Chronic Kidney Disease (CKD)

 

Individualize BP-lowering therapy and treatment targets in people with frailty, high risk of falls, very

 limited life expectancy, or symptomatic postural hypotension.

Treatments that delay progression of CKD with a strong evidence base include RASi and SGLT2i. In

 people with CKD and heart failure, SGLT2i confer benefits irrespective of albuminuria.

Initial dips in eGFR are expected following initiation of hemodynamically active therapies, including both

 RASI and SGLT2i. GFR reductions of ≥30% from baseline exceed the expected variability and warrant

 evaluation.

CKD is not a contraindication to an invasive strategy for people with acute or unstable heart disease.

 Imaging studies are not necessarily contraindicated in people with CKD and the risks and benefits should

 be determined on an individual basis.

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Radio-opaque shadows on ABDOMINAL X-RAY

• A substance is more radiopaque if it contains atoms of high atomic number (AN) such as calcium, iodine, barium, or lead.
• Bone, which contains calcium (AN 20), is more radiopaque than soft tissue, which is made up mostly of carbon (AN 6), hydrogen (AN 1), and oxygen (AN 8). 
• Iodine (AN 53) is the key constituent of radiocontrast material and lead (AN 82) is an effective barrier to x-rays.

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What Do You See

The eye is very complex and contains various tissues and structures that work together to provide vision.

 Eye problems can range from benign, self-resolving processes to malignant, and possibly metastatic

 tumors. Eye disorders can be caused by various factors, resulting in various signs and symptoms. They

 can be as trivial as minor irritation or pain all the way to blurred vision or blindness. Strabismus is a

 visual disorder in which the eyes are misaligned and point in different directions. When the eyes are

 misaligned, typically one eye will fixate on objects of interest while the other eye turns in (esotropia), out

 (exotropia), down (hypotropia), or up (hypertropia).

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Management of DM in Patients With CKD

• Monitor for changes in BP, serum creatinine, & serum K+ within 2–4 weeks of initiation or increase in the dose of an ACEi or ARB. 

• Continue ACEi or ARB therapy unless serum creatinine rises by > 30% within 4 weeks following initiation of treatment or an increase in dose.

• FDA recommends, metformin should NOT be used with serum creatinine ≥ 1.5 mg/dl in men & ≥ 1.4 mg/dl in women or with decreased creatinine clearance in people > 80.

• Recommended is treating patients with T2D, CKD, & an eGFR ≥ 30 ml/min per 1.73 m2 with metformin.

ADA/KDIGO Consensus Statements:

All patients with Type 1 diabetes or Type 2 diabetes and CKD should be treated with a

comprehensive plan, outlined and agreed by health care professionals and the patient 

together, to optimize nutrition, exercise, smoking cessation, and weight, upon which are

layered evidence-based pharmacologic therapies  aimed at preserving organ function and 

other therapies selected to attain intermediate targets for glycemia, blood pressure, and lipids.

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Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS)

Myocardial Infarction:

Classified into 5 types based on etiology and circumstances:

• Type 1: Spontaneous MI caused by ischemia due to a primary coronary event (eg, plaque rupture, erosion, or fissuring; coronary dissection).
• Type 2: Ischemia due to increased oxygen demand (eg, hypertension), or decreased supply (eg, coronary artery spasm or embolism, arrhythmia, hypotension).
• Type 3: Related to sudden unexpected cardiac death. 
• Type 4a: Associated with percutaneous coronary intervention (signs and symptoms of myocardial infarction with cTn values > 5 × 99th percentile URL). 
• Type 4b: Associated with documented stent thrombosis. 
• Type 5: Associated with coronary artery bypass grafting (signs and symptoms of myocardial infarction with cTn values > 10 × 99th percentile URL).

Infarct location

• Right ventricular infarction usually results from obstruction of the right coronary or a dominant left circumflex artery; it is characterized by high RV filling pressure, often with severe tricuspid regurgitation and reduced cardiac output.
• An inferoposterior infarction causes some degree of RV dysfunction in about half of patients and causes hemodynamic abnormality in 10 to 15%. RV dysfunction should be considered in any patient who has inferoposterior infarction and elevated jugular venous pressure with hypotension or shock. RV infarction complicating LV infarction significantly increases mortality risk.
• Anterior infarcts tend to be larger and result in a worse prognosis than inferoposterior infarcts. They are usually due to left coronary artery obstruction, especially in the anterior descending artery; inferoposterior infarcts reflect right coronary or dominant left circumflex artery obstruction.

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Acute Cholangitis

Legend says that Cholangitis was first defined in 1877 by Jean-Martin Charcot, at which time the

 pathognomonic triad of fever, right upper quadrant pain, and jaundice was described. Today, cholangitis is

 defined as the presence of increased hepatic intraductal pressure with a concurrent infection of the

 obstructed bile.

Chole: Derived from the Greek word “cholē” meaning bile.

Angio: Comes from the Greek “angeion” meaning vessel.

Cholangitis: Bacterial infection of the biliary tree.

The pathogens identified as causative agents of acute ascending cholangitis are gram-negative and

 anaerobic organisms, the most common including Escherichia coli, Klebsiella, Enterobacter,

 Pseudomonas, and Citrobacter.  

Iatrogenic introduction of bacteria commonly occurs post- ERCP in individuals with biliary obstruction.

Charcot triad has a high specificity (95.9%), while sensitivity is low (26.4%).

Tokyo guidelines (2018) have a sensitivity of 100% and specificity of 87.4%.

 

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Pseudo- Conditions in Medicine

 

The term ‘pseudo’ means ‘false’, ‘pretended’, ‘unreal’, or ‘sham’. Likely to be of Greek

origin, pseudes means false. There are a number of ‘pseudo’ terms and syndromes that we see

in the common practice. Even though the meaning of pseudo is unreal or sham, however

several medical conditions/ syndromes are true entities as described above.

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Acute Pulmonary Embolism

"D" sign:

In a physiologically normal heart, LV pressure > RV pressure. When viewing heart in a parasternal short

 axis during systole the LV maintains a circular appearance, bowing the intraventricular septum into the

 right ventricle. A D-shaped left ventricle or flattening of the interventricular septum with a D-shaped

 configuration is a feature described with significant RV overload / right heart strain such as that occurring

 with complications of a sizable pulmonary embolic event.

McConnell's sign:

An echocardiographic finding of segmental right ventricular wall‐motion abnormality with apical sparing,

 is highly specific in acute pulmonary embolism and may guide rapid intervention when other testing is

 not feasible.

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Thyroid storm

 

Thyroid storm is a rare and life-threatening condition characterized by an acute exacerbation of

 thyrotoxicosis (elevated free triiodothyronine or free thyroxine and suppressed thyrotropin) with severe

 clinical symptoms. It often results in multiorgan failure involving one or more organ systems such as the

 central nervous, cardiac, hepatic, pulmonary, respiratory, digestive, and gastrointestinal excretory

 systems.

Specific Strategic Steps for Treatment

• Therapy to control increased adrenergic tone: Beta-blocker
• Therapy to reduce thyroid hormone synthesis: Thionamide
• Therapy to reduce the release of thyroid hormone: Iodine solution
• Therapy to block peripheral conversion of T4 to T3: Iodinated radiocontrast agent, glucocorticoid, PTU, propranolol
• Therapy to reduce enterohepatic recycling of thyroid hormone: Bile acid sequestrant

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Urinalysis & Urine Sodium

     

Theophilus Protospatharius, a seventh-century physician who wrote the first manuscript focused

 exclusively on urine called "De Urinis", determined heating urine would precipitate proteins,

 documenting proteinuria as a disease state. French scholar named Gilles de Corbeil (12th century)

 classified 20 different types of urine, recording differences in urine sediment and color and introduced the

 "matula," a glass vessel in which a physician could assess color, consistency, and clarity.

Following includes the complete analysis of urine:

Visual exam

• Color. 

• Clarity

Dipstick test

• Acidity (urine pH). 

• Bilirubin. 

• Blood (hemoglobin). 

• Glucose. 

• Ketones

• Leukocyte esterase.

• Nitrites. 

• Protein

• Urine specific gravity test. 

Microscopic exam

• Crystals. 

• Epithelial cells. 

• Bacteria, yeast and parasites (infections). 

• Red blood cells (RBC). 

• Urinary casts: 

• White blood cells 

Fractional excretion of Sodium (FE Na).

• [(U Na x P Cr) / (P Na x U Cr)] x 100
• U = Urine, P = Plasma, Cr = Creatinine, Na = Sodium.
• Re-absorption and filtration accounted (Both).
• Should not be used with normal renal function.

Acute Kidney Injury (AKI)

• FE Na < 1%
• Urine sodium < 20 mEq/L.

Acute Tubular Necrosis (ATN)

• FE Na > 2%
• Urine sodium > 40 mEq/L.

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Capnography

CAPNOGRAPHY V/S PULSE OXIMETRYCAPNOGRAPHY 

• Provides a measure of ventilation – or concentration of CO2 exhaled air
• (aka end tidal CO2 or etCO2).
• Not effected by supplemental oxygen.
• Reflects breath-to-breath ventilation.
• Appear not normal if the patient has stopped breathing.
• Apnea or hypoventilation is detected immediately by capnography

PULSE OXIMETRY 

• Measures oxygenation or arterial blood oxygen saturation & pulse rate.
• Detects oxygen deficiency (hypoxia).
• May appear normal even if the patient has stopped breathing.
• Takes time to detect Apnea or hypoventilation.

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Hypoglycemia

Hypoglycemia In Diabetics

Type 1 DM/Type 2 DM,
Kidney disease: insulin not cleared out of circulation well.
Medications for Diabetic.

More frequently:
Meglitinides, 
Sulfonylureas,
Insulin 
Very infrequently:
Metformin,
GLP-receptor agonists,
SGLT-2, and 
DPP-4 inhibitor

Hypoglycemia In Non-Diabetics:

Hormonal dysfunction             

Addison's disease

Hypopituitarism

Non-B cell tumors.

Post-gastric bypass

Insulinomas.

Drugs: 

NSAID’s, phenylbutazone, propoxyphene,  

Quinine 

Lithium, TCA, chlorpromazine,   

Fluoxetine, sertraline,

ACE-inhibitors, arbs, beta-blockers.

Levofloxacin, trimethoprim-sulfamethoxazole, 

Mifepristone, 

Heparin

Mercaptopurine.

Haloperidol, pentamidine, 

Disopyramide, 

isoniazid, methotrexate, 

fenfluramine, thiazide diuretics,        

Opioid analgesic tramadol.

                                                          

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