http://serratiopeptidase.weebly.com/
http://www.ehow.com/about_5130452_serratiopeptidase-side-effect.html
If you suffer from pain to any extent – occasionally, chronically or somewhere in between – an enzyme known as serratiopeptidase may just be the answer for you. This is especially true if you have an aversion to, or are experiencing any side effects of, the medication you currently use for pain management. Whether you take prescription or over-the-counter “painkillers,” serratiopeptidase is a safe, natural alternative with no known side effects.
Serratiopeptidase, also known as serrapeptase, is a proteolytic (that is, having the ability to break down proteins into simpler compounds) enzyme which is naturally present in the silkworm intestine. Now, before you go running for cover, screaming, “I’m not swallowing anything that came from a worm’s innards!” – let me just emphasize: The type that is available to consumers today is processed through fermentation of plant-grown enzymes, and is generally of such purity that it is suitable even for consumption by vegetarians.
Serrapeptase has been widely used for over 30 years in many Asian and European countries. In Austria and Germany for instance, it is available by prescription only. Fortunately, in the U.S. – and elsewhere – this is not the case. It is so safe, in fact, that it can be taken by children, pregnant women, and has even been successfully used on pets.
Chronic inflammation lies at the heart of a myriad of ailments, including headaches, muscle and joint pain (from exercise, or in conditions such as arthritis or fibromyalgia) – and ultimately, even more serious diseases such as cancer and heart disease. Unlike conventional pain med’s, which are designed to only relieve the inflammation, serratiopeptidase actually breaks down the protein deposits (known as fibrin) which often remain – and continue to cause pain and discomfort – even after your body has healed from an injury or other irritation.
And, as stated, serrapeptase has no known side effects – unlike aspirin, ibuprofen, naproxen, and other over-the-counter NSAIDs – as well as acetaminophen (which is not classified as an NSAID.) These non-prescription drugs have been proven in clinical studies to cause stomach, kidney, liver, and even heart problems, especially when used regularly, and for prolonged periods. What’s worse, certain prescription med’s – especially in the NSAIDs category – have had even more serious side effects, which have been well-documented in the media in recent years.
So for the millions of pain sufferers who turn to these medications on a regular basis, the emergence of serratiopeptidase as a viable alternative is most welcome, to put it mildly. In upcoming articles, we will be keeping you informed of exciting news and developments on this incredible enzyme – as well as the best source for obtaining it – so bookmark this site, and check back often.
This is a drug that I found out in my clinic. Before this, I never get to know this drug. Never have I know that this drug exist and it's so "natural". I really thought this is something artificial or some sort of complex channel blockers. [Most of the clinical studies conducted do not document any side effects. In the few that do document side effects, there is not enough data to determine if they are caused by the serratiopeptidase or if they were just a coincidence. With the positive results of the preliminary data, there is sure to be more studies to document the benefits and side effects.]
Thursday, December 16, 2010
Thursday, December 9, 2010
Conditions I Learnt Today
After looking at so many articles, the condition is actually named Chronic Fatigue Syndrome to replace other names like I mentioned below. I guess it's the difference between how the Americans and British call them? PVS seems to be written by UK people...
Post-Viral Syndrome: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1710789/pdf/jroyalcgprac00029-0021.pdf
I am going to share some conditions I witnessed today. First, post-viral syndrome. There is one patient who complains of whole body-ache after a viral infection.
Quote: "The syndrome typically follows an upper respiratory tract infection from which the sufferer fails to make a full recovery, complaining of a multitude of symptoms which may persist for months or even years. The cardinal symptom is profound
muscular fatigue and this is often accompanied by muscle pain, headache, paraesthesiae, dizziness, urinary frequency, cold extremities, bouts of sweating and fainting attacks. Other symptoms are poor memory, lack of concentration, sleep disturbance, mild expressive and receptive dysphasia, hyperacusis and emotional lability. Clinical examination usually shows no abnormalities, nor do routine laboratory investigations. The diagnosis is therefore one of exclusion. The illness follows one of three courses: many patients recover completely, in others there is a relapsing and remitting course and in some there is chronic illness. Relapses are precipitated by undue physical or mental stress: patients who rest adequately in the early stages are said to have the best chance of an early, complete recovery without relapse."
There is another term which I want to bring up: Neurasthenia. 'Neurasthenia is a condition of nervous exhaustion, characterised by undue fatigue on slightest exertion, both physical and mental, with which are associated symptoms of abnormalfunctioning, mainly referable to disorders of the vegetative nervous system. The chief symptoms are headache, gastrointestinal disturbances, and subjective sensations of all kinds'. (The term has remained in use in some European countries including France and Russia, but has become virtually obsolete in the United States.)
The doctor told me that there are people who suffer from this condition and landed up in their most downs in their life. It took one year for that person to finally decided to find the meaning of his life and strife to rid of this syndrome and become a normal person again. That was how debilitating this condition can do to a person.
Post-Viral Syndrome: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1710789/pdf/jroyalcgprac00029-0021.pdf
I am going to share some conditions I witnessed today. First, post-viral syndrome. There is one patient who complains of whole body-ache after a viral infection.
Quote: "The syndrome typically follows an upper respiratory tract infection from which the sufferer fails to make a full recovery, complaining of a multitude of symptoms which may persist for months or even years. The cardinal symptom is profound
muscular fatigue and this is often accompanied by muscle pain, headache, paraesthesiae, dizziness, urinary frequency, cold extremities, bouts of sweating and fainting attacks. Other symptoms are poor memory, lack of concentration, sleep disturbance, mild expressive and receptive dysphasia, hyperacusis and emotional lability. Clinical examination usually shows no abnormalities, nor do routine laboratory investigations. The diagnosis is therefore one of exclusion. The illness follows one of three courses: many patients recover completely, in others there is a relapsing and remitting course and in some there is chronic illness. Relapses are precipitated by undue physical or mental stress: patients who rest adequately in the early stages are said to have the best chance of an early, complete recovery without relapse."
There is another term which I want to bring up: Neurasthenia. 'Neurasthenia is a condition of nervous exhaustion, characterised by undue fatigue on slightest exertion, both physical and mental, with which are associated symptoms of abnormalfunctioning, mainly referable to disorders of the vegetative nervous system. The chief symptoms are headache, gastrointestinal disturbances, and subjective sensations of all kinds'. (The term has remained in use in some European countries including France and Russia, but has become virtually obsolete in the United States.)
The doctor told me that there are people who suffer from this condition and landed up in their most downs in their life. It took one year for that person to finally decided to find the meaning of his life and strife to rid of this syndrome and become a normal person again. That was how debilitating this condition can do to a person.
Thursday, November 11, 2010
Diet and Lifestyle
I am going to make a summary in regards of patient education for diet and lifestyle.
1. Exercise
CDC recommends 30-60 minutes of moderate (brisk walking, bicycling, vacuuming, gardening, or anything that causes small increases in breathing or heart rate) to vigorous (running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate) physical activity per day at least 5 days per week in all children.
Almost all patients should be able to incorporate recommended levels of physical activities in their lifestyle.
Barriers: Bad weather, lack of time and access to facilities or equipment etc. Attempts to further characterize and eliminate these barriers. PE classes are currently inadequate to meet physical activity recommendations.
2. Effect on Adolescents (all positive health-related behaviors)
- Decreased smoking
- Decreased drug use
- Increased fruit and vegetable consumption
- Decreased risk of pregnancy and STD
- Decreased anxiety, stress and depression
- Decreased illicit drug use
- Increased seat belt use
- Increased academic performance
3. Food
Plenty of fresh fruits and vegetables (5 servings) and less than 30% of total calories as fat
Fruit juice (can take only 10-12 ounces) is often an unrecognized culprit in childhood obesity and is not a substitute for fresh fruits.
Parents play a part as model since children will learn by example.
4. Others...
Avoid all diet fads and diet "revolutions"
Avoid anorexic drugs
Change composition of the diet
Attend multiple office visits to establish a baseline and to motivate continual weight loss
Decrease caloric intake to approx 500kcal/day less than energy expenditure --> loss 1 pound/week
Positive reinforcement from a support group etc.
Treat comorbid conditions
Hypercholesterolemia diet management:
Begin with Step 1 diet of AHA: no more than 300mg cholesterol, no more than 30% total fat and no more than 10% saturated fat.
Continue for at least 6 months. If cholesterol levels do not normalize, consider AHA step 2 diet: no more than 200mg cholesterol, no more than 30% total fat, and no more than 7% saturated fat.
1. Exercise
CDC recommends 30-60 minutes of moderate (brisk walking, bicycling, vacuuming, gardening, or anything that causes small increases in breathing or heart rate) to vigorous (running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate) physical activity per day at least 5 days per week in all children.
Almost all patients should be able to incorporate recommended levels of physical activities in their lifestyle.
Barriers: Bad weather, lack of time and access to facilities or equipment etc. Attempts to further characterize and eliminate these barriers. PE classes are currently inadequate to meet physical activity recommendations.
2. Effect on Adolescents (all positive health-related behaviors)
- Decreased smoking
- Decreased drug use
- Increased fruit and vegetable consumption
- Decreased risk of pregnancy and STD
- Decreased anxiety, stress and depression
- Decreased illicit drug use
- Increased seat belt use
- Increased academic performance
3. Food
Plenty of fresh fruits and vegetables (5 servings) and less than 30% of total calories as fat
Fruit juice (can take only 10-12 ounces) is often an unrecognized culprit in childhood obesity and is not a substitute for fresh fruits.
Parents play a part as model since children will learn by example.
4. Others...
Avoid all diet fads and diet "revolutions"
Avoid anorexic drugs
Change composition of the diet
Attend multiple office visits to establish a baseline and to motivate continual weight loss
Decrease caloric intake to approx 500kcal/day less than energy expenditure --> loss 1 pound/week
Positive reinforcement from a support group etc.
Treat comorbid conditions
Hypercholesterolemia diet management:
Begin with Step 1 diet of AHA: no more than 300mg cholesterol, no more than 30% total fat and no more than 10% saturated fat.
Continue for at least 6 months. If cholesterol levels do not normalize, consider AHA step 2 diet: no more than 200mg cholesterol, no more than 30% total fat, and no more than 7% saturated fat.
Sunday, October 31, 2010
Common Problems in Pediatrics
Fever of unknown origin (FUO) implies fever of prolonged duration (>=14 days), documented temeperature greater than 101 degrees on multiple occasions and uncertain etiology, for ex. infection, connective tissue disease, malignancy, etc.
History: Fever (Spiking? Intermittent? Describe the quality and duration), Toxicity (How severe is it?), Weight Loss, Anorexia
Exposure: Any ill contacts, residence (zoonotic infections), travel, food, drugs
Discriminative: Rashes, Pallor, Jaundice, Vasculitis, Tonsils, BCG flare, lymphadenopathy, hepatosplenomegaly, joint swelling.
Kawasaki Disease (aka mucocutaneous lymph node syndrome)
Three phases of the disease as listed here, some authors put "four":
Acute febrile phase - 1-2 weeks
1 The temperature is elevated (>104°F).
2 The child is irritable.
3 Bilateral conjunctivitis and rash are present.
4 The hands and feet develop the erythema and edema that cause the child to refuse to walk. Note that this finding may be the last to develop. Lack of extremity findings may cause consideration of incomplete Kawasaki disease.
5 The tongue and oral mucosa become red and cracked.
6 Hepatic dysfunction may develop.
7 Cardiac complications noted in the first stage include myocarditis and pericarditis.
Subacute phase - Begins when fever and other signs have abated. This phase should end by the 4th week.
1 This is characterized by persistent irritability, anorexia, and conjunctival injection.
2 Fever resolution begins this stage. However, persistent fever beyond 2-3 weeks may be an indication of recrudescent Kawasaki disease. (See Recrudescent Kawasaki disease below).
3 If fever persists, the outcome is less favorable because of a greater risk of cardiac complications.
4 Thrombocytosis develops, and the platelet count may exceed 1 million/mm3.
5 Desquamation of the fingertips and toes begins at this time.
6 Aneurysm formation may occur during this stage.
7 Children are at greatest risk of sudden death during this phase.
Convalescent phase - Approximately 4-6 weeks
1 This phase begins when all signs of illness have disappeared and continues until acute-phase reactants (ESR, CRP level) have returned to normal.
2 The most significant clinical finding that persists through this phase is the presence of coronary artery aneurysms.
(Taken from http://emedicine.medscape.com/article/804960-overview)
Lab test to do: Platelet count, ESR, echocardiogram (to look for coronary artery aneurysm. Big thing, can cause death)
Symptoms to look out for in your clinic: Fever, Rash, Conjunctival injection, Oropharyngeal changes, Peripheral extremity changes and cervical lymphadenopathy. Of course there are tons of other symptoms you may associate with this condition but these are the few things that you can pick up. One thing to note about this condition is that you need to have vigilant to be able to pick this condition up.
Treatment: IVIG and aspirin.
Inguinal Hernia
Patent processus vaginalis. Need to show patient how to reduce it. Do not attempt to massage it as it will cause adhesion and complications. Complication of this indirect inguinal hernia that you should pick up: distressed, irreducible, vomit or abdominal distention.
Hydrocele
Tend to get bigger during the evenings. Wait till 2years old for operation unless testis is big and tense. If there is any recent onset of tense testis, you need to exclude tumor.
Wheezing ==> High pitched musical sound heard during expiration and is caused by turbulence of air in the airway. Need to differentiate: broncholitis (viral, 3-6mths); bronchitis (viral, bacteria, atypical, affect older children); Pneumonia (viral, bacteria, atypical, any age group).
Wheezing = Mucosal edema + secretion (bronchospasm is not characteristic)
Recurrent Wheezing
1. Age -- > Congenital vs Non-congenital
2. Sudden wheezing -- > Foreign body
3. Pattern -- > Episodic vs Persistent
4. Assoc c cough -- > GERD, asthma, allergy
5. Assoc c feeding -- > GERD
6. Better/wose c positional changes -- > tracheomalacia, anomalies of great vessel
7. FH of wheezing -- > asthma, allergy
Fact about GER (affect 65% healthy infants, this is reflux, not a disease) whilst GERD affects 1:300 infants and associated with FTT, feeding/oral aversion, esophagitis
Types of childhood wheezing
Is divided into: 1) Transient Wheezing (typically occurs around 0-3 y/o during viral infection); 2) Non-atopic Wheezing; 3) IgE-associated wheezing/asthma
Intussusception
Re current jelly stool
3months to 1 year
Irritability and colicky pain
Laparotomy Reduction +/- resection
Newborn vomit
- Malrotation volvulus ==> green vomit (bilous vomit)
- Pyloric stenosis ==> 2-8wks (nonbilous projectile vomit)
Glue ear
http://www.ehealthmd.com/library/glueear/ge_whatis.html
Also known as otitis media with effusion, middle ear effusion, secreting otitis with effusion, serous otitis with effusion. (just put the effusion in it) Children comes with deafness. Frequently associated with Eustachian tube obstruction or dysfunction, e.g. adenoitis/nasopharyngitis; rhinosinusitis; cleft palate (the soft palate plays a role in closing or opening the Eustachian tube, therefore it makes sense when you don't have a soft palate, there is trouble for you to maintain the pressure in your middle ear)
Management:
1. Wait and see
2. Antibiotics (symptoms persist for more than 48 hrs), nasal steroid, decongestant
3. Surgery: ventilation tube (grommets) +/- adenoidectomy
History: Fever (Spiking? Intermittent? Describe the quality and duration), Toxicity (How severe is it?), Weight Loss, Anorexia
Exposure: Any ill contacts, residence (zoonotic infections), travel, food, drugs
Discriminative: Rashes, Pallor, Jaundice, Vasculitis, Tonsils, BCG flare, lymphadenopathy, hepatosplenomegaly, joint swelling.
Kawasaki Disease (aka mucocutaneous lymph node syndrome)
Three phases of the disease as listed here, some authors put "four":
Acute febrile phase - 1-2 weeks
1 The temperature is elevated (>104°F).
2 The child is irritable.
3 Bilateral conjunctivitis and rash are present.
4 The hands and feet develop the erythema and edema that cause the child to refuse to walk. Note that this finding may be the last to develop. Lack of extremity findings may cause consideration of incomplete Kawasaki disease.
5 The tongue and oral mucosa become red and cracked.
6 Hepatic dysfunction may develop.
7 Cardiac complications noted in the first stage include myocarditis and pericarditis.
Subacute phase - Begins when fever and other signs have abated. This phase should end by the 4th week.
1 This is characterized by persistent irritability, anorexia, and conjunctival injection.
2 Fever resolution begins this stage. However, persistent fever beyond 2-3 weeks may be an indication of recrudescent Kawasaki disease. (See Recrudescent Kawasaki disease below).
3 If fever persists, the outcome is less favorable because of a greater risk of cardiac complications.
4 Thrombocytosis develops, and the platelet count may exceed 1 million/mm3.
5 Desquamation of the fingertips and toes begins at this time.
6 Aneurysm formation may occur during this stage.
7 Children are at greatest risk of sudden death during this phase.
Convalescent phase - Approximately 4-6 weeks
1 This phase begins when all signs of illness have disappeared and continues until acute-phase reactants (ESR, CRP level) have returned to normal.
2 The most significant clinical finding that persists through this phase is the presence of coronary artery aneurysms.
(Taken from http://emedicine.medscape.com/article/804960-overview)
Lab test to do: Platelet count, ESR, echocardiogram (to look for coronary artery aneurysm. Big thing, can cause death)
Symptoms to look out for in your clinic: Fever, Rash, Conjunctival injection, Oropharyngeal changes, Peripheral extremity changes and cervical lymphadenopathy. Of course there are tons of other symptoms you may associate with this condition but these are the few things that you can pick up. One thing to note about this condition is that you need to have vigilant to be able to pick this condition up.
Treatment: IVIG and aspirin.
Inguinal Hernia
Patent processus vaginalis. Need to show patient how to reduce it. Do not attempt to massage it as it will cause adhesion and complications. Complication of this indirect inguinal hernia that you should pick up: distressed, irreducible, vomit or abdominal distention.
Hydrocele
Tend to get bigger during the evenings. Wait till 2years old for operation unless testis is big and tense. If there is any recent onset of tense testis, you need to exclude tumor.
Wheezing ==> High pitched musical sound heard during expiration and is caused by turbulence of air in the airway. Need to differentiate: broncholitis (viral, 3-6mths); bronchitis (viral, bacteria, atypical, affect older children); Pneumonia (viral, bacteria, atypical, any age group).
Wheezing = Mucosal edema + secretion (bronchospasm is not characteristic)
Recurrent Wheezing
1. Age -- > Congenital vs Non-congenital
2. Sudden wheezing -- > Foreign body
3. Pattern -- > Episodic vs Persistent
4. Assoc c cough -- > GERD, asthma, allergy
5. Assoc c feeding -- > GERD
6. Better/wose c positional changes -- > tracheomalacia, anomalies of great vessel
7. FH of wheezing -- > asthma, allergy
Fact about GER (affect 65% healthy infants, this is reflux, not a disease) whilst GERD affects 1:300 infants and associated with FTT, feeding/oral aversion, esophagitis
Types of childhood wheezing
Is divided into: 1) Transient Wheezing (typically occurs around 0-3 y/o during viral infection); 2) Non-atopic Wheezing; 3) IgE-associated wheezing/asthma
Intussusception
Re current jelly stool
3months to 1 year
Irritability and colicky pain
Laparotomy Reduction +/- resection
Newborn vomit
- Malrotation volvulus ==> green vomit (bilous vomit)
- Pyloric stenosis ==> 2-8wks (nonbilous projectile vomit)
Glue ear
http://www.ehealthmd.com/library/glueear/ge_whatis.html
Also known as otitis media with effusion, middle ear effusion, secreting otitis with effusion, serous otitis with effusion. (just put the effusion in it) Children comes with deafness. Frequently associated with Eustachian tube obstruction or dysfunction, e.g. adenoitis/nasopharyngitis; rhinosinusitis; cleft palate (the soft palate plays a role in closing or opening the Eustachian tube, therefore it makes sense when you don't have a soft palate, there is trouble for you to maintain the pressure in your middle ear)
Management:
1. Wait and see
2. Antibiotics (symptoms persist for more than 48 hrs), nasal steroid, decongestant
3. Surgery: ventilation tube (grommets) +/- adenoidectomy
Thursday, October 21, 2010
Clinical Pearls
These are 100 clinical pearls I come through from a forum. Why not read them and check it out?
1. If a patient has a fever, give acetaminophen (unless it is contraindicated)
2. If a patient is on a statin or you order a statin, get baseline LFTs and check frequently
3. If a patient is found to have abnormal LFTs, get a TSH
4. If a patient is going to surgery (including cardiac catheterization), make them NPO
5. All NPO patients must also have their urine output measured (type "urine output")
6. If a woman is between 12 and 52 years old and there is no mention of a very recent menses (that is, < 2 weeks ago), order a beta-hCG
7. Don't forget to discontinue anything that is no longer required (especially if you are sending the patient home)
8. When a patient is stable, decide whether or not you should change locations (if you anticipate that the patient could crash in the very near future, send the patient to the ICU; if the patient just needs overnight monitoring, send to the ward; if the patient is back to baseline, send home with follow-up)
9. In any diabetic (new or long-standing), order an HbA1c as well as continuous Accuchecks.
10. If this is a long-standing diabetic, also order an ophthalmology consult (to evaluate for diabetic retinopathy)
11. In any patient with respiratory distress (especially with low oxygen saturations), order an ABG
12. In any overdose, do a gastric lavage and activated charcoal (no harm in doing so, unless the patient is unconscious or has risk for aspiration)
13. In any suicidal patient, admit to ward and get "suicide contract" and "suicide precautions"
14. Patients who cannot tolerate Aspirin get Clopidogrel or Ticlopidine
15. Post-PTCA patients get Abciximab
16. In any bleeding patient, order PT, PTT, and Blood Type and Crossmatch (just in case they have to go to the O.R.)
17. In any pregnant patient, get "Blood Type and Rh" as well as "Atypical Antibody Screen"
18. In any patient with excess bleeding (especially GI bleeding), type "no aspirin" upon D/C of patient
19. If the patient is having any upper GI distress or is at risk for aspiration, order "head elevation" and "aspiration precautions"
20. In any asthmatic, order bedside FEV1 and PEFR (and use this to follow treatment progress)
21. Before you D/C a patient, change all IV meds to PO and all nebulizers to MDI
22. In any patient who has GI distress, make them NPO
23. All diabetic in-patients get Accuchecks, D/C oral hypoglycemic agents, start insulin, HbA1c, advise strict glycemic control, recommend diabetic foot care
24. All patients with altered mental status of unknown etiology get a "fingerstick glucose" check (for hypoglycemia), IV thiamine, IV dextrose, IV naloxone, urine toxicology, blood alcohol level, NPO
25. If hemolysis is in the differential, order a reticulocyte count
26. If you administer heparin, check platelets on Day 3 and Day 5 (for heparin-induced thrombocytopenia), as well as frequent H&H
27. If you administer coumadin, check daily PT/INR until it is within therapeutic range for two consecutive days
28. Before giving a woman coumadin, isotretinoin, doxycycline, OCPs or other teratogens, get a beta-hCG
29. If you give furosemide (Lasix), also give KCl (it depletes K+)
30. All children who are given gentamycin, should have a hearing test (audiometry) and check BUN/Cr before and after treatment
-
31. Don't forget about patient comfort! Treat pain with IV morphine, nausea with IV phenergan, constipation with PO docusate, diarrhea with PO loperamide, insomnia with PO temazepam
32. ALL ICU patients get stress ulcer prophylaxis with IV omeprazole or ranitidine
33. If you put a patient on complete bedrest (such as those who are pre-op), get "pneumatic compression stockings"
34. If fluid status is vital to a patient's prognosis (such as those with dehydration, hypovolemia, or fluid overload), place a Foley catheter and order "urine output"
35. If a CXR shows an effusion, get a decubitus CXR next
36. If you intubate a patient you ALSO have to order "mechanical ventilation" (otherwise the patient will just sit there with a tube in his mouth!)
37. With any major procedure (including surgery, biopsy, centesis), you MUST type "consent for procedure" (typing consent will not reveal any results)
38. With any fluid aspiration (such as paracentesis or pericardiocentesis), get fluid analysis separately (it is not automatic). If you don't order anything on the fluid, it will just be discarded.
39. With high-dose steroids (such as in temporal arteritis), give IV ranitidine, calcium, vitamin D, alendronate, and get a baseline DEXA scan.
40. In all suspected DKA or HHNC, check osmolality and ketone levels in the serum.
41. In ALCOHOLIC ketoacidosis, just give dextrose (no need for insulin), in addition to IV normal saline and thiamine
42. All patients over 50 with no history of FOBT or colonoscopy should get a rectal exam, a FOBT, and have a sigmoidoscopy or colonoscopy scheduled.
43. All women > 40 years old should get a yearly clinical breast exam and mammogram (if risk factors are present, start at 35)
44. All men > 50 years old should get a prostate exam and a PSA (if risk factors are present, start at 45)
45. If a patient has a terminal disease, advise "advanced directives"
46. In any patient with a chronic disease that can cause future altered mental status, type "medical alert bracelet" upon D/C
47. Any patient with diarrhea should have their stool checked for "ova and parasites", "white cells", "culture", and C.diff antigen (if warranted)
48. Any patient on lithium or theophylline should have their levels checked
49. All patients with suspected MI should be given a statin (and check baseline LFTs)
50. All suspected hemolysis patients should get a direct Coombs test
51. Schedule all women older than 18 for a Pap smear (unless she has had a normal Pap within one year)
52. Pre-op patients should have the following done: “NPO”, “IV access”, “IV normal saline”, “blood type and crossmatch”, “analgesia”, “PT”, “PTT”, “pneumatic compression stockings”, “Foley”, “urine output”, “CBC”, and any appropriate antibiotics
53. If a patient requires epinephrine (such as in anaphylaxis), and he/she is on a beta-blocker, give glucagon first
54. If lipid profile is abnormal, order a TSH
55. All dementia and alcoholic patients should be advised “no driving”
56. To diagnose Alzheimer’s, first rule out other causes. Order a CT head, vitamin B12 levels, folate levels, TSH, and routine labs like CBC, BMP, LFT, UA. Also, if the history suggests it, order a VDRL and HIV ELISA as well
57. Also rule out depression in suspected dementia patients
58. For all women who are sexually active and of reproductive age, give folate. In fact, you should give ALL your patients a multivitamin upon D/C home
59. All pancreatitis patients should be made NPO and have NG suction so that no food can stimulate the pancreas
60. Send patients home on a disease-specific diet: diabetics get a “diabetic diet”, hypertensives get a “low salt diet”, irritable bowel patients get a “high fiber diet”, hepatic failure patients get “low protein diet”, etc
61. Do not give a thrombolytic (tPA or streptokinase) in a patient with unstable angina patient
62. Patients who are having a large amount of secretions, order “pulmonary toilet” to reduce the risk of aspiration
63. Every patient should be advised to wear a “seatbelt”, to “exercise”, and advised about “compliance”
64. In any patient who presents with an unprotected airway (as in overdoses, comatoses), get a CXR to rule out aspiration
65. In any patient with one sexually transmitted disease (such as Trichomonas), check for other STDs as well (Gonorrhea, Chlamydia, HIV, syphilis, etc.) and do a Pap smear in all women with an STD
66. Remember to treat children with croup with a “mist tent” and racemic epinephrine
67. Any acute abdomen patient with a suspected or proven perforation, give a TRIPLE antibiotic: Gentamycin, Ampicillin, Metronidazole
68. Get iron studies in patients with microcytic anemia if the cause is unknown. Order “iron”, “ferritin”, “TIBC”
69. Women with vaginal discharge should get a KOH prep, saline (wet) prep, vaginal pH, cervical gonococcal, chlamydia culture
70. If a woman is found to have vaginal candida, check her fasting glucose
71. When the 5 minute warning screen is displayed, go through the following mnemonic (RATED SEX). I know it probably is not the best mnemonic, but it is difficult to forget!:
Recreational drugs / Reassurance
Alcohol
Tobacco
Exercise
Diet (eg. high protein, no lactose, low fat, etc.)
Seat belt / Safety plan / Suicide precautions
Education (“patient education”)
X (stands for safe seX)
72. All suspected child abuse patients should be admitted and you should order THREE consults: consult “child protection services”, consult “ophthalmology” (to look for retinal hemorrhages), consult “psychiatrist” (to examine the family dynamics)
73. When a woman reaches menopause, she should have a “fasting lipid profile” checked (because without estrogen, the LDL will rise and the HDL will drop), a DEXA scan (for baseline bone density), and of course, FOBT and colonoscopy (if she is over 50)
74. If colon cancer is suspected, order a CEA; if pancreatic cancer, order CA 19-9; if ovarian cancer, order CA 125.
75. Remember to give “phototherapy” to a newborn with pathologic unconjugated bilirubinemia (it is not helpful if it is predominantly conjugated). Also, with phototherapy, keep the neonate on IV fluids (the heat can dehydrate them), and give erythromycin ointment in their eyes
76. Before giving a child prednisone, get a PPD
77. If a patient is found to have high triglycerides, check “amylase” and “lipase” (high triglycerides can cause pancreatitis)
78. Remember that any newborn under 3 weeks of age who develops a fever is SEPSIS until proven otherwise. Admit to the ward and culture EVERYTHING: “blood culture”, “urine culture”, “sputum culture”, and even “CSF culture”. And give antibiotics to cover EVERYTHING.
79. If you get a high lead level in a child, you have to check a “venous blood lead level” to confirm. If the value is > 70, admit immediately and begin IV “dimercaprol” and “EDTA”. Order “lead abatement agency” and “lead pain assay” upon discharge.
80. If you perform arthrocentesis, send the synovial fluid for “gram stain” and the 3 Cs: “crystals”, “culture”, and “cell count”
81. If a patient has exophthalmos with hyperthyroidism, it is not enough to just treat the hyperthyroidism (as the eye findings may worsen). You should give prednisone.
82. If any patient has cancer, get an “oncology consult”.
83. In a patient with rapid atrial fibrillation, decrease the heart rate first (then worry about converting to sinus rhythm). Use a CCB (diltiazem) or a beta-blocker (metoprolol) for rate control.
84. In any patient with new-onset atrial fibrillation, make sure you check a TSH
85. In any patient with suspected fluid volume depletion, order “postural vitals” to detect orthostasis
86. Before a colonoscopy or a sigmoidoscopy, you should prepare the bowel: make the patient NPO, give IV fluids (if necessary) and order “polyethylene glycol”.
87. Any patient with Mobitz II or complete heart block gets an immediate “transcutaneous pacemaker”. Then order a cardiology consult to implant a “transvenous pacemaker”
88. If calcium level is abnormal, order a “serum magnesium”, “serum phosphorus”, and “PTH”
89. Treat both malignant hyperthermia and neuroleptic malignant syndrome with “dantrolene”
90. All splenectomy patients get a “pneumovax”, an “influenza” vaccine, and a “hemophilus” vaccine if not previously given.
91. If you give INH (for Tb), also give “pyridoxine” (this is vitamin B6)
92. If you give pyrazinamide, get baseline “serum uric acid” levels
93. If you give ethambutol, order an ophthalmology consult (to follow possible optic neuritis)
94. If you perform a thoracocentesis (lung aspirate), send the EFFUSION as well as a peripheral blood sample for: LDH and protein (to help differentiate a transudate versus an exudates) and pH of the effusion
95. Give sickle cell disease children prophylactic penicillin continuously until they turn 5 years old
96. Any patient with a recent anaphylactic reaction (for any reason), should get “skin test” for allergens (to help prevent future disasters) and consult an allergist
97. Do not give cephalosporins to any patient with anaphylactic penicillin allergies (there is a 5% cross-reactivity)
98. Order Holter monitor on patients who have had symptomatic palpitations.
99. Any patient with a first-time panic attack gets a “urine toxicology” screen, a TSH, and “finger stick glucose”
100. All renal failure patients get: “nephrology consult”, “calcium acetate” (to decrease the phosphorus levels), “calcium” supplement, and erythropoeitin"
Source taken from: http://cafemedico.net/forums/clinical-subjects-discussion-forum/11024-best-clincal-mcq-pearls.html
1. If a patient has a fever, give acetaminophen (unless it is contraindicated)
2. If a patient is on a statin or you order a statin, get baseline LFTs and check frequently
3. If a patient is found to have abnormal LFTs, get a TSH
4. If a patient is going to surgery (including cardiac catheterization), make them NPO
5. All NPO patients must also have their urine output measured (type "urine output")
6. If a woman is between 12 and 52 years old and there is no mention of a very recent menses (that is, < 2 weeks ago), order a beta-hCG
7. Don't forget to discontinue anything that is no longer required (especially if you are sending the patient home)
8. When a patient is stable, decide whether or not you should change locations (if you anticipate that the patient could crash in the very near future, send the patient to the ICU; if the patient just needs overnight monitoring, send to the ward; if the patient is back to baseline, send home with follow-up)
9. In any diabetic (new or long-standing), order an HbA1c as well as continuous Accuchecks.
10. If this is a long-standing diabetic, also order an ophthalmology consult (to evaluate for diabetic retinopathy)
11. In any patient with respiratory distress (especially with low oxygen saturations), order an ABG
12. In any overdose, do a gastric lavage and activated charcoal (no harm in doing so, unless the patient is unconscious or has risk for aspiration)
13. In any suicidal patient, admit to ward and get "suicide contract" and "suicide precautions"
14. Patients who cannot tolerate Aspirin get Clopidogrel or Ticlopidine
15. Post-PTCA patients get Abciximab
16. In any bleeding patient, order PT, PTT, and Blood Type and Crossmatch (just in case they have to go to the O.R.)
17. In any pregnant patient, get "Blood Type and Rh" as well as "Atypical Antibody Screen"
18. In any patient with excess bleeding (especially GI bleeding), type "no aspirin" upon D/C of patient
19. If the patient is having any upper GI distress or is at risk for aspiration, order "head elevation" and "aspiration precautions"
20. In any asthmatic, order bedside FEV1 and PEFR (and use this to follow treatment progress)
21. Before you D/C a patient, change all IV meds to PO and all nebulizers to MDI
22. In any patient who has GI distress, make them NPO
23. All diabetic in-patients get Accuchecks, D/C oral hypoglycemic agents, start insulin, HbA1c, advise strict glycemic control, recommend diabetic foot care
24. All patients with altered mental status of unknown etiology get a "fingerstick glucose" check (for hypoglycemia), IV thiamine, IV dextrose, IV naloxone, urine toxicology, blood alcohol level, NPO
25. If hemolysis is in the differential, order a reticulocyte count
26. If you administer heparin, check platelets on Day 3 and Day 5 (for heparin-induced thrombocytopenia), as well as frequent H&H
27. If you administer coumadin, check daily PT/INR until it is within therapeutic range for two consecutive days
28. Before giving a woman coumadin, isotretinoin, doxycycline, OCPs or other teratogens, get a beta-hCG
29. If you give furosemide (Lasix), also give KCl (it depletes K+)
30. All children who are given gentamycin, should have a hearing test (audiometry) and check BUN/Cr before and after treatment
-
31. Don't forget about patient comfort! Treat pain with IV morphine, nausea with IV phenergan, constipation with PO docusate, diarrhea with PO loperamide, insomnia with PO temazepam
32. ALL ICU patients get stress ulcer prophylaxis with IV omeprazole or ranitidine
33. If you put a patient on complete bedrest (such as those who are pre-op), get "pneumatic compression stockings"
34. If fluid status is vital to a patient's prognosis (such as those with dehydration, hypovolemia, or fluid overload), place a Foley catheter and order "urine output"
35. If a CXR shows an effusion, get a decubitus CXR next
36. If you intubate a patient you ALSO have to order "mechanical ventilation" (otherwise the patient will just sit there with a tube in his mouth!)
37. With any major procedure (including surgery, biopsy, centesis), you MUST type "consent for procedure" (typing consent will not reveal any results)
38. With any fluid aspiration (such as paracentesis or pericardiocentesis), get fluid analysis separately (it is not automatic). If you don't order anything on the fluid, it will just be discarded.
39. With high-dose steroids (such as in temporal arteritis), give IV ranitidine, calcium, vitamin D, alendronate, and get a baseline DEXA scan.
40. In all suspected DKA or HHNC, check osmolality and ketone levels in the serum.
41. In ALCOHOLIC ketoacidosis, just give dextrose (no need for insulin), in addition to IV normal saline and thiamine
42. All patients over 50 with no history of FOBT or colonoscopy should get a rectal exam, a FOBT, and have a sigmoidoscopy or colonoscopy scheduled.
43. All women > 40 years old should get a yearly clinical breast exam and mammogram (if risk factors are present, start at 35)
44. All men > 50 years old should get a prostate exam and a PSA (if risk factors are present, start at 45)
45. If a patient has a terminal disease, advise "advanced directives"
46. In any patient with a chronic disease that can cause future altered mental status, type "medical alert bracelet" upon D/C
47. Any patient with diarrhea should have their stool checked for "ova and parasites", "white cells", "culture", and C.diff antigen (if warranted)
48. Any patient on lithium or theophylline should have their levels checked
49. All patients with suspected MI should be given a statin (and check baseline LFTs)
50. All suspected hemolysis patients should get a direct Coombs test
51. Schedule all women older than 18 for a Pap smear (unless she has had a normal Pap within one year)
52. Pre-op patients should have the following done: “NPO”, “IV access”, “IV normal saline”, “blood type and crossmatch”, “analgesia”, “PT”, “PTT”, “pneumatic compression stockings”, “Foley”, “urine output”, “CBC”, and any appropriate antibiotics
53. If a patient requires epinephrine (such as in anaphylaxis), and he/she is on a beta-blocker, give glucagon first
54. If lipid profile is abnormal, order a TSH
55. All dementia and alcoholic patients should be advised “no driving”
56. To diagnose Alzheimer’s, first rule out other causes. Order a CT head, vitamin B12 levels, folate levels, TSH, and routine labs like CBC, BMP, LFT, UA. Also, if the history suggests it, order a VDRL and HIV ELISA as well
57. Also rule out depression in suspected dementia patients
58. For all women who are sexually active and of reproductive age, give folate. In fact, you should give ALL your patients a multivitamin upon D/C home
59. All pancreatitis patients should be made NPO and have NG suction so that no food can stimulate the pancreas
60. Send patients home on a disease-specific diet: diabetics get a “diabetic diet”, hypertensives get a “low salt diet”, irritable bowel patients get a “high fiber diet”, hepatic failure patients get “low protein diet”, etc
61. Do not give a thrombolytic (tPA or streptokinase) in a patient with unstable angina patient
62. Patients who are having a large amount of secretions, order “pulmonary toilet” to reduce the risk of aspiration
63. Every patient should be advised to wear a “seatbelt”, to “exercise”, and advised about “compliance”
64. In any patient who presents with an unprotected airway (as in overdoses, comatoses), get a CXR to rule out aspiration
65. In any patient with one sexually transmitted disease (such as Trichomonas), check for other STDs as well (Gonorrhea, Chlamydia, HIV, syphilis, etc.) and do a Pap smear in all women with an STD
66. Remember to treat children with croup with a “mist tent” and racemic epinephrine
67. Any acute abdomen patient with a suspected or proven perforation, give a TRIPLE antibiotic: Gentamycin, Ampicillin, Metronidazole
68. Get iron studies in patients with microcytic anemia if the cause is unknown. Order “iron”, “ferritin”, “TIBC”
69. Women with vaginal discharge should get a KOH prep, saline (wet) prep, vaginal pH, cervical gonococcal, chlamydia culture
70. If a woman is found to have vaginal candida, check her fasting glucose
71. When the 5 minute warning screen is displayed, go through the following mnemonic (RATED SEX). I know it probably is not the best mnemonic, but it is difficult to forget!:
Recreational drugs / Reassurance
Alcohol
Tobacco
Exercise
Diet (eg. high protein, no lactose, low fat, etc.)
Seat belt / Safety plan / Suicide precautions
Education (“patient education”)
X (stands for safe seX)
72. All suspected child abuse patients should be admitted and you should order THREE consults: consult “child protection services”, consult “ophthalmology” (to look for retinal hemorrhages), consult “psychiatrist” (to examine the family dynamics)
73. When a woman reaches menopause, she should have a “fasting lipid profile” checked (because without estrogen, the LDL will rise and the HDL will drop), a DEXA scan (for baseline bone density), and of course, FOBT and colonoscopy (if she is over 50)
74. If colon cancer is suspected, order a CEA; if pancreatic cancer, order CA 19-9; if ovarian cancer, order CA 125.
75. Remember to give “phototherapy” to a newborn with pathologic unconjugated bilirubinemia (it is not helpful if it is predominantly conjugated). Also, with phototherapy, keep the neonate on IV fluids (the heat can dehydrate them), and give erythromycin ointment in their eyes
76. Before giving a child prednisone, get a PPD
77. If a patient is found to have high triglycerides, check “amylase” and “lipase” (high triglycerides can cause pancreatitis)
78. Remember that any newborn under 3 weeks of age who develops a fever is SEPSIS until proven otherwise. Admit to the ward and culture EVERYTHING: “blood culture”, “urine culture”, “sputum culture”, and even “CSF culture”. And give antibiotics to cover EVERYTHING.
79. If you get a high lead level in a child, you have to check a “venous blood lead level” to confirm. If the value is > 70, admit immediately and begin IV “dimercaprol” and “EDTA”. Order “lead abatement agency” and “lead pain assay” upon discharge.
80. If you perform arthrocentesis, send the synovial fluid for “gram stain” and the 3 Cs: “crystals”, “culture”, and “cell count”
81. If a patient has exophthalmos with hyperthyroidism, it is not enough to just treat the hyperthyroidism (as the eye findings may worsen). You should give prednisone.
82. If any patient has cancer, get an “oncology consult”.
83. In a patient with rapid atrial fibrillation, decrease the heart rate first (then worry about converting to sinus rhythm). Use a CCB (diltiazem) or a beta-blocker (metoprolol) for rate control.
84. In any patient with new-onset atrial fibrillation, make sure you check a TSH
85. In any patient with suspected fluid volume depletion, order “postural vitals” to detect orthostasis
86. Before a colonoscopy or a sigmoidoscopy, you should prepare the bowel: make the patient NPO, give IV fluids (if necessary) and order “polyethylene glycol”.
87. Any patient with Mobitz II or complete heart block gets an immediate “transcutaneous pacemaker”. Then order a cardiology consult to implant a “transvenous pacemaker”
88. If calcium level is abnormal, order a “serum magnesium”, “serum phosphorus”, and “PTH”
89. Treat both malignant hyperthermia and neuroleptic malignant syndrome with “dantrolene”
90. All splenectomy patients get a “pneumovax”, an “influenza” vaccine, and a “hemophilus” vaccine if not previously given.
91. If you give INH (for Tb), also give “pyridoxine” (this is vitamin B6)
92. If you give pyrazinamide, get baseline “serum uric acid” levels
93. If you give ethambutol, order an ophthalmology consult (to follow possible optic neuritis)
94. If you perform a thoracocentesis (lung aspirate), send the EFFUSION as well as a peripheral blood sample for: LDH and protein (to help differentiate a transudate versus an exudates) and pH of the effusion
95. Give sickle cell disease children prophylactic penicillin continuously until they turn 5 years old
96. Any patient with a recent anaphylactic reaction (for any reason), should get “skin test” for allergens (to help prevent future disasters) and consult an allergist
97. Do not give cephalosporins to any patient with anaphylactic penicillin allergies (there is a 5% cross-reactivity)
98. Order Holter monitor on patients who have had symptomatic palpitations.
99. Any patient with a first-time panic attack gets a “urine toxicology” screen, a TSH, and “finger stick glucose”
100. All renal failure patients get: “nephrology consult”, “calcium acetate” (to decrease the phosphorus levels), “calcium” supplement, and erythropoeitin"
Source taken from: http://cafemedico.net/forums/clinical-subjects-discussion-forum/11024-best-clincal-mcq-pearls.html
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