ER Toxicity

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Physical Examination &History Taking in the ER

Study: Timing of BP Pills Might Matter

Taking a blood pressure pill at bedtime instead of in the morning might be healthier for some high-risk people.

New research suggests that simple switch may normalize patterns of blood pressure in patients at extra risk from the twin epidemics of heart and kidney disease.

Why? When it comes to blood pressure, you want to be a dipper. In healthy people, blood pressure dips at night, by 10 to 20 percent. Scientists don't know why, but suspect the drop gives arteries a little rest.

People with high blood pressure that doesn't dip at night — the non-dippers — fare worse than other hypertension sufferers, developing more serious heart disease. Moreover, heart and kidney disease fuel each other — and the 26 million Americans with chronic kidney disease seem most prone to non-dipping. In addition to heart problems, they're at extra risk of their kidney damage worsening to the point of dialysis.

Most blood pressure patients need two or three medications. So Italian researchers performed an easy test: They told 32 non-dippers with kidney disease to switch one of those drugs from a morning to a bedtime dose. In two months, nearly 90 percent of these high-risk patients had turned into dippers. Their nighttime blood pressure dropped an average of 7 points, without side effects or increase in daytime blood pressure.

Better, a key sign of kidney function improved significantly, too, Dr. Roberto Minutolo of the Second University of Naples reports this month in the American Journal of Kidney Diseases.

It's the latest research in the field of chronotherapy: How our bodies' internal rhythms make certain diseases worse at certain times of the day, and in turn affect how to time treatments.

While the Italian study is too small for proof, similar studies from Europe also back a bedtime switch for non-dippers. The work is catching the attention of U.S. hypertension specialists, and now doctors at Baltimore's Johns Hopkins University are planning a larger study to see if a bedtime switch really could give certain people healthier hearts and kidneys.

How big a problem is non-dipping?

"I think it's huge," says Hopkins' Dr. Lawrence Appel. "This is our best lead" into why black Americans with kidney disease, in particular, tend to worsen despite treatment.

Appel found 80 percent of black kidney patients in a recent study were non-dippers. Most startling, 40 percent had nighttime blood pressure that was even higher than daytime levels.

Two-thirds of chronic kidney disease patients, and at least 10 percent of the general population, are estimated to be non-dippers, says Dr. Joseph Vassalotti of the National Kidney Foundation. One theory is that their bodies have trouble excreting salt.

Yet few patients have ever heard of the problem — and few doctors know who is affected. Most people get their blood pressure checked only during the day. A 24-hour blood pressure monitor can tell but is rarely used, partly because insurance seldom pays for the extra visit to download and diagnose the readings.

And most patients who take several once-a-day pills swallow them all in the morning, meaning they all start wearing off around the same time, says Dr. Gina Lundberg of St. Joseph's Hospital in Atlanta.

"It does make good sense to take some in the morning and some in the evening," says Lundberg, a spokeswoman for the American Heart Association.

Everyone has an internal clock, determined by genes, that affects health. Many of these biological rhythms are circadian, meaning they fluctuate on a 24-hour cycle.

Consider how that can affect the timing of treatments. Some older "statin" pills fight cholesterol best if taken at bedtime; they target a liver enzyme that's most active at night. Asthma attacks are more frequent at night, and the stomach secretes more heartburn-causing acid at night, affecting some patients' dosing requirements. Researchers even are studying how to better time certain cancer chemotherapies and allergy treatments.

The best-known example: Blood pressure jumps in the early morning hours, as the awakening body produces more stress hormones. That's also why heart attacks and strokes are most common in the morning.

The nighttime dipping problem has gotten far less attention. The new Italian study marks an important advance, says Dr. Mahboob Rahman of the University Hospitals of Cleveland.

"We know now that you can change medication timing and lower blood pressure at night," he explains.

That doesn't mean everyone should switch willy-nilly to bedtime dosing. Morning may be best for people on just one drug, and no one yet knows if the switch truly gives non-dippers better overall health. "That's the million-dollar question," Rahman cautions.

Still, Lundberg says it's worth asking your doctor how to time doses, saying one at night for someone taking multiple medicines couldn't hurt.

--LAURAN NEERGAARD, AP Medical Writer

Pediatric CPR Demonstration

Adult CPR Video Demonstration

The Role of Antibiotics and Nasal Steroids on Acute Sinusitis

This article I came across only shows that not all sinus infections are created uhm infected equal. he-he

Seriously, this British study is a known fact since a long, long time ago to most people in the medical profession.

In fact, this was harped on us over and over again by our professors in the Best Medical School along Aurora Boulevard in the Philippines years back when I was a young med student.

Since most acute sinus infections are caused by viruses which are self- limiting ergo no amount of antibiotics and nasal steroids can help cure them of the infection but still a lot of medical practitioners give them for reasons that they only know--

--is it because of trying to please their patients; that they will be satisfied that their doctor have given them something for their troubles rather than the “normal” advice in this particular case of just drinking plenty of fluids, rest and steam inhalations?

Or are they just beholden to the drug companies that give them some percentage of their sales, finance their travels for medical seminars or what have you?

Anyway this study published by HealthDay News is nothing but a re-affirmation of that belief that in most cases of sinus infections, antibiotics and nasal steroids actually doesn’t work.

Here’s the rest of the news…

TUESDAY, Dec. 4 (HealthDay News) -- Antibiotics and nasal steroids work no better than a placebo in combating sinus infections, a new British study shows

"Antibiotics are probably not as effective as have been previously believed, particularly for the majority of cases of acute sinusitis," said study author Dr. Ian Williamson, a senior lecturer in primary medical care at the University of Southampton. "Patients should turn more to symptomatic remedies like analgesics while the body heals itself, usually over a period of three days to three weeks. Topical steroids have little overall effect, but may be beneficial, particularly in milder cases of acute sinusitis."

"For sinusitis, however it is being diagnosed in the primary-care setting, many of these cases do not require treatment, and a more cautious and conservative approach would seem to be warranted," added Dr. Reginald F. Baugh, vice chairman of Texas A&M Health Science Center College of Medicine and director of the division of otolaryngology at Scott & White, in Temple, Texas.

But other experts say the study, published in the Dec. 5 issue of the Journal of the American Medical Association, is no reason to scrap antibiotics altogether in this scenario.
"This is a helpful and useful study, and we shouldn't condemn antibiotics in those people who need them," said Dr. Michael Stewart, chairman of the department of otolaryngology at New York Presbyterian-Weill Cornell Medical Center, in New York City.

But, he added, only a minority of sinus infections are bacterial and will respond to antibiotics. The majority are viral infections, which won't respond to antibiotics.

According to an accompanying editorial, sinus problems account for 25 million doctor's office visits in the United States each year. Antibiotics are used to treat sinus infections 85 percent to 98 percent of the time in the United States.

Overuse of antibiotics not only won't help a patient with a viral infection get better, it will contribute to the growing problem of antibiotic resistance, experts have noted.

"Antibiotic resistance is rising dramatically, and there is no question about that," Baugh said.
For this study, 240 adults with sinus infections were randomized to one of four treatment groups: 500 milligrams of the antibiotic amoxicillin three times a day for seven days plus 200 micrograms of the nasal steroid budesonide once a day for 10 days; a placebo in place of the antibiotic plus budesonide; amoxicillin plus a placebo in place of budesonide; or two placebos.

In the amoxicillin group, 29 percent of patients had symptoms lasting at least 10 days, and 33.6 percent of those not receiving amoxicillin had the same symptom length of time.

In both the budesonide and no-budesonide groups, exactly 31.4 percent of patients had symptoms lasting at least 10 days.

The nasal steroids seemed to be more effective in individuals who had less severe symptoms.

As the editorial pointed out, most patients with acute sinusitis will get better on their own. Unfortunately, there's no good way to determine who has viral sinusitis and who has bacterial sinusitis.

"It's difficult to make a distinction in a primary-care setting," Baugh said.

If the symptoms are worse, treatment might be warranted, he added. "But for the bulk, I would assume it would be more of a wait-and-see approach. The bugs are winning," he said.

While researchers investigate possible new treatments, sinus infections sufferers might look to analgesics or brief use of steam inhalations, Williamson said.

Dr. William Morris, chairman and director of the department of osteopathic manipulative medicine at Touro College of Osteopathic Medicine in New York City, recommends an alternative approach: manual pressure to the bottom of the head and beginning of the neck, to allow better drainage from the head.

"One of the problems with sinusitis is that the sinuses tend to get closed up," he said. "If you don't drain properly, bacteria is just happy as a clam. If you can increase drainage and improve flow through the sinuses, you're going to be facilitating the process."

Worm study shows antidepressant may lengthen life

This article from Reuters looks promising for the millions who are suffering from cases of Depression worldwide.

But it is still a big but like the other experimental drugs. This is certainly worth the wait if ever it will be successful in the future.

Anyway, read on...


WASHINGTON (Reuters) - An antidepressant may help worms live longer by tricking the brain into thinking the body is starving, U.S. researchers reported on Wednesday.

The drug, called mianserin, extended the life span of the nematode Caenorhabditis elegans by about 30 percent, the researchers reported in the journal Nature. They hope to find out if the same mechanism can help people live longer.

Three other compounds, including another antidepressant, have similar effects, said Michael Petrascheck of the Fred Hutchinson Cancer Research Center in Seattle. But the life-extending benefits come at a cost.

"Weight gain and increased appetite seems to be one of the side effects. It is one of the reasons these are not such popular antidepressants," Petrascheck said in a telephone interview.

Many studies have shown that slightly starving certain animals -- reducing how much they eat by about 30 percent -- can cause them to live longer.

It is not entirely clear if this occurs in humans, but researchers are keen to duplicate the beneficial effects of calorie restriction without the misery of going hungry.

Howard Hughes Medical Institute researcher Linda Buck and colleagues were looking for drugs that might do this.

C. elegans is a roundworm, or nematode, much studied because despite its tiny size, its biology is similar to that of humans and other animals.

Buck's team did a random search through 88,000 different drug compounds to see if any of them happened to make C. elegans live longer.

They found four drugs that extended life span by 20 percent to 30 percent. The drug with the strongest effect was mianserin, in a class of drugs known as tetracyclic antidepressants.

It blocks brain cell signaling by the neurotransmitter or message-carrying chemical serotonin, which is linked with mood and appetite.

The drug is used in Europe under several brand names, including Bolvidon, Norval and Tolvon but not usually in the United States. It can cause aplastic anemia and other effects on immune system cells.

Buck's team found that in addition to interfering with serotonin in the worm, it also blocked receptors for another neurotransmitter, octopamine.

They said some other research suggests that serotonin and octopamine may complement one another -- with serotonin signaling the presence of food and octopamine signaling starvation.

Buck said it is possible that mianserin drug tips the balance in the direction of octopamine, tricking the brain into thinking it has been starved.

Petrascheck said another antidepressant, mirtazapine, had similar effects. An antihistamine and migraine drug called cyproheptadine, as well as a compound not used in people called methiothepin also affected serotonin and extended worm life span.
They tested other popular antidepressants that affect serotonin and found they did not make the worms live longer.

He is worried that people will rush to take the drugs in the hope of living longer.
"It is a stretch from a worm to a human being," Petrascheck said.

(Reporting by Maggie Fox, editing by Will Dunham and David Wiessler)

New Guideline to Treat Unprovoked Seizure

A guideline developed by the American Academy of Neurology recommends a routine electroencephalogram (EEG) and brain scans be considered when diagnosing and treating adults who experience their first unprovoked seizure. Evidence shows such tools often detect brain abnormalities that caused the seizure and predict seizure recurrence. The guideline is published in the November 20, 2007, issue of Neurology, the medical journal of the American Academy of Neurology.

The guideline recommends a routine EEG be considered as part of the diagnosis of a person with a first unprovoked seizure. “Evidence shows an EEG revealed abnormalities indicating epilepsy in about one in four patients and was predictive of seizure recurrence,” said Krumholz, who is also a professor of neurology at the University of Maryland School of Medicine.

The guideline also recommends CT or MRI brain scans be routinely considered since the scans are significantly abnormal in one of 10 patients, helping to indicate the cause of their seizure. “A CT scan or MRI may lead to the diagnosis of disorders such as a brain tumor, stroke, an infection, or other structural lesions and may help determine a person’s risk for a second seizure,” said Krumholz.

For adults who experience their first unprovoked seizure, Krumholz says the results of an EEG, CT or MRI will influence aspects of patient care and management, including drug treatment, patient and family counseling, and the need for immediate hospitalization and subsequent follow-up.

Seizures are among the most common serious neurological disorders cared for by neurologists. Annually approximately 150,000 adults will have a first seizure in the United States. It is estimated that in 40 to 50 percent of these people, seizures recur and are classified as epilepsy.

Source: American Academy of Neurology

Listening for the Sounds of Heart Failure Part II

ON Auscultation:

Recognizing the Extra Heart Sounds

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Body Oddities

Ever wonder why your eye suddenly starts twitching or why you start hiccupping uncontrollably in public and simply can't stop? Or how about pondering the medical reason behind yawning or getting a brain freeze immediately after eating ice cream? Well, according to experts there are medical reasons for such oddities and what you're about to read may surprise you.

Sneezing
Achewww! Known as sternutation, the act of sneezing removes an irritant from the nose. When a particle or cluster of particles pass through nasal hairs and reach the nasal mucosa, they trigger histamine production. This reaches nerve cells in the nose which signals to the brain to initiate a sneeze. Particles such as dust may irritate the nose and result in a sneeze. Sneezing is more common for people with allergies when they're exposed to various allergens like animal dander and pollen.

Hiccups
Hiccups are the result of a spasm in the diaphragm, which contracts to pull air into the lungs causing a sudden rush of inhaled air. According to Dr. Michael Farber, Director, Executive Health Program, Hackensack University Medical Center, "This sets off a chain reaction causing the airway opening to close quickly which in turn halts the flow of air thus causing the vocal cords to react by closing quickly, creating the characteristic hic." Hiccups may be the result of eating a big meal, swallowing air, drinking carbonated beverages, tobacco use or sudden emotional excitement. He explains, "Hiccups may improve through basic maneuvers such as relaxation or distraction, eating and drinking, or techniques of altered breathing."

Blushing
Awwww, you're blushing. Turning red in the face is caused by the dilation of blood vessels in the face. In fact, this normal physiologic response allows the transfer of heat from our bodies to the skin's surface. Dr. Yael Halaas, board-certified facial plastic surgeon in New York explains, "Several factors cause blushing such as a change of temperature, spicy foods, emotional responses and alcohol. Some medical conditions can also cause blushing such as Acne Rosacea." In this condition, there is an increase of vasculature and enlargement of blood vessels in the face. This condition can be treated by a dermatologist or qualified physician.

Brain Freeze
This almost instantaneous headache is a reaction to a cold substance coming into the roof of the mouth. Better known as brain freeze, Dr. Michael Farber says, "Typical onset is within seconds of exposure to a cold precipitant, as the body reacts by initially reducing blood flow to the region to conserve heat followed by enhanced blood flow return to the region." Nerves within the area sense this and transmit the sensation back to the nerve base as pain. His advice -- relieve pain by pressing the tongue against the roof of the mouth to warm the area.

Eye Twitch
According to experts, eye twitching is essentially a spontaneous spasm of muscles surrounding the eye. The involuntary twitching of an eyelid muscle may last less than a minute, although twitching may occur in one eye or the other, in both or underneath the eye. Some experts attribute it to fatigue, stress or caffeine. If spasms persist a doctor should be consulted.

Yawning
Known as the act of opening the mouth by taking a deep breath, yawning is a reflex often associated with fatigue, stress or boredom. Some experts say the real reason why we yawn is a result of low oxygen levels in our lungs. As such, when we're resting we don't use our entire lung capacity and just use air sacs at the bottom of our lungs. If the air sacs don't get fresh air, they partially collapse and as a result our brain prompts the body to yawn or possibly sigh to get more air into the lungs.

Leg Cramps
Although painful sensations caused by contracting or over shortening of muscles, better known as leg cramps, may occur infrequently they may also be a sign of medical disorders. For instance, in a young athlete leg cramping may be associated with dehydration, especially after intense exercise. According to Dr. Sean McCance, Orthopedic and Spine Surgeon, Mount Sinai Hospital and Lenox Hill Hospital, in the elderly population leg cramps is a common symptom of a condition called spinal stenosis. "Spinal stenosis is a narrowing of the spinal canal, which leads to compression of the nerves in the lower back. When people stand up and walk, the compression gets worse and that causes vague aching, cramping and sometimes pain and numbness in the legs." Plus, he says in general leg cramping can be a sign of poor blood supply to the legs. Typically when a patient complains of leg cramping; both a spinal exam and a vascular exam are performed.

Double Jointedness
Double-jointedness, or the ability to have flexible joints that bend in unusual ways, is also known as hypermobility. Basically, joints and surrounding structures such as ligaments and tendons are abnormally flexible which enables people to bend or rotate them in various ways. For instance, if people can bend their thumbs backwards to their wrists, this is the result of misaligned joints, abnormally shaped ends of one or more bones at a joint. Essentially, joints that stretch more than what is considered normal. The extreme flexibility signifies a wide range of movement between the bones as the result of a shallow socket, extra stretchy ligaments or bone ends that are smoother than normal.

Pins & Needles
Oooh, ahhhh, owww....when it comes to the pins and needles sensation in your legs, there could be a variety of reasons why it's occurring. Dr. Sean McCance explains, "When pins and needles is in one leg only, it is more likely related to a mechanical problem, whereas if it is in both legs, it is more likely related to a metabolic problem such as a vitamin deficiency, excessive alcohol use, or diabetes." In the setting of lower back pain he says it could be a sign of a herniated disc. This could cause symptoms including pins and needles and numbness in the leg, as well as pain and weakness. He adds, "That is best assessed by physical examination by a spinal specialist followed by an MRI."
#


--Vicki Salami/ AOL Body

Signs & Symptoms & Syndromes

1. Amenorrhea- Primary: absence of menses by age 16.
Secondary: absence of menses for 6 months in a female with previously normal menstruation, or absence of menses for 3 normal intervals with a history of oligomenorrhea.
2. Anuria- <100 ml urine/day Foley catheter.
3. Asterixis- Flapping with wrists hyperextended.
4. Babinski's sign- stroke sole of foot, & toes dorsiflex if pyramidal track lesion.
5. Battle's sign- Ecchymoses of mastoid process; basilar skull fracture.
6. Brudzinki's Sign- Neck flexion causes hip & knee flexion.
7. Carnett's Sign- Disappearance of tenderness when abdominal muscles are contracted, indicates intra-abdominal pain.
8. Chadwick's sign- cervix & vaginal cyanosis.
9. Chandelier Sign- Cervical motion tenderness.
10. Charcot's Sign/Triad-upper quadrant pain, jaundice, fever; gallstones.
11. Cheilosis- cracked lips; Riboflavin deficiency.
12. Cheyne Stokes respiration- Periodic breathing with periods of apnea (Elevated Intracranial Pressure)
13. Chvostek's sign- Tapping cheek results in facial spasm; hypocalcemia.
14. Colon cutoff sign- Spasm of splenic flexure with no distal colonic gas. (Abdominal X-ray).
15. Courvoiser's Sign- Palpable non-tender gallbladder with jaundice; pancreatic or biliary malignancy.
16. Cullen's Sign- Bluish periumbilical discoloration; peritoneal hemorrhage.
17. Cushing's Triad- Bradycardia, hypertension, abnormal respirations, ascending weakness.
18. Decerebration- Extension of legs & arms; wrists & fingers flex with midbrain & pons functioning.
19. Decortication- Noxious stimuli causes flexion of arms, wrists & fingers with leg extension, indicates damage to contralateral hemisphere above midbrain.
20. Dupuytren's contracture- Fibrotic palmar ridge to ring finger/ Palmar contracture; cirrhosis.
21. Egophony- E to A changes.
22. Fetor Hepaticas- Odor of breath & urine caused by Mercaptans.
23. Fever of Unknown Origin (FUO)- >/= 38.3*C,(>/=101*F), undiagnosed after 1 week of evaluation & extensive studies.
24. Free Air Under Diaphragm- Ruptured Viscus (CXR).
25. Glossitis- B12, folate deficiency.
26. Grey Turner's Sign- Flank ecchymoses; retroperitoneal hemorrhage.
27. Hegar's sign- Softening of uterine isthmus.
28. Hepatic angle sign- Loss of lower margin of right, lateral, liver angle (X-ray).
29. Homan's Sign- Dorsiflexion of foot elicits calf tenderness.
30. Horner's syndrome- eyelid ptosis, miosis, & anhydrosis.
31. Iliopsoas Sign- Elevation of legs against examiners hand causes pain; retrocecal appendicitis.
32. Jugular venous distention- (at 45* measure perpendicular distance from the sternal angle to top of column of blood= jugular venous pressure in cm H2O.
33. Kayser-Fleischer rings- Bronze Corneal pigmentation; Wilsons disease.
34. Kernig's Sign- Flexing hip & extending knee elicits resistance.
35. Kussmaul respirations- Deep sighing breathing
36. Levine's Sign - Patient describes pain with clenched fist over the sternum.
37. L4- S1 range or in the C5 to C7 disks- Most herniation occurs.
38. Meniere's disease: inner ear disorder involving a triad of symptoms of vertigo, tinnitus, and hearing loss.
39. Mercedes Benz Sign- Gallstones appearing as radiolucent clefts (Abdominal X-ray).
40. Moliminial symptoms- Mid-cycle ovulatory pain; premenstrual, increased discharge; breast tenderness, water retention, dysmenorrhea.
41. Muerkhe Lines- Narrow, arc-shaped bands of pallor in nail beds; hypoalbuminemia.
42. Murphy's Sign- Right Upper Quadrant Tenderness & Arrest of respiration secondary to pain/ Inspiratory arrest upon RUQ palpation; cholecystitis.
43. Myxedema- condition resulting from advanced hypothyroidism or thyroxine deficiency.
44. Normal CVP: approximately 4 to 10 cm.
45. Normal Intra Ocular Pressure: 13 to 22 mmHg
46. Normal PCWP: 4 to 13 mmHg.
47. Obtundation- Awake but not alert.
48. Obturator Sign- Flexion of right thigh & external rotation of leg causes pain in pelvic appendicitis.
49. Oculocephalic reflex- Dolls eyes maneuver, observation of eye movements in response to lateral rotation of head, no eye movements or loose movements occurs in bihemispheric (diencephalons) lesion.
50. Oculovestibular reflex- Cold caloric maneuver, raise head 60 degrees & irrigate ear with cold water, causes tonic deviation of eyes to irrigated ear if intact brain stem (midbrain); If conscious, causes nystagmus, vertigo, emesis.
51. Oliguria - <20 ml/h, 400-500 ml urine/day
52. Osler's Maneuver- Inflate cuff above systolic. If the radial artery pulse remains palpable, the true blood pressure may be 53. pH of expectorated blood- alkaline= pulmonary; acidic= GI.
54. Plummers nails- Distal onycholysis, separation of fingernail from nail bed.
55. Puddle Sign- Examiner flicks over lower abdomen while auscultating for dullness with patient on all fours; detects greater than or equal to 120 ml.
56. Pulsus paradoxus- Inspiratory drop in systolic blood pressure; >18= severe attack.
57. Racoon's eyes- Periorbital ecchymoses; skull fracture.
58. Raynaud's Syndrome- Red, blue or numb hands when exposed to cold.
59. Renal Bruits- high- pitched systolic & diastolic bruit just below costal margin lateral to midline; renal artery stenosis.
60. Rhonchi- fine, high-pitched, end-inspiratory crackles.
61. Rinne test- Air conduction last longer than bone conduction when tuning fork is placed on mastoid process.
62. Rovsing's Sign- Pressure to left colon causes referred pain at McBurneys point (RLQ); appendicitis.
63. Sentinel loop- Spasm of transverse colon (Abdominal X-ray).
64. SGOT/AST: Serum glutamic-oxaloacetic transaminase; peaks in 24 to 36 hours in MI.
65. SGPT/ ALT: Serum glutamic pyruvic transaminase.
66. Sister Joseph's Nodule- Umbilical nodule; carcinoma metastasis.
67. Spider angiomas- Arterioles with stellate red capillaries.
68. Stigmata of Liver Disease- Umbilical venous collaterals (Caput Medusae), jaundice, spider angiomas, palmar erythema.
69. Stupor- Unconscious but awakeable with vigorous stimulation.
70. Tactile fremitus- Increase vocal conduction when patient says 99.
71. Terry's nails- White proximal nail beds; cirrhosis.
72. Thumb Printing- Edema & gas of intestinal wall. (Abdominal X-ray).
73. Trousseau's sign- sign for hypercalcemia in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally.
74. TSH- T3, T3RU, T4.
75. Virchow's Triad- Immobilization, trauma, malignancy
76. Weber test- lateralization of sound when tuning fork is placed on top of head.
77. Whispered pectoriloquy- Decreased loudness of whisper during auscultation

Listening for the Sounds of Heart Failure

Recognizing Heart Murmurs on Auscultation:

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Here's the last part of the Lesson--
Lesson XXI

Health Bits

Pediatricians to FDA: No cold meds to children under 6 (CNN)---Cold and cough medicines given to infants and toddlers work no better than dummy pills and can be dangerous, pediatricians seeking to curb their use told government health advisers Thursday.

The doctors told the Food and Drug Administration advisers that the over-the-counter medicines shouldn't be given to children younger than 6 because they don't help them and aren't safe. Such a prohibition would go beyond last week's drug industry move to eliminate sales of the nonprescription drugs targeted at children under 2.

The group petitioned the FDA...


Wyeth Philippines, Inc.(ABS- CBNNews) on Thursday filed a formal notice and voluntary product withdrawal plan with the Bureau of Food and Drugs (BFAD) and Department of Health (DOH), saying it will voluntarily withdraw Dimetapp Oral Drops, the company's medicine for treatment of colds in infants. Click here for
more


Experts: Drug-resistant staph deaths may surpass AIDS toll(AP)

More than 90,000 Americans get potentially deadly infections each year from a drug-resistant staph "superbug," the government reported Tuesday in its first overall estimate of invasive disease caused by the germ.

Deaths tied to these infections may exceed those caused by AIDS, said one public health expert commenting on the new study. The report shows just how far one form of the staph germ has spread beyond its traditional hospital setting.

The overall incidence rate was about 32 invasive infections per 100,000 people. That's an "astounding" figure, said an editorial in Wednesday's Journal of the American Medical Association, which published the study.

Most drug-resistant staph cases are mild skin infections. But this study focused on invasive infections --click here




Study shows no language effects from vaccines (Reuters)--
A mercury-based vaccine preservative did not appear to affect language or other similar brain functions in children, U.S. researchers said on Wednesday in the first of a series of studies meant to lay to rest the controversy over thimerosal. More on this story


Landmark malaria vaccine clears another hurdle in tests on infants (AFP)--The most ambitious attempt to engineer a vaccine against malaria has cleared another key hurdle, with tests among African babies showing the prototype to be safe and highly protective, a study released on Wednesday said.

Known by its lab name of RTS,S the prototype is raising high hopes of the first vaccine shield against a disease that claims more than a million lives a year -- 800,000 of them African children aged under five -- and sickens hundreds of millions more.More..

Guide to Complete History Taking & Physical Examination

HISTORY IDENTIFYING DATA:
Patients name, age, race, sex; referring physician or clinic.

SOURCE AND RELIABILITY:
Name and reliability of informant (patient, old chart, relative).

HISTORY OF PRESENT ILLNESS (HPI):
Describe the course of the patients illness, including when it began, character of the symptoms; location where the symptoms began; aggravating or alleviating factors; pertinent positives and negatives, other related diseases; past illnesses or surgeries, past diagnostic testing.

PAST MEDICAL HISTORY (PMH): Past diseases, surgeries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, COPD, MI, Cancer, TB. In children include birth history, prenatal history, immunizations, type of feedings.

MEDICATIONS:

ALLERGIES:
Penicillin?

FAMILY HISTORY:
Medical problems in relatives; specifically ask about problems similar to patients illness. Asthma, MI, heart failure, hypertension, CA, TB, diabetes, kidney diseases, hemophilia.

SOCIAL HISTORY:
Alcohol, smoking, drug usage. Marital status and children; employment and home situations; exposure to carcinogens or environmental agents. In children include: Sleep, play habits, grade in school.

REVIEW OF SYSTEMS (ROS):
General:
Weight gain or loss, appetite loss, fever, chills, fatigue, night sweats.

Skin:
Rashes, bruising, skin discolorations.

Head:
Headaches, dizziness, tenderness, lumps or masses; history of seizures, head trauma.

Eyes:
Visual changes, visual acuity, visual field deficits, diplopia, inflammation.

Ears:
Tinnitus, vertigo, pain, discharge.

Nose:
Nose bleeds, discharge, sinus diseases.

Mouth & Throat:
Dental diseases, hoarseness, sore throat, pain.

Respiratory:
Cough, shortness of breath, sputum (color, amount), chest pain; history of PTB; vaccination for influenza or pneumococcus. Positive Purified Protein Derivative (PPD Testing).

Cardiovascular:
Chest pain, orthopnea, paroxysmal nocturnal dysonea; dyspnea on exertion, claudication, extremity edema.

Gastrointestinal:
Odynophagia, dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, melena, hematochezia, constipation, bloody stool, change in bowel habits, jaundice.

Genitourinary:
Dysuria, frequency, hesitancy, hematuria, polyuria, discharge, impotence, testicular masses, penile discharge.

Gynecological:
Gravida/para, abortions, LMP (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding; last pelvic exam and pap smear, breast masses, self-examination, mammography.

Endocrine:
Polyuria, polydipsia, polyphagia, skin or hair changes, cold or heat intolerance, hormonal therapy.

Musculoskeletal:
Joint pain or swelling, arthritis, myalgias.

Skin:
Easy bruising, bleeding tendencies.

Lymphatics:
Lymphadenopathy.

Neuropsychiatric:
Weakness, seizures, paresthesias, memory changes, emotional depression disturbances.

PHYSICAL EXAMINATION

Vital Signs:
Temperature, heart rate, respiratory rate, blood pressure (right and left arm, sitting and standing height), weight.

Skin:
Rashes, scars, moles; capillary refill (in seconds).

Lymph Nodes:
Cervical, supraclavicular, auxiliary, inguinal nodes; size, mobility, tenderness, consistency.

Head:
Bruising, tenderness. In pediatric patients check fontanelles.

Eyes:
Pupils equal round and react to light and accommodation (PERRLA); extra ocular movement intact (EOMI); visual fields and acuity. Fundoscopy (fundi, papilledema, arteriovenous nicking, hemorrhages, or exudates), conjunctiva; scleral icterus, ptosis.

Ear:
Discharge, acuity, tympanic membranes (dull, shiny, intact, injected, bulging).

Nose:
Discharge, exudates, polyps. Pediatrics: Nasal flaring.

Mouth & Throat:
Mucus membrane color and moisture level; oral lesions, dentitions, tonsils, erythema.

Neck:
Jugular venous distention (JVD), thyromegaly, lymphadenopathy; range of motions, masses, bruits, hepatojugular reflex (HJR).

Chest:
Equal expansion, tactile fremitus, percussion, auscultation, rhonchi, crackles, rubs, breath sounds, egophony, whispered pectoriloquy.

Heart:
Point of maximal impulse (PMI), thrills (palpable tubulance); regular rate & rhythm (RRR), first & second heart sounds (S1 & S2); gallops, murmurs (grade 1-6), pulses (grade 0-2+).

Breast:
Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia.

Abdomen:
Contour (flat, scaphoid, obese, distended); scars, bowel sound, tenderness, organomegaly, masses, liver span; splenomegaly, guarding, rebound, bruits; percussion note (tympanic), costovertebral angle tenderness (CVAT), inguinal masses.

Genitourinary:
External lesions, hernias, scrotum, testicles, varicoceles.

Pelvic Exam:
Vaginal mucosa, cervical discharge; uterus size & masses, adnexa, ovaries, suprapubic tenderness.

Extremities:
Joint swelling, range of motions, edema (grade 1-4+); cyanosis, clubbing, edema (CCE);pulses (radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses), Homans sign,; cyanosis, varicosities.

Rectal Exam:
Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood; presence or absence of stool in rectal vault, prostate (nodules, tenderness, size).

Neurological:

Mental status & affect; cranial nerves 1-12; gait, strength (graded 0-5); touch sensation, pressure, pain, position & vertigo; deep tendon reflexes (graded 0-4+) (biceps, triceps, patellar, ankle); Romberg’s test (ability of patient to stand erect with arms outstretched and eyes closed).

Cranial Nerve Exam:

I: Smell
II: Visions & Visual fields;
III, IV, VI: Pupil responses to light; positional & pursuit eye movements, ptosis.
V: Facial sensation, ability to open jaw against resistance, corneal reflex.
VII: Close eyes tightly, smile, shows teeth.
VIII: Watch tick, Weber test; Rinne’s Test.
IX, X: Palette moves in midline when patient says ah, speech.
XI: Shoulder shrug & turns head against resistance.
XII: Stick out tongue in midline. Heel to skin test.

Labs:
Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC (hemoglobin, hematocrit, WBC count, platelets, differential); X-rays, ECG, Urine Analysis (UA), liver function tests (LFTs).

MINI-MENTAL STATUS EXAM

Orientation:
What is the year, day of the week, date, month? = 5 points What is barrio, town, city, country, hospital, floor? = 5 points

Registration: Repeat: 3 objects: apple, book, coat = 3 points

Attention/Calculation: Spell WORLD backwards = 5 points

Memory: Recall 3 objects = 3 points

Language: Name a pencil & a watch = 2 points Repeat, No ifs, ands or buts = 1 point

Three stage command:
Take this paper in your right hand, fold it in half, and put it on the floor= 3 points

Written Command:
Close your eyes. = 1 point Write a sentence = 1 point

Visual Spatial:
Copy two overlapping pentagons = 1 point

TOTAL SCORE 30 POINTS

Normal: 25-30
Mild Intellectual Impairment: 20-25
Moderate Intellectual Impairment: 10-20
Severe Intellectual Impairment: 0-10

MD's Notes

Welcome to Medicine Pearls!

Below is what this blog is all about. Feel free to voice your opinions, suggestions, questions, violent reactions, etc.

Subjective:

-- Medical Education and Career Dilemmas

Objective:

--Welfare of the people in the health profession;
--career guides
-- study guides
-- white and green humor
-- true stories
--useful website links

Assessment:

-- Peer and Professional Help in day-to- day activities and practice

Prognosis:

-- Better Medical Professionals