🛑Precipitating factors leading to diabetic ketoacidosis (DKA) are:

✅Infection (30-40%) The most common precipitating factor

✅Non-compliance with treatment (25%)

✅Newly diagnosed diabetes ( 10-20%)
✅ Alterations to insulin dose (13%)

✅Myocardial infarction (<1%)

#Not and Note

#سؤال
🛑نحن نعلم بأن دواء metformin يعتبر اول خط علاجي في معالجة مريض السكري النوع الثاني ،ولكن متى يمنع استخدم هذا الدواء في معالجة السكري من النوع الثاني حتى إذا كان وظائف الكلى في المستوى الطبيعي ولايوجد فشل في عضله القلب؟

🛑الاجابه في حاله مرض Mitochondrial diabetes

✅داء السكري الميتوكوندري

التعريف

حدث نوع نادر من داء السكري بسبب طفرة في DN الميتوكوندري



✅الخصائص

يمكن أن يظهر على أنه من النوع 1 أو النوع 2 اعتمادًا على شدة نقص الأنسولين.


✅ضعف السمع الثنائي (عادة ما يسبق تطور مرض السكري) → قياس السمع.

✅العلاج

مع مرض السكري من النوع 2: بسبب طفرة الميتوكوندريا الكامنة يمكن أن يكون العلاج الأولي المختار مع السلفونيل يوريا

✅يمنع استخدام الميتفورمين بسبب خطر الإصابة بالحماض اللبني.

من المتوقع أن يؤدي خلل الميتوكوندريا في العضلات إلى ارتفاع مستوى اللاكتات تم اكتشاف طفرة A3243G في الأصل لدى المرضى الذين يعانون من اعتلال عضلي ميتوكوندريا واعتلال دماغي وحماض لاكتيكي ونوبات تشبه السكتة الدماغية (متلازمة ميلاس.

.

✅ارتفاع نسبة الجلوكوز + الصمم العصبي الحسي يعتبران من أمراض السكري الميتوكوندريا

🛑Mitochondrial diabetes

Definition

✅A rare variant of diabetes occurred due to mutation in the mitochondrial DN

209

✅Features

Can present as type 1 or type 2 depending on the severity of insulinopenia.


Diagnosis

✅Mitochondrial diabetes is suspected in female patients with a strong familial clustering of diabetes, with predominantly maternal transmission of disease and the presence of sensorineural deafness.

Genetic analysis A3243G mutation in the tRNA gene

✅Treatment

with type 2 DM presentation: due to an underlying mitochondrial mutation can be with sulfonylureas is the initial treatment of choice

✅Metformin is contraindicated due to risk of development of lactic acidosis.

✅A mitochondrial dysfunction in muscle is expected to lead to a higher lactate The A3243G mutation was originally detected in patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS syndrome)


✅High glucose + sensorineural deafness think of mitochondrial diabetes

🛑بخصوص نقطه QT prolongation
ل ادويه fluoroquinolones

بتكون اكثر عند استخدام moxifloxacin وأقل في ciprofloxacin

بحيث
Change in QTc from baseline for moxifloxacin was found to be +16.34 to 17.83 ms, while the change with ciprofloxacin was +2.27 to 4.93

وطبعا غالبا بتحدث في وجود another risk factor

✅Structural heart disease (eg, history of myocardial infarction or heart failure with reduced ejection fraction


✅• Hepatic impairment
✅ Kidney impairment
✅Sepsis

✅Electrolyte disturbances (eg, hypocalcemia, hypokalemia, hypomagnesemia)

✅Age >65 years

✅او في حاله استخدام دوائين او اكثر معروف عنهم انه يعملوا prolong the QT interval 

مثل ادويه

erythromycin, antipsychotics, and tricyclic antidepressants)

Systemic Fluconazole

✅او تداخل دواء قد يزيد من ادويه fluoroquinolones


#lexicomp

🛑Most clinical cases of drug-induced QT prolongation occur in the presence of at least one of these risk factors, and >70%🤔 occur in the presence of two or more.
✅ • Electrolyte disorders – hypokalaemia, hypomagnesaemia, hypocalcaemia, risk increases with lower levels. (Hypokalaemia-related QTc prolongation is commonly observed in acute psychotic admissions)
✅• Drugs or conditions which may impact on electrolytes e.g., diuretics, dietary supplements, severe acute illness, gastroenteritis.

✅ • Kidney or liver disease (risk increases with increased severity) – also consider impact on metabolism of other drugs/risk of increased adverse effects
✅• Age ≥ 65 years
✅• Female sex
✅ Baseline QTc interval >480 msec
✅ Personal history/congenital or family history of long QT syndrome
✅ • Cardiac risk factors such as heart failure, left ventricular hypertrophy, bradycardia (heart rate <60), IHD, myocarditis, MI

✅Untreated thyroid disease – more common with hypothyroidism
✅ • Unexplained syncope/presyncope
✅ • Family history of sudden cardiac death or syncope
✅ • Prescribed a drug that may affect elimination of psychotropic drug e.g., affecting cytochromes or drug transporters required for elimination
✅• Drug toxicity e.g., due to patient’s metaboliser status, drug interaction or accidental or intentional overdose
✅ • Prescribed another drug with potential to prolong QTc interval
✅• Methadone dose ≥100 mg/day

#NUh

🛑Acute coronary syndrome in women

✅.Women of all ages have higher rates of in-hospital and long-term complications from ACS than men.
✅Women derive the same benefit from aspirin,P2Y12 inhibitors,anticoagulants,β-blockers,ACE inhibitors, and statins as men, but women may be at higher risk of adverse events( Women have a higher rate of bleeding complications, renal failure, and vascular complications.)

✅ Women with NSTE-ACS and high-risk features (e.g., troponin positive) should undergo an early invasive strategy.

✅ Women with NSTE-ACS and low-risk features should not undergo early invasive treatment because of the lack of benefit and the potential for harm(classIII).

#ACCP2024

🛑فائده ادويه Aldosterone receptor blockers مثل spironolactone في مريض Acute coronary syndrome بتكون افضل كلما كان البدء بها بوقت مبكر افضل من التأخير بها (بعد سبع إيام من دخول المريض في ACs)
✅

✅طبعا تضاف إلى ادويه ACEI و BET blockers  في مريض MI اذا كان لدى المريض
✅diabetes
✅Symptomatic heart failure
✅LVEF < 40%


#ACCP2024

🛑Principles of antimicrobial therapy of Pseudomonas aeruginosa infections


✅For patients who have sepsis or septic shock, have neutropenia and bacteremia, have severe burns, or are in a setting where the incidence of resistance to the chosen antibiotic class is high (eg, >10 to 15 percent), we suggest empiric therapy with a combination of two antipseudomonal agents (Grade 2C). The two agents should be from different antibiotic classes (eg, a beta-lactam with an aminoglycoside،Fluoroquinolones

✅For patients without any of these additional risk factors for mortality or resistant organisms, we suggest empiric treatment with a single antipseudomonal agent (Grade 2B)

#Uptodate 2024

#remember

✅Nearly all infections of the female genital tract that are not caused by sexually transmitted pathogens are likely to involve anaerobic bacteria
#UPTODATE2024

🛑vancomycin and anaerobes bacteria

✅Active against gram-positive anaerobes; inactive against gram-negative anaerobes except when given orally where vancomycin greatly diminishes the colon microbiota including B. fragilis

#Uptodate

Chat GPt
راح يفيدك كثير المهم رغبتك ف التعلم وطريقه الإدخال
مثال بسيط أخبرته بأن يعتبر نفسه كلينك فارمسي ويلخص لي الادوية التي تاخذ ع معده فارغه ثم طلبت منه وضعه ع شكل pdf

#remember
✅Arterial Blood Gas (ABG)

✅Arterial blood gases should be used for assessing respiratory failure in Critically ill Patients or those with Shock or Hypotension (Systolic blood pressure < 90mmHg)

(British Thoracic Society, 2017)

🛑 pulmonary embolism and Chest X-ray

✅usually normal in PE😁
✅Should be performed in all patients with symptoms or signs suggestive of PE➡️ to exclude other pathology

#Not and Note

🛑ABG Use in

1 🛑. Evaluation of Oxygenation:

✅Determine arterial oxygen (PaO₂) levels in conditions like hypoxemia or respiratory distress.

✅Assess response to oxygen therapy or mechanical ventilation.

2.🛑 Assessment of Ventilation:

✅Monitor arterial carbon dioxide (PaCO₂) levels in respiratory failure, COPD, or hyperventilation syndromes.

🛑3. Acid-Base Imbalance:

✅Diagnose and monitor metabolic or respiratory acidosis/alkalosis in conditions like diabetic ketoacidosis, renal failure, or sepsis.

🛑4. Monitoring Critically Ill Patients:

✅Track changes in pH, PaO₂, and PaCO₂ during severe illness, trauma, or after major surgery.

#remember

✅  improving glycemic  control reduce microvascular complications but this has no significant impact upon cardiovascular morbidity and mortality.

✅lowering blood pressure significantly reduced morbidity from both microvascular and macrovascular disease.

#Not and Note