What is Basilar Migraine

by Mikai InternalMedicine

Basilar Migraine (Migraine with Brainstem Aura)

– A subtype of migraine with aura, characterized by symptoms originating from the brainstem and/or both hemispheres of the brain. –

**Key Features:** – Reversible neurological symptoms, typically lasting 5–60 minutes, followed by a throbbing headache. – Symptoms may include: – Vertigo (spinning sensation) – Dysarthria (difficulty speaking) – Tinnitus (ringing in the ears) – Hypacusis (reduced hearing) – Diplopia (double vision) – Ataxia (lack of coordination) – Dysphasia (difficulty understanding or expressing speech) –

**Rationale:** These symptoms reflect brainstem and cerebellar dysfunction. –

**Diagnosis:** – Based on clinical criteria (IHS classification) and exclusion of other causes (e.g., stroke, vestibular disorders). – Imaging (MRI) may be needed to rule out structural lesions. –

**Management:** – Acute treatment: Triptans (e.g., sumatriptan) or antiemetics (e.g., metoclopramide). – Preventive therapy: Beta-blockers (e.g., propranolol) or anticonvulsants (e.g., topiramate) if frequent attacks. – **Rationale:** Targets both the aura and headache phases. **Note:** If symptoms persist or worsen, urgent evaluation for stroke or other serious conditions is essential.

Do you know parameter to adjust ventilator? eg for COPD patients?

by Mikai CriticalCareInternalMedicine

**Ventilator Parameters for COPD Patients:** –

**Mode:** Assist-Control (AC) or Pressure Support (PS) ventilation. –

*Rationale:* AC ensures a guaranteed tidal volume (Vt), while PS allows patient-initiated breaths, reducing work of breathing. –

**Tidal Volume (Vt):** 6–8 mL/kg ideal body weight (IBW). – *Rationale:* Lower Vt reduces risk of dynamic hyperinflation and barotrauma. –

**Respiratory Rate:** 12–16 breaths/min. – *Rationale:* Avoids excessive minute ventilation, which can worsen auto-PEEP. –

**Flow Rate:** 60–80 L/min. – *Rationale:* Higher flow rates help reduce inspiratory time, mitigating air trapping. – **Inspiratory Time:** 0.8–1.0 seconds. – *Rationale:* Shorter inspiratory times reduce risk of dynamic hyperinflation. –

**PEEP:** 4–8 cmH₂O. – *Rationale:* Moderate PEEP counteracts intrinsic PEEP (auto-PEEP) without overdistension. –

**Inspiratory Flow Pattern:** Square wave or decelerating. – *Rationale:* Square wave reduces inspiratory time; decelerating improves comfort. –

**Pressure Support (PS) Level:** 5–15 cmH₂O (adjust to minimal support). – *Rationale:* Ensures patient effort is minimized without excessive assistance. –

**Ventilator Parameters for COPD Patients:** –

**Mode:** Noninvasive ventilation (NIV) preferred (e.g., BiPAP, CPAP). – **IPAP (Inspiratory Positive Airway Pressure):

** Start at 8–10 cm H₂O, titrate to improve gas exchange. –

**EPAP (Expiratory Positive Airway Pressure):** Start at 4–5 cm H₂O to prevent dynamic hyperinflation. – **Backup Rate:** 12–14 breaths/min to prevent respiratory fatigue. – **Rationale:** NIV reduces work of breathing and improves gas exchange in COPD exacerbations. –

**Oxygen Therapy for COPD:** – **Target SpO₂:** 88–92% to avoid CO₂ retention (Harrison’s 2022). –

**Flow Rate:** Start at 1–2 L/min via nasal cannula; titrate to maintain SpO₂ in target range. –

**Avoid High Flow:** >2–3 L/min may worsen hypercapnia due to loss of hypoxic drive (Cardiac Drug Therapy 7th Ed). – **Rationale:** Excessive O₂ can suppress respiratory drive in COPD patients with chronic hypercapnia.

**Auto-PEEP Monitoring:

** Regularly check for intrinsic PEEP and adjust settings to minimize it. – *Rationale:* Auto-PEEP exacerbates hyperinflation and hemodynamic compromise.

Context:  [Manual of Intensive Care Medicine] preset volume if the patient does not initiat e any spontaneous breaths.  During the control and assisted breaths, the Vt and inspirat ory flow and  charac teristics are exactly the same with each breath.  i. Advantages: the patient receives a guarant eed Vt and the most  widely used mode of MY. Whe...

[pocket-medicine_-the-massachusetts-general-hospital-handbook-of-internal-medicine] MECHANICAL VENTILATION Indications • Improve gas exchange c oxygenation c alveolar ventilation and/or reverse acute respiratory acidosis • Relieve respiratory distress T work of breathing (can account for up to 50% of total oxygen consumption) T respiratory muscle fatigue • Apnea, airway protection,...

[Manual of Intensive Care Medicine] Pplat. However, there is a theoretic concern that too-rapid lun g inflation  can cause "deformation inju ry."  b. In PS mode, patients determine their own Vi. Vi is specified for PC  ventilation in that one can determine how quickly to achieve the pressure  limit.  c. In asthma and COPD, the expirat...
Source Document:  Manual of Intensive Care Medicine
pocket-medicine_-the-massachusetts-general-hospital-handbook-of-internal-medicine

Good medical quotes for today

by Mikai InternalMedicine

MIKAI RAG

Start a conversation…

Good quote for today

“The art of medicine is to amuse the patient while nature cures the disease.” — Voltaire

  • “Wherever the art of medicine is loved, there is also a love of humanity.” — Hippocrates
  • “The greatest medicine of all is teaching people how not to need it.” — Hippocrates
  • “Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided.” — Paracelsus
  • “The good physician treats the disease; the great physician treats the patient who has the disease.” — William Osler
  • “The doctor sees all the weakness of mankind; the lawyer only the knavery.” — Oliver Goldsmith
  • “The art of medicine consists of amusing the patient while nature affects the cure.” — Voltaire
  • “The physician must not treat the disease but the patient who is suffering from it.” — Maimonides
  • “The best doctors in the world are doctor patience and doctor diet.” — Gouthama Buddha
  • “The greatest mistake in the treatment of diseases is that there are no diseases; there are only sick people.” — Paracelsus
  • “The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.” — Thomas Edison
  • “The art of medicine is to distract the mind of the patient from the malady, and to keep him in good spirits.” — Richard Quain
  • “The doctor is a man who prescribes medicines of which he knows little, to cure diseases of which he knows less, in human beings of whom he knows nothing.” — Voltaire
  • “The physician must not only be prepared to do his duty himself, but also to secure the cooperation of the patient, the attendants, and the externals.” — Hippocrates
  • “The art of medicine is to amuse the patient while nature cures the disease.” — Voltaire
  • “The greatest medicine is the teaching of how not to need it.” — Hippocrates
  • “The doctor sees all the weakness of mankind; the lawyer only the knavery.” — Oliver Goldsmith
  • “The art of medicine is to distract the mind of the patient from the malady,

Disease in parrots that can affect humans?

by Mikai InternalMedicine

1. Psittacosis (Ornithosis) – Caused by *Chlamydia psittaci* – Transmission: Inhalation of aerosolized feces, nasal secretions, or feathers from infected birds. – Symptoms: Fever, headache, myalgia, pneumonia (atypical), and possible extrapulmonary manifestations (e.g., hepatitis, encephalitis). – Diagnosis: Serology (IgM/IgG), PCR, or culture (high-risk, biosafety level 3). – Treatment: Doxycycline (100 mg PO/IV BID × 10–14 days) or macrolides (azithromycin 500 mg PO × 1 day, then 250 mg PO daily × 4 days) for mild cases. – Rationale: Doxycycline is first-line due to its efficacy against Chlamydiae; macrolides are alternatives for mild disease. –

2. Avian Tuberculosis – Caused by *Mycobacterium avium* complex (MAC), primarily *M. avium* subsp. *avium* or *M. genavense*. – Transmission: Inhalation of aerosolized droplets or ingestion of contaminated material. – Symptoms: Chronic, progressive weight loss, fever, night sweats, and pulmonary or disseminated disease (e.g., lymphadenopathy, hepatosplenomegaly). – Diagnosis: Acid-fast bacilli (AFB) staining, culture (slow growth), or molecular tests (e.g., PCR). – Treatment: Multidrug regimen (e.g., rifampin, ethambutol, clarithromycin, and moxifloxacin) for ≥12 months. – Rationale: MAC is intrinsically resistant to many antibiotics; prolonged therapy is required. –

3. Cryptococcosis – Caused by *Cryptococcus neoformans* or *C. gattii* (from pigeon droppings, but parrots can carry *C. neoformans*). – Transmission: Inhalation of fungal spores from contaminated droppings. – Symptoms: Pulmonary infection (cough, dyspnea) or meningitis (headache, fever, altered mental status). – Diagnosis: India ink stain, cryptococcal antigen (serum/CSF), or culture. – Treatment: Fluconazole (mild pulmonary disease) or amphoter

Context:  [HarrisonPrincipleofInternalMedicine2025] that can be used to treat some infections. The prevalence of resistance...

[HarrisonPrincipleofInternalMedicine2025] which the course of the illness can be inferred. In perplex - ing cases, it is useful to remember that uncommon presentations of common diseases are more likely than rare etiologies. Thus, even in...

[HarrisonPrincipleofInternalMedicine2025] hypersensitivity reactions, inoculate toxins, transmit pathogens, create openings in the skin for secondary bacterial infection, and incite fear or disgust. Human beings are obligate hosts for few ectoparasites but can serve as facultative, dead-end, or paratenic (accidental) hosts for many others. ...
Source Document:  HarrisonPrincipleofInternalMedicine2025

Any pontine structure or circulation related to migraine?

by Mikai with No Comment InternalMedicine

**Dorsolateral Pons**: The dorsolateral pons is implicated in migraine pathogenesis due to its role in the trigeminovascular network. Dysfunctional brainstem regulation here may lead to impaired regional blood flow and perimeningeal vasodilation, contributing to migraine symptoms. – *Rationale*: Harrison’s Principles of Internal Medicine (2025) and the Oxford Handbook of Neurology highlight the brainstem’s role in cranial autonomic dysfunction, which is secondary to the headache cascade. – **Circulation**: While no specific pontine circulation is uniquely tied to migraine, the posterior circulation (e.g., basilar artery) supplies the pons and may be indirectly involved in brainstem dysfunction. However, primary vascular changes are not causative but secondary to trigeminovascular activation. – *Rationale*: Vascular changes in migraine are secondary, as per Harrison’s, and not the primary driver of the headache cascade.

Context:  [HarrisonPrincipleofInternalMedicine2025] studies indicate that vascular changes in migraine and cluster headache, when present, are similarly driven by these cranial auto - nomic systems. Thus, they are secondary, and not causative, events in the headache cascade. Moreover, they can often be mistaken for symptoms or signs of cranial sinus ...

[pdfcoffee.com_oxford-handbook-neurology-pdf-free] produced by dysfunctional brainstem regulation of craniovascular afferents.  In a genetically predisposed individual, activation of the trigeminovascular  network in the dorsal midbrain and dorsolateral pons presumably causes:  (a) impaired regional blood fl ow to the brain, (b) perimengeal vasodilat...

[HarrisonPrincipleofInternalMedicine2025] peripheral or central nervous system (CNS) are damaged or activated inappropriately. Headache may originate from either or both mechanisms. Relatively few cranial structures are pain-producing; these include the scalp, meningeal arteries, dural sinuses, falx cerebri, and proximal segments of the lar...
Source Document:  HarrisonPrincipleofInternalMedicine2025
pdfcoffee.com_oxford-handbook-neurology-pdf-free

Treatment of psoriasis

by Mikai with No Comment InternalMedicine

**First-line therapies:** – **Topical corticosteroids:** High-potency for limited disease (e.g., clobetasol 0.05%). Rationale: Rapid suppression of inflammation and proliferation. – **Vitamin D analogs (e.g., calcipotriene):** Moderate efficacy, often combined with corticosteroids. Rationale: Inhibits keratinocyte proliferation and promotes differentiation. – **Topical retinoids (e.g., tazarotene):** Useful for stable plaque psoriasis. Rationale: Normalizes keratinocyte differentiation. – **Second-line therapies:** – **Phototherapy (UVB, PUVA):** For moderate-to-severe disease. Rationale: Suppresses immune response and reduces hyperproliferation. – **Systemic agents (e.g., methotrexate, cyclosporine):** For severe or refractory cases. Rationale: Immunosuppression and anti-inflammatory effects. – **Biologics (e.g., adalimumab, ustekinumab):** For severe disease unresponsive to other therapies. Rationale: Targets specific immune pathways (TNF-α, IL-12/23). – **Lifestyle modifications:** – Avoid triggers (e.g., stress, infections, smoking). – Moisturize skin to reduce dryness and cracking. **Guidelines:** – AAD (American Academy of Dermatology) recommends stepwise approach based on disease severity. – EMA (European Medicines Agency) approves biologics for moderate-to-severe psoriasis.

Context:  [Tintinallis_Emergency_Medicine] areas. Initial management of exogenous photosensitivity is similar to the  sunburn reaction, including the avoidance of the sun until the eruption has  cleared. Discontinue the causative agent, if possible.    ■   PSORIASIS   Psoriasis is a chronic skin disorder characterized by symmetric discrete  ...

[Full text of _Harrison's Internal Medicine 2022, 21th Edition Vol 1 & Vol 2_#page=6327] ™ PSORIASIS  Psoriasis is one of the most common dermatologic diseases, affecting up  to 2% of the world’s population. It is an immune-mediated disease clin-  ically characterized by erythematous, sharply demarcated papules and  rounded plaques covered by silvery micaceous scale. The skin lesions of...

[Nelson-essentials-of-pediatrics] corticosteroids. Psoriasis Psoriasis is a common papulosquamous condition characterized  by well-demarcated, erythematous, scaling papules and plaques.  Psoriasis occurs at all ages, including infancy, with onset of  30% of cases during childhood. The disease is characterized  by a chronic and relap...
Source Document:  Full text of _Harrison's Internal Medicine 2022, 21th Edition Vol 1 & Vol 2_#page=6327
Nelson-essentials-of-pediatrics
Tintinallis_Emergency_Medicine

Different between type 1 and type 2 diabetes and variants

by Mikai with No Comment InternalMedicine

Different between type 1 and type 2 diabetes and variants Assistant: Type 1 and type 2 diabetes are distinct autoimmune disorders that affect how the body regulates blood sugar. Here’s a breakdown of the key differences: *

**Type 1 Diabetes:** *

**Cause:** Autoimmune destruction of insulin-producing beta cells in the pancreas. *

**Insulin Production:** Little to no insulin production. *

**Onset:** Typically develops in childhood or adolescence, but can occur at any age. *

**Risk Factors:** Genetic predisposition and environmental triggers. *

**Treatment:** Insulin injections or insulin pump therapy are essential for survival. *

**Type 2 Diabetes:** *

**Cause:** Insulin resistance (cells don’t respond properly to insulin) and progressive decline in insulin secretion. *

**Insulin Production:** Initially, the pancreas may produce enough insulin, but over time, it may not be enough to overcome insulin resistance. *

**Onset:** Usually develops in adulthood, but increasingly seen in children and adolescents due to rising obesity rates. *

**Risk Factors:** Obesity, physical inactivity, family history, age, ethnicity. *

**Treatment:** Lifestyle modifications (diet and exercise), oral medications, and/or insulin may be needed. *

**Variants:** *

**Latent Autoimmune Diabetes in Adults (LADA):** Sometimes called “Type 1.5 diabetes,” it’s a slower-progressing form of autoimmune diabetes that occurs in adults. It’s often misdiagnosed as type 2 diabetes initially.

* **Monogenic Diabetes Syndromes:** These are rare forms of diabetes caused by mutations in a single gene. They can be inherited and may present differently from type 1 or type 2 diabetes. *

**Gestational Diabetes:** Develops during pregnancy due to hormonal changes that can lead to insulin resistance. It usually resolves after delivery, but increases the risk of type 2 diabetes later in life. *

**Secondary Diabetes:** Diabetes caused by another medical condition, such as cystic fibrosis, pancreatitis, or certain medications (e.g., corticosteroids).

Context:  [Full text of _Harrison's Internal Medicine 2022, 21th Edition Vol 1 & Vol 2_#page=45755] in type 2 DM....

[diabetic_standards-of-care-2025] type 1 diabetes). Type 1 diabetes and type 2 diabetes are heterogeneous diseases in which clinical presentation and disease progression may vary considerably. Classification is important for determining personalized therapy, but some individuals cannot be clearly classified as having type 1 or type 2 ...

[Full text of _Harrison's Internal Medicine 2022, 21th Edition Vol 1 & Vol 2_#page=45525] @ ATYPICAL DIABETES   It is increasingly recognized that some forms of diabetes have features  of both type 1 and type 2 diabetes. These are distinct from monogenic  forms (MODY) as they have not been linked to single gene defects.  The development of a type 2 diabetes phenotype before puberty and  ...
Source Document:  Full text of _Harrison's Internal Medicine 2022, 21th Edition Vol 1 & Vol 2_#page=45525
Full text of _Harrison's Internal Medicine 2022, 21th Edition Vol 1 & Vol 2_#page=45755
diabetic_standards-of-care-2025

Any blood test to predict the anoxic brain injury

by Mikai with No Comment CriticalCareInternalMedicine

MIKAI RAG

Any blood test to predict the anoxic brain injury?

**Neurological Biomarkers:** – **Neuron-Specific Enolase (NSE):** – Elevated levels correlate with poor outcomes in anoxic brain injury. – Rationale: NSE is released from damaged neurons; levels >33 µg/L at 48–72 hours post-injury suggest poor prognosis. –

**S100B Protein:** – Elevated levels may indicate blood-brain barrier disruption. – Rationale: Levels >0.1 µg/L at 24–48 hours post-injury are associated with worse outcomes. –

**Glial Fibrillary Acidic Protein (GFAP):** – Elevated levels indicate astrocyte damage. – Rationale: Levels >1.5 ng/mL at 24–72 hours post-injury correlate with poor prognosis. –

**Inflammatory Markers:** –

**C-Reactive Protein (CRP) and Interleukin-6 (IL-6):** – Elevated levels may reflect systemic inflammation post-anoxia. – Rationale: Higher levels are associated with increased mortality, but not specific to anoxic injury alone. –

**Electrolytes and Metabolic Markers:** – **Lactate and Creatinine Kinase (CK):** – Elevated lactate suggests tissue hypoxia; CK may indicate muscle damage (e.g., from seizures). – Rationale: Useful for assessing systemic response but not specific to brain injury. –

**Limitations:** – No single biomarker is definitive; clinical correlation with neurological exam and imaging is essential. – Therapeutic hypothermia may alter biomarker kinetics, requiring cautious interpretation.