Examining a Diabetic Patient

 General Medicine  Comments Off
Aug 072012
 

Diabetes mellitus is a clinical syndrome characterized by chronic hyperglycemia and disturbances in carbohydrate,lipid and protein metabolism. A patient with diabetes need a complete physical examination to look for any related complications and to manage accordingly.

General Appearance

Check the weight and look for obesity and measure BMI

Facial appearance: note any features of cushings disease

State of hydration

Lower Limbs

Inspect and look for any ulceration, infection, hair loss, skin atrophy.

Check injection sites on the thigh and note any skin atrophy due to insulin use.

Palpate all the peripheral pulses that includes femoral, popliteal, posterior tibial, dorsalis pedis.

Check pedal edema that can be present due to nephropathy.

Feel the tempreture as the feet may be cold due to ischemia.

Do the neurological assessment by  checking the sensations including those of dorsal column.

Reflexes may be diminished due to neuropathy and also look for any signs of proximal muscle wasting.

Joints for Charcot’s joints ( loss of proprioception )

Upper Limbs

Nails : for candidiasis

Feel upper limb injection sites

Check Blood pressure in supine and standing to detect autonomic neuropathy Continue reading »

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Acute pancreatitis

 General Medicine, General Surgery  Comments Off
Aug 032012
 

Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland. Acute pancreatitis is sudden swelling and inflammation of the pancreas. In acute cases the gland heals without any impairment of function or any morphologic changes.

Acute pancreatitis can have severe complications and high mortality despite treatment. While mild cases are often successfully treated with conservative measures.

Etiology

The pancreas is an organ located behind the stomach that produces chemicals called enzymes, as well as the hormones insulin and glucagon. Most of the time, the enzymes are only active after they reach the small intestine, where they are needed to digest food.

When these enzymes somehow become active inside the pancreas, they eat (and digest) the tissue of the pancreas. This causes swelling, bleeding (hemorrhage), and damage to the pancreas and its blood vessels.

Acute pancreatitis affects men more often than women. Certain diseases, surgeries, and habits makes more likely to develop this condition.

The condition is most often caused by alcoholism and alcohol abuse (70% of cases in the United States). Genetics may be a factor in some cases. Sometimes the cause is not known, however.

Other conditions that have been linked to pancreatitis are:

  • Autoimmune problems (when the immune system attacks the body)
  • Blockage of the pancreatic duct or common bile duct, the tubes that drain enzymes from the pancreas
  • Damage to the ducts or pancreas during surgery
  • High blood levels of a fat called triglycerides.
  • Injury to the pancreas from an accident

Other rare causes may include:

  • Complications of cystic fibrosis
  • Hyperparathyroidism.
  • Reye syndrome
  • Use of certain medications (especially estrogens, corticosteroids, thiazide diuretics, and azathioprine)
  • Viral infections, including mumps coxsackie B,  and campylobacter.

Clinical Signs and Symptoms

The most common symptom of acute pancreatitis is pain. Almost everybody with acute pancreatitis experiences pain. Continue reading »

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Managing Hypertensive Emergency

 General Medicine  Comments Off
Aug 022012
 

A hypertensive emergency (formerly called “malignant hypertension”) is severe hypertension (high blood pressure) with acute impairment of one or more organ systems (especially the central nervous system, cardiovascular system and/or the renal system) that can result in irreversible organ damage. In a hypertensive emergency, the blood pressure should be substantially lowered over a period of minutes to hours with an anti hypertensive  agent.

Definition

The term hypertensive emergency is primarily used as a specific term for a hypertensive crisis with a diastolic blood pressure greater than or equal to 120 mmHg and/or systolic blood pressure greater than or equal to 180mmHg. Hypertensive emergency differs from hypertensive crisis in that, in the former, there is evidence of acute organ damage.

Laboratory Evaluation

Obtain electrolyte levels, as well as measurements of blood urea nitrogen (BUN) and creatinine levels to evaluate for renal impairment. A dipstick urinalysis to detect hematuria or proteinuria and microscopic urinalysis to detect red blood cells (RBCs) or RBC casts should also be performed

A complete blood cell (CBC) and peripheral blood smear should be obtained to exclude microangiopathic anemia, and a toxicology screen, pregnancy test, and endocrine testing may be obtained, as needed.

Management

If a patient presents to the emergency department with a high B.P the role of the treating physician is to determine either the patient is exhibiting any signs of end organ damage or not.

Thus, optimal control of hypertensive situations balances the benefits of immediate decreases in BP against the risk of a significant decrease in target organ perfusion. The emergency physician must be capable of appropriately evaluating patients with an elevated BP, correctly classifying the hypertension, determining the aggressiveness and timing of therapeutic interventions, and making appropraite decisions. Continue reading »

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