How to know whether the patient is well or unwell?

This is something difficult to explain in words or learn from reading books. Only time and real-world experience can teach us to improve. Let's begin with a short case scenario:

"During one of the morning reviews, there was a new adult case admitted to the acute cubicle overnight for septic shock secondary to an infected upper back carbuncle. At my first glance, I whispered in my heart, "He doesn't look well and requires further intervention." Upon examining in detail, he actually had Kussmaul breathing despite being on HFNC. He was tachypnoeic (respiratory rate 32) and lethargic-looking. He was also drowsy. A blood gas taken stat showed pH 7.11, pCO2 35, pO2 80, HCO3 7.5, BE -21. Upon explaining to the family members, Anaes was called for elective intubation."

If we are unsure, we should be back to the basics, such as:
(1) Vital signs
• Blood pressure
• Pulse rate
• Respiratory rate (count the respiratory rate carefully, don't guess)
• Temperature
• SPO2
• Pain score

(2) GCS and consciousness

(3) Peripheral perfusion: CRT, warm / cold, skin color, pulse volume
(4) CVS: any raised JVP? any murmur or abnormal heart sound?
(5) Lungs: any signs of pulmonary oedema or pleural effusion?
(6) Abdomen: any distension / tenderness / guarding?
(7) Bilateral lower limbs: pitting oedema might suggest fluid overload
(8) Urine output. If the patient has been admitted since yesterday night, and there is no or very minimal urine output, it is abnormal!

Additional points that suggest the patient is relatively unstable:
• Is the blood pressure supported by inotropes (e.g. IVI Noradrenaline)?
• Is the patient on high oxygen supplements (e.g. venturi mask 60%, high flow mask (HFM), high flow nasal cannula (HFNC), CPAP, BiPAP)

Key learning points:
🍊 It is important to recognize unwell patients early and give priority management to those patients

🍊 Early resuscitation significantly improves patient outcomes compared to giving treatment in a fully deteriorated condition

🍊 Unwell patients should be reviewed more frequently (e.g. three or more times a day) to recognize deterioration earlier

Personally, I would say recognizing an unwell patient is more than half the journey to becoming a safe and competent doctor, as it helps in deciding further management, such as initiating resuscitation, calling for help, blood taking, and referring relevant teams.

==========
▶️ Kussmaul breathing // "Air hunger" breathing pattern
- Example: https://www.youtube.com/watch?v=raEKXVfuWTo&t=16s
- Characteristics: Deep, labored, and rapid breathing.
- It is a compensatory mechanism in response to severe metabolic acidosis, such as in DKA or severe AKI. The body attempts to expel excess carbon dioxide to balance the blood's pH levels.

▶️ ABG interpretation
https://t.me/nota_perubatan/1472

▶️ Gasping
https://t.me/nota_perubatan/344

Disclaimer:
The scenario above is provided for educational purposes only and does not represent the full details of a real-life clinical situation. The information shared is based on limited data and is intended to facilitate discussion and learning rather than reflect actual management decisions or protocols.

It is not meant to substitute professional medical advice, nor should it be used for medicolegal evaluation. Any resemblance to real events or patients is purely coincidental.

#miscellaneous@nota_perubatan
#houseman@nota_perubatan

Hypertension and relevant investigations

1️⃣ Baseline investigations for newly diagnosed hypertension
🔸 Full blood count (FBC)
🔸 Renal profile, electrolytes
- Slight hypernatraemia and/or hypokalaemia: primary aldosteronism needs to be ruled out

🔸 Fasting blood glucose and/or HbA1c
🔸 Fasting serum lipid (FSL)
🔸 Urine FEME. To look for proteinuria / other kidney problems
🔸 Thyroid function test (TFT)
🔸 ECG

====== ====== ======
2️⃣ Additional tests if indicated (based on initial / baseline investigations or if clinically suspicious of secondary causes of hypertension):
🔸 Echocardiogram. Indications e.g. suspected heart failure, atrial fibrillation, presence of murmur, suspected pulmonary hypertension (especially sleep apnoea, COPD)

🔸 Urine albumin-to-creatinine ratio (Urine ACR). An independent risk factor for cardiovascular disease (depending on resource availability)
🔸 Chest X-ray. Indications e.g. abnormal lungs examination

🔸 USG KUB + doppler. To assess for renovascular disease

🔸 24H urine metanephrine (tests for Pheochromocytoma)
🔸 24H urine catecholamine (tests for Pheochromocytoma)

🔸 Overnight 1mg Dexamethasone Suppression test (tests for Cushing syndrome)
🔸 24H urine cortisol (tests for Cushing syndrome)

🔸 IGF-1 (tests for acromegaly)

Related post:
▶️ Baseline investigations for a newly diagnosed T2DM
https://t.me/nota_perubatan/788

Further reading:
1. https://www.uptodate.com/contents/overview-of-hypertension-in-adults
2. https://www.e-mfp.org/issues/2011v6n1/hypertension.html
3. CPG Management of Hypertension 2018

#GIM@nota_perubatan

Medications and Hyperuricaemia
⚽️ Associated with increased risk of hyperuricaemia / gout
• Loop diuretics e.g. furosemide
• Thiazide diuretics / thiazide-like diuretics e.g. hydrochlorothiazide
• ARB (other than losartan)
• ACEi
• Beta blockers
• Cyclosporine

⚾️ Associated with reduced risk of hyperuricaemia / gout
• Calcium channel blocker e.g. amlodipine, nifedipine
• Losartan

🗒 Consider to change diuretics to alternative anti-hypertensives e.g. losartan, calcium channel blockers
🗒 Consider risks and benefits / indications when prescribing medications associated with increased risk of hyperuricaemia

Keyword: gout
Reference: Management of Gout 2021

#GIM@nota_perubatan

Morning serum cortisol (AM cortisol) VS 24-hour urine cortisol

🦋 Morning serum cortisol is commonly used to assess adrenal insufficiency
- Low cortisol levels may indicate impaired adrenal function (adrenal insufficiency)

🦋 24-hour urine cortisol is used to evaluate hypercortisolism (Cushing's syndrome)
- Measures the total cortisol excreted over a 24-hour period, providing a more accurate assessment of cortisol overproduction
- High 24-hour urine cortisol suggests Cushing's syndrome

Send morning serum cortisol TRO adrenal insufficiency; send 24H urine cortisol TRO Cushing syndrome

#GIM@nota_perubatan

MedTweetMY Professional is pleased to host an upcoming webinar on Parkinson’s Disease and Menopause, featuring two distinguished speakers. Dr. Mohamed Azlam bin Mohamed Micdhadhu, Consultant Neurologist and Internal Medicine Physician at Hospital Seberang Jaya, will present on “Extending ‘On’ Time: Strategies for Minimizing Motor Fluctuations in Parkinson’s Disease.” Joining him is Dr. Low Kah Pin, Consultant Obstetrician, Gynaecologist, and Robotic/Advanced MIS Surgeon at Island Hospital Penang, who will discuss “Surgical Menopause: Turning the Heat Down on Hot Flashes.” Secure your spot now by registering via the link below. https://zoom.us/webinar/register/WN_krW-E13CST-lbKFS6CpaUQ

#event@nota_perubatan

How do gestational trophoblastic diseases (e.g. choriocarcinoma, hydatidiform moles) cause hyperthyroidism?

• Choriocarcinoma produces high amount of human chorionic gonadotropin (hCG)

• hCG shares a structural similarity with TSH

• At very high levels, hCG can bind to TSH receptors on the thyroid gland, stimulating it to produce excess thyroid hormones (T3 and T4)

#ObsGyn@nota_perubatan

Spectrum of acute coronary syndrome (ACS)

🐝 Cardiac biomarkers refer to cardiac troponins or Creatine Kinase Myocardial Band (CK-MB)
- There are many cardiac enzymes available. However, only cardiac troponins and CK-MB are specific for myocardial infarction
- Raised cardiac biomarkers indicates myocardial injury

🍊 Injury VS infarction. Myocardial injury may be due to:
- Ischaemic causes: Myocardial Infarction (MI)
- Non-ischaemic causes: myocarditis, renal failure

🥎 A patient with UA may progress to NSTEMI or even STEMI

Abbreviations:
MI: myocardial infarction
NSTE-ACS: non-ST elevation acute coronary syndrome
NSTEMI: non-ST elevation myocardial infarction
STEMI: ST elevation myocardial infaction
UA: unstable angina

#GIM@nota_perubatan

I would like to express my heartfelt gratitude to my House Officers, who have been incredibly supportive during my on-call duty. On-call shifts can be demanding due to various factors. I'm very happy to witness their growth—from initially adapting to the work system to confidently clerking patients and formulating management plans for common cases. Keep up the great work, continue striving for excellence, and never stop learning. Your hard work and perseverance will take you far!

#motivation@nota_perubatan

Suggestions

Over the years, I have encountered many interesting experiences as a HO and MO in different departments and places. I believe knowledge sharing is important. Knowledge that is not shared may eventually be lost. 

Is there anything that comes to mind—something you’d like me to share?  

I will also do my best to find relevant resources and provide some valuable insights. 

You may use this Google Form to give your comment / suggestion:
https://forms.gle/QkQYTMRReMbQCttH7

I appreciate your responses and look forward to hearing your thoughts! 

❤️❤️❤️❤️❤️

@nota_perubatan

Hypertensive urgency
"62-year-old male with underlying hypertension presents to the ED with persistent headache.  Upon arrival, BP 190/110 mmHg. No neurological deficit, no dyspnoea, no chest pain, no blurred vision."

🍡 Definition
- Severe increase in BP (≥180 / 110 mmHg)
- Without acute end organ damage (e.g. acute pulmonary oedema, ACS, acute ischaemic / haemorrhagic stroke, hypertensive encephalopathy, heart failure)

💥 Target BP reduction
- 25% reduction in BP over 24 hours but not lower than 160/100 mmHg

🎸 Management
- Bed rest (rest in quiet room, with no talking or active listening)
- Check BP every 30 minutes (up to 2 hours)
- Aim 10 to 20 mmHg reduction in systolic BP after 2 hours 🔹
- If BP is persistently ≥180 / 110 mmHg after 2 hours, start anti-hypertensive
- Check BP every 30 minutes (up to 1 hour)
- Aim 10 to 20 mmHg reduction in systolic BP after 1 hour 🔹

🔹 If BP achieves target, allow discharge

🦋 Choices of anti-hypertensives
- Nifedipine 10 mg stat, may repeat after 1 - 2 hours
- Captopril 12.5 mg stat, may repeat after 1 - 2 hours
- Labetalol 200 mg stat, may repeat after 4 hours

🔧Hypertensive urgency discharge plan
- EOD BP monitoring (at home / nearest clinic). If BP ≥180/110 mmHg, repeat after 5 minutes.
- Review BP control in 1 - 2 weeks, KIV to adjust anti-hypertensive
- Advise for compliance to anti-hypertensive and follow-up

Come to nearest health facility immediately if:
- Repeated BP is persistently high (higher or same as the first reading)
- Symptomatic (e.g. shortness of breath / chest pain / dizziness etc.)

💎 CPG recommendations / points:
1. Do not reduce BP rapidly (within minutes to hours) in hypertensive urgencies as it may precipitate ischaemic events.

2. If BP responded with adequate rest (after 2 hours), discharge with Hypertensive Urgency Discharge Plan

3. If BP do not respond to adequate rest, start with combination oral pharmacotherapy targeting a BP reduction of 25% within 24 hours.

4. No role for intravenous anti-hypertensive

Reference
1. CPG Management of Hypertension 2018

#GIM@nota_perubatan
#ED@nota_perubatan

House Officer Preparatory Courses 

"The HO Preparatory Course module was effective in increasing levels of confidence and readiness for medical graduates"[1]

Yesterday, I received an interesting question about my thoughts on House Officer preparatory courses. 

In my humble opinion, I strongly support medical graduates enrolling in these courses, regardless of whether they are local or overseas graduates. These programs help bridge the gap between theoretical knowledge and practical application, allowing graduates to transition more smoothly into the demanding clinical environment. 

In fact, whenever I meet a new first-poster HO, one of my first questions is always: 
"Have you ever joined any pre-HO courses before?"  While different individuals might have different opinions, personally I joined before  and I found the courses helpful.

Regardless of who organizes them, these courses provide valuable insights into the job scope, helping graduates prepare both mentally and physically. They allow future HOs to anticipate challenges they may encounter at work, fostering confidence and readiness for their responsibilities ahead. 

Reference:
[1] The effectiveness of a Malaysian House Officer (HO) preparatory course for medical graduates on self-perceived confidence and readiness: A quasi-experimental study
https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0235685

#houseman@nota_perubatan

❓ Are you struggling to retain endless medical facts for exams? 
❓ Feeling lost in clinical rotations and unsure about case presentations? 
❓ Worried about missing key details that could make or break your understanding? 

You’re not alone—medical studies are tough, but learning the right way makes all the difference! Pelajar Medik is a new and growing knowledge-sharing channel, designed specifically for medical students who need a clear and concise way to strengthen their basic medical knowledge. 

🌟 Think of it as the medical student version of t.me/nota_perubatan, tailored to your level of learning! 

🚨 The channel is still new, but over time, it will accumulate more and more valuable sharings—so don’t miss out on the journey! 

📌 Easily scroll through the channel anytime—especially when exams are near—to quickly review the most important points. 

📢 Best of all—it’s completely FREE, forever! Just pure medical knowledge at your fingertips. 

This channel was created out of pure enthusiasm for medical knowledge and a genuine passion for helping medical students succeed. 

🔗 Join now and be part of its early growth! https://t.me/pelajarmedik 

📢 Do share with your juniors in medical school—so they can benefit too! 🏥✨ 

Dear followers, this t.me/pelajarmedik is my new channel, may share with juniors in medical school to join.  I will also share related notes from time to time

Diagnostic criteria for Latent Tuberculosis Infection (LTBI)
📌 Absence of any clinical features suggestive of active TB
- productive cough, haemoptysis, loss of appetite, unexplained weight loss, fever, night sweats, fatigue

📌 Normal or static chest X-ray findings
- 'Static CXR' here means CXR with features suggestive of healed TB lesions, e.g. presence nodules and fibrotic lesions that are well demarcated

📌 A positive tuberculin skin test (TST) OR Interferon Gamma Release Assay (IGRA)

External link:
Chest x ray - Tuberculosis healed, (TB), Inactive TB: https://www.youtube.com/watch?v=U7zvKbjYX7I

#GIM@nota_perubatan

Approach to treatment interruption in anti-TB

40 years old male, with smear positive PTB, on day 30 of anti-TB treatment (intensive phase). He was admitted for worsening of transaminitis, possibly drug induced liver injury (DILI). Anti-TB was withheld.

How to determine whether the anti-TB has to be restarted as day 1 or can be continued from previous number of days?

🎁 Interruption in intensive phase:
- If ≥ 14 days, to restart from the beginning, i.e. Day 1, until the total number of planned doses
- If <14 days, to continue from the last dose until the total number of planned doses

🎁 Interruption in the maintenance phase:
- If interruption occurs after receiving 80% of the total planned doses, treatment may be stopped If the sputum AFB smear was negative at the initial presentation. If sputum AFB smear was positive, treatment should be continued to achieve the total number of planned doses.

- If <80% of total planned doses were received and interruption lapse is ≥2 months, restart treatment from the beginning

- If <80% of total planned doses were received and interruption lapse is <2 months, continue treatment from date it stops to complete full course


Footnote:
The decision needs to be individualised, taking into consideration the reason for the interruption, response to treatment up to the point of interruption and total planned/expected doses of treatment.

Reference:
CPG Management of Tuberculosis 2012
Sabah Handbook on Management of Tuberculosis in Adults

#GIM@nota_perubatan

The Malaysian Consensus on the Management of Acute and Persistent Hyperkalaemia: A Multidisciplinary Approach 2024

Downloaded from https://www.msn.org.my/wp-content/uploads/2024/10/Consensus-Statements-for-Managing-HK-FINAL.pdf

#guidelines@nota_perubatan

Emergency management of hyperkalaemia

Remember, not all cases of hyperkalaemia require fast correction with lytic cocktail❗️

Source: The Malaysian Consensus on the Management of Acute and Persistent Hyperkalaemia: A Multidisciplinary Approach 2024

#GIM@nota_perubatan
#ED@nota_perubatan