Posted by Dr. Zirak from IP 22.214.171.124 on July 13, 2010 at 15:47:28:
I have written a book called Doctor to Doctor. It is a presentation from a doctor for Doctors.It contains two golden principles, twelve practice secrets, one great debate and one sincere advice.
It is for doctors of all specialities.
Here is an excerpt form the book:
"Practice secret nine: When prescribing always start with the lowest possible dose. Few exceptions are there.
While evaluating patient symptoms it is difficult to quantify them. For example, it is hard to know how much itchy the patientís itch is. I mean whether the itch the patient is having is minimum, moderate or severe is difficult to quantify. Moreover, the questions like ďHow would you describe your itch on the scale of 1-10?Ē are really not helpful because the patient with a scale 3 itch doesnít necessary have the less severe disease or need to medications than patients with a scale 6 itch. This is so because these are subjective readings and donít help in quantifying the symptom. One person may determine his itch to be on the scale of 3 while other with the same grade of itch might describe it on the scale of 7. This applies to many other symptoms e.g. pain. We donít have an external source to validate patient claims. We donít have a machine with which we can tell how severe their itch or pain is the patient having.
Like I said there are no reliable sources available to quantify symptoms patients are having. One golden tool of mine for quantifying symptoms is the nature of patient sleep. If a symptom precludes the patient from having a good night sleep then I would probably judge his symptom(s) is (are) of high grade.
This concept becomes relevant when it becomes to prescribing. When we canít quantify the symptom, how can we know how much to prescribe? When we donít know whether they are having mild/moderate or severe symptoms, how we can be sure to give them the correct medications according to their needs? The medications are different for different grades of symptoms. For example, in treatment of milder itch I give Hydroxyzine 10 mg tablet but in severe itch, I prescribe 25 mg strength.
So keeping all the above discussion my golden doctrine is to start with the lowest possible dose. You can always increase the dose if clinically needed. Starting with the lowest possible dose has many advantages. For example, it improves the compliance. Patient might take one tablet a day that you give them rather than four tablets a day. Also with low dose the incidence of complications and adverse effects is low.
There are few exceptions. First like I said if there is the lack of sleep this indicates a severe disease mandating higher or more potent drugs to be prescribed. Secondly, it also depends on what the underlying diagnosis is. For example, the pain in myocardial infarction is of severe type indicating the need for more potent pain killers like morphine. Like wise I know that certain diseases in the Dermatology present with the severe itch. For example, Nummular Dermatitis and Lichen Planus. For treating these conditions, I would prescribe the higher doses of anti-histamines. Even if a patient with nummular dermatitis would describe his itch as of scale 3, I would always treat it with higher doses of anti-histamines.
So as a general rule start with the lowest possible dose but if the patient is not sleeping or the your diagnosis of underlying disease tells you that the patient is having such disease which has severe symptoms, start with the higher dose. "
If you liked this then you must read the whole book.
It is published thru lulu.And it is available at the lulu website. Please click the link below:
www.lulu.com/ product/paperbac k/doctor- to-doctor/ 11726160(copy and paste into your browser please)
Kaiser Simab Zirak
Consultant Dermatologist (Skin Specialist)
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