Nota Perubatan

"Patient X with underlying ESRF, admitted for acute pulmonary oedema secondary to hypertensive emergency. BP remains 200/120 despite on IVI GTN 80 mcg/min. How much more IVI GTN that can be given to stabilize the BP while awaiting for HD/SU?" 2 commonly used parenteral anti-hypertensive agents in adults (1) Nitroglycerine // Glyceryl trinitrate - Initially IVI GTN 5 - 25 mcg/min. If BP remains uncontrolled, it's safe to give up to 200 mcg/min in general - Onset of action: 2 - 5 minutes - Duration of action: 3 - 5 minutes - Preferred in acute coronary syndrome, acute pulmonary oedema =========== (2) Labetalol - IV Labetalol 20 mg slow bolus for about 5 minutes (at least 2 minutes), followed by 40 - 80 mg every 10 minutes (maximum total dose = 200 mg) - Onset of action: ≤5 minutes - Duration of action: 3 - 6 hours In the setting of stroke — IV Labetalol 10 - 20 mg slow boluses over 2 minutes at 10-minute interval: - If patient is planned for Alteplase, BP has to be reduced to ≤185/110 mmHg - BP >220 / 120 mmHg may require anti-hypertensive, to keep BP at mild hypertension 160 - 180 / 90 - 100 mmHg - Used to controlled BP in the setting of stroke (labetalol has minimal vasodilator effects on cerebral blood flow) Further reading: 1) CPG Management of Hypertension 2018 2) CPG Management of Ischaemic Stroke 2020 #GIM @nota_perubatan

Serum Ascites Albumin Gradient (SAAG) Formula: Serum albumin - peritoneal fluid albumin 🪐 High gradient (more than 11 g/L); indicates presence of portal hypertension - Liver problem e.g. cirrhosis, alcoholic hepatitis, Budd-Chiari syndrome - Cardiac problem e.g. congestive heart failure, constrictive pericarditis 🪐 Low gradient (less than 11 g/L); indicates absence of portal hypertension. Causes e.g.: - Peritoneal carcinomatosis - Peritoneal TB - Pancreatitis - Nephrotic syndrome #GIM @nota_perubatan

Pleural tapping // Thoracocentesis 🌿 Indications (i) Diagnostic — e.g. suspected TB, malignancy, empyema (ii) Therapeutic — symptomatic relief for massive pleural effusion 🌿 Relative contraindications - Uncooperative patients - Uncorrected bleeding diathesis (INR >2.5, platelet <25) - Small amount of fluid: fluid <1 cm from chest wall (inadequate window for thoracocentesis) 🌿 Remember to get written consent from patient. Explain the indications and risks. 🌿 Risks / Possible complications - Common (mild): pain (20%), cough - Re-expansion pulmonary oedema (~7.5%) - Pneumothorax (<5%) - Haemothorax (1%) - Chest wall haemorrhage - Pleural infection / empyema (<1 in 2000) - Intercostal nerve, artery or vein injury - Liver / Splenic trauma - Failed procedure 🌿 Site of pleural tapping - Supine position: midaxillary line (done in safety triangle) - Seated position: posterior midscapular line 🌿 Blood investigations (where indicated) - FBC, RP, LFT, LDH, CRP - Blood C&S - Coagulation profile (to exclude coagulopathy prior to pleural tapping) 🌿 Pleural fluid samples sent: - Cytology (ideally 25 - 50 mL) - Biochemistry: pH, glucose, protein, LDH - AFB - Adenosine Deaminase (ADA) - used to rule in / rule out TB in pleural fluid - MTB C&S - FEME, C&S 🦋 What is the maximum volume that can be drained? - Typically not more than 1500 mL, to avoid re-expansion pulmonary edema 🦋 What is the next step if pleural effusion is not safe for pleural tapping? - CECT thorax 🦋 How about pleural effusions secondary to congestive cardiac failure? - 75% of the cases will resolve after 2 days of diuretic treatment. - Thoracocentesis is reserved for refractory cases ***There is a saying — whenever you encounter a massive unilateral pleural effusion, there is high chance it's either TB or malignancy until proven otherwise ===== Related posts: ▶️ Landmark and position for thoracocentesis // pleural tapping https://t.me/nota_perubatan/1008 ▶️ Pleural effusion in CXR VS ultrasound https://t.me/nota_perubatan/830 ▶️ Light's criteria for pleural effusion; causes of transudative VS exudative pleural effusion https://t.me/nota_perubatan/781 Further reading 1) https://dx.stanford.edu/procedures/Procedures_Thoracentesis.pdf 2) British Thoracic Society Guideline for pleural disease 2022 3) https://radiopaedia.org/articles/thoracentesis?lang=us #GIM #ED @nota_perubatan

MedTweetMY is excited to host another session of our MedTweetMY Back to Basics series (MTM BTB), and we are delighted to welcome back Dr. Ahmad Mahyuddin bin Dato’ Mohamed, an esteemed Orthopedic Specialist. This time, Dr. Mahyuddin will present on the topic of “Common Lower Limb Fractures.” Just three months ago, Dr. Mahyuddin delivered an insightful presentation on “Common Upper Limb Fractures.” We are thrilled to have him return to discuss lower limb fractures, expanding our understanding of this crucial subject. Here are the details for the upcoming program: Date: June 8, 2024 Day: Saturday Time: 8:30 - 9:30 PM Venue: Zoom Webinar via MedTweetMY Join us for an enlightening evening where you won’t regret tuning in! Gain valuable knowledge about lower limb fractures that can enhance your practice. To register, please click the link below or scan the QR code on the poster. https://zoom.us/webinar/register/WN_DPrJO_gqReq4XUNAsqmrdA Participants will earn 1 MMA CPD point and receive an e-certificate for the program. #events

Risks of oesophagogastroduodenoscopy (OGDS) - overall rare, <2% of patients: - Infection - Aspiration - Bleeding (<1%) - Bowel perforation (<1%) - Risks of oversedation: Hypotension, cardiac arrest / cardiac arrhythmia, airway obstruction Complications can be identified in first 24 hours of OGDS Monitoring of symptoms and signs of complications post OGDS: - Haematemesis - Fever - Abdominal pain / discomfort - Tachycardia, hypotension Notes: Advise patient to stop taking proton pump inhibitor at least 2 weeks before OGDS. If needed, patient may be given MMT or Gaviscon. This is to reduce false negative in rapid urease test // CLO test. Further reading: - https://www.ncbi.nlm.nih.gov/books/NBK532268/ Related posts: Urea breath test (UBT) ▶️ https://t.me/nota_perubatan/1244 #GIM @nota_perubatan