How To Examine Jugular Venous Pressure

How To Examine Jugular Venous Pressure

Examination of jugular venous pressure is one of the main component of systemic examination of cardiology ward.The JVP can be estimated by observing the level of blood in either the internal or external jugular vein.Both vein have valve but it is less in internal jugular vein.As blood flow towards the heart,the do not affect  this and may even make the waveform easier to see.The normal waveform has 2 peaks per cycle which help them distinguish it from the carotid artery pulse.

The JVP reflects central venous or right atrial pressure(normally < 7mm/Hg/9cm H2O) and indirectly right ventricular function.The sternal angle is approximately 5cm above the right atrium ,so the JVP should be no more than 4cm above this angle when the patient lies at 45 degree.If the JVP is low ,the patient may have to lie flat for it to be seen,if high,the patient may need to sit upright.

Position Of Jugular Vein and Carotid Artery

The internal jugular vein enter the neck behind the mastoid process.It run deep to sternocleidomastoid muscle before entering the thorax between the sternal and clavicular head and can only be examined when the neck muscle are relaxed.Although the vein itself cannot be seen,a diffuse pulsation is visible when the pressure in the internal jugular vein is elevated.

The external jugular vein is more superficial ,prominent and generally easier to see.Although it can be obstructed as it traverse the deep fascia of the neck,this rarely present a problem.If it is visible,pulsatile  and not obstructed,it can be used to assess JVP.Due to the anatomy of the innominate vein,the JVP is best examined on the patient's right side and internal jugular vein is used.

The carotid pulsation best feel at the anterior border of sternocleidomastoid muscle along the superior border of thyroid cartilage.

Procedure:

1.Position the patient so that he is reclining supine comfortably until the waveform is clearly visible(at 45 degree).

2.Rest the patient 's head on a pillow to ensure that the neck muscle are relaxed.

3.Look across the neck from the right side of the patient .

4.Identify the jugular vein(can use torchlight for identification) and its pulsation.

5.If you are not certain,use the abdomino-jugular reflux or occlusion to confirm it is the JVP.

-Abdomino-jugular reflux:

Gently press over the abdomen for 10 seconds.This is increase venous return to the right side of the heart temporarily and JVP normally rises.This rise may take 15 second to decrease in congestive heart failure.

-Occlusion:

The JVP waveform is obligated by gently occluding the vein at the base of the neck with your finger.This help to differentiate between carotid artery and jugular vein .(Remember ,we need only jugular vein,not carotid artery).By pressing at the base of the neck with your finger,try feel for pulsation along SCM muscle.If there is still pulsation with pressing at the base,it will be the carotid artery.Due to the thick wall of artery ,pulsation will be present even with pressing.If the pulsation is absent with pressing at the base,then it is the jugular vein which we needed.

6.The JVP is the vertical height in cm between the top of the venous pulsation and the sternal angle,whether they are sitting at 45 degree or not.

7.Identify the timing and form of the pulsation and note any abnormality..

by Lakdhes.

Treatment Of Migraine

Treatment Of Migraine

Migraine is a chronic disorder characterized by recurrent moderate to severe headaches often in association with a number of autonomic nervous system symptoms. 
Typically the headache is unilateral (affecting one half of the head) and pulsating in nature, lasting from 2 to 72 hours. Associated symptoms may include nausea, vomiting, photophobia (increased sensitivity to light), phonophobia (increased sensitivity to sound) and the pain is generally aggravated by physical activity. Up to one-third of people with migraine headaches perceive an aura: a transient visual, sensory, language, or motor disturbance which signals that the headache will soon occur.
Migraines are believed to be due to a mixture of environmental and genetic factors. About two-thirds of cases run in families. Fluctuating hormone levels may also play a role: migraine affects slightly more boys than girls before puberty, but about two to three times more women than men. Propensity for migraines usually decreases during pregnancy. The exact mechanisms of migraines are not known. It is, however, believed to be a neurovascular disorder.The primary theory is related to increased excitability of the cerebral cortex and abnormal control of pain neurons in the trigeminal nucleus of the brainstem

Drug Used In Migraine

A.Drug used for acute migraine headache:

1.Nsaid

-paracetamol

-aspirin

-diclofenac

-ibuprofen

-naproxen

2.Antiemetic

-domperidone

-metoclopramide

3.5HT1 Agonists

-sumatriptan

-rizatriptan

-zolmitriptan

-almotripton

-frovatriptan

4.Ergot alkaloid

-ergotamine

B.Drug For Prophylaxis of Migraine

1.Anti histamine n 5HT antagonist
-pizotifen

2.Beta blocker

-propranolol

3.Tricyclic anti depressant

-amitriptyline

4.Both calcium and sodium chanel blocker

-flunarizine

5.Other drugs:

-Valproic acid

-Methysergide

-Gabapentin

-Calcium  channel blockers

• Verapmil
• nifedipine

by Lakdhes..

How To Manage Bleeding Disorder :

How To Manage Bleeding Disorder :

Thromboembolism

Thrombosis  is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel is injured, the body uses platelets (thrombocytes) and fibrin to form a blood clot to prevent blood loss. Alternatively, even when a blood vessel is not injured, blood clots may form in the body if the proper conditions present themselves. If the clotting is too severe and the clot breaks free, the traveling clot is now known as an embolus.

Thromboembolism is the combination of thrombosis and its main complication, embolism.When a thrombus occupies more than 75% of cross-sectional area of the lumen of an artery, blood flow to the tissue supplied is reduced enough to cause symptoms because of decreased oxygen (hypoxia) and accumulation of metabolic products like lactic acid. More than 90% obstruction can result in anoxia, the complete deprivation of oxygen, and infarction, a mode of cell death.

  

Treatment For Bleeding Disorder:

Anti Platelet Drugs

Classification:

1.Cyclooxygenase inhibitor

-Aspirin

2.Adenosine diphosphate  receptor inhibitor

-Clopidogrel

-Prasugrel

-Ticlopidine

3.Gylcoprotein inhibitor

-Abciximab

-Eptifibatide

-Tirofiban

4.Diphosphoesterase inhibitor

-Cilostazol

5.Adenosine reuptake inhibitor

-Dipyridamole

Fibrinolytic/Thrombolytic Drug

1.Streptokinase

2.Urokinase

3.Alteplase

4.Reteplase

5.Tenecteplase

6.Tissue plasminogen activator

Anti Fibrinolytic

1.Aminocaproic acid

2.Tranexamic acid

3.Protamine sulfate

4.Vitamin k

5.Aprotinin

Anticoagulant Drug

 Used In Vivo

A.Parenteral  Anticoagulant Drugs:

a)Indirect Thrombin Inhibitor:

1.Regular Heparin/Standard Heparin

2.Low molecular weight /irregular heparin

-Tinzaparin

-Pamparin

-Dalteparin

-Nadroparin

-Ardeparin

-Enoxaparin

-Reviparin

3.Synthetic Pentasaccharide

-Fondaparinux

b.Direct Thrombin Inhibitor

-Hirudin

-Argatroban

-Bivalirudin

-Melagatran

-Ximelagatran

B.Oral Anticoagulant Drug

-.warfarin

-Dicoumarol

Used in Vitro

a.Heparin

b.Calcium chelating agent

1.3.8 % Na Citrate

2.Na Oxalate

by Lakdhes..

Lipid Lowering Drugs

How To Manage Obesity 

Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems. People are considered as obese when their body mass index (BMI), a measurement obtained by dividing a person's weight in kilograms by the square of the person's height in metres, exceeds 30 kg/m2.

Obesity increases the likelihood of various diseases, particularly heart disease, type 2 diabetes, obstructive sleep apnea, cert.in types of cancer, osteoarthritis and asthma. Obesity is most commonly caused by a combination of excessive food energy intake, lack of physical activity, and genetic susceptibility, although a few cases are caused primarily by genes, endocrine disorders, medications or psychiatric illness. Evidence to support the view that some obese people eat little yet gain weight due to a slow metabolism is limited; on average obese people have a greater energy expenditure than their thin counterparts due to the energy required to maintain an increased body mass.

Dieting and physical exercise are the mainstays of treatment for obesity. Diet quality can be improved by reducing the consumption of energy-dense foods such as those high in fat and sugars, and by increasing the intake of dietary fiber. If diet, exercise and medication are not effective, a gastric balloon may assist with weight loss, or surgery may be performed to reduce stomach volume and/or bowel length, leading to earlier satiation and reduced ability to absorb nutrients from food.Anti-obesity drugs may be taken to reduce appetite or inhibit fat absorption together with a suitable diet.Those are:

Lipid lowering

A.Predominantly Cholesterol Lowering Agent

1.HMG CoA Reductase Inhibitor( statin)

-Atorvastatin

-Pravastatin

-Simvastatin

-Fluvastatin

-Rosuvastatin

2.Cholestrol absoprtion inhibitor

-Ezetimibe

3.Bile salt sequestering inhibitor

-Cholestyramine

-Colestipol

-Colesevelam

4.Nicotinic Acid(Vit.B3)

B.Predominantly TG Lowering Agent:

1.Fibrate derivatives:

-Phenofibrate

-Bezafibrate

-Ciprofibrate

-Gemfibrozil

2.Highly poly unsaturated long chain n-3 fatty acid:

-Eicosapentanoic acid

-Docosahexanoic acid

by Lakdhes

Anti Diarrhoeal Medicine(Treatment For Diarrhoea )

Anti Diarrhoeal Medicine

   

Treatment For Diarrhoea:

Diarrhoea is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and electrolyte disturbances such as potassium deficiency or other salt imbalances.

       

Opioid agonist:

-Loperamide

-Diphenoxylate



2.Kaolin and pectin;



3.Somatostatin;


4.Colloidal Bismuth compound;

-Bismuth subcitrate

-Bismuth subsalicylate

-Bismuth dinitrate



5.Bile Salt Binding Resins;

-Colestipol

-Cholestyramine


Advantage Of Loperamide :
Although all opioid  have anti diarrhoel effect ,Loperamide is an ideal drug for diarhhoea because :
-it does not cross blood brain barrier 
-it has no analgesic effect
-it is not potential for addition 
-tolerance to long term use has not been reported 

-Diphenoxylate Hydrochloride is available only in combination with atropine sulfate.This is because atropine prevent euphoria(side effect of diphenoxylate).

Role of Tetracycline 
The main cause of acute watery diarrhoea is Rota virus and V.Cholera.So viral acute watery diarrhoea need not treat with Tetracycline.But if the cause of acute watery diarrhoea is bacterial V.Cholera confirmed ,then we can use Tetracycline  because v.Cholera is highly sensitive to Tetracycline .

Oral Rehydration Salt

Oral Rehydration Therapy (ORT) is a simple treatment for dehydration associated with diarrhea, particularly gastroenteritis or gastroenteropathy, such as that caused by cholera or rotavirus. ORT consists of a solution of salts and sugars that is taken by mouth. It is used around the world, but is most important in the developing world, where it saves millions of children a year from death due to diarrhea, the second leading cause of death (after pneumonia) in children under five.

Types:
1.Citrate Saline
2.Bicarbonate Saline

3.Rice Saline

4.Oral Rehydration Salt(ORS)

Composition of ORS:

1.NaCl  -2.6g/l

2.KCl   -1.5g/l

3.Trisodium citrate dihydrate -2.5g/l

4.Anhydrous glucose    -13.5g/l

In cases where ORS is not available, homemade solutions are often used.

by Lakdhes

Treatment For Constipation

Constipation Medicine

Treatment For Constipation

Constipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation. Severe constipation includes obstipation (failure to pass stools or gas) and fecal impaction .Constipation is common; in the general population incidence of constipation varies from 2 to 30%.Constipation is a symptom with many causes. These causes are of two types: obstructed defecation and colonic slow transit . About 50% of patients evaluated for constipation at tertiary referral hospitals have obstructed defecation.This type of constipation has mechanical and functional causes. Causes of colonic slow transit constipation include diet, hormones, side effects of medications, and heavy metal toxicity.Treatments include changes in dietary habits, laxatives, enemas, biofeedback, and surgery. Because constipation is a symptom, not a disease, effective treatment of constipation may require first determining the cause.

A.Luminally active agent:
a.Bulk forming Laxative
-Methylcellulose
-Phsyllium
-Polycarbophil


b.Osmotic Laxative
-Sorbitol
-Magnesium oxide
-Polyethylene Glycol
-Lactulose

c.Stool surfactant agent
-Docusate
-Glycerin suppository
-Mineral oil

B.Non Specific Stimulant 
1.Diphenylmethane derivative
-Bisacodyl 
-Phenolphthalein 
-Sodium Picosulfate 

2.Anthraquinone derivatives
-Alone 
-Cascara 
-Senna

3.Castor Oil


4.Lubiprostone
-for chronic constipation



C.Prokinetic Agent 
1.Tegaserod 
2.Misoprostol
3.Opioid Antagaonist



by Lakdhes..

Great Hotels

Great Hotels

Elqui Domos in Chile 

Paris’ Latin Quarter

\

Ubud Hanging Gardens Hotel,Bali, Indonesia

by Lakdhes..

Treatment For Peptic Ulcer Disease

Pharmacology

Peptic Ulcer Disease

Peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm. As many as 70–90% of such ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach; however, only 40% of those cases go to a doctor. Ulcers can also be caused or worsened by drugs such as aspirin, ibuprofen, and other NSAIDs.

Classification

By Region/Location-

-Duodenum (called duodenal ulcer)

-Esophagus (called esophageal ulcer)

-Stomach (called gastric ulcer)

-Meckel's diverticulum (called Meckel's diverticulum ulcer; is very tender with palpation)

Modified Johnson Classification of peptic ulcers:
-Type I: Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis along the locus minoris resistantiae.

-Type II: Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion.

-Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid oversecretion.

-Type IV: Proximal gastroesophageal ulcer
Type V: Can occur throughout the stomach. Associated with chronic NSAID use (such as aspirin).

Signs and symptoms

-abdominal pain, classically epigastric with severity relating to mealtimes, after around three hours of taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are exacerbated by it)

-bloating and abdominal fullness

-waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus - although this is more associated with gastroesophageal reflux disease)

-nausea, and copious vomiting

-loss of appetite and weight loss

hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting.

-melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin)

-rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis. This is extremely painful and requires immediate surgery

Drugs for Peptic Ulcer Disease

A)Acid Neutralizer /Antacids:
1.Sodium Bicarbonate
2.Calcium Bicarbonate
3.Magnesium Hydroxide
4.Aluminium Hydroxide

B)Agent that enhance mucosal resistance:
1.Sucralfate
2.Misoprostol
3.Colloidal Bismuth Compounds.

C.Agent that reduce HCL secretion :
Directly acting:
a)H2 -receptor blocker:
-ranitidine
-cimetidine
-nizatidine
-famotidine

b)Proton pump inhibitor(PPI):
-omeprazole
-esomeprazole
-pantoprazole
-lansoprazole
-rabeprazol

c)Anti Muscarinic drugs:
-Pirenzepine
-Telenzepine

Indirectly Acting :Antibiotics
-metronidazole
-Amoxicilin
-Tetracycline
-Clarithromycin

In case of H.Pylori causing peptic ulcer:
-Triple Therapy or,
-Quadruple Therapy can be used


Triple Therapy x 14 days :twice daily
1.PPI
2.Clarithromycin(500mg)
3.metronidazole (500mg) /Amoxicilin(1grm)/Tetracycline (500mg)


Quadruple Therapy x 14 days:
1.PPI(twice daily) or H2-Receptor Antagonist 
2.Metronidazole (500mg)
3.Tetracycline (500mg)
4.Bismuth Subsalicylate (525mg)

Single antibiotic regimens are ineffective in eradicating H.Pylori infection and lead to microbial resistance.So combination therapy with 2 or 3 antibiotic  is associated with highest rate of H.Pylori eradication.

by Lakdhes.