Nota Perubatan

Category: Internal Medicine

  • Commonly Used Fluids in the Hospital

    IV Fluid Composition

    Intravenous Fluid Composition

    Reference table for common IV solutions. All concentrations are in mmol/L unless otherwise noted.

    Solution mOsm/L Glucose (g/L) Caloric value (kcal/L) NaCl Na⁺ Cl⁻ K⁺ Ca²⁺ Mg²⁺ Lactate ion Acetate ion Maleate ion Others
    Normal Saline (0.9%) 308 9 154 154 pH ≈ 5.5
    NaCl 3% 1026 513 513 pH ≈ 5
    Half saline (0.45%) 154 4.5 77 77
    Hartmann’s solution OR Ringer’s lactate 278 6 131 111 5 2 29 pH ≈ 6.5
    Dextrose 5% (D5%) 278 50 pH ≈ 4.3
    Dextrose 10% (D10%) 555 100 400 pH ≈ 4.3
    Dextrose 50% (D50%) 2523 500 pH ≈ 4.2
    NSD5% 585 50 200 9 154 (150) 154 (150) pH ≈ 4
    HSD5% 430 50 200 77 77 77 pH ≈ 4
    QSD1 OR 1/5 Saline D4.23% OR NaCl 0.18% D4.23% 296 42.3 170 31 (30.8) 31 (30.8)
    QSD10% OR 1/5 Saline D10% OR NaCl 0.18% D10% 615 100 400 1.8 31 (30) 31 (30)
    Sterofundin (1/1 E ISO) 304 (309) 6.8 140 127 4 2.5 1.0 24 5 pH 5.1 – 5.9
    Succinylated Gelatin 4% 274 154 120 Succinylated gelatin 40 g/L
    Mannitol 20% 1100 Mannitol 200 g/L
    pH 6.3
    Mannitol 10% 550 Mannitol 100 g/L
    pH 6.3

  • 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

  • Medical Ward Round Pop-up Questions for HO

    Here are just some of the questions that I encountered and still remembered. I will add on from time to time.

    1. How do you correct the potassium level of this patient?
    2. What are the ddx for bilateral lungs crepitations?
    3. Which artery supplies anterior circulation of the brain?
    4. What is lytic cocktail?
    5. Can you interpret this ECG?

    Not scary, but it will be more interesting if you know the answers. The discussion and input would be much more meaningful.

  • Acute Coronary Syndrom (ACS) – STEMI / NSTEMI / Unstable Angina

    Miscellaneous

  • NYHA Classification

    💎 Class I

    • No limitation of physical activity
    • Ordinary physical activity does not cause undue fatigue, palpitation or shortness of breath

    💎 Class II

    • Slight limitation of physical activity
    • Comfortable at rest
    • Ordinary physical activity results in fatigue, palpitation, shortness of breath or chest pain.

    💎 Class III

    • Marked limitation of physical activity
    • Comfortable at rest
    • Less than ordinary activity causes fatigue, palpitation, shortness of breath or chest pain

    💎 Class IV

    • Symptoms of heart failure at rest
    • Any physical activity causes further discomfort

    Examples of ordinary physical activities:

    • walking at moderate pace, light housework (e.g. sweeping floors), climbing a few flights of stairs,

    Examples of less than ordinary physical activities:

    • walking at slower pace, showering

  • Forrest Classification for Gastric Ulcers

    OGDS report of patient X (he was sent back from scope room to the ward): “Forrest 3 clean base ulcer at antrum and fundus…” — What is Forrest 3 ulcer? Is it dangerous?

    Forrest I
    • Ia: Spurting (rebleed risk without treatment = 85 – 100%)
    • Ib: Oozing (rebleed risk without treatment = 10 – 30%)

    Forrest II
    • IIa: Visible vessel (rebleed risk without treatment = 50 – 60%)
    • IIb: Adherent clot (rebleed risk without treatment = 25 – 35%)
    • IIc: Pigmented spot (rebleed risk without treatment = <8%)

    Forrest III
    • III: Clean base (rebleed risk without treatment = <5%)

  • Dengue

    Miscellaneous

    Let’s learn dengue from our ID Physicians. Upon completion of the course, you will get a certificate of completion as well, use your real name. https://www.openlearning.com/courses/dengue-training-for-secondary-care

  • Helicobacter Pylori (H. Pylori) Infection

    Eradication Therapy ⭐️

    Proton-pump inhibitor

    • T Esomeprazole (Nexium®) 40mg OD for 6weeks, or
    • T Pantoprazole 40mg BD for 2 weeks, then 40mg OD for 4 weeks

    Antibiotics

    • T Amoxicillin 1g BD for 2 weeks + T Clarythromycin 500mg BD 2 weeks

  • Killip Classification

    Killip 1:

    • No clinical signs of heart failure

    Killip II: Mild heart failure

    • Crepitations heard at lower third / less of the lungs
    • Elevated JVP
    • S3 heart sound

    Killip III

    • Frank acute pulmonary oedema: crepitations heard more than one-third of the chest

    Killip IV Cardiogenic shock + pulmonary oedema

    • Hypotension (SBP <90 mmHg)
    • Evidence of peripheral vasoconstriction (oliguria, cyanosis, sweating)
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