Nota Perubatan

Author: notaperubatan

  • Haemorrhagic Stroke

    Estimating Intracranial Bleed (ICB)

    Principles of Management

    A. Medical Management

    (1) BP control
    “In patients with hyperacute (<6 hours) intracerebral haemorrhage, we suggest lowering blood pressure to below 140mmHg (and to keep it above 110mmHg) to reduce haematoma expansion.” — European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage 2021

    • Aggressive lowering of BP to less than 140 mmHg has no change in mortality but there is improved functional outcome

    (2) Anti-epileptics

    • Patients presented with seizures should be treated with anti-epileptics
    • No role of prophylactic antiepileptics
    • Consider EEG if the altered mental status is out of proportion with the imaging findings / brain injury

    (3) Sugar control

    • Target: 5- 8 mmol/L
    • Avoid hyper / hypoglycaemia. Hyperglycaemia is associated with worse morbidity and mortality.

    (4) DVT prophylaxis

    • Mechanical: intermittent pneumatic cuff is better than TED stocking
    • Chemical prophylaxis (i.e. anticoagulant): If the clot is stable, may start unfractionated heparin / LMWH within 48 hours of haemorrhagic stroke
    • Proven DVT / PE should be treated

    Note: Fever is an independent prognostic factor for poor outcome [ref]

    B. Surgical Management

    GENERAL INDICATIONS OF SURGICAL INTERVENTION — Craniotomy & Evacuation of clot:

    • Clot volume more than 30 mL. However, clot >60 mL + GCS <8 is not recommended for surgical intervention. (30-day mortality >90% (https://www.sciencedirect.com)
    • Midline shift more than 5 mm
    • Lobar haemorrhage within 1 cm with clot >30 mL
    • Rapid deterioration
    • GCS 6 – 12. Motor score >3
    • Significant mass effect due to edema, causing raised ICP or neurological deficit

    Notes

    • Management is often case to case basis
    • Gold standard of diagnosis of haemorrhagic stroke is via CT brain plain

    Case Presentation and Highlights

    “60 years old male, with underlying hypertension, defaulted follow-up for >2 years. Upon arrival at ED, GCS E1V1M1, BP 220/130 mmHg. The patient was intubated to secure airway and sent for CT brain. CT brain image shows large right basal ganglia bleeding with midline shift”

    1) Before referring neurosurgery, we can calculate the clot volume first. Sometimes the initial questions being asked by Neurosurgical team when they picked up phone call would be GCS on arrival & clot volume from CT brain.

    2) By reading the GENERAL INDICATIONS OF SURGICAL INTERVENTION — Craniotomy & Evacuation of clot, we can roughly know whether the case is suitable for surgical intervention.

    • The definitive management is decided by Neurosurgical team

    Keywords: intracranial bleeding (ICB)

  • Target INR and Duration of Anticoagulation for Certain Cases

    “60 years old male, with underlying HFrEF He presented with shortness of breath and bilateral lower limbs swelling for 1 week. Formal Echocardiogram done during current admission shows apical clot at left ventricule with size of 3.8 cm2. The patient was concerned regarding the duration of warfarin.”

    🌵 Atrial fibrillation
    Target INR: 2 – 3
    Duration: life-long

    🌵 Mural thrombosis — left ventricular, post-MI
    Target INR: 2 – 3
    Duration: 3 – 6 months, then reassess (e.g. via Echocardiogram)

    🌵 VTE & recovered without sequelae (1st episode, idiopathic / unprovoked)
    Target INR: 2 – 3
    Duration 3 – 6 months

    🌵 VTE & recovered with sequelae (1st episode, idiopathic / unprovoked)
    Target INR: 2 – 3
    Duration: 3 – 6 months, probably life-long after reassessment of the risks and benefits of continuing lifelong

    🌵 VTE (1st episode, provoked — inherited thrombophilia, anti-phospholipid syndrome, malignancy)
    Target INR: 2 – 3
    Duration: at least 3 months, probably life-long or till risk factor resolved

    🌵 Mechanical bileaflet or tilting disc prosthetic heart valve
    Target INR: 2.5 – 3.5
    Duration: life-long

    🌵 Mechanical caged ball or caged disc prosthetic heart valve
    Target INR: 3 – 4
    Duration: life-long

    Further Reading

    1. Sarawak Handbook of Medical Emergencies 4th ED

  • Furosemide

    Adverse Effects

    Ototoxicity

    Illustrated example: “A 58-year-old male with underlying HFrEF and chronic kidney disease stage 4, presented with acute decompensated CCF. He was started with IV furosemide for rapid diuresis. On day 3 of admission, he complained of decline in hearing, with on and off tinnitus.”

    Furosemide is a commonly used medication in patients with fluid overload. However it can lead to ototoxicity especially in:
    ⛽️ Very high dose of furosemide (e.g. IV Furosemide >240 mg/hour)
    ⛽️ Lower doses of furosemide (e.g. IV Furosemide 80 – 160 mg/hour) but concurrent use of other ototoxins such as aminoglycosides (e.g. gentamicin, amikacin) OR with impaired kidney functions (i.e. AKI / CKD)

    The hearing disorder can be transient / permanent

    Mechanisms of ototoxicity
    ⛽️ Furosemide interferes with the ion transport mechanisms in the cochlea, particularly affecting the stria vascularis, which is responsible for maintaining the ionic balance necessary for hearing

    Other adverse effects of furosemide

    ⛽️ Hyponatraemia
    ⛽️ Hypokalaemia
    ⛽️ Hypotension
    ⛽️ Hyperuricaemia
    ⛽️ Metabolic alkalosis

    Hence, we should be more aware if the patients in the ward reporting hearing disturbances while on furosemide treatment. Reduce the dose of furosemide if higher doses are not necessary.

    Miscellaneous

    • Furosemide (Lasix®) vial: 10 mg/mL. Example: IVI Lasix 0.5 mL/hr = 5 mg/hr = 120 mg/day = 40 mg TDS
    • Furosemide 40 mg is equivalent to bumetanide 1 mg. At higher bumetanide doses, this ratio falls. Bumetanide is usually used only if the patient is unresponsive to furosemide.

    References / Further Readings

    1. Loop diuretics: Dosing and major side effects (https://www.uptodate.com/contents/loop-diuretics-dosing-and-major-side-effects)

    Keywords: frusemide, lasix

  • List of Books / Guides for HOs

    Here is a non-exhaustive list of guidebooks and references suitable for HOs that I know of. I read many of them during my HOship.

    🌼 Medical Department

    🌼 O&G Department

    Note: for O&G it usually depends on which hospital you are working. Different hospitals have their respective O&G department protocol which could be slightly different from the others

    🌼 Orthopaedics

    • Guidelines for House Officer Orthopaedic Department Hospital Melaka*
    • x-ray interpretation for orthopaedic house officer*

    🌼 Surgery

    • Johor Bahru manual of surgery*

    🌼 Paediatric Department

    • Paediatric Protocol 4th ED 2019 (https://t.me/nota_perubatan/709)
    • Alia’s Illustrated Extra Notes to Neonatal Jaundice*
    • Alia’s Illustrated Extra Notes to Total Fluid Intake*

    🌼 Emergency Department

    • Guide to Essentials in Emergency Medicine, 3rd Edition* (By Shirley Ooi et al)
    • Dengue in emergencies* (by HKL Emergency & Tramatology Department)
    • ETD protocol / Medication dilution protocol in respective ETD
    • Tintinalli’S Emergency Medicine Manual, Eighth Edition* (for those who would like to study deeper in Emergency Medicine)

    🌼 Anesthetic

    • Basic Anaesthesia Handbook (UiTM Press)*

    🌼 Primary care (Klinik Kesihatan)

    • Common Clinical Problems In Primary Care: A Quick Guide (2022)*

    🌼 Hospital Ampang HO Guide (for various departments)

    🌼 Medicorp

    https://medicorp.onpay.my/order/form/bookstore (CPG Made Easy, HO Log Books Compilations, Clinical Skills Guidebook, Nebulizer Pocket Book of Adult Dosages & Normal Values)

    Clinical Skills, Episiotomy Repair & Suturing Workshop
    https://medicorp.onpay.my/order/form/clinicalskillsuturing_workshop

    I’m not sure whether there is still online courses for various departments like last time. I think can contact Dr @DrIlianaMohamad for enquiries

    🌼 Others

    • Alia’s Illustrated Extra Notes to Performing Physical* (for those who are not familiar with proper physical examinations — important for end posting examination short cases)

    *Book titles that can be searched at Shopee / bookstores

  • Medications – Generic Names & Brand Names

    Generic NameBrand Name

    Ampicillin / Sulbactam

    Unasyn

    Apixaban

    Eliquis

    Cefoperazone

    Cefobid

    Ceftazidime

    Fortum

    Ceftriaxone

    Rocephine

    Co-amoxiclav

    Augmentin

    DIazepam

    Valium

    Levetiracetam

    Keppra

    Rivaroxaban

    Xarelto

    Sodium valproate

    Epilim

  • Training Pathways

    O&G
    https://m.youtube.com/watch?v=WOcC31N8bbQ

    Surgery
    https://m.youtube.com/watch?v=5glYoN81hLc

    Internal Medicine
    https://m.youtube.com/watch?v=rM5J-ZzENCg

    Paediatrics
    https://m.youtube.com/watch?v=6pwn_ZNCLz0

    Orthopaedics
    https://m.youtube.com/watch?v=zZbpBdTq1Xk

    Emergency Medicine
    https://m.youtube.com/watch?v=59xoXugUxU

    Credit: Newcastle University Medicine Malaysia Youtube Channel

    ======

    MMED / MRCP / MRCPH / MRCOG
    https://pagalavan.com/education/for-future-doctors-housemanship-medical-officer-and-postgraduate-training-part-3/

  • Cephalosporin

    First Generation

    • Cefazolin
    • Cefalexin

    Second Generation

    • Cefuroxime
    • Cefoxitin

    Third Generation

    • Cefoperazone (Cefobid)
    • Ceftazidime (Fortum)
    • Ceftriaxone (Rocephine)

    Fourth Generation

    • Cefepime

    Fifth Generation

    • Ceftaroline

  • Houseman is the Most Important Person during Ward Round!

    You have to know your patients well, especially the presentation, diagnosis, and progress. If your MO is the first day he / she came today and not understanding the case, you are the one who will present to your MO, then specialist.

    The investigation that you traced and printed out / wrote on the investigation chart will be read by MO and specialists, to decide on management.

    You are the one who will usually document MO / specialist’s plan during ward round

    Your documentation will be read by staff nurses as well as allied healh professionals (physiotherapist, occupational therapist, dietitian, pharmacist etc.) for their case management

    You have to make sure documentation is correct and eligible to avoid error

    (HO is not the least important, but the MOST IMPORTANT person during ward round. Imagine if the HO in charge is suddenly not available, the ward round would become haywired and take longer than usual time to finish)

  • Tracing Investigation Results as HO

    ❗️The rules of tracing investigations (for newbies)❗️

    1. Learn to trace

    • Which system to open? What is the ID / password? Where to trace?
    • Where to write the results? (typically in an investigation chart in respective wards)
    • Every investigation that you / other have sent need to be traced, to check whether the results are normal or abnornal

    2. Trace with knowledge

    • Need to know the normal values of each investigation (esp the basic investigations), which one is significant
    • Give priority to tracing investigation results for patients who are relatively unwell or unstable / post-surgery (e.g. severe or active bleeding, dehydrated, tachycardic, hypotensive)

    3. Trace with action

    • Do not shy away / do nothing / ignore if the result is abnornal
    • You can
      • Inform to MO or ward specialist for further management
      • Correct first, then inform your MO (e.g. hyperkalaemia, hypokalaemia)
      • Inform your plan to MO first, then take subsequent action accordingly
    • Urgency to inform – immediately? tomorrow morning? later during afternoon round?
      • Some repeated investigations if remains normal, no urgency to inform unless

    That’s all that I can think of.

    Conclusion: Trace every investigation sent, and take appropriate action on the result traced

    We are definitely not a clerk, doing all the paperworks, but this is our responsibility to our patients

    Importance of tracing investigation results – it will guide us what to do next for the patients

    One of the most important task / responsibility of a House Officer is to TRACE samples sent.
    (to further clarify my statement – tracing investigation results is the responsibility of every doctor who is treating his / her patients, regardless of whether you are an HO, MO or specialist)

    We are not decision maker; while still in training, we cannot make final decision for patients most of the time.

    HO’s job is to trace and update results once available, for the specialist / MO to make appropriate clinical decision.

    For example, “Patient X admitted for community acquired pneumonia. On day 4 of admission, he was clinically well and planned for discharge by specialist during ward round.” During the ward round, you highlighted that the blood C&S aerobic day 2 shows Gram Positive Cocci in clusters.

    Will this change the management? Yes

    • Because of this pending culture result, the patient will not be discharged, and the antibiotics will be continued until the final culture result is available.

  • I Met Two New Taggers Today During My Night Shift

    I met 2 new taggers today during my oncall (HO night shift)
    We introduced to each other first. Then, “What have you learned today? (just asking without any intention)”

    “Blood taking , ABG, blood C&S, how to review patient, how to fill in the lab form …etc”

    Me: “You are so lucky to learn so much today! 😃”

    Tagger HO: “But we haven’t taken blood today; we observe only… We will start taking tomorrow.”

    Me: “Okay, let me complete my oncall review first. If I have blood I will let you take if you want.”

    Remember, not all the time we have opportunity to only observe during the first day.

    During my FIRST day of life as HO in labour room, I was already asked by SN in-charge to do VE, blood taking, branula insertion etc., like I was already well trained to do all those procedures (of course not, it was my ‘day one of life’ as House Officer)

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