Case report (Kawasaki Disease)

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Lung Cancer

- Lung cancers or lung neoplasms can be generally divided into 3 broad categories, namely:

• Primary lung cancer (where cancer develops in the lung tissue itself)
• Secondary lung cancer (due to deposits of cancer cells originating from other cancer organs)
• Mesothelioma (cancer of the layer of tissue (pleura) that surrounds the lung ) - not really a lung cancer per se.

- Primary lung cancers can be further classified into

• benign (cancers that do not spread to other organs)
• malignant (cancers that do spread)

- More than 20 bengin & malignant primary lung cancers have been identified & classified histologically.

- However, 90 - 95% of these lung cancers are bronchogenic carcinomas.

- About 5% are bronchial carcinoids and 2 - 5% are mesenchymal & other miscellaneous lung cancers.

Re: Manjul Tripathi

Pharyngitis is one of the leading reason for physician visits by adults world wide. Approximately 10% of adults with pharyngitis who are seen by physicians are infected with group A Streptococcus (GAS)--the only etiology for which antibiotic treatment is currently acceptable. However, almost three-quarters of all patients with pharyngitis who present for medical care continue to receive antibiotics. In addition, doctors frequently prescribe broad-spectrum antibiotics, including the newer macrolides, although GAS remains sensitive to penicillin and is increasingly resistant to macrolides.

Guidelines from expert panels are shifting away from recommending positive culture results before antibiotic treatment and toward using clinical criteria and/or rapid testing for GAS (followed by confirmatory culture if the rapid test is negative). Neuner and colleagues (2003) conducted a cost-effectiveness analysis of five pharyngitis management strategies and studied the impact of a decision rule on those strategies. The five strategies chosen were observation only; empirical treatment with no testing; throat culture for all patients, with treatment for GAS-positive results; optical immunoassay (OIA) rapid testing, culture for negative results, and treatment for any positive result; and OIA alone, with treatment for positive results.

The baseline prevalence of GAS infection in pharyngitis was 9.7%. At this prevalence, the culture strategy was most effective and least expensive; it was followed in efficacy (in order) by OIA/culture, OIA alone, and observation. Empirical therapy was notably less effective than the other four strategies. The OIA/culture strategy was twice as expensive per patient as culture alone. For any prevalence between 6 and 20%, the culture strategy was most effective and least expensive. Only when OIA specificity was >98% did it become the more effective strategy, but culture remained least expensive at all specificity ranges. Only if the prevalence of GAS pharyngitis exceeded 71% would empirical treatment become the least expensive strategy. This point might be relevant if a highly predictive clinical decision rule was first applied to an individual patient.

This study supports the continued use of throat culture before the treatment of pharyngitis in adults as the most effective and least expensive approach. OIA with or without culture is more expensive but clinically effective. Empirical treatment at current prevalence rates of GAS pharyngitis is not recommended.

In an accompanying editorial, Bisno (2003) notes that the American College of Physicians has accepted the use of a clinical algorithm as a substitute for any microbiological testing in making decisions about the treatment of acute pharyngitis in adults. The American Academy of Family Physicians and the Centers for Disease Control and Prevention are supportive of this approach. In the study by Neuner's group, empirical treatment remained less effective and more expensive than other strategies, even when the best algorithm was used. Culture alone was most effective at the present U.S. prevalence of GAS pharyngitis. Because treatment has a minimal impact on clinical symptoms and contagion, and because suppurative or nonsuppurative sequelae are currently rare, the main goal in managing acute pharyngitis in adult patients should be to reduce the inappropriate use of antibiotics, particularly given the trend of physicians to prescribe broad-spectrum antibiotics. The Infectious Diseases Society of America now recommends the use of rapid antigen testing so that a decision regarding antibiotic treatment can be made quickly before the patient leaves the doctor's office. This approach is consistent with the study by Neuner and colleagues, which finds it to be as effective as culture alone, although more expensive. In any event, Bisno concludes that some testing should be performed; if treatment is indicated, penicillin is the drug of choice for nonallergic patients.

Having said the above, if treatment still fails, a re-evaluation of the the patient (in this case, your sister) should be done as the initial diagnosis maybe wrong. A step-wise approach should be taken and investigations retaken. Keep an open mind as to the diagnosis and keep looking out for differential diagnosis, as a once famous professor said - the eyes does not see what the mind does not know. :) Hope this helps and sorry for the extremely late reply. All the best in the recovery of your sister. God bless.

Defeacation reflex

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Chest tube insertion

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Malaria

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Pneumothorax

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Leptospirosis

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Re: Yumin

Hi yumin, you could check out the Natural Guideline Clearinghouse at www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5946&nbr=3915, or you can simply just download the file from http://www.journals.uchicago.edu/doi/pdf/10.1086/425368?cookieSet=1. Its from IDSA website at http://www.idsociety.org/content.aspx?id=4430.

False localising sign & 3rd cranial nerve palsy

The false localising sigh
• Neurological signs that indicates a pathology far-away from the expected anatomical site.

• Commonest examples are 6th cranial nerve palsy (unilateral or bilateral) and papilloedema secondary to raised intracranial pressure (e.g. chronic meningitis and tumour)

• The reason for false localizing sign in the 6th CNP is due to its’ long intracranial course.

Surgical and medical 3rd nerve palsy
• As the name suggest, the causes of surgical 3rd CNP are compressive lesions (such as aneurysm or tumours)and medical 3rd CNP are those that you’ll see in the medical wards that may involve the course of 3rd cranial nerve.(such as diabetes = most common)

• So, to learn more about the causes of 3rd CNP, you’ll have to cover a wide range of diseases from surgical causes to medical causes that may injure or affect the 3rd nerve anywhere along its’ course. But the important points you’ll need to know are in the ptosis flow chart. 

• Pupillary involvement (dilated pupil that does not react to light shone in either eye) is an important sign differentiating "surgical," including traumatic, from "medical" causes of isolated third nerve palsy. (as shown in my previous flow chart on ptosis)

• Surgical 3rd nerve / Compressive lesions of the 3rd nerve—eg, aneurysm of the posterior communicating artery and uncal herniation due to a supratentorial mass lesion—characteristically have pupillary involvement. Patients with painful acute isolated third nerve palsy and pupillary involvement are assumed to have a posterior communicating artery aneurysm until this has been excluded. Pituitary apoplexy is a rarer cause.

• Medical causes of isolated third nerve palsy include diabetes, hypertension, and giant cell arteritis.

COPD (case presentation)

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Re: mishita (Paediatric Protocol for Malaysian Hospital)

Hey Mishita, I've been asking around and noticed that there are Malaysian protocols on haematological diseases such as the Paediatric Protocol for Malaysian Hospital and they cover heamatological diseases such as anaemia, thalassaemia, ITP, haemophilia and leukeamia. I'm sorry about the previous mistaken information. I have the file with me here and hope this helps. This is the 2008 second edition (the latest I can find) I couldn't find anything for the adults though, but i'll continue to search for it. Hopefully I'll find something useful for you.
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Re: Mishita

It's ok.:) As for the other blood disorders, Malaysian MOH per se does not have any CPGs on them. Therefore, u can use any management plan from the text books recommended by your various universities. As a guide, make sure your resources are up to date. By that, it's best to get them from journals or research publications. In view of this, it'll be ridiculous to put up all the literatures available online for this topic. I suggest that u either stick to the text books recommended by your university, ask the lecturers whom u're under and get the name of their referrences, do your own research of the latest updates on the particular topic and make sure u state your sources when asked or if u're working or attached to any hospital - ask them if they have a hospital guideline for the different blood disorders. Hope this helps.

Blood disorders

Hi Mishita,

There are Clinical Practice Guidelines (CPGs) that u can get from Malaysia Ministry of Health (MOH) website that fit your request of blood diseases such as diagnosis & management of Immune Thrombocytopenic Purpura (ITP) 2006 and diagnosis & management of Chronic Myeloproliferative Disorder 2004. There are no other CPGs by Malaysian MOH on other blood disorders up to 2009. Hope this helps. If u have other request, just let me know. I'll try to help out.

GINA & GOLD guidelines

Hi Kirara, you can find the GINA guidelines for diagnosis and management of asthma in children 5 years and younger at http://www.ginasthma.com/download.asp?intId=380 and GOLD guidelines for diagnosis, management, and prevention of COPD at http://www.goldcopd.com/download.asp?intId=504

Please take note that these files are not meant for commercial purposes and are strictly for personal, clinical or academic use only.

Speech disorders

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Fluid management

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Breathing

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COPD (treatment)

Smoking cessation

· Since smoking is the main cause for COPD, stopping is definitely the treatment option. This has proved to prolong the survival in patients with COPD.

· Although lost lung function is not regained, the lung damage stops. (rate of FEV₁ reverts back to that of non-smokers)

· For those who can’t stop smoking without an aid, replacement therapy such as nicotine patch, gum or inhaler helps to some certain extend. (user dependant)

· Oral medication to help smoking cessation is another alternative. (e.g. bupropion)

Bronchodilators

· These are medications used to enlarge a narrow airway by action of relaxing the muscles around the airway.

· There are short acting (medication that last only a short period of time after use) & long acting bronchodilators.

· The bronchodilators are in inhaler or oral preparations. (However, inhaled medications have fewer side effects)

· Examples are ipratropium (short acting) and salmeterol (long acting). Theophylline’s use is limited due to its’ narrow therapeutic range. (this means that the individual taking this medication is at a higher risk of getting toxic levels of the medication thus increasing the adverse effects)

Oxygen

· This therapy can be given at home (if the equipment and operator skills are available).

· The therapy shows reduced symptoms & improved survival in patients with COPD. (provided they have stopped smoking)

· The oxygen saturation (Sa_O2) is best kept above 90%.

Lung transplant

· This is only done if all methods of treatment above are tried and have failed & the function of the lung is severely low.(FEV₁ is less than 25%)

Lung volume reduction surgery

· Still another method used to help patients with COPD.

· However, this is a highly specific treatment for a selected group of COPD patients.

COPD (signs & symptoms)

Do you have COPD?

Symptoms of COPD

- symptom is the change in the body's structure, function, or sensation, experienced by the patient & indicative of disease.

1. cough with phlegm
2. breathlessness on mid exertion
3. wheeze (breathing with difficulty & noisily)

Signs of COPD

- sign is an objective indication of disease, discoverable on examination of the patient (usually) by a physician.

- early signs

1. wheezing upon exhalation

- late signs

1. tachypnoea (rapid breathing-the definition varies with the age of the patient)
2. hyperinflated chest (over expansion / distension of chest)
3. marked widespread wheeze
4. 'Pink puffers' or 'blue bloaters'

Cardiac murmurs

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COPD & smoking

Why does smoking causes COPD?

- In a smoker's lung, there are basically two things that take place:

1. the lung reacts to smoke particles (e.g. nicotine, tar) => know as indirect injury
2. the smoke particles react to the lung => known as direct injury

- Indirect injury:

• In smokers, there is an accumulation of immune cells (immune cells protecting the body are liken to the policemen & soldiers that protect a country) within the alveoli. (remember the tree analogy? These are the leaves)
• It is believed that the immune cells (neutrophils and macrophages) are attracted to the lung alveoli by the smoke particles, nicotine. (as an action of local immune cells.)
• Of the 2 immune cells, 1 of them (neutrophils) release a variety of protein substances (e.g.neutrophil elastase, proteinase 3 & cathepsin G) finally resulting in lung alveolar damage.
• The other immune cell (macrophage) also releases a protein substance calledmetalloproteinase which causes additional damage to the lung alveoli. (It's just like a war occuring within a country's gates. When bullets are fired, innocent people get hurt too.)

- Direct injury:

• Smoking plays a role in causing direct injury to the lungs by producing harmful products known as reactive oxygen species / "free radicals".
• Free radicals cause lung alveolar damage by destroying the 'guys' that maintain the well-being of the alveoli (known as alpha 1 anti-trypsin)

- All these insults results in the loss of alveolar attachments (supporting structure) & thus acollapse of brochial wall upon breathing. (this is what happens in emphysema)

- The continuous insult in the alveoli causes deposits of hardening tissue (fibrosis) hence thenarrowing of airflow and airway limitation. (this is chronic bronchitis)

COPD (causes)

Causes of COPD/COAD

- Chronic Obstructive Pulmonary Disease (COPD) commonly occurs in individualsover the age of 35. (It is a progressive disease, therefore it takes time to show physical signs.)

- The single and most inportant cause of COPD is smoking. (Why? check out the next update!!)

- Did you know that in 90% of patients suffering from COPD, it is the result of long-term heavy cigarette smoking? The remaining 10% are non-smokers who develop COPD for which the reason is still uncertain. (medical X-files ^_^)

- In the majority of clinical settings, a patient either has COPD or asthma, not both. However, although asthma (reversible, over-reactive airway) is a distinct disorder, it may be a part of COPD in some patients. (but this is for the respiratory specialist to crack their heads over. ^_^)

- For the past few decades, the increase in smoking, environmental pollutants, and other noxious gas exposures has caused the incidence of COPD to rise dramatically.

-COPD is even ranked in the top 5 causes of morbidity(a diseased state) worldwide.

- Other causes of COPD would include occupational dust exposure (e.g. coal miners) & repeated lung infections. (e.g. tuberculosis)

COPD (Introduction)

COPD (Chronic Obstructive Pulmonary Disease) / COAD (Chronic Obstructive Airway Disease)

Introduction:

COPD and COAD are the one and the same. The usage of the terms depends on the country you come from. (^_^)

Definition:

- Lung disease are generally grouped into 2 categories, namely obstructive & restrictive diseases.

- Obstructive disease

• means - an increase resistance to air flow
• due to partial / complete obstruction
• at any level of the airway

- Restrictive disease

• means - a decrease in the ability of the lung to expand
• and - a decrease in the lung's air storage capacity

-COPD falls under the obstructive category of lung diseases. (However, note that there are no absolutes in the medical line. There are COPDs without obstructive elements! )

[NB: a tip for medical or nursing students in answering exam questions - if there is an answer to a question which states words such as ALL or NEVER or anything along that line, the chances that the answer is wrong is certain.(^_^)]

-COPD is a common progressive obstructive disorder ofthe airway with little or no reversibility.

-Clinically, COPD includes a combination of

• chronic bronchitis (a person with persistent productive cough for most days, in at least 2 consecutive years)
• emphysema (a person with permanent increase of air spaces beyond the normal size, at the level away from the terminal bronchioles-in other words, alveolar region)
• Think of the lung as an inverted tree, with it's trunk (trechea) slowly progressing to the leaves. The twigs of the tree are the bronchioles and the leaves are the alveoli / terminal sac.
• accompanied by destruction of their walls
• with / without obvious deposits of hardening tissue (due to reactive process to the disease).

Ptosis (flow chart)

Case based learning (Ophthalmology)

1 case followed by 2 scenarios.

These slides are a compilation of my short and humble experience in various departments. It is also altered slightly for the purpose of case based learning. However, the identity is not revealed for the privacy of the patient.

Case proper

A 45 year old woman came into HTJS accident and emergency department. For the previous 2 days, her left eye had been red and watering. There was slight blurring of vision and the eye was moderately uncomfortable. There was no history of trauma. There right eye was asymptomatic. There was no past eye history. She was fit and well and not taking any pharmacological or traditional medication.

The acute red eye is a common ophthalmological presentation caused by various conditions ranging from trivial to sight-threatening.

What are the important causes of red eye do you know of?

Answer: (Please click & drag the empty section below to reveal the hidden answer. ^_^)

Are you contented with the history taken?

If yes, justify your statement.

If no, what further questions would you have asked her?

Suggest some physical examination you would carry out in this patient to aid in your diagnosis and their expected findings.

Answer: (Please click & drag the empty section below to reveal the hidden answer. ^_^)

¨ recent upper-respiratory tract infection

¨ direct contact with an infected person

¨ onset (abrupt / insidious)

¨ type of visual blurring (isolated fields/all fields)

¨ photophobia (secondary iritis)

¨ rash (herpes simplex)

¨ headache

¨ Examine the eye with its adnexa. (also with fluorescein stain)

¨ Direct ophthalmoscope

¨ Visual acuity & visual field

¨ Lymph node palpation

With the symptoms she had, what is the most likely diagnosis?

Answer: (Please click & drag the empty section below to reveal the hidden answer. ^_^)

Acute viral conjuctivitis

Dr. Ceccilia of the A&E department diagnosed her to be viral conjunctivitis and commenced a broad spectrum topical antibiotic, arranging a routine review appointment in 3 days but warning the patient to return urgently prior to this if the symptoms worsened.

Do you agree with this method of management?

What would be your management for her?

Answer: (Please click & drag the empty section below to reveal the hidden answer. ^_^)

Management for viral conjunctivitis is supportive and no specific treatment is available.

¨ Topical antiviral agents (e.g. aciclovir, trifluorothymidine) are effective against herpes simplex.

¨ Vasoconstrictors/ antihistamine may reduce symptoms.

¨ Artificial tears are used for soothing effect.

¨ Antibiotics are prescribed only when diagnosis is in doubt.

¨ Topical steroids reduces symptoms but should be used when diagnosis is certain & under ophthalmological supervision.

¨ Antihistamines

¨ Levocabastine HCl 0.05% ophthalmic solution (Livostin)

¨ 1 drop four times daily (up to 2 weeks)

¨ Emedastine difumarate 0.05% solution (Emadine)

¨ 1 drop four times daily

¨ Mast cell stabilizers

¨ Cromolyn sodium 4% solution (Crolom)

¨ 1 drop four to six times daily

¨ Ketotifen fumarate 0.025% solution (Zaditor)

¨ 1 drop two to four times daily

¨ Lodoxamide tromethamine 0.1% solution (Alomide)

¨ 1 or 2 drops four times daily (up to 3 months)

¨ Nedocromil sodium 2% solution (Alocril)

¨ 1 drop twice daily

¨ Olopatadine hydrochloride 0.1% solution (Patanol)

¨ 1 drop twice daily

Sccenario 1

The patient returned to the hospital later the same day complaining that the pan in the left eye had become severe. There was now frontal headache and malaise. The vision in the eye had become much worst (counting fingers only). The eye was very inflamed and the cornea looked hazy. The pupil was oval in shape and failed to react to direct and consensual light stimulation. There was left relative afferent pupillary defect.

What is the most likely diagnosis? What features of the history and examination lead you to this conclusion?

Answer: (Please click & drag the empty section below to reveal the hidden answer. ^_^)

¨ Acute angle closure glaucome

¡ Unilateral eye pain

¡ Often with headache

¡ Poor vision

¡ Hazy cornea (due to oedema)

¡ Oval mid-dilated fixed pupil

¡ Haloes around lights (corneal oedema)

¡ Loss of red reflex

¡ Hypermetropia

¡ Previous symptoms of similar attack

¡ Nausea, vomiting

What is the differential diagnosis and why?

Answer: (Please click & drag the empty section below to reveal the hidden answer. ^_^)

¨ Iritis is the main differential diagnosis, but few other conditions cause such pain with visual loss.

¨ Conjunctivitis and blepharitis cause disconfort only.

¨ Acute corneal problems may cause pain but usually there is a history of trauma or an obvious ulcer on staining with fluorescein.

How would you manage this patient?

Answer: (Please click & drag the empty section below to reveal the hidden answer. ^_^)

¨ Urgent referral to an ophthalmologist is necessary, as permanent visual loss can rapidly occur if untreated.

¨ Initial treatment is to lower the intraocular pressure using

¡ β-blocker :Timolol, 0.5%, 1 drop in the affected eye

¡ Cholinergic :Pilocarpine, 2% eyedrops, two drops every 15 minutes for 2–3 hours

¡ Carbonic A.I. :Acetazolamide, 500 mg orally or 250 mg intravenously

¡ α-adrenergic :Apraclonidine, 1%, one drop every 12h)

¡ Oral agents :glycerol, 1.0 to 1.5 g/kg in a 50% solution

ú oral isosorbide can be substituted (1.5 to 2.0 g/kg).

¡ Intravenous :mannitol (20% solution, 2 g/kg given over 30 min)

¨ Give sedation, antiemetics, and analgesics as necessary to control pain nausea and agitation.

¨ peripheral iridotomy, which establishes a communication between the posterior and anterior chambers & prevent further occurance. (argon or Nd:YAG laser)

¨Rarely, surgical peripheral iridectomy is required.

Scenario 2

The patient attended the next appointment as scheduled, but the left eye was now considerably more uncomfortable and visual acuity was reduced to 6/18. Photophobia was a prominent feature. Dr. Cecilia suspected acute glaucoma. The appearance of the left eye is as below.

Describe the abnormality seen here and suggest the diagnosis.

Answer: (Please click & drag the empty section below to reveal the hidden answer. ^_^)

This is acute uveitis. The episcleral vessels are dilated (ciliary fluch), the corneal appears misty (endothelium is covered with inflammatory precipitates), and the iris is indistinct due to the anterior chamber cellular reaction. There is a mixed hypopyon (layered white blood cells) and hyphema (hemorrhage) within the inferior anterior chamber. The pupil has scarred in places to the lens by posterior synechiae, which causes the irregular appearance of the pupil.

What is the management of this condition?

Answer: (Please click & drag the empty section below to reveal the hidden answer. ^_^)

¨ Topical steroids are the main treatment. A dilating drop such as atropine, cyclopentolate or homatropine can also be prescribed: as this eases the pain and helps stop the formation of permanent posterior synechiae (adhesions between the iris and lens)

What are the systemic associations of this disorder?

Answer: (Please click & drag the empty section below to reveal the hidden answer. ^_^)

¨ ¾ of all cases are idiopathic. Ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis, arthritis of inflammatory bowel diseases (Crohn’s disease, ulcerative colitis), sarcoidosis, juvenile chronic arthritis are the most frequently identified associations.