Sunday, May 7, 2017

Cardiovascular Examination

Blood Pressure Measurement

Lower Limb Neurological Examination

Upper Limb Neurological Examination

Cranial Nerve Examination

Breast Examination

Respiratory Examination

Peripherical Vascular Examination

Monday, March 13, 2017

Is Your Skincare Right for Your Age?

Lotions, Botox, Dysport, Fillers, Lasers, Skin Tightening…it’s great to have so many skincare options, but how do you know when it’s time to start using them? At what age should you start thinking of adding one (or more) of these to your routine? And, is it ever too late to try to fix something?

Here are some good general guidelines:






In Your 20’s:
  • It is NEVER too early to start sunscreening your face, neck, chest and hands every morning. Start in your teens or 20s if you can. That 30 seconds you invest once in the morning will save your skin years of aging.
  • Establish (and stick to) a solid basic skincare routine – a good antioxidant under your sunscreen in the morning followed by a good moisturizer. At night, use a vitamin A cream like retinol (non-prescription) or Renova/tretinoin (prescription).
  • Don’t “fix” problems you don’t have. If you are 25, and have no frown lines, starting Botox/Dysport just wastes your time and money. Start only when you see problems developing; and who knows, you may get lucky and never have need.

In Your 30’s:
  • By their mid-30’s, most women and men are starting to show signs of frown lines, crow’s feet, or upper lip lines. This is usually a good time to start preventive treatments with small doses of Botox/Dysport 2-3 times a year– but only if you actually have these problems.
  • Almost everyone can benefit from photorejuvenation/IPL starting in their 30’s. There is a big difference in the power and results with different IPLs so please see the information on SkinTour.com on this laser cousin. It clears up small brown spots, dilated blood vessels, and generates a little collagen which improves skin texture.

Over 40:
  • Fillers can help with early signs of volume loss (sagging), which affects most women/men by the age of 40-50. Starting with a syringe or two of hyaluronic acid filler 1-2 twice a year retards the sagging. Everyone is very individual on this, so consult your doctor for an individualized plan for correction of existing sagging and then maintenance.
  • Laser treatments need to be customized at this age. You might be someone who can benefit from skin tightening like Thermage/Ultherapy, etc. or you might need more intense laser skin improvement like the Fraxel Dual or fractionated carbon dioxide laser – it really varies by the individual, so you will need a consult.
  • Over 60? Your skin can still be noticeably and safely improved with these technologies, it just takes a little more time, more treatments and more expense.

And, some good advice for all ages:
  • Don’t believe everything you hear from marketers or friends. Do your own web research (on reputable sites) and talk to your doctor, but also take into account your own skin and its reactions. We are all different, so what works for others might not work for you.
  • Don’t start more than one new skincare product at a time.
  • Remember it often takes 1-3 months to see a beneficial effect of a new skincare product.




You can find older posts regarding ASEAN politics and economics news at SBC blog, and older posts regarding health and healthcare at IIMS blog. I thank you.

Sunday, March 5, 2017

Cambodia - Very Venomous Snakes Found - Taxonomy, Clinical, First Aid, Treatment, Antivenom

Bungarus candidus (Malayan Krait , Common Krait , Blue Krait , Javan Krait)







Bungarus fasciatus (Banded Krait , Golden Banded Snake)








Bungarus flaviceps (Red-headed Krait , Yellow-Headed Krait , Kinabalu Krait)







Calliophis maculiceps (Small-spotted Coral Snake)








Calloselasma rhodostoma (Malayan Pit Viper)








Daboia siamensis (Eastern Russell's Viper , Daboia , Tic-Polonga , Siamese Russell's Viper , Seven Pacer , Chain Snake)






Naja kaouthia (Monocellate Cobra , Thailand Cobra , Monacled Cobra , Bengal Cobra , Monocled Cobra)







Naja siamensis (Thai Spitting Cobra , Isan Spitting Cobra , Indo-Chinese Spitting Cobra)






Ophiophagus Hannah (King Cobra , Hamadryad , Jungle Cobra)







Ovophis monticola (Mountain Pit Viper , Blotched Pit Viper , Mountain Iron-head Snake , Chinese Mountain Pit Viper , Western Mountain Pit Viper, Indo-Malayan Mountain Pit Viper





Rhabdophis chrysargos (Speckle-bellied Keelback)








Rhabdophis nigrocinctus (Green Keelback , Banded Keelback)







Rhabdophis subminiatus (Red-necked Keelback , Heller's Keelback (R. s. helleri))







Trimeresurus albolabris (White-lipped Green Pit Viper , White-lipped Pit Viper , White-lipped Tree Viper)






Trimeresurus vogeli (Vogel's Green Pitviper , Vogel's Pitviper)






Trimeresurus popeiorum (Pope's Pit Viper , Pope's Green Pit Viper , Pope's Tree Viper , Red-tailed Pit Viper, Pope's Bamboo Pit Viper)





Trimeresurus macrops (Dark Green Pit Viper , Large-eyed Pit Viper , Kramer's Pit Viper)









You can find older posts regarding ASEAN politics and economics news at SBC blog, and older posts regarding health and healthcare at IIMS blog. I thank you.

Cambodia - Very Venomous Snakes Found - Trimeresurus macrops

Trimeresurus macrops ( Dark Green Pit Viper ) 
Original photo copyright © Dr Anita Malhotra


































Family: Viperidae

Subfamily: Crotalinae

Genus: Trimeresurus

Species: macrops

Common Names: Dark Green Pit Viper , Large-eyed Pit Viper , Kramer's Pit Viper

Local Names: Ngu khiaw Hang Mai

Region: Southeast Asia

Countries: Cambodia, Thailand, Vietnam


Trimeresurus macrops ( Dark Green Pit Viper ) Original photo copyright © Dr Julian White

Taxonomy and Biology

Adult Length: 0.40 m

General Shape: Small in length, moderately slender bodied snake with tapering prehensile tail. Can grow to a maximum of about 0.75 metres. Head is short, triangular shaped and distinct from narrow neck. Eyes are large in size, golden yellow, cat-like, with vertically elliptical pupils. Dorsal scales are keeled except for the first dorsal scale row.

Habitat: Often found among small bush vegetation in plain and hill terrain up to about 1000 metres. Occasionally enters dwellings in search of prey and often found in urban areas including Bangkok.

Habits: Arboreal and mainly nocturnal, often seen at dusk or early morning.

Prey: Feeds mainly on rodents, lizards, birds and tree frogs.

Venom

General: Venom Neurotoxins
Probably not present
General: Venom Myotoxins
Unknown
General: Venom Procoagulants
Unknown
General: Venom Anticoagulants
Unknown
General: Venom Haemorrhagins
Unknown
General: Venom Nephrotoxins
Unknown
General: Venom Cardiotoxins
Probably not present
General: Venom Necrotoxins
Unknown
General: Venom Other
Unknown

Clinical Effects

General: Dangerousness
Unknown, but potentially lethal envenoming, though unlikely, cannot be excluded
General: Rate of Envenoming
Unknown but likely to be moderate
General: Untreated Lethality Rate
Unknown but lethal potential cannot be excluded
General: Local Effects
Local pain & swelling
General: Local Necrosis
Does not occur, based on current clinical evidence
General: General Systemic Effects
Does not occur, based on current clinical evidence
General: Neurotoxic Paralysis
Unlikely to occur
General: Myotoxicity
Not likely to occur
General: Coagulopathy & Haemorrhages
No reports of coagulopathy, though related species can cause bleeding problems
General: Renal Damage
Does not occur, based on current clinical evidence
General: Cardiotoxicity
Unlikely to occur
General: Other
Does not occur, based on current clinical evidence

First Aid

Description:

First aid for bites by Viperid snakes likely to cause significant local injury at the bite site.

Details

1. After ensuring the patient and onlookers have moved out of range of further strikes by the snake, the bitten person should be reassured and persuaded to lie down and remain still. Many will be terrified, fearing sudden death and, in this mood, they may behave irrationally or even hysterically. The basis for reassurance is the fact that many venomous bites do not result in envenoming, the relatively slow progression to severe envenoming (hours following elapid bites, days following viper bites) and the effectiveness of modern medical treatment.

2. The bite wound should not be tampered with in any way. Wiping it once with a damp cloth to remove surface venom is unlikely to do much harm (or good) but the wound must not be massaged.

3. All rings or other jewellery on the bitten limb, especially on fingers, should be removed, as they may act as tourniquets if oedema develops.

4. The bitten limb should be immobilised as effectively as possible using an extemporised splint or sling; if available, crepe bandaging of the splinted limb is an effective form of immobilisation.

5. If there is any impairment of vital functions, such as problems with respiration, airway, circulation, heart function, these must be supported as a priority. In particular, for bites causing flaccid paralysis, including respiratory paralysis, both airway and respiration may be impaired, requiring urgent and prolonged treatment, which may include the mouth to mask (mouth to mouth) technique of expired air transfer. Seek urgent medical attention.

6. Do not use Tourniquets, cut, suck or scarify the wound or apply chemicals or electric shock.

7. Avoid peroral intake, absolutely no alcohol. No sedatives outside hospital. If there will be considerable delay before reaching medical aid, measured in several hours to days, then give clear fluids by mouth to prevent dehydration.

8. If the offending snake has been killed it should be brought with the patient for identification (only relevant in areas where there are more than one naturally occurring venomous snake species), but be careful to avoid touching the head, as even a dead snake can envenom. No attempt should be made to pursue the snake into the undergrowth as this will risk further bites.

9. The snakebite victim should be transported as quickly and as passively as possible to the nearest place where they can be seen by a medically-trained person (health station, dispensary, clinic or hospital). The bitten limb must not be exercised as muscular contraction will promote systemic absorption of venom. If no motor vehicle or boat is available, the patient can be carried on a stretcher or hurdle, on the pillion or crossbar of a bicycle or on someone's back.

10. Most traditional, and many of the more recently fashionable, first aid measures are useless and potentially dangerous. These include local cauterization, incision, excision, amputation, suction by mouth, vacuum pump or syringe, combined incision and suction ("venom-ex" apparatus), injection or instillation of compounds such as potassium permanganate, phenol (carbolic soap) and trypsin, application of electric shocks or ice (cryotherapy), use of traditional herbal, folk and other remedies including the ingestion of emetic plant products and parts of the snake, multiple incisions, tattooing and so on.

Treatment

Treatment Summary: Bites by this species are not recorded, but might cause moderate, possibly major local & systemic effects, including coagulopathy/bleeding. Urgently assess & admit all cases. Antivenom therapy is probably the key treatment, especially for coagulopathy.

Key Diagnostic Features: Local pain, swelling, blistering, necrosis + coagulopathy, bleeding

General Approach to Management: All cases should be treated as urgent & potentially lethal. Rapid assessment & commencement of treatment including appropriate antivenom (if indicated & available) is mandatory. Admit all cases.

Antivenom Therapy: Antivenom is the key treatment for systemic envenoming. Multiple doses may be required.

Antivenoms

1. Antivenom Code: SAsTRC01
Antivenom Name: Green Pit Viper Antivenin
Manufacturer: Science Division, Thai Red Cross Society
Phone: ++66-2-252-0161 (up to 0164)
Address: Queen Saovabha Memorial Institute
1871 Rama IV Road
Pathumwan
Bangkok 10330

Country: Thailand

Cambodia - Very Venomous Snakes Found - Trimeresurus popeiorum

Trimeresurus popeiorum ( Pope's Pit Viper ) 
Original photo copyright © Dr Anita Malhotra


























Family: Viperidae

Subfamily: Crotalinae

Genus: Trimeresurus

Species: popeiorum

Common Names: Pope's Pit Viper , Pope's Green Pit Viper , Pope's Tree Viper , Red-tailed Pit Viper, Pope's Bamboo Pit Viper

Local Names: Ular Kapak Ekor Merah , Ular Engkerudu Daun

Region: Indian Sub-continent + Southeast Asia

Countries: Cambodia, India, Laos, Malaysia, Myanmar, Thailand, Vietnam


Trimeresurus popeiorum ( Pope's Pit Viper ) Original photo copyright © Dr Julian White

Taxonomy and Biology

Adult Length: 0.40 m

General Shape: Small in length, moderately slender ( males ) to moderately stout ( females ), cylindrical bodied pitviper with a medium ( males ) to moderately short ( females ) prehensile tail. Can grow to a maximum of about 0.93 metres. Head is moderately large, longer than broad, triangular shaped and distinct from neck. Snout is rounded when viewed from above and obliquely truncate when viewed from the side. Eyes are moderately large in size with vertically elliptical pupils. Dorsal scales are strongly keeled in males and weakly keeled in females. Dorsal scale count 21 to 23 ( 25 ) - 21 ( 23 ) - 15 ( 17 ).

Habitat: Tropical montane primary and secondary forest regions at elevations up to about 1500 metres.

Habits: Mainly nocturnal and semi-arboreal. Often seen climbing in low bushes near forest streams.

Prey: Feeds mainly on rodents, small birds, lizards and frogs.

Venom

General: Venom Neurotoxins
Probably not present
General: Venom Myotoxins
Unknown
General: Venom Procoagulants
Unknown
General: Venom Anticoagulants
Unknown
General: Venom Haemorrhagins
Unknown
General: Venom Nephrotoxins
Unknown
General: Venom Cardiotoxins
Probably not present
General: Venom Necrotoxins
Unknown
General: Venom Other
Unknown

Clinical Effects

General: Dangerousness
Unknown
General: Rate of Envenoming
Unknown
General: Untreated Lethality Rate
Unknown
General: Local Effects
Insufficient clinical reports to know
General: Local Necrosis
Insufficient clinical reports to know
General: General Systemic Effects
Insufficient clinical reports to know
General: Neurotoxic Paralysis
Unlikely to occur
General: Myotoxicity
Not likely to occur
General: Coagulopathy & Haemorrhages
No reports of coagulopathy, though related species can cause bleeding problems
General: Renal Damage
Insufficient clinical reports to know
General: Cardiotoxicity
Unlikely to occur
General: Other
Insufficient clinical reports to know

First Aid

Description:

First aid for bites by Viperid snakes likely to cause significant local injury at the bite site.

Details

1. After ensuring the patient and onlookers have moved out of range of further strikes by the snake, the bitten person should be reassured and persuaded to lie down and remain still. Many will be terrified, fearing sudden death and, in this mood, they may behave irrationally or even hysterically. The basis for reassurance is the fact that many venomous bites do not result in envenoming, the relatively slow progression to severe envenoming (hours following elapid bites, days following viper bites) and the effectiveness of modern medical treatment.

2. The bite wound should not be tampered with in any way. Wiping it once with a damp cloth to remove surface venom is unlikely to do much harm (or good) but the wound must not be massaged.

3. All rings or other jewellery on the bitten limb, especially on fingers, should be removed, as they may act as tourniquets if oedema develops.

4. The bitten limb should be immobilised as effectively as possible using an extemporised splint or sling; if available, crepe bandaging of the splinted limb is an effective form of immobilisation.

5. If there is any impairment of vital functions, such as problems with respiration, airway, circulation, heart function, these must be supported as a priority. In particular, for bites causing flaccid paralysis, including respiratory paralysis, both airway and respiration may be impaired, requiring urgent and prolonged treatment, which may include the mouth to mask (mouth to mouth) technique of expired air transfer. Seek urgent medical attention.

6. Do not use Tourniquets, cut, suck or scarify the wound or apply chemicals or electric shock.

7. Avoid peroral intake, absolutely no alcohol. No sedatives outside hospital. If there will be considerable delay before reaching medical aid, measured in several hours to days, then give clear fluids by mouth to prevent dehydration.

8. If the offending snake has been killed it should be brought with the patient for identification (only relevant in areas where there are more than one naturally occurring venomous snake species), but be careful to avoid touching the head, as even a dead snake can envenom. No attempt should be made to pursue the snake into the undergrowth as this will risk further bites.

9. The snakebite victim should be transported as quickly and as passively as possible to the nearest place where they can be seen by a medically-trained person (health station, dispensary, clinic or hospital). The bitten limb must not be exercised as muscular contraction will promote systemic absorption of venom. If no motor vehicle or boat is available, the patient can be carried on a stretcher or hurdle, on the pillion or crossbar of a bicycle or on someone's back.

10. Most traditional, and many of the more recently fashionable, first aid measures are useless and potentially dangerous. These include local cauterization, incision, excision, amputation, suction by mouth, vacuum pump or syringe, combined incision and suction ("venom-ex" apparatus), injection or instillation of compounds such as potassium permanganate, phenol (carbolic soap) and trypsin, application of electric shocks or ice (cryotherapy), use of traditional herbal, folk and other remedies including the ingestion of emetic plant products and parts of the snake, multiple incisions, tattooing and so on.

Treatment

Treatment Summary: Bites by this species are not recorded, but might cause moderate, possibly major local & systemic effects, including coagulopathy/bleeding. Urgently assess & admit all cases. Antivenom therapy is probably the key treatment, especially for coagulopathy.

Key Diagnostic Features: Local pain, swelling, blistering, necrosis + coagulopathy, bleeding

General Approach to Management: All cases should be treated as urgent & potentially lethal. Rapid assessment & commencement of treatment including appropriate antivenom (if indicated & available) is mandatory. Admit all cases.

Antivenom Therapy: Antivenom is the key treatment for systemic envenoming. Multiple doses may be required.

Antivenoms

1. Antivenom Code: SAsCRI01
Antivenom Name: Polyvalent Anti Snake Venom Serum
Manufacturer: Central Research Institute
Phone: ++91-1-792-72114
Address: Kasauli (H.P.) 173204
Country: India

2. Antivenom Code: SAsTRC01
Antivenom Name: Green Pit Viper Antivenin
Manufacturer: Science Division, Thai Red Cross Society
Phone: ++66-2-252-0161 (up to 0164)
Address: Queen Saovabha Memorial Institute
1871 Rama IV Road
Pathumwan
Bangkok 10330
Country: Thailand

3. Antivenom Code: SAsSII01
Antivenom Name: SII Polyvalent Antisnake Venom Serum ( lyophilized )
Manufacturer: Serum Institute of India Ltd.
Phone: +91-20-26993900
Address: 212/2, Hadapsar,
Off Soli Poonawalla Road,
Pune-411042. India
Country: India

4. Antivenom Code: SAsSII02
Antivenom Name: SII Bivalent Antisnake Venom Serum ( lyophilized )
Manufacturer: Serum Institute of India Ltd.
Phone: +91-20-26993900
Address: 212/2, Hadapsar,
Off Soli Poonawalla Road,
Pune-411042. India

Country: India