PUO (Pyrexia of Unknown Origin) - Practical definition

"PUO is a fever, the cause of which is unknown to the patient for weeks and even unknown to the treating physician  after weeks of investigations and the byestanders are even more eager to know the cause, than the patient or the doctor  !" - Definition by an  'Un known' doctor.

Doctor, what’s the right way to swallow a pill?

After nearly 10 years of medical education and another 5 years of medical practice I realized that the simplest questions are OFTEN the hardest to answer.

When a 50 year old lady raising her innocent eyes but with a wicked smile asked me this question during a busy morning schedule, I was stumped. Should I use my old strategy as a senior resident to my junior resident ; “what man you don’t even know this, go and refer the books!!”, or should I roll my eyes up, sigh and say “pss…..”. She added “Doctor, I find it difficult to swallow tablets since childhood”. “Ok, she really needs help!” ( & SO DO I : I was sweating under my collar) But her pertinent question made me rake my mind and up came the following points:

1. Be confident - Anyone with a normal upper GI tract can swallow any tablet available in the market. Beware Mucomelt (N-acetyl cysteine) 600mg is a dispersible tablet and if you try to swallow one you will surely choke. A rotacap is for inhalation and a suppository is for the place it’s supposed to be inserted. Clearly specify this in your prescription or else you know what happens.

2. Drink one cup of cool water before you try to swallow a pill, it helps to lubricate the path of the pill. Remember its cool water not cold or hot water.

3. Avoid beverages (i.e. tea and coffee) and some fruit juices as they contain tannins that decrease drug availability.

4. Place the pill on the center part of the tongue. Too much backward the placement will elicit the gag reflex making pill swallowing an unpleasant experience.

5. Don’t place the pill for long in the mouth before swallowing as it will either stick to the tongue or dissolve partially giving rise to bad taste in mouth eliciting vomiting reflex.

6. Carbonated water (i.e. soda) will reduce the foreign body sensation while swallowing the pill.

7. Drinking the water through a straw will produce enough suction to push the tablet deep into the throat effortlessly. Water bottles are another option.

8. Apply your chin to your chest while swallowing this will open up the esophagus and close the larynx. This position also restricts respiratory exertion while swallowing.

9. Sip a small quantity of water only while swallowing which helps faster and forceful deglutition movements.

10. Another technique is, fill your mouth up with liquid, hold your head back and open your mouth and drop the pill in your mouth with liquid still in it. Then close your mouth, bring your head back to a normal position and swallow; this will be like drinking a beverage. Almost any size pill can be easily swallowed with this trick.

11. Don’t forget to drink another glass of water after you have swallowed the pill as it prevents the pill from sticking to the esophagus.

12. If everything fails try syrups, injections or inhalation.

13. Cutting, chewing, crushing, mixing with food, opening the capsule etc may alter the pharmacokinetics of the drug and hence done only under supervision of a pharmacist.

“Doctor, what’s the right way to swallow a pill?”

So the next time somebody asks you this question : BINGO U KNOW WHAT 2 SAY.

Thiamine - An essential component in the management of DKA/HONK

A 65year old male with history of poorly controlled type 2 DM since 20years on OHA and borderline systemic hypertension on hydrochlorothiazide presented to the casualty with vomiting and tiredness. On evaluation he was found to have very high blood sugars. Urine ketone bodies were strongly positive. He was initiated on DKA regimen with insulin infusion and IV saline with hourly blood sugar monitoring and 4th hourly serum electrolyte measurements mainly K+. The next day patient was found to be drowsy in spite of normalized blood sugar levels, corrected acidosis and dyselectrolaemia. Chest auscultation showed bilateral crepitations. Fluid overload, LV dysfunction and cerebral edema were thought of. CT brain did not reveal cerebral edema. ECG was unremarkable except for sinus tachycardia. ECHO showed low ejection fraction (25%) with a dilated heart. Cardiac enzymes and ECGs were normal in spite of serial monitoring. RFTs were within normal range.2 days passed and patient was remaining drowsy, disoriented and in pulmonary venous congestion in spite of controlled infusion of IV fluids with CVP monitoring. Considering a background history chronic alcohol abuse, poor general nutrition, on and off use of frusemide for dependent pedal edema possibility of thiamine deficiency was thought of and  he was started on IV thiamine. Within a day or 2 patient had a remarkable restoration of sensorium, and follow up ECHO showed an improvement of EF to 65%. Quantitative essay of thiamine report came after five days which was low. Patient had severe encephalopathy and cardiovascular manifestations of thiamine deficiency precipitated by high carbohydrate metabolic turn over seen in DKA with a background history of alcoholism and poor nutrition both well known to cause thiamine deficiency. He was also using diuretics which will deplete an already limited  thiamine stores. From the above case one will see that it is always prudent to add thiamine to the management protocol for DKA/HONK. Thiamine estimation is unavailable many a times and time consuming also.