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Drastic and devastating

Drastic and devastating

The title of this post presents two important words from the medical dictionary. “drastic” can be first seen in the homeostasis introduction to medical physiology course. It emphasizes the lack of adaptive and accommodative responses to sudden and strong changes in the environment. In such conditions the outcome can be quite damaging or even fatal. The word “devastating” can be found in the pathology essays such as those changes due to severe infections and it usually concerns a local pathological change, e.g. necrosis. Though the two words may originally concern natural events in the environment, they may provide clues to medical care and case evaluation.

In medical practice the care-giver should avoid harsh interventions in terms of course and dose. The treatment may be better doing when it is decent and incremental (opposite to drastic). That view in the medical care – in some situations – entails ‘partial correction’ of the concerned disorder as”rapid*” ‘full correction’ may bring about quite unwanted or even fatal hazard. It is always wise to have an overall vision of the medical case with top-to-bottom estimate so that such extreme flip-flops can be better appreciated and avoided. The treatment should be both problem- and patient-tailored. As the body’s reserves to accommodate changes (temperature, water, food, etc.) is limited and varying from time to time one should be careful not to be too rush or too slow.

By the way, the medical opposite of devastating can be ‘mild’ or ‘trivial’.

Take-home massage:

1- Be decent, systematic, and incremental.

2- Observe well.

3- Be open-minded, generous and evolution-ready.

4- Make your expectations as modest and small as you can.


* Suggested steps of management could be:

1- Reverse the current event.

2- Restore/establish base line.

3- Treat residual illness.


Orthotherapia (orthocura) – an interview –

orthotherapia (orthocura)

Interviewer: Hallo, everybody! Welcome to this episode of “medical views”. Today, we have another very exciting view of medical care, namely “orthotherapia or orthocura”. Let’s greet our guest; Mr. Physician 21, welcome back to our program!

Physician 21: Thank you. I am very happy to be with you today.

Interviewer: Would you explain the core concept of your orthotherapy?

Physician 21: Well. To start with, the idea is not by any means very novel but more it gathers and harmonizes some basic medical principles in a well structured and meaningful medical philosophy.

Interviewer: So, what are the main pillars of your idea?

Physician 21: Orthotherpia or orthocura claims that among all possible medical care regimens there could be only one that best suits a given medical case. While in this regard the conception of a presumed bodily functional hierarchy would be in the centre, some medical peculiarities are also much concerned including patient type, medical remedy type and mode of application.

Interviewer: Very fine Mr. Physician 21. Now, we are about to get that well structured and meaningful medical philosophy of orthotherapy. Would you bring us closer to those very interesting medical presumptions; first, what do you mean by bodily functional hierarchy?

Physician 21: The bodily functional hierarchy would mean that the various physiological functions and their body organs may be ordered in such hierarchical manner so that one function would be prioritized in respect to another. An example could be: lung > stomach > heart > liver and spleen > muscle and bone > gonad and kidney > brain. Such conception of possible hierarchically ordered body organs would help appreciate disease evolution from one side and disease management order from the other side.

Interviewer: How nice! We would perceive a glimpse of ‘alternative medicine’ in that presumption of bodily functional hierarchy, would you say that?

Physician 21: Well, I should say that I am not an expert in alternative medical methods. Anyhow, as I already said in the beginning the idea may not be very novel and it should make use of much of the well known medical arts.

Interviewer: Would you give practical examples to further explain that?

Physician 21: Well. Let’s consider a case of fever with signs of dehydration. The dehydration may be first corrected by giving appropriate fluids and then the body temperature could be assessed and managed accordingly. In such case, prioritizing fever to dehydration would be inappropriate and cost-ineffective. Another example could be the improvement of anxiety which reflects neurologic stress on practicing some suitable kind of sports. Again, in that case over consumption of anxiolytics may be cost-ineffective.

Interviewer: you mean that in handling diseases it makes great sense which disease or organ function to consider first to achieve a rather smooth and nature-coping healing process.

Physician 21: That is it. Thank you.

Interviewer: To summarize, “orthotherpy” or “orthocura” would emphasize the significance of choosing the management regimen with the presumption of natural hierarchical order of body functions and systems. Thank you very much. Mr. Physician 21 for this very interesting information.

Physician 21: Thank you too.

The clinical session algorithm

The clinical session algorithm

The excitement and challenge of the medical session are not to overlook especially for newly practicing physicians. Red cheeks, heart knocking, hand sweating and even head whirl may be typically experienced by many doctors even by quite experienced ones. The reason for such clinical session tension could be overestimation of the job and/ or lack of the successful scheme (algorithm) for medical management.

In this essay, I wish to emphasize that the tactful handling of medical care including clinical session is a matter of training and learning where the inherent talent influences the length of time necessary for such clinical mastering. About clinical session or examination questions regarding its duration, steps and order plus precautions and ethics are indeed worth noting. These together will shape out what is known as ‘the clinical sense’.

1- Context: what is the context of the clinical session?

By clinical session context I mean the time-place frame of the patient’s presentation. These circumstantial provisions may have influence on the clinical session as for professional progress and patient-doctor expectations. Besides care about medical perfection and contentedness the question whether a medical fee could or could not be considered can be quite sensible.

2-Patient type:  what kind of patient is this?

Broadly speaking patients may be seen as either chattering or serious. Because in some cases such definition and judgment of the patient may take time for the sake of fairness and respect to all patients, this question should be considered from the beginning and throughout the clinical session.

3- Presentation: what level of urgency does this case have?

The level of urgency may be graded in 4 levels: 1) life threatening problem, 2) potentially ailing problem, 3) naturally resolving problem and 4) intervention sparing problem.

In order to adequately define the level of urgency good knowledge and appreciation of the possible presentations (complaints) in the different diseases is required. For example, headache can be a symptom of different diseases like stress, constipation, muscle inflammation due to cold for example, fever, sinusitis, high blood pressure, etc. The level of urgency and, hence, appropriate management will vary for the same complaint from one disease to another.

4- Management plan: what to do for this case?

This question is answered at 3 levels: 1) immediate plan, 2) remote plan, and 3) Follow up plan.

The immediate plan is instituted for either therapeutic or prophylactic aspects. It can be omitted when there is no need for it or when the case cannot be yet well judged. Referral of the patient to a more experienced colleague and/ or medical care center is also possible option for immediate management plan. The remote plan may form a further management step or follow certain preparation with or without medications. The follow up plan can be needed for life long or relatively time lasting cases.

5- Clinical session closure:  what to do when you are done?

Considering the appropriate ethics, time and progress of the clinical session, the closure of the session should be smooth and well prepared ensuring that all the medical instructions and treatment plan given to the patient in writing and having the required and ‘allowable’ contact information taken by both physician and patient.

The physician’s guide

the physician's guide

The physician’s guide is an indispensible tool to summarize basic medical and clinical knowledge and experiences. It should be concise, easily demonstrable, regularly updated and greatly physician-specified (self made).

Here is a personal view of such important medical tool.

The Hippocratic Oath

Section 1: normal values (pediatrics: growth milestones or curves, caloric and fluid requirements and calculations; CBC; hemoglobin electrophoresis; plasma electrophoresis; liver function; kidney function; urine; stools; semen; hormones; electrolytes; arterial boold gases; and ECG findings).

Section 2: preparation-oriented drug index (topical formulas: skin, eye, ear, and nose; tonics and food supplements; antimicrobials: antiseptic, antibiotic, antifungal, antiprotozoal, and antihelimenthics; analgesics and antipyretics; antihistaminics; corticosteroids; skeletal muscle relaxants; antispasmodics; antihypertensives and cardiac agents; hemostatics, hypoglycemics; neuropsychiatric agents (sedatives and hypnotics, anticonvulsants, brain stimulants, antidepressants, antiparkinsonians); and beauty preparations (shampoos, cosmetics, soaps, etc.).

Sections 3: natural foods and herbs – sorted alphabetically – and their uses (basilica, chamomile, garlic, green tea, onion, thyme, etc.).

Section 4: medicines’ doses and instructions tables (neonate, child, and adult).

Section 5: crude models of medical prescriptions (orthopedic, eye, ear, nasopharyngeal, dermal, gynecologic, oral, cardiac, digestive, liver, renal, respiratory, and neuropsychiatry).

Section 6: medical algorithms (pediatrics: infant of diabetic mother, muconial aspiration, low birth weight, prematurity, neonatal jaundice, respiratory distress, etc.; adults: HTN, DM, bronchial asthma, cardiac asthma, DVT, diabetic ketoacidosis, hypoglycemia, stroke, etc.).

The physician’s bag

the physician's bag

In alignment with the order needed for a well resolved physician a competent and feasible preparation of the physician’s bag should be realized. This process entails a thorough understanding and mastering of the commonest medical problems that may be a matter of urgency or emergency. Here are some of these cases arranged according to their relative frequency rather than their emergency level:

  1. Fainting or syncope: – let the person feel that he/she is attended, e.g. hold the arm and ask about how he/she is now, while feeling the radial pulse. – apply the ABC scheme (air way, breathing, and circulation). – notice the colors, odors, sweating, tremors or special positions, if any. And – take the vital data (pulse, blood pressure and temperature). Manage accordingly.
  2. Anxiety bouts (attacks): – reassure the person that he/she is attended, i.e. appropriate care can be available. – notice pulse rate, hand sweating and temperature. – try to encourage the person to talk about some topics like the type of food, sports, books he/she likes and if he/she have certain fears or current personal problems. – discuss the possibility of immediate treatment, e.g. with a beta blocker (nonselective), and outline a management plan that can multidimensional, e.g. physical, dietary and/or medical.
  3. Hammering headaches: – reassure the person that the case is not serious. – take the vital data (pulse, blood pressure and temperature). – ask the person if he/she is taking any medications or if there is (are) some chronic illness (es). – encourage the patient to drink normal water after making sure there would be no risks (e.g. the person can swallow normally, no intoxication by a corrosive substance for example, no water restriction, etc.). Manage accordingly.
  4. Fever: – reassure the person that the case is not serious. – ask about specific pain or other complaints, e.g. diarrhea or colic. – if this would seem conservative and neutral, encourage the person to drink normal water, fresh juice like lemonade and orange that have the same temperature as that of the environment. – take the vital data and notice the colors, odors, sweating, tremors or special positions, if any. Manage accordingly.
  5. Renal colic: – reassure the person. – the typical renal colic follows the course of the renal system on either right or left side, i.e. the loin region, the ureter and the urethra. – ask for a precipitating factor, e.g. drinking water problem, unbalanced food intake, exposure to cold, or stress. – take the vital data and notice the colors, odors, sweating, tremors or special positions, if any. Manage accordingly.
  6. Chemical intoxication: – reassure the person. – take the vital data and notice the colors, odors, sweating, tremors or special positions, if any. – after withdrawal or avoidance of the intoxicating agent the condition resolves gradually and steadily over time. Manage accordingly.
  7. Difficult breathing (asthma): – reassure the person. – ensure good ventilation of the room, e.g. open the windows. – notice the colors, odors, sweating, tremors or special positions, if any. – assess for ABC. – notice lower limb edema, abdominal enlargement and or tenderness, neck vein pulsations. – auscultate the chest for abnormal inspiratory or expiratory sounds. – consider possible heart and or lung diseases. Manage accordingly.
  8. Bleeding nose (epistaxis): – reassure the person. – let the person breath by his/her mouth and then compress the nasal cartilages against the nasal septum from outside. – ask the person to raise his/her head little up while still closing the nose. – after the condition has stabilized, the person is advised to avoid the precipitating factors, e.g. avoiding sun burns. – notice the colors, odors, sweating, tremors or special positions, if any. And – take the vital data (pulse, blood pressure and temperature). Manage accordingly.
  9. Cut wound: – control the bleeding site by compression with clean and sterile gauze. – special wound healing plaster and or surgical stitching may be used as required.
  10. Chest pain: – reassure the patient. – risk factors include family history of coronary heart disease, hypertension, diabetes and smoking. – under medical supervision , e.g. by an ambulance, and while explaining it as being absolutely precautionary, refer the person to the nearest hospital or an intensive care unit for best medical care.

The physician’s bag contents include:

  1. Physician’s guide.
  2. Physician’s stationary: a prescription or note-block, pen, plastic ruler (about 10 cm length).
  3. Medical disposables: 3- 5 plastic examination gloves, 2-5 sterile scalpels, 2-5 sterile plastic syringes (1, 3, and 5 ml), 1-3 i.v. canulas (small and medium), medical cotton and gauze, and 2-5 tongue depressors and sterile surgical needle.
  4. Medicines and medical stuffs: ampoules and tablets (atropine, theophylline, antihistamine, NSAID, corticosteroid, hyoscine, nonselective beta blocker), and surgical betadine.
  5. Apparatuses and instruments: stethoscope, sphygmomanometer, torch, thermometer,  needle holder and arm tourniquet.

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