Friday, March 30, 2012

Initiating and maintainance dose of warfarin therapy

* Usually starts with 3-5mg of warfarin on D1 and D2 for non-urgent anticoagulation with no co-morbidities

Ref: Warfarin Management - A practical approach

Wednesday, March 21, 2012

Target INRs for common indications for warfarin therapy

Target INRDisease States
2.0 +/- 0.5AF, prophylaxis of stroke and other systemic embolism
2.5 +/- 0.5Prophylaxis or treatment of DVT, PE, heart valve disease, arterial disease
3.0 +/- 0.5Mechanical prosthetic heart valves, AMI, hypercoagulable states

It is recommended that INR be assessed:
- every 4 wks in stable patients
- every 2 wks in less stable patients and less compliant patients
- more frequently if and when situation warrants

Tuesday, March 20, 2012

HASBLED risk score

UseAssess risk of bleeding in AF
ScoringHypertension  +1
Abnormal renal and liver fn  +1 each
Stroke            +1
Bleeding         +1
Labile INR     +1
Elderly (>65yrs) +1
Drugs or alcohol  +1 each
AssessmentScore > 3 = High risk
.AF, Anticoagulant

Thursday, March 15, 2012

Bleeding Risk Index

Independent Risk Factors:
- Comorbid conditions (eg serious cardiac illness, renal insufficiency, poor general conditions)
- Concomitant use of heparin
- INR level
- Worsening liver dysfunction

Controlling these independent risk factors will reduce their associated risk of bleeding

Number of comorbid condns at start of therapyOne (+1)
Two (+2)
Three (+3)
Concomitant use of heparinAge 60-79 yrs  (+2)
Age 80 or more (+4)
INR level2.0 - 2.9     (+1)
3.0 or more (+2)
Worsening liver dysfunction during therapy
(bilirubin rising to 4 mg/dl (68.4 umol/L) or more)
Yes  (+2)
- low risk: 0 - 2 points
- moderate risk: 3 - 4 points
- high risk: 5 or more points

Tuesday, March 6, 2012

Brandt-Daroff Home Exercises

To speed up the compensation process and end the symptoms of vertigo. This exercise will not cure these conditions, but over time they can reduce symptoms of vertigo.

To do the Brandt-Daroff exercise:
  • Start in an upright, seated position.
  • Move into the lying position on one side with your nose pointed up at about a 45-degree angle.
  • Remain in this position for about 30 seconds (or until the vertigo subsides, whichever is longer), then move back to the seated position.
  • Repeat on the other side.
People using this exercise usually are instructed to do 20 repetitions of the exercise at least twice a day.

What To Expect After Treatment
Symptoms sometimes suddenly go away during an exercise period. More often, improvement occurs gradually over a period of weeks or months.

How Well It Works
These exercises can help your body get used to the confusing signals that are causing your vertigo. This may help you get over your vertigo sooner.

There are no risks in doing these exercises.

YouTube video link:

Sunday, March 4, 2012

Well's Criteria for Pulmonary Embolism

Well's Criteria for Pulmonary Embolism
UseEstimates likelihood of pulmonary embolism
Scoringclinically suspected DVT (+3 points)
alternative diagnosis is less likely than PE (+3 points)
tachycardia (+1.5 points)
immobilization/surgery in previous four weeks (+1.5 points)
history of DVT or PE (+1.5 points)
hemoptysis (+1 point)
malignancy (treatment for within 6 months, palliative) (+1 point)
Assessment  Traditional interpretation:
  *  > 6 - High (59% probability)
  * 2 to 6 - Moderate (29% probability)
  * < 2 - Low (15% probability)

Alternative interpretation (used in CGH)
  * > 4 - PE likely. Consider diagnostic imaging. Repeat if scan within 1 week if strong suspicion
  * 4 or less - PE unlikely. Consider D-dimer
Follow up investigations
(+) D-dimer(-) D-dimer
Low pretest probability scoreUrgent scan
If (-), discharge
< 1% risk of DVT.
No scan
.Pulmonary embolism

Well's Criteria for Deep Vein Thrombosis

Well's Criteria for DVT
UseEstimates likelihood of deep vein thrombosis
ScoringActive cancer (ongoing treatment or within previous 6 months or palliative) (+1)

Paralysis, paresis or recent plaster immobilization of the lower extremities (+1)

Recently bedridden for > 3 days, or major surgery within 12 weeks (+1)

Localised tenderness along the distribution of the deep venous system (+1)

Entire leg swollen (+1)

Calf swelling by > 3 cm (measured 10 cm below tibial tuberosity) (+1)

Pitting oedema confined to symptomatic leg (+1)

Collateral superficial veins (non-varicose) (+1)

Previous documented DVT (+1)

Alternative diagnosis at least as likely (-2)
Assessment  Score of 2 or higher — deep vein thrombosis is likely. Consider imaging the leg veins.
Score of less than 2 — deep vein thrombosis is unlikely. Consider blood test such as d-dimer test to further rule out deep vein thrombosis

Cawthorne Cooksey Exercises

Cawthorne Cooksey Exercises
  1. In bed or sitting
    1. Eye movements -- at first slow, then quick
      1. up and down
      2. from side to side
      3. focusing on finger moving from 3 feet to 1 foot away from face
    2. Head movements at first slow, then quick, later with eyes closed
      1. bending forward and backward
      2. turning from side to side
  2. Sitting
    1. Eye movements and head movements as above
    2. Shoulder shrugging and circling
    3. Bending forward and picking up objects from the ground
  3. Standing
    1. Eye, head and shoulder movements as before
    2. Changing form sitting to standing position with eyes open and shut
    3. Throwing a small ball from hand to hand (above eye level)
    4. Throwing a ball from hand to hand under knee
    5. Changing from sitting to standing and turning around in between
  4. Moving about (in class)
    1. Circle around center person who will throw a large ball and to whom it will be returned
    2. Walk across room with eyes open and then closed
    3. Walk up and down slope with eyes open and then closed
    4. Walk up and down steps with eyes open and then closed
    5. Any game involving stooping and stretching and aiming such as bowling and basketball
Diligence and perseverance are required but the earlier and more regularly the exercise regimen is carried out, the faster and more complete will be the return to normal activity. Ideally these activities should be done with a supervised group. Individual patients should be accompanied by a friend or relative who also learns the exercises.

(Adapted from Dix and Hood, 1984 and Herdman, 1994; 2000)


Saturday, March 3, 2012

ABCD2 Score for TIA

ABCD2 Score for TIA
UseEstimates risk of stroke after a TIA
ScoringAge >= 60 (+1 if yes)
BP >= 140/90 mmHg at initial evaluation (+1 if yes)

Clinical features of TIA:
  - unilateral weakness (+2 if yes)
  - speech disturbance without weakness (+1 if yes)

Duration of symptoms:
  - 10 - 59 minutes (+1 if yes)
  - >= 60 minutes (+2 if yes)

Diabetes Mellitus present? (+1 if yes)
Assessment  Stroke risk:
     - 0-3: low risk
     - 4-5: moderate risk
     - 6-7: high risk

Thursday, March 1, 2012


UseRule Out Stroke In the Emergency Room
ScoringScore: 0 for no
- Has there been loss of consciousness or syncope?  (-1 for yes)
- Has there been seizure activity?  (-1 for yes)
- Is there a new onset or waking from sleep?
       - asymmetric facial weakness  (1 for yes)
       - asymmetric arm weakness  (1 for yes)
       - asymmetric leg weakness  (1 for yes)
       - speech disturbance  (1 for yes)
       - visual field defect  (1 for yes)
AssessmentIf total score > 0: stroke likely
If less or equals to 0: low probability but cannot exclude

Wednesday, February 29, 2012

Alvarado Appendicitis Score

Alvarado score
UseEvaluate likelihood of appendicitis in adult
ScoringScore: 0 for no
- Migration of pain to right lower quadrant  (1 for yes)
- Anorexia or acetone in urine  (1 for yes)
- Nausea-vomiting  (1 for yes)
- Right lower quadrant tenderness  (2 for yes)
- Rebound pain  (1 for yes)
- Fever  (1 for yes)
- WBC > 10K  (2 for yes)
- Left shift (over 75% neutrophils)  (1 for yes)
Assessment<5:  appendicitis less likely
 5-6: possible appendicitis
7-8: probably appendicitis
>8: very probably appendicitis

Peripheral vs Central Vertigo

Distinguishing Characteristics of Peripheral vs. Central Causes of Vertigo

FeaturePeripheral VertigoCentral Vertigo
Nystagmus   Combined horizontal and torsional
No directional change with gaze
Inhibited by eye fixation
Fade after a few days
Purely unidirectional
Directional change with gaze towards fast phase
Not inhibited by eye fixation
May last weeks to months
Imbalance Mild to moderate
Able to walk
Severe imbalance
Unable to stand still or walk
Nausea, vomiting May be severeVaries
Hearing loss, tinnitusCommonRare
Non-auditory symptomsRareCommon
Latency following
provocative test
Long (up to 20 seconds)Short (up to 5 seconds)

Reference:  Initial Evaluation of Vertigo, Jan 15, 2006 American Family Physician

Tuesday, February 28, 2012

Shock Index

Shock Index
UseEvaluate possibility of acute critical illness
Calculationheart rate/systolic blood pressure
Normal0.5 - 0.7
Significancelow sensitivity
> 0.9: associated with higher risk of morbidity, mortality and admission