Knowing the language of a disease

Palpation of the radial pulse is often one of the first things that doctors do when examining a patient. The pulse is examined for its rate, rhythm and character. The peripheral pulses are also examined to see if they are equally and symmetrically felt. Each of these aspects of the pulse can offer diagnostic clues to the doctor who understands the language of diseases.

Here is an example of how an examination of the pulse allowed one doctor to make a diagnosis that startled his students.

Dr X was told that a particular patient had a heart murmur. He was not allowed to auscultate the patient to determine anything more about the murmur. He was only allowed to palpate the patient's pulse. Thirty seconds after examining the patient's pulse, Dr Sandy said: This patient has aortic regurgitation. His students, new to clinical medicine, were all stunned.
They asked him: How did you correctly diagnose a valve abnormality in the heart by simply feeling the pulse?
Elementary, my dear students, Dr X replied. I noted that the pulse was of a collapsing nature. Only a few conditions are associated with a collapsing pulse and a heart murmur. Aortic regurgitation is one of them.

Do you know what cardiac abnormality to diagnose when:

1. The pulse is of small volume and rises slowly to its peak? This kind of pulse is called the anacrotic pulse.

2. The pulse has two distinct peaks during systole? This kind of pulse is called the bisferiens pulse.

3. The pulse disappears during inspiration? This kind of pulse is called the paradoxical pulse.

Rashes

A raised, reddish, patchy with irregular bordered margins, silvery-whitish scale, over the elbow measuring around 10 cm x 8 cm.







It is important to describe what ever you see in totality. This is just a rough guide - nature of the rash (raised or flat), colour, shape, margins, any characteristic signs/nature of rash that will give away the diagnosis of a particular rash, (for e.g. silvery scale in psoriasis)and site of the rash seen. These are not placed in order and should only be used as a guide. I personally prefer to tell the location of a rash first. (E.g. I see a rash over Mrs. X's elbow. It is a raised, reddish...etc)

While describing a rash seen is VERY important to come to a diagnosis, NEVER forget that the patient's age, gender and presentation of illness are also an EXTREMELY important aid in coming to a diagnosis.
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There is a rash seen on the left, anterior to medial, middle half shin of Mr. X. It is measuring around 8 cm x 7 cm, erythematous, tender (I'm sure it is!), swollen (compare both sides of his leg) with shinny skin (these are the give away, after this...its quite pointless to go on..), with poorly defined margins with some satellite lesions (red round patches seen around the main big patch).

It also gives a BIG plus point if you can add a point or two from your history taking (e.g. the site of the current rash is over a previous wound while Mr. X was gardening, cuts, blisters, burns, insect bites, surgical wounds.) This helps seals the diagnosis of cellulitis.
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This is rash seen all over the back of Mr. Z. It is flat, erythematous (maculopapular rash), typically described as isles of white in a sea of red, that is blanchable (disappears upon pressure). Putting this together with his symptoms of fever, body aches and retro-orbital pain, with the leucopenia and thrombocytopenia, a diagnosis is easily established. Though not shown here, the rash in dengue is usually centipetal. This means that the rash starts on the limbs before "moving" or spreading to the trunk (differentials would be coxsacki virus, secondary syphilis, rRocky mountain spotted fever, smallpox). Centrifugal means the rash starts on the trunk (differentials would be chickenpox, rubella, measles (rubeola), & typhus.

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I'm sorry I can't put up more pictures as there are just too many to mention here. However, I hope that you get the idea of it. :)

Re: Raymond 2

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Re: Raymond

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Influenza vaccination, a trick or a treat?

Suppose a healthy adult comes to you and asks: "Do you think I should take the Influenza vaccine?"; What will you advice? In order to answer that question you will need to know how effective the Influenza vaccine is in protecting people against Influenza, as well as the degree of risk due to the vaccine itself. Reading the article below from the Cochrane Review might help you answer that question.

Link

The Cholera threat...

There is currently an epidemic of cholera in Haiti. Should all patients with cholera be treated with antibiotics? International guidelines recommend that patients with moderately severe and severe cholera be treated promptly with antibiotics. How do we differentiate between a mild case, a moderately severe case and a severe case of cholera? We can do that by looking at the degree of dehyration. A severe case of cholera is one where the dehyration amounts to 10 percent or more of the body weight. A moderately severe case is one where the dehydration amounts to 5 to 10 percent of the body weight. And a mild case will be one where the dehyration is minimal, less than 5 percent of body weight.

So, what are the antibiotics that can be used for cholera? Doxycycline, Azithromycin or Ciprofloxacin can be used.

Should contacts of cholera patients be given prophylactic antibiotics? The answer is No. Finally, when should a doctor suspect cholera? Cholera should be suspected in any diarrhoeal illness of short duration (less than 24 hours) which is associated with dehydration. Vomiting often accompanies the diarrhoea and there is no fever.

This site has the WHO guidelines for cholera treatment and a good write-up on the antibiotics of choice for the disease.

(NB: Only a single dose of an antibiotic is needed for treatment of cholera. Either 300mg OD Doxycycline or 1gram OD Azithromycin or 1gram OD Ciprofloxacin)

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