family medicine uitm: 2011

Sunday 16 October 2011

The Cardiology Clinic

17 years old malay lady was referred to the cardio clinic for valve replacement therapy. She is a known case of .

In the social history, she just finished her SPM and is just staying at home with her parents. Her father is a fisherman and mother is a housewife
Admitted in July 2011 for:
1) B-Thallasemia Intermediate
　
　
2) Congenital Heart Disease in failure complicated by ventilator assisted pneumonia, sacral sore and pneumothorax
ECHO (July 2011): Thickened valve leaflets, mod AR and severe MR with valve prolapse
Tracheal Aspirate (7/7/2011): Burkhodelia cepasia
rpt culture @ 11/7/2011: burkhedellia cepasia
rpted culture on 14/7/2011: <RSA
latest TA @ 18/7/2011: no pathogen isolated
　
　
3) Right foot drop ? secondary to malpositioning whilst intubated
doing physiotherapy under rehab HSB
　
　
　
　
pt was admitted to Hospital Tanjung Karang initially for anemia
she was transfused at least 4p PC - she was told that she had thallasemia and the other family members need to be screened for it
　
　
she also complained of cough, fever, SOB and generalised edema
later on, she was transferred to HSB in view of worseining anarsace (generalised edema) where she was intubated for more than 1mth --> initially intubated then put on tracheostomy
She was treated with frusemide as inpatient
　
　
She was discharged well on T captopril 25mg BD, T metoprolol 25mg BD and hemetinics.
Currently she denied any SOB, palpitation or leg swelling
She claim to have on and off chest pain - can be at rest or on exertion
　
　
BO/ PU as normal
no diarrhea/ vomitting
no fever/ fits/ faints
　
　
　
　
　
Social & Occupational History
mother and father - not govn servants, father is a fisherman
4/8 siblings
born SVD at term - was well till age 11 years old
She presented at 11 years old with rapid breathing --> was seen in Hospital Tanjung Karang then transferred to Hosp Klang --> sb IJN for heart problem - was told that it was too early for a valve replacement therapy
　
　
3rd child - bowel operation on D2 of birth ? intussusception, currently well
no FHx of congenital heart disease
Physical ExaminationGeneral Examination
　
alert
mild pallor
small build
finger clubbing+
walking with a limp - pt not wearing her splint for the right foot drop
　
　
　
　
BP 123/ 78
HR 88bpm reg
Collapsing pulse +
no radio - radial or radio-femoral delay
JVP not raised
no stigmata of IE
　
　
Lungs: clear, no crepitations
CVS: Thrills palpable over the precordium, Apex displaced at 6th ICSMCL
HS I + II + PSM heard loudest at the LSE, radiating to the axilla
Right foot drop with reduced sensation up to right ankle
　
　
[amended >>]ECG: SR noa cute ischemic changes[<< amended]　
　
Plan: (s/b Dr Zaidi)
to rpt ECHO at Sg Buloh UiTM today
TCA Cardio x1/12
cont captopril and metoprolol - already have a one months supply
TCA nearest hospital if condition worsen
　
　
Zahirah

70 years old lady
　
　
kc
HPT
DM
non smoker, no alcohol
FHx:
3/4 siblings
all brothers and sisters have DM/ HPT
one brother died from CCF
father - has DM/ HPT/ IHD/ CVA
mother - no known medical illness
　
　
Medications: No allergies
Aspirin 150mg OD
Plavix 75mg OD
Frisemide 20mg OD
Glicazide 40mg BD
Metformin 1g BD
Isosorbide dinitrate 10mg TDS
Simvastatin 20mg ON
Trimetazidine 2mg TDS
　
　
referred from HSB for angiogram
　
　
Admitted to HSB on 27/9/2011 for Unstable angina
presented with sudden onset of heavybess oveer the central chest at rest a/w giddiness and sweating
　
　
blood Ix at HSB:
FBC - wcc 9 hb 13.6 plt 307
RP: Ur 4.6 Na 138 K 4.2 Cr 49
FBS: 7.2
Hba1c 10.6%
TFT - T415 TSH 1.03
TG 1.31
LDL 3
HDL 1.16
Tot chol 4.78
　
　
Hep Bs Ag non reactive
Hep CV Ab non reactive
HIV non reactive
　
　
ECHO @ 29/9/2011:
Chambers size: normal sizes
LV contraction: Bradycardia
Valve morphology: mild tricuspid regurgitation with PASP 22mmhg
LVH/ ASH/ SAM: LVH 1.6cm
Conclusion: EF 56%
　
　
Since discharged from HSB, no more chest pain/ SOB/ leg swelling
c/o neck pain under physio for ? cervical spondylosis
　
　
OE:
alert
pink
not tachypneic
Lungs: clear
CVS: HS I + II + no added sounds
no pedal edema
　
　
ECG - SR, T inv I, aVL, V2 - V6
　
　
Plan: (s/b Dr Zubin)
for angiogram on 1/11/2011 - pt agreeable
for GSH
keep NBM after light breakfast @ 6am
withold OHA prior to angiogram - pt informed
consent form signed
TCA cardio clinic after angiogram
　
　
Zahirah
　Cardio clinic check list:
1) Explore and address the pt's general complaints
2) Explore pt's ICE
3) Explore and address pt's complaints specific to his condition
4) Explore pt's drug compliance
5) Explore any drug side effects
     -minor side effects: reassure, provide symptomatic relieve and encourage pt to continue treatment
                                  if still not relieved, withraw the tx
     -major side effects: ask specifically about drug toxicity
6) Reinforce pt's knowledge on TB and TB Tx
7) Safety Netting

The Respi Clinic

65 years old chinese gentleman turned up at the Respi clinic as he developed generalised itchy maculopapular rashes on D8 of the treatment. He was then admitted for reintroduction of anti TB following the onset of adverse reactions on Akurit 4 + pyrodixine.
TB clinic check list:
1) Explore and address the pt's general complaints
2) Explore and address pt's complaints specific to his condition
3) Explore pt's ICE
4) Explore pt's drug compliance
5) Explore any drug side effects
     -minor side effects: reassure, provide symptomatic relieve and encourage pt to continue treatment
                                  if still not relieved, withraw the tx
     - Rifampicin (R)
        Isoniazid (H)
       Pyrazinamide (Z)
       Ethambutol (E)
       Streptomycin (S)
     -major side effects: ask specifically about drug toxicity
     -double check on drug interactions:
       Rifampicin: Liver Enzyme Inducer - drug plasma level decrease secondary to increase drug metabolism
                                                             OHA, OCP, Oral anticoagulat (warfarin), Cyclsporin,
                                                             Corticosteroids, Cimitedine, PI, Phenytoin, digitalis glycosides,
                                                            theophylline (Oral, Cs, Ps)
       Isoniazide: Liver Enzyme Inhibitor - drug plasma level increased secondary to decrease drug metabolism
                                                              Phenytoin, CBZ
6) Reinforce pt's knowledge on TB and TB Tx
     -dietry
     -excercise
     - herbal medicine
7) Safety Netting

59 years old obese lady referred to respi clinic TRO OHS (Obesity hypoventilation syndrome) with overlapping OSA. She has the following problems:
1) DM/ HPT
2) Decompensated CCF
3) TRO OHS with overlapping OSA
4) TRO COAD/ adult onset BA: previously working in a painting factory dealing with chemicals for many years and was involved in spraying chemical compounds. She developed sx of SOB with wheezing after stopped working 5 years ago which has become more frequent since the past 2 years. No positive FHx of BA, and there was no obvious PEFR reversibilty seen in the ward.

Investigations done:
HRCT: no evidence of intistial fibrosis
Lung function test: severe restriction
ECHO: poor window dt very obese pt, Mild MR and Mild TR, EF: 56%
ECG: poor R wave progression
ABG: Respiratory acidosis with Type 2 RF (ph 7.318 pco2 59 po2 47 hco3 25.4

Medications:
MDI combivent 2 puffs TDS
MDI seretide 2 puffs BD
montelukast 10mg ON
perindopril 4mg OD
metformin 1g BD
frusemide 40mg OD
aspirin 150mg OD
SR neulin 250mg OD
atorvastatin 40mg OD
Bromohexine 8mg TDS
SC actrapid 16u TDS
SC insulatard 26u ON

Chest clinic checklist:
1) Explore and address the pt's general complaints
2) Explore pt's ICE
3) Explore and address pt's complaints specific to his condition
    ESS
    Mallampati score
4) Explore pt's drug compliance
5) Explore any drug side effects
6) Reinforce pt's knowledge on her condition and current treatment
     -dietry
     -excercise
     - herbal medicine
7) Safety Netting

Saturday 8 October 2011

NADI 2011

THE INCRETIN STORY -Evolving From Science to Clinical Practice

DIABETES AND RAMADHAN - Balancing glycemic control during Ramadhan

HYPOGLYCEMIA

DIABETES IN CKD

Thursday 28 July 2011

ABG SAVES LIVES

http://orlandohealth.com/MediaBank/Docs/SLP/2010%20ABG%20SLP.pdf

The Normal Values:

pH: 7.35 - 7.45
pCO2: 35 - 45mmHg/ 4 - 6
pO2: 80 - 100mmHg/ 10 - 13
HCO3: 22 - 26mmHg
BE: +/- 3mEQ

Cellular Metabolism

HCO3- + H+ --> CO2 + H2O

The by-product of cellular mechanism is CO2 and H2O
CO2 is carried from the blood to the lungs
Excess CO2 will combine with H2O to produce H2CO3 (Carbonic Acid)
Why is it important to maintain normal cellular metabolism?
The shift of equation in to maintain the normal body pH:

CO2 will change the pH in the opposite direction (CO2 increase, PH decrease)
HCO3- will change the pH in the same direction (HCO3- increase, pH increase)

Interpretation of ABG:

ABG provides information on the pt's:

Oxygenation status
Acid-base balance status

Acid-Base Balance

Normal PH range : 7.35 - 7.45
This narrow normal PH range need to be maintain for normal cellular metabolism to take place
pH less than 6.8 and more than 7.8 is not compatible with life
Two main organs that are involved in the acid-base balance are the kidneys and the lungs
The body maintains the normal PH range by two buffering mechanisms/ systems:

Lung/ Respiratory buffer response (Respiratory Compensation)
Renal/ Metabolic buffer response (Metabolic Compensation)

Respiratory (Lungs) Buffer Response

Respiratory compensation takes 1-3min
The level of carbonic acid will eitrher increase/ decrease the rate and depth of ventilation until appropriate CO2 level is re-established
How does the carbonic acid increase/ decrease the rate and depth of ventilation? What is the underlying mechanism?

Metabolic (Renal) Buffer Response

Metabolic compensation will take hours to days
In the effort to maintain normal pH in the blood, the kidney either excrete or retain HCO3-
When the pH rises, the kidney will compensate by excreting HCO3- in the urine
When the pH decreases, the kidney will compensate by retaining HCO3-
What is the role of haemodyalisis in acid-base balance?

Oxygenation status in ABG

The component of ABG used to evaluate the blood oxygenation is paO2
Why is the pO2 lower then the sO2 in certain circumstances? The answer lies behind the Oxyhaemoglobin Dissociation Curve.
Type I Respiratory Failure
Type 2 Respiratory Failure

Respiratory Acidosis

Low pH, High pCO2
Differential Dx
Management

Respiratory Alkalosis

High pH, Low pCO2
Differential Dx
Management

Metabolic Acidosis

Low pH, Low HCO3-
Differential Dx
Management

Metabolic Alkalosis

High pH, High HCO3-
Differential Dx
Management

Compensation

In the event of an acid-base imbalance, the body attempts to compensate via two primary buffering response system which is the lungs and the kidneys
The aim is to restore the body normal pH for optimal cellular metabolism to take place
Compensation can be divided into:

Uncompensated

either the respiratory or metabolic component is abnormal, not both
pH is abnormal

Partially compensated

both the respiratory and metabolic components are abnormal
pH is abnormal

Fully compensated

both the respiratory and metabolic components are abnormal
pH is within the normal range
pH = 4 is the normal range

In compensation, we need to know:

are we dealing with acidosis or alkalosis
which system is the primary problem
which system is compensating

Mixed Respiratory and Metabolic Acidosis

Low pH
High pCO2 and Low HCO3-

Mixed Respiratory and Metabolic Alkalosis

High pH
Low pCO2 and High HCO3-

Chronic and Acute changes in ABG

Metabolic compensation takes hours to days
Respiratory compensation takes 1-3mins
Hence, a Full metabolic compensation indicates a chronic problem whereas a Full respiratory compensation indicates an acute problem

Other issues in ABG interpretation

What is the expected pco2 calculation in metabolic and respiratory acidosis?
What is the role of Anion Gap calculation in metabolic acidosis?
What is the role of Base excess calculation?
False results in ABG
Is it important to differentiate between a venous or arterial blood sample in ABG interpretation? How to differentiate between venous and arterial blood gases? How does this effect the ABG result interpretation? - regardless of whether it is venous or arterial, if pco2 is high - need to hyperventilate the patient, don't wait to repeat the ABG.

	7.35 – 7.45
pH	7.29	ACIDOSIS
pCO2	30	ALKALOSIS
HCO3-	18	ACIDOSIS
PARTIALLY COMPENSATED METABOLIC ACIDOSIS
pO2	80	LOW
pCO2	60	HIGH
TYPE 2 RESPIRATORY FAILURE

Wednesday 20 July 2011

CLINICAL PRACTICE GUIDELINES

MALAYSIA
1) Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus
http://www.mems.my/file_dir/8744697374dc0e0db6586e.pdf
2) Academy of Medicine
http://www.acadmed.org.my/index.cfm?&menuid=67

WHO GUIDELINES

NICE GUIDELINES

References

1. http://www.mimsonline.com/mimsonline/

drugdetails.aspx?id=2398&dcname=My&SearchTy

pe=Brand

2. http://www.nlm.nih.gov/medlineplus/druginfo/

medmaster/a698009.html

3. http://www.medicinescomplete.com/mc/

martindale/current/17634-v.htm#m17634-a3-y

4. http://www.drugdigest.org/DD/DVH/Uses/

0,3915,352|Irbesartan,00.html#interactions

CPG TYPE 2 DM Fourth Edition - 2009, CPG INSULIN THERAPY

Issues:
1) Hypoglycemia secondary to dilutional hypeglycemia
2) Tight Glycemic control in MI patients
3) Initiation of treatment in newly dx type 2 DM - OHA and Insulin
4) Insulin dose adjustment

A 50 years old gentleman presented to ED HSB with sudden onset of central chest discomfort radiated to the back, shoulder and left arm associated with sweating. pain relieved post Streptokinase

RF:
Smoker 15-20/ day for 30 years
HPT
Strong FHx
newly dx Type II DM

Background Hx:
HPT on T Atenolol 50mg BD
Staghorn calculus with renal impairment in 2008
Gout on NSAIDS

In the ward:
T lovastatin 20mg ON
T isordil 10mg TDS
T aspirin 150mg OD
T plavix 75mg OD
T carvidelol 3.125mg BD
Sc insulatard 10u ON
T metformin 500mg BD

Blood Ix: 18/7/2011
CK 317 (30-200)
LDH 467 (125-220)
AST 48 (5-34)

FBC: wcc 10.67 (4-11) hb 15.4 (13-17) plt 109 (110-450)
Lipid (mmol/l)
TG 14.06 (Lipaemic sample)
LDL 7.74
HDL 0.7
Tot Chol 14.84

HbA1c 11.9%

RP
Ur 6 (3.2 - 7.4)
Cr 144.9 (62 - 115)
Na 126 (136-145)
K 3 (3.5-5.1)

LFT
TP 67 (64 - 83)
Albumin/ Globulin ratio 0.76
Bili 14 (3.4 - 20.5)
ALT (42)
Albumin 29 (35-50)
ALP 80 (40-150)
Cl 92 (98-107)

RP 19/7/2011
Ur 5.9 (3.2 - 7.4)
Cr 154 (62 - 115)
Na 131 (136-145)
K 3.3 (3.5-5.1)
Cl 93

RP 21/7/2011
Ur 6.4 (3.2 - 7.4)
Cr 156 (62 - 115)
Na 131 (136-145)
K 3.3 (3.5-5.1)

Albumin 30
GGT 133.9 (5-85)
-------------
Baseline RP:
Feb 2009 ur 11.5 Cr 328 UA 695
(presented to uro with Left staghorn calculi)
RP within x1/52: ur 7.5 Cr 155

CXR @20/7/2011
Mild cardiomegaly

ECHO @ 21/7/2011

ADJUSTING/ TITRATING INSULIN DOSE
http://www.mems.my/file_dir/8744697374dc0e0db6586e.pdf
Insulin Therapy - adjusting the dosage
http://www.fpnotebook.com/Endo/Pharm/InslnDsng.htm
http://tde.sagepub.com/content/32/1/19S.full
blood glucose conversion table
http://www.bcchildrens.ca/NR/rdonlyres/841862E6-5AE1-4938-A479-E6C38D615EA3/20417/glucoseunits.pdf
diabetes mx in ramadhan
http://www.medscape.com/viewarticle/412367
http://www.diabetes.org.my/article.php?aid=636
dm in children
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5189
pt information
http://www.uptodate.com/contents/patient-information-diabetes-mellitus-type-2-insulin-treatment
initiating treatment
http://care.diabetesjournals.org/content/32/1/193.full
practice guideline for type 2 dm
http://www.diabetes.org.my/file_dir/138985421945a7495312db5.pdf
titrating insulin
http://clinical.diabetesjournals.org/content/27/2/72.full
http://clinical.diabetesjournals.org/content/23/2/78.full
Dilutional effect of hyperglycemia

CPG STEMI 2007 (Second Edition)

Cardiovascular deaths account for 20 - 25% of total death in govn hospital from 2000-2005
The high mortality is probably due to delay presentation, delay diagnosis resulting in delay treatment
Death most frequently occur soon after the onset of symptoms = Pre-hospital phase
Trials have shown that early reperfusion therapy results in myocardial salvage --> sig reduction in morbidity and mortality
Hence, need to educate the public regarding the sx and the need to present to hospital early
Also need to train the ED on the best way to deal with STEMI
ACS=Unstable angina, STEMI, NSTEMI --> indicates ongoing myocardial ischemia

Unstable angina/ NSTEMI: Acute Subtotal occlusion of the coronary artery
STEMI: Acute Total occlusion of the coronary artery (Transmural)

ACS is most often caused by atherosclerotic occlusion of the coronary arteries (ruptured, fissured, ulcerated on top of thrombosis and coronary vasospasm)
Rarely, non artherosclerotic occlusion (coronary vasospasm alone, coronary embolism/ vasculitis) causes ACS
Typical chest pain --> ECG: no ST elevation --> cardiac biomarkers --> normal: Unstable angina

high : NSTEMI

--> ECG: ST elevation --> STEMI

Criteria for STEMI:
ECG Changes:

Evolution of ECG changes (time frame - immediately post occlusion --> weeks --> moths --> years):

Hyperacute T waves/ Peaked T waves due to localized hyperkalemia
ST segment elevation at the J point - Concave appearance
ST segment elevation become more pronounced - change in morphology to convex, rounded upwards
ST segment elevation may become indistinguishable from T wave
Q wave develops (indicates irreversible myocardial death) with loss of R wave amplitude as the ST segment elevates
within x2/52 post MI:

ST segment returns to the isoelectric baseline
Deepen Q wave
T wave inversion
Reduced R wave amplitude

Pathophysiology of Myocardial Infarction:

Acute total occlusion of the coronary artery secondary to atherosclerotic or non atherosclerotic occlusion (rare) leads to myocardial necrosis
Sequale of event post occlusion

Evolution of ECG changes in correlation with the cardiac biomarkers
The ECG leads effected depends on the location of infarct

Coronary artery anatomy

Left main stem and Right Coronary Artery arises from the ostia of the aortic valve
Left main stem divides into the Left Circumflex artery (LCX- supply) and the Left Anterior Descending Artery (LAD - supply the 2/3rd of the anterior interventricular septum and the anterior part of the heart)
RCA divides into the Posterior Descending Aretry (PDA - supply the psoterior interventricular septum). RCA supplies the SA node, AV node and Inferior border of the LV

ECG changes:

Inferior AMI
Anteroseptal AMI
Anterolateral AMI
Right sided Involvement
Posterior Involvement

Complications of Myocardial Infarction
Treatment of AMI:

Immediate
Post MI management: Physiorapist, cardiac rehab nurse referral
Cardiac RF management:

BP control (how vigorous)
Blood gluscose control - Dietician referral
Hyperlipidaemia

Cardiac Rehabilitation

Advice to Post MI patients (The Do's and Dont's)

Anatomy of the Heart
http://www.wisc-online.com/objects/ViewObject.aspx?ID=AP12504

ECG: http://lanoswww.epfl.ch/personal/schimmin/uni/ecglex/ekg.htm

ECG: Eclectrocardiogram
Records the electrical activity of the heart from the electrodes placed on the skin in specific locations
Indications:
Procedure:

ECHO:

Indications:
Procedure:
Interpretation:

Anatomy: https://www.healthbase.com/hb/pages/cardiac-surgery.jsp
Pathophysiology of Atherosclerosis

Risk fc for artherosclerosis

HIV

http://library.med.utah.edu/WebPath/AIDS2011.PDF
http://ww1.cpa-apc.org:8080/publications/HIV/ment-ill.pdf
http://www.academicjournals.org/ijpc/PDF/Pdf2009/Nov/Moosa%20et%20al.pdf
http://schizophreniabulletin.oxfordjournals.org/content/23/4/675.full.pdf
http://apps.who.int/gb/ebwha/pdf_files/EB124/B124_6-en.pdf
http://www.ncbi.nlm.nih.gov/pubmed/11495342
www.who.int/gb/ebwha/pdf_files/EB124/B124_6-en.pdf

Psychosocial Aspects of

CASE COMMENTARY
MEDICINE
The Untold Story

Table of Content

Abstract

HIV/ AIDS should not be taken lightly as it as a huge psychocosial implication both on the patient and the society - the public's perception - if you are HIV positive, you are dirty, if the country have a high prevalence of HIV, reflects that the society is morally degaraded ... (bad)

Epidmic/ Prevalence of HIV in normal subjects and in mentally ill pts and in schizophrenioa

Mental disorders, including substance use disorders, are risk factors for contracting HIV, and
the presence of HIV/AIDS increases the risk of development of mental disorders.

So, did the pt develop HIV first then Schizophrenia, or the other way around

Not only the psychoscial implication, health also it at risk - opportunistic infection, tumor risk, multi organ disease/ involvement --> can affect child, husband, other workers, pregnant

HIV and AIDS are commonly percieved by the public as two similar entities. But in actual fact, HIV and AIDS are somewhat rather different in terms of .. although they share the same ...

When it comes to dealig with HIV and AIDS in the community, there are many sensitive issues that needs to be addressed by the Primary Care Physicians. Sensitrive issues starts from the pre test to post test - hence pre test and post test counselling is important to deal with the sensitiviteis related to HIV. AIDS

Psychosocial implications of Dx someone with AIDS/ HIV...

The sequale of Dx AIDS/ HIV

Stigma underlying HIV/ AIDS

Medicolegal issues - notify, contact tracing, notify spouse/ partners/ family members - medicolegal issues with respect to HIV in mentally ill pt when it comes to notification

HIV in mentally ill patient - how to prevent transmission, how to do contact tracing when history is not reliable

pre and post test counselling in mentally ill pt

Support groupd for HIV with mental illness/ schizophrenia

Should HIV test be routinely done for schizophrenia/ metally ill pt? is it going to be cost effective.

Risk reduction programme/ measure

Introduction

Her Story

fleeting history - initially the way she answers questions and tells her story sounds very convincing. However, conflicting hx from day to day, from one dr to another intrigued me to find out the true story from her family members

Seeking for the true story somehow was challenging - very seldom we see the family members around

After they knew the dx, more family was seen at her bedside

Hx from younger sibling -

Hx from elder sibling -

Hx from sibling staying with her -

The Real Story

family's perception - first impression, initial reaction to the dx, response x1/52 later

family's concern

Case Examinations and Investigations

Case Management and Plan

Patient's ideas, concerns and expectation

patient's perception/ understanding of HIV and AIDS

family's perception/ understanding of HIV and AIDS

Issues to discuss/ Problem list

Discussion

The appropriateness of the term Sexual promiscuity (what seems promiscious to someone might not be promiscious to others with different religion and beliefs) vs High risk behaviours

AIDS and HIV are used interchangeably in the society. AIDS and HIV have their own meaning

Conclusion

References

CHAPTER 1 - HUMAN IMMUNODEFICIENCY VIRUS 6
INTRODUCTION 6
BIOLOGY OF HUMAN IMMUNODEFICIENCY VIRUS 8
OTHER HUMAN RETROVIRUSES 21
EPIDEMIOLOGY OF AIDS 24
RISK GROUPS FOR HUMAN IMMUNODEFICIENCY VIRUS INFECTION 32
NATURAL HISTORY OF HIV INFECTION 33
PROGRESSION OF HIV INFECTION 37
IDIOPATHIC CD4+ T-LYMPHOCYTOPENIA 41
PREVENTION OF HIV TRANSMISSION 42
TREATMENT FOR AIDS 44
CHAPTER 2 - DIAGNOSIS OF AIDS 57
DIAGNOSTIC TESTS FOR HUMAN IMMUNODEFICIENCY VIRUS 57
PEDIATRIC HIV INFECTION AND AIDS 76
CRITERIA FOR AIDS-RELATED COMPLEX 80
OTHER CAUSES OF IMMUNOSUPPRESSION 81
CHAPTER 3 - OPPORTUNISTIC INFECTIONS IN AIDS 82
PNEUMOCYSTIS JIROVECI (CARINII) INFECTIONS 82
CYTOMEGALOVIRUS INFECTIONS 86
MYCOBACTERIAL INFECTIONS 88
CRYPTOCOCCUS NEOFORMANS INFECTIONS 95
HERPESVIRUS INFECTIONS 97
CANDIDA INFECTIONS 101
Page 4
TOXOPLASMA GONDII INFECTIONS 104
HISTOPLASMA CAPSULATUM INFECTIONS 106
COCCIDIOIDES IMMITIS INFECTIONS 108
GASTROINTESTINAL PROTOZOAL INFECTIONS 109
BACTERIAL INFECTIONS SEEN WITH AIDS 112
CHAPTER 4 - NEOPLASMS ASSOCIATED WITH AIDS 121
KAPOSI’S SARCOMA 121
MALIGNANT LYMPHOMAS 124
OTHER NEOPLASMS 129
CHAPTER 5 - ORGAN SYSTEM PATHOLOGY IN AIDS 131
RESPIRATORY TRACT PATHOLOGY IN AIDS 131
GASTROINTESTINAL TRACT PATHOLOGY IN AIDS 149
CENTRAL NERVOUS SYSTEM PATHOLOGY IN AIDS 164
PERIPHERAL NERVE AND MUSCLE PATHOLOGY IN AIDS 181
OPHTHALMIC PATHOLOGY IN AIDS 188
LYMPH NODE PATHOLOGY IN AIDS 191
BONE MARROW AND PERIPHERAL BLOOD IN AIDS 198
THYMUS IN AIDS 202
ENDOCRINE ORGAN PATHOLOGY IN AIDS 203
HEPATOBILIARY SYSTEM PATHOLOGY IN AIDS 206
CARDIOVASCULAR PATHOLOGY IN AIDS 212
GENITOURINARY PATHOLOGY IN AIDS 217
DERMATOPATHOLOGY IN AIDS 224
PANCREAS IN AIDS 236
PREGNANCY AND THE PLACENTA IN AIDS 238
Page 5
HEAD AND NECK PATHOLOGY IN AIDS 239
BONE, JOINT, AND SOFT TISSUE PATHOLOGY IN AIDS 241
CYTOPATHOLOGY IN AIDS 244
PEDIATRIC AIDS 245
CHAPTER 6 - SAFETY PROCEDURES WITH AIDS 251
EDUCATIONAL GOALS 251
UNIVERSAL PRECAUTIONS 252
OSHA REGULATIONS 253
OCCUPATIONAL AND NON-OCCUPATIONAL HIV EXPOSURES 257
INVASIVE AND SURGICAL PROCEDURES 260
THE SURGICAL PATHOLOGY LABORATORY 262
THE AIDS AUTOPSY 263
MORTUARY AND FORENSIC LABORATORY PROCEDURES 264
ATHLETICS AND HIV INFECTION 266
CHAPTER 7 - MEDICOLEGAL ISSUES AND AIDS 269
DEATH INVESTIGATION AND CERTIFICATION IN AIDS 269
DETERMINATION OF CAUSE AND MODE OF DEATH WITH HIV INFECTION 269
ETHICAL ISSUES ARISING FROM THE AIDS EPIDEMIC 272
HIV TESTING AND COUNSELING 274
BLOOD AND TISSUE BANKING AND AIDS

Research is urgently needed to adequately respond to the AIDS epidemic among
people with persistent and recurrent psychiatric disorders such as schizophrenia,
depression or bipolar disorder. This program announcement (PA) is sponsored by
the NIMH to stimulate investigator-initiated research that targets persons with
severe mental illness (SMI) either before or after HIV infection. It solicits
studies on the SMI population that address the epidemiology of HIV infection,
epidemiology of sexual and drug-use risk behaviors and other relevant risk
behavior patterns, risk reduction and transmission prevention interventions,
treatment of mental illness and the neuropsychiatric sequelae due to HIV
infection, service provision research or other issues relevant to persons with
SMI. An important objective of this PA is to encourage integration both across
and within these different areas and the translation of these research findings
to applied mental health and public care systems. Multidisciplinary research
teams and collaborative alliances are encouraged.

review. Data
from a dozen or so studies conducted since 1990 confirm
and strengthen the impressions that persons with
schizophrenia should be considered a group with a
much higher than average risk for developing
HIV/AIDS and that they have special needs for protection
as a public health measure. Mental health service
providers need to be aware of these findings.
Schizophrenia Bulletin, 23(4):675-684,1997.

Ana-Maria Schweitzer, MA

Michael B. Mizwa

Michael W. Ross, MA, PhD, MPH

HIV/AIDS: Adults

INJECTIONS

IV CANNULA
IM
LONG LINE
SHORT LINE
FEMORAL CATHETER

Blood Taking Procedures

TIPS ON BLOOD TAKING PROCEDURE:

Introduce yourself
Consent

Explain the reason for the procedure
Explain the procedure
Explain the risk of the procedure
Ask for any allergies to elastoplast
Obtain patient's consent to undergo the procedure - verbal/ written

Positioning

Make the patient comfortable
Position the patiet according to standard guidelines

Blood Taking Procedures can be viewed in the following videos:
http://www.wonderhowto.com/how-to-draw-blood-with-standard-venepuncture-procedure-235565/

http://library.med.utah.edu/WebPath/TUTORIAL/PHLEB/PHLEB.html#2

Follow the safety and infection control procedures - PROTECT YOURSELF AND PROTECT YOUR PATIENTS
Organization of blood collection:

Test order/ request form from Clinician
Phlebotomy Supplies and Labels
Patient Identification: Perform 2 patient ID

Outpt: Ask Name and DOB
Inpt: Compare Name and MRN on ID bracelet with EACH label

Tourniquet Application

Apply tourniquet 3-5 inches away from the intended puncture site
Do not leave the tourniquet on for more than 1min --> can lead to Haemolysis
Ask the pt to tighten their fist and NOT to pump their fist as this can increase K+ and ionized Ca2+ levels
Let the alcohol dry first before puncturing --> otherwise can lead to Haemolysis

Vein Selection and Dilatation

Choose appropriate site - the median cubital and cephalic veins are most frequently used
Allow 10-15min post transfusion before obtaining a blood sample
The vein must be held in place for successful needle penetration
Palpate and trace the path of veins with the index finger
Arteries pulsate, are most elastic, and have a thick wall
Thrombosed veins lack resilience, feel cord like, and roll
easily
If superficial veins are not readily apparent, you can force
blood into the vein by massaging the arm from wrist to
elbow, tap the site with the index and second finger, apply
warm, damp washcloths to the site for 5 minutes, or lower
the extremity to allow the veins to fill.
Do not:

Draw sample above IV line --> contamination by IV fluids
Draw sample from arm with cannula. fistula/ vascular graft
Draw specimen from area of extensive scarring/ burn
Draw through an existing haematoma
Draw specimen from an artery
Site Cleansing

Needle Selection
Order of Draw
Vacutainer Collection
Syringe Collection
Tube Inversion - Invert tube gently 5x, DO NOT Shake - vigorous mixing can cause Haemolysis
Recheck Label
Specimen Delivery

THE FOLLOWING ARE NEEDED FOR ROUTINE VENIPUNCTURE

Evacuated collection tubes – the tubes are designed to fill a predetermined volume of blood by vacuum
The rubber stoppers are color coded according to the additive the tube contains
Blood should NEVER be poured from one tube to another since the tube can have different additives or coatings
Needles – The gauge number indicates the bore size: the larger the gauge number, the smaller the needle bore
Holder – use with the evacuated system
Tourniquet – wipe off with alcohol and replace frequently
Alcohol wipes – 70% isopropyl alcohol
Adhesive bandages / tape – protects the venipuncture site after collection
Needle disposal unit – needles should NEVER be broken, bent, or recapped
Needles should be placed in disposal unit IMMEDIATELY after their use
Gloves – can be made of latex, rubber, or vinyl, and are worn to protect the patient and the phlebotomist
Syringes – may be used in place of the evacuated collection tube for special circumstances

PROCEDURE:

Position the patient so he or she is comfortable and safe in case the patient becomes faint and falls
Recommended needle size: 20G, 21G or 22G
Closed vacutainer system is recommended
Select tube or tubes appropriate for type of samples desired
Select site for venipuncture
Put on gloves
Prepare venipuncture site with alcohol prep. Cleanse in a circular
fashion, beginning at the site and working outward

DO NOT PALPATE VENIPUNCTURE AREA AFTER CLEANSING. Allow site to dry
Apply the tourniquet 3-4 inches above the selected puncture site
Do not place too tightly or leave on more than 1 minutes
Remove needle shield. Perform venipuncture WITH PATIENT’S ARM IN A DOWNWARD POSITION AND TUBE STOPPER UPPERMOST
This reduces the risk of backflow of any anticoagulant into the patient’s circulation
Push the tube onto the needle, puncturing the stopper
REMOVE TOURNIQUET AS SOON AS BLOOD APPEARS IN TUBE, within 2 minutes of venipuncture
DO NOT ALLOW CONTENTS OF TUBE TO CONTACT THE STOPPER DURING THE PROCEDURE
When first tube has filled to its stated volume, remove it from the holder
Place succeeding tube in holder puncturing stopper to initiate flow
While each successive tube is filling invert previous tube GENTLY 5 times
DO NOT SHAKE. Vigorous mixing can cause hemolysis
When all tubes of blood have been collected, remove the last tube from the vacutainer holder, place a cotton ball or gauze over the site and withdraw the needle in a smooth and cautious manner so as not to bruise the vein
After withdrawing the needle fully, apply pressure to the cotton ball over the puncture site and hold pressure
If patient is able ask them to apply pressure for 3 to 5 minutes until the bleeding stops
Discard the needle of the vacutainer into the biohazard container WITHOUT RECAPPING the needle
Immediately invert the last tube GENTLY

CAUSES FOR REJECTION OF SAMPLE

The quality of laboratory results are directly affected by the quality of the blood sample obtained from the patient
Samples may need to be rejected as unacceptable for the following reasons:

Hemolysis - this is usually caused by a procedural error such as using too small of a needle, or pulling back to hard on the plunger of a syringe used for collecting the sample

Haemolysis is defined as the release of cellular components of erythrocytes and other blood cells into the extracellular space of blood. These cellular components can cause interference in laboratory measurements, potassium being a commonly measured analyte to be affected

Clotted - failure to mix or inadequate mixing of samples collected into an additive tube
Insufficient sample (QNS) - certain additive tubes must be filled completely
When many tests are ordered on the same tube be sure to know the amount of sample needed for each test
Wrong tube collected for test ordered
Tubes not processed before shipping to lab
Tubes held too long in facility before shipping
Submitting specimens in expired collection tubes. It is the responsibility of the submitter to ensure that specimens are collected in tubes that have not expired

ORDER OF DRAW

Blood collection tubes must be drawn in a specific order to avoid cross-contamination of additives between tubes. The recommended order of draw for plastic vacutainer tubes is:

First - blood culture bottle or tube (yellow or yellow-black top)
Second - coagulation tube (light blue top). If just a routine coagulation assay is the only test ordered, then a single light blue top tube may be drawn. If there is a concern regarding contamination by tissue fluids or thromboplastins, then one may draw a non-additive tube first, and then the light blue top tube.
Third - non-additive tube (red top)
Last draw - additive tubes in this order:
1. SST (red-gray or gold top). Contains a gel separator and clot activator.
2. Sodium heparin (dark green top)
3. PST (light green top). Contains lithium heparin anticoagulant and a gel separator.
4. EDTA (lavender top)
5. ACDA or ACDB (pale yellow top). Contains acid citrate dextrose.
6. Oxalate/fluoride (light gray top)

NOTE:Tubes with additives must be thoroughly mixed. Erroneous test results may be obtained when the blood is not thoroughly mixed with the additive.

ADVICE TO PATIENTS

Some people have a fear of needles or of blood and can feel faint. If this is the case for you, it is not a problem but please make sure you let the person who is taking your blood know in advance so you can be positioned correctly to reduce this situation arising. If you are taking any blood thinning medicines the procedure should be discussed with your doctor prior to your blood being taken. * A tourniquet will be placed around the upper part of your arm, this will be pulled fairly tight to reduce the blood flow causing the veins in your arm to swell this makes it much easier to locate the vein. * The area is wiped with an antiseptic wipe to reduce the potential germs on your skin surface (everybody has them!) they will wait for this to dry. * The needle will then be inserted through the skin to the vein this is like a pricking sensation it will not hurt excessively. * If you are having fasting bloods taken you may have a “cannula” or “butterfly” placed in the back of your hand and secured. It will be explained to you that as you will be having blood taken over a period of time, this method will reduce the need for repeated insertions of a needle. * The blood will be extracted via either a syringe with a needle, or more often a needle attached to a device where different vacum vials-(small bottles) can be connected so a small amount of blood goes into each vial for a variety of different tests, hence the different coloured vials. * The needle will be removed and a small spot plaster put on the site to minimalise the chance of infection. Please inform the person attending to you if you have allergies to any plasters. If the site does become inflamed, red and sore you will need to visit the doctor. * Pressure will be applied to the wound site for a few minutes to reduce the likelihood of bruising. Do not be too keen to release this pressure too quickly otherwise you may bruise or the site may bleed. * If you have been lying down for the procedure you will need to sit up slowly. * The blood sample will be carefully labelled with all your personal relevant details and stored correctly by the person who took your sample. * The blood samples are then sent to a laboratory where they will be carefully analysed. * The results of your blood test will be sent back to your own Doctor they will then call you in for a consultation and the results will be explained to you. If you are not sure you will remember what is being said during this appointment, it can be a good idea to take a friend or family member with you. If you are going to receive results of a sensitive nature for instance the HIV test, counsellors are available to help you

Tuesday 19 July 2011

COPD

ANATOMY

DISCUSSION:

COPD : Chronic airway obstruction with little or no reversibility
It includes Emphysema and Chronic Bronchitis
Emphysema: Histological Dx - enlarged air spaces with destruction of alveolar walls
Chronic Bronchitis: Clinical Dx - Chronic cough with sputum production on most days for 3 mths for 2 consecutive days
COPD and Asthma do not co exist:
Hyperinflation in COPD/ Asthma occurs secondary to:

Increase intraluminal secretion
Airway inflammation
Bronchospasm
Loss of elastic recoil of thoracic wall musculature

Pathophysiology of Hyperinflation - the above factors will lead to progressively increaing End Expiratory Volume
Pathophysiology of COPD:
COPD rarely exist in isolation - normally co-exist with other co-morbids such as HPT, DM, IHD

Pathophysiology: Cigarette smoke induces a pulmonary and systemic inflammation which will release infalmmatory mediators such as ... that will act on different organs such as the kidney, heart, pancreas

BRADYCARDIA

This is an ECG of a gentleman who presented with

MMED (Family Medicine) 2011 - Year One

Welcome to the Family Medicine UiTM blogspot website. I have created this blog to share a few interesting cases that me and my collegues who are doing MMED (Family Medicine) under UiTM have seen so far. We are in Year One of our Masters Training and yet have a long way to go to become a dedicated and respectful FMS. So far, we are finding it somehow rather difficult to find the time to do our revision due to our family and hospital work commitments. Nonetheless, with full support from one another, we are confident that we can go through this together as a Team.

As we go along the long winding road of Master training in Family Medicine, it is very easy to forget that we are not merely Physicians that focus mainly on the disease management, but we are FMS to-be that will be enduring not only on the patient's disease management but also indwell on the impact of the illness on the patient's life and family dynamics as a whole. We should always reflect on this one important question each time we deal with a patient:

HOW DOES "THIS" PLAY A ROLE IN YOUR LIFE

Please feel free to share your views, opinion and experiences with us with regards to the training in Masters of Family Medicine.

Dr. Zahirah Tharek
Trainee Lecturer
Primary Care Medicine Discipline
UiTM Sungai Buloh Campus