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Posts Tagged ‘Medical education’

Xanthopsia and the distribution of Jaundice in body fluids

Posted by iskanbasal on April 2, 2009

What is it, xanthopsia?

In deep jaundice, the ocular fluids are yellow, and this
is considered to explain the extremely rare symptom of
xanthopsia (seeing yellow).

The wikipedia definition is here:

“Xanthopsia refers to the predominance of yellow in vision due to a yellowing of the optic media of the eye. The most common cause is digoxin toxicity and the development of cataracts which can cause a yellow filtering effect”.

The General Practice notebook definition :

The patient with xanthopsia complains that his vision has a yellow tinge.

Xanthopsia is caused by:

  • severe jaundice
  • digoxin toxicity.

I’m reviewing now the liver diagnostic tests and procedures and have posted about in a previous post. The metabolism of bilirubin and its secretion by the liver is one of the important subjects related to the liver function and testing. I’m reading important notes about bilirubin metabolism and how jaundice is distributed in body fluids. One is the term xanthopsia which in wikipedia is associated with cataracts and digoxin toxicity but not with deep jaundice. Another notes about the distribution of jaundice is that exudate tends to be more icteric than transudates because it contains more protein-bound bilirubin; that urine, sweat, semen and milk contain bile pigment in the deeply jaundiced patient. But most importantly is the fact that bilirubin is readily bound to elastic tissue. Skin, ocular sclera and blood vessels have a high elastic tissue content, and easily become icteric. This also accounts for the disparity between the depth of skin jaundice and
serum bilirubin levels during recovery from hepatitis and cholestasis.

I’m reading on this outstanding textbook of liver diseases, but only few things as it is too much vast:

Diseases of the Liver

and Biliary System by SHEILA SHERLOCK and JAMES DOOLEY

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Posted in Lab | Tagged: , , , | Leave a Comment »

Variability is the law of life

Posted by iskanbasal on March 21, 2009

Sir William Osler said, “Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.”

This statement is cited in the article about the new , precise definition of acute myocardial infarction which I already posted below. The authors Shaun Senter MD and Gary S. Francis MD describe the wide variety of presentation of myocardial infarction and explain the need to make precise diagnosis before taking action. I read the article and learned new things in this subject. When studying a certain condition on my textbooks I try to keep in mind the most important clinical features that describe it and make a single picture of the disease but I should also be aware to the variability of presentation of a pathological condition. It might be that this variability depends on the extent to which tissues and organs are involved in a certain disease  or to the way a patient’s organism responds depending on their age, sex or other factors; I’m not sure but this what I think could be. The autors review the current criteria that is established by international cardiovascular societies for making diagnosis of MI:

“The cornerstone of diagnosis remains a high level of clinical suspicion, serial ECGs, and troponine” they say. Particulary the focus on the role of troponine. There is also a clinical classification of MI in five different types.

Read the article here.

Recently I studied some chapters on the Jacques Wallach Interpretation of diagnostic tests, 8th ed and I found very good tables for the interpretation  of biomarkers in this context, one about the characteristics of serum markers for MI is this :

Early appearance: Myoglobin, CK isoforms, glycogen phosphorylase isoenzyme BB, heart fatty acid-binding protein
High specificity: cTnI, cTnT, CK-MB, CK isoforms
Wide diagnostic window: cTnT, cTnI, LD, myosin hight and heavy chains
Risk stratification: cTnT, cTnI, CK-MB
Predicts reperfusion: Myoglobin, cTnI, cTnT, CK isoforms
Indicates reinfarction after 2–4 d: CK-MB

The Wallach’s textbook confirm the possibility of false-positive ECG in >10% to 20% of AMI cases in the ED and nondiagnostic in about 50%. But here there is an additional note about newer biomarkers being studied as independent predictors of cardiac risk which I did not know before such as The ischemia-modified albumin and others.

I’d like, here below, to summarize  only the clinical features of MI which describe the clinical variability of the condition cited in the article  above:

.

  • the presentation of myocardial infarction varies from 25% of patients with no symptoms to patients with severe, crushing chest pain.
  • Discomfort may occur in the upper back, neck, jaw, teeth, arms, wrist, and epigastrium and it build up in a crescendo manner. It can lessen in the standing position. A pressure sensation, air hunger, or gas “building up” can be described.
  • Shortness of breath, diaphoresis, nausea, vomiting and even syncope may occur.
  • The only symptoms may be shortness of breath and diaphoresis
  • symptoms last from minutes to hours and can be releived by sublingual nitroglycerin.
  • Atypical presentaion or less prominent symptoms may make the diagnosis difficult in the elderly and in patients with diabetes, and in women.
  • On physical exam the patient may appear pale and diaphoretic and the skin cool. Heart sounds are soft and a fourth heart sound may be audible. BP may be low and tachycardia and pulmonary edema are poor diagnostic features.

Posted in Cardiology | Tagged: , , , | Leave a Comment »

Primary Prevention Of Atherosclerotic Heart Disease: New Data from the AHA

Posted by iskanbasal on March 12, 2009

Thanks to KevinMd where I got information about reachMd radio. Actually it is a good educational site, there are many prog to follow and I just finished my first act of listening to an interesting program on the primary prevention of atherosclerotic heart disease and got a CME 0.25 credit. As only a medical student I only wanted to listen and develop a little my english and also get new important information directed to general practice. The clinical researcher discussed in this activity the results of a trial  in which patients with a normal level of cholesterol= 130mg/dL but with high levels of C reactive protein called CRP (which is considered an important risk factor for CAD) took a statin to prevent the occurence of cardiac events. The trial resulted in a 44% reduction in cardiovascular events and was stopped early because the benefits were very evident.   

Primary Prevention Of Atherosclerotic Heart Disease: New Data from the AHA

Listen here.

Posted in Cardiology | Tagged: , , , | Leave a Comment »

A new, precise definition of acute myocardial infarction

Posted by iskanbasal on March 5, 2009

This article from the Cleveland clinic journal of medicine discusses very important issues in the diagnosis and differential diagnosis of Myocardial infarction.

Read the article here

“Several international cardiovascular societies have revised their diagnostic criteria for acute myocardial infarction (MI) (J Am Coll Cardiol 2007; 50:2173–2188). The cornerstone of diagnosis remains a high level of clinical suspicion, serial electrocardiograms, and troponin levels. This article reviews the new definition and the appropriate clinical tools necessary to diagnose acute MI accurately”

KEY POINTS The clinical presentation of acute MI varies considerably from patient to patient. Therefore, one must consider the symptoms, serial electrocardiographic findings, and serial biomarker results in concert.

KEY POINTS Troponin I or T is now the preferred biomarker of myocardial necrosis. Still, troponin can be elevated in many conditions other than ischemic heart disease.

KEY POINTS Electrocardiographic signs of acute ischemia have been precisely defined, but electrocardiography can give false-positive or false-negative results in a number of conditions.

KEY POINTS MI is now categorized into five types depending on cause.

Posted in Cardiology | Tagged: , , | 2 Comments »

Hepatology 2009 from Bernard Sebastian Kamps

Posted by iskanbasal on February 4, 2009

From Bernd Sebastian Kamps

A new book on Hepatology in  free PDF , here is the textbook.

The textbook includes 300 pages about viral hepatitis and two chapters about
the management of HBV/HIV and HCV/HIV coinfection.

Hepatology 2009
A clinical textbook
501 pages
ISBN: 978-3-924774-63-9

Posted in Free medical books, General practice, internal medicine | Tagged: , , , | Leave a Comment »

Students whose behaviour causes concern: Case history

Posted by iskanbasal on January 2, 2009

I found this article from the British medical journal interesting as it concerns either medical student or medical professionals.

“What should you do when you see a fellow student behaving inappropriately? After a group of students wrote to the BMJ about their experience during an elective, we sought the opinions of an ethicist (doi:10.1136/bmj.a2882), a dean (doi:10.1136/bmj.a2884), a GMC representative (doi:10.1136/bmj.a2876), and a lecturer from an African university (doi:10.1136/bmj.a2875)”.

Posted in Medical education, Medstudent | Tagged: , , | Leave a Comment »

The Physical Examination

Posted by iskanbasal on June 6, 2008

“This month we introduce a new series, The Physical Examination,
kicked off by a paper by Drs. Diaz-Guzman and Budev on evaluating pleural effusions
(page 297). The series will be managed by David Rolston, MD, our deputy editor”.

This announcement  introducing a new section in the cleveland Journal of Medicine that i would like to follow. I have a link to this journal here in the rigth side bar below “Reading room”. But the surprising thing for me is what the editor is pointing out in his presentation to the series:

“The physical examination used to be a foundation of clinical practice, but it is
under assault. A specialist in inpatient medicine here at Cleveland Clinic decried the
inefficiency of time spent by residents performing and documenting the examination

How often, he asked, does the examination actually change the diagnostic workup?……”

read the article here.

I also know about the Jama’s section on the physical examination, but this is much more sophisticated to read as it discusses the evident-base findings to the different manuvers in performing a physical examination.

this is the first article of this section at the Cleveland Journal of medicine:

accuracy of the physical examination in evaluating pleural effusion”

Posted in Clinical examination, Medical education, medical journals, Signs and symptoms | Tagged: , , | Leave a Comment »

Osteoporosis in Men

Posted by iskanbasal on April 7, 2008

This is the last title in the Clinical practice Audioarticles at the NEJM.

“A 65-year-old asymptomatic man is concerned about his risk of osteoporosis. His mother died after a hip fracture at 74 years of age. The patient has no history of fractures but has lost 7.6 cm (3 in.) in height; he does not smoke and has never taken corticosteroids. He drinks two glasses of beer (16 oz, or about 0.5 liter, each) per . . .”.

The audioarticles need now an individual subscription.

Posted in Medical education | Tagged: , , | Leave a Comment »

 
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