Modification in Acute Rheumatic Fever Diagnostic Jones Criteria

The previously recommended diagnostic criteria used in Acute Rheumatic Fever has been modified in 2014 by the WHO and American Heart Association. Segregartion of the risk group into High risk and low risk group is an important feature.Low risk population are those who have incidence of RHD (Rhematic Heart disease) less than or equal to 1/1000 population/year and incidence of ARF (Acute Rheumatic Fever ) less than or equal to two /100000 population.

The previously accepted Jones Criteria still holds true for the low risk population.

HOWEVER, in the high risk population just the presence of MONOARTHRITIS or POLYARTHALGIA is sufficient to diagnose the ARF as MAJOR CRITERIA unlike in previous system where polyarthritis was must. 

Similarly in Minor Criteria the presence of MONOARTHALGIA is sufficient to daignose the condition. The value of ESR measured on the 1st hour with a value >= 30mm/hr is sufficeint  in low reisk populationwhile that of >= 60mm/hr is needed in low risk population to consider acute  rheumatic fever.

Presence of Clinically evident Sydenham Chorea is enough to diagnose the ARF.

Similarly, Arthritis with Carditis is enough to diagnose the condition.

Presence of Subcutaneous nodule or Erythema Marginatum with one of the major criteria diagnoses the condition.

Revised Jones Criteria 2014
Screenshot taken from http://circ.ahajournals.org/content/early/2015/04/23/CIR.0000000000000205

Visit http://circ.ahajournals.org/content/early/2015/04/23/CIR.0000000000000205 the site and download the PDF file for full details.

Malaria treatment guideline of Government of Nepal.

Malaria is endemic disease in Nepal.

The most common causative agent being plasmodium vivax and plasmodium falciparum. Plasmodium malariae has not been reported in the last 20 years and no cases of plasmodium ovale.

Of the total malaria cases 17-25% cases were plasmodium falciparum cases.

No deaths have been reported after 2014 in Nepal due to malaria and its associated complication.

Anopheles fluviatis and Anopheles annularis are the most common mosquito associated with malaria in Nepal.

The guideline provided by the government of Nepal for the treatment of malaria include the following drugs and regimens. The drugs are available free of cost at health post across the highly susceptible areas of Nepal.

Treatment of Uncomplicated Vivax malaria

Day 1	Chloroquine 600mg (10mg/kg) (4 tabs)	Primaquine 0.25mg/kg (2 tabs)
Day 2	Chloroquine 600mg  (10mg/kg) 4 tabs	Primaquine 0.25mg/kg (2 tabs)
Day 3	Chloroquine 300mg (5mg/kg) 4 tabs	Primaquine 0.25mg/kg (2 tabs)
Day 4-14		Primaquine 0.25mg/kg (2 tabs)

1 tab Choloroqine = 150mg base

1 tab primaquine = 7.5mg

Primaquine is contraindicated in children < 6 months and breastfeeding ladies.

If the status of the patient about G6PD deficiency can not be ruled out, Primaquine 0.75mg/kg once a  week for 8 weeks to be used.

Treatment of uncomplicated falciparum malaria

Day 1	Coartem 4 tab 2 doses 12 hours apart (Artemether 80mg and Lumefantrine 480mg.)
Day 2	Coartem 4 tab 2 doses 12 hours apart (Artemether 80mg and Lumefantrine 480mg.)
Day 3	Coartem 4 tab 2 doses 12 hours apart (Artemether 80mg and Lumefantrine 480mg)	Primaquine 0.25mg/kg (2 tabs) single dose

Coartem is a Artimesinin Combination therapy (ACT) and consists of Artemether and Lumefantrine in a combination of 20mg  and 120mg of drugs respectively.

1 tab primaquine = 7.5mg

In first trimester of pregnancy, Coartem is not recommended and hence quinine isused.

Tab Quinine 10mg/kg (2 tabs) q8hrly for 7 days

 1 tab quinine = 300mg

Treatment of Complicated falciparum malaria

For >20kg BW Inj Artesunate 2.4mg/kg BW IV/IM at stat (0), 12 hours and every 24 hours then after For <20kg Inj Artesunate 3mg/kg BW IM at stat (0), 12 hours and every 24 hours then after

OR

Inj Artemether 3.2mg IM stat and 1.6mg IM once daily

OR

Inj Quinine 20mg/kg stat BOLUS dose over 4 hours in D5 or DNS solution Inj Quinine 10mg/kg q8hourly MAINTAINENCE dose with the drug not exceeding 5mg/kg/hour

Once the patient tolerates oral medication start on ACT/Primaquine or Quinine therapy as in uncomplicated falciparum malaria.

Artesunate can be given in any trimester of pregnancy.

Malaria treatment Guideline recommended by Government of Nepal.
Source: http://edcd.gov.np/malaria-treatment-chart

For more details of malaria control and treatment of Nepal, visit http://www.edcd.gov.np/publications/category/27/Malaria.

Etiological Classification of Anaemia

Anaemia is defined as the decrease in the RBC number, hematocrit or the hemoglobin level as per the age, sex and the altitude at which the patient resides. Anaemia results from the reduction in the oxygen carrying capacity of the blood and results in the symptoms developed due to the reduced oxygen supply of the organs.

Anaemia can be divided based upon the etiology, morphology and the clinical presentation. 

Based upon the cause, anaemia develops either due to blood loss, increased destruction or decreased production. The Blood loss could be acute as in trauma( Concealed hemorrhage as in blunt abdominal or chest  injuries and  revealed hemorrhage as in road traffic accidents), in the post operative period following a major surgery, or acute obstetric blood loss as in ectopic pregnancy, incomplete abortion or in postpartum hemorrhage. Most of these cases present as SHOCK rather than anaemia and require active intervention  with IV fluid. Moderate amount of loss can lead to anaemia.

Chronic Blood loss is most commonly seen with GI ulcerations , parasitic infestation most commonly hookworm, and abnormal menstrual bleeding like polymenorrhagia.

Classification of Anaemia based on etiology.

Hemolysis is either due to intracellular cause or extracellular cause. The cellular cause generally leads to abnormal RBC which are easily sequestered in Spleen and hence destroyed. All the membrane defects  either acquired (Paroxysmal Nocturnal Hemoglobinuria) or congenital (Spherocytosis or ovalocytosis), Enzyme defect (G6PD deficiency), Hemoglobinopathies  (Thalassemia spectrum of  disease).

Extracellular causes  could be autoagglutination as seen in transfusion related ABO incompatibility or Rh incompatibility seen in Erythroblastosis fetalis.  Autoimmune diseases such as  SLE, RA, malignancy, drugs, mycoplasma  infection can cause hemolysis. Other extracellular  causes include    

mechanical trauma, Infections like  malaria, lead poisoning, Viper venom, and sequestration seen in Hypersplenism can cause hemolysis.

Classification of hemolytic anemia

The decrease production of RBC is either genetic defect as seen in thalassemia or fanconi an anemia,

nutritional  deficiency of iron, vitamins and proteins.  Deficiency of erythropoeitin seen in renal failure, and anaemia of chronic illness.  Leukemia has pancytopenia, and space occupying lesions in marrow restrict RBC growth. parvovirus b19 and chronic infection as well cause anaemia.

Causes of decreased production of RBC.

Complete Chest Examination (Respiratory System): How to describe.

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>>May be first you want to see how to write a history of COPD.

Elderly  gentleman, ill looking, thin built (with Temporal hollowing, Buccal Hollowing, Supraclavicular, suprasternal hollowing, Subclavicular hollowing, with thin limbs, thin skin and prominently visible vessels) lying in semirecumbent position with IV canula of 20G and nasal prongs delivering 3l of O2/min is conscious, cooperative and well oriented to time, place and person.

On general physical examination, there is central cyanosis with peripheral cyanosis.

Bilateral pitting edema extending upto the mid thigh is present which is non tender with normal overlying skin. Sacral edema is present.

But no clubbing, no pallor, no icterus seen. Hydration status of the patient is normal. Accessible Lymph nodes are not palpable.

On examination of the vital signs,

Pulse is 70 beats/min taken on right radial artery, regular, catacrotic, euvolemic, no radio radial and radio femoral delay. All the peripheral pulses are palpable, and no carotid bruit heard. Condition of the arterial wall is normal.

Blood pressure measured on the right arm in sitting position was 130/80 mm of mercury.
Temperature taken on right axilla was 37.2^oC.

Respiratory rate is 22/min, thoracoabdominal type with nasal flaring, pursed lip breathing and use of accessory muscles of respiration.

JVP was elevated and was 5 cm from the manubriosternal angle in the semirecumbent position.

On examination of the respiratory system

On Inspection of the upper respiratory tract , no DNS, Polyp, discharge or congestion present on the nose. Nasal flaring and Pursed lip breathing present. Use of accessory muscles of respirations seen (with prominent SCM, Scalene, trapezius. Rectus abdominis, pectoralis). The oral cavity looks grossly normal with no congestion, ulcerations on posterior pharynx and bilateral tonsils looks grossly normal.

On inspection of Lower respiratory system, shape of the chest is tending to barrel. 
Trachea is present in the midline.

Bilateral symmetry of chest wall is seen. Bilateral equal movement with respiration present.

Apical Impulse is not visible.

No other visible pulsation, scar marks and dilated vessels seen.

Presence of Supra and Infrascapular hollow is present and equal in both side. 

Prominent and Horizontal ribs with widened and hollow intercostal space seen but no intercostal indrawing, no subcostal indrawing and no intercostal fullness.

Spine is centrally placed and no skeletal deformity present. No drooping of Shoulder. 

No Respiratory examination is complete without Cardiac examination. Click here to know how to describe the precordium.

On palpation, Trachea is centrally placed. Apical impulse is not palpable.

Chest movement is bilaterally equal.

On measurement of the chest, chest expansion on inspiration was 84.5cm and expiration was  82cm with inspiratory expiratory difference of 2.5cm. The Anteropostero Diameter was 35 cm and Transverse diameter is 40cm and AP to Transverse ratio being 7:8(tending  to barrel). 
The Right hemithorax is 41 cm and left hemithorax is 41 cm.

Increased vocal fremitus palpable in the right subcostal  area.

On percussion, dull note was present over the right sub mammary region.  Resonant sound heard on the other area all over the  chest.

Liver dullness started from 6^th right Intercostal area in the midclavicular line.

Cardiac Dullness was not obliterated.

On Auscultation,  Bilaterally decreased air entry with prolonged expiration is present. Bronchial breath sound heard over the right sub mammary region along with Crackles present. Increased vocal fremitus present with aegophony on right sub mammary region.

Provisional diagnosis: COPD with right inframammary consolidation.

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Rule of 3: Cerebellum

Rule of three 

Cerebellum

 Rule of three applies in cerebellum where it can be divided in 3 zones based upon its fucntion and phylogey. Similarly, three lobes are formed by primary and posterior fissures. The cerebellum is suppied by three arteries viz Superior cerebellar artery (SCA) and Anterior inferior cerebellar artery (AICA) both branches of basilar artery while posterior inferior cerebellar artery (PICA) is a branch of pair of ascending vertebral arteries.  On cellular level  the superficial layers are formed by basket cells and stellate cells forming the molrcular layer. These cells project into Purkinjee fibers which are the inhibitory cells releasing GABA and project into the deep nucleus. Deep Nucleus includes Globose, Emboliform , Dentate and Fascitigeal nuclei. 

There are three surfaces anatomically the superior or the tentorial surface beneath the tentorium cerebri. Lateral Surface covered by the petrosal bone and posterior by the occipital bones.

Rule of Two: Xray

There are various topics in medicine that can briefly be remembered with a single number and such topics are included in this page titled RULE OF NUMBERS.

Rule of Two

Reading X-ray in Orthopedics

While reading  X-ray in orthopedics, rule of two applies. That is when-ever you read a X ray you need to have 2 views, one joint above the suspected injury site and 1 joint below, comparing both the limbs, repeated/taken 2 weeks apart and commented by 2 orthopedicians.

2 View: AP and lateral view recommended in mostly to see the deformity/ displacement , angulation

2 abnormalities: If one abnormality found always look for the next one as finding one might mask the concurrent another injury.

2 Joints: One joint above and 1 joint below to rule out involvement of joints (r/o assosciated subluxation and dislocations)

2 limbs:  If doubtful always compare with contralateral limb.

2 occasions: Always compare with previous Xray  if available.

2 evaluations: If no previous films, reevaluate the patient and repeat Xray on followup.

2 reviews:  If doubtful should always be reviewed by another observer.

Rule of 9: Burn

Wallace Rule of Nine
For rough estimation of the body surface area that is affected by Burn, Wallace rule of nine is used. It  is used for adult. Slight modification is done in case of children as they have larger head compared to adults and hence Lund and Browder chart is used. The skin is grossly allocated the value of 9% as demostrated in the chart and diagram below.

Wallace Rule of Nine
(source: https://twitter.com/pjonline_news/status/596994284466802688)

Body part
Head	9%
Right upper extremity	9%
Left Upper extremity	9%
Anterior Chest	9%
Posterior Chest	9%
Anterior right lower extremity	9%
Posterior left lower extremity	9%
Posterior right lower extremity	9%
Posterior left lower extremity	9%
Perineum	1%
Total	100%

Body part

Head

9%

Right upper extremity

9%

Left Upper extremity

9%

Anterior Chest

9%

Posterior Chest

9%

Anterior right lower extremity

9%

Posterior left lower extremity

9%

Posterior right lower extremity

9%

Posterior left lower extremity

9%

Perineum

1%

Total

100%

Precordial Examination: How to describe

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Do you know the Jones Criteria used for diagnosing  the acute Rhematic fever has been recently modified. Learn more.

On inspection of the precordium, there is no precordial bulge (Precordium looks normal in shape). Apical impulse is visible 1 cm lateral and inferior to the left  nipple. No visible pulsations seen (JVP, Supraclavicular, suprasternal, LLSB, epigastric). No scar marks (Incision of CABG, mitral valve replacement, pacemaker) and puncture marks (Pericardiaocentesis) seen . No dilated veins seen.

On palpation, Apex beat is located 1 cm lateral to the midclavicular line in the 5^th ICS. (After measuring with a scale.) The character of apical impulse is hyperdynamic (heaving/ tapping/ hyperdyanamic and hypodynamic).  No palpable S3/S4 and thrills.

No thrill and palpable S3 over the tricuspid area.

No heave over the LLSB.

No palpable P2. No thrill felt over the aortic and pulmonary area. No thrill radiating along the carotid and Infraaxillary area.

On ausculatation, Loud S1(soft/loud) is heard at the apex. S2 is heard. (there is no splitting of S2 and no audible P2). S3and S4 were not audible. No murmur(diastolic/systolic), no added sound(opening snap, click), no precordial rub and knock noted.

(If murmur present)

High pitch (High/Low) Mid (Early/mid/late) Systolic Murmur (Systolic/ Diastolic) of Grade III(Grade of murmur) is heard over the apex (site of auscultation) at the peak of expiration (Inspiration/ Expiration) in the left lateral position (forward stooped/ left lateral position) with radiation to axilla(abdomen/ along carotids.)

No Precordial examination is complete without respiratory examination. Follow link to know how to describe the chest.

Note: All the things placed in brackets are the alternatives that can be used to describe certain cardiac condition and its corresponding findings.

Abbreviations

CABG coronary Artery bypass graft

ICS intercostal space

JVP jugular venous pressure

LLSB left lateral sternal border

P2/A2 pulmonary second heard sound / aortic second heart sound

S1/S2/S3/S4 Heart Sounds.

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