Accurate blood pressure recording: is it difficult?

BACKGROUND: Blood pressure (BP) measurement is a routine procedure but errors are frequently committed during BP recording. AIMS AND SETTINGS: The aim of the study was to look at the prevalent practices in the institute regarding BP recording. The study was conducted in the Medicine Department at Government Medical College, Chandigarh, a teaching institute for MBBS students. METHODS: A prospective, observational study was performed amongst the 80 doctors in a tertiary care hospital. All of them were observed by a single observer during the act of BP recording. The observer was well versed with the guidelines issued by British Hypertension Society (BHS) and the deviations from the standard set of guidelines issued by BHS were noted. The errors were defined as deviations from these guidelines. STATISTICAL METHODS: The results were recorded as percentage of doctors committing these errors. RESULTS: In our study, 90% used mercury type sphygmomanometer. Zero error of the apparatus, hand dominance was not noted by any one. Every one used the standard BP cuff for recording BP. 70% of them did not let the patient rest before recording BP. 80% did not remove the clothing from the arm. None of them recorded BP in both arms. In out patient setting, 80% recorded blood pressure in sitting position and 14% in supine position. In all the patients where BP was recorded in sitting position BP apparatus was below the level of heart and 20% did not have their arm supported. 60% did not use palpatory method for noticing systolic BP and 70% did not raise pressure 30-40 mm Hg above the systolic level before checking the BP by auscultation. 80% lowered the BP at a rate of more than 2 mm/s and 60% rounded off the BP to nearest 5-10 mm Hg. 70% recorded BP only once and 90% of the rest re inflated the cuff without completely deflating and allowing rest before a second reading was obtained. Conclusion: The practice of recording BP in our hospital varies from the standard guidelines issued by the BHS.

Metastasis to thyroid from lung carcinoma.

Metastasis to thyroid gland are rare. The primary sites which metastasize to thyroid gland include the breast, lung, kidney and stomach. Among lung cancer metastasizing to the thyroid, adenocarcinomas are the commonest followed by squamous, small cell and large cell carcinomas. The bronchioloalveolar carcinoma has not been reported to metastasize to the thyroid. In this case report we document this rare occurrence.

Circadian pattern in cerebro vascular disorders.

Over the last decade, various studies have been reported to evaluate the circadian pattern of cardiovascular and cerebro-vascular diseases. The data from Indian population is lacking. We undertook this prospective observational study to evaluate the circadian variation in disorders like cerebro-vascular accidents and transient ischemic attacks. Total of 146 patients (events) were studied. Only 10 patients had TIA's. 55% had hemorrhage and 45% had infarction. The 24 hours period was divided into 6 equal portions of 4 hours each. The maximum events were seen between 4 am to 8 am and 12 noon to 4 pm (23.28%) each. Minimum events were seen between 12 midnight to 4 am 14/146 - 9.58%). The circadian variation in occurrence of cerebro-vascular disorders was present with two equal peaks.

Wasp sting induced neurological manifestations.

Wasp stings generally cause local reactions like pain, wheal, flare, edema and swelling, which are generally self-limiting. Multiple stings can lead to vomiting, diarrhea, generalized edema, dyspnea, hypotension, collapse, renal failure or death. Unusually, they may cause serum sickness, vasculitis, neuritis or encephalitis. We report a case of a 40 year old male who developed focal neurological deficit 10 hours following a wasp sting, which was confirmed to be ponto-cerebellar infarction on MRI scan, and recovered within five days.

Left atrial myxoma presenting as pseudobulbar palsy.

A case of left atrial (LA) myxoma presenting as pseudobulbar palsy, due to multiple cerebral infarcts, without any cardiac manifestations, is presented. LA myxoma is rare cause of embolization to CNS causing ischemic infarcts. Due to multiple CNS infarcts patient can present with varied clinical picture and pseudobulbar palsy is not a very common presentation. It was a real diagnostic dilemma before LA myxoma was diagnosed on echocardiography.

Circadian pattern of cardiovascular and cerebrovascular diseases in geriatric population.

OBJECTIVES: Over last 13 years various studies have been done to evaluate the circadian pattern in cardiovascular and cerebrovascular diseases in adults and the existence of such variation in Indian population also has been demonstrated. The data on this variation in geriatric patients does not exist. METHODS: We undertook this prospective observational study at Government Medical College and Hospital, Chandigarh to evaluate the circadian variation in disorders like acute myocardial infarction (AMI), unstable angina (USA), non Q wave MI (non QMI), cerebrovascular accidents (strokes, both ischemic and hemorrhagic) and transient ischemic attacks (TIA). OBSERVATIONS: We studied 158 patients (56.98% males and 43.02% females), mean age was 69 +/- 4 years. 34.17% each had AMI and CVA, 22.78% and USA and 7.59% had NON Q MI, only two patients in our study group had TIAs. We divided 24 hours into four equal quarters each for analysis. RESULTS: We observed that maximum episodes were seen during the period between 6 am till 12 noon 58/158 (36.71%) and a second peak was seen during 6 pm and 12 midnight when 40/158 events were recorded (25.31%). The least number of episodes were seen during the period between 12 midnight till 6 am 22/158 (13.92%). Similar peaking of events was noted for acute myocardial infarction but only one peak was seen for unstable angina. For cerebrovascular accidents two similar peaks were noted between 6 am till 12 noon and 12 noon till 6 pm. CONCLUSIONS: Our study population (geriatric patients) shows the presence of a definitive circadian variation with two comparable peaks. One during the morning hours (6 am-12 noon) and another peak between 6 pm and 12 midnight in patients having acute coronary diseases. In cerebrovascular accidents patients too, similar peaks were noted between 6 am till 12 noon and 12 noon till 6 pm.