" is extremely common.

As compared to the written tests like your Part 1 & 2A, I think PACES is much more tougher in terms of the spectrum of the questions that you may be asked, it can range from the most basic (eg physiology), or common diseases but in details (eg prevalance and epidemio), or rare stuff (eg a rare sign), to the updated management (most current practice guidelines, trials and future developement).

Hence, for reading material, I'd suggest the "gold standard" - "An Aid to the MRCP PACES" Vol 1&2 by Ryder and the "250 Cases in Clinical Medicine" by Baliga. But bear in mind that these books do not cover the "Station 5" - a new format in PACES.

Beside the books, do keep yourself updated with the latest guidelines (eg NICE, SIGN guidelines) and important medical trials (you need to confidently name them out - to show that you're practising evidence-based medicine).

2. Showmanship

Now we come to the practising part. It's a blessing if you can find a mentor (usually they'll be too busy to guide), or at least you can form your own study group. No doubt for this exam an extensive amount of time need to be spent on practising, for the clinical method, examination routines, history taking and communication skills. I think the tip is you really have to merge it into your daily practice, meaning seeing all your patients like your exam cases, then you'll improve fast.

Among all, I'd say bedside manner is of the utmost importance, and this is really something will make you stand out from other candidates. And make sure that you perform it as something natural, not like showing it just for the exam's sake. Greet the patient warmly, examine them with respect and dignity, and thank them sincerely!

3. Luck

Now we come to the most difficult part. Believe me that this is a highly unpredictable exam, therefore luck does play a role here. The set of examiners that you get, the patients/ surrogates, or even the candidates in your carousel - all are crucial factors in deciding whether or not you will pass. You may be very confident about your knowledge and skill, but luck MAY as well go wrong, and failed you totally. So, for your luck to go smoothly, my sincere advice is - do pray a lot! ;)


Next entry: Case Presentation in PACES

PACES Case Sharing

The UK trip is very rewarding in terms of learning experience. Here I'd just like to share a few "tricky" cases that I've seen during my attachment/ courses:

#1
In station 5, you're asked to see a lady complained of lethargy and joint pain. This lady has intermittent fever, arthralgia and history suggestive of Raynaud's phenomeon. She also has background history of Hypertension for years. So you suspect this is a case of SLE.
Straightforward? Not really.
Examiner hintingly asked what is the link btw hypertension and SLE.
Further history (only if you specifically asked) revealed that she was treated with Hydralazine for months before symptoms onset. So ya, this is a drug-induced lupus. Did that come into your mind?
Questions discussed were about percentage of anti-histone ab positivity (only about 30% in Hydralazine-induced, as compared to other drugs) and what are slow/ fast acetylators.

#2
Cardiac murmurs!
This is gonna be the best case I've auscultated.
Basically there are full of murmurs: You hear ESM over aortic area to carotid, EDM over LLSE, then also systolic murmur over apex to axilla, with MDM in mitral area as well.
So you thought this is a case of mixed mitral (MS/MR) and mixed aortic valve disease (AS/AR)?
Examiner then said there's no primary mitral valve disease.
The diagnosis is actually mixed aortic valve disease. At mitral area, the systolic murmur you heard is just part of the Gallavardin phenomenon, and diastolic murmur is the Austin Flint murmur due to AR.
Tricky enough?

#3
Station 5 again. You're asked to see a lady presented with seizure, and you should examine her hands.
She has family history of epilepsy. On visual survey you noted she has an AVF at left arm.
ESRF with seizure? Was it due to electrolyte imbalance?
In her hands you noted lesions suggestive of peri-ungual fibroma. So you thought this is a case of Tuberous sclerosis, but there's no facial angiofibroma.
Time's up.

Wanna know the answer? Yes she's a case of tuberous sclerosis with epilepsy. ESRF was because she underwent bilateral nephrectomy due to severe renal angiomyolipoma hemorrhage.
Then why is that she doesn't have the typical facial angiofibroma?

Well, she underwent laser therapy for cosmetic reason!

So these are a few..will share more later!

Magic Medicine Formula (4)

Dear friends, time for some medical formulas again;) This time the topic is about poisoning. A fairly common problem to encounter in ER, as well as popular in exam questions, and more importantly, you usually can't obtain any history from the patients! So the "clues" are crucial in helping to reach the diagnosis. Below are some tips that I found useful:

Check if the patient's having:
- Respiratory depression? Think of opiates, benzodiazepine toxicity;
- Coma? Think of benzodiazepines, alcohol, opiates, barbiturates;
- Constricted pupils? Think of opiates or organophosphates;
- Dilated pupils? Think of tricyclics, amphetamines;
- Hyperthermia? Think of amphetamines, ecstacy, aspirin, cocaine;
- Tachycardia? Think of salbutamol, antimuscarinics, tricyclics;
- Metabolic acidosis? Think of alcohol, paracetamol, theophylline, methanol;
- Seizures? Think of tricyclics, phenothiazines, theophyllines.

Quick mnemonics to help in diagnosis/ management:

Think that patient with cholinergic toxicity (eg organophosphate) is "wet" and look for DUMBELS:

D - Diarrhea/ diaphoresis
U - Urination
M - Miosis
B - Bradycardia
E - Emesis
L - Lacrimation
S - Salivation

*Presentation of Glyphosate poisoning can mimic organophosphote poisoning but the management is VASTLY different - must be aware of that!

Anticholinergic toxicity, in contrast, is very "dry" and look for:
"Hot as hades, blind as a bat, dry as a bone, red as a beet, mad as a hatter"!

For tricyclic antidepressants, main presentation can be remembered as:
TCA = Three C's = Convulsion, Coma, Cardiotoxic (remember to do a stat ECG!)

For paracetamol overdose, the important King's college criteria for liver transplantation can be remembered as:
pH less than 7.3 OR all three of PCM:
P - PT>100 sec
C - Creatinine > 300 mmol/L
M - Major encephalopathy (Grade III/ IV)

Severe poisoning of certain drugs might require hemodialysis and they are BLAST:
B - Barbiturates
L - Lithium
A - Alcohol
S - Salicylates
T - Theophylline

And just to remember that the first & last alphabet i.e. Barbiturates & theophylline - hemoperfusion can be done too.

And lastly, must know the antidote for specific overdose/ poisoning and certainly not searching for books when you see a poisoning case! ;)


Related posts:
Magic Medicine Formula (1)
Magic Medicine Formula (2)
Magic Medicine Formula (3)

Magic Medicine Formula (3)

3rd part: Time for microbiology!
Always confused by various types of bacteria & viruses? Well, not anymore!=)

You only need some codes..

Gram Positive cocci - SSE
S - Staphylococci
S - Streptococci
E - Enterococci

Gram Negative cocci - MN
M - Moraxella
N - Neisseria (N.meningitidis & N.gonorrhea)

Gram Positive baccilli (rods) - ABCD.LN
A - Actinomyces
B - Bacillus anthracis
C - Clostridium group
D - Corynebacterium diphtheriae
L - Listeria
N - Nocardia

Obligate intracellular bacteria - R.CML
R - Rickettsia
C - Chlamydia & Coxiella
M - Mycoplasma pneumoniae
L - Legionella pneumophilia

Spirochaetes - BTL
B - Borrelia
T - Treponema
L - Leptospira

And the rest are (very much mostly) Gram Negative bacilli!

And trust me, with these simple codes, you're just gonna tell the types of bacteria almost instantly!=)

As for the viruses, a few rules can help:

1. DNA-containing viruses are the HHAPPP(Y) viruses (Herpes, Hepadna, Adeno, Papova, Pox, Parvo); and the rest are RNA-containing viruses.

2. All DNA viruses are double-stranded except Parvoviruses.
3. All RNA viruses are single-stranded except reovirus.

Again, hope it helps!
Ok my dear friends, I've shared with you my (season 1) magic medicine studying tips;)

Hopefully I'll come up with more in the near future, and most importantly, pls let me know if they really help in your study and I'll be glad to hear it!=)

Magic Medicine Formula (2)

Ok..now we come to the 2nd part. Well, MRCP really likes to ask about genetic diseases and mode of inheritance. It'll be a waste if you do not master this part, but to memorize all that is obviously not an easy task.

A general rule is, Autosomal dominant conditions are mostly with "structural/ phenotypical" abnormalities; whereas autosomal recessive conditions are with "metabolic" disorders.

A list of major genetic diseases with which genes they are linked to:

Chromosome 1: Gaucher disease
Ch 2: Gilbert's syndrome
Ch 3: Von Hippel-Lindau syndrome
Ch 4: Huntington's, adult polycystic kidney disease (APKD 1)
Ch 5: Familial adenomatous polyposis (FAP)
Ch 6: Hemochromatosis
Ch 7: Cystic Fibrosis
Ch 8: Hereditary spherocytosis
Ch 10: MEN II
Ch 11: MEN I
Ch 12: Von Willebrand's disease
Ch 13: Wilson disease
Ch 14: HOCM
Ch 15: Marfan's syndrome
Ch 16: APKD 2
Ch 17: Neurofibromatosis Type I (von Recklinghausen's disease)
Ch 21: Autoimmune polyendocrine syndrome (APS) Type I
Ch 22: Neurofibromatosis Type II

Long and boring list? Any simplifying method? Ok here we go:

"Von Hippel-Lindau" = 3 words = Ch 3
"Huntington" = "Hunt 4 food" = Ch 4
"FAP" = "polyp has 5 alphabets" = Ch 5
"Hemochromatosis" = "HemochromatoSIX" = Ch 6
"Cystic Fibrosis" = "Think F is a mirror image of 7" = Ch 7
"Spherocytosis" = "Think 8 has double spheroids" = Ch 8
"Wilson" = "WIlson looks like 13 if you rotate the W a bit?" = Ch 13
"Marfan" = "Marfan's syndrome has 15 alphabets" = Ch 15
"APKD" = "APKD has 4 alphabets, polycystic kidney has 16 alphabets" = Ch 4 & 16!
"Neurofibromatosis Type I" = "von Recklinghausen has exactly 17 alphabets!" = Ch 17
"Neurofibromatosis Type II" = "Type 2 = 22" = Ch 22

Easier? After I found these linking methods, I think I'm just not gonna forget them for life!

Hope it helps!=)
And in the next post, I'll share about how I remember bacteria family!


Magic Medicine Formula (1)

Magic Medicine Formula (1)

Hi dear friends, time to share my studying tips. Well, to relate magic with medicine, hmm I would say that learning magic has definitely improved my memory. However, I think to study medicine, such a profound and broad field with countless facts and terminology involved, mere memory might not be adequate. Then I found a very useful tool, it's definitely not something new, which are "mnemonics". Quote from English artist William Wolcott, "Nothing is ordinary if you know how to use it." You might think mnemonics are nothing special, but if you know how to use it, my personal experience is, it's purely magical.

Mnemonics help to memorize facts in a quick, organized and (far) painless way. But take note that, the quality of mnemonics are extremely important, as the bad ones, will not only waste your memory space, it may fail you! For example, let's take a look at this (found this in snowy's blog but not by him, just for eg purpose, no offence):

SAM Suka Fry Ayam Peha - Classification for ischaemic heart disease.

S - sudden cardiac death
A - angina
M - MI
S - silent IHD
F- failure of heart (heart failure)
A- arrhythmia
P- postinfarctional cardiosclerosis

A few things to point out:
1. Poorly organized, and most importantly, do we need a mnemonics for classification of IHD?
2. Facts are not entirely true, e.g. arrhythmia is not a "type" of IHD?
3. Do you think "SAM Suka Fry Ayam Peha" is an easy-to-remember phrase?
4. Facts not "concrete" enough. To improve the quality, try use more professional terminology (so that you can impress your examiners).

An example of good one:
Wilson's disease : ABCD

A - Asterixis
B - Basal ganglia degeneration
C - Copper accumulation with reduced Ceruloplasmin level, causing Cornea deposits (Kayser-Fleischer rings), Choreiform movements, psyChiatric abnormalities, liver Cirrhosis and treatment is with Chelation.
D - Dementia

See the difference? So much essential facts in just 4 alphabets.

And to further improve it, sometimes the mnemonics are purposely made "naughty", and some will find it even easier to memorize! (Of corz, this is subjected to personal preference)

For example, adverse effects of Amiodarone: BITCH

B - Bradycardia
I - Interstitial lung fibrosis
T - Thyroid dysfunction
C - Corneal microdeposits
H - Hypersensitivity/ Hepatitis

I'm sure you're gonna remember it for life? Effortlessly?=)

Or one more way is, try to create a "funny" relation between the facts.

E.g. 1: Have you heard of "Argyll Robertson pupil" is like a prostitute? Because it accommodates but does not respond! (to light)

E.g. 2: 3 zones of adrenal cortex: GFR - glomerulosa, fasciculata and reticularis, which mainly regulate balance of salt (mineralocorticoids), sugar (glucocorticoids) and sex (androgens).
So the mnemonics for this: The deeper you go, the sweeter it gets. =)

And lastly, when you get familiar with the system, you can always create mnemonics of your own! First, look for the facts that you find it very hard to remember. E.g. from my own experience, I'm always confused with the terms of signs for aortic regurgitation, until I found a way to remember it!

(Darren's mnemonic) "In the MCQ about AR, the answer D is True!"
So from head to toe,
M - de Musset's sign (head nodding)
C - Corrigan's sign (carotic pulsation)
Q - Quincke's sign (nail bed capillary pulsation)
D - Duroziez's sign (femoral murmur)
T - Traube's sign ('pistol shot' in femoral artery)

Piece of cake now?=)

Ok so in conclusion, what I have shared are the principles of mnemonics and how they can help you to study. Obviously it's not possible for me to show all the mnemonics that I know (my blog will get out of space!). But if you have any problem remembering certain group of facts, feel free to tell and probably I can share the related mnemonics to help.

Finally, thanks for reading.
In the next post, I'll share about how I remember genetics and chromosomes!=)

Preparing for MRCP?

Ok since there are quite some questions on how did I prepare for my Part 1, hmm probably I'll just show you what have I got for my preparation:

The top and the bottom form the essentials. Many seniors told me that the minimum requirement is to finish Oxford handbook and K&C Clinical Medicine..cover to cover. To be honest, it's true. Painstaking and time-consuming but, this is what MRCP is about!


And the rest of the books that I displayed, are the supplementary. (Disclaimer: I'm not the best person to recommend which books to get, I'm just sharing my opinions) After the exam, I would now sort the books by their "usefulness" like this:


1. "Best of Five" - The questions' format are quite close to the exam's, hence a good practise book.


2. "An Aid to the MRCP" - Fantastic mnemonics! Though the facts provided are quite limited, but the mnemonics are helpful for quick revision.


3. "Update for the MRCP" - I think this is a should-get. Up-to-date information is essential when you sit for the exam, which you'll be tested on the latest facts!


4. "Basic Medical Sciences for MRCP" - This book I'm planning to sell it. Anyone's interested? (oops I hope the author is not reading this). Well, my humble opinion is, maybe the facts are somewhat inadequate and contents are not focused enough on Part 1=)


Beside books, I do have somemore things to share.


From USMLE Step 1, to Step 2 then now Part 1, I have to confess that, yes, I did use magic in my exams. HEHE. They're called "Darren's magic medicine formulas".
I'll share about the "formulas" in my next posts. Hope you all will find it useful!=)