Bone Pain

This is a good website for you to learn and also gauge the types of bone pain patients experience, variations of their bone pain and their grievances. They complain because they have a real reason and often doctors don't seem to care much about their patients. Please do read these cases and make your own notes. Be happy and thankful that you do not suffer from any form of bone pain that these patients are experiencing.

Matching Conditions to Medications

OSTEOARTHRITIS (OA)

STUDY QUESTIONS

1. How does pain arise?
2. What are the common causes of pain?
3. What are the simple non invasive measures for pain management?
4. What are the invasive complex measures for pain management?
5. What are the pain medications?
6. How are pain medications formulation/made?
7. What are some examples of pain medication commonly used by patients?
8. What are the adverse effects of pain medications?
9. How can bone changes be monitored?
10. What are the necessary clinical investigations in bone pain?

LOOK UP

1. C-Reactive Protein (CRP)
2. ANA
3. SED

MEDICATIONS

Make a list of medications mentioned by the patients and look them up.

CASES

I have picked out cases for you to try and work them out on your own.

Case 1

I forgot to mention that I was tested for RA, which was negative, I was told. I haven't been retested in several years, and I also have not been sent for any bone scans, x-rays, or other screenings for Osteoarthritis (except for my neck, done by the chiropractor), or any of the other related diseases. I do run a high level of C-Reactive Protein, which was recently higher than ever, and I do not know what my ANA is, or if my SED rate is elevated. Thyroid levels are low but within normal ranges... Hoping the orthopedic with run some thorough tests...

Case 2
I was diagnosed with Fibromyalgia at age 40, although symptomatic for a couple years prior to that. I am now 44. I have extreme fatigue, morning stiffness, joint pain in my hands, wrists, ankles, shoulders, and now in one of my knees. I also have severe chronic tendonitis in my right elbow which has now spread upward toward my shoulder. I do have some degenerated disks in my neck C3-C6 which causes frequent headaches. My body is tender to pressure, not only at the "tender points", but anywhere that the bone is close to the skin, such as forearms, shins, hips, etc. I went to a Rheumatologist who said I had a difficult to treat condition and should just learn to live with it! I went to physical therapy a few times, a chiropractor, and my family doctor. My family doctor is the only one who understands my frustration and she has been more than willing to do "trial and error" to see what helps me. Currently I only take Cymbalta, which helps considerably with the stress of living in pain, along with muscle relaxor Flexeral which helps me sleep. I have tried many NSAIDS but they really do not help me much since I have been taking them for so long, so I don't take them anymore. Excedrin Tension headache does helps with my neck/headache pain a bit. Nothing seems to help with my tendonitis except ice. I am going to see a different Rheum. but couldn't get in until December. I am seeing an orthopedic for my tendonitis next week. My biggest problem is because I "Look" fine, no one takes my pain and fatigue seriously and I get a lot of ribbing about being a "complainer" or a hypochondriac, which is almost worse than dealing with the pain!!

Case 3
I find it amazing how many of us suffer from multiple problems. I have had fibbromyalgia for over 30 yres, have had a brain tumor, breast cancer, PMR, osteoarthritis, have had both knees totally replaced, and degenative arthritis and bone sdpurs in my shoulder and neck. My hands and feet hurt constantly along with the muscles in my upper arms. Now I am having shortness of breath and sharp shooting pains up both sides of my neck with only minimal activity. I am in the process of going through tests to diagnose this. I recommend that every once in awhile you take a "wallow day"...where you just cry, feel sorry for yourelft, rail against the world and scream why me?? and then get up the next day, go to work, and live your life. My daughter has lupus and Raynauds, and she also takes a wallow day every so often. Believe me...it works. I don't know how this is all going to turn out but I am going to fight to the very end!

Find other cases at the link above and do your own self-study.

Type A blood needed for a 12-yo girl

This is a call for help from Facebook. Please help if you can.
TQ
Prof Faridah

Rizna Md Aros
Dear All,

This is Raja Nurkamilia, my cousin's daughter. Shes only 12years old. Shes in ICU PPUM fighting for her life. Anybody who are A+ blood type (preferably male donor) n able to help pls call 012 9196955 (rina) tq so much again. God Bless.

Share · Tuesday at 22:55 via Mobile ·
http://www.facebook.com/rizna.m.aros?sk=wall

Rina M.Shaharuddin Salam to all. My name is Rina. The girl mentioned is my daughter. She has AML leukemia. A week ago she developed complications due to pneumonia. Her body is unable to fight the infection as she has no white cells. Doctors have given the maximum dosage of antibiotics but it has yet to show results. We are trying something fairly new now. What we need are white cells from donors. Procedure is that there will be a briefing by the specialist for the potential donor before we can proceed with the blood donation. Should you be keen, some of your time will definitely need to be invested as it's not as straight forward as a normal blood drive. Why we prefer male is because their veins are bigger and the machine is highly sensitive. O+ is acceptable. If that's ok with you, then do call me. Thank you..

Tuesday at 23:44

Doc charged with molesting patient

A government doctor/specialist is being charged in court for molesting a patient:http://thestar.com.my/news/story.asp?file=/2012/1/12/courts/10244849&sec=courts.


What are your responses if the patient happens to be you or your wife?
Who can touch and examine who and which part and when?
Do doctors know right from wrong, halal disentuh, haram dilihat?
Are doctors free to see, touch, feel and experience?
What are patients' rights when the private part is to be exposed to a doctor of the opposite sex?
Would you ask a male doctor to examine your pregnant wife?
Would you ask a female doctor to examine your husband?
What can possibly go wrong in the examination room when the private part is visible?
Private practice is by a doctor; there is no chaperone. Can the husband be present while the male doctor examines the female patient?
Do male doctors get excited while in practice at their clinic when they see an attractive female patient?
Do doctors take advantage of their patients who don't know their rights?

SGD: Concept of Compensation

At SGD a student asked questions about the nature of compensation:

1. What is the meaning of compensation?
2. What are the types of compensation?
3. Why is the opposite of a condition taken as the compensation?
4. Why is there 2 phases for compensation, acute and chronic phases?
5. Which conditions have 2 phases for compensation?

There are 4 simple acid-base disorders: respiratory acidosis, respiratory alkalosis, metabolic acidosis and metabolic alkalosis. 

Respiratory acidosis has a 2-phase compensatory mechanism - acute and chronic. Respiratory alkalosis has a 2-phase compensatory mechanism - acute and chronic. In respiratory conditions, the compensation is two-phase - acute and chronic. The acute phase involves correction by blood buffers and the chronic phase involves the kidneys. 

In respiratory acidosis, the chronic compensation involves mechanisms to conserve and increase the bicarbonate levels (this resembles metabolic alkalosis), and occurs by two means - regeneration of bicarbonate and reabsorption of bicarbonate.

In respiratory alkalosis, the chronic compensation involves mechanisms to reduce the levels of bicarbonate and to increase acids in the blood. The chronic compensatory phase involves excretion of bicarbonate and conservation/regeneration of acids.

Metabolic acidosis has a single phase compensation. Metabolic alkalosis has a single phase compensation. In metabolic conditions, the compensation is single phase. 

In metabolic acidosis, there is excess acids in the blood and the blood pH drops. The compensation in metabolic acidosis is to breathe fast (hyperventilate), which resembles the mechanism for respiratory alkalosis.

In metabolic alkalosis, there is loss of acids and excess bicarbonate exists in blood. The compensation in metabolic alkalosis is to breathe slowly (hypoventilate) or breathe into a paper bag and breathe the same expired air from the paper bag.

SGD: Compensation in Metabolic Acidosis

Questions asked by a student at SGD:

1. Why in Metabolic Acidosis, the compensation has no acute phase? 
2. Why is Respiratory Alkalosis single phase?
3. Is the compensation acute or chronic?
4. How long is the compensation in Metabolic Acidosis?

In Metabolic Acidosis, there is a marked drop in bicarbonate concentration, and pH falls considerably. The compensation is a steady (smooth hyperbolic) increase in PCO2. In the acute phase response or compensation, the blood buffers try to correct the change first and breathing slows down (becomes slower, hypoventilate). The slowed breathing continues past the 10-minute critical timeline and for up to 12 to 24 hours (approx. 1 day) whereby the body is able to retain sufficient CO2 to increase the PCO2 and the pH steadies to a higher level but never reaching 7.40. A rising pH and PCO2 are sufficient to tell us that compensation is taking place. When the PCO2 is high and pH near normal, then that is considered as complete compensation, and the patient should be breathing normally by 24 hours (one day observation).

SGD: Factors Affecting Plasma pH, PCO2 and HCO3

Please use the Henderson-Hasselbalch (HH) equation to answer Q2a-c.

In the HH equation, there are 3 terms which can be variable: pH, PCO2 and HCO3.

Since there are 3 variables, it means that if you know the values for 2 variables, you can work out the unknown variable.

pH - is controlled by HCO3 and PCO2

PCO2 - is controlled by pH and HCO3

HCO3 - is controlled by pH and PCO2


WHAT YOU MUST KNOW

For learning, assessment and exam purposes, you must remember that these 3 variables always work together. Disturbing any one variable will disturb the other 2, which will respond to the change. Thus, you have what is called compensation coming into play.

EXAMPLES OF CASES

In the conditions we get at the hospital (vomiting, diarrhoea, emphysema, coma, hysteria, ketoacidosis, poisoning, etc), usually pH is altered by the alteration of HCO3 or PCO2 (simple acid base disorders). We look at the physical state of the patient and we should know whether the respiratory system is held up or not.

HOW TO UNDERSTAND AND INTERPRET

If the main change (lesion) is due to respiratory causes, then it is more likely that the PCO2 changed, causing blood pH to change, and the compensation will be the corresponding change in the HCO3, which needs to correct and bring back pH towards normal.

If the main change is due to metabolic causes, then it is more likely that the HCO3 changed, causing blood pH to change, and the compensation will be the corresponding change in the PCO2, which needs to correct and bring back pH towards normal.

IS IT ACIDOSIS OR ALKALOSIS?

Whether it is acidosis or alkalosis depends on what the causative agent was and what the initial effect was on blood pH.

If a patient ingested (makan) a whole bottle of aspirin, that gives rise to metabolic acidosis.

If a patient has diarrhoea (cirit-birit) for 3 days, that gives rise to metabolic alkalosis.

If a chronic smoker has difficulty breathing, coughs a lot and has water in his lungs (emphysema), that is respiratory acidosis.

If a patient suffers from Duchenne Muscular Dystrophy (DSD), the breathing muscles are affected (usually the muscles for expiration), and if his respirator fails to operate, he should have respiratory acidosis.

BREATHING CHANGES

Breathing has significant effects on blood pH. Breathing rate affects blood pH. Breathing rate can be normal, fast or slow, depending on the state or condition a person is in.

Breathing fast is hyperventilation.

For example, this occurs after you dashed from your car into your house because you saw a burglar with a knife in your compound. When you are immediately inside the safe confines of your house, you are still panting and hyperventilating but that should cease within some 20 minutes when you can think properly.

Breathing slowly is hypoventilation.

For example, you are so full after eating 2 plates of nasi biryani from your favourite restaurant tepi jalan. The only thing you can do next is to sit back and breathe slowly cos even your lungs cannot expand properly cos your tummy is so tight and full, filled to the limits, that your lungs are slightly compressed. This slow breathing is dangerous as you tend to retain a lot of CO2 in your lungs and in the blood. Your blood pH drops as a result of high PCO2 in the blood. Now, when you have a lot of CO2 in blood, what comes next? What is the special property of CO2? I have told you in class that CO2 is a special gas that has a special property and that it can penetrate all parts of the body, diffuse everywhere and anywhere in the body but there is one location in the body that it likes to go to. Where is that? Yes, CO2 prefers to go to the brain. What does CO2 do to the brain? There are chemoreceptors in the brain that react to blood pH (from the reaction of CO2 with H2O). Essentially high CO2 tells the brain to go to sleep. And you will fall asleep after your nasi biryani feast, and also suffer from respiratory acidosis cos you can't breathe properly until that nasi biryani empties out of your tummy in 4 hours and your lungs can breath again.

RULES ABOUT BREATHING

Alveolar ventilation - hyperventilation reduces blood PCO2; hypoventilation increases blood PCO2

If the lungs are damaged (crushed or excised) - you can still live but with assisted respiratory support.

WHAT ABOUT BICARBONATE?

Bicarbonate is bicarbonate and never mention bicarbonate ion unless you failed chemistry in Form 5.

Bicarbonate is a negative ion or an anion with a negative one charge (-1).

You can write bicarbonate in full on exams but you can also just write HCO3 or HCO3-. Nobody cares whether you put a negative one for bicarbonate or not. It is clearly understood that bicarbonate has a negative one charge whether you write it or not.

What is special about bicarbonate?

The bicarbonate balance in blood deals with 2 things - regeneration and reabsorption. What is what?

Regeneration of bicarbonate means bicarbonate is generated once more. You start visualising at the glomerulus. I told you in class that blood bicarbonate concentration is the same as that in the glomerular filtrate because bicarbonate diffuses freely through the glomerulus. Now the problem is how to get back the bicarbonate from the renal tubules into blood. First you need to regenerate bicarbonate inside the tubular cells by combining bicarbonate with secreted protons to form carbonic acid, which instantaneously breakdown to H2O and CO2. Both H2O and CO2 diffuse and get inside the tubular cells. H2O goes to combine with cellular CO2 to form carbonic acid which dissociates to form proton and bicarbonate ... which can then exit the tubular cells into interstitial fluid and re-enters blood. This reabsorption is accompanied by sodium and water.

Reabsorption of bicarbonate means bicarbonate is absorbed and that the absorption process goes on until bicarbonate goes back where it belongs (blood). I have told you in class that of the many blood buffers, 70% of CO2 exists as bicarbonate in blood plasma. That process of bringing bicarbonate from the renal tubules back into blood plasma is referred to as reabsorption (serapan balik ke dalam darah semula).

If you study carefully you will see that the regeneration is the first part and reabsorption is the second part. Both processes are linked, and must occur in tandem, before bicarbonate reappears in blood.

EXCRETION

What is excreted and when does excretion occur?

Acidosis - excess protons are excreted in urine.

Alkalosis - excess bicarbonate is excreted in urine.

In acidosis, the urine is more acidic than normal but there is a limit to the acidity of urine. The acidity of urine stops at pH4.5 (round about that #) and it cannot be any lower. If you get a urine specimen and the pH says 3, I think there's something funny with that urine specimen. Probably it is a ghost urine (hantu jembalang).

In alkalosis, the urine is slightly more alkaline than normal and there is no limit to the alkalinity of urine, but of course the patient may pass out first. If the upper limit of blood pH is 7.45, you would expect urine from a dead person to be more than pH8. Next time you see a urine specimen with pH more than 8, let me know, I will bring kain kafan too.

SGD: Acid-Base Homeostasis, Fluid & Electrolyte Balance and Potassium Metabolism

I had finished my SGD when 2 students approached me and asked who was their SGD tutor. I asked them which group and they said Group 7. That time I didn't have this info (below) with me. I could not take them as I was already tired teaching my group but I asked the 2 girls to get in touch with the students in my group.

Next time ask the Block Coordinator for the names of tutors for all the groups, or ask Pejabat Akademik before the SGD. I have informed Pejabat Akademik that students must be informed of who their tutors are and this info should be printed on the time-table. For Phase 2, if they can print PBL tutors' names + Groups + Room #s, why can't they do the same for Year 1 SGDs?

This is the info that the Block Coordinator e-mailed to the lecturers (tutors) but the students were not informed for which they did not know who was taking them for SGD. I am not in-charge but I regret that your SGD tutor failed to show up for class.

from:		Dr. Iskandar Zulkarnain Alias iskandarza@kb.usm.my
to:		"A.Rashid, Faridah" <faridahar@gmail.com>,  "Aini, Suzana" <ainiszn@kck.usm.my>,  "Swamy, Dr" <mswamy@kb.usm.my>,  soriani <soriani@kb.usm.my>,  sirajuden <sirajuden@kb.usm.my>,  "Julia, Omar" <julia@kb.usm.my>,  "Hasnan, Nordin" <hans@kb.usm.my>,  "Mar, Dr" <winmar@kb.usm.my>,  "Iskandar, ZA" <iskandarza@kb.usm.my>
date:		Sun, Mar 18, 2012 at 12:09 PM
subject:		SGD Groups

Salam and good morning,


Here is a new grouping system for Chempath SGD provided by Academic.


SGD GROUPS YEAR 1 MEDICAL STUDENTS 2011/12. There are 18 groups totally.


1.      GROUP 1A & 1B – JOM
2.      GROUP 2A & 2B  – NSY
3.      GROUP 3A & 3B  – FAR
4.      GROUP 4A & 4B – KNSS
5.      GROUP 5A & 5B – IZA
6.      GROUP 6A & 6B – WMK
7.      GROUP 7A & 7B – HN
8.      GROUP 8A & 8B – MS
9.      GROUP 9A & 9B - ASA


Thank you
Dr. Iskandar ZA.

Rat poison

Amina Filali swallowed rat poison after being severely beaten during a forced marriage to her rapist. Moroccan activists have stepped up pressure to scrap laws that allow rapists to marry their victims - after a 16-year-old girl killed herself.
More at: http://www.bbc.co.uk/news/world-africa-17379721

1. What is rat poison?

2. How should rat poison be stored?

3. Who makes rat poison for Morocco, Africa?

4. How much rat poison did she ingest?

5. What are the immediate signs & symptoms of rat-poison poisoning?

6. What is the acid-base status in rat-poison poisoning?

Albino

There are 2 types of albinism - complete and partial. Albinism occurrence is the same in males and females. The gene is inherited from the mother, on the X chromosome. A female albino will have 2 doses of the recessive gene while an albino male will only have one dose (there is only one X chromosome in a male). The affected body parts are white or the hair is blonde and the eyes are blue to dirty green. The dirty green iris indicates a stage before the iris becomes blue (as in blue-eyed non-albino Caucasians).

A normal non-albino Caucasian baby can have dark brown eyes at birth, which give way to a dirty green iris and eventually becomes crystal blue, and the baby ends up with normal blue eyes.

The pigmentation is missing in albinos. There are 4 types of albinos based on genetic classification of the enzymes involved. More on genetic aspects of albinism

It is not surprising to find albino children in a family where all have dark skin. An albino child can be born to a normal mother with dark skin. Albino children and families are normal people and must be respected as other human beings. They must not be insulted or critised as they have not done anything wrong. Allah SWT made them that way, so we have to appreciate people who are albino.

I was once in a primary school where there was an American Caucasian boy (Eric, like the pic below) who was albino and so was his younger brother (Carl), ... and his sister, .... and father.... the whole family! It was a thrill playing football with Eric in the afternoon after class because Eric couldn't open his eyes wide to see where the ball was! Goal! Goal! Goal! Of course Eric got into a fight with the other boys! Ha ha ha....

The next time you see an albino, say "Hi" and ask for a photo. And remember to thank him/her.

Albinism in an African boy/man Wikipedia - Albinism

Albinistic girl in Papua New Guinea Wikipedia - Albinism

An Indian family of albinos. http://www.dailymail.co.uk/- biggest albino family

Ibn Sina (Avicenna)

View his summary at the London Archives

Chinese toddler Yueyue died

Yueyue has died - YouTube video