Thursday, April 23, 2009

Interesting ECG (4)

A 50 year-old man with diabetes/ hypertension/ ischemic heart disease presented with acute onset of limbs weakness, right side more severe than left (power 3/5 and 4/5 respectively). He has otherwise no complaint of dyspnea or chest pain. History revealed that he was admitted about a month ago for an ACS (acute coronary syndrome) event. His ECG was noted to as below:



Base on the clinical scenario and the ECG, what do you think is the diagnosis?

(Answer's in comment)


Also read:
Interesting ECG (1)
Interesting ECG (2)
Interesting ECG (3)

Saturday, April 18, 2009

Always Ask Further!

Last time we talked about that some assumptions are bad. And it's true that we assume things rather often, and sometimes when we ask further, we might get some surprising answers!;)

#1
When suspecting peptic ulcer in an elderly,

Doc: "Pakcik, do you have gastric pain quite often?"
Pt: "Ya..."
Doc: "Have you passed blackish stool before?"
Pt: "Blackish? No never..."

If ask further, "So what's the colour of your stool?"
Pt: "Oh it's RED. With some blood one."

Isn't red worse than black? But patient might not be aware of it!


#2
When suspecting poor glucose control,

Doc: "Pakcik, do you take your medication?"
Pt: "Ya ya..I always remember."
Doc: "Then do you check your blood sugar at home?"
Pt: "Ya ya..the control is always good."

If ask further, "How good is your good control?"
Pt: "Oh it's always below 25 mmol/L."

Sometimes, you really need to check pt's definitions of "good control"!


#3
When suspecting orthopnea,

Doc: "Pakcik, how many pillows you use to sleep at night?" (classical standard ques)
Pt: "Oh I use two."
Doc: "How long have you been doing that?"
Pt: "Hmm almost 4 years already."

So pt's having orthopnea for 4 years?
If ask further, "Why do you use 2 pillows?"

Pt: "Oh I use one to hug and one below my head."

And all these are real scenarios. Tricky enough? ;-)

Sunday, April 12, 2009

Magic Medicine Formula (4)

Dear friends, time for some medical formulas again;) This time the topic is about poisoning. A fairly common problem to encounter in ER, as well as popular in exam questions, and more importantly, you usually can't obtain any history from the patients! So the "clues" are crucial in helping to reach the diagnosis. Below are some tips that I found useful:

Check if the patient's having:
- Respiratory depression? Think of opiates, benzodiazepine toxicity;
- Coma? Think of benzodiazepines, alcohol, opiates, barbiturates;
- Constricted pupils? Think of opiates or organophosphates;
- Dilated pupils? Think of tricyclics, amphetamines;
- Hyperthermia? Think of amphetamines, ecstacy, aspirin, cocaine;
- Tachycardia? Think of salbutamol, antimuscarinics, tricyclics;
- Metabolic acidosis? Think of alcohol, paracetamol, theophylline, methanol;
- Seizures? Think of tricyclics, phenothiazines, theophyllines.

Quick mnemonics to help in diagnosis/ management:

Think that patient with cholinergic toxicity (eg organophosphate) is "wet" and look for DUMBELS:

D - Diarrhea/ diaphoresis
U - Urination
M - Miosis
B - Bradycardia
E - Emesis
L - Lacrimation
S - Salivation

*Presentation of Glyphosate poisoning can mimic organophosphote poisoning but the management is VASTLY different - must be aware of that!

Anticholinergic toxicity, in contrast, is very "dry" and look for:
"Hot as hades, blind as a bat, dry as a bone, red as a beet, mad as a hatter"!

For tricyclic antidepressants, main presentation can be remembered as:
TCA = Three C's = Convulsion, Coma, Cardiotoxic (remember to do a stat ECG!)

For paracetamol overdose, the important King's college criteria for liver transplantation can be remembered as:
pH less than 7.3 OR all three of PCM:
P - PT>100 sec
C - Creatinine > 300 mmol/L
M - Major encephalopathy (Grade III/ IV)

Severe poisoning of certain drugs might require hemodialysis and they are BLAST:
B - Barbiturates
L - Lithium
A - Alcohol
S - Salicylates
T - Theophylline

And just to remember that the first & last alphabet i.e. Barbiturates & theophylline - hemoperfusion can be done too.

And lastly, must know the antidote for specific overdose/ poisoning and certainly not searching for books when you see a poisoning case! ;)


Related posts:
Magic Medicine Formula (1)
Magic Medicine Formula (2)
Magic Medicine Formula (3)

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