HyperKalemia VS HypoKalemia

* Normal Serum  K⁺ : 3.5 - 5.0 mmol/L 

Metabolic Syndrome

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I always forget the criteria to diagnose Metabolic Syndrome as I thought it is not much important, but nowadays... the incidence of Metabolic Syndrome is keep increasing as as result of Obesity and some other factors.... So you guys please remember this, I'm sure your lecturer going to ask about this quite often...

Cushing Syndrome

* Clinical syndrome resulting from excess circulating glucocorticoid

Causes
1) Exogenous: Steroid Toxicity (Tx for Nephrotic, SLE, JRA, IBD) 
2) Endogenous : Adrenal CA/Adenoma, CAH, Cushing disease, Ectopic-ACTH

Head-to-Toe Examination ---> Mainly for Exogenous Cause (as a cause for CS)

1) General
    - Orange on stick appearance
    - Central Obesity
    - Hyperpigmentation (ACTH-dep)

2) Face
    - Moon Face, Plethoric Face, Acne, Hirsuitism, Frontal balding (female)

3) Eyes
    - Cataract, Papilloedema (funduscopy)

5) Oral
    - Candidiasis

4) Back
    - Dorsal fat pad, Vertebaral tenderness (osteoporosis)
    - Neck: Skin Infxn

5) Arms
   - Bruises, Thin skin, Skin Infxn (folds area), prox m/s wasting
   - Test for Prox Myopathy

6) Fingers
   - Bad ungual infection

7)) Abdomen
   - Central Obesity, Striae (purple/red), Scar (any reason)
   - Palpate --> Epigastric tenderness (>> steroid usage --> PUD)
   - Check for Ascites

8) Legs
    - Bruises, Thin skin, Thin limbs, Prox m/s wasting
    - Palpate for leg edema also
    - Test for Prox Myopathy

9) Complete with
    - BP --> HPT
    - RBS/ Dipstick --> DM
    - Weight & Height --> Growth Failure
    - Ask Hx of Long Steroid Tx
    - Any Bony pain/ patho# --> Osteoporosis

Graphic presentation of Cushing Syndrome

Principle Management of Nephrotic Syndrome

1) Confirm Diagnosis
    - Fulfill the criteria: 
        > 1g/m²/day urine protein, Albumin < 25g/L, Gen Edema
    - Exclude secondary causes ---> 
        Infection (Hep B, HIV. Malaria), Malignancy (Lymphoma, Leukemia), CTD (SLE)


2) General Measures
    - Control Edema --->
       Normal protein & less salt diet, +/- Frusemide with caution  (ROF in Chronic Edema) 
    - Asses Hemodynamic (Hypo/Hypervolemia) --->
       Daily Nephrotic Chart & I/O Chart
    - Penicillin V Prophylaxis ---> Dose according to age

3) General Advice
    - Nature of disease -->
       Most will relaspe (85%-95%) - Consult Dr if Pro 2+ in 3 conseq days/ edema+
       Mostly idiopathic, Not affect renal fx
    - Home dipstick monitoring --> Once daily at early morning 
    - Tx option & its Cx -->
       Long Term Steroid, Cushing's, Immunocompromised (avoid infectious contact)
    - Immunization : Pneumococcal Vaccine -->
       Give during remission

4) Specific Tx for Primary Nephrotic Syndrome 
    - Long Term Corticosteroid or
    - Cyclophosphamide --> For frequent relapse/ Steroid dependent 
    - Steroid Resistant --> Renal biopsy (specific Tx depend on HPE) + supportive 

5) Manage Cx of Nephrotic Syndrome/ Cx of the Tx (if any)
    - Hypovolemia --> Tx: Human Albumin fast infusion
    - Spont Bacterial Peritonitis --> Tx: IV C. Pen + 3rd Gen Cephalosporin
    - Thrombosis --> Prophylaxis

    - Cushing's Syndrome --> Tx: Taper down steroid/ change to Cyclophosphamide 
    - Immunocompromised --> 
       Immunization, avoid infectious contact, fever come to hospital
    - Acute Adrenal Crisis --> when udergone stress TX : HCT/ Prednisolone 
    - Loosing protein --> Muscle Wasting Tx: advice on diet (high calorie) 

Clubbing: Causes

CLUBBING CAUSES:..................CLUBBING

• Cyanotic heart disease
• Lung disease (hypoxia, lung cancer, bronchiectasis, cystic fibrosis)
• UC/Crohn's disease
• Biliary cirrhosis
• Birth defect (harmless)
• Infective endocarditis
• Neoplasm (esp. Hodgkins)
• GI malabsorption

Sequence of Elevated Enzyme Post-MI

"C-AST-Le" (CASTLE):

• CK-MB.... first
• AST......... second
• LDH......... third
• *Also: can use the last 'E' for ESR.

Respiratory Failure

* mintak maaf kualiti gambar kurang memuaskan tapi yg penting still boleh baca kan....

Carpal Tunnel Syndrome : Causes

Mnemonic is MEDIAN TRAP

• Myxoedema
• Edema premenstrually
• Diabetes
• Idiopathic
• Agromegaly
• Neoplasm

• Trauma
• Rheumatoid arthritis
• Amyloidosis
• Pregnancy

Preparation for Blood Transfusion

* Patient already agreed for blood transfusion 

1) Prepare blood product: make sure same blood for same pt
2) Put patient on large branula
3) Give N/S 1st - to check the patency of branula
4) VSx check : esp Temperature & BP (pre-tx)
5) Get Transfusion set (w/out filter)
6) check VSx again (post-Tx)
7) Stand there for 10 mins to monitor any:
        Acute Tx Reaction (Fever, Hypotension, Flushing, Urticaria, dark urine)
        Mx: Stop transfusion, give IV HCT, Anti-Histamine, once resolve cont transfuse slowly
8) Give diuretics in between 1 pint to another 1
9) Repeat FBC post-Tx   


~credit to Dr Muna~

Management of DVT

1) Diagnosis of DVT by:

1. Clinical Probability (Hx, PE)
2. U/S Doppler
3. D- Dimer 

2) Management of DVT (Hep-Warfarin Therapy)

1. Exclude Pul Embolism; Clinical: Hemoptysis, Tachycardia, Ix: ECG, CXR, ABG, CTPA
2. Blood Ix (for DVT) : FBC, PT/APTT, baseline INR & APTT ratio, Thrombophilia Screening 
3. Start Heparin
• UFH - Loading dose 5000 U bolus, then 1000 U/HR by IVI, Monitor APTT ratio 6 HRly aim 2-3 (and change accordingly)
• LMWH - No need monitoring (give S/C)
4. START Warfarin D2 (aim INR: 2-3)
5. STOP Heparin when INR > 2 x 2 consecutive days (Combination of Hep-Warfarin at least 5 days)
6. Take DAILY INR for 1st week
7. Maintenance Dose Warfarin ~ 2-10 mg/d
8. Duration of Warfarin:

• Idiopathic: 6 month
• Recurrent: 6 month - 1 yr  

3) Find Underlying Causes 

4) Combined with Mechanical Tx of DVT

• TED Stocking : minimize post-thrombotic event 
• PhysioTx/ Encourage Mobility