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Showing posts from March, 2011

Hypertension and ACEI/ARB

No guidelines have suggested that Angiotensin Converting Enzyme Inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB) can be given together. Yet in practice, well i should say malpractice, many doctors do prescribe both simultaneously. This is not good at all since recent trials have shown that using both together doubles the risk of hyperkalemia and doubles the level of creatinine and risk of developing ESRD within 6 months of bi therapy.


It is a benzodiazepine receptor antagonist. It acts by binding with high affinity to specific sites on the GABA receptor and thus competitively antagonises the binding of the benzodiazepine e.g. diazepam. In a case of overdose, a cumulative dose of 1-5 mg I.V given over 2-10 minutes should respond well. If sedation reappears then additional course can be repeated after 20-30 minutes.

White cap hypertension

This phenomenon has not been given its due importance. Many of us surely know the term 'White Coat Hypertension'. The latter refers to an increase of up to 20 mm Hg in the systolic blood pressure of the patient if a doctor is taking the B.P measurement. 'White Cap' actually refers to the cap of the nurses. It was compulsory in the 1980s and still worn in many settings. It was seen that when nurses take the B.P then also there was an increase of up to 10 mm Hg of the systolic blood pressure compared to a home setting. Since in our setting it is the nurse who takes the B.P measurement, then the above named term is more appropriate. Also another conclusion from this is that doctors are scarier than nurses. :-)

Body surface area mesurement

Various formulas exist to estimate the body surface area, the simplest one being that published by Mosteller in the NEJM in 1987. The formula goes like this. . . The refe rence value for an adult is considered to be 1.73  m². A proteinuria of at least 3.5 g/ day/1.73  m² BSA   is considered diagnostic for nephrotic syndrome. 

Stroke risk after T.I.A

The scoring system used is the ABCD score. A - Age : 1 pt for age > 60 yr B - Blood pressure : 1 pt for B.P > 140/90 mmHg C - Clinical features : 1 pt for speech disturbance without weakness,                                  2 pts for unilateral weakness D - Duration of symptoms : 1 pt for 10-59 min,                                           2 pts for > 60 min       Diabetes : 1 pt if present. Low risk : 0-3 pts Moderate risk : 4, 5 pts High risk : 6, 7 pts

Back to the roots.

A Short History of Medicine 2000 B.C. - "Here, eat this root." 1000 B.C. - "That root is heathen, say this prayer." 1850 A.D. - "That prayer is superstition, drink this potion." 1940 A.D. - "That potion is snake oil, swallow this pill." 1985 A.D. - "That pill is ineffective, take this antibiotic." 2000 A.D. - "That antibiotic is artificial. Here, eat this root."

H. Pylori - diagnosis and treatment

We usually use the serological test ( anti H. Pylori anti bodies ) to test for the presence of the micro organism in our setting. But unfortunately this least expensive method is also the least accurate one. The sensitivity of this test is 85% while its specificity is only 79%. The more accurate tests with a sensitivity and specificity of around 95% include: 1) Urea breath test, 2) Fecal antigen test. N.B: Sensitivity refers to the % of ill persons who are correctly identified as having a particular disease. Specificity refers to the % of healthy persons who are correctly identified as not suffering from a particular disease. Treatment: Eradication treatment that we usually use includes a PPI (proton pump inhibitor) and 2 antibiotics for 14 days, the regimen with the greatest proven efficacy. It includes: 1) Cap Omeprazole 20 mg B.D + 2) Tab Clarithromycin 500 mg B.D + 3) Cap Amoxicillin 1 g B.D or Tab Metronidazole 500 mg B.D if allergic to amoxicillin.

Hypertension and microalbuminuria

Microalbuminuria is defined as a level of 30-300 mg of albumin in the 24 hr urine sample. Usually albumin is not present in urine. Instead of 24 hr urine, the simpler test we do in casualty is urine dipstick in a spot sample of urine. If we get a result of 1+ to 3+ it is considered as microalbuminuria. The clinical implication of this is that it indicates early renal damage in the HBP patients. So don't forget urine dipstick in HBP patients.


A person can be labelled as prediabetes patient if he has: 1) A Fasting Plasma Glucose (FPG) of 5.6-6.9 mmol/L or 2) An Oral Glucose Tolerance Test (OGTT) of 7.8-11.0 mmol/L or 3) An HbA1c of 5.6-6.4%. The implication of this group of persons is that in the next 5 yr, it has 40% chance to get into the diabetic group. A good diet, regular exercise, weight loss, control of blood pressure is recommended for these patients.

Pretibial myxedema

It is also called as thyroid dermopathy. It is characterised by localised skin lesions in the pretibial region. This is due to the deposition of hyaluronic acid in the dermis. O/E: Lesions are usually asymmetrical, bilateral, firm and non-pitting type of edema.

Somogyi phenomenon

It refers to the hyperglycemia that occurs by counter regulatory hormones in response to hypoglycemia induced by insulin. This is most commonly observed as morning hyperglycemia. The problem with this phenomenon is that we will have a tendency to increase the evening dose of insulin to try to decrease the morning hyperglycemia but in doing so we will induce more severe hypoglycemia at night and it will be detrimental for the patient. The counter regulatory hormones include: 1) Glucagon 2) Epinephrine 3) Cortisol 4) Growth hormone. Another cause of morning hyperglycemia is hypoinsulinemia resulting from the dawn's phenomenon.

Dexamethasone and asthma

Studies showed that a 2-day course of dexamethasone is as effective as a 5-day course of prednisolone in the treatment of mild to moderate asthma. Both drugs have the same bioavailability (fraction of an administered dose of unchanged drug that reaches the systemic circulation) but the half life of prednisolone varies between 8-24 hr while that of dexamethasone ranges between 32-72 hr.