Reading of this weekend from ward-round

Few interesting cases were seen in today's ward-round
1. A 60-year old lady who's previously well with only known hypertension was admitted with 1 month's history of progressive bilateral glove-stocking distribution of sensory loss, tingling pain, and proximal / distal muscle weakness. Examination showed wasting of small hand & feet muscles, power 3 in all 4 limbs, generalised hyporeflexia & hypotonia in all 4 limbs, CN VII / XII palsy, and mild bilateral ptosis. Otherwise, ECG, cardiovascular, GI, and urological symptoms were unable. Patient is currently investigated for nerve conduction abnormalities, and herself & family are uncertain about this thus deferred. Possible diagnosis include CIDP v.s. other causes of peripheral sensory-motor polyneuropathy
Reading:
- CIDP on emedicine

2. Found out from renal that statin-induced myopathy is more common in nephrotic syndrome. A young man in his mid-thirities was admitted for headache which turned out to be a cerebral sinus thrombosis. His cholesterol was noted to be very high thus recommended to increase his simvastatin to atorvastatin 80mg. Baseline LFT was normal, however his renal team came by and recommended his dose to be reduced because of increased rhabdomyolysis risk
- Further raeding on FDA

The Lunatic Lament - Story of Syphilis

There was a young man of Back Bay
Who thought syphilis just went away.
And thought that a chancre
Was merely a canker
Acquired in lascivious play.
Now first he got acne vulgaris,
The kind that is rampant in Paris
It covered his skin
From forehead to shin
And now people ask where his hair is.
With symptoms increasing in number,
His aorta's in need of a plumber
His hear is cavorting
His wife is aborting
And now he's acquired a gumma.
Consider his terrible plight -
His eyes won't react to the light
His hands are apraxic.His gait is ataxic.
He's developing gun-barrel sight.
His passions are strong as before
But his penis is flaccid, and sore.
His wife now has tabes
And sabre-shinned babies
She's really worse off than a whore.
There are pains in his belly and knees.
His sphincters have gone by degrees.
Paroxysmal incontinence,
With all its concomitants,
Brings on quite unpredictable pees.
Though treated in every known way,
His spirochetes grow day by day.
He's developed paresis,
Converses with Jesus,
And thinks he's the Queen of the May."

By Isaac Asimov
This poetic manifest reveals the myriad of sickening phenomenon arising from this chronic, indolent infection.

Further reading:
1. Links to emedicine on neurosyphilis

Simple approach to ABG interpretation

Have came across numerous ABG interpretation books, and so far this frame work provides the easiest & fastest application. Adopted from BMJ / TTSH Intensive care handbook.
Hope you may find this helpful too (note inter-personal preferences may vary)

Reading: Procalcitonin

Today I was asked to order procalcitonin test for a patient with suspected infection.
The patient was well, no particular localising symptoms currently. However approximately 2 weeks ago he was treated as probable meningoencephalitis with improvment of headache & diplopia. Lab results returned normal, and an informative lab message showed:

" Procalcitonin: +ve if elevated suggestive of bacterial / parasite / fungal infections. It may not be raised in localised infection, chronic inflammation, or chronic autoimmune diseases. It is not usually elevated in fracture / surgery, and rarely exceeds 5. Procalcitonin begins to rise after onset of infection in 2hrs, peaks in 12 - 24 hours, and 1/2 life 22 - 29 hours".

Attacked reference: wikipedia (inside contain reading links)

Mnemonics - Extensor plantars & absent ankle jerks (PG)

Sex can make those 'F***ing' ankles clutch down (From anonymous author)

Sub-acute combined degeneration of the cord (B12 deficiency)
Cauda equina lesion
Motor neuron disease
Tabes Dorsalis *syphilis*
Frideriech's ataxia
CVA + Diabetes

Menomoics - Autonomic Drugs

Anticholinergic drug side-effects:
"Know the ABCD's of anticholinergic side-effects"
- Anorexia
- Blurred vision
- Constipation / confusion
- Dry mouth / dilated pupils ('ANTI' constriction)
- Sedation / urinary stasis


Cholinergics - "IF you know these, you will be 'LESS DUMB'"
- Lacrimation
- Excitation of nicotinic receptors
- Salvation
- Sweating
- Diarrhoea
- Urination/micturition
- Broncho-constriction
* 'Con' stricts the pupil

Neurology reading of the week: GBS, CVA, Peripheral neuropathy

First day in neurology's encountered with few interesting cases:
- Stroke
- Guillain Barre Syndrome
- Peripheral neuropathy - secondary to amyloidosis

Please click on the links below
1. GBS on eMedicine: See my summarised sheet on google docs
2. Stroke (NEJM Review)
3. Peripheral neuropathy

Presentation of the week - ECG changes in a poisoned patient

This week was asked to prepare a talk on ECG rounds. The topic that I chose was ECG changes in a poisoned patient. It is interesting to know how different drugs (especially anti-arrhythmics) can cause ECG changes and it can help us appreciate the myocardial electrophysiology.
Hope you'll find this helpful.