Nota Perubatan

The Kind Boss The story happened about a year ago. After working for a few years since Housemanship, some of us finally received an offer for permanent positions as Medical Officers. Just a few weeks before the eplacement system opened, I went to meet my direct superior, the hospital director. "Boss, recently a few of us here have received offers for permanent positions. Honestly, I'm in a dilemma. I love the people and the working environment in this hospital, and I’m currently also holding some portfolios with ongoing tasks. At the same time, I’m also thinking of returning to a place near my hometown in Semenanjung Malaysia and planning to further my career in department X in the future. I’m not sure what is the best decision to make." He replied, "For me, if you have already served here for two years, I have no reason to persuade you to stay longer. Go ahead and chase your dream. Don’t worry too much about the manpower here. We will never have enough manpower. Just remember to hand over your portfolios to your colleagues. All the best for your future!" @nota_perubatan

Some causes of hyponatraemia 🍏 Hypotonic hyponatraemia (i) Hypovolemic hypotonic hyponatraemia - Extrarenal loss (urine sodium <20 mmol/L): vomiting, diarrhoea, haemorrhage, burns, 3rd space loss - Renal loss (urine sodium >20 mmol/L): osmotic diuresis, diuretics, salt-losing nephritis (e.g. post-obstructive uropathy, polycystic kidney disease), adrenal insufficiency (ii) Euvolemic hypotonic hyponatraemia - SIADH - Hypothyroidism - Psychogenic polydipsia - Drugs that mimic ADH action: desmopressin, oxytocin (iii) Hypervolemic hypotonic hyponatraemia - Cardiac failure - Liver cirrhosis - Nephrotic syndrome 🍏 Hypertonic hyponatraemia - Hyperglycaemia - Mannitol 🍏 Pseudohyponatraemia - Hyperlipidaemia - Hyperproteinaemia #GIM@nota_perubatan #ED@nota_perubatan

The physiology tried to k_ll him. The anatomy said "not today." https://www.threads.com/@aaaaaamiiil.jpeg/post/DRJ5X1IkfOp?xmt=AQF06i23hLtAZt4WjtQTCyAJDFFQTSSVGCTUfr3kbWtNz-hnW4WFwhe4pY7EDPrCc-LLLaA9&slof=1

33 years old male, previously no known medical illness. He presented with lethargy, generalized and persistent abdominal pain, nausea and vomiting for 2 days. Other than surgical cause of acute abdomen, give one important medical cause of acute abdomen that must be considered: Answer: Diabetic ketoacidosis Remember to check capillary blood glucose. @nota_perubatan

Hypochromic Microcytic Anaemia: Iron Deficiency Anaemia, Thalassaemia Trait, or Both? Imagine a factory (bone marrow) that produces blood. Iron acts as the raw material, while red blood cells (RBCs) are the product. In iron deficiency anaemia, there is a lack of raw materials (iron), so the RBCs produced should be reduced. On the other hand, in thalassaemia trait, there is a faulty blueprint (globin gene mutation or deletion), causing the factory to produce a large quantity of poor-quality products (RBCs) despite adequate raw materials (iron). In iron deficiency anaemia, the RBC count is usually low. In thalassaemia trait, the RBC count could be normal or high, along with low MCV. ===== Here is a case scenario: "A 13-year-old girl presented to outpatient clinic. Her mother reported that she looked pale and was easily fatigued recently. There was no known family history of Thalassaemia." FBC result: WBC 7.8 x10⁹/L RBC 5.65 x10¹²/L🔺 Hb 7.4 g/dL 🔻 MCV 60 fL 🔻 MCH 23 pg 🔻 PLT 226 x10⁹/L Iron profile: Ferritin 4 ng/mL TSAT 15% ===== Hypochromic microcytic is a commonly encountered condition especially in primary care setting / ED. Sometimes coexisting iron deficiency and Thalassaemia trait may occur. History and physical examination might be unremarkable for Thalassaemia. In that case, treat iron deficiency first to optimise the iron profile.  Repeat FBC and iron profile after some time e.g. 3 months.

How to know whether the patient might have Thalassaemia trait and we should aim to send Hb analysis later once iron deficiency is optimised?

We can calculate Mentzer index: - Mentzer index <13 suggests a patient likely has thalassemia trait. - Mentzer index >13 indicates a higher probability of iron deficiency anemia Mentzer Index is just a screening tool, not a definitive diagnosis. Further testing, such as iron profile (including serum ferritin) and Hb analysis, is necessary to confirm the diagnosis. 👉 Mentzer index: https://notaperubatan.com/mentzer-index/ Why iron profile must be optimised first before sending sample for Hb analysis? - Iron deficiency can mask the diagnosis of Thalassaemia. - Iron deficiency artificially lowers the levels of HbA2. - HbA2 is supposed to be elevated in Thalassaemia trait. However, iron deficiency might make HbA2 level appear normal, potentially missing the thalassemia diagnosis. ===== Expected result of Hb analysis for Thalassaemia trait: - HbA: Normal or mildly reduced - HbA2: Elevated - HbF: Normal or slightly increased If we send a sample for peripheral blood film (full blood picture), anisopoikilocytosis with the presence of target cells can be seen in those with thalassaemia traits. Related posts: ▶️ Algorithms for Form 4 Thalassaemia Screening Programme and Thalassaemia screening at health clinic https://t.me/nota_perubatan/1824 ▶️ Iron deficiency related definitions https://t.me/nota_perubatan/888 #GIM@nota_perubatan

Iron profiles of iron deficiency anaemia, Thalassaemia and Anaemia of chronic illness. 1️⃣ Iron deficiency anaemia - Serum Iron: ↓↓↓ - TIBC: ↑↑↑ - UIBC: ↑↑↑ - TSAT: ↓↓↓ - Ferritin: ↓↓↓ In iron deficiency anaemia, all parameters show compensatory increase in iron-binding capacity due to low iron stores. 2️⃣ Anaemia of chronic illness - Serum Iron: ↓ - TIBC: ↓ - UIBC: ↓ - TSAT: ↓ - Ferritin: Normal or ↑ - In anaemia of chronic illness, iron is sequestered due to inflammation (↑ hepcidin in inflammation) - Ferritin rises as an acute-phase reactant, despite low serum iron 3️⃣ Thalassaemia - Serum Iron: Normal or ↑ - TIBC: Normal or ↓ - UIBC: Normal or ↓ - TSAT: Normal or ↑ - Ferritin: Normal or Normal or ↑ In Thalassaemia, iron metabolism is typically intact or overloaded due to ineffective erythropoiesis and repeated transfusions =====

Sometimes, TIBC may appear normal in iron deficiency anaemia. Do you know why?👇🏻

Some factors that affect iron profile: - TIBC may be low in liver disease due to impaired transferrin synthesis - Ferritin may rise due to inflammation / acute infection - Recent iron supplementation may elevate serum iron and ferritin, potentially masking iron deficiency - Inflammatory cytokines increase hepcidin, reducing iron absorption and trapping iron in macrophages Abbreviations TIBC: Total iron binding capacity UIBC: Unsaturated iron binding capacity TSAT: Transferrin saturation Related post: ▶️ Iron deficiency related definitions https://t.me/nota_perubatan/888 #GIM@nota_perubatan

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Algorithms for Form 4 Thalassaemia Screening Programme and Thalassaemia screening at health clinic Note that MCH ≤27 pg is an important cut-off point Source: CPG Management of Thalassaemia (2nd ED, 2024) #General@nota_perubatan

If the neck swelling is big and easily palpable, what is the next step to establish the diagnosis (regardless whether CT scan report is available)? 👉 Answer: Refer ENT team for excision biopsy of the left cervical lymph node

Expected platelet level post platelet transfusion (in adults) 60 years old male, with underlying aplastic anaemia, came to outpatient clinic to review FBC. Noted platelet level is only 5. He is admitted for 4 units platelet transfusion. What is the expected platelet level after 4 units of platelet transfusion? 1 unit of random platelet is about 50 - 70 mL

1 unit random platelet typically increases platelet level up to 5 - 10 x 10⁹/L

👉 Answer: 4 units random platelet will increase the platelet by 20 - 40 x 10⁹/L Hence, the expected platelet level for the above patient would be 25 - 45 x 10⁹/L Usually for this kind of case, we would follow-up the patients with repeated FBC in about 1 week post transfusion. Lifespan of normal platelet is 7 - 10 days. Lifespan of transfused platelet would be shorter. 🍏 Other notes: - When collecting platelet from blood bank, use a box without ice. (Platelets should be kept at room temperature 20 - 24°C. Cold storage changes the surface of the platelets, causing them to be rapidly cleared from the body after transfusion.) - Platelet should be transfused as soon as it is received from the Blood Bank - Transfusion of each pack of platelet should not exceed 30 minutes. Related post: ▶️ Expected Hb post transfusion https://t.me/nota_perubatan/671 #GIM@nota_perubatan

Haemoglobin cutoffs to define anaemia in individuals and populations 📌 Children - 6 – 23 months: Hb <10.5 g/dL - 24–59 months: <11.0 g/dL - 5 - 11 years: <11.5 g/dL - 12–14 years, nonpregnant girls: <12.0 g/dL - 12–14 years, boys: <12.0 g/dL 📌 Adults - 15–65 years, nonpregnant women: <12.0 g/dL - 15–65 years, men: <13.0 g/dL 📌 Pregnancy - First trimester: <11.0 g/dL - Second trimester: <10.5 g/dL - Third trimester: <11.0 g/dL 🌐 Haemodilution in pregnancy: Maternal physiological adaptation to pregnancy: plasma volume expansion exceeds the increase in red blood cell mass, resulting in functional hemodilution. There is a drop in the concentration of red blood cells, hemoglobin, and hematocrit. Hemodilution is most pronounced during second trimester. Hence, WHO sets a lower hemoglobin threshold for second trimester compared to the first and third. In third trimester, plasma volume continues to increase, but at a slower rate. The discrepancy between plasma and RBC mass narrows, and hemoglobin levels stabilize 👉 Severity of anaemia according to age group: https://notaperubatan.com/haemoglobin-hb-cutoffs/ Further reading: WHO Guideline on haemoglobin cutoffs to define anaemia in individuals and populations https://www.who.int/publications/i/item/9789240088542 #general@nota_perubatan