Dear Yin Ling,
If I am to ask you to comment on this, what will you say?
This is like getting engaged but not married, question is, ARE YOU IN BIG TROUBLE OR ARE YOU NOT?
Can you get out of the mess or are you stuck!?
The diagnosis was invented in May 2003 Systolic 120 to 139
Diastolic 80 to 89
Based on MRFIT there is a continuous increase in risk as bp rises If there is Pre DM, why not Pre HPT?
Optimal bp is less than 120 80
Annual mortality rate for those with Pre HPT is more than 3 times that of a normal person. NHAMES
Over 4 yrs, conversion of Pre Hpt to Hpt in the elderly is more than 50%
Progression is fast, almost 60% by 4 yrs
Pre Hpt is less in those more than 60yrs as most have PROGRESSED TO HPT!
Prevalence is 37% in msia! MORE COMMON IN MALES Worldwide PREVALENCE is 38%
Rising obesity is associated with Pre Hpt Pre Hpt is associated with insulin resistance LV mass is higher in Pre Hpt
Pre Hpt 27% increase in all cause mortality And
66% increase in cvs mortality
Management. Wt reduction, salt reduction, stress management, but reduction is not sustainable with time.
Wt loss is best
Salt reduction is second best
Drugs?? Do we treat one third of the entire adult population??
No outcome data if Pre Hpt ALONE!
BUT trials have shown that we shd treat when there are other risk factors or when risk scores are high.
Look for target organ damage, if so TREAT!
The younger the patient, the more vigilant the search for secondary causes.
1. Confirm the High BP
2. Search for underlying causes 3. Search for Target organ damage Remember "High BP causes damage!"
76) on the Solitary Pulmonary nodule
Dear Yin Ling,
This finding is worrying for both doctor and patient. How do you approach this diagnostic problem?
More than half of all solitary pulmonary nodules are benign. Benign nodules have many causes, including old scars and infections. It is surrounded by normal lung tissue and is not associated with any other abnormality in the lung or nearby lymph nodes
Infectious granulomas (reactions to a past infection) cause most benign lesions.
Common infections that increase the risk for developing a solitary pulmonary nodule include:
Tuberculosis
Lung diseases caused by a fungus
Lung cancer primary or secondary is the most common cause of cancerous
(malignant) pulmonary nodules. Approximately 20-‐30% of all cases of lung cancer appear as Solitary Nodules on chest X-‐ray films. Therefore, the goal of
investigating is to differentiate a benign growth from a malignant growth as soon and as accurately as possible.
It should be considered potentially cancerous until proven otherwise.
A solitary pulmonary nodule is most often found on a chest x-‐ray or a chest CT scan, which are often done for other symptoms or reasons.
The clinical decision is whether the nodule in lung is probably benign. This is more likely if:
The nodule is small, has a smooth border, and has a solid and even appearance on an x-‐ray or CT scan
Patient is young and do not smoke
We may then choose to just watch the nodule on x-‐rays in 2 mths.
Age: Risk of malignancy increases with age.
Risk of 3% at age 35-‐39 years Risk of 15% at age 40-‐49 years Risk of 43% at age 50-‐59 years
Risk of greater than 50% in persons older than 60 years.
Patients who have an older chest X-‐ray film has a goldmine for comparison. This is important because the growth rate of a nodule can be ascertained. The doubling time of most malignant Nodules is 1-‐6 months.
Repeat chest x-‐rays or chest CT scans are the most common way to follow the
nodule. If the CT scan demonstrates fat within the nodule, the lesion is likely benign, hamartoma. Nowadays lung PET scans may be done. Malignant cells have a higher metabolic rate than normal cells and benign abnormalities; therefore, the glucose uptake of malignant cells is higher. Positron emission tomography (PET) involves using a radiolabeled substance to measure the metabolic activity of the abnormal cells. Malignant nodules absorb more of the substance than benign nodules and normal tissue and can be readily identified on the 3-‐dimensional, colored image.
PET scan is an accurate, noninvasive exam, but the procedure is expensive.
If repeated x-‐rays show that the nodule size has not changed over 2 years, it is most likely benign and a biopsy is not needed.
Persons who have been clinically diagnosed with a benign Nodule should schedule the recommended follow-‐up, as follows:
Chest X-‐ray films should be taken every 3 months for the first 12 months and then every 6 months for the following 12 months.
After this 2-‐year period, the Nodule may be observed yearly for up to 5 years.
We may choose to biopsy the nodule to rule out cancer if:
You are a smoker
You have other symptoms of lung cancer
The nodule has grown in size or has changed compared to earlier x-‐rays.
A transbronchial needle aspiration (TBNA) biopsy may be done if the nodule is close to the airway.
Transthoracic needle aspiration (TTNA) biopsy: This type of biopsy is used if the lesion is not easily accessible on the airway wall or is smaller than 2 cm in diameter.
If the SPN is on the periphery of the lung, a biopsy sample has to be taken with the help of a needle inserted through the chest wall and into the SPN. It is usually performed with CT guidance.
With SPNs larger than 2 cm in diameter, the diagnostic accuracy is higher (90-‐95%).
However, the accuracy decreases (60-‐80%) in nodules that are smaller than 2 cm in diameter.
77) on Blessings
Dear Yin Ling,
Are you aware of the Different kind of Blessings?
The Ulnar Blessing:
An ulnar claw is an abnormal hand position that develops due to a lesion with the ulnar nerve. A hand in ulnar claw position will have the ring and little fingers drawn towards the back of the hand at the MPJoint and curled towards the palm at the PIP and DIP when the fingers are extended.
Remember the action of the Lumbricals!? What is the LAST muscle used in the act of MALE Micturition?!! The medial two lumbricals are not working due to ulnar
damage, the 3rd & 4th lumbricals are unable to extend the PIP & DIP joints at the 4th & 5th digits, so the medial two digits are clawed; clawing is caused by extension of MP joint by Extensor digitorum and flexion caused by Flexor digitorum..
The ulnar nerve controls the 3rd & 4th lumbricals, the three hypothenar muscles, the dorsal & palmar interossei, the palmaris brevis and the adductor pollicis. Ulnar nerve damage may also cause hypothenar atrophy.
The ulnar claw can present as a "hand of benediction" or "pope's blessing".
However, the term "hand of benediction" or "pope's blessing" also commonly refers to a similar hand position which is caused by damage to the median nerve and is only present when the patient is asked to ... make a fist!!
Hence students are often confused because of these different Blessings!!
A different hand of benediction results from injury of the Median nerve:
The pope's hand is seen with median nerve dysfunction when asking the patient to make a fist due to inability to flex 1st & 2nd fingers at PIP. The median nerve
controls the 1st & 2nd lumbricals, three thenar muscles (abductor pollicis brevis, flexor pollicis brevis, and via a distal branch the opponens pollicis). Additionally there may be thenar atrophy.
The extensor digitorum is left unopposed and the metacarpophalangeal joints of index and middle fingers remain extended while attempting to ... make a fist.
Therefore in median nerve injury, there will be BENEDICTION sign when making a FIST....but NO benediction sign when fingers are EXTENDED!!
Medical students must first understand the ALL IMPORTANT Question the late Professors of Anatomy used to ask us: What is the last muscle used in the act of