Eruption Sequence of baby teeth (deciduous teeth)

                 Teeth                      Average “eruption” time (in months after birth)
1) Lower central incisor                                     8 months
2) Upper central incisor                                    10 months
3) Upper lateral incisor                                     11 months
4) Lower lateral incisor                                     13 months
5) Lower first molar                                          16 months
6) Upper first molar                                         16 months
7) Upper canine                                              19 months
8) Lower canine                                              20 months
9) Lower second molar                                    27 months
10) Upper second molar                                  29 months

Systemic Lupus Erythematosus: Classification Criteria

Differential Diagnosis of Lymphadenopathy

Syndromes in Rheumatoid Arthritis

1. Sjogren's syndrome (common):
keratoconjunctivitis sicca and xerostomia (dry eyes and mouth)

2. Felty's syndrome (rare):
arthritis, splenomegaly, neutropenia

3. Caplan's syndrome (rare):
multiple pulmonary nodules and pneumoconiosis

Only DMARDs (not analgesics or NSAIDs) alter the course of rheumatoid arthritis !!!

Malaysia: Health Human Resources 2011

Source: Health Facts 2012 by Malaysian Ministry of Health

Mnemonic for Ankylosing Spondylitis

Extra-articular Manifestations of Ankylosing Spondylitis
6 "A's"
Atlanto-axial subluxation
Anterior uveitis
Apical lung fibrosis
Aortic incompetence
Amyloidosis (kidneys)
Autoimmune bowel disease (UC)

Consider AS in the differential for causes
of aortic regurgitation!!!

Rule of 2s
AS occurs in
0.2% of the general population
2% of HLA-B27 positive individuals
20% of HLA-B27 positive individuals
with affected family member

The 2·3 Pattern of Smoking Cessation

• Onset of withdrawal is 2-3 hours after last cigarette

• Peak withdrawal is at 2-3 days

• Expect improvement of withdrawal symptoms at 2-3 weeks

• Resolution of withdrawal at 2-3 months

• Highest relapse rate within 2-3 months

Androgen replacement therapy

Indications:
hypogonadism(=impaired production or function of gametes or sex hormones or both

Contraindications:
1. prostate cancer
2. breast cancer
3. hematocrit >52%
4. congestive heart failure (CHF)

Types:
1. oral
-testosterone undeconate
-more negative effect on liver

2. muscular
-mixture of testosterone esters
-testosterone isobutyrate
-testosterone undeconate
-once every 2-3 weeks

3. buccal
-mouth patch/mucoadhesive polymer with testosterone

4. transdermal
patch(andropatch)
-testosterone patches are worn either on the body or on the scrotum
-body patch application is rotated between the buttocks, arms, back or abdomen
-applied once a day
gel(testogel)
-testosterone gels that are applied daily to the shoulders, upper arms, or abdomen.

5. implantation of testosterone capsule
-about 6 months

Monitor/follow:
1. Prostate-Specific Antigen (PSA)
2. Digital rectal examination (DRE)
3. lipid
4. liver function test (LFT)
5. hematocrit

Adverse effects:
1. benign prostatic hyperplasia (BPH)
2. prostate cancer
3. gynecomastia
4. fluid retention--> worsen hypertension and heart failure
5. liver damage
6. headache
7. polycythemia--> myocardial infarction, stroke, clot development
8. sleep apnea

4 cardiovascular drugs which are used for more than 50 years

1. Aspirin
-antiplatlet

2. Warfarin
-vitamin K antagonist

3. Digoxin
-cardiac glycosides

4. Spironolactone
-aldosterone antagonist

Needlestick Injury and Infection

Risk of Developing Infection from a Hollow Needle Puncture

Hepatitis B Virus (HBV) 30%
Hepatitis C Virus (HCV) 3%
HIV 0.3%

Gastric Ulcer vs Duodenal Ulcer

Gastric Ulcer

-more frequent in older patient, male:female 1:1
-epigastric pain
-food intake exacerbates pain
-patient tends not to eat --> weight loss
-risk of cancer (always perform biopsy!!)

Duodenal Ulcer

-more frequent in younger patient, male:female 3:1
-pain in right umbilical area(duodenal area)
-vomiting tend to relieve pain
-pain more frequent during hunger/night time/early morning
-food intake relieves pain
-patient tends to eat more --> no weight loss or weight gain
-lower risk of cancer
-bleeding more frequent (more ulcers)

Drug treatment for tuberculosis

Rifampin is the drug of choice for treatment; in most cases, the treatment duration is at least 18 months without rifampin

Ethambutol (EMB) is used to prevent rifampin resistance if the organism is resistant to isoniazid (INH); EMB can be discontinued as soon as the organism is found to be susceptible to rifampin and INH.

Pyrazinamide is used for the first 2 months of treatment to decrease the treatment duration from 9 months to 6 months if the organism is susceptible to rifampin and INH

Urine alkalinisation

1. Salicylate poisoning
- recommended in all symptomatic patients with regard of hypokalemia (common in salicylate poisoning)
- Diamox should NEVER be used as for acidemia and subsequent increased toxicity
- Urinary alkalinization by PO NaHCO3 enhances the elimination of weak acids: salicylates, phenobarbital, chlorpropamide, chlorophenoxy herbicides, formic acid, and methotrexate

2. Pure uric acid stones
- dissolved with oral alkalinization, K citrate, Na bicarbonate --> urinary pH 6.5-7

3. Rhabdomyolysis
- IV bicarbonate

4. Hemoglobinuria (heatstroke)

Bi- and Trifascicular Block

Bifascicular block or one-and-a-half block = Left Anterior Fascicular Block (LAFB)/ Left Posterior Fascicular Block (LPFB) + Right Bundle Branch Block (RBBB)

Trifascicular block = LAFB/LPFB + RBBB + First degree AV block

Wolff-Parkinson-White (WPW) Syndrome

Had practical lesson in Arrhythmia-ICU today. Dr. Valek kicked off the session with some ECGs for us to interpret. I am quite satisfied with myself for not knowing 'only' 4 of them, LOL. I must really thank Dr. Thaller :)

I was quite amazed by the multiple ECGs of a same patient with WPW syndrome.

Something I read about WPW syndrome but did not realised its importance:

-if there is short PR interval, wide ORS with delta wave but patient doesn't have paroxysmal tachycardia, the patient has only preexcitation and this is called WPW pattern.

-if there is WPW pattern(as mentioned above) and patient has history of paroxysmal tachycardia, it is then only called WPW syndrome

-the most common arrhythmia in WPW syndrome is Atrioventricular Reentrant Tachycardia(AVRT)

-there are two forms of AVRT: orhtodromic AVRT and antidromic AVRT (depending on how the impulse goes in the reentrant circuit)

-Vagal maneuvre can be used to terminate AVRT as it transiently blocks AVN

-Atrial Fibrillation and Atrial Flutter can occur too

-Rx: antiarrhythmics

-Do not use calcium channel blocker, digoxin or beta blocker!!

-iv procainamide for AF and AFL in patient with bypass tract. Electrical cardioversion can be considered

-radiofrequency cathether ablation (95% success rate)

*Study Lown-Ganong-Levine Syndrome too!

Abdominal Aorta Aneurysm (AAA)

Lucky to see a case of abdominal aorta aneurysm(AAA)on Thursday but maybe not so lucky for that patient because in case of aneurysm rupture, the mortality is quite high. Managed to see and feel what is written on textbook--- pulsatile abdominal mass above the umbilicus. It amazed me! We saw the CT angiography with 3D reconstruction too. Wow, it is just so unbelievable that such a big aneurysm has developed in his abdomen and produces so many 'bends' or 'kinks'. The patient is going to have endovascular treatment---a stent graft will be placed into his abdominal aorta to prevent the rupture.



Risk factors:
smoking, hypertension, age over 70 years old, family history of AAA

Symptoms:
75% asymptomatic
in case of acute expansion or disruption of wall: pain(abdominal, back, flank pain), hypotension, pulsatile abdominal mass rarely partila intestinal obstruction, ureteric obstruction and hydronephrosis, GI bleeding(duodenal mucosal hemorrhage, aortoduodenal fistula), aortocaval fistula, distal embolisation(blue toe)

Diagnosis:
pulsatile abdominal mass, bruits on auscultation, abdominal USG, CT, MRI, Doppler

Treatment:
smoking cessation, HTN control, DM control, hyperlipidemia control
surgery or endovascular options(stent graft)

Pioneers in Radiology

Curie - radium
Laterbur - MRI
Hounsfield - CT
Dotter - angiography
Cannon - GI radiology

'Disorders of calcium metabolism' and 'God doesn't like you very much'

Today we had a lecture on 'Disorders of calcium metabolism' with Prof. Broulik.

One of the slide was about 'DiGeorge's syndrome'.

He said 'This is bad luck.'

and the next slide was about 'Polyglandular Autoimmune syndrome'.

The comment he gave this time was:

'This is again bad luck. God doesn't like you very much.'


HAHAHAHAHAHAHAHAHAHA