MD Notes

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I had to present a CME in hospital lastweek, so i prep the slides. Thought might as well share them here :)

Wow! I’m surprise how “hardworking” i am at this (sigh, 3-4 days to finish one small chapter) :p

This chapter will focus on Pneumonia. Pneumonia could easily be one of the commonest infection in Medical Ward. Both it’s diagnosis & management is pretty straight-forward (with some exception of course).

In general, pneumonia can be classified by

epidemiology

1. Community acquired pneumonia
2. Hospital Acquired pneumonia (contracted 48hr after admission)
3. Ventilator Acquired Pneumonia

microbial etiology

1. Viral Pneumonia
2. Bacterial Pneumonia

specific type

• Aspiration Pneumonia
• SARS
• H1N1
• atypical pneumonia

Common differential diagnosis:

• Tuberculosis
  in socially vulnerable groups (IVDU, prisoners, homeless, poor etc), with prolonged fever, cough, night sweats, hemoptysis. Be skeptical and investigate!
• Meliodosis
  in disposed groups, diabetic (DM) working in agriculture with high spiking fever and other organs/systemic involvement
• Congestive heart failure
  sometimes easily mistaken as pneumonia. Look for failure symptoms! But bear in mind that a congested lung is also predisposed to infections.
• Lung Carcinoadenoma
  old patient, especially chronic smokers with constitutional symptoms.

Clinical Presentation

Pneumonia USUALLY presented with cough and fever. Cough can be productive with yellowish sputum. Understand that elderly patient might have sub-clinical presentation. ( hehe…this simply means that the symptoms are not obvious) so sometimes u should follow ur gut and order a CXR anyway (nah, i only say sometime, ok? :p afterall, u may developed this 6th sense after gaining some “experience”)

Physical Examination

(artwork from COPD.nhlbi.nih.gov)

During examination, u may find crepitation, decrease air entry, transmitted sound or even ronchi. Also check for these:

• clubing – if you suspect COAD
• throat – look for URTI symptoms
• liver – may sometime appear to be enlarged, which could just be pushed down by diaphragm due to hyper-expanded lung

note the respiratory rate, effort and whether patient is out of breath

Investigations

FBC – look for leucocytosis
CXR – patchy hazziness or consolidation
SpO2 +/- ABG – especially if patient appear to be in respiratory distress
Sputum C+S

some additional test:
Blood C+S – if having high spiking temperature
Sputum AFB x3, mantoux – if suspecting pulmonary tuberculosis PTB
Throat swab for H1N1 – especially in rapidly progressing disease

Treatment

The goal of treatment for pneumonia, simply put, are such:

1. ensure patient getting adequate oxygen
2. get rid of the lung infection

General managements

1. Give oxygen
   Nasoprong Oxygen (ranging from 0.5litre to 3 litre/min)
   facemask (not readily used in ward nowadays)
   Ventimask 31,40,60 %
   high flow mask (use with caution)
2. Antibiotic
   for community acquired pneumonia: -
   IV. Augmentin 1.2g TDS (Oral Augmentin 625mg BD)
   T.Erythromycin ES 800mg BD
   for severe pneumonia: -
   IV. Rocephine 1g OD/BD
   T.Azithromycin 500mg OD x5/7
3. Chest physiotherapy
4. Nebulization of bronchodilators (when there is ronchi)
   Neb.Combivent
   Neb. A:V:N 1:1 6 hourly
   (frequency depending on severity.. ranging from continuous, 2hourly to 8 hourly)

Alarming situations

Sooner or later, when we failed to treat the patient adequately, they will develop, so called respiratory distress. It is generally classified as:

1. Type I respiratory failure
2. Type II respiratory failure

Respiratory failure generally denotes condition where respiratory effort failed to translate to adequate oxygenation (Basically, PaO2 < 60). Type I and Type II differs by CO2 retention.

Type I respiratory failure = low PaO2, normal/low PaCO2
Type II respiratory failure = low PaO2, but HIGH PaCO2 (PaCO2 > 50)

Generally, type I might still respond with administration of high concentration of oxygen, but type II might NOT. CO2 washout in chronic CO2 retention patient may lead to respiratory depression (as CO2 is potent stimulation in the brain for respiratory act).

As such, in respiratory failure, consider more aggressive method of oxygenation. This is because, patient will eventually becomes fatigue with labored breathing. Refer to intensivist (aneast) and the following may be considered:

BIPAP

• may or may not be readily available (sometimes even in tertiary centres, BIPAP machine is still relatively less in quantity, hence, not available to all)
• requires a conscious patient with spontaneous breathing (since the machine is triggered by respiration)
• BIPAP is less invasive and very effective especially in COAD patients with type II respiratory failure.

intubation

• ventilatory support for patient with sepsis secondary to pneumonia and decrese level of consciousness.
• though, sometimes the dilemma is rather about how fast we could get the patient OFF the ventilator, before further insult of Ventilator Acquired   Pneumonia – with even more resilient bugs!

Conclusion

in the end of the day, most patient will get well. Some, unfortunately, may succumb. Our duty is to treat adequately (and sometime agressively :p) and to recognize the early warning signs! Leave the rest to the Guy “up-stairs”…

and before u go to sleep at night, be thankful, because u’re still breathing :)

PS: sorry for the boring post, surprised u are still awake to read this line! hehe

As i promised, this blog will start to peel the facts about Medical related conditions.

I’ve taken the liberty to review the statistic available about the major cause of death in Malaysia between 2006-2008 (the most up-to-date data provided by Malaysia Statistic Department. Click HERE to download the pdf files.)

As u can see, ischemic heart disease in the major cause of death in Malaysia. So, today i’m going to focus on ischemic heart disease :)

THE ALARMING SIGNS

When a patient suddenly complaint of severe chest pain, sweatiness and gasping for air… u better attend them immediately. The current understanding in cardiology is that TIME LOST is equal to MUSCLE LOST.

However, bear in mind that patient do not always present with typical symptoms… so called ATYPICAL PRESENTATION :

• epigastric pain
• severe backpain
• numbness of upper limbs
• sore neck
• difficulty in breathing

these are things that could easily be missed!

Recently, a medical specialist has given me a pretty neat deduction. He says:

if your patient is having Hypotension (below 90/60 mmHg), then u will need to think of SHOCK. and there is not too many etiology to SHOCK, namely:

1. hypovolemic
2. cardiogenic
3. septicemic
4. neurogenic
5. anaphylatic

so, all you need to do now, is to exclude them one-by-one.

HYPOVOLEMIC:
severe dehydration caused by acute bleeding, acute AGE, prolonged poor oral intake, polyuric state can be easily discerned.

SEPTICEMIC:
if the patient is having very severe infections: lungs, tropical infections

NEUROGENIC:
usually trauma cases involving the spine

ANAPHYLATIC:
if there is obvious allergy history and precipitation factor. And usually with concurrent bilateral periorbital swelling, lips swelling, rashes which is hard to miss!

* also, please check the dxt if a patient collapse. Hypoglycemia can also tip the patient off!

If u are able to exclude the rest, then cardiogenic cause is probable.

REACT!

Once u think of cardiogenic cause, then you’ll need to decide what to do next.

1. Order stat ECG and interpret it.
2. Decide if it is ischemic in nature: exclude arrythmia
3. give supportive measures: nasoprong oxygen and bed rest
4. closer monitoring: cardiac monitor, BP monitoring, spo2
5. transfer to acute cubicle

If decided as ischemic event, your working diagnosis is Acute Coronary Syndrome (ACS)

General Management for ACS:

S/L GTN 1/1 Stat & PRN
T. Clopidogrel 300mg Stat & 75mg OD
T. Aspirin 300mg OD & 150mg OD
T. Simvastatin 20mg ON (may given 40mg OD)
T. Metoprolol 25mg BD * provided not hypotensive or bradycardic
T. Perindopril 2mg OD * provided not hypotensive
T. Isordil 10mg TDS
T. Vasteral 20mg TDS
S/C Fundaparinox 2.5mg OD
+/- S/C Morphine & IV Maxolon
+/- Inotropic support
Nasoprong oxygen 3L/min
Strict bed rest

Specific Management

Once diagnosed as ACS, our next burning question is whether patient is a ST-elevation myocardial infarction (STEMI). That is because, STEMI will benefit from thrombolytic agent (streptokinase). The diagnosis require 2 out of 3 positive criteria, namely

1. typical chest pain
2. ECG changes
3. CE raised

as u can see, ACS is just a temporary diagnosis which includes the following(s):

• unstable angina

1. Typical chest pain
2. ECG with ischemic changes but no ST segment deviation,
3. CE Normal

• ST-elevation myocardial infarction (STEMI)

1. Typical chest pain
2. ECG show ST segment elevation + ST depression of reciprocal leads +/ – pathological Q.
3. CE Raised

• non-ST elevation myocardial infarction (NSTEMI)

1. Typical chest pain
2. ECG with ischemic changes but no ST segment deviation,
3. CE Raised

The specific management differ slightly from this point onwards:

Unstable Angina:
stabilization and close monitoring

STEMI:
streptokinase OR urgent interventional angioplasty (primary PCI) is indicated
- Streptokinase within 12 hour from onset of pain
- Primary PCI (please see detail in guideline PDF in the end of this bolg)

NSTEMI:
streptokinase is NOT indicated.
Early angiogram +/- angioplasty is beneficial

Other considerations

Classification of heart failure following a myocardial infarction:

KILLIP classification

•     Killip class I
includes individuals with no clinical signs of heart failure.

•     Killip class II
includes individuals with rales or crackles in the lungs, an S3, and elevated jugular venous pressure.

•     Killip class III
describes individuals with frank acute pulmonary edema.

•     Killip class IV
describes individuals in cardiogenic shock or hypotension (measured as systolic blood pressure lower than 90 mmHg), and evidence of peripheral vasoconstriction (oliguria, cyanosis or sweating).

Stratification of risk (mortality) for patient with myocardial infarction

TIMI stands for ‘Thrombolysis In Myocardial Infarction’ and is the name of a study group coordinating several trials, particularly focusing on percutaneous coronary intervention, thrombolysis as well as cardiovascular disease in general.

TIMI risk scoring is for stratification of risk of mortality after unstable angina & NSTEMI

positive findings of each of the following carries +1 point:

1. Age >= 65 yr
2.  >= 3 CAD risk factors (Family Hx, HPT, HPL, DM, smoker)
3. known stenosis >= 50%
4. Aspirin use within 7 days
5. Recent severe angina (<24 hr)
6. positive cardiac markers
7. ST deviation >= 0.5mm

mortality by 14 days:

0-2     = 2.9%
3    = 4.7%
4    = 6.7%
5    = 11.5%
6-7    = 19.4%

mortality, MI or urgent revascularization by 14 days

0-1    = 4.7%
2    = 8.3%
3    = 13.2%
4    = 19.9%
5    = 26.2%
6-7    = 40.9%

(source: Antman et al JAMA 2000)

References:

This is the CPG published from Malaysian Heart Association: STEMI, PCI

With the blink of an eye, i’m actually come close to 3 years in service. Quite amazing when u look down the memory lane. In goes a naive boy and out it come a grown man :p

So, i’ve got this lovely lady who told me she actually enjoyed reading my blog a bit, and to be honest, it is quite the inspiration to start writing again :) To start things off, i’m writing something more work-related.  i’m going to talk about how I survive Medical Department posting back then.

Medical department is basically a gigantic dump-yard for people who are sick and could not be chuck anywhere else. (But of course i’m not implying people in medical as trash :p coz, i’ve seen better trash elsewhere)

Back to the topic! Medical, therefore is ALWAYS overloaded. Needless to say, u should have your mind ready, to deal with all kind of sh*t now. For a department that takes is all kinds, one need to be prepared for all sort! simple logic, right? To tackle the handling of ill patients is anything but SIMPLE. Doesn’t mean u can’t TRY :p

Here’s how to keep your mind in line:

RULE NO.1 : ORIENTATE YOURSELF

to do so, u may borrow the wisdom of others before u… so READ the bloody case-note! :p so trust me, this is one of the most time-consuming task to beat. (Makes u wish u’ve got those non-sense Speed-reading crap they sell on TV).

Rule of thumb is to fly-over it wihout missing any important details. How to do that? 2 important tips: SECTIONS & KEYWORDS

SECTIONS:

before u read the gibberish words, (most likely scribbled down due to lack of time, or just plain sleepiness) learn the format of the sectionning!

Start by reading the ADMISSION clerking. That is when the most information is collected from the patient. Focus on the MEDICAL OFFICER ENTRY, coz honestly, some house-officer would write the whole grandmother story, u might as well try finish with Harry Potter first! At this point, search for their POSITIVE findings, what DIAGNOSIS they come up with, and how they PLAN to tackle it.

Next, read the PROGRESS during each review. Do so by focusing on the initial DIAGNOSIS. for example, if it is a case of pneumonia, the pay attention on the lung findings… is the crepitation reducing? how about the air entry? is there any ronchi? …. and of course their relevent investigation and stats: spo2 improving? serial CXR ordered? FBC parameter changes? Simply put, just be meticuluos!

take notice on CHANGING DIAGNOSIS. Somewhere along the lines, NEW FINDINGS are made… and it changes the diagnosis and the ways we deal with the sick. So, look for the reason WHY they change the diagnosis, and HOW they are going to be treated.

now, u will have to keep track of the PENDING TASK through-out the reviews. Perhaps some investigation should have been performed but yet to be done. If anything need sorting out, put it in your LATEST PLAN and get to it right away :)

u pretty much could safely OMIT any of the NURSING REPORT. If u need, read only the MOST RECENT ones (those written AFTER the last doctor review). See if there is any ACUTE CHANGES/PROBLEMS which happened over the night. And this would safe u embarrassment in front of the senior doctor when the nurses knows better than u!

KEYWORDS

if you noticed what i just did, u’ll see that i highlighted the important points in CAPITAL LETERS to make it easier for u to catch my point. Unfortunately, no one gonna highlight it in the case-note. u’ll just have to compensate by training ur mind to look for keywords that matters :) This, my dear,  is be one of the most time-saving, and potentially, life-saving skill.

for starters. looked for MEDICAL TERMS. u won’t missed much if u didn’t missed these!

RULE NO.2: CHECK

PHYSICAL EXAMINATION

check your patient! PHYSICAL EXAMINATION is your No.1 friend… anything u FIND will tell you what u could do NEXT.

In case u needed to save time, u may do away a few irrelevant examinations. But bear in mind, whatever u DID NOT examine will be MISSED totally (…and come to bite u in the arse later :p) To avoid this, turn on ur thinking cap and figure out which part to pay attention to. Look for the TELL-TALE SIGN. For example, a cold periphery suggest patient might be under-volume (dehydrated), so one would check the pulse for the pulse volume, check the tongue to see if it is coated or smooth-out..

VITAL SIGNS

the reason they are called the vital signs is because they are VITAL. Each parameter tell you that the patient might/might not be getting better. Use it to help u.

CHARTING

run through the other charts, Dxt, Input/output, GCS, PERF to name a few. These charts not only tell us how is the patient progress is, they also serve as a reminder for things we might have missed. For example, u may be treating the patient for kidney failure, but he may be also a known case of diabetic which is poorly controlled. Failure to optimize his sugar control may hinder his recovery.

RULE NO.3: DOUBLE CHECK!

double check the MEDICATION CHART. The meds we prescribe is our weapon of success. Check it everytime to be sure u are using the right tool. see if they are suitable for the suspected disease.

Also, check if they have been given too long. Some medication like Mist KCL might hide themself among the pages… i’ve seen few people missed that out and started giving oral kalimate or lytic cocktail ALONG with Mist KCL (and of course, they did not borther to check the case-note for the fact that the patient was previously hopokalemic, which is rather unlikely to become hyperkalemic in just a few days)

with that, i’m sure u’d understand ur case better and would be more ready to help the patient to their full recovery. I’d start focusing on systems and disease in the next few blog :) so stay tune!