Morning MEDtalks with Dr KK Aggarwal 3rd July 2018

J P Nadda / Anupriya Patel/ Ashwini Kumar Choubey/ Dr Mahesh Sharma On Doctors Day

1. Doctors are the back bone of the society
2. Whatever the MOH has been able to achieve is due to doctors
3. More than 5000 private doctors have contributed to National PMSMA program
4. Nadda Ji will be remembered for Ayushman Bharat and NMC
5. MOH is open for increasing the reimbursement rates for caesarean or any other justified surgical procedure under Ayushman Bharat
6. For Ayushman Bharat the doctors and the government must work as one unit
7. Modicare is going to the largest scheme of the world
8. 1.5 lac wellness centers will be built over next few years
9. Government is planning for MBBS: PG ratio of 1:1.
10. Once that happens who will provide the primary care. We will need more health councillors for providing primary care.

Smelly urine

If your wee smells more concentrated than normal, it could be an early sign of diabetes, revealed Now Patient’s Chief Medical Officer, Dr Andrew Thornber to Express.co.uk. Urine doesn’t usually smell at all - unless you’ve eaten foods like asparagus that could make it smell stronger.

Vedic Reference (Dr Mukta): The food articles that are heavy to digest should be taken in less amount and the light food articles can be taken in ample amount

अल्पादाने गुरूणां च लघूनां चातिसेवने|

मात्रा कारणमुद्दिष्टं द्रव्याणां गुरुलाघवे||३४०||

गुरूणामल्पमादेयं लघूनां तृप्तिरिष्यते|

मात्रां द्रव्याण्यपेक्षन्ते [१] मात्रा चाग्निमपेक्षते||३४१||

Charak samhita 27/340-341

CT in appendicitis

Low radiation (2-4 mSV), contrast or plain, abdominopelvic CT is the preferred test in suspected appendicitis in adults. CT has higher diagnostic accuracy than ultrasound or MRI.  In patients with appendiceal perforation contrast improves the delineation of the phlegmon or abscess.  The imaging features of acute appendicitis are enlarged appendiceal double-wall thickness (>6 mm) and appendiceal wall thickening (>2 mm).

Incidental gallstones

Gallstones that are diagnosed in an asymptomatic patient based on an imaging study done for an unrelated reason. Majority will remain asymptomatic. Patients who develop symptoms typically report biliary colic. It is rare for a previously asymptomatic patient to present with complications of gallstone disease without first having had episodes of biliary colic.

Wait until a patient becomes symptomatic before performing cholecystectomy prevents unnecessary surgery as majority with incidental gallstones will never develop biliary colic.

But go for prophylactic cholecystectomy in patients at increased risk for gallbladder cancer and are good surgical candidates (anomalous pancreatic ductal drainage where pancreatic duct drains into the common bile duct, gall bladder polyp, porcelain gallbladder and large gallstones of > 3 cm.

It may also have a role in the treatment of some patients with hemolytic disorders or those who are undergoing a gastric bypass.

Natural history of GB stone

Majority of patients with incidental gallstones will not develop symptoms attributable to the gallstones. Only 15% will become symptomatic during 15 years of follow-up

Patients who develop symptoms typically report biliary colic rather than symptoms associated with the complications of gallstone disease (such as cholecystitis, pancreatitis, and choledocholithiasis).

The classic description is of an intense, dull discomfort located in the right upper quadrant, epigastrium, or (less often) substernal area that may radiate to the back (particularly the right shoulder blade) The pain is usually steady and not colicky. The pain is often associated with diaphoresis, nausea, and vomiting. It is not exacerbated by movement and is not relieved by squatting, bowel movements, or passage of flatus

The pain typically lasts at least 30 minutes, plateauing within an hour. The pain then starts to subside, with an entire attack usually lasting less than six hours

Once a patient develops symptoms, the symptoms are likely to recur and the patient is at increased risk for the development of complications. 70 percent of those with a history of biliary colic developed recurrent symptoms within two years. Other complications of gallstone disease occur at a rate of approximately 1 to 2 percent per year

Diabetes and gall stones

Patients with diabetes mellitus are at increased risk for the development of severe gangrenous cholecystitis but the magnitude of the risk and the risks and costs of cholecystectomy do not warrant prophylactic cholecystectomy in patients with asymptomatic gallstones. Only 10 percent of the initially asymptomatic patients develop biliary colic and 4 percent develop other gallstone complications; these values are similar to the general population.

When to give aspirin in acute MI

The loading dose (300 mg water soluble) should be given as soon as possible after the diagnosis is made ( ER or ambulance) to any patient with a STEMI after the diagnosis is made irrespective of treatment strategy. There is no evidence that higher doses are more effective, and they may lead to greater gastric irritation.

Once the reperfusion strategy (PCI, fibrinolysis, or no reperfusion) has been chosen, give a P2Y12 receptor blocker to all patients.

PCI: ticagrelor or prasugrel

Streptokinase or tenecleptase: clopidogrel

No reperfusion therapy: Ticagrelor.

Participate in survey on Inflammatory bowel disease: https://docs.google.com/forms/d/e/1FAIpQLSedaDx2iXiwU1vBpYdU6ebfCap-7PYAPSqXRJTeg8ULvNOcLg/viewform