Act as Internalist 👨🏻‍⚕️🫀🩺

Clinical/biochemical features often present in patients with adrenal insufficiency Symptoms (often insidious) • Lethargy, fatigue, low mood • Anorexia, weight loss • Nausea and vomiting • Postural hypotension • Abdominal pain • Diarrhoea/constipation Physical signs • Pigmentation (palmar creases, mucous membranes) • Vitiligo • Postural hypotension • In Addisonian crisis: shock (low BP, reduced tissue perfusion), pyrexia, coma Blood • Hyponatraemia • Hyperkalaemia • Hypoglycaemia (fasting or spontaneous) • Hypercalcaemia • Anaemia • Normal anion gap metabolic acidosis (mild) Other • History of other autoimmune disorders

West Haven grading of hepatic encephalopathy Stage 0 No change in personality or behaviour No asterixis Stage 1 Impaired concentration and attention span Sleep disturbance, slurred speech Euphoria or depression Asterixis present Stage 2 Lethargy, drowsiness, apathy or aggression Disorientation, inappropriate behaviour, slurred speech Stage 3 Confusion and disorientation, bizarre behaviour Drowsiness or stupor Asterixis usually absent Stage 4 Comatose with no response to voice commands Minimal or absent response to painful stimuli

🫀 Anticoagulation After Prosthetic Valve Replacement — Quick Guide

🔵 MECHANICAL VALVES

💊 Warfarin = lifelong

• Mechanical AVR → Target INR 2.5 (2.0–3.0) • Mechanical MVR → Target INR 3.0 (2.5–3.5) • Mechanical AVR + MVR → Target INR 3.0 (2.5–3.5) • Mechanical TVR → Target INR 3.0 (2.5–3.5)

🚫 DOACs are NOT recommended in mechanical valves.

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🟢 BIOPROSTHETIC (BIOLOGICAL) VALVES

Usually no lifelong anticoagulation just because of the valve.

🔹 Surgical bioprosthetic AVR/MVR/TVR

→ Warfarin may be used for the first 3–6 months → Target INR 2.5 → Then usually aspirin 75–100 mg/day if there is no other indication for anticoagulation. ---

🟣 WHAT ABOUT DOACs?

✅ Bioprosthetic valve + AF:

DOACs can be used after 3 months in appropriate patients. ⚠️ During the first 3 months after surgery, VKA is generally preferred.

❌ Mechanical valve = NO DOACs

--- 🧠 اللي تفتكره

Mechanical → Warfarin lifelong Mechanical MVR → INR 3 Mechanical AVR → INR 2.5 Bioprosthetic → anticoagulation 3-6M Bioprosthetic + AF → DOAC can be considered after 3 months

فضلاً وليس أمرا شاركوا القناة مع الاخرين للاستفادة منها وحتى يستمر النشر والابداع.