Nota Perubatan

An important lesson learned today: Newly discovered thrombocytopaenia without bleeding should not automatically prompt platelet transfusion. Identifying the underlying cause is more important, particularly in new-onset thrombocytopaenia. A peripheral blood film is a useful early investigation and may provide important diagnostic clues. Some causes of thrombocytopaenia, such as thrombotic thrombocytopaenic purpura (TTP), generally contraindicate platelet transfusion as it may worsen thrombosis, unless there is life-threatening bleeding. #GIM@nota_perubatan #ED@nota_perubatan

"60 years old female with history of recurrent stroke,  admitted for orthostatic pneumonia. She is unable to speak since few years ago after stroke. On day 3 of admission, informed by staff nurse the patient has persistent elevated blood pressure. Abdominal examination by the attending doctor noted suprapubic distension. Urinary cathether was inserted and about 1 liter of urine was drained. BP subsequently was back to normal." We always encounter patients with elevated blood pressure in the ward. What are some of the very common inpatient causes that need to be considered? - Pain - Agitation / Delirium - Respiratory distress - Acute urinary retention - Sleep deprivation - Chronic hypertension-related (hypertensive urgency / hypertensive emergency / undiagnosed hypertension / anti-hypertensive not yet restarted in the ward) - Medications e.g. inotropes infusion Learning points: - Touch. Always attend and assess the patient thoroughly to identify the possible causes of elevated BP.  - Not all elevated BP requires anti-hypertensive in the first place. Always identify and treat the main cause. For example, if pain is the main problem, treat pain with analgesia then reassess BP and symptoms. - Remember to document the assessment findings, what had been given and the management plan in the case notes. No documentation = never done. @nota_perubatan

𝐉𝐎𝐌 𝐒𝐄𝐑𝐓𝐀𝐈 𝐊𝐀𝐌𝐈 𝐌𝐈𝐍𝐆𝐆𝐔 𝐈𝐍𝐈! Seksyen HIV/STI/Hepatitis C, Jabatan Kesihatan Negeri Sarawak akan menganjurkan Webinar dengan topik ‘𝐸𝑣𝑒𝑟𝑦𝑡ℎ𝑖𝑛𝑔 𝑌𝑜𝑢 𝑁𝑒𝑒𝑑 𝑓𝑜𝑟 𝑆𝑇𝐼 𝐶𝑎𝑠𝑒 (𝐹𝑖𝑟𝑠𝑡 𝑉𝑖𝑠𝑖𝑡)’ oleh Dr Lim Han Hua, Pakar Perubatan Penyakit Berjangkit, Hospital Umum Sarawak. Tarikh: 26 Februari 2025(Khamis) Masa: 2.30 petang-3:30 petang FB JKN Sarawak

Inhaler education is a pivotal role of pharmacists and other HCPs. Inhaler technique errors are highly prevalent and have been documented in up to 90% of patients. These errors, especially critical inhaler errors, are associated with poor disease control, adverse clinical outcomes, and increased burden on the healthcare cost. At JKK Farmasi Respiratori, Amalan & Perkembangan Farmasi, KKM, we recognise the magnitude of this issue. In response, we are proud to present our validated national inhaler education videos. After two years of dedicated work, from storyboard development and filming to editing; the project has finally been completed. We are pleased to announce that all nine inhaler technique videos are now available: MDI : https://youtu.be/XoxVZ0InJjE?si=hL6Kpf4GrVdaaEm4 Spacer with mouthpiece: https://youtu.be/voskihsx6Fk?si=KiS-HjS2o-MmerGq Spacer with facemask: https://youtu.be/CeXpwhD1-eU?si=qg33Jk8cvvbOy1J2 Turbuhaler : https://youtu.be/Uu2wuxEJ5VE?si=nYWxBCeyZ9ENiuRz Accuhaler: https://youtu.be/bCOrmH8SPGw?si=sACT1Vtd8AM3I21k Ellipta: https://youtu.be/SuL0w7pRt9Q?si=Kp-GRFoDdr3TLya4 Breezhaler: https://youtu.be/vEs1SB3pgrw?si=ULwthaJakmI1CN8e Nexthaler: https://youtu.be/OTMiyDZVgB8?si=ePdGyDO3KyPiBDeg Respimat: https://youtu.be/BidjblaNH3s?si=Y1z6wv6BwsL7GhFB We would like to express our sincere appreciation to our collaborator, the Malaysian Thoracic Society (MTS). Special thanks also go to my hardworking JKK members, and the PUB team, KKM, whose commitment made this project possible. Thank you for your continuous support. Sincerely, Dr Jaya Muneswarao, PhD Pegawai Farmasi, Hospital Pulau Pinang Pengerusi Jawatankuasa Kerja Farmasi Klinikal (Pengkhususan Farmasi Respiratori), KKM Shared from https://www.facebook.com/share/16rG5omYwW/ #medications

Post-transfusion haemoglobin level (in transfusion-dependent Thalassaemia) (i) What is the target? 👉🏻 13.5 – 15.5 g/dL (ii) When to take the FBC sample? 👉🏻 1 hour after transfusion Further reading: Handbook on Clinical Use of Blood (3rd ED, 2020), page 137 #GIM@nota_perubatan

"14 years old male with underlying Beta Thalassaemia major on regular monthly packed cell transfusion at Thalassaemia Daycare clinic in the hospital. He has a massive splenomegaly, causing intermittent abdominal discomfort." Have you been wondering when should a Thalassaemia patient undergo splenomegaly? Indication for splenectomy (in Thalassaemia): • Packed cell transfusion requirement >200 - 250 mL/kg/year and severe iron overload could not be adequately controlled with iron chelation. [average blood transfusion requirement in transfusion dependent Thalassaemia is ≈180 mL/kg/year] • Evidence of hypersplenism (persisting anaemia, leucopenia and thrombocytopenia) • Massive splenomegaly that crosses umbilicus causing discomfort and risk of infarct or rupture from trauma However, splenomegaly is not performed routinely in thalassaemia patients especially in a child <5 years old due to risk of sepsis and thromboembolism. Splenomegaly in Thalassaemia is due to excessive destruction of red blood cells and extramedullary hematopoiesis. Extramedullary hematopoiesis could be significantly reduced by optimal blood transfusion and iron chelation. Hence, pre-transfusion haemoglobin in transfusion dependent thalassaemia should be kept between 9 - 10 g/dL. Those with heart disease and clinical evidence of extramedullary haematopoiesis should have higher target of pre-transfusion haemoglobin — 11 - 12 g/dL. Further reading: CPG Management of Thalassaemia (2nd ED, 2024) #GIM@nota_perubatan

Iron chelation therapy in thalassaemia When to start iron chelation therapy in thalassaemia patients? Is this patient having iron overload? 🔸 Transfusion-dependent thalassaemia - All patients with iron overload, i.e. serum ferritin >1000 ng/mL on two occasions at least two weeks apart, should be started on iron chelation therapy - Target: serum ferritin <1000 ng/mL, liver iron concentration (LIC) <7 mg Fe/g dw and cardiac T2* >20 ms. 🔹Non-transfusion dependent thalassaemia - Iron chelators should be started at ≥10 years of age if liver iron concentration (LIC) ≥5 mg Fe/g dw OR serum ferritin ≥800 ng/mL - Iron chelators should be temporarily discontinued when liver iron concentration (LIC) ≤3 mg Fe/g dw OR serum ferritin ≤300 ng/mL Footnotes: - Optimisation of iron chelation therapy is important to prevent and treat multiorgan complications of iron overload in thalassaemia patients. - Iron chelators should be started after discussion with a paediatrician / physician / haematologist - Liver iron concentration is measured from MRI Further reading: CPG Management of Thalassaemia (2nd ED, 2024) #GIM@nota_perubatan

Advanced care planning (ACP) a guide for healthcare practitioners in Malaysia (August 2024) #guidelines@nota_perubatan

Job list in a medical ward Here are some typical tasks in a medical ward. You can organise them into a job list in whatever style that suits you. - Blood taking - Branula insertion - New case clerking - Discharge / KIV discharge - PM review / Post HD review - Imaging request - Procedure - Referral - Trace lab result / radiology report / old notes - X-ray - etc. #houseman@nota_perubatan

Job list / Task list “At 3.30 pm, while flipping through the case notes of patient X, I realised that I had not requested an inpatient USG KUB for the severe AKI (the plan was given during the morning round). I quickly ran to the Radiology Department to request the inpatient scan. Luckily, it was granted on the same day, and I was asked to inform the ward staff to send the patient immediately to the Radiology Department for the USG KUB.” I encountered this situation a few years ago, when I was working as a new HO in the medical ward. Having a job list in hand is important to guide us to work systematically. It provides a big picture of the pending, ongoing, or completed tasks, especially in hectic situations. We can also prioritise the tasks accordingly based on the job list. Another example of teamwork is when one colleague is presenting during the ward round with the specialist, while another colleague from another cubicle helps to jot down the tasks given. By the time the ward round finishes, everyone can focus on the task list instead of spending time flipping through the case notes multiple times. Basically, there are two different styles of job lists, depending on your personal preference. You can either group the tasks into different types or categories, or have a list of patients and jot down the tasks under each patient. Or, if you’re a legend or there are not many tasks, you can just keep the list in your mind. 😂 #houseman@nota_perubatan

How to start Syr Morphine for severe and persistent cancer pain? Aim to give regular dose (4 hourly) plus PRN dose for additional breakthrough pain - PRN dose is similar to regular dose (example: Syr Morphine 5 mg 4 hourly + 5 mg PRN) 🍀Syr Morphine (natural opioids) - Immediate release formulation - Preparation: usually 2 mg per mL solution - Onset of action: 30 minutes - Peak action: 60 minutes after administration - Duration of action: 4 hours - Bluebook prescriber category: B (can be prescribed by Medical Officer) - Prescribe in mg (not mL) to avoid confusion. 🍀Steps: - Start at 5 mg 4 hourly and 5 mg PRN - Calculate total morphine usage after 24 hours (regular dose + additional PRN doses used) - Divide total dose by 6 to get the new 4 hourly dose - Always remember to prescribe regular dose + PRN dose for syr Morphine Remarks: - In patients with renal impairment, the dose should be reduced or interval between doses should be increased - In elderly, start with lower dose — 2.5 mg 4 - 6 hourly instead of 5 mg 4 hourly 🍀Example: Patient X was started on Syr Morphine 5 mg 4 hourly with Syr Morphine 5 mg PRN. He required 3 PRN doses of syr Morphine over the past 24 hours. Total morphine required over 24 hours: (5 mg × 6) + (5 mg × 3) = 30 + 15 = 45 mg New 4 hourly dose: 45 ÷ 6 = 7.5 mg 👉 New prescription: Syr morphine 7.5 mg 4 hourly and 7.5 mg PRN Further reading: - CPG management of cancer pain (2nd ED, page 21) - Handbook of palliative medicine in Malaysia (1st ED, page 18) #Medications@nota_perubatan

How to remove a pigtail catheter Have you ever tried to remove a pigtail catheter for the first time and it just wouldn’t come out? It feels stuck no matter how hard you try, until a more senior doctor comes over and shows you where to cut. 😅 Pigtail catheters have a coiled tip that anchors the catheter internally. Many also have a locking mechanism (usually a suture), that must be released before removal. Steps in removing a pigtail catheter: - Prepare sterile equipment: gloves, scissors / blade, dressing set / disposable sterile set, saline - Unlock the pigtail: cut the suture at the hub that holds the coil (refer the video below) - Withdraw the pigtail catheter gently, while applying counter-pressure to stabilize the skin around the exit site - Inspect the tip of the pigtail catheter to ensure the full pigtail catheter is intact. - Apply a sterile occlusive dressing. - Watch for signs of infection or leakage ⚠️ Never pull a pigtail catheter with force. Always unlock the coil first. Pulling with force can cause severe pain, tissue trauma or bleeding and risk of retained catheter fragments if the catheter breaks. https://youtu.be/Jc1DKoC4rYQ?si=W5Plf46Q_OrTzGqs #Surgery@nota_perubatan #GIM@nota_perubatan

Localizing Myocardial Infarction via ECG Leads ECG leads correspond to specific regions of the heart: 🔹Septal MI: V1, V2 🔹Anterior MI: V3, V4 🔹Lateral MI: I, aVL, V5, V6 🔹Inferior MI: II, III, aVF 🔹Posterior MI: reciprocal changes in V1–V3 (typically manifests as ST depression, tall R waves and an upright T wave) Sometimes, myocardial infarction may extend beyond a single region. • Example: ST changes in V3–V4 (anterior) plus I, aVL, V5–V6 (lateral) suggest an anterolateral MI. ===== In certain circumstances, we will also perform posterior ECG and / or right-sided ECG, addition to the standard 12-lead ECG. When to do a posterior ECG (V7–V9)? 🥕 If posterior wall involvement is suspected, especially when inferior or lateral STEMI shows ST depression in V1–V3 (highly suggestive when combined with upright T waves and tall R waves) *Cut-off for posterior leads ST elevation: ≥0.5 mm in V7–V9 (≥1 mm for men <40 years). When to do a right-sided ECG (V3R–V6R; V4R is a sensitive marker for right ventricular infarction)? 🥕 Right-sided ECG is done especially if inferior STEMI (up to 40 – 50% of inferior MI have RV involvement). Those patients with right ventricular infarction may also have hypotension due to impaired right heart function. Related posts: ▶️ ECG leads placement https://t.me/nota_perubatan/1573 ▶️ Have you heard of the mnemonic PAILS in interpreting ECG for ACS? https://t.me/nota_perubatan/1181 #ECG@nota_perubatan #ED@nota_perubatan

Some causes of hyponatraemia 🍏 Hypotonic hyponatraemia (i) Hypovolemic hypotonic hyponatraemia - Extrarenal loss (urine sodium <20 mmol/L): vomiting, diarrhoea, haemorrhage, burns, 3rd space loss - Renal loss (urine sodium >20 mmol/L): osmotic diuresis, diuretics, salt-losing nephritis (e.g. post-obstructive uropathy, polycystic kidney disease), adrenal insufficiency (ii) Euvolemic hypotonic hyponatraemia - SIADH - Hypothyroidism - Psychogenic polydipsia - Drugs that mimic ADH action: desmopressin, oxytocin (iii) Hypervolemic hypotonic hyponatraemia - Cardiac failure - Liver cirrhosis - Nephrotic syndrome 🍏 Hypertonic hyponatraemia - Hyperglycaemia - Mannitol 🍏 Pseudohyponatraemia - Hyperlipidaemia - Hyperproteinaemia Related posts: ▶️ Corrected sodium level in hyperglycaemia https://t.me/nota_perubatan/614 #GIM@nota_perubatan #ED@nota_perubatan