Asthma. Intermittent or persistent?

Those suffering from intermittent asthma do not need daily medications to maintain good control. On the other hand, those with persistent asthma will need daily maintenance medications to prevent exacerbations. Luckily for us, there is a rule of thumb that will help make the clinical distinction between intermittent and persistent asthma easier.

This rule of thumb is the “rule of twos” (abbreviated as Ro2). This is a quick and easy checklist to go through with your patients. If they answer “yes” to any of the rules of two, asthma is considered to be “persistent” or inadequately controlled.

• Are they symptomatic more than 2 days a week?
• Are they requiring their rescue inhaler more than 2 days per week?
• Are they experiencing nighttime symptoms more than 2 days per month?
• Are they requiring a course of oral steroids more than 2 times a year?

Hopefully some of you can put the Ro2 to use in practice!

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Have a great week! Good luck to those studying for exams.

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Triads, pentads and classic presentations (part 11)

Apologies for not having posted in a while! The Weekly Mnemonic is back with number 11 of the “Triads” series. This time, 3 triads with the focus is on women’s health are presented.

Meig’s syndrome will resolve with resection of the benign ovarian mass and consists of the triad of: 1) ascites 2) pleural effusion 3) benign ovarian tumour.

The female athlete triad consists of 3 conditions and is found in females participating in sports activities which value a low body weight: 1) eating disorder 2) amenorrhea 3) osteoporosis or osteopenia.

Polycystic ovary syndrome is an anovulatory state which includes the following 3 classic findings: 1) signs of hyperandrogenism (hirsutism, acne, hair loss, etc.) 2) oligomenorrhea or amenorrhea 3) polycystic appearance of ovaries on ultrasound.

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Happy Easter! Thanks for reading and/or following the blog. :)

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Scoring and risk stratification (part 5)

The Alvarado score is a popular score used in emergency medicine to determine the likelihood of an appendicitis. This score is a high sensitivity for appenciditis and is therefore best for ruling it out (sensitivity of a score of 5 is 99% and specificity of a score of 7 is 81%). It is unreliable in children and more reliable in men than women. You may refer to a systematic of the Alvarado score below.

The Alvarado score has 8 criteria for a total score of 10 points. Alvarado score may be remembered using the following memory trick: “My Appendix Feels Likely To Rupture Now”.

My = Migration of pain to the right iliac fossa

Appendix = Anorexia

Feels = Fever of 37.3 Celsius or more

L = Leukocytosis

T = Tenderness in the right iliac fossa

R = Rebound tenderness

N = 1) Nausea or vomiting 2) Neutrophilia

**Tenderness in the right lower quadrant and leukocytosis count for 2 points each. All other criteria count for 1 point.

A score of 1 to 4 points has a 30% probability of being appendicitis. No imaging is suggested (note: if score is 4 points and there is clinical suspicion, imaging is suggested). The patient may be discharged.

A score of 5 to 6 points has a 66% probability of being appendicitis. A CT of the abdomen is suggested. The patient should be observed +/- admitted.

A score of 7 to 10 points has a 93% probability of being appendicitis. Consult a surgeon.

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Please refer to this article by Ohle et al. entitled “The Alvarado score for predicting acute appendicitis: a systematic review” for more reading. Thanks for reading!

*Note: this tool (and other risk stratification tools posted on this blog) is only for use by medical professionals in the medical context. If you are concerned for your health, please consult your physician!

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Scoring and risk stratification (part 4)

Hello again and Happy New Year! I hope this year brings you new challenges and much joy. This week, another scoring tool will be shared. It is called the ”Curb65” rule. It sounds like a really catchy weight loss program for the New Year, don’t you think? In fact, it is a scoring tool for determining the 30-day mortality risk of patient’s presenting to hospital with a community acquired pneumonia. The link for the original article for the Curb65 rule’s validation is below. Here are the 5 criteria for CURB65:

C = Confusion (new onset)

U = Urea (i.e. blood urea nitrogen) > 7 mmol/L

R = Respiratory rate > 30

B = Blood pressure < 90 mm Hg systolic or < 60 mmHg diastolic

65 = Age > 65

 Each criteria is 1 point. Here is the details of the scoring system:

– A score of 0 or 1 has a low mortality risk (1.5%) and is likely suitable for home management.

– A score of 2 has a intermediate mortality risk (9.2%) and should be considered for hospital management (e.g. short stay or close outpatient follow-up)

– A score of 3 or more has a high mortality risk (22%) and should be managed in-hospital and considered for ICU management if the score is 4 or 5.

 If you do not have access to blood chemistry and are in a community clinic, you may alternatively use the CRB65 score. This is the same criteria as the CURB65, but conveniently only includes the clinical criteria. Again, it predicts 30-day mortality. Here is the scoring system for CRB65:

Each criteria is 1 point

– A score of 0 has a low mortality risk (1.2%) and is likely suitable for home management.

– A score of 1 or 2 has an intermediate mortality risk (8.15%) and should be considered for hospital assessment/referral.

– A score of 3 or 4 has a high mortality risk (31%) and should be managed in-hospital and needs urgent hospital assessment.

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Click here to consult the original article by Lim et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study.

*Note: this tool (and other risk stratification tools posted on this blog) is only for use by medical professionals in the medical context. If you are concerned for your health, please consult your physician!

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Your submissions

Thanks to those who submitted suggestions to TheWeeklyMnemonic in the past month.

One reader suggested the “AMERICA” mnemonic for the TIMI risk score which was previously posted here. It is always nice to review things that we have forgotten!

Rebecca shared an equally practical mnemonic for the management of opioid prescriptions for chronic pain. She obtained this from her palliative care course. The mnemonic in question is the “5A Opioid monitoring tool“, which is summarized below. You may refer to this link for a PDF which goes into more detail on how to use one version of the 5As.

• Analgesia (i.e. degree of pain relief provided by the opioids)

• Activities of daily living (i.e. the patient’s physical and psychosocial function)

• Adverse effects and remedies for these (i.e. constipation, nausea, etc.)

• Aberrant drug-taking behaviour (i.e. abuse/misuse)

• Accurate medication record

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Thanks for the contributions. Keep them coming! Have a great week.

The Weekly Mnemonic has more than 10, 000 views! To celebrate, in December, The WM will change its look and will offer a Christmas prize to one of its followers! Have a wonderful week.

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Healing

This week we present two mnemonics related to non-healing. “FETID” provides a differential for a non-healing fistula and “TIME” is handy mnemonic to know when dealing with a chronic wound.

FETID for fistula*

F = Foreign body

E = Epithelialization if the fistulas tract

T = Tumor

I = Infection/Inflammation

D = Distal Obstruction

TIME for non-healing wound*:

T = Tissue is non-viable or deficient

I = Infection or Inflammation

M = Moisture imbalance (i.e. too dry or too wet)

E = Edge of is wound is non-advancing or undermining

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The Weekly Mnemonic is approaching 10, 000 views. Stay tuned, because some time after that benchmark, The WM will change its look and just might offer a prize to one of its followers! Have a great week.

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FETID was taken from Pestana’s surgical notes and TIME was taken from the following link.

Coffee for strep throat

Have you ever had to look up the modified Centor criteria when someone comes to you with a possible strep throat? You will have to look no more once you know the mnemonic “Old CAFE”. The WM is pretty sure it doesn’t exist elsewhere, so it just might be an exclusive one. :)

Old = Age

C = Cervical lymphadenopathy

A = Absence of cough

F = Fever

E = Exudates in the tonsillar region

Here is how to calculate the modified Centor criteria:

Age < 15 = +1 point

Age > 44 = -1 point

All the rest of the “CAFE” criteria = + 1 point

Here is how to use the modified Centor criteria:

-1 to 1 point = No testing, no antibiotics

2 to 3 points = Perform a culture, give antibiotics if culture positive

4 to 5 = Treat empirically with antibiotics +/- culture

Please click here to the following article for more information on pharyngitis guidelines.

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Have a great week and happy studies.

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