Pathophysiology of Acute Coronary Syndrome.

Acute coronary syndromes result from coronary plaque disruption that exposes the vascular basement membrane to circulating blood cells and plasma components. Exposure of the basement membrane leads to generation of a thrombus.

The formation of a thrombus consists of four distinct phases: platelet adhesion, activation, aggregation, and stabilization. The first step in this process is endothelial disruption, or plaque rupture, which exposes subendothelial collagen and other platelet-adhering ligands, such as von Willebrand factor (vWF) and fibronectin. Platelet receptors bind these ligands, causing adhesion of a thin platelet monolayer. Adhesion occurs primarily through binding of platelet glycoprotein IIb/IIIa receptors to collagen and GP Ib receptors to von Willebrand factor. The adhered platelets become activated and release alpha granules, which contain adenosine diphosphate (ADP), thromboxane, and serotonin. These substances, as well as other platelet agonists, cause local vasoconstriction and further activate surrounding platelets. Aspirin, a cyclooxygenase inhibitor, inhibits the synthesis of some of these thrombogenic substances, therefore slowing thrombogenesis activation. Platelets skimming along blood vessel walls recognize and adhese to certain proteins in the basement membrane including collagen, fibronectin and others. These and other platelets in this microenvironment are then activated by platelet agonists (ADP, epinephrine, thrombin, thromboxane A2, etc). Plaque disruption releases tissue factors that activate factor VII and the extrinsic coagulation pathway. The platelet surface activates both the extrinsic and intrinsic coagulation pathways, leading to the formation of thrombin. Thrombin converts fibrinogen to fibrin, thus providing a fibrin mesh that stabilizes the aggregate. Heparin inhibits this stabilization phase of thrombogenesis by combining with antithrombin III to inactivate factor X and prevent thrombin formation.

Platelet activation results in a conformational change of the platelet glycoprotein IIb/IIIa receptor on the surface and promotes externalization of the IIb/IIIa glycoproteins within. Each platelet contains 40,000 to 80,000 surface IIb/IIIa receptors and an additional 20,000 IIb/IIIa glycoproteins stored interiorly. Once platelet activation occurs, the glycoprotein IIb/IIIa receptor readily binds divalent fibrinogen molecules, thus cross-linking the adjacent platelets. Known as "platelet aggregation," this process results in a local platelet plug at the site of endothelial injury.

Activated platelets express 40,000-80,0000 glycoprotein IIb/IIIa inhibitors on their cell surfaces. Fibrinogen, a bivalent protein freely circulating in the serum, can then bind at each end to a glycoprotein IIb/IIIa receptor on two different platelets. This will quickly lead to a platelet –fibrinogen –rich thrombus in a coronary artery at the site of the initial plaque rupture. 

If the thrombus obstructs flow of blood to downstream myocardium, ischemia or frank infarction is the result.

Focus Assessment with sonography for trauma.

Focused assessment with sonography for trauma (FAST), on the other hand, is an important and valuable diagnostic alternative to DPL (Diagnostic Peritoneal Lavage) and CT that can often facilitate a timely diagnosis for patients with BAT(Blunt abdominal Trauma)

The benefits of the FAST examination include the following:

• Decreases the time to diagnosis for acute abdominal injury in BAT
• Helps accurately diagnose hemoperitoneum
• Helps assess the degree of hemoperitoneum in BAT
• Is noninvasive
• Can be integrated into the primary or secondary survey and can be performed quickly, without removing patients from the clinical arena
• Can be repeated for serial examinations
• Is safe in pregnant patients and children, as it requires less radiation than CT
• Leads to fewer DPLs; in the proper clinical setting, can lead to fewer CT scans (patients admitted to the trauma service and to receive serial abdominal examinations)

Contraindications to Thrombolysis

Absolute contraindications to thrombolysis include active internal bleeding, history of hemorrhagic stroke, head trauma or major surgery within four weeks, recent thromboembolic CVA and persistent uncontrolled hypertension.

The Essence of Life

Hi everyone, I know its been quite a while. Thank you all for the messages, keep them coming.


Yeah, really i have been doing a lot of thinking on what the real essence of life is.
Life is defined as the existence of an individual human being.
As doctors we learn on how to care for people to preserve their lives
Every single disease has a downward toll it could take and cause death and this is what we work to prevent (the downward toll) but many as medical professionals seem to forget this, we think we are healers. Well i wouldn't agree with anyone on that because all we try to initiate is the physiological healing process and if the body doesn't arise to the challenge then our quest will be futile.
Yeah, we seem to witness people die and babies given birth to but yet we don't have power over life only God has but then do we acknowledge him for it. We have lost consciousness of the fact that he is the author of life for funny reasons
1. We have still gotten the breath of life
2. Every thing seems to be going on fine in our life

But well after all this said and done
After all this achievements
After this unending race
What will you be remembered for; A snake passing by a rock leaving no landmarks??
Nay, is that what its all going to be at the end?
Take a minute, close your eyes and take a deep breathe, ask yourself why you are still living? Why God has chosen to keep you alive to achieve purpose, many are gone 6fts below now not because they planned for it. So what is your purpose, to keep seeking this unending earthly treasures?
 Possibly, you are even counting days to becoming a doctor--- you got a set out plan on how to become a consultant, fellow, professor, a politician, whatever? But is it not all Vanity with no fulfillment and satisfaction if God is not in it, i solemnly tell you there is a continual lust to keep running and if your gaze are on things that will go with the wind, then its all a messed up life.
Seek eternal treasures and i tell you the treasures of this earth will be added unto you and the race would be worthwhile because you are assured of the future.
So my beloved ones get understanding with all thy getting.


Yeah, its the ramblings of a medic......
                                          PEACE.

SUMMER PRACTICE 1

After 6 weeks of clinical rotations, taking me to a teaching hospital and private hospital facilities in Nigeria, i have finally seen what it seems like to be a working doctor.It has been quite an adventure, and I feel I have grown much not only as a physician-in-training but as a person. I've seen the start of  life when we delivered  newborn patient during OB/Gyn, and the end of another when I took turns performing CPR,but thank God she woke up. I’ve been amazed at how adaptable the human body can be,, but I’ve also been perplexed at how vulnerable our bodies can be at the same time, with a fine line between life and death.

It’s easy to get emotional with cases like these, as we are all human beings with feelings, but we learn to set emotions and biases aside for the time being and focus on treating the patient to the best of our abilities, no matter if the patient is the victim or the criminal. While we strive to understand the mechanisms behind disease and how to manage them, much of medicine still remains mysterious and beyond control of even the most trained of physicians. It’s been a pleasure and honor to be able to experience the world of medicine.

1. Writing H&Ps

During your clinical years, residency, and beyond, you’ll be writing a lot of notes on the patients you see. The most common types of notes you’ll write are H&Ps (aka History & Physical or the similarly related Consult Notes) and SOAP notes (aka Progress Notes). The H&P is the note you write when you see a patient for the first time, in which you record the patient’s initial complaints, findings, and background history. Naturally, knowing how to write H&Ps requires knowing how to do a thorough interview and physical examination. There is no one single way to write the H&P, Consult, or SOAP notes, and you’ll notice that different doctors may write them slightly differently. Regardless, here are the basic components of the H&P:

• CC — Chief Complaint (or Reason for Consult if you’re writing a consult note)
• HPI — History of Present Illness
• ROS — Review of Systems (N/V, Diarrhea/Constipation, HA, CP, SOB, etc.)
• PMH — Past Medical History
• PSH — Past Surgical History
• Medications
• Allergies
• SH — Social History (smoking/EtOH/drugs, occupation)
• FH — Family History
• VS — Vital Signs (temperature, blood pressure, pulse rate, respiratory rate, oxygen saturation)
• PE — Physical Exam Findings (General, HEENT, Neck, CV, Pulm, Abd, Ext, Neuro. Psych)
• Lab Results (CBC, CMP and other labs when applicable)
• Assessment and Plan

2. Writing SOAP Notes

As I stated above, the first note you write of a patient will be the H&P note. Every subsequent time you visit the patient, you’ll write a Progress Note (aka SOAP Note), to update on the progress of your patient’s hospital stay and make updated plans. The Progress Note is often called the SOAP note because of the acronym of its four components: Subjective, Objective, Assessment, and Plan. Often, you’ll see that the assessment and plan written together as one section with the listing of the assessed diagnoses, and the plans written under each diagnosis. Here are the basic components of the SOAP note:

•  S — Subjective is what the patient says. It could be quotes, or it could be information that the patient tells you. You also write the symptoms the patient denies having here.  i.e. “Pt c/o mild lower abd pain but says otherwise ‘doing well’. Denies N/V/HA/CP/SOB…” etc.

• O — Objective is what you find out about the patient, from physical examination, vitals, or lab values that you looked up about the patient. i.e. “NAD, HRRR, lungs clear, Abd soft/NT, no edema. Vitals: 97°-80-12-110/70. Labs: WBC 5.0, Hb 9.1….” etc.

• A — Assessment is a brief statement summarizing the big picture of how the patient is doing. i.e. “28 yo G1P1 EDC 9/2/12 s/p ND day #2 doing well…” etc.

• P — Plan is what you plan to do for this patient, like which medication you will prescribe, what the patient should do, what further test you want to order for the patient, or when the patient should follow up. i.e. ” continue post-partum care, repeat complete blood count in the morning, control pain with motrin…” etc.

3. Reading Radiographs

You’ll also encounter many situations during your rotations in which you’ll need to read X-rays, ultrasounds, CTs, and MRIs, whether it’s a chest X-ray during your internal medicine rotation, pelvic ultrasound during your OB/Gyn rotation, or CT of the abdomen during your surgery rotation prior to an abdominal aortic aneurysm repair.

4. Knowing Lab Values and Vital Sign Values

Knowing the normal reference values for vital signs and lab results will save you time and headache . Know what the lab values mean, and what their relationships are to each other (i.e. Increased BUN and Creatinine with a BUN/Cr ratio >20 usually means renal failure due to pre-renal cause, AST > ALT in alcoholic liver damage, etc.). Know important formulas like the Winter’s Formula and the calcium correction formula for hypoalbuminemia.  Know the cut-offs for normal blood pressure, pre-hypertension, and hypertension. Know cut-off values for BMI. Know cut-off values for pre-diabetes and diabetes at fasting and 2-hour post-prandial. 

5. Learn Abbreviations

You will find that in practice, abbreviations are extensively used, and you will need to know them to understand patient charts and doctors notes, as well as to write your own notes. Here are some common abbreviations you’ll see during your rotations:

• Pt — Patient
• c/o — complains of
• s/p — status post, meaning a procedure is completed (i.e. s/p appendectomy in 2006, meaning the patient had an appendectomy in 2006).
• c (with a dash over it) — with
• Ø — no
• HA — headache
• MMM — moist, mucosal membranes
• PERRLA — pupils equal, round, and reactive to light and accomodation
• EOMI — extraocular movements intact
• RRR — regular rate and rhythm
• CTAB — clear to auscultation bilaterally (referring to the lungs)
• SOB — shortness of breath
• CP — chest pain
• ND/NT — non-distended/non-tender
• RUQ, LUQ, RLQ, LLQ — right upper quadrant, left upper quadrant, right lower quadrant, left lower quadrant.
• N/V — nausea and vomiting
• AAOx3 — alert and oriented to person, place, and time (the patient knows who he/she is, where they are, and what day it is)
• AAOx2 — alert and oriented to person and place, but not time (the patient knows who he/she is, where they are, but not what day it is)
• AAOx1 — alert and oriented only to person (the patient knows who he/she is, but not where they are or what day it is)
• NKA, NKDA — no known allergies, no known drug allergies
• NC — non-contributory
• BID — twice per day
• TID — three times per day
• PO/IV/IM — by mouth, intravenous, intramuscular
• DNR/DNI — do not resuscitate/do not intubate

6. Performing a Focused Patient Encounter

While during Basic Sciences we learn how to do a full exam and interview, which can take up to an hour to do. But in the clinical setting, we will need to learn how to do a much shorter, more focused patient encounter, meaning completing both the interview and physical exam within 15 minutes or less.  

7. Knowing Trade Names

While you won’t be tested on trade names on any of the licensing exams, you will quickly pick up the trade names of drugs as you go through your clinical rotations. The trade names are used as frequently as the generic names in practice, and everyone in the medical teams you will work with will know both, so try to make the effort to remember them. 
PEACE.

WPW--Wolf-Parkinson-White Syndrome

• Wolf-Parkinson-White Syndrome (WPW) is a reentrant rhythm disturbance that can degenerate into malignant wide complex tachydysrhythmias, which can be life-threatening.
• The likelihood of WPW with atrial fibrillation degenerating into ventricular fibrillation is exceedingly rare at 0.1%.
• Nodal agents, such as beta blockers, calcium channel blockers and adenosine, should not be used in wide complex tachycardias or atrial fibrillation for therapeutic or diagnostic purposes if WPW is suspected.
• Preferred agents for wide complex tachycardias where WPW is suspected are class 1A (e.g., procainamide) or class 3 (e.g., amiodarone) agents. ACLS 2005 guidelines emphasize the use of amiodarone in patients with depressed cardiac function (EF<40%).
• Electrolyte disturbances (e.g., hypokalemia, hyperkalemia and metabolic acidosis) can increase the risk for arrhythmia and Sudden Cardiac Death.

GLASGOW AND BLANTYRE COMA SCALE

Yeah, i am back again. I really wanted to make out time for another write-up b4 the week ran out. lol

My first time on rotation in an A&E ward, i had taken time to try to study and take in the images of things, situation and attitude of  patients, family members and the medical staff. In the process of looking around like a lukman in a busy room, i noticed a coma scale pasted on the wall and i snapped it........

I had hardly gone through it before a resident doctor asked me if i could grade a patient in a comatose state with Glasgow. Well i was so glad to say i could, so lucky me.

Then in pediatrics ward i was asked about the scale again and this time i wasn't lucky cos the consultant said what coma scale is used for grading in children that are not talking yet and thus i loooooooked ............

Well we will get back to the remainder of the story l8r.

This is the scale:

Pls note the differences between both 

There is no minimum of 0 in Glasgow, its 3 but in Blantyre there could be 0.

Blantyre total is 5 and Glasgow is 15

Both are used to grade improvement or deterioration in comatose patient

In Glasgow 7-9 is seen as the red-zone

In Blantyre its 2 that is redzone

You can thank me later but you could do well to add more differences and similarities not mentioned.

PEACE

Some Thoughts About Diabetes

A colorful all-natural veggie-filled lunch.

Rotating in endocrinology and working with many individuals with diabetes have really given me a peek into the life-long lifestyle challenges of living with diabetes. For those who become dependent on insulin, seemingly worse than the multiple daily injections and finger pin pricks before each meal is the freedom that is taken away when one lives with diabetes: the freedom to eat spontaneously, the freedom to eat certain classifications of food, the freedom to eat certain amounts of food. Every meal becomes a daily concern. There’s the pressure to have a strict routine eating habit, eating a consistent amount for each meal day after day, and to space apart meals to correspond with the dose and duration of the insulin. The complications that come years after, like kidney failure, blindness, nerve damage, and gangrenous hands and toes that lead to amputation are even worse, and unfortunately, I’ve seen quite a few patient that suffer further more from these.

Personally, seeing what diabetic patients have to go through everyday really makes me want to eat healthier, avoid sugar, and exercise more, doing whatever it takes to decrease the risk of diabetes. Right now, it makes me hesitate every time I eat something sweet. . Seeing what the patients have to go through with diabetes and the difficulty of its management makes me so worried about developing the disease. I don’t ever want myself, or anyone else, to have to go through some of the experiences of the patients I’ve seen.
so live healthy. 
peace

BASIC TISSUE TYPES.

Hello, everyone. I really do apologize as i do know this page is long overdue for a new post.

It was really a busy summer holiday and settling down after resumption hasn't been quite easy. Anywaz, i will try to make up for it. Lets get to business....

I was just going thru some stuffs and i  began to wonder why we had to cram the types of tissues that make up the human body in those days of histology. Well i beg ur pardon if you didnt cram it but well i did so looking back now i cant but laugh. 

This is it:

cell--------------tissue-----------------organ-----------system

so if that is it, remember dis, every organ u decide to envision in ur mind has 

1. epithelial lining

2. its supplied and supported by vascular and connective tissues

3. it has musculature

4. its innervated by a nerve.

Thats all...   Peace

Welcome Back To School............

Happy new month
Happy new season
Happy new session
Wishing us all the very best this new academic year.

AZOTEMIA

Azotemia refers to an elevation of blood urea, nitrogen and creatinine levels and is largely related to reduced GFR. It is without clinical manifestations but can be seen in biochemical index.

Its progression to clinical manifestations and systemic biochemical abnormalities is termed UREMIA.  Uremia is not characterized by failure of renal excretory functions only but also by a host of metabolic and endocrine alterations incident to renal failure. There are also secondary manifestations like uremic gastroenteritis, pheripheral neuropathy and cardiovascular involvements ( uremic pericarditis).

Azotemia can be classified by its pathological relation to the kidney as

1. Pre-renal: it include any extra renal disease that reduces perfussion of the kidneys and reduce GFR.

2. Renal: includes diseases of the kidney and occurs in Nephritic syndrome, renal failure

3.Post-renal: occurs as a result of obstruction to urine flow.

                                                                                                                        PEACE

FATIGUED at end of school year?

Its a privilege  to make out time to write again. I am so sorry i have been missing in action for a while.

Well today, i will be expressing my view on fatigue.

Its ending of school session around the world and we as students are all eager to finish school year and start our vacation. As it seems, due to this reason, quite a couple of us are just in school in body but our mind is off school. I wonder if its nostalgic feelings about having 2 months of our own timetable or .......

Well i really can't say what the reason for this is as we struggle to read and pass our exams in time.

On my end, i have discovered many are in a state of  FATIGUE. 

Fatigue could be physical or mental.

Tiredness is a psychological state of being. It is a transient decrease in maximal cognitive performance resulting from prolonged periods of cognitive activity. It can manifest as somnolence or lethargy. It is also being regarded as mental fatigue and can't be clinically measured.

Whereas, physically fatigue people can be clinically observed and treated with rest and other beneficial therapies. This form of fatigue can be measured as body fluid indexes could show changes. sleep deprivation in these end period alongside with continuous studying and reduced eating could cause this and note its just for a while because its reversible.

So friends, i indulge you all to finish the race in time. Put in more efforts, don't relent, keep pushing and remember the G- factor for with God alone is success possible.

                                                                                                                                            PEACE