Saturday, February 25, 2012
Osteoporosis general management and myth
A talk by enocrinologist from netherland named prof Socrates papapoulas regarding osteoporosis. He outlined biphosphonates and Hrt (forfemale) is the option for osteoporosis. Bisphosphonates better in the sense of risk of breast ca for Hrt. He outlined the risk factor for osteoporosis such as smoking, alcoholic , low BMI, low calcium intake, advancing age, race and etc. he stress the important of vit D (800micro grame) per day. Regarding the myth of atypical fracture and slower healing of hip fracture by biphosphonates, evidence proves that it is unrelated for biphosphonates vs placebo. Regarding the long term uses of biphosphonates for osteoporosis, he stated that for 5years treatment with biphosphonates, it will remain for the next 5 year. Evidence proves that no increased fracture risk compared 5 year biphospphonates and 5 year placebo and 10 year biphosphonates in FLEX study for alendronates.another study for Iv zoledronic acid annually showed similar results. It also critised orthopods not using biphosphonates for hip fracture pt. It stated a old people with fracture needs treatment for osteoporosis without checking Bone mineral density as it is proven by fracture.
Saturday, October 08, 2011
Intensive Talk with Prof Falagas
Summary:
Bacteria develop multiple resistance to antibiotic
By:
1)producing B-lactamase
2)overexpression efflux pump to release extra antibiotic
3)antibiotic modify enzyme
4)ribosomal mutation
Thus appear all superbug such as ESBL, carbapenemase producing klebsiella etc
Pt infected with ESBL +ve had relative risk 1.85 of mortality compared to normal bugs
Treatment of commonest bugs in ICU –Acinetobacter spp.
Recommended to do C+S with MIC
Therapy promptly early
Start therapy right at beginning
Modification therapy as nessasary (de-escalation) early
Tigercycline- a new agt
It evades tetracycline efflux pump and ribosomal protective mechanism
Bacteriostatic
That is limitation no good blood level for therapeutic
Varied response to acinetobacter
Imipenem –launch with 4g/day
Recommend 2g/d as reduce seizure
Not enough as moderate susceptible organism need 1g qid .
Recommended for high MIC acinetobacter to give prolong infusion meropenem 1 g tds as long as 3 hr compared with 30min normally given.
Study proved similar dose with prolong infusion better outcome
Colistin monotherapy
Got 52% isolates for acinetobacter were polymycin only susceptible
The rest need colistin and one other antibiotic (rec add carbapenem)
As highest % of survival
Benault et al. showed Obesity highest rate septic shock
Partly related with leptin def
DM
FOsfamycin-good for Klebsiella spp and pseudomonas spp.
Another talk by gastro
If NDM1 may give fosfamycin + carbapenem.
UGIB
Commonest cause H. pylori followed by NSAID, Antiplatelet
Risk of UGIB-age, multiple co-morbidity and H/O peptic ulcer
If pt got cardiovascular problem, may restart antipltelet after 4-5 days of peptic ulcer
Bacteria develop multiple resistance to antibiotic
By:
1)producing B-lactamase
2)overexpression efflux pump to release extra antibiotic
3)antibiotic modify enzyme
4)ribosomal mutation
Thus appear all superbug such as ESBL, carbapenemase producing klebsiella etc
Pt infected with ESBL +ve had relative risk 1.85 of mortality compared to normal bugs
Treatment of commonest bugs in ICU –Acinetobacter spp.
Recommended to do C+S with MIC
Therapy promptly early
Start therapy right at beginning
Modification therapy as nessasary (de-escalation) early
Tigercycline- a new agt
It evades tetracycline efflux pump and ribosomal protective mechanism
Bacteriostatic
That is limitation no good blood level for therapeutic
Varied response to acinetobacter
Imipenem –launch with 4g/day
Recommend 2g/d as reduce seizure
Not enough as moderate susceptible organism need 1g qid .
Recommended for high MIC acinetobacter to give prolong infusion meropenem 1 g tds as long as 3 hr compared with 30min normally given.
Study proved similar dose with prolong infusion better outcome
Colistin monotherapy
Got 52% isolates for acinetobacter were polymycin only susceptible
The rest need colistin and one other antibiotic (rec add carbapenem)
As highest % of survival
Benault et al. showed Obesity highest rate septic shock
Partly related with leptin def
DM
FOsfamycin-good for Klebsiella spp and pseudomonas spp.
Another talk by gastro
If NDM1 may give fosfamycin + carbapenem.
UGIB
Commonest cause H. pylori followed by NSAID, Antiplatelet
Risk of UGIB-age, multiple co-morbidity and H/O peptic ulcer
If pt got cardiovascular problem, may restart antipltelet after 4-5 days of peptic ulcer
Sunday, October 02, 2011
Neurology examination (basic fundamental)
Student, house officer, medical officer hates the most ! neurology system. Coz, no particular song lyrics to sing ! all other system got same chores to sing.-Inspection, palpation, percussion and auscultation.
To me, neurology famous song would be look and proceed + investigator.
The rule no 1- when ask to look at the face, please do look for upper and lower limb grossly also ! This is what i called LOOK thoroughtLY !
Rule no 2-Pretend yourself as a wireman,
rule of thumb - for neuro, first ,level of lesion-brain, cerebellum, brain stem, spinal cord, anterior horn , peripheral nerve or muscle.
After that second question- left or right brain or level of lesion
lAST-cause of the lesion
Then bingo- You are PASSED.
rule no 3- don't panic- apply for all
Rule no 4- common thing come first-apply for ALL physical examination.
Rule no 5- use your rule no2 rule then give the diagnosis with statement like this is a 40 year old (middle-aged) gentleman with left hemiparesis which is due to right cerebral infarct. etc..
Bingo, you are passed then just answer all the question.......to get better marks.
Good luck, the next will be cranial nerve. If you like the blog, pls do CLICK on google ads on top or side to show APPreciation! Your appreciation is my best inspiration!
To me, neurology famous song would be look and proceed + investigator.
The rule no 1- when ask to look at the face, please do look for upper and lower limb grossly also ! This is what i called LOOK thoroughtLY !
Rule no 2-Pretend yourself as a wireman,
rule of thumb - for neuro, first ,level of lesion-brain, cerebellum, brain stem, spinal cord, anterior horn , peripheral nerve or muscle.
After that second question- left or right brain or level of lesion
lAST-cause of the lesion
Then bingo- You are PASSED.
rule no 3- don't panic- apply for all
Rule no 4- common thing come first-apply for ALL physical examination.
Rule no 5- use your rule no2 rule then give the diagnosis with statement like this is a 40 year old (middle-aged) gentleman with left hemiparesis which is due to right cerebral infarct. etc..
Bingo, you are passed then just answer all the question.......to get better marks.
Good luck, the next will be cranial nerve. If you like the blog, pls do CLICK on google ads on top or side to show APPreciation! Your appreciation is my best inspiration!
Tuesday, September 27, 2011
undergraduate exam tips
Medical Students ask me the tips of passing clinical exam. The answer is stay calm, then perform what you practice everyday. My prof used to tell us if should practice at least 400 times before went for exam .If you failed, then you should also pretend to practice 400-500 times.
Tips no 1 , be systematic. For abdomen, CVS and respiratory. All following the normal song sequence, - Inspection, palpation, percussion and auscultation. For CVS, percussion part can be skipped. Every medical students worried about neuro. Actually neuro also got own sequence. First,inspection, then tone , power and reflex for motor. Then sensory, the last cerebellar system. for upper limb AND lower limb problem. for cranial nerve, just follow the sequence from 2nd to 12th nerve.
tip no 2, don;t panic. If panic, practice 1000 times, also may Failed. TAKE A DEEP breath and made it a norm routine for you.
Tip no 3, know the topics needed to know for undergraduate!
eg for 3 rd year
CVS- valvular disease-mitral regurgitation, aortic regurgitation, aortic stenosis. Mitral stenosis a bit rare. Prosthetic valve normally mechanical.
Respiratory-bronchiectasis,idiopathic pulmonary fibrosis, pleural effusion, pneumonia
abdomen -polycystic kidney disease, hepatomegaly, splenomegaly, hepatosplenomegaly. Pls memorise the causes of hepato, splenomegaly and hepatosplenomegaly.
Tip no4., Do not cause pain for patient! Pt cry or shout. 100 % failed !
Tip no 5, listen to examiner command, do not argue with examiner or else.......
Last, good luck for the candidates. Take exam as a challenge. Failing exam may make you a better Dr. Trust me about that ! all the top Dr failed their exam before.
It not means you should fail to be good ! it just means failing is nothing . It just a system to access the knowledge and coping !
Tips no 1 , be systematic. For abdomen, CVS and respiratory. All following the normal song sequence, - Inspection, palpation, percussion and auscultation. For CVS, percussion part can be skipped. Every medical students worried about neuro. Actually neuro also got own sequence. First,inspection, then tone , power and reflex for motor. Then sensory, the last cerebellar system. for upper limb AND lower limb problem. for cranial nerve, just follow the sequence from 2nd to 12th nerve.
tip no 2, don;t panic. If panic, practice 1000 times, also may Failed. TAKE A DEEP breath and made it a norm routine for you.
Tip no 3, know the topics needed to know for undergraduate!
eg for 3 rd year
CVS- valvular disease-mitral regurgitation, aortic regurgitation, aortic stenosis. Mitral stenosis a bit rare. Prosthetic valve normally mechanical.
Respiratory-bronchiectasis,idiopathic pulmonary fibrosis, pleural effusion, pneumonia
abdomen -polycystic kidney disease, hepatomegaly, splenomegaly, hepatosplenomegaly. Pls memorise the causes of hepato, splenomegaly and hepatosplenomegaly.
Tip no4., Do not cause pain for patient! Pt cry or shout. 100 % failed !
Tip no 5, listen to examiner command, do not argue with examiner or else.......
Last, good luck for the candidates. Take exam as a challenge. Failing exam may make you a better Dr. Trust me about that ! all the top Dr failed their exam before.
It not means you should fail to be good ! it just means failing is nothing . It just a system to access the knowledge and coping !
Wednesday, September 21, 2011
cognition after carotid endarterectomy or stenting
A neurology 77 published a interesting report regarding the topic above.
divided in 2 arms -one for CEA ( carotid endarterectomy) , another CAS (carotid artery stenting)
the NIHSS (NIH stroke scale) assessed at baseline and 1 daY postprocedure. Modifie RANKIN SCALE at baseline, 1 and 6 month. Cognition assessed in the week before procedure and 6 months later.Pt also assessed for mood using Beck depression inventory II.
MRI with DWI performed 1 to 3 days before and 3 days thereafter to assessnew ischemic lesion.]
Result:significant decrease in cogntion sumscore after CAS from baseline to 6 month
NO significant decrease score after CEA.
The mean difference between changes was not statistically significant.
the worst cogntion functioning inpt treated with CAS consistent with higher rate NEW ischemic DWI lesion after CAS
divided in 2 arms -one for CEA ( carotid endarterectomy) , another CAS (carotid artery stenting)
the NIHSS (NIH stroke scale) assessed at baseline and 1 daY postprocedure. Modifie RANKIN SCALE at baseline, 1 and 6 month. Cognition assessed in the week before procedure and 6 months later.Pt also assessed for mood using Beck depression inventory II.
MRI with DWI performed 1 to 3 days before and 3 days thereafter to assessnew ischemic lesion.]
Result:significant decrease in cogntion sumscore after CAS from baseline to 6 month
NO significant decrease score after CEA.
The mean difference between changes was not statistically significant.
the worst cogntion functioning inpt treated with CAS consistent with higher rate NEW ischemic DWI lesion after CAS
Wednesday, September 07, 2011
Peripheral neuropathy
Peripheral neuropathy or polyneuropathy-diffuse peripheral lesion, often symmetrical
Onset-
Childhood-CMT
Adult-diabetes
Older adult- paraproteinemia
Acute onset-AIDP, porphyria, toxic, vasculitis,tick paralysis, diphtheria
Chronic-B 12 def, paraproteinemia, diabetes.
Symptom-
Motor-distal weakness predominates.
Sensory-tingling (positive), numbness (negative)
Autonomic-orthostatic lightheadedness, gastroparesis, sweating abnormalities
Diff diagnosis by pattern
Pattern 1 : symmetrical ,prox and distal weakness + sensory loss
CIDP, vasculitis
Pattern 2 : symmetrical distal weakness +sensory loss
DM, drug and toxin, hereditary neuropathies, amyloidosis , paraproteinemia
Pattern 3: Asymmertical distal weakness and numbness
Infectious neurpathy, multifocal trauma, entrapment, vasculitic
Pattern 4: asymmetrical distal or prox weakness without sensory loss
Multifocal motor neuropathy, motor neuron disease, inclusion body myolitis
Pattern 5: asymmetric prox and distal weakness with sensory loss
Malignant infiltration, polyradiculopathy, HNPP
Pattern 6: symmetric small fibre sensory neuropathy without weakness
DM, amyloid, HIV
Pattern 7 marked proprioception loss
HIV, B6 toxicity, sjogren, paraneoplastic
Pattern 8: Neuropathywith cranial nerve involve
HIV,lyme, AIDP, sarcoidosis, malignant infiltration,antiGd1b neuropathy
Acute neuropathies
Guillain barre
Vasculitic neuropathic
Acute intermittent porphyria
Diphteria
Heavy metal
Tick paralysis
Chronic:
Mononeuropathic –trauma entrapment’
Multiple mononeuropathic- vasculitic
Polyarteritis nodosa
Sjogren
Wegener grnulomatosis
HNPP
Multifocal motor neuropathic
Polyneuropathic
DM,
Nutritional eg B12, B6, B1 def ,
Alcoholic
CIDP
Paraneoplstic
Paraproteinemia
Infectious-HIV, CMV, lyme, leprosy
Sarcoid
Metabolic- renal, hepatic or hypothyroid
Heavy metal- arsenic, lead, mercury
Drug- vincristine, flagyl, sisplatin , amiodarone,
Onset-
Childhood-CMT
Adult-diabetes
Older adult- paraproteinemia
Acute onset-AIDP, porphyria, toxic, vasculitis,tick paralysis, diphtheria
Chronic-B 12 def, paraproteinemia, diabetes.
Symptom-
Motor-distal weakness predominates.
Sensory-tingling (positive), numbness (negative)
Autonomic-orthostatic lightheadedness, gastroparesis, sweating abnormalities
Diff diagnosis by pattern
Pattern 1 : symmetrical ,prox and distal weakness + sensory loss
CIDP, vasculitis
Pattern 2 : symmetrical distal weakness +sensory loss
DM, drug and toxin, hereditary neuropathies, amyloidosis , paraproteinemia
Pattern 3: Asymmertical distal weakness and numbness
Infectious neurpathy, multifocal trauma, entrapment, vasculitic
Pattern 4: asymmetrical distal or prox weakness without sensory loss
Multifocal motor neuropathy, motor neuron disease, inclusion body myolitis
Pattern 5: asymmetric prox and distal weakness with sensory loss
Malignant infiltration, polyradiculopathy, HNPP
Pattern 6: symmetric small fibre sensory neuropathy without weakness
DM, amyloid, HIV
Pattern 7 marked proprioception loss
HIV, B6 toxicity, sjogren, paraneoplastic
Pattern 8: Neuropathywith cranial nerve involve
HIV,lyme, AIDP, sarcoidosis, malignant infiltration,antiGd1b neuropathy
Acute neuropathies
Guillain barre
Vasculitic neuropathic
Acute intermittent porphyria
Diphteria
Heavy metal
Tick paralysis
Chronic:
Mononeuropathic –trauma entrapment’
Multiple mononeuropathic- vasculitic
Polyarteritis nodosa
Sjogren
Wegener grnulomatosis
HNPP
Multifocal motor neuropathic
Polyneuropathic
DM,
Nutritional eg B12, B6, B1 def ,
Alcoholic
CIDP
Paraneoplstic
Paraproteinemia
Infectious-HIV, CMV, lyme, leprosy
Sarcoid
Metabolic- renal, hepatic or hypothyroid
Heavy metal- arsenic, lead, mercury
Drug- vincristine, flagyl, sisplatin , amiodarone,
Tuesday, September 06, 2011
History taking
As a physician doing round every day and taking students from time to time.
I found a common weakness for my junior colleague (House officer) and students. Increasing House officer in ward make them taking care of only 6 patients per person but ironically they clark a poor quality of history.
History taking saves lives. proper history can anticipate severity of disease, diagnosis and give proper treatment to patient. MY FELLOW prof. teach me in my first lesson proper history taking which i think i need to share with my fellow juniors.
first, chief complaint!
4 C need to be applied for history taking- condition, cause, confirm and complication
Condition -for example, if pt complaint of chest pain then chest pain is the condition.then you need to ask every thing about chest pain (this condition) from character, onset, severity, associating condition eg sweating, vomiting..... plus precipitating and relieving factor
cause- try to establish the cause for example is it IHD, pneumonia, costocondritis
confirm the complaint- is it real chest pain or just diff in taking breath or worse underlying psychaitric cause! My experience, pt with underlying ischemic heart disease complaint of chest pain admitted for unstable angina when further history taking found wife had extra marital condition and ended up chest pain. ECG all normal. I refer psychiatrict and problem solved!
complication- pt if chest pain due to heart attack , maybe pt will collapse or got ventricular rupture......
This is the basis for clarking history, if provisional diagnosis already confirmed then need to get risk factor for the cause eg... heart attack - risk factor will be age, sex, diabetis, hypertension, smoking and family history......
If failed to obtain all this, it won't be good history.
One real story happening yesterday, patient presented with tremor but diagnosed by HO as stroke. On examination, pt got cog wheel rigidity worse on one side, mask like facies, bradykinesia. turn out to be Parkinson disease. This happens HO not bother to take proper history and PE!
I found a common weakness for my junior colleague (House officer) and students. Increasing House officer in ward make them taking care of only 6 patients per person but ironically they clark a poor quality of history.
History taking saves lives. proper history can anticipate severity of disease, diagnosis and give proper treatment to patient. MY FELLOW prof. teach me in my first lesson proper history taking which i think i need to share with my fellow juniors.
first, chief complaint!
4 C need to be applied for history taking- condition, cause, confirm and complication
Condition -for example, if pt complaint of chest pain then chest pain is the condition.then you need to ask every thing about chest pain (this condition) from character, onset, severity, associating condition eg sweating, vomiting..... plus precipitating and relieving factor
cause- try to establish the cause for example is it IHD, pneumonia, costocondritis
confirm the complaint- is it real chest pain or just diff in taking breath or worse underlying psychaitric cause! My experience, pt with underlying ischemic heart disease complaint of chest pain admitted for unstable angina when further history taking found wife had extra marital condition and ended up chest pain. ECG all normal. I refer psychiatrict and problem solved!
complication- pt if chest pain due to heart attack , maybe pt will collapse or got ventricular rupture......
This is the basis for clarking history, if provisional diagnosis already confirmed then need to get risk factor for the cause eg... heart attack - risk factor will be age, sex, diabetis, hypertension, smoking and family history......
If failed to obtain all this, it won't be good history.
One real story happening yesterday, patient presented with tremor but diagnosed by HO as stroke. On examination, pt got cog wheel rigidity worse on one side, mask like facies, bradykinesia. turn out to be Parkinson disease. This happens HO not bother to take proper history and PE!
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