Nota Perubatan

Author: notaperubatan

  • Hypokalaemia

    “Dr., this patient X has hypokalaemia, potassium 2.5. Can I fast correct with IV KCl 2g stat?”

    Introduction

    • Normal range of serum potassium: 3.5 – 5.1 mmol/L
    • Severity of hypokalaemia:
      • Mild: 3.1 – 3.5 mmol/L -> oral potassium supplement, then repeat RP tomorrow
      • Moderate: 2.5 – 3 mmol/L -> ECG + consider fast correction with IV KCl, then repeat serum potassium after 1 hour
        • ±IV KCl maintenance in drip / oral supplementation
      • Severe: <2.5 mmol/L -> ECG + fast correction with IV KCl, then repeat serum potassium after 1 hour
        • ±IV KCl maintenance in drip / oral supplementation

    *There is no fixed rule on the treatment. Treatment must be aligned with clinical judgement.

    Calculation of potassium deficit & requirement

    (i) Potassium deficit

    Potassium deficit (g) = [(4 – current potassium level) × 0.4 × bodyweight]/13.4]

    • 1 g KCl contains 13.4 mmol potassium & 13.4 mmol chloride (as shown in the picture above)
    • 1 vial = 10 mL KCl = 1 g KCl

    (ii) Potassium requirement

    Potassium daily requirement (g) = 1 mmol/kg/day

    Example

    Patient X, weight 60kg, serum potassium 2.5 mmol/L

    • Deficit: [(4 – 2.5) x 0.4 x 60] / 13.4 = 2.68 g
    • Daily requirement: 1 x 60 / 13.4 g = 4.47 g
    • Correction of deficit: fast correct with IV KCl 2g in 200 mL NS over 2 hours
      • Repeat serum potassium post correction
    • Daily requirement:
      • If the patient is on IV drip maintenance e.g. 4 pints NS / 24 hours, may add 1g KCl in each pint NS (the calculated requirement is 4.47 g per day. Hence 1g in each pint is applicable.)
      • If the patient is not on IV drip and having good oral intake, add oral potassium supplement (e.g. Tab Slow K 1.2 g TDS for 3 days), and encourage oral intake

    Medications for hypokalaemia

    • Intravenous – IV KCl, examples of administration:
      • IV KCl 1g in 100 mL NS over 1 hour
      • IV KCl 2g in 200 mL NS over 2 hours
    • Oral:
      • Tab Slow K e.g. 1.2 g TDS
      • Mist KCl e.g. 15 mL TDS

  • Hyperkalaemia

    Introduction

    • Normal range of serum potassium: 3.5 – 5.1 mmol/L
    • Severity of hyperkalaemia:
      • Mild: 5.5 – 5.9 mmol/L
      • Moderate: 6 – 6.4 mmol/L
      • Severe: ≥6.5 mmol/L
    • One very common cause of ‘hyperkalaemia’ is lysed sample. Remeber to check lab formal report whether there is any documentation regarding lysed sample. In that case, it is better to repeat RP / potassium first before starting treatment for the ‘hyperkalaemia’.
    • Not all hyperkalaemia cases require fast correction with lytic cocktail!
    • Moderate / Severe hyperkalaemia warrants fast correction, but also depends on clinical condition

    Lytic cocktail regime

    • IV Calcium gluconate 10% over 10 minutes (ideally attach with cardiac monitor during administration), then
    • IV Dextrose 50% 50 mL , then
    • IV Actrapid 10 units (1 mL)

    Repeat serum potassium 1 hour post lytic cocktail, may require repeated lytic cocktail / urgent haemodialysis if persistent severe hyperkalaemia

    Oral Kalimate

    • Dose example: PO Kalimate 15 g TDS for 3 days
    • Do not give oral Kalimate for long term due to risk of bowel necrosis

    Flowchart of emergency management of hyperkalaemia

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

  • Hypercalcaemia

    “49 years old man, no known medical illness, presented with lethargy for 3 weeks, loss of appetite for 2 weeks, and constipation for 3 days. At ED, noted corrected serum calcium 3.98 mmol/L”

    Introduction

    • Normal range of serum calcium: 2.1 – 2.65 mmol/L
    • Severe hypercalcaemia = Serum calcium >3.5 mmol/L
    • Acute therapy is warranted if serum calcium >3 mmol/L or severe symptoms
    • Patients with severe hy[ercalcaemia are usually dehydrated during initial presentation

    Investigations

    (i) Initial investigations

    • FBC, RP, Ca, Mg, PO4
    • LFT (look for ALP level)
    • Thyroid function test
    • iPTH (intact parathyroid hormone)

    (ii) Other investigations to be considered

    • If suspect PTB / TB related hypercalcaemia: CXR, Sputum AFP x1, x2, x3; Sputum MTB GeneXpert
    • If suspect malignancy (e.g. multiple myeloma): urine protein electrophoresis, serum protein electrophoresis, skeletal survey, full blood picture,
    • KUB X-rays, KUB USG e.g. if AKI not resolving despite on hydration — TRO obstructive uropathy

    Acute therapy of severe hypercalcaemia

    1) Hyperhydration

    • Initially 300 – 500 mL normal saline over 1 hour, sometimes up to 10 – 20 mL/kg over 1 hour
    • Followed by 3 – 4L (=6 – 8 pints) normal saline over 24 hours
    • Correct electrolyte abnormality e.g. IV KCl maintenance / fast correction for hypokalaemia; IV MgSO4 for hypomagnesaemia
    • Hyperhydration with 3 – 4L normal saline over 24 hours can be given for 2 – 3 days, depending on clinical response and assessment
      • The patient must be reassessed (e.g. after 24 hours of fluid) to determine whether fluid can be titrated down or maintained. Check input/output balance, RP, and electrolytes.
      • How much fluid to be given depends on patient’s hydration status (e.g. from IVC diameter & collapsibility; presence of GI loss, amount of oral intake, urine output; CVP monitoring if available), haemodynamic status (BP, HR), and whether patient having fluid restriction (e.g. CCF, ESRF)
    • Normal saline helps to restore extracellular fluid (i.e. rehydrate the patient) and to promote calcium excretion (Na competitively inhibits renal tubular absorption of Ca)

    2) Diuretics

    • IV Frusemide 20 – 40 mg TDS
    • DO NOT use thiazides which can reduce calcium excretion
    • IV Frusemide helps to prevent fluid overload and to further promote calcium excretion

    3) Bisphosphonates

    Examples:

    • Zoledronate (Zometa®): IV Zoledronate 4 mg over at least 15 minutes (agent of choice for malignancy-associated hypercalcaemia because it’s more potent and effective than pamidronate)
    • Pamidronate: IV Pamidronate 30 mg / 60 mg / 90 mg in 1L normal saline over 4 – 6 hours.
      • Action starts after several days and lasts for weeks to months
      • Example dose: 30 mg for Ca <3 mmol/L, 60 mg for Ca 3 – 3.4 mmol/L, 90 mg for Ca >3.4 mmol/L)
    • Useful especially if suspect hypercalcaemia due to malignancy. Bisphosphonates work by inhibiting bone resorption.
    • Prescriber category: A* (must be discussed with specialist for initiation and dosage)
    • Treatment can be repeated if hypercalcaemia recurs (usually after 2 – 3 weeks)

    4) Treatment of underlying disease / cause

    Further reading

    • Sarawak Handbook of Medical Emergencies (4th edition)

  • Hypocalcaemia

    “Patient X, presented with fitting episode. Upon arrival at ED, blood taken shows serum calcium 1.4, albumin 40″

    Introduction

    • Normal range of serum calcium: 2.1 – 2.65 mmol/L
    • Fast correction is indicated if the patient is symptomatic or if hypocalcaemia is severe e.g. <1.8 mmol/L

    Correction of severe / acute symptomatic hypocalcaemia:

    Fast correction, followed by infusion

    (i) Fast correction

    • IV calcium gluconate 10% 10 mL over 10 minutes

    (ii) IV infusion of Calcium gluconate 10%

    • Rate: 1 mg elemental calcium/kg/hr // 0.5 – 2 mg/kg/hr
    • Dilute 50 mL (i.e. 5 vials) of Calcium gluconate 10% into 400 mL of D5% or normal saline -> final volume = 450 mL -> 1mg/mL of elemental calcium solution
    • For example, a 70 kg patient requiring 1 mg/kg/hr of elemental calcium will need 70 mL of infusion per hour
    • Correct hypomagnesaemia if present.
    • Treat underlying cause

    Writing the instruction:

    1. Add 50 mL of Calcium gluconate 10% into 400 mL normal saline. Total volume = 450 mL = 1 mg/mL calcium.
    2. Run diluted IVI calcium gluconate 10% at 50 mL/hr*
    3. Repeat serum calcium after fast correction
    4. Monitor serum calcium and albumin levels 4 -6 hourly
    5. Aim corrected calcium level 2 – 2.25 mmol/L
    6. Correct hypomagnesaemia if present

    [*If the patient’s weight is 70 kg, 50 mL/hr = 0.71 mg/kg/hr (within the range of elemental calcium 0.5 – 1 mg/kg/hr)]

    [*If the patient has fluid restriction, e.g. ESRF consider to give half of the standard infusion e.g. 25 mL/hr]

    Notes

    • 1 mL calcium gluconate 10% contains ≈9 mg // 0.23 mmol of elemental calcium
    • Avoid dilution in fluid that contains calcium, such as Hartmann’s solution
    • Cardiac monitoring during calcium infusion. Stop calcium infusion if bradycardia is present
    • Prolonged QTc is an ECG finding in hypocalcaemia
    • Side effects of calcium infusion: bradycardia, heart block, may precipitate digoxin induced cardiotoxicity

    Further reading:

    • Sarawak Handbook of Medical Emergencies 4th ED (7.16)

  • As a House Officer, How to Cope with the Posting You Don’t Like

    Sometimes you might encounter a posting you don’t enjoy. In fact, many HOs, even the most hardworking or ‘capable’ ones, struggle in certain departments. It might be due to long hours, steep learning curves, unsupportive colleagues, or simply because the specialty doesn’t align with your interests. Regardless, every posting must be completed — so the real question is: how to cope and survive it without burning out?

    Shift the mindset: from “endurance” to “learning”

    Instead of counting down days, try reframing the posting as an opportunity to gain skills that may not seem valuable now but will matter later, especially when you become a Medical Officer (MO).

    Ask yourself: “What can I pick up here that will be useful for me as an MO?” Even if you dislike the environment, the skills and resilience you build will follow you throughout your career.

    Even if you dislike the environment, the skills and resilience you build will follow you throughout your career.

    Build small support systems

    Surviving a tough posting is much easier with allies.

    • Connect with fellow HOs —cover each other when possible.
    • Identify approachable MOs or specialists who are willing to teach.
    • Keep in touch with friends or family outside the hospital for emotional balance.

    A strong support system prevents you from feeling isolated.

    Take care of your basics

    When the workload feels overwhelming, neglecting yourself makes it worse.

    • Sleep whenever you can — even a short nap helps if you are too tired. Click here for the sharing related to sleep & post-call fatigue.
    • Eat proper meals — don’t rely solely on caffeine and snacks.
    • Exercise lightly — even 10 minutes of stretching or a short walk helps release stress.
      Your body is your strongest asset during HOship — don’t burn it out too early.

    Separate work from self-worth

    Some postings come with harsh words, constant scolding, or unrealistic demands. It’s easy to internalize this and feel like you’re not good enough. Learn from feedback, but don’t let toxic comments define you.

    Create small wins

    Instead of waiting for the posting to end, look for daily victories:

    • A patient you managed well.
    • A skill you performed better than yesterday.
    • A day you went home earlier than expected.
      Celebrating small wins gives you momentum to keep going.

    Keep the bigger picture in mind

    HOship is temporary. Six postings may feel long, but once you’ve completed them, you’ll never have to go back. Remind yourself: this is just a phase. Every day survived is one day closer to finishing.

    Not every posting will suit your personality or future goals. But each one shapes you into a more capable, resilient doctor. Instead of seeing the “difficult posting” as wasted time, treat it as training for grit, adaptability, and survival — qualities every good doctor needs.

    If you’re struggling, know this: you’re not alone, and it will get better.

  • Every Day is a Learning Day, Make Yourself Better Than Yesterday

    Life as a doctor, or even just as a human being, is never about instant perfection. It’s about progress. If we make it our goal to be just a little better than who we were yesterday, we will eventually look back and see how far we’ve come.

    Growth comes in small steps

    Becoming better doesn’t mean giant leaps every day. It often means small, consistent steps. For example:

    • Yesterday, you might have missed an important detail during ward round. Today, you make the effort to double-check your notes and present more confidently.
    • Yesterday, you might have been unsure about interpreting an ECG. Today, you take time review and learn from your seniors.
    • Yesterday, you struggled to take blood after two attempts. Today, you adjust your technique, stay calmer, and manage to get it on the first try.
    • Yesterday, you had difficulty inserting a branula and needed help from a colleague. Today, you prepare better, take your time, and succeed independently
    • Yesterday, you filled up the imaging request form but missed some clinical details. Today, you include a clearer history and justification, making it easier for radiology to accept your request.
    • Yesterday, you felt nervous when referring a case and struggled to give a clear summary. Today, you organize your thoughts, present the case systematically, and the referral goes much smoother.

    These small changes may not seem dramatic in the moment, but over weeks and months, they build into noticeable growth.

    When we view every day as a learning day, we stop being afraid of imperfection. Instead, we start valuing progress.

    It’s easy to compare ourselves with peers — who is faster, smarter, or more confident. But the real competition is not with others; it’s with ourselves. Ask: Am I better today than I was yesterday? If the answer is yes, even in the smallest way, then you are moving in the right direction.

    Becoming better than yesterday doesn’t happen overnight. It happens one choice, one action, one lesson at a time. Every day we get a chance to improve — whether in knowledge, skills, or attitude. So take each day as an opportunity. Make the effort to grow, even just a little. Because if you learn something new every day, you will always be moving forward.

  • 5 Good Attitudes Every Junior Doctor Should Have

    Starting life as a junior doctor is both exciting and overwhelming. The transition from medical school to housemanship or MOship is a big leap. Beyond medical knowledge, what truly shapes our growth — and how others perceive us — is our attitude.

    Be humble

    No matter how well you did in medical school, housemanship is a different ballgame. Be willing to learn, ask questions, and accept feedback — even if it feels uncomfortable at times. Humility allows you to grow faster and gain the respect of your seniors and colleagues.

    Be responsible and reliable

    Patients’ lives depend on us. As junior doctors, it’s crucial to take responsibility for your tasks — from updating case notes to following up on laboratory results. If you’re unsure, seek help early. Reliability builds trust, not just with your team but also with patients.

    Be punctual

    Time is important in medicine — not just for you, but for your whole team and your patients. Being punctual shows respect for others and responsibility for your role. Arriving on time for ward rounds, clinics, or on-call handovers allows work to run smoothly and prevents unnecessary delays in patient care

    Respect and empathy for everyone

    Good attitude isn’t only about how you treat seniors, but also how you treat nurses, allied health staff, cleaners, and patients’ families. Respect is universal — and empathy reminds us that medicine is not only science, but also humanity.

    Be adaptable and willing to grow

    You’ll rotate through multiple departments, sometimes far from your comfort zone, or sometimes being rotated to the department(s) that you are not interested at all. Instead of resisting, embrace the change. Every posting, every environment, teaches you something different — from clinical skills to teamwork and resilience.

    With the right attitude — humble, responsible, positive, respectful, and adaptable — you will not only survive, but also grow into the kind of doctors that patients trust and colleagues respect.

  • The Grass Isn’t Always Greener on the Other Side

    We often look at other paths and wonder if they’re better than where we stand today. Private practice, overseas opportunities, or even exploring a field outside medicine — all of these can look like “greener pastures” when our current situation feels dry and exhausting. But here’s the truth: the grass is rarely greener on the other side. It only looks greener because we are standing at a distance. Once we step closer, we see that it has its own weeds, its own dry patches, and its own struggles.

    The illusion of “better elsewhere”

    It’s easy to think going for private practice will bring instant happiness, moving overseas will guarantee a better lifestyle, or switching to a different industry will be a perfect escape. Yet every path comes with its own challenges — workload, expectations, uncertainties, and sacrifices. What seems easier from afar is often just different, not necessarily better. The allure of “greener pastures” can be powerful. But before uprooting everything, it’s worth asking: Have I truly nurtured the soil I’m standing on?

    Where the grass truly becomes greener?

    The reality is this: the grass is always greener where you choose to water it. When you invest in your current situation — learning, adapting, building relationships, and making the best out of what you have — that’s when things start to bloom. If you take the time to grow despite in a difficult situation, the opportunities for progress will eventually reveal themselves. Developing resilience and adaptability, which will serve you well no matter where you go later.

    Watering your own grass and your own growth

    If you water your own grass with effort, patience, and consistency, you may find that your patch of ground — no matter how ordinary it seemed at first — becomes greener than you ever imagined. Remember to invest in self-growth. Take courses, seek mentorship, initiate projects that excite you.

    Before looking at the other side and wishing for what it seems to offer, ask yourself: Am I watering the grass where I am now?

    The truth is, private practice, overseas jobs, or even alternative careers might or might not suit you — but they all come with their own struggles. What matters most is how much effort you put into the ground beneath your feet. Because in the end, the grass is not greener on the other side. It’s greener where you choose to water it.

  • The Comfort Zone

    The transition from House Officer to floating Medical Officer

    After completing housemanship, most of us will step into the role of floating Medical Officers — often within the same hospital where we trained. The environment feels familiar, the colleagues are known, and the system is predictable. It is a safe place to begin, and in many ways, a comforting one.

    One day, the posting letter comes. Suddenly, we are placed far away from our hometown, family, and the place we once called our training ground. The comfort of the familiar is replaced by the discomfort of distance. Often, we don’t get to decide where we work. Instead, we follow the postings assigned to us and move wherever we are needed. It feels daunting, even unfair at times — why am I the one being posted so far away?

    The discomfort of distance

    Being placed far from home brings its own struggles. Everything feels heavier without family nearby. Festive seasons carry a quiet loneliness. Even small things — favorite food stalls, familiar roads, childhood friends — suddenly become distant memories.

    The hidden opportunities

    Yet, behind the discomfort lies opportunity. A new hospital means new working environment, new colleagues, and learning practices that suit the local setting. Each environment exposes us to different patient demographics, healthcare challenges, and systems of work. The learning curve is steep when posted to a non-specialist district hospital. I found myself re-learning important basics from different departments — skills and knowledge we had long left behind during Housemanship. It was a necessary step, not only to adapt well, but also to become as competent as possible in serving a district hospital. I believe, these broaden our skills, sharpen our adaptability, and strengthen our confidence.

    And perhaps most importantly: we might discover our true interest, and even hidden talents.

    During Housemanship, life was too hectic, too rushed. We were focused only on surviving the day and completing tasks. But as young MOs in a new place, we now have some breathing space to observe, explore, and ask ourselves: Which field excites me? What am I naturally good at? Where do I feel most alive?

    The interests and talents we uncover now will guide our future decisions — whether it is entering a master’s program, becoming a specialist, or pursuing as a subject matter expert in the field we love.

    Discovering the beauty of people

    Another hidden blessing of being placed far away is discovering the kindness of strangers. When I worked in a different place, I was touched by how the staff treated me like family. They were always friendly, never made me feel like an outsider, often shared food, and even celebrated my departure when I had to leave.

    Experiences like these remind us that although we may be far from home, we are never truly alone. There are good people everywhere — waiting to connect, support, and journey with us.

    Growth beyond comfort

    Staying forever in one place may feel safe, but it can also keep us stagnant. Growth comes from movement, exploration, and facing the unknown. Being placed far from home may seem like a setback at first, but in reality, it is a gift — a push towards growth we might never choose for ourselves. It is definitely not punishment, but preparation for us to progress further.

    So if you find yourself far from your comfort zone, don’t despair. Embrace it as an opportunity — to grow, to discover your interests, and to shape your future. You are still young, and this could be the turning point that eventually leads you to the field you love, the expertise you build, and the career you are meant to have.

  • When Misfortune Is a Sign of Fortune

    When you think you’re unfortunate, you may be more fortunate than you realize

    It is natural for us to sometimes feel weighed down by life’s struggles. We may look at our challenges—be it financial burdens, health concerns, family conflicts, or career setbacks—and think, “Why is life so unfair to me?” In those moments, it is easy to label ourselves as unfortunate.

    But pause for a while. Step back, and you may realize: even in hardship, you are still more fortunate than many others.

    The hidden perspective

    Someone who worries about bills may still have a roof over their head, while countless others sleep without shelter. A person feeling exhausted from work has, at the very least, a job—something many are still praying for. Even those who complain about their health may still be able to walk, speak, or see, while others struggle daily with permanent disabilities.

    This is not to dismiss your struggles, but to remind you that fortune is not only measured by what you lack—it is also found in what you already have.

    Gratitude as strength

    This isn’t about guilt-tripping ourselves into feeling better. Pain is valid. Struggles are real. But gratitude offers a lens—not to erase hardship, but to soften its edges. It reminds us that even in darkness, there are flickers of light. Think of someone who has lost everything in a natural disaster. Or a child growing up without access to clean water. Or a refugee fleeing violence with no certainty of tomorrow. These are not abstract examples—they are real lives unfolding right now. And yet, many of these individuals still find moments of joy, resilience, and hope.

    Everyone has their own cross

    No life is free of difficulty. What looks like a “perfect life” from afar often hides silent battles. When you compare your life to others, you may see only what you don’t have, not what they are enduring behind closed doors. Your challenges may feel heavy, but they could be lighter compared to the unseen burdens of someone else.

    Choosing to see fortune

    Being “fortunate” is not only about wealth, success, or comfort. Sometimes, it is as simple as being alive, having loved ones who care, or the ability to hope. By choosing to recognize this, you turn feelings of misfortune into opportunities for growth, empathy, and resilience.

    A gentle reminder

    So, the next time you feel the weight of misfortune, take a moment to pause. Look around you and acknowledge the silent blessings that form the foundation of your life. The roof, the food, the safety, the health—these are not small things. They are the bedrock of a fortunate existence. Recognizing this doesn’t diminish your struggles, but it does place them in a proper perspective, allowing for a deeper sense of gratitude and resilience.

+