Macter’s Clinical Excellence & Leadership Program (CELP)Issues and updates on Internal Medicine, discussed in the eighth session of CELP’s National CME Series 2008
KARACHI: The 8th session of the National CME series for family physicians under Macter’s Clinical Excellence & Leadership Program (CELP) was held on August 28, 2008 at LNH, Karachi. The program was largely attended by General Practitioners from across Karachi and Sindh.
More than 600 doctors have so far registered themselves in this ongoing event.
The eighth session was focused on internal medicine and was addressed by Dr Asim Noor Head of the Department of Medicine LNH, Dr Samina Ghaznavi senior consultant physician LNH, Dr Naseem Salahuddin consultant physician in Medicine and Infectious diseases from Indus Hospital and Dr Mashoor Alam professor of Medicine LNH.
Talking about the Fever of unknown origin (FUO) also known as Pyrexia of unknown origin (PUO), Dr Asim Noor discussed in detail the etiology, pathogenesis, investigation and management of FUO entity, which the general & family physicians very commonly come across. He told the audience that history and examination of the patients are key to the diagnosis of the disease. He stressed upon the participants to take detailed history from the patient and perform a thorough physical examination whenever a patient comes with a history of fever and that the request for investigations should be made keeping in view the findings on history and examination.
Regarding the etiology of FUO he apprised the participants that there were so many etiologies present but the common causes were infection, malignancy and collagen vascular disease. Drug induced fever is one of the causes which generally go unnoticed most of the times and dramatic response is achieved when the antibiotics are stopped, he further added.
Nosocomial infections were also a major cause of FUO in hospitalized patients and as per protocol the Intravenous line has to be changed every three days to reduce chances of septic thrombophlebitis and sinusitis in patients with Nasogastric tube. He also highlighted the injudicious use of antimalarials and urged upon the need to discourage the irrational use of sulfadoxine + pyrimethamine combination drug.
He said that family physicians should advise their patients to maintain daily temperature chart as the documentation of fever is extremely important because 20 % of the cases of FUO remain undiagnosed.
Mentioning malignancy as one of the causes of FUO he informed the audience that the prevalence of cancer of colon was increasing in our society and the main reason he pointed out was the change in dietary habits as the consumption of western diets like pizzas, burgers has increased considerably also reduced consumption of wheat (laal gandum) has led to an increase in the incidence of colonic cancer.
Dr Asim Noor concluded his presentation with the take home message “Any fever lasting longer than 3 weeks should be properly evaluated, don’t ignore patients can complicate at any time even if diagnosis and proper treatment has been initiated, therefore always seek expert help for PUO”.
Dr Samina Ghaznavi presented her lecture on Vitamin B deficiencies. She very comprehensively elaborated the deficiency states of vitamin B family and told the audience that vitamin B deficiencies develop after a prolonged state of illness and the diagnosis is largely made on clinical grounds. The main reason for developing deficiency of these vitamins in our region was the malabsorption states, she added.
Dr Samina urged upon the need of using balanced diet to prevent these deficiencies , she was of the view that general practitioners can play an important role in educating and guiding people about the significance of eating healthy food that include meat, fish, vegetables, cereals, milk and other dairy products.
Dr Naseem Salahuddin in her session discussed about the rational use of antibiotics. During her presentation she discussed various cases whereby injudicious use of antibiotics resulted not only in drug induced fever and other adverse effects but it is extremely unethical as well. She further said that in deteriorating economic conditions of the country where the buying power of the people is eroding, putting an unnecessary burden on patient’s pocket was unfair too. This could also lead to loss of work days, she added.
She stressed the audience that before prescribing the antibiotics they themselves should ask a question—is antibiotic really needed? The answer to that is a careful history and a good physical and clinical assessment.
She informed the audience that 75% of prescriptions for treating Upper Respiratory Tract Infections (URTIs) in outpatient clinics were limited to antibiotics and as a fact the majority of these prescriptions were unnecessary since most of the URTIs' were caused by viruses, she revealed.
Dr Naseem Salahuddin urged upon the need of Improved diagnostic methods for correct diagnosis, treating only bacterial infections with an antibiotic and on the use of appropriate dose and duration of treatment. She also stressed upon getting the Culture and Sensitivity test done before the initiation of an antibiotic even in emergency situations like endocarditic and or meningitis.
Dr Naseem concluded her lecture presentation with these final remarks. “Don’t panic, take your time assess the patient carefully and then prescribe an antibiotic”
A very comprehensive overview on typhoid fever was presented by Professor Mashoor Alam. He said that the high prevalence of typhoid in our society was due to the extremely unhygienic conditions we are living in.
