Top 5 Things Your Doctor Forgot to Tell You About Amoxicillin

General Practitioners and Family Doctors lead a busy schedule. We have to see our patients fast because there’s a really long line. And we always want what is best for our patients, no matter how busy we get. Amoxicillin is one of the most prescribed of the antibiotics depending on where you are in the world.

In order to make up for time, some stuffs about Amoxicillin may not have been discussed with you. Here are 5 things he/she may not have explained fully:

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Remember Zinc: the gut vitamin for diarrhea

Since the consensus was published in 2005, a lot of doctors forget zinc supplementation as part of the treatment algorithm for diarrhea. Some pediatricians argue that most of their patients were already prescribed multivitamins that contain adequate zinc content that further supplementation may not be necessary. But how sure are they that the mother is giving the multivitamins to their sick child?

In my rural health primary practice, many mothers are surprised that I recommend zinc or other vitamins during illness. Further probing told me that they stop all vitamins once they have a sick child. It was an old practice that was passed down but is now obsolete.

Related Story: Gatorade in Diarrhea: not First Line therapy

The following is WHO’s recommendations regarding zinc:

Zinc can be given as a syrup or as dispersible tablets, whichever formulation is available and affordable. By giving zinc as soon as diarrhoea starts, the duration and severity of the episode as well as the risk of dehydration will be reduced. By continuing zinc supplementation for 10 to 14 days, the zinc lost during diarrhoea is fully replaced and the risk of the child having new episodes of diarrhoea in the following 2 to 3 months is reduced.

This was taken from Treatment of Diarrhea 2005.

Remember to supplement zinc during diarrhea and if you are a mother reading this article, ask your pediatrician if you can switch to better forms of zinc than your plain old multivitamins. Also, stress to the caregiver it’s importance so as to greatly increase compliance.

Zinc sulfate drops and syrup are available for free in barangay health centers. We are only one of the 46 countries that have a national policy on this.

Dr. Mella is currently the head of the Committee on Diarrheal Diseases in Olongapo City. This is part of an education campaign to combat diarrhea.

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Gatorade in Diarrhea: not First Line therapy

Gatorade, a popular sports drink, is continually being used by some pediatricians despite the fact that it is not a first line therapy for acute diarrhea or vomiting. It is marketed as a sports drink and should only be used as such.

Gatorade is a fluid high in sugars and low in salts. It is preferred by most infants and toddlers due to the taste but the risk of osmotic diarrhea prevents me from recommending it. Its use can only be recommended if there is no suitable replacement for plain ORS but the quantity required to treat some signs of dehydration is still dependent on the salt content. Compared to ORS, you will need twice the amount of Gatorade to replenish the same amount of fluid deficit. ORS is therefore cheaper and far more effective. If the patient may exhibit NO signs of dehydration, Gatorade can be actually be used. However, there lies no consensus among concerned medical parties and is therefore not recommended. Start oral rehydration salts early to prevent further dehydration instead.

Related Story: What Your Doctor Wants To Know About Your Diarrhea: Quality and Quantity

Other common fluids also exist that are used by Filipina mothers that may be harmful include coffee, carbonated drinks and carbonated juices. I have met many mothers who have given coffee to a sick infant, further increasing the dehydration and the diarrhea. These are mothers who are usually reluctant to seek consult and are the ones that bring their child to attention only when severe dehydration and malnutrition is observed.

Salt is the primary method of treating diarrhea. Rice washings could be salted to provide a better alternative but the WHO recommends early access to ORS since the recipe is often forgotten.

ORS is provided free in barangay health centers and, if there is shortage, is inexpensive when bought in a local drug store. Gatorade and other fluids are far more expensive, less efficacious, and could be harmful to the child.

Dr. Mella is currently the head of the Committee on Diarrheal Diseases in Olongapo City. This is part of an education campaign to combat diarrhea.

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“Q-tingin:” Estimating Fluid Deficit by Physical Examination

Olongapo City – In the published manual of the WHO entitled “Treatment of Diarrhea” (2005), fluid deficits in dehydration and response to therapy need not be calculated using laboratory values but rather by straightforward physical examination.

Diarrhea with NO SIGNS of dehydration can have a fluid deficit of no greater than 5% or 50 ml per kg body weight. Thus a 15 kg child with diarrhea who is alert, drinks normally, and has normal physical exam is estimated to have at most 750ml of fluid deficit and correction of that deficit by increased oral fluid intake or ORS can be beneficial.

Diarrhea with SOME SIGNS of dehydration can have a fluid deficit of 5-10% or 50-100 ml per kilogram of body weight. For a 15 kg child with diarrhea who is restless/irritable, has sunken eyes, thirsty/drinks eagerly, and/or skin pinch that goes back slowly, his fluid deficit is estimated to be in the 750-1500 ml range. The patient should be weighed to detect clinical response as most patients begin to lose weight at this stage of dehydration. ORS, continued feeding, and zinc supplementation is recommended.

Related Story: Mom’s Best Arsenal Against Diarrhea: Oral Rehydration Salts!

Diarrhea with SEVERE SIGNS of dehydration can have a fluid deficit of more than 10% or greater than 100 ml per kilogram body weight. Thus the same 15 kg child above, should he become lethargic or unconscious, have sunken eyeballs, drinks poorly or not able to drink, and/or with a very slow (>2 sec) skin pinch over the abdomen, is likely to have a deficit of more than 1500 ml! This patient should be admitted. IV fluids and ORS are an emergency measure. Death follows if there is no immediate fluid replacement in 24 hours.

These fluid deficit estimation can be used in many etiologies of dehydration such as hyperemesis and severe exercise. Reference used in this article was provided by WHO and can be downloaded from this link:

Treatment of Diarrhea.Manual for Health Workers

Dr. Mella is currently the head of the Committee on Diarrheal Diseases, Olongapo City Health Office

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Aspirin Should Not Be Stopped Perioperatively, from Medscape

Olongapo City, Philippines by Zero Mella MD — It’s still a popular belief of IM consultants that aspirin should be stopped 7 to 9 days before surgery. The belief is that it may cause increase bleeding risk especially in major abdominal surgeries. Some old cardiologists still adhere from this belief. A medscape article tells us that they may be doing more harm than good.

A phenomenon termed aspirin withdrawal effect causes platelet rebound and prothrombosis which could lead to a cardiovascular event with a mean onset at 11 days from stopping the aspirin.

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Trust your doctors: ethical dilemmas in remote medical consults

A 35 year-old female came in at Afable Medical Center, with severe 10/10 (NAS) hypogastric pain of sudden duration. Palpation revealed a tender abdomen to deep palapation at the left lower quadrant. There was no fever and no relief to Mefenamic Acid, an over the counter analgesic.

Initial Assesment was a possible Nephrolithiasis. CBC and Urinalysis were normal except for 2-4 WBC on the urine sample. No crystals were seen. Tramadol and Buscopan per IV were given to the patient with substantial relief. Admission was offered for observation and to prep for an ultrasound. A referral to a urologist was recommended.

Related Story: Warning: Bioflu should not be used every 4 hours!!!

The patient agreed and was admitted.

It was a Sunday and, since Olongapo City was short of medical practitioners, I had to wait for an available urologist to examine my patient. For temporizing measure, I gave Tramadol and Cefuroxime (a broad spectrum antibiotic). I also have to wait until a sonologist would have to be available for an ultrasound.

All my management was sound and under protocol.

After a few hours, she bursts out in anger.

“Uuwi na po ako; wala daw po ako sakit. [Trans. I’m going home, they told me I have no illness]

“Who told you?” I asked.

She gave me her cellphone and I talked to a Dermatologist who was very angry that I admitted her sister-in-law with 2-4 WBC.

I told her that I saw the patient in severe pain and that she had to undertake more tests.

She told me that I was an ingrate and that I know nothing about her sister-in-law’s condition.

She dropped the phone. I asked my patient for the doctor’s name and she refused. She paid for the bill after signing a HAMA agreement.

This was four years ago and I regret I did not sue. The attending physician, or the one that is actually present, has precedence over a medical case. Medical opinions outside of the case are just that, medical opinions. Having a board certified specialty training in Dermatology doesn’t make you an expert over matters you cannot see. You can have a triple specialty or subspecialty but if you do not oversee the case, you shouldn’t make inferences that can damage the reputation of the attending.

The dermatologist violated the PMA Code of Ethics and is liable for slander. My story is one of many I have encountered in clinical practice. I have met patients time after time asking for a second opinion hoping to discredit the previous doctor in their care. I always tell the patients about differences in practices and that their previous doctor was doing the best he can. I do not wish to stain anybody’s reputation but time after time, I hear my own patients telling me that some specialty consultant said something bad about me, or that another patient I knew, is spreading a nasty rumor after his/her kid is not feeling well despite the meds I gave. Each of us doctors graduated with a degree of Medicine and sworn to uphold an oath. Each one had a different set of teachers and a different set of values. In a time when teamwork is needed, I see a crab-mentality issue going on.

“Hindi yan magaling… [Trans. That doctor is no good…]

I actually heard this comment coming from another doctor. The doctor he was referring to was a specialist that has serviced the community for more than 20 years and has done a ton of charity work. I actually found out that the commenter had a daughter who has graduated with the same specialty as the victim and needed a recommendation of patients to see.

This has got to stop! This is bad practice. This is unethical practice. Medical Doctors are becoming scarce and the remaining Filipino doctors are discriminating each other.

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2010 in review

The stats helper monkeys at mulled over how this blog did in 2010, and here’s a high level summary of its overall blog health:

Healthy blog!

The Blog-Health-o-Meter™ reads Fresher than ever.

Crunchy numbers

Featured image

A Boeing 747-400 passenger jet can hold 416 passengers. This blog was viewed about 1,800 times in 2010. That’s about 4 full 747s.

In 2010, there were 9 new posts, growing the total archive of this blog to 38 posts. There were 11 pictures uploaded, taking up a total of 2mb. That’s about a picture per month.

The busiest day of the year was December 10th with 35 views. The most popular post that day was 200% Customs Tax, Only in the Philippines!.

Where did they come from?

The top referring sites in 2010 were,,,, and

Some visitors came searching, mostly for bioflu, bioflu side effects, risk of hypertension, bpi trade, and vasovagal syncope and hyperventilation.

Attractions in 2010

These are the posts and pages that got the most views in 2010.


200% Customs Tax, Only in the Philippines! March 2010


Warning: Bioflu should not be used every 4 hours!!! October 2010


Case Studies: Vasovagal Syncope and Hyperventilation Syndrome October 2009


Welcome to Zero MD! May 2010


ALFM Peso Bond Fund Inquiry October 2009