By admin | Categories: Medical Articles | Tags: | Date: 18th October 2018

Chest Pain should be investigated properly to exclude any life threatening underlying disorder. In this article will cover tests your doctor should run to evaluate chest pain.

Investigation of chest pain most of the time requires three main tests

  • Electrocardiogram (ECG)
  • Cardiac Biomarkers or Enzymes
  • Chest-X-Ray

Electrocardiogram (ECG)

ECG is the single most important test for evaluating chest pain. It helps in excluding life threatening underlying heart disorders which can be fatal. Patients having chest pain with normal ECG chances of Myocardial Infarction (MI) is around 10 percent while some studies say the number is around 1-2 percent. So if the ECG is normal it is highly unlikely that the chest pain if of cardiovascular origin.

ECG should be done immediately after stabilizing the patient and recording vitals.

Most patients with MI will have abnormal ECG findings, 50% of them will have diagnostic ECG changes (ST segment elevation with Q waves) while 30% can have ECG findings consistent with angina (ST segment depression with or without T wave inversion). Any ECG finding is considered to be a new one until proven otherwise by an old ECG.

Apart from cardiovascular origin a patient presenting with chest pain can have abnormal ECG findings especially in cases of:

Aortic dissection– Non specific changes, while 1-2% of cases have acute ST segment elevation
Pulmonary embolism– S wave in lead 1, Q wave in lead 3, T wave in lead 3
Electrolyte imbalance.

Cardiac Enzymes

Aspartate Transaminase, Lactate Dehydrogenase, Lactate dehydrogenase sub forms are no longer used as they are not specific for cardiac tissue and there delayed elevation does not help in early diagnosis of recent MI.

Creatine Kinase (CK) are found in brain, kidney, lungs and gastrointestinal tract, so they can be elevated in number of diseases involving these tissues like renal insufficiency, trauma, seizures.

Currently we use Cardiac specific Creatine Kinase also known as CK (MB) which is released from injured cardiac tissue into the blood stream and can easily be detected within 4-6 hours after the onset of ischemia.

Therefore CK (MB) is an excellent marker for detecting an acute MI. the level of CK(MB) peaks in about 12-24 hours and normalizes in 2-3 days. The test is usually repeated every 6-12 hours in an emergency department.

Cardiac Troponins T, I, C are found in cardiac and straiated muscles. T & I isoforms for cardiac and skeletal muscles differ they are also called as cardiac troponins. Both cardiac troponins have similar sensitivity and specificity detecting myocardial injury and are the preferred markers for the diagnosis of myocardial injury. It should be noted that Cardiac troponin T might be elevated in some non cardiac conditions like polymyositis, dermatomyositis, renal disease.

Cardiac troponins maybe elevated as long as two weeks after an episode of MI thus making them excellent late markers of recent MI. If CK(MB) eve is normal with increased cardiac troponin the finding is suggestive of minor infarction or sustained minor myocardial damage. If both the markers are elevated the patient have had acute MI.

Chest X Ray

Every patient with chest pain should have chest X ray. The radiological test gives very important clue for any non cardiovascular causes of chest pain like pneumothorax, pneumomediatinum (esophageal rupture), pleural effusion, infiltrates, pneumonia. Aortic dissection shows up in chest x ray as widened mediastinum. Pulmonary embolism may be seen in a chest x ray with loss of lung volume or decreased vascular markings.

Other Tests

  • Arterial blood gas (ABG)
  • BNP (for heart failure)
  • Spiral CT scan etc

Dr. Rahil Ahmad

Dr. Rahil is keen in practicing a holistic approach for the physical and mental well being with importance of preventive medicine and sustainable lifestyle changes of his patients of all ages.

Chest Pain can be caused by many underlying disorder which can be very simple like some gastric trouble to life threatening like angina or aortic dissection. Every patient with chest pain should be treated with utmost care and all possible investigation should be done to exclude any life threatening disorders.

Important causes of chest pain

Pulmonary embolism

Chest pain due to pulmonary embolism is mostly pleuritic , especially when pulmonary infarction develops. Chest pain is associated with dyspnea, tachycardia and hypoxemia. EKG is most of the time nonspecific but may show S wave in lead 1, Q wave in lead 3 and T wave in lead 3 (S1Q3T3). Spiral chest CT lung scan usually confirms the diagnosis. Pulmonary angiogram may also be used.


Chest pain due to pericarditis is usually sharp, positional and pleuritic in nature. Chest pain may be relieved by leaning forward and pericardial rub is present. Pericarditis may be preceded by any viral illness. EKG changes may be present with ST elevation without formation of Q waves. Cardiac enzyme levels are normal and the pain responds well to anti-inflammatory agents.


Myocarditis may also be preceded by viral illness as in pericarditis, chest pain is generally vague and mild. CK levels (total) as well as MB fraction (CK-MB) are often elevated. Conduction abnormalities with Q waves might be present.

Aortic Dissection

Chest pain due to aortic dissection is sharp and tearing in nature and extremely severe radiating to back. Loss of pulse or aortic regurgitation murmur often develops. On chest X ray look for midiastinal widening. Diagnosis is usually confirmed by MRI, transesophageal echocardiogram, CT scan or aortogram.

Musculoskeletal Disorders

Osteochondritis, cervical osteoarthritis, radiculitis : Are one of the most common cause of chest pain. Pain is usually stabbing in nature, atypical and localized. Chest pain might be pluritic, changes with motion and palpation. EKG changes are absent.

GastroIntestinal Disorders

Esophageal Reflux: Chest pain due to esophageal reflux is made worse with recumbency or after meals. The pain is associated with regurgitation and relieved by antacids. Episodes of spasms may occur due to ingestion of cold liquids also known as diffuse esophageal spasm or nutcracker esophagus. The chest pain is most of the time relieved by taking nitroglycerin. Diagnosis of esophageal re-flux is made by upper GI series, endoscopy or esophageal manometry.

Peptic ulcer disease, pancreatitis, cholecystitis may sometimes mimic infarction but there is an element of abdominal pain and tenderness as well with radiation to back. USG confirms cholecystitis while in pancreatitis serum level of amylase is raised.


Sudden abrupt onset of chest pain which is pleuritic in nature, absent breath sounds with shortness of breath is most of the time due to pneumothorax which can be confirmed by chest X ray.

Myocardial Infarction

Chest pain due to myocardial infarction is more sever and usually more than 20 minutes. It might be associated with radiation to left arm and jaw with diaphoresis, perspiration, dizziness, vomiting and dyspnea. EKG changes are present depending upon the intensity and site of infarction. Cardiac enzymes are raised.

Mitral Valve Prolapse

Chest pain due to mitral valve prolapsed is transient with midsystolic click murmur usually a young female with no risk factor.

Aortic stenosis

Chest pain with typical systolic ejection murmur.


Pain is sharp and increases with inspiration or while taking deep breaths as in pneumonia, frictional rub or dullness maybe present. Respiratory or lung infection is present with other respiratory symptoms.

Dr. Rahil Ahmad

Dr. Rahil is keen in practicing a holistic approach for the physical and mental well being with importance of preventive medicine and sustainable lifestyle changes of his patients of all ages.

Chest pain is one of the most common problems for which patients visit clinics and hospitals in Sharjah, Dubai, UAE. Patients with chest pain may have may have an underlying cause which is very simple in nature can be treated by painkillers but the reason for chest pain can be because of life threatening problem which should always be excluded.

The setting in which chest pain occurs provides one of the most important clue for the evaluation. The history of chest pain is more important than the actual physical examination. Important features of history of chest pain usually involves following main points:

  • Duration
  • Location
  • Quality
  • Radiation
  • Frequency
  • Aggravating and relieving factors.

There are few important aspects that physician and patient should remember so as to take quick action and come to quick clinical

Pain described as tightness or heaviness, upper abdominal pain, nausea vomiting, bradycardia (decreased rate of heartbeat), fall in blood pressure (dizziness, fainting) can be due to Angina, acute coronary syndrome or inferoposterior wall ischemia.

If the patient can pin point the exact location of the pain which is sharp and knife like associated or reproduced by changes in position or by touching it is less likely that the pain has cardiovascular origin.

Nitroglycerin (dilates the smooth muscles) can worsen the pain (Gastroesophageal reflux disease) or it may decrease the pain within minutes (Transient ischemia, Esophageal spasm).

Physical Examination: Read Causes of Chest Pain

Initial Impression: Diaphoresis, Increased rate of breathing or an anxious patient may give clue about life threatening underlying cause of chest pain.

Blood Pressure: Difference of 20 mm of Hg or more in both the arms maybe suggestive of Aortic dissection.

Hypo-tension: May be due to massive pulmonary embolism or cardiac shock.

Increased rate of breathing (Tachypnea) and Increase heart beat (Tachycardia) is very non specific but is always present in pulmonary embolism. Fever may suggest pneumonia. Esophageal rupture also presents with chest pain and mediastinitis.

If there is pain while palpating (touching the chest wall) the chest pain could of musculoskeletal in origin.

New murmurs and abnormal heart sounds:

RBBB (right bundle branch block) & right ventricular infarction: Wide physiological splitting of second heart sound with inspiration.

LBBB (left bundle branch block), anterior or lateral wall infarction: New paradoxical splitting of second heart sound.

Fourth heart sound: can occur with angina or infarction.

Significant Aortic regurgitation is almost always associated with aortic dissection. Mitral regurgitation can occur in patients with angina or infarction with papillary muscle dysfunction.

Lung Auscultation for Crackles, asymmetrical (spontaneous pneumothorax) or absent breath sounds (pneumothorax and pleural effusion).

Extremities should be examined for swelling (unilateral)- pulmonary embolism or for pulses (absence pf pedal pulse –Aortic dissection)

Tests: Investigations For Evaluating Chest Pain

Read Tests for Chest Pain in detail

ECG (Electrocardiograph) is the single most initial test to rule out cardiac cause of chest pain and should be done with 12 leads immediately after initial assessment and recording of vitals. Patients presenting with acute chest pain and normal ECG the chances of chest pain being cardiac in origin is about 10 percent and in some studies 1-2 percent. So it is very important to record ECG so as to differentiate between cardiac and non cardiac causes of chest pain.

Cardiac Enzymes: CK (MB), cardiac troponins play a vital role in workup of the patient to determine whether the chest pain is cardiac in origin, angina or ischemia. They are also important markers of recent myocardial infarction.

Chest x ray: Can tell the origin of the chest pain, if it is due to some lung infection, aortic dissection, esophageal rupture, pulmonary embolism.

Taking preventive methods to avoid health problems during Umrah & Hajj is very important as millions Muslims from all parts of the world come and gather to perform Hajj & Umrah. Umrah Vaccines & Hajj Vaccines are given to prevent spread of some communicable disease due close contact during Hajj and Umrah.
Umrah vaccination program’s aim is to prevent various infection that can occur and spread quickly due to close gathering of people at one place

Umrah Vaccines

Price is inclusive of G.P consultation, which is mandatory for vaccination

Meningococcal Vaccine (Mandatory)

This vaccine is mandatory. It protects against meningitis. The vaccine should be give at least 10 days before leaving for pilgrimage and not more than 3 years before. If you have been vaccinated for meningitis earlier make sure you carry the card with you as it will be valid for 3 years.

AED 350    185 AED

Seasonal Flu or Influenza Vaccine (Not Mandatory)

Flu vaccine is not mandatory but it is recommended by KSA. Especially children less than 5 years and elders or people with some chronic disease. We do strongly suggest you to get your flu shot before leaving for Umrah or Hajj.
This vaccine is not mandatory, but it is recommended. It will cost you 100 AED

Pneumococcal Vaccine (Not Mandatory)

Pneumococcal vaccine for Umrah is not mandatory but it is highly recommended as well. Adults aged 65 years and above or young people with chronic conditions like diabetes, kidney disease, lung disease or people who have weak immune system are more prone to Pneumonia. Pneumococcal vaccine prevents against that.

Other Vaccines:

Yellow Fever & Polio Vaccine is mandatory for people coming from countries which are declared “ Yellow Fever Infected ” Countries or where Polio is still not eradicated or endemic.

Some Travel Tips

Make sure you get vaccinated at least 2 weeks before going for Umrah or Hajj.

  • Always wash your hands regularly
  • Carry first aid kit with you.
  • Make sure to hydrate yourself well with water and juices.
dr syed rahil ahmad

Dr. Rahil Ahmad

Dr. Rahil is keen in practicing a holistic approach for the physical and mental well being with importance of preventive medicine and sustainable lifestyle changes of his patients of all ages.

It is a comprehensive article where we will learn symptoms, causes, diagnosis, treatment and vaccines for pneumonia. Pneumonia is a infectious condition which can cause cough, chest pain and high grade fever.

Signs & Symptoms of Pneumonia

Bacterial Pneumonia usually presents with following signs and symptoms

  • Cough,
  • Fever,
  • Sputum production,
  • Breathlessness,
  • Chest pain.


It can be either productive cough or dry cough depending upon the bugs that caused pneumonia in the first place. The interstitial pneumonia caused usually by atypical organisms like Peumocystis, viruses, mycoplasma and sometimes often legionella results in dry cough.

Sputum Production

The quality and degree of sputum production tells us what maybe the cause of pneumonia. Streptococcus pneumoniae, Klebsiella and Haemophilus have significant purulent sputum production.

Strept pneumoniae: Rusty colored sputum ( gets its color from oxidation of blood)
Klebsiella: Currant Jelly sputum, has a mucoid characteristic (from the thick mucoplysaccharide coating of the bacteria)

Chest Pain

Usually worsens with taking deep breath and most of the time associated with lobar pneumonia from strep pneumoniae.

Some Specific Signs and Symptoms due to Specific Organism

Mycoplasma: Dry cough, chest soreness, Anemia (hemolysis from cold agglutinin)
Legionella: Confusion, headache, lethargy, diarrhea and abdominal pain
Peumocystis: Marked breathlessness, and cough. Usually in HIV positive patients with CD4 count less that 200/uL.

Causes of Pneumonia

Pneumonia can be caused by bacteria, bacteria like organisms, viruses and fungi.

Most common cause of Pneumonia is bacteria especially Streptococcus Pneumoniae which is the number one cause of pneumonia in all age groups expect for children less than 5 years where virus is the most common cause of pneumonia.

The typical agents responsible for pneumonia are strept pneumoniae, haemophilus and moraxella.

The atypical agents like Legionella, mycoplasma and chlamydia can cause pneumonia as well.

Other than that virus are responsible for mild pneumonia. Some influenza virus may case serious type of pneumonia known as SARS (sudden acute respiratory syndrome) which can be fatal at times.

It is important to know that you can get exposed to these germs in certain predisposing conditions. The history of your work, travel and recent contact may be important in knowing the type of germs causing pneumonia. I have illustrated few examples below.

  • Smokers, people with chronic respiratory disease: Haemophilus Influenza
    Young and health people: Mycoplasma (Walking Pneumonia)
  • Old aged smokers with history of living around infected water source like coolers : Legionella
  • HIV positive with CD4 count less that 200/uL and not taking prophylactic meds: Pneumocystis Jeroveci
  • Exposure to animals especially at the time they are giving birth: Coxiella Burnatti (Q Fever)
  • Alcoholics: Klebsiella
  • Following influenza viral infection: Staph Aureus
  • Exposure to birds: Chlamydia Psittaci
  • Exposure to bat or bird droppings especially if you do recreational cave exploration: Histoplasma Capsulatum
  • Hunters, exposure to rabbits: Francisella tularensis
  • Travel to South east Asia: SARS, Avian Influenza
  • Hospital Stay more than 48 hours : Klebsiella, Pseudomonas, E.coli, Staph Aureus
  • Inhibited gag reflux due to brain injury, swallowing problem, or excessive use of alcohol or drugs: Klebsiella causing Aspiration Pneumonia.
  • Decreased immunity, decreased neutrophils, steroid overuse: Aspergillus

How To Diagnose Pneumonia

Pneumonia can be suspected initially on the basis of clinical signs and symptoms like fever, cough with sputum, breathlessness, chest pain. There maybe some atypical signs like absence of fever if the patient is immuno-compromised or malnourished. Cough maybe dry, depending upon the cause of pneumonia. There might be confusion, lethargy, abdominal pain and lethargy if it pneumonia is due to legionella. Past history of exposure and occupational history might give some clue about cause of pneumonia.

Chest X-ray

As far as tests are concerned chest x-ray is the single most initial test which not only tells about the presence of disease but also initial clue to determining the diagnosis. On the basis of chest X-ray it can be determine if the disease is restricted to one lobe (Lobar Pneumonia) or it is bilaterally present in both the lungs with interstitial infiltrates. X-ray also helps in finding out if pneumonia is associated with plural effusion or not.

Lobar Pneumonia is mainly caused by typical agents like s.pneumoniae, haemophilus, morexella.

Interstitial Infiltrates : Seen mainly in pneumonia caused by pneumocyctis, mycoplasma, chlamydia, coxiella and sometimes legionella.

Sputum culture

Sputum also helps in diagnosing pneumonia, it might be rusty colored if caused by s.pneumoniae or currant jelly if the causative organism is klebsiella. The sputum culture is the most specific test for diagnosing lobar pneumonia as the other atypical organisms do not produce enough sputum and also difficult to show up on Grams stain or regular bacterial culture.

Other tests

Sometimes invasive tests are required to diagnose pneumonia like bronchoscopy, thoracentesis, pleural biopsy, or culture of pleural fluid.
Most specific test for diagnosing pneumonia is with open lung biopsy which is almost never performed.

Specific diagnostic methods for diagnosing pneumonia based on causative organism

  • Mycoplasma : antibody titre. Cold agglutinins can also be performed but it has limited sensitivity and specificity.
  • Peumocyctis Jiroveci: Bronchioalveolar lavage. Increased LDH.
  • Coxiella, Chlamydia (Pneumoniae and Psittaci), coccidioidomycoses : specific antibody titres.
  • Legionella: Bacteria can be cultured in charcoal yeast extract, urine antigen test, direct fluorescent antibodies and specific antibody titers.

Treatment of Pneumonia

Treatment of Pneumonia depends on two major factors:

  • Severity of the disease: Patient needs hospitalization or not
  • Type of pneumonia: Is it community acquired or Hospital Acquired.

Severity of the disease

Mild pneumonia can be treated without admitting the patient, however if the disease is sever the patient has to be admitted to undergo treatment. There are major determinants of severity. Read signs & symptoms of pneumonia to understand better.

Degree of hypoxia (Deprivation of oxygen supply)- If the partial pressure of oxygen is less than 60 mm of HG, oxygen saturation is below 94 percent on room air, respiratory rate above 30/minute, confusion or disorientation, uremia (building up of nitrogenous waste in the body due to renal failure caused by hypoxia in this case).

Hypotension– Systolic below 90 and diastolic below 60 mm of HG

Other markers of severity:

High fever, hypothermia, leucopenia (decrease in WBC) , usually less than 4000/ cubic mm, rapid pulse >125/min, hyponatremia (decrease in sodium content of the body), dehydration.

Patients with serious underlying illness are also needed to be hospitalized. These co-morbid conditions include cancer, renal disease, liver disease or chronic lung disease.

Treatment of Community Acquired Pneumonia:

Non Hospitalized

Antibiotics are used to treat pneumonia. The specific causative germ or bacteria is not known at the time of the start of the treatment, so treatment is started with emperical therapy.

If the there is no need to admit the patient the antibiotic of choice for “Outpatient Community Acquired Pneumonia” is Macrolides (Azithromycin or Clarithromycin)

New Flouroquinolones (levofloxacin or gatifloxacin)can also be used and are generally second line drug of choice.
Macrolides or New flouroquinolones

Since mild cases of community acquired pneumonia are usually mycoplasma and chlamydia pneumoniae we do not use 2nd and 3rd gen cephalosporis as they do not cover all the atypical agents.


Hospitalized patients are usually treated with new fluoroquinolones or 2nd or 3rd generation cephalosporins (cefuroxime or ceftriaxone) combined with a macrolide or doxcycline
New Fluoroquinolones or 2nd-3rd gen cephalosporins +Macrolide / Doxycycline

Treatment of Hospital Acquired Pneumonia

Some patients might develop pneumonia while there stay in hospital usually after 48 hours of stay. Main causes of hospital acquired pneumonia are

1-Gram negative bacilli (Pseudomonas, Klebsiella, E.coli)
2-Gram positive bacilli (Methicillin resistant Staph Aureus)- MRSA

The empirical therapy is done usually with 3rd generation cephalosporins with anipseudomonal activity (Ceftazidime or cefotaxime) or carbepenems (imipenem) or beta lactam/beta lactamase inhibitor combination (piperacillin/tazobactam) with coverage of MRSA by Vancomycin or linezolid.
3gen cephalosporin/carbepenem/b-lactam,lactamase inhibitor + Vancomycin

Aminoglycosides like amikacin, gentamycin is added to prevent drug resistance, synergistic effect and to make better gram negative coverage.

Once the result of sputum culture or bronchoalveolar lavage or pleural fluid culture is out, we can adjust the antibiotics accordingly. Read diagnosing pneumonia for better understanding.

Special bugs need special antibiotics

1-Pneumocystis: Trimethoprim Sulfamethoxazole (TMP/SMZ). Steroids should be used if the infection is severe (arterial PO2 is less than 70mmof HG or A-a gradient is greater than 35 mm of HG). If patient is allergic to TMP/SMZ, I.V pentamidine or atovaquone can be used. Dapsone or atovaquone can be used prophylactically.

2- Coxiella Brunetti (Q-Fever)- usually treated with doxycycline or erythromycin as an alternative.

3-Coccidioidomycoses- no need for treatment for primary pulmonary disease. Treatment is required only for disseminated disease or if the patient is immunocompromised. Life threatening disease is treated with amphotericin while milder form is treated with fluconazole or itraconazole.

Those patients who are at risk for pneumonia should receive pneumococcal vaccine.

Prevention of Pneumonia: Pneumonia Vaccine

Pneumococaal vaccine is used to prevent disease caused by Streptococcus Pneumoniae, which includes disease of blood (septicemia) brain (meningitis) and Lungs (Pneumonia). Pneumococcal vaccines are generally of two types:

  • Pneumococcal Polysaccahride Vaccine 23 (PPSV 23): Made from 23 strains of bacteria.
  • Pneumococcal Conjugate Vaccine 13 (PCV 13): Used in children and recently approved by FDA to be used in adults aged 50 and above.

Pneumococcal Polysaccahride Vaccine 23 (PPSV 23)

It usually given to age groups between 19 and 64 years old with medical conditions or risk factors like:

  • Lung disease
  • Cardiac disease
  • Kidney Disease
  • Cigarette smoker
  • Immunocompromised patient
  • HIV positive
  • Leukemia
  • Lymphoma
  • Any medical condition that weakens immune system

Booster shot is given after 5 years

All patients older than 65 years without any contraindication to the vaccine or if its more than 5 years since they received there last dose. Booster dose is given after 5 years

Pneumococcal Conjugate Vaccine 13 (PCV 13)

PCV 13 is recommended for adults more than 19 years old with medical condition like asplenia (non functional spleen) splenectomy (spleen has been removed), Sickle cell anemia, CSF leaks or any type of implants in ear, especially cochlear implants.

If doctor recommends both vaccine, usually PCV 13 is given first followed by PPSV23 after two months. If the patient has already taken PPSV 23 shot and needs PCV 13 there should be a gap of at least one year

Contraindications for the Pneumococcal Vaccine:

Life threatening allergy to the vaccine
Allergic reaction to any of the components of the vaccine
Moderately or severely Ill : Might have to wait until you recover.

Pneumococcal Vaccine can be given if you have mild fever or cold

Pregnancy: Pregnant women should get vaccinated only if they need it. There is no data that shows that the vaccine is safe in pregnancy but mother who received shots of pneumococcal vaccine early in pregnancy not knowing that they were pregnant did not caused any harm to the baby

Side Effects of Pneumococcal Vaccine

1-Mild redness and swelling at the place where shot was given
2-Mild Fever, Marked swelling and redness at the site of vaccination, body ache and weakness (Only in 1% of cases)

3-Allergic reaction to Pneumococcal Vaccine: This could be life threatening and you should immediately seek medical attention as soon as you notice any of the following signs and symptoms of allergic reaction:

  • Breathing difficulty
  • High fever
  • Wheezing
  • Generalized skin rash and redness
  • Hoarseness of voice
  • Dizziness, weakness
  • Increased heart beat.

Flu vaccine cost in UAE varies from 100 AED to 300 AED. Such huge variation in price is based on the fact that where are you getting yourself vaccinated.

Flu or Influenza vaccine is annual vaccine which can be given to everyone aged 6 months or above. Since culture and awareness is not enough in UAE regarding Flu vaccine all hospitals and Medical Clinics see sudden increase in children and adults suffering from flu during winter season.

Flu vaccine is given intra muscularly and since the Influenza virus mutates every year the vaccine needs to be taken every year just before the start of winter season. But it is never too late to take the Flu Vaccine.

There are two major roadblocks which I have noticed while convincing people and spreading awareness regarding Influenza shots.

  • Insurance companies do not cover flu vaccine
  • People do not have much awareness regarding the same.

If taken annually Flu vaccine is known to decrease frequency as well as severity of Flu. It is especially true for children in day care centers or school going kids. Each family member should take the vaccine to see benefits of the vaccine.  It is a very well known fact that if a child brings flu from school and day care centers most of the time each member of family will get it. So as doctors we always advise each member to go for the vaccine. Make sure you read our Seasonal Flu Guide to find out how to cope up with it and methods to prevent flu from spreading

Flu usually gets better in a week’s time, but can get prolonged in children, pregnant women, elderly and people who are on immune suppressant medications. So these people should always be the first one to be given vaccine and clinics should prioritize them as well which administers flu vaccine.

Flu vaccine is available in most of the reputed Clinics, Hospitals and Medical Centres. The availability of the vaccine can be an issue some time. So if you know a nearby Clinic or Medical Centre has Flu vaccine you should get it.

Make sure you always consult Pediatrician or G.Pbefore taking the vaccine. Usual side effect is redness and soreness at the site of the infection which usually goes away in couple of days. People who are allergic to Chicken eggs should always be careful about getting the vaccines. Currently Flu vaccine provides protecting against Type A (swine flu) and Type B sub-types which are the most common types of flu in Dubai, Sharjah or other Emirates of UAE.

At Bristol Medical Centre flu vaccine is available for adults as well as children which cost 100 AED. Make sure you do consult the GP or Pediatrician if you want flu vaccine for yourself or for your child.

What is Peptic Ulcer Disease?Peptic Ulcer Disease [PUD] is a misnomer. In early 20th century it was believed that the ulcer of stomach and duodenum [First part of small intestine, just after stomach] was caused by gastric enzyme Pepsin and thus it was started to be called as peptic ulcer disease.

Basically, peptic ulcer disease is a pathological condition with formation of ulcers either in stomach or in duodenum. Duodenal ulcers are 4 times more common than gastric [stomach] ulcers. Another important distinction between gastric ulcers and duodenal ulcer is that around 4-5 percent of stomach ulcers can be due to malignant tumor, thus justifying multiple biopsies to rule out any carcinogenic origin. Duodenal ulcers are most of the time benign and does not require multiple biopsies.

Signs & Symptoms of Peptic Ulcer Disease

Symptoms of peptic ulcers gives an important clue towards diagnosis of the disease. Though, these signs and symptoms are not enough to distinguish between Gastric or duodenal ulcers or even the diagnosis of ulcer alone.

Nausea & Vomiting is present in both gastric and duodenal ulcers.

Most common presentation of Peptic ulcer is mid-epigastric pain. The pain of stomach ulcers usually increases with food , while in duodenal ulcers usually the midepigastric pain decreased after taking food.

Weight loss is also associated with peptic ulcer disease. Since pain of gastric ulcer increases with the intake of food they are more likely to cause increase in weight loss when compared to duodenal ulcers where pain is relieved after having a meal.

Tenderness of abdomen is usually not present in almost 80-85 percent of cases of peptic ulcer disease, until the ulcer has caused perforation.

Other important symptoms might include hematemesis [Vomiting of blood] or malena [ black colored or tarry stools due to oxidation of iron in hemoglobin]
The above signs and symptoms are not enough to distinguish between gastric and duodenal ulcers and the patient might need and endoscopy or special imaging technique like barium swallow or upper gastrointestinal series.

There can be many causes of peptic ulcer and some special techniques can be required for proper diagnosis and treatment of peptic ulcer disease which we will discuss in detail in subsequent articles.

Eating disorder effects men as well. But being largely associated with females, men with eating disorder are not only under-diagnosed but also under-treated

Recent study conducted by National Association of Anorexia Nervosa and Associated Disorders (ANAD), estimated that 10-15% of Americans with eating disorders are male. Men with eating disorders are not only under-diagnosed but also not treated properly and neither being researched.

BMJ Open published the research from Oxford university in UK which studied 39 patients of eating disorder out of which 10 were men between ages from 16-25.

The researchers framed their questions on four basic theme which are most relevant in diagnosing, identifying and managing patients with eating disorders like Anorexia Nervosa or Bulimia.

  • Recognizing Signs & Symptoms of eating disorder
  • Understanding that their is a problem
  • Seeking help
  • First and initial contact with a health care provider.

The research team concentrated answers of male patients only. The results were alarming. The symptoms of eating disorder like not eating for days, purging, obsessive calorie counting, excessive exercising, binging and forced vomiting were present in most of them and the fact that they themselves took several months to years just to release this could due to some kind of eating disorder. The common thought that eating disorders effect only girls seems to prevail not only in general public but also in these men as well.

The fact that eating disorder is more common in females, does not mean it cannot occur in male. The male patients who actually suffer from these disorders fall prey to generalization and in turn remain under-diagnosed and under-treated.

The other two revelation was that some of them realized that they do have some kind of eating disorder only when they were admitted to hospital for any acute illness either associated with eating disorder or when a physician asks detailed personal and social history.

Other had apprehension for seeking professional medical advice for not being taken seriously. While those who took medical advice got mixed response from health care worker. Which is not encouraging as well. This makes even health workers like doctors and nurses bias towards the gender in diagnosing and treating eating disorder.

Awareness is the only solution to this problem. The word needs to be spread not only to general public but also among health workers who seems who have gender bias as well when it comes to eating disorders.

The research team was not shy to point out that the sample size of the research was too small and the subject needs to be further researched with more older population as well as greater sample size.

Currently we are going through winter weather. During this period “seasonal flu” is very common and may affect any member in family. Here we recommend few health tips to avoid getting flu infection.

  1. Its responsibility of everyone to prevent spread of common cold infection. One should cover his / her sneeze or cough in tissue paper or kerchief …or if nothing is available, in sleeves of arm or his/her own hands.  Wash your hands immediately with soap and water. Hand hygiene is very important in preventing many infections.
  2. Don’t cough or sneeze in open air. Doing so will spread myriads of virus particles in air …which if inhaled by any susceptible person or child /infant may lead to infection in them.
  3. Do not expose young infants /children to infected / overcrowded areas.
  4. vaccinate your ward  against  flu virus  “be wise immunize
  5. Consult pediatrician if your ward gets any of symptoms of flu like sneezing, runny nose, cough, watering from eyes, fever.

WHO draft guideline proposes to reduce daily sugar intake to 5 percent of the total energy consumption


WHO today issued a draft guideline where they have reduced the daily “Free Sugar” intake from 10 % of total calories to 5 %. Earlier guideline was issued in the year 2002 in which daily free sugar consumption was set to less than 10 percent of daily energy intake.


Free Sugar is extra sugar added in the form of sucrose, glucose and fructose in various cola based drinks and fruit juices (which already has natural sugars). Apart from cola and fruit juices free sugar is consumed in the form of sweeteners in coffee, cakes and drinks like tea.


WHO issued drafted a new guideline where the organization have proposed that daily intake of sugar should not exceed 5 percent of total calories consumed in a day. The idea behind decreasing or cutting the sugar intake by half is that more and more people consume large amount of sugar that could replace better nutritionally adequate sources of calories and also increase daily intake of total calories which have been linked to diseases like heart disease, obesity, hypertension and possible type 2 diabetes mellitus.


In recent survey it has been concluded that about 5 percent of people consume 575 kcal of via sugar which is equivalent of 5 cans of sugary drink or soda. While on an average 50 percent of US population consumes sugary drink daily.


WHO also made a case in point about dental diseases and cavities which can be directly linked to sugar intake in which about 80 to 90 percent of children had the disease while almost 100 percent adults had dental cavities.


Important thing to note is that this is a draft guideline, where WHO has said that reducing sugar intake from 10 percent to 5 % can result in various health benefits. Five percent amounts to 6 teaspoon of sugar for an adult with normal BMI [Body Mass Index].


The draft guideline will be peer to peer reviewed and comments are invited from March 5 to 31st. After reviewing comments and peer to peer review if necessary the previous guideline of daily sugar intake could be revised to current draft guideline of 5 percent consumption of free sugar intake daily.

Hyperuricemia is increased uric acid level in the blood.

Uric acid level to be safe below 6mg/dl

Increased uric acid level occurs because of:

Decreased removal of uric acid from the blood or its increased production or a combination of these two mechanisms.

When should you think you have a uric acid problem?

If you develop any one of the following symptoms, it calls for a uric acid checkup;

  1. Joint pain
  2. Abdominal or flank pain

Causes of uric acid:

  1. Food and drinks listed in the limited diet below*
  2. Obesity
  3. Stress
  4. Severe illness
  5. High blood pressure
  6. High blood sugar
  7. High cholesterol
  8. Hypothyroidism
  9. Hyperparathyroidism
  10. Extreme Physical exertion
  11. Kidney disease
  12. Exposure to lead
  13. Malignancy
  14. Some of the medication and supplements

Possible complications of hyperuricemia include the following:

  • Gout
  • Acute uric acid nephropathy
  • Uric acid nephrolithiasis
  • Chronic renal insufficiency

What are the work ups required for proper management?

  1. Serum Uric acid
  2. Complete blood count
  3. Blood glucose
  4. Lipid profile
  5. Liver function test
  6. Electrolyte, BUN, Creatinine
  7. Thyroid stimulating hormone
  8. Serum calcium and phosphorous
  9. Urinary uric acid excretion
  10. In patients with gout: radiograph
  11. In patients with hyperuricemia and suspected renal problem: renal sonogram

What are the Food that needs to be limited in patients with hyperuricemia?*

  • Alcoholic beverages (all types)
  • Meats, such as beef, chicken, duck, pork, ham, bacon, turkey, veal, venison
  • Organ meats: liver, kidney, brain
  • Fish: anchovies, scallops, salmon, sardines, herring, mussels, codfish, tuna, trout and haddock
  • Shellfish, such as crab, lobster, oysters and shrimp
  • Processed food like bakery items, chips, snacks, frozen dinner
  • Refined carbohydrate like white bread, white rice, pasta, Sugary beverages
  • Vegetables: asparagus, cauliflower, peas, spinach, beans, mushroom

Which Food items can be included in the diet?

  • Skim milk
  • Low-fat dairy products (yogurt, cheese, cottage cheese)
  • Whole-grain products
  • Plant oils (olive, canola, sunflower)
  • Vegetables except the ones mentioned in the limited diet list
  • High fiber or dietary soluble fibers such as Isabgol, Oats, Broccoli , apples, oranges, pears, strawberries, blueberries, bananas, cucumbers, celery, barley and carrots.
  • Vitamin C rich food or supplements


Drinking around 2 liter of water daily helps in reducing the accumulation of uric acid in blood.

In this article we will discuss in detail about Hypothyroidism, its causes, clinical features or signs & Symptoms, diagnosis and management as well as treatment of hypothyroidism.

Causes of Hypothyroidism

Primary Hypothyroidism

Hypothyroidism can be of three types depending on source of pathology. Primary Hypothyroidism is a condition when there is something intrinsically wrong with thyroid and it does not produce adequate amount of thyroid hormones like T3 and T4.  This one is the most common cause of hypothyroidism and more than 95% of cases of hypothyroidism as of primary in nature.

Primary hypothyroidism can be secondary to many pathological states, most common being Hashimoto Disease which is a kind of chronic hypothyroidism. Hashimoto disease or thyroiditis results in goiter and is associated with anti-microsomal antibodies. The disease will be discussed in detail in subsequent articles.

Other causes include treatment of hyperthyroidism like surgery, radioactive iodine. Iodine deficiency and genetic defects in synthesis of T3 and T4 can lead to primary hypothyroidism as well.

Drug Induced Hypothyroidism: Drugs like lithium, amiodarone, acetylsalicylic acid, interferon and sulfonamides can cause primary hypothyroidism.

Secondary Hypothyroidism

Pituitary induced hypothyroidism is also known as secondary hypothyroidism. The blood level of TSH as well as T3 and T4 is decreased unlike primary hypothyroidism in which T3 and T4 is decreased while serum TSH is high.

Tertiary Hypothyroidism

Pathology is in hypothalamus which is responsible for release of Thyroid Releasing Hormone [TRH]. Decreased level of TRH causes pituitary to release less TSH which results in underproduction of T3 and T4 by thyroid glands resulting in tertiary hypothyroidism.

Signs & Symptoms

Hypothyroidism based on age of the patient can be classified under two major categories. In new born hypothyroid state is also known as cretinism or juvenile hypothyroidism while in adults it is called as adult hypothyroidism


The classical features of cretinism includes following signs & symptoms

  • Physiological jaundice
  • Horse cry
  • Constipation
  • Wide set eyes
  • Umbilical hernia
  • Feeding problems
  • Drowsiness and state of sleepiness [Somnolence]

With progression of age the child has coarse facial features, protruding tongue, flat nose, impaired mental development, delayed milestones and dwarfism.

Scanty hair with dry scaly skin is also seen in juvenile hypothyroidism

Signs & Symptoms of Hypothyroidism in adults

Signs and symptoms of adult hypothyroidism include classical history where patient complains of following

  • Constipation
  • Cold intolerance
  • Weight gain
  • Muscle cramps
  • Lethargy
  • Stiffness
  • Decreased appetite

On close examination doctor may illicit following history and signs

  • Coarse and deep voice
  • Loss of hearing
  • Slow deep tendon reflexes [Prolonged relaxation phase]
  • Flat and expressionless face, scanty hair, cool skin with large tongue and swelling around the eyes
  • High cholesterol, decreased blood sodium levels and anemia might also be associated.

Diagnosis, Investigation & Lab tests

Diagnosis of hypothyroidism is made by physical findings and symptoms. Tests are run to confirm the diagnosis and start the treatment

Blood TSH level is increased while T3 and T4 is decreased in primary hypothyroidism

Blood TSH level is decreased along with T3 & T4 in secondary and tertiary hypothyroidism.


Management and treatment of hypothyroidism is done based on age and other co-morbid conditions. For patients who are older or have coronary artery disease [CAD] the aim is to restore normal metabolic state gradually so that cardiovascular system is not stressed.

Levothyroxine [T4] is given with close monitoring of T3 and TSH. Usually it takes 4-6 weeks before the levels are stabilized and dosage is adjusted accordingly.

In adults the dosage is around 100 micro-grams per day. While in older patients the dosage is kept around 25-75 micro-grams per day of levothyroxine.

If there is suspicion of supra-thyroid cause like secondary and tertiary hypothyroidism it is advisable to give hydrocortisone first then change it to thyroid hormone.

The weight in pregnancy gain varies every month. During 1st trimester there is no weight gain or less gain because of vomiting. Average weight gain should be 1Kg to 1.5 kg per month in 2nd and 3rd trimester. Baby’s growth is maximum in last trimester. Weight gain should not be more than 0.5 kg per week.

Following are the good examples of dos & don’ts in pregnancy


  • Smoking should be avoided completely.
  • Partner should avoid smoking inside the house.
  • Passive smoking is also dangerous to the fetus.
  • Avoid alcohol in any form.
  • Reduce coffee and aerated drinks.
  • Avoid red fish like king mackerel, red tuna, red salmon and deep sea fish as mercury content is high in them.
  • Include more proteins like dal, green grams, nuts, eggs, fish and milk.
  • Eat fiber rich foods, whole wheat products.
  • Eat fruits and vegetables to avoid constipation.
  • Drink plenty of water.
  • Avoid strenuous exercise in 1st trimester.
  • Reduce frequency of sexual relationship in first three months and avoid completely in case of threatened abortion.
  • X-ray exposure should be avoided during pregnancy.

Generally almost all of the diseases or disorders of esophagus results in either pain while swallowing (odynophagia) or difficulty in swallowing (dysphagia). Difficulty while swallowing is more common than pain while swallowing. Difficulty while swallowing might be for type of food like solids, semi solids or liquids. This relationship of type of food and difficulty while swallowing can point towards certain disorders of esophagus. The progression of symptoms, in this case dysphagia is also an important thing to take into consideration. Progressive dysphagia starting from solid foods, then semi solids and then to liquid food is typical of various esophageal disorders.

Presence or absence of constitutional symptoms like fever, weight loss or loss of appetite may point towards a serious disorder. Occupation and social history may contribute towards the final diagnosis of the disease. The best initial test to come to final diagnosis for disease of esophagus is barium swallow or barium esophagram. If the results show clear signs of obstruction this should be followed by upper endoscopy.

Below are few esophageal disorders which might result in difficulty in swallowing. Each disorder is discussed in detail in separate articles.

    • Achalasia
    • Esophageal Cancer
    • Progressive Systemic Sclerosis (Scleroderma)
    • Diffuse Esophageal Spasm (Nutcracker Esophagus)
    • Plummer Vinson Syndrome
    • Schatki’z Ring
    • Esophagitis
    • Zenker’s Diverticulum
    • Mallory-Weiss Syndrome

These diseases might be associated with difficulty in swallowing or even pain while swallowing. Tests like barium swallow; upper endoscopy and manometry are done apart from taking proper history and understanding signs and symptoms of disease. Some of the disease may also be associated with chest pain like diffuse esophageal spasm which can be difficult to diagnose. Make sure you consult our General Practitioner if you are having problems in swallowing

The esophageal disorders even if when it is not cancer might be associated with weight loss, just because patients find it difficult to eat due to pain and difficulty swallowing rather than decrease in appetite. Previous drug history or tolerance to cold, anemia, personality disorder like bulimia, forced vomiting, retching may give an important clue for coming to the final conclusion as to what is the reason for esophageal discomfort.

This article was to give a general overview of esophageal disorders and disease which can cause difficulty or pain while swallowing. Each esophageal disorder is discussed in detail in a separate post.

Gastroesophageal Reflux Disease [GERD] is a term given to a condition when stomach acids flows upwards or backwards from stomach to esophagus. Normally, lower esophageal sphincter prevents the backward flow. LES most of the time is contracted and relaxes only when you swallow the food. If due to any reason the LES does not remain in the state of contraction the gastric acid flows from stomach to esophagus causing Gastoesophageal Reflux Disease or GERD.

Factors that can result in decreased tone of lower esophageal sphincter thus causing GERD

  • Caffeine
  • Nicotine
  • Peppermint
  • Alcohol
  • Chocolate
  • Drugs (Anticholinergic drugs, Nitrates, Calcium Channel Blockers)
  • Idiopathic (Unknown Cause)

As the tone of lower esophageal sphincter decrease the backward flow of gastric acid from stomach to esophagus results in GERD, especially when a person is lying flat.


Usually, GERD causes dyspepsia or epigastric pain which is most of the time sub-sternal along with following differentiating symptoms:

  • Hoarseness
  • Wheezing
  • Cough
  • Metal like taste in mouth
  • Sore throat

Epigastric pain can be due to number of other diseases like gastritis, pancreatitis, ulcer disease etc. The above symptoms along with sub-sternal pain points the cause of discomfort related to Gastroesophageal Reflux disease.


Acid reflux disease is a condition where LES or lower esophageal sphincter is not able to remain in the state of contraction which results in back flow of gastric acids from stomach to esophagus. Diagnosis of acid Reflux Disease [GERD] is mostly clinical. Which means doctor does not have to do any specific test to diagnose GERD. The clinical signs & symptoms of GERD are enough for diagnosing Gastroesophageal Reflux Disease [GERD]. If a person has Epigastric pain which is radiating below the sternum with bad metallic taste in mouth GERD can be suspected and treatment can be started. If clinical diagnosis is made treatment can be started immediately.

Only if the diagnosis of GERD is not clear or the patient’s clinical presentation is equivocal a specific test called as 24-Hour PH monitoring is required. 24 hour PH monitoring is done by placing an electrode few centimeters below gastroesophageal junction (place where gullet and stomach meets). The instrument records the PH and average PH of that area is determined. Endoscopy can be done to see the changes in the lower esophagus, but a normal endoscopic finding does not exclude the presence of Gastroesophageal reflux disease [GERD]


Drugs can be used to treat Gastroesophageal Reflux Disease effectively. Three types of drugs can be used

  • Proton Pump Inhibitors (PPIs): Example: Omeprazole, Pantoprazole, Rabeprazole. All have equal efficacy. Goal is to keep PH of the stomach acid above 4.0.
  • H2 Blockers: These class of drugs are used if the symptoms are mild or moderate and are intermittent.
  • Prokinetic Drugs: Drugs like metachlopromide can be used to relieve the symptoms of GERD. Another prokinetic drug “Cisapride” was discontinued from US due to its fatal adverse effect. Cisapride was known to cause Ventricular Arrhythmias.

H2 Blockers and Prokinetic drugs have equal efficacy in treating mild intermittent forms of Gastroesophageal Reflux disease. But these drugs should not be used if symptoms are severe. For severe symptoms of GERD PPIs are the best class of drugs.


The goal of surgical treatment is to tighten the Lower Esophageal Sphincter (LES) so that stomach acids do not flow back or upwards to esophagus. The indications of surgical treatment for GRED are as follows:
If patient does not respond to medical treatment with Proton Pump Inhibitors

Side Effects of PPIs: diarrhea & headache

Alternative to life long or long term medical treatment with PPIs. Two surgical methods are most commonly used to treat GERD surgically:
Laproscopic Nissen’s Fundoplication
Purse-String Suture in LES to make it tighter.

Old people need healthcare services more frequently than any other age group. Over the course of one year of service in Al Nahda, Sharjah, we have identified two problems.

Most of the old age residents in UAE are dependents that mean they do not have any regular source of income of their own, which makes it difficult for them to visit doctors and pay for the services.
In this age group most residents of Sharjah have individual insurances, which means they if they have Insurance from Dubai, they do not have access to healthcare in Sharjah. Even if they do it is limited to very few health care facilities.
So we decided to take action. Yes, we do care for elderly. Bristol Medical Centre has decided to give special offer to old age and elderly residents of Sharjah & Dubai.


Elderly Package includes following:

  • GP consultation: AED 50/- only
  • 25% flat discount on all other services offered at our clinic, including dental services.

Eligibility: 65 years or older.

We hope you appreciate our efforts and will help us spread the news to anyone who might benefit from our offer.


The procedure of Circumcision is done to remove the foreskin of the tip of penis surgically. It is a very common procedure which is done for various religious, medical and cosmetic reasons. Most of the time in new-born circumcision is done for religious reasons, in adults and older children it can be done for various medical reasons like:

  • Balanoposthitis: inflammation of foreskin
  • Phimosis: Faliure of foreskin retraction
  • Paraphimosis: retracted foreskin cannot be returned to its original position.


Although in an infant there is no immediate benefit of circumcision which is why it is done because of religious requirement. Medically in long term circumcision has known to have following benefits:

  • Lower risk of urinary tract infections in childhood and infancy
  • Lower risk of penile cancer
  • Lower risk of STDs (sexually transmitted diseases)
  • Decrease risk of cervical cancer and some infections in female partner.
  • Prevents balanoposthitis, phimosis, paraphimosis
  • Better personal hygiene


It is usually done either by General Surgeon or Urologist. For new born circumcision the baby will lay on his back and his arms and legs will be secured. If not done previously, blood test is done to see if the blood clots on time and to know the blood group and hemoglobin levels. Local anesthesia is given in the form of an injection or foam to numb the penis. There are many techniques to perform circumcision. The preferred method is decided by the doctor depending on age of the baby and experience of the doctor. All of the methods work by cutting of blood circulation of the foreskin to prevent bleeding when the doctor cuts the foreskin. Circumcision procedure usually takes 30 minutes and the baby is discharged.


Healing usually takes place within 7-10 days. After the procedure baby can be little fussy and irritable. Medicine is given to decrease the pain and prevent infection. Circumcision charges varies quite a bit depending upon hospital and clinic and which doctor is performing the procedure. It can range anywhere from 1000 AED to 3000 AED.

At Bristol Medical Centre, circumcision is performed by highly experienced General Surgeon, Dr. Bharti Chavda, who has more than 15 years of experience in Gen. Surgery. Call 065266615 for details, pricing and appointment.


18th October 2018
18th October 2018
18th October 2018
18th October 2018


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