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🏥 Your 2nd Year Clinical Survival Guide

"Starting from Zero" - Everything You Need for Your First Hospital Posting

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PART 1 - THE MINDSET FIRST

• You show up every day
• You watch and ask questions
• You write things down and look them up that night
• You keep this guide updated as you learn new things

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PART 2 - THE 5 THINGS YOU NEED ON DAY 1

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PART 3 - THE MOST IMPORTANT SKILL - HISTORY TAKING (SOCRATES + SYSTEM)

The Universal History Format (use this for EVERY patient)

• "What brought you to hospital today?" - in patient's own words
• Write it as: "Fever for 3 days" or "Chest pain since morning"

• Any previous hospital admissions?
• Hypertension / Diabetes / Asthma / TB / Heart disease?
• Any previous surgeries?

• Current medications? Dosage?
• Any allergies? (especially drug allergies - ask this EVERY time)

• Parents/siblings with similar illness?
• Diabetes, hypertension, cancer in family?

• Smoking (pack-years = packs/day x years smoked)
• Alcohol (units/week)
• Occupation
• Living conditions (for infectious diseases)

• Go through each system briefly: any cough? bowel issues? urinary symptoms? etc.

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PART 4 - GENERAL EXAMINATION (What to check on EVERY patient)

The 4 Vitals - Check These First, Every Time

General Appearance - Look at the patient from the foot of the bed:

• Conscious? Alert? Confused?
• Comfortable or in distress?
• Pale, jaundiced, cyanosed?
• Well-nourished or malnourished?

Hands (examine first):

• Nails: clubbing, pallor (anemia), koilonychia, leukonychia
• Palms: palmar erythema, Dupuytren's contracture
• Pulse: rate, rhythm, character, volume

Eyes:

• Conjunctival pallor = anemia
• Scleral icterus = jaundice
• Xanthelasma = hyperlipidemia

Mouth:

• Central cyanosis (blue tongue) = hypoxia
• Tongue: smooth tongue = iron/B12 deficiency

Lymph nodes: always check neck, axilla, groin

Edema: press shin for 5 seconds - pitting or non-pitting?

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PART 5 - SYSTEM-BY-SYSTEM QUICK GUIDES

🫀 CARDIOVASCULAR (Heart)

1. Inspect: Visible pulsations, scars from surgery
2. JVP (Jugular Venous Pressure): look at neck veins, raised in heart failure
3. Palpate: Apex beat (normally 5th intercostal space, midclavicular line)
4. Auscultate with stethoscope - 4 areas:
   • Aortic: 2nd right intercostal space
   • Pulmonary: 2nd left intercostal space
   • Tricuspid: left lower sternal border
   • Mitral: apex (5th ICS, MCL)

• Heart Failure: breathlessness, bilateral leg edema, raised JVP, basal crackles
• Hypertension: often found by chance, check BP both arms
• MI (Heart Attack): crushing central chest pain radiating to left arm/jaw, diaphoresis (sweating)

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🫁 RESPIRATORY (Lungs)

• White/clear = viral, asthma
• Yellow/green = bacterial infection
• Rusty = pneumonia (lobar)
• Pink frothy = pulmonary edema
• Blood-stained = TB, cancer, PE

1. Inspect: Rate, work of breathing, use of accessory muscles, shape of chest
2. Tracheal position (normally midline - pushed away in effusion, pulled toward in collapse)
3. Expansion: Hands on chest - equal movement?
4. Percussion: Resonant (normal air), Dull (fluid/consolidation), Hyperresonant (pneumothorax)
5. Auscultation: Vesicular (normal), Bronchial (consolidation), Added sounds:
   • Crackles/crepitations = fluid (pneumonia, CCF)
   • Wheeze = airway narrowing (asthma, COPD)
   • Pleural rub = pleuritis

• Pneumonia: fever, cough, purulent sputum, dullness to percussion, bronchial breath sounds
• Asthma: wheeze, breathlessness, chest tightness, worse at night/with triggers
• TB: chronic cough >3 weeks, fever, night sweats, weight loss, hemoptysis

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🫃 ABDOMEN (GI)

1. Inspect: Distension, scars, visible veins (caput medusae = portal hypertension), pulsations
2. Auscultate FIRST (before palpating, otherwise bowel sounds change): Normal = gurgling every 5-10 sec; Absent = ileus/peritonitis; Tinkling = obstruction
3. Percuss: Liver dullness (right side), spleen dullness (left), shifting dullness = ascites
4. Palpate: Light then deep, watch patient's face for pain
   • Liver: start from right iliac fossa, move up
   • Spleen: start from right iliac fossa toward left hypochondrium
   • Renal angles: punch tenderness = kidney infection
   • Special signs: Murphy's (cholecystitis), McBurney's (appendicitis), Rovsing's (appendicitis)

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🧠 NEUROLOGY

• CN II: Visual acuity (read a chart)
• CN III/IV/VI: Eye movements ("follow my finger" - H pattern)
• CN V: Facial sensation
• CN VII: "Show your teeth, close your eyes tight, raise your eyebrows"
• CN IX/X: "Say ahh" - uvula midline?
• CN XII: Tongue out - midline?

1. Tone: passive movement of limb - normal/hypertonia/hypotonia
2. Power: grade 0-5 (0=no movement, 3=against gravity, 5=full normal)
3. Reflexes: use tendon hammer - knee jerk (L3/4), ankle jerk (S1), biceps (C5/6)
4. Sensation: light touch, pinprick
5. Coordination: finger-nose test, heel-shin test

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🍼 PEDIATRICS (Children)

• BCG: at birth (against TB)
• OPV + IPV: at birth, 6, 10, 14 weeks (polio)
• DTP (Penta): 6, 10, 14 weeks (diphtheria, tetanus, pertussis)
• MMR: 9-12 months (measles, mumps, rubella)

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👶 OBSTETRICS & GYNECOLOGY (OBG)

• G_P_A_ : Gravida (total pregnancies), Para (deliveries >28 wks), Abortion (<28 wks)
• LMP (Last Menstrual Period) - to calculate gestational age and EDD
• EDD (Expected Date of Delivery) = LMP + 9 months + 7 days (Naegele's rule)

• Blood pressure every visit (watch for preeclampsia - BP >140/90 after 20 weeks)
• Fundal height = gestational age in weeks (roughly)
• Fetal heart sounds: normal 110-160 bpm

• Eclampsia: seizures in pregnancy - give MgSO4
• PPH (Postpartum Hemorrhage): >500mL blood loss after delivery
• Cord prolapse: cord visible at vagina - emergency C-section

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PART 6 - IMPORTANT INVESTIGATIONS (Lab Values to Know)

CBC (Complete Blood Count)

LFT (Liver Function Tests)

KFT (Kidney Function Tests)

RBS/FBS (Blood Sugar)

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PART 7 - COMMON DRUGS YOU'LL SEE ON PRESCRIPTIONS

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PART 8 - WARD PRACTICAL SKILLS (Watch First, Then Practice)

1. IV cannulation - insert IV line into vein
2. Blood sample collection (venipuncture)
3. ABG (Arterial Blood Gas) - for respiratory patients
4. Urine catheter insertion (Foley's)
5. NG (Nasogastric) tube insertion
6. Measuring blood pressure manually
7. Reading ECG (electrocardiogram) - see below

ECG Reading - 5-Step Approach

1. Rate: Count big squares between two R waves, divide 300 by that number. Normal 60-100 bpm.
2. Rhythm: Regular or irregular? P wave before every QRS?
3. Axis: Normal = -30° to +90°
4. P waves: Present? Normal shape?
5. QRS + ST changes: Look for ST elevation (STEMI), ST depression (ischemia), Q waves (old MI), widened QRS (bundle branch block)

• PR interval: 0.12-0.20 sec (one big square)
• QRS: <0.12 sec (3 small squares)
• QT: <0.44 sec (adjusted for rate)

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PART 9 - HOW TO PRESENT A CASE (On Ward Rounds)

"This is [Mr/Mrs X], a [age]-year-old [male/female] who presented with [chief complaint] for [duration]. On history, [relevant positives and negatives]. On examination, vitals are [state vitals]. General examination revealed [findings]. Systemic examination of [relevant system] showed [findings]. Investigations showed [key results]. My impression is [diagnosis/differential]. The patient is currently on [treatment]."

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PART 10 - YOUR DAILY LEARNING ROUTINE (Do This Every Day)

Morning (Before Ward Rounds)

• Review the patients you are following from yesterday
• Look up ONE topic from yesterday that you didn't understand
• Know your patients' vitals from the nursing chart before rounds

During Ward Rounds

• Stand where you can see and hear clearly
• Write every unfamiliar term in your notebook
• Note what questions the senior doctor asks the patient
• Ask "What does that finding mean?" when you have a moment

Evening (After Posting)

• Pick ONE new topic you encountered today
• Read about it for 20-30 minutes from your textbook or notes
• Write a 5-line summary of what you learned
• Ask me (Orris) to explain anything you still don't understand

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PART 11 - DAILY TOPIC SCHEDULE (2-Week Rotation Starter)

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PART 12 - EMERGENCY SIGNS - CALL FOR HELP IMMEDIATELY

• Airway: patient unable to speak/gurgling sounds
• Breathing: RR >30 or <8, SpO2 <90%, severe labored breathing
• Circulation: BP <90/60, HR >130 or <40, cold clammy skin
• Disability: GCS dropping, new-onset seizure, unequal pupils
• Exposure: high fever >40°C, massive bleeding

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HOW TO USE THIS GUIDE GOING FORWARD

1. What department you're in
2. One condition or case you saw
3. One question you couldn't answer

• A focused explanation of that condition
• What to look for on examination
• What questions might be asked about it
• A 3-5 line summary to add to your notes

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❤️ CARDIAC MODULE - Complete Clinical Guide

For 2nd Year Students on Cardiology/Medicine Posting

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SECTION 1 - CARDIAC HISTORY TAKING

5 Key Cardiac Symptoms

• Rheumatic fever as a child? (causes valvular disease)
• Family history of sudden cardiac death or early heart disease?
• Smoking, diabetes, hypertension, high cholesterol? (risk factors)
• Previous heart attack or stents?

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SECTION 2 - CARDIOVASCULAR EXAMINATION (Step-by-Step)

THE SEQUENCE: Inspect → Palpate → Percuss → Auscultate

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STEP 1 - HANDS (Start here always)

1. Rate - count for 15 sec x 4 (normal 60-100 bpm)
2. Rhythm - regular or irregular? (irregular = AF - atrial fibrillation)
3. Character - normal / bounding (aortic regurgitation) / weak/thready (shock) / collapsing (AR)
4. Volume - normal / increased / decreased
5. Radio-radial delay - feel both wrists together (delay = aortic dissection, coarctation)
6. Radio-femoral delay - feel wrist + groin simultaneously (delay = coarctation of aorta)

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STEP 2 - BLOOD PRESSURE

• Measure both arms (difference >15 mmHg = subclavian stenosis or aortic dissection)
• Normal: <120/80 mmHg
• Hypertension: ≥140/90 mmHg
• Pulse pressure = Systolic - Diastolic (normal ~40 mmHg)
  • Wide pulse pressure (>60) = aortic regurgitation, thyrotoxicosis
  • Narrow pulse pressure (<25) = aortic stenosis, cardiac tamponade

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STEP 3 - FACE & EYES

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STEP 4 - JVP (Jugular Venous Pressure)

1. Patient at 45 degrees, head turned slightly left
2. Look at the right side of the neck - find the internal jugular vein (not the carotid - JVP has 2 waves, is non-pulsatile, and goes away when you press on it)
3. Normal = top of pulsation <4 cm above sternal angle

• Right heart failure
• Cardiac tamponade (with pulsus paradoxus)
• Superior vena cava obstruction
• Fluid overload

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STEP 5 - PRAECORDIUM (Chest)

• Scars: midline sternotomy scar = bypass surgery; left lateral = mitral valve surgery
• Visible pulsations: apex beat visible? Heaves?

• Apex beat: Normally at 5th intercostal space, midclavicular line
  • Displaced outward/downward = cardiomegaly (heart failure, dilated cardiomyopathy)
  • Tapping quality = mitral stenosis
  • Heaving/thrusting = left ventricular hypertrophy (hypertension, aortic stenosis)
• Parasternal heave: Place palm on left sternal border - heave felt = right ventricular enlargement
• Thrills: Palpable vibration = severe murmur present (like feeling a cat purr)

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STEP 6 - AUSCULTATION (The most important step)

         2nd Right ICS = AORTIC area (A)
         2nd Left ICS  = PULMONARY area (P)
Left sternal border    = TRICUSPID area (T)
      5th ICS, MCL     = MITRAL/Apex area (M)

• S1 (lub) = mitral + tricuspid valves CLOSING at start of systole
• S2 (dub) = aortic + pulmonary valves CLOSING at end of systole
• Listen: lub-DUB ... lub-DUB (S2 louder at base)

• S3 (lub-dub-ta): heard after S2, at apex - sign of heart FAILURE (volume overload)
• S4 (ta-lub-dub): heard before S1, at apex - sign of STIFF ventricle (hypertension, LVH)

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COMMON MURMURS TO KNOW

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STEP 7 - LUNGS (always do this after cardiac exam)

• Basal crackles (crepitations) at both lung bases = pulmonary edema from left heart failure
• Pleural effusion (stony dullness, absent breath sounds) = can be from heart failure

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STEP 8 - ABDOMEN & LEGS

• Hepatomegaly (enlarged liver): right heart failure causes liver congestion - tender liver
• Ascites: right heart failure (shifting dullness)
• Pitting edema: press shin/ankle for 5 seconds - indentation = pitting edema from heart failure, hypoalbuminemia

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SECTION 3 - MOST COMMON CONDITIONS YOU'LL SEE

1. HEART FAILURE

• ECG: may show LVH, old MI, arrhythmia
• Chest X-Ray (CXR): look for ABCDE:
  • A - Alveolar edema (bat-wing shadowing)
  • B - Kerley B lines (horizontal lines at bases)
  • C - Cardiomegaly (CTR >0.5)
  • D - Dilated upper lobe veins
  • E - Effusion (pleural)
• BNP/NT-proBNP: elevated in heart failure (best marker)
• Echo (TTE): measures ejection fraction - the GOLD STANDARD test

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2. HYPERTENSION

• Renal artery stenosis
• Pheochromocytoma (episodic headache, sweating, palpitations)
• Hyperaldosteronism (low potassium + high BP)
• Coarctation of aorta

• Heart: LVH, heart failure, IHD
• Eyes: hypertensive retinopathy (papilledema, AV nipping, flame hemorrhages)
• Aorta: dissection
• Deep kidneys: proteinuria, CKD
• Stroke/brain: hemorrhagic stroke, hypertensive encephalopathy

• Young patient: ACE inhibitor (Ramipril 2.5-10mg OD)
• Elderly/African: Calcium channel blocker (Amlodipine 5-10mg OD)
• With fluid overload: Thiazide diuretic (Hydrochlorothiazide 12.5-25mg OD)

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3. ISCHEMIC HEART DISEASE (IHD) / ANGINA / MI

Stable Angina → Unstable Angina → NSTEMI → STEMI
(chronic)           (ACS - Acute Coronary Syndrome)

• Sudden severe crushing/squeezing central chest pain
• Radiation to left arm, jaw, neck, back
• Sweating (diaphoresis), nausea, vomiting
• Breathlessness
• Sense of doom
• Note: Diabetics and elderly can have SILENT MI (no pain - just breathlessness, fatigue)

1. MONA (old mnemonic, still useful to know):
   • Morphine (for pain)
   • Oxygen (if SpO2 <94%)
   • Nitrates (GTN) - sublingual
   • Aspirin 300mg (chewed, not swallowed)
2. Dual antiplatelet: Aspirin + Clopidogrel (or Ticagrelor)
3. Reperfusion within 90 min: Primary PCI (angioplasty + stent) is GOLD STANDARD. If not available: thrombolysis (streptokinase or tPA)
4. Anticoagulation: Heparin
5. Long-term: Beta-blocker + ACEi + Statin + Dual antiplatelets

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4. ATRIAL FIBRILLATION (AF)

• No visible P waves (replaced by fibrillatory baseline - wavy line)
• Irregularly irregular QRS complexes
• Ventricular rate usually fast (100-180 bpm) if uncontrolled

• Pulmonary (PE, pneumonia)
• Ischaemia (MI)
• Rheumatic heart disease
• Alcohol / thyrotoxicosis
• Thyroid (hyperthyroidism - very common cause)
• Electrolytes (low K/Mg)
• Sepsis / surgery

1. Rate control: Beta-blocker (metoprolol) or Digoxin
2. Rhythm control: Cardioversion (electrical or chemical with amiodarone)
3. Anticoagulation to prevent stroke: Warfarin or DOACs (apixaban, rivaroxaban) - based on CHA₂DS₂-VASc score

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SECTION 4 - ECG INTERPRETATION (Step-by-Step System)

Step 1 - Check the basics

• Patient name, date, speed (25 mm/sec standard), calibration (1mV = 10mm)

Step 2 - Rate

• Regular rhythm: 300 ÷ number of large squares between R waves
• Irregular: count QRS complexes in 10-second strip × 6

Step 3 - Rhythm

• Is it regular or irregular?
• Is there a P wave before every QRS?
• Regular + P before every QRS = sinus rhythm ✓

Step 4 - Axis

Step 5 - P wave

• Present? Normal shape? Duration <0.12 sec? Positive in I and II?
• Absent = AF or junctional rhythm

Step 6 - PR interval

• Normal: 0.12-0.20 sec (3-5 small squares)
• Short (<0.12): WPW syndrome
• Prolonged (>0.20): 1st degree AV block
• Progressive lengthening then dropped beat: 2nd degree (Wenckebach)
• No relationship between P and QRS: 3rd degree (complete) heart block

Step 7 - QRS, ST, T waves

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SECTION 5 - IMPORTANT CARDIAC INVESTIGATIONS AT A GLANCE

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SECTION 6 - CARDIAC DRUGS SUMMARY (You'll See These Daily)

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SECTION 7 - QUICK REFERENCE CARD (Memorize These)

NORMAL CARDIAC VALUES:
HR: 60-100 bpm
BP: <120/80 mmHg
Apex beat: 5th ICS, MCL
PR interval: 0.12-0.20 sec
QRS: <0.12 sec
EF (ejection fraction): 55-70% normal; <40% = HFrEF

KEY NUMBERS:
JVP normal: <4 cm above sternal angle (at 45°)
BNP: >100 pg/mL = likely heart failure
NT-proBNP: >125 pg/mL = heart failure
Troponin: ANY elevation = myocardial injury

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TODAY'S SUMMARY (5 Lines)

1. Cardiac exam follows: Hands → Pulse → BP → Face → JVP → Praecordium (IPPPA) → Lungs → Legs
2. S3 = heart failure; S4 = stiff ventricle (HTN/LVH)
3. STEMI = ST elevation on ECG → call senior immediately → aspirin + reperfusion
4. AF = irregularly irregular pulse, no P waves, risk of stroke → anticoagulate
5. Heart failure = dyspnea + edema + raised JVP + basal crackles → treat with BADS drugs

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🔬 CARDIAC INVESTIGATIONS - How to Learn & Read All of Them

Complete Guide for Clinical Students

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THE BIG PICTURE - What Test Gets Ordered When?

Patient comes with cardiac complaint
            ↓
STEP 1: ECG (first, always, within 10 minutes)
            ↓
STEP 2: Blood tests (Troponin, BNP, CBC, LFT, KFT, lipids)
            ↓
STEP 3: Chest X-Ray
            ↓
STEP 4: Echocardiogram (Echo/TTE) - structure & function
            ↓
STEP 5: Stress Test / Holter (if needed)
            ↓
STEP 6: CT Angio / MRI (specialized)
            ↓
STEP 7: Coronary Angiography (invasive - gold standard for arteries)

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TEST 1 - ECG (Electrocardiogram)

What is an ECG?

The 12 Leads - What Each One "Looks At"

Limb leads (on arms and legs):

Chest/Precordial leads (V1-V6):

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The ECG Waveform - What Each Part Means

         R
        / \
       /   \
P    T/     \
 \  / \     S
  \/   \   /
  Q     \_/

P wave → QRS complex → T wave

• Small square = 0.04 sec (40 ms) horizontally
• Large square = 0.20 sec (200 ms) = 5 small squares
• Vertically: 1 small square = 0.1 mV

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How to READ an ECG - The 7-Step System (Never Skip Steps)

Step 1 - Check Calibration & Speed

• Standard speed: 25 mm/sec
• Standard calibration: 10 mm = 1 mV (look for calibration box at start)

Step 2 - Heart Rate

Rate = 300 ÷ (number of large squares between two R peaks)

Step 3 - Rhythm

1. Is it regular? (Are R-R intervals equal?)
2. Is there a P wave before every QRS? (= sinus rhythm)
3. Is the QRS narrow (<3 small squares) or wide?

Step 4 - Axis

• LAD: LBBB, left anterior fascicular block, inferior MI
• RAD: RBBB, right ventricular hypertrophy, lateral MI, PE

Step 5 - P Waves

• Present and upright in leads I and II = sinus rhythm
• Absent = AF, junctional rhythm, or complete heart block
• Peaked P in II (>2.5mm) = right atrial enlargement (P pulmonale)
• Broad notched P in II = left atrial enlargement (P mitrale)

Step 6 - PR Interval (0.12-0.20 sec)

Step 7 - QRS, ST segment, T waves

• Inverted T in V1-V4 = anterior ischemia, PE, right heart strain
• Tall peaked T = hyperkalemia (early), hyperacute STEMI
• Flattened T = hypokalemia, ischemia

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ECG Patterns to Recognize Immediately

STEMI (Emergency - shout for help):

• ST elevation in at least 2 leads in the same territory
• New LBBB can also = STEMI equivalent

AF (Atrial Fibrillation):

• No P waves
• Irregularly irregular QRS
• Wavy/fibrillatory baseline

Complete Heart Block (3rd degree):

• P waves march at their own rate (~30-60 bpm)
• QRS complex marches at its own slower rate
• They have NO relationship to each other
• Wide QRS (escape rhythm from ventricles)

Ventricular Tachycardia (VT):

• Wide QRS tachycardia (rate >100, QRS >0.12)
• Monomorphic (all QRS same shape) = regular VT
• If pulseless = VF → Defibrillate immediately

WPW (Wolff-Parkinson-White):

• Short PR (<0.12 sec)
• Delta wave (slurred upstroke of QRS)
• Wide QRS
• Accessory pathway bypasses AV node

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TEST 2 - ECHOCARDIOGRAM (Echo / TTE)

What is it?

Types of Echo

The Most Important Echo Numbers to Know

What the Echo Report Will Tell You

• EF% - the most important single number
• Wall motion abnormality (WMA) = area of heart not moving = previous MI

• TAPSE >17mm = normal RV function
• <17mm = RV dysfunction (cor pulmonale, PE, right heart failure)

• Each valve graded as: Normal / Mild / Moderate / Severe regurgitation or stenosis
• Aortic valve area (AVA): Normal >2 cm², Severe AS <1 cm²

• Pericardial effusion = fluid around heart
• Large effusion + hemodynamic compromise = cardiac tamponade (emergency)

• E/A ratio for diastolic function
• Pressure gradients across valves (e.g., mean gradient >40 mmHg = severe AS)

How to understand Echo views (what the probe shows):

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TEST 3 - CORONARY ANGIOGRAPHY (Cardiac Cath / Angio)

What is it?

When is it done? (Indications)

What you see on angiogram:

• Normal artery: Smooth, well-defined lumen with good dye flow
• Stenosis: Narrowing of the artery - described as % blockage (e.g., 70% stenosis)
• Occlusion: Complete block, no dye flow beyond the point
• TIMI flow grade:
  • Grade 0 = no flow (complete occlusion)
  • Grade 1 = trickle
  • Grade 2 = partial flow
  • Grade 3 = normal flow ✓

What happens after angio?

PCI (Angioplasty + Stent):

• Balloon inflated to open stenosis
• Stent (metal mesh tube) placed to keep artery open
• Drug-eluting stent (DES) = coated with drug to prevent re-narrowing
• Post-stent: dual antiplatelet for at least 12 months (Aspirin + Clopidogrel)

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TEST 4 - BLOOD TESTS IN CARDIAC PATIENTS

Cardiac Enzymes / Biomarkers

Troponin (the most important)

• Released when heart muscle cells die
• Types: Troponin I (TnI) and Troponin T (TnT) - high sensitivity versions used now
• Any elevation = myocardial injury (must interpret with clinical context)

• PE (pulmonary embolism)
• Myocarditis
• Sepsis
• Renal failure
• Tachyarrhythmia
• Stroke/subarachnoid hemorrhage

BNP / NT-proBNP (Heart Failure Marker)

• Released by ventricles when they are stretched (volume/pressure overload)
• Best test for: "Is this dyspnea cardiac or respiratory?"

CK-MB (Creatine Kinase - MB fraction)

• Older marker, less specific than troponin
• Still used in some centers to detect re-infarction (rises faster than troponin after repeat MI)

Other Blood Tests Ordered in Cardiac Patients

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TEST 5 - CHEST X-RAY (CXR) IN CARDIAC DISEASE

How to Read a CXR Systematically (ABCDE)

A - Airway

• Trachea midline? (pushed = tension pneumothorax, mediastinal mass)

B - Bones & Borders

• Look at ribs, clavicles for rib notching (coarctation of aorta)
• Heart borders sharp? (blurred = consolidation next to heart)

C - Cardiac size

• CTR (Cardiothoracic Ratio): Widest heart diameter ÷ widest chest diameter
• Normal < 0.5 (heart occupies less than half the chest)

• 0.5 on PA film = cardiomegaly

D - Diaphragm

• Right higher than left (liver below)
• Loss of costophrenic angle = pleural effusion
• Air under diaphragm = perforated viscus (surgery emergency)

E - Everything Else (pulmonary vasculature)

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TEST 6 - STRESS TEST (Exercise ECG / TMT)

What is it?

Why done?

• Diagnose angina / ischemia
• Risk-stratify after MI
• Assess exercise-induced arrhythmias

Positive stress test (= ischemia) - stop the test if any of these:

• ST depression >1mm (horizontal or downsloping) during exercise
• ST elevation during exercise
• Chest pain reproduced
• BP drops during exercise (hypotension = severe disease)
• Serious arrhythmia (VT, VF)

Contraindications (don't do stress test in these patients):

• STEMI within 2 days
• Unstable angina (ongoing chest pain)
• Uncontrolled heart failure
• Severe aortic stenosis
• Uncontrolled arrhythmia

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TEST 7 - HOLTER MONITOR & AMBULATORY ECG

What is it?

Why used?

• Patient reports palpitations, dizziness, blackouts - but ECG in clinic is normal
• Monitor for paroxysmal AF (comes and goes)
• Assess heart rate response to antiarrhythmic drugs

Types:

What to look for in a Holter report:

• Maximum and minimum heart rate over 24 hours
• Any pauses (>3 seconds = significant)
• PACs (premature atrial contractions) or PVCs (ventricular)
• Paroxysmal AF episodes
• Does the patient's diary symptoms match any arrhythmia on the recording?

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TEST 8 - CT CORONARY ANGIOGRAPHY (CTCA) & CARDIAC MRI

CTCA (CT Coronary Angiogram)

• Non-invasive way to look at coronary arteries using a CT scanner + contrast dye
• Used for: Intermediate-risk chest pain, ruling out significant CAD
• Gives calcium score (higher = more plaque = higher CV risk)
• Cannot treat (unlike invasive angiography) - only diagnoses

Cardiac MRI (CMR)

• Best test for: Myocarditis, cardiomyopathy, cardiac masses, pericardial disease, viability assessment
• No radiation
• Late gadolinium enhancement (LGE): Shows areas of scar tissue (fibrosis) - crucial for cardiomyopathy diagnosis
• Not available everywhere - done in specialized centers

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SUMMARY TABLE - Which Test Answers Which Question?

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DAILY CARD - Stick This on Your Notebook

ECG READING ORDER (Never skip):
1. Rate  2. Rhythm  3. Axis  4. P waves
5. PR interval  6. QRS  7. ST & T waves

NORMAL VALUES:
HR: 60-100  |  PR: 3-5 small squares
QRS: <3 squares  |  QT: <11 squares
ST: flat/isoelectric  |  T: same direction as QRS

STEMI = ST elevation in 2+ contiguous leads → EMERGENCY
AF = No P waves + irregular QRS
3rd degree block = P and QRS unrelated → EMERGENCY

ECHO: EF <40% = systolic failure (HFrEF)
TROPONIN: Any rise = myocardial injury
BNP >400 = heart failure likely

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🏥 INPATIENT WARD - Everything You Need to Know

All Departments | Fast & Practical

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THE GOLDEN RULE IN ANY WARD

Every patient in every department needs the same 3 things from you:

1. A proper history
2. A proper examination
3. A plan (investigations + treatment)

The rest is just department-specific details layered on top.

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PART 1 - WHAT HAPPENS IN THE WARD (Daily Routine)

The Typical Ward Day

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The Hierarchy - Know Who is Who

Consultant (Attending) → Head of team
        ↓
Senior Resident (PG 2-3) → Runs the ward
        ↓
Junior Resident (PG 1) → Day-to-day orders
        ↓
Intern → Direct ward work
        ↓
YOU (Student) → Learn, observe, assist

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PART 2 - UNIVERSAL WARD SKILLS (Every Department)

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SKILL 1 - Reading the Bedside Chart

TEMPERATURE CHART (TPR chart):
- Temperature: plotted as dots - look for fever spikes (>38°C) or hypothermia (<36°C)
- Pulse: plotted as line
- Respiration rate: noted
- Blood pressure: recorded each shift
- SpO2: oxygen saturation
- Input/Output chart: IV fluids in + oral in / urine out + drain out

• Max temp in last 24 hours - fever? improving?
• Pulse rate trend
• Blood pressure - high/low?
• Urine output - minimum acceptable = 0.5 mL/kg/hour (e.g., 70kg person = 35 mL/hour minimum)
• Any overnight events written in nursing notes?

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SKILL 2 - IV Lines & IV Fluids

Types of IV Access:

IV Fluid Types - Know These 5:

How to read an IV order:

"1 pint NS over 6 hours" = 500 mL normal saline → drip rate = 500/6 = ~83 mL/hour

Drops/min = (Volume in mL × 20) ÷ (Time in minutes)

Signs that IV site needs to be changed:

• Redness, swelling, pain at cannula site = phlebitis → change site immediately
• Fluid not draining = blocked → flush gently or re-site
• Cannula sites should be changed every 72 hours routinely

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SKILL 3 - Oxygen Therapy

Oxygen Delivery Devices:

• Most patients: 94-98%
• COPD patients: 88-92% (too much O2 can suppress their drive to breathe)

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SKILL 4 - Reading Drug Charts & Prescriptions

Parts of a Drug Chart:

Regular medications: given every day at set times
PRN (as needed): given only when patient asks or when certain condition met
One-time (STAT) dose: given immediately once
IV medications: separate section, with rate

Common Abbreviations on Drug Charts:

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SKILL 5 - Writing a Progress Note (SOAP Format)

Date: 24/06/2026    Time: 08:30    Day 3 of admission

S - Subjective (what the patient says):
"Patient reports reduced chest pain today. Still some breathlessness on exertion.
Slept well. Appetite improving."

O - Objective (what you find):
Vitals: T 37.2°C, P 88 bpm regular, BP 128/82, RR 18, SpO2 97% on room air
General: Alert, comfortable at rest
CVS: S1 S2 heard, no murmurs. JVP not raised.
RS: Clear air entry bilaterally, no crackles.
Abdomen: Soft, non-tender
Investigations: Today's Troponin 0.04 (down from 1.2 on admission). ECG: sinus rhythm, no new changes.

A - Assessment (your impression):
NSTEMI - clinically improving. Troponin trending down. Haemodynamically stable.

P - Plan:
Continue aspirin 75mg + clopidogrel 75mg + atorvastatin 40mg + ramipril 2.5mg
Urology review not needed
Echo ordered - pending
Plan for stress test before discharge
Discussed with Dr. [Senior name]

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SKILL 6 - Recognizing a Sick Patient (ABCDE Emergency Approach)

• SpO2 <90% despite O2
• BP <90/60 or falling
• HR <40 or >150
• GCS drop of >2 points
• Unresponsive patient
• New seizure

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PART 3 - DEPARTMENT-SPECIFIC WARD KNOWLEDGE

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🏥 GENERAL MEDICINE WARD

What you see here:

Most Common Admissions & What to Know:

1. Diabetic Patient in Ward

2. Hypertensive Patient

• Target BP in ward: <140/90 (general), <130/80 (diabetic/CKD)
• Hypertensive emergency: BP >180/120 + end organ damage (headache, visual changes, confusion, chest pain) → IV labetalol or nitroprusside - call senior immediately
• Hypertensive urgency: BP >180/120, NO end organ damage → oral antihypertensives, reduce slowly over 24-48 hours

3. Fever in a Ward Patient

1. Blood culture (2 sets from different sites, before antibiotics)
2. Urine culture and sensitivity (C&S) + urine routine
3. CXR
4. CBC with differential (neutrophils up = bacterial, lymphocytes up = viral)
5. Examine: IV sites, wound sites, chest, abdomen, legs (for DVT)

• Low grade: 37.5-38°C
• Moderate: 38-39°C
• High grade: >39°C
• Hyperpyrexia: >41°C (emergency - brain damage risk)

4. Stroke Patient in Medicine Ward

• Neuro obs every 4-8 hours: GCS, pupils, limb power
• BP (target varies - don't over-lower in first 24 hours)
• Blood glucose (hyperglycemia worsens stroke)
• Swallow assessment before giving oral food/drugs (aspiration risk)
• DVT prophylaxis (compression stockings, heparin)

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🔪 SURGERY WARD

What you see here:

Pre-Operative Patient (Before Surgery):

• Patient fasted? (6 hours for food, 2 hours for clear fluids)
• Consent signed?
• Blood group and cross-match done?
• Investigations: CBC, KFT, LFT, coagulation, ECG, CXR
• Allergies documented?
• Regular medications reviewed (hold metformin, warfarin, aspirin as instructed)
• IV access secured?
• Anaesthesia review done?
• Mark the site of surgery?

Post-Operative Patient (After Surgery):

• Vitals trend
• Pain score (0-10) - is analgesia adequate?
• Wound: dry and intact? Any ooze, redness, dehiscence?
• Drains: type, color, amount of output
• Urine output (catheter bag)
• Bowel sounds returned? Passing gas? (before allowing oral feeds)
• IV site clean?
• DVT prophylaxis ordered?

Surgical Drains - What You'll See:

• Serous (clear/straw yellow) = normal wound fluid
• Serosanguinous (pink) = normal after surgery
• Sanguinous (frank blood) = active bleeding - call senior
• Purulent (cloudy/thick) = infection
• Bilious (green) = bile leak
• Chylous (milky white) = lymphatic leak

Wound Dressings - How to Assist:

1. Wash hands, gloves on (sterile for clean wounds)
2. Remove old dressing - note: wet? soiled? adherent?
3. Clean wound with saline or antiseptic (per surgeon's instruction)
4. Inspect wound: is it healing? Any dehiscence (opening), infection, necrosis?
5. Apply new dressing
6. Document wound appearance in notes

• Primary intention: edges closed (sutured) - clean surgical wounds
• Secondary intention: left open to heal from base - infected/large wounds
• Tertiary (delayed primary): cleaned first, then closed later

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👶 PEDIATRICS WARD

The key difference: everything depends on AGE and WEIGHT

Calculating Drug Doses in Children:

• Age 1-10 years: Weight (kg) = (Age + 4) × 2
• e.g., 6-year-old: (6+4) × 2 = 20 kg

Common Pediatric Ward Problems:

Fever in a Child

• Simple: <15 min, one episode, no focal features → benign, good prognosis
• Complex: >15 min, focal, repeated → investigate for meningitis
• Immediate management: ABC, position (lateral), diazepam if >5 min (0.5 mg/kg PR or IV 0.2-0.3 mg/kg)

Dehydration in Children

• Deficit = % dehydration × weight × 10 mL/kg
• Plus maintenance fluids per day (Holliday-Segar rule):
  • 0-10 kg: 100 mL/kg/day
  • 10-20 kg: 1000 mL + 50 mL/kg for each kg above 10

  • 20 kg: 1500 mL + 20 mL/kg for each kg above 20

Jaundice in Newborn (Neonatal Jaundice)

• Physiological: Appears day 2-3, gone by day 14 in term, day 21 in preterm - normal
• Pathological: Appears <24 hours OR persists >14 days OR bilirubin very high → treat
• Treatment: Phototherapy (blue light breaks down bilirubin through skin)
• Severe: Exchange transfusion (double-volume blood exchange)

Common Pediatric Presentations Table:

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🤰 OBG WARD (Obstetrics & Gynecology)

Obstetrics Section:

• G = Gravida (total pregnancies including current)
• P = Para (deliveries >28 weeks)
• A/L = Abortions/Live births
• Example: G3P2A1 = 3 pregnancies, 2 deliveries, 1 abortion

• 1st: 0-13 weeks (organogenesis - MOST drug-sensitive)
• 2nd: 14-26 weeks (growth phase)
• 3rd: 27-40 weeks (preparation for birth)

Gynecology Section:

• Ectopic pregnancy (always check pregnancy test in female of reproductive age with pelvic pain)
• PID (pelvic inflammatory disease)
• Ovarian cyst - torsion or rupture
• Uterine fibroid with bleeding
• Post-operative hysterectomy/myomectomy

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🦴 ORTHOPEDICS WARD

• 5 P's: Pain (out of proportion = compartment syndrome!) | Pallor | Paresthesia | Paralysis | Pulselessness
• Any of these = emergency - compartment syndrome or vascular injury

• Classic: Pain out of proportion to injury, pain on passive stretch, tense swollen limb

• Check weights are hanging freely
• Limb in correct position
• Skin under traction device - pressure sores?

• All hip/knee replacement patients → low molecular weight heparin (enoxaparin) + compression stockings
• Early mobilization encouraged

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👁️ ENT WARD

• Bleeding (primary = within 24 hours, secondary = days 5-10) → emergency return to OR
• Pain score, able to swallow
• No hot drinks/spicy food for 2 weeks

• Tie/flange secure (2-finger gap)
• Inner tube cleaned every 4-8 hours
• Suction PRN
• Always have same-size spare tube at bedside
• Emergency: tube blocked → remove inner tube → if still blocked → deflate cuff → if still blocked → remove tube → ventilate via stoma

1. Sit forward, breathe through mouth
2. Pinch soft part of nose for 10 minutes continuous
3. If not stopped: anterior nasal packing (Merocel/BIPP)
4. Posterior bleed: posterior packing, ENT review

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🧠 NEUROLOGY / NEUROSURGERY WARD

Neuro Obs (Neurological Observations):

1. GCS (E+V+M, max 15)
2. Pupils: Size (mm), equality, reaction to light (PEARL = Pupils Equal And Reactive to Light)
3. Limb power: Grade 0-5 each limb
4. Temperature, BP, pulse

1. Hypertension (high BP)
2. Bradycardia (slow heart rate)
3. Irregular breathing (Cheyne-Stokes) → This is a pre-terminal sign - call senior immediately

• Patient in lateral decubitus (fetal position) or seated leaning forward
• Level: L3-L4 or L4-L5 (below spinal cord ending at L1-L2)
• Normal CSF: Clear, opening pressure 6-20 cmH2O

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PART 4 - PRACTICAL PROCEDURES (Watch Then Assist)

Blood Transfusion - Safety Steps (MUST follow every time):

1. Two nurses check at bedside: patient name, hospital number, blood group, expiry date
2. Check for patient identity band - matches blood product label
3. Take pre-transfusion baseline vitals
4. Each unit runs over 4 hours (unless emergency)
5. Check vitals 15 min after starting (most reactions happen early)

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PART 5 - DISCHARGE PLANNING (Happens in All Wards)

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THE MASTER CHECKLIST - For Every Patient, Every Day

BEFORE ROUNDS:
□ Check vitals chart (last 24 hours)
□ Check urine output
□ Check input/output balance
□ Read nursing notes for overnight events
□ Know today's investigation results

ON ROUNDS:
□ Present patient in SOAP format
□ Know what's being planned for today
□ Write down any new orders or changes

AFTER ROUNDS:
□ Note down 1 new thing you learned
□ Ask "what does this finding/result mean?"
□ Look up any term you didn't understand

END OF DAY:
□ Update your progress note
□ Check evening vitals
□ Confirm handover done

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QUICK EMERGENCY REFERENCE - Stick This on Your Pocket Card

PATIENT SUDDENLY DETERIORATES:
→ ABCDE approach
→ Call senior immediately
→ High-flow O2 via non-rebreather mask
→ IV access × 2, blood tests
→ ECG, CXR, ABG

HYPOGLYCEMIA (<70 mg/dL):
→ 15g glucose (3 glucose tablets / 150mL juice)
→ Recheck in 15 min
→ If unconscious: 25mL of 50% dextrose IV

ANAPHYLAXIS:
→ Stop trigger, call help
→ Adrenaline 0.5mg IM (lateral thigh)
→ O2 high flow, IV access, fluids

SEIZURE:
→ Position safely, lateral
→ Time it
→ Diazepam if >5 minutes
→ Check glucose

CARDIAC ARREST:
→ Shout for help + call crash team
→ Start CPR: 30 compressions : 2 breaths
→ Get defibrillator
→ Do not stop until team arrives

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🏥 GENERAL MEDICINE - Complete Ward Guide

Everything You Need to Know | Condition by Condition

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WHO YOU WILL SEE IN GENERAL MEDICINE

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CONDITION 1 - DIABETES MELLITUS

Two Main Types:

Diagnosis (WHO Criteria):

Symptoms of Diabetes ("PUPIL"):

• Polyuria (passing lot of urine)
• Unaccountable weight loss
• Polydipsia (excessive thirst)
• Infections - recurrent (skin, urine, fungal)
• Lethargy / fatigue

Monitoring in Ward:

• 4-point BGL: fasting, pre-lunch, pre-dinner, bedtime
• Target in hospital: 140-180 mg/dL (less strict than outpatient targets)
• HbA1c every 3 months outpatient

Diabetes Emergencies - The Big 3:

1. Hypoglycemia (BGL <70 mg/dL)

• Mild: Sweating, trembling, palpitations, hunger, anxiety
• Moderate: Confusion, slurred speech, headache
• Severe: Seizure, loss of consciousness

1. If conscious: 15g fast-acting carbs (150 mL juice / 3-4 glucose tablets / 1 tbsp sugar)
2. Wait 15 minutes, recheck
3. If still <70: repeat
4. If unconscious/unable to swallow: 25-50 mL 50% dextrose IV (D50W) OR glucagon 1mg IM
5. Once recovered: give snack with complex carbs to prevent recurrence
6. Find and fix the CAUSE

2. DKA - Diabetic Ketoacidosis (Type 1 mainly)

• BGL usually >250 mg/dL (but can be lower in "euglycemic DKA")
• Nausea, vomiting, abdominal pain
• Kussmaul breathing (deep, labored - blowing off CO2)
• Fruity/acetone smell on breath
• Dehydration, confusion, drowsiness

3. HHS - Hyperosmolar Hyperglycemic State (Type 2 mainly)

Diabetic Complications - Know These:

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CONDITION 2 - HYPERTENSION

Definition: BP ≥140/90 mmHg on 2+ separate readings

Classification:

Asking About Secondary Hypertension (5% of cases):

• Headache, sweating, palpitations in episodes? → Pheochromocytoma
• Weakness, low potassium? → Hyperaldosteronism (Conn's syndrome)
• Snoring, daytime sleepiness? → Obstructive sleep apnea
• Young female, flank bruit? → Renal artery stenosis
• Coarctation: radio-femoral delay, leg claudication

Target Organ Damage - "BRAIN-HEART-KIDNEY-EYE":

Treatment - Drug Choice:

Hypertensive Emergency vs Urgency:

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CONDITION 3 - PNEUMONIA

Community-Acquired Pneumonia (CAP) - Most Common Type

• Fever, rigors (uncontrollable shaking)
• Productive cough - rusty/yellow/green sputum
• Pleuritic chest pain (sharp, worse on breathing)
• Breathlessness
• Reduced breath sounds + dullness + bronchial breathing on the affected side

• CXR: consolidation (white area in lung)
• CBC: raised WBC (neutrophilia = bacterial)
• Blood cultures: 2 sets before antibiotics
• Sputum for C&S
• ABG if SpO2 <94% or unwell
• Urine Legionella antigen (if atypical suspected)

• Confusion (new)
• Urea >7 mmol/L (BUN >20 mg/dL)
• Respiratory rate ≥30/min
• Blood pressure <90 systolic or <60 diastolic
• Age ≥65

• Non-severe: Amoxicillin 500mg TDS oral (or Amoxicillin-clavulanate)
• Add azithromycin/doxycycline if atypical suspected
• Severe: IV co-amoxiclav + IV azithromycin
• Follow local antibiogram for your hospital

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CONDITION 4 - TUBERCULOSIS (TB)

Extremely Common in South Asia, Africa, Southeast Asia

• Fever - low-grade, worse in evenings
• Night sweats
• Weight loss (significant, unintentional)
• Swelling - lymph nodes (cervical mainly)
• Weakness, anorexia
• Cough >3 weeks, hemoptysis

1. Sputum AFB smear (3 samples - early morning preferred)
2. GeneXpert MTB/RIF (rapid PCR - gold standard for quick diagnosis, also detects rifampicin resistance)
3. Sputum culture (takes 6-8 weeks but gold standard)
4. CXR: upper lobe infiltrates, cavities, hilar lymphadenopathy
5. Mantoux/TST: positive = ≥10mm induration in 48-72 hrs (≥5mm in immunocompromised)

• Rifampicin: Orange-red urine/tears (warn patient - NORMAL), hepatotoxicity
• INH: Peripheral neuropathy (give pyridoxine/B6 with it), hepatotoxicity
• Pyrazinamide: Gout (raises uric acid), hepatotoxicity
• Ethambutol: Color blindness (red-green), vision changes

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CONDITION 5 - DENGUE FEVER

Very Common in Tropical Countries

• NS1 antigen: positive day 1-5 (early)
• IgM antibody: positive after day 5
• CBC: leukopenia (low WBC), thrombocytopenia (platelet <100,000 = concern, <20,000 = risk of major bleed)
• Rising hematocrit (Hct) = hemoconcentration = plasma leakage happening

• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation (ascites, pleural effusion)
• Mucosal bleeding (gums, epistaxis, melena)
• Lethargy or restlessness
• Liver enlargement >2 cm
• Rapid increase in Hematocrit + rapid fall in platelet

• NO specific antiviral
• Supportive: IV fluids (Ringer's Lactate preferred), strict fluid balance
• NO aspirin, NO NSAIDs (both increase bleeding risk)
• Paracetamol for fever only
• Monitor platelet and Hct every 6-12 hours
• Platelet transfusion only if <10,000 OR <20,000 with bleeding

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CONDITION 6 - ANEMIA

Definition: Hb <13 g/dL (men) / <12 g/dL (women) / <11 g/dL (pregnancy)

Classify First - By MCV (Mean Corpuscular Volume):

Microcytic (MCV <80 fL) - Small red cells:

Normocytic (MCV 80-100 fL) - Normal sized cells:

Macrocytic (MCV >100 fL) - Large red cells:

Blood Film - What to Look For:

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CONDITION 7 - ACUTE KIDNEY INJURY (AKI)

Definition (KDIGO Criteria): Any ONE of:

• Rise in creatinine ≥0.3 mg/dL within 48 hours
• Rise in creatinine ≥1.5× baseline within 7 days
• Urine output <0.5 mL/kg/hour for ≥6 hours

Classify by Cause:

Investigations in AKI:

• Serum creatinine, urea, electrolytes
• Urine output monitoring (strict hourly in severe AKI)
• Urinalysis + microscopy (casts, protein, blood)
• Renal ultrasound (rule out obstruction)
• ABG (look for metabolic acidosis)
• Urine Na, urine osmolality (pre vs intrinsic)

Life-Threatening Complications of AKI ("AEIOU"):

• Acidosis - treat with bicarbonate if severe
• Electrolytes - hyperkalemia (most dangerous!)
• Ingestion (toxins/drugs that worsen renal function - stop nephrotoxics)
• Overload (fluid overload → pulmonary edema)
• Uremia symptoms (encephalopathy, pericarditis, platelet dysfunction)

Hyperkalemia in AKI - Treatment Sequence:

1. Peaked/tall T waves (first sign)
2. Widened QRS
3. Sine-wave pattern → cardiac arrest

Pre-renal AKI Management:

1. IV fluid challenge: 500mL NS/RL over 30 min, reassess
2. Monitor urine output hourly
3. Stop nephrotoxic drugs (NSAIDs, aminoglycosides, contrast, ACEi temporarily)
4. Treat underlying cause (sepsis, heart failure)

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CONDITION 8 - LIVER DISEASE / JAUNDICE

Classify Jaundice:

Causes to Know:

Cirrhosis - Complications to Recognize in Ward:

Hepatitis:

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CONDITION 9 - ASTHMA & COPD

Asthma:

• RR >25/min
• HR >110 bpm
• Unable to complete sentences
• SpO2 <92%
• PEFR 33-50% of best

• Silent chest (no wheeze - air entry very poor - extreme danger)
• SpO2 <92%
• Exhaustion
• PaCO2 normal or raised (patient too tired to hyperventilate)

1. O2 to target SpO2 94-98%
2. Nebulized salbutamol 5mg + ipratropium 0.5mg back-to-back
3. Systemic steroids: prednisolone 40mg oral or hydrocortisone 100mg IV
4. Magnesium sulfate 2g IV (if severe/life-threatening)
5. IV salbutamol or aminophylline (ICU if needed)

COPD (Chronic Obstructive Pulmonary Disease):

• Increased breathlessness + increased sputum + change in sputum color
• O2 target: 88-92% (not >94% - hypercapnic drive)
• Controlled O2 via Venturi mask (24% or 28%)
• Nebulized salbutamol + ipratropium
• Prednisolone 30mg × 5 days
• Antibiotics if infective exacerbation (amoxicillin or doxycycline)
• ABG to check CO2 (rising CO2 + acidosis = BiPAP needed)

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CONDITION 10 - SEPSIS

Definition: Life-threatening organ dysfunction caused by dysregulated host response to infection

• RR ≥22/min
• Altered mental status (GCS <15)
• Systolic BP ≤100 mmHg

Septic Shock:

• Sepsis + need for vasopressors to maintain MAP ≥65 mmHg + serum lactate >2 mmol/L

Sepsis Six (Do ALL within 1 hour):

• Piperacillin-tazobactam (Tazocin) 4.5g TDS IV
• Or ceftriaxone 2g OD IV
• Add metronidazole if abdominal source suspected

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CONDITION 11 - ELECTROLYTE DISTURBANCES

Hyponatremia (Na+ <135 mEq/L)

• Hypovolemic: Normal saline fluids
• SIADH: Fluid restriction (1000 mL/day), treat cause
• NEVER correct Na faster than 8-10 mEq/L per 24 hours - risk of osmotic demyelination syndrome (brain damage)

Hyperkalemia (K+ >5.5 mEq/L)

Hypokalemia (K+ <3.5 mEq/L)

• Oral: KCl (Slow-K) 600mg TDS if mild and patient eating
• IV: Add KCl 40 mEq to 1L NS/RL over 4 hours - NEVER push IV potassium (causes cardiac arrest)
• Max IV rate: 20 mEq/hour via peripheral line (40 mEq/hour only in ICU with monitoring)

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DAILY CLINICAL APPROACH IN GENERAL MEDICINE WARD

The Morning Pre-Round Checklist (Do For Each Patient):

PATIENT: _______________  Day ___ of admission
Diagnosis: _______________

VITALS (last 24h):
□ Max Temp: ___  (fever still present?)
□ Pulse: ___  (tachycardia / bradycardia?)
□ BP: ___  (controlled? high? low?)
□ RR: ___  (tachypneic?)
□ SpO2: ___  (on how much O2?)
□ BGL: ___ (if diabetic)

INPUT/OUTPUT:
□ IV fluids in: ___
□ Urine out: ___  (adequate? >0.5 mL/kg/hr?)

RESULTS:
□ Today's blood tests: ___
□ Imaging: ___
□ Cultures pending? Yes / No

MEDICATIONS:
□ IV antibiotics – correct dose and timing?
□ Any drug reviews needed?

PLAN TODAY:
□ Change IV to oral antibiotics?
□ New investigation needed?
□ Consultation needed?
□ Discharge planning?

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IMPORTANT INVESTIGATIONS QUICK REFERENCE

What Each Lab Test Tells You:

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GENERAL MEDICINE WARD - TOP DRUGS YOU'LL SEE EVERY DAY

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POCKET CHEAT SHEET - EMERGENCY VALUES IN GENERAL MEDICINE

CALL SENIOR IMMEDIATELY IF:
→ SpO2 <90% despite O2
→ BP <90/60 or falling fast
→ HR >140 or <40
→ RR >30
→ GCS drop ≥2 points
→ Na+ <120 or >155 mEq/L
→ K+ >6.5 or ECG changes of hyperK
→ Glucose <50 or >500 mg/dL
→ Lactate >4 mmol/L
→ Active massive bleeding
→ Unresponsive patient
→ Severe uncontrolled pain not responding to analgesia

5 MOST COMMON CAUSES OF FEVER IN A MEDICINE WARD:
1. Pneumonia / chest infection
2. UTI
3. IV line infection (phlebitis / septic thrombophlebitis)
4. DVT
5. Drug fever (usually appears 7-10 days after starting new drug)

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1. Diabetes - Types, diagnosis, DKA, HHS, hypoglycemia, complications
2. Hypertension - Classification, target organ damage, drug choices, emergencies
3. Pneumonia - CURB-65, organisms, antibiotics
4. Tuberculosis - Symptoms, diagnosis, HRZE treatment, DOTS
5. Dengue - Phases, warning signs, NS1/IgM, fluid management
6. Anemia - Micro/Normo/Macrocytic classification, blood film
7. Acute Kidney Injury - Pre/intra/post-renal, hyperkalemia treatment
8. Liver disease - Jaundice types, cirrhosis complications (ascites, SBP, encephalopathy)
9. Asthma & COPD - Exacerbation management, O2 targets
10. Sepsis - qSOFA, Sepsis Six
11. Electrolytes - Hyponatremia, hypo/hyperkalemia

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🏥 GENERAL MEDICINE - CONTINUED

Part 2 | Conditions 12 to 20

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CONDITION 12 - THYROID DISEASE

Quick Anatomy of Thyroid Hormone Axis:

Hypothalamus → TRH
      ↓
Pituitary → TSH
      ↓
Thyroid gland → T3 + T4

• TSH HIGH → Thyroid not making enough → Hypothyroidism
• TSH LOW → Thyroid making too much → Hyperthyroidism
• TSH is always the FIRST test to order

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HYPOTHYROIDISM

Causes:

Symptoms - "SLOW":

• S - Slow metabolism: weight gain, constipation, bradycardia, slow reflexes
• L - Low temperature tolerance: cold intolerance, feeling always cold
• O - Other: dry skin, hair loss, puffy face/eyes (myxedema), hoarse voice
• W - Weakness: fatigue, lethargy, muscle cramps, depression, poor memory

Signs on examination:

• Bradycardia
• Dry, coarse skin
• Non-pitting periorbital edema (myxedema)
• Slow-relaxing (hung-up) tendon reflexes
• Goiter (enlarged thyroid) if due to iodine deficiency or Hashimoto's
• Macroglossia (large tongue)

Investigations:

• TSH: HIGH (most sensitive test)
• Free T4: LOW
• Anti-TPO antibodies: positive in Hashimoto's
• CBC: may show macrocytic anemia
• Lipids: often elevated (hypothyroidism raises LDL)
• ECG: bradycardia, low voltage, flattened T waves

Treatment:

• Levothyroxine (T4) - synthetic thyroid hormone
• Starting dose: 25-50 mcg OD (start low especially in elderly/cardiac patients - can precipitate angina)
• Take on empty stomach, 30-60 minutes before food
• Increase by 25 mcg every 6-8 weeks
• Monitor TSH 6-8 weeks after any dose change
• Target TSH: 0.5-2.5 mIU/L

Myxedema Coma (Extreme Hypothyroidism - Emergency):

• Severely ill, unconscious, hypothermic, bradycardic
• Precipitated by: cold exposure, infection, sedative drugs
• Treatment: IV T4 + IV hydrocortisone + warming + ICU

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HYPERTHYROIDISM

Causes:

Symptoms - "FAST":

• F - Fast heart: palpitations, tachycardia, AF
• A - Anxious, agitated, tremor of hands, heat intolerance, sweating
• S - Slim down: weight loss despite good appetite, diarrhea
• T - Tired yet hyperactive: insomnia, weakness, menstrual irregularity

Graves' Disease Specific Signs:

• Exophthalmos (proptosis - bulging eyes) - pathognomonic
• Pretibial myxedema (thickened skin over shins)
• Diffuse smooth goiter with bruit
• Thyroid acropachy (clubbing - rare)

Investigations:

• TSH: LOW (suppressed, often undetectable)
• Free T3/T4: HIGH
• TRAb: positive in Graves'
• Thyroid scan (Tc-99m): Graves' = diffuse uptake; toxic adenoma = focal hot nodule

Treatment:

Thyroid Storm (Thyrotoxic Crisis) - Emergency:

• Extreme hyperthyroidism: very high temp, extreme tachycardia/AF, confusion, vomiting, heart failure
• Precipitated by: surgery, infection, trauma, contrast dye
• Treatment: High-dose methimazole + Lugol's iodine (blocks hormone release) + propranolol + steroids + treat precipitant + ICU

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CONDITION 13 - PEPTIC ULCER DISEASE (PUD) & UPPER GI BLEED

Peptic Ulcer Disease

Causes:

1. H. pylori (Helicobacter pylori) - most common cause worldwide
2. NSAIDs (aspirin, ibuprofen, diclofenac) - inhibit prostaglandins that protect stomach
3. Stress ulcers - critically ill patients in ICU
4. Zollinger-Ellison syndrome - rare; gastrinoma causing massive acid production

Symptoms:

• Epigastric pain (burning/gnawing)
• Nausea, bloating
• Heartburn
• Complications: bleeding (hematemesis, melena), perforation (sudden severe pain), obstruction (persistent vomiting)

H. pylori Testing:

H. pylori Eradication (Triple Therapy × 14 days):

• PPI (omeprazole 20mg BD) + Amoxicillin 1g BD + Clarithromycin 500mg BD
• If penicillin allergy: Replace amoxicillin with metronidazole
• Confirm eradication 4 weeks after completing antibiotics with UBT or stool antigen

Acid Suppression Drugs:

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Upper GI Bleed (UGIB)

Presentation:

• Hematemesis = vomiting blood (bright red = active; coffee-ground = older blood)
• Melena = black, tarry, offensive-smelling stools (blood digested in upper GI)
• Hematochezia (bright red rectal bleeding) only if very massive UGIB

Causes:

Glasgow-Blatchford Score (Pre-endoscopy risk score):

• Score 0 = low risk → outpatient management possible
• Score ≥7 → needs urgent endoscopy and likely intervention

Immediate Management of UGIB:

ABCDE FIRST - assess stability
         ↓
IV access × 2 (large bore, 16G+)
         ↓
Blood tests: CBC, LFT, KFT, coagulation, GROUP & CROSSMATCH
         ↓
IV fluids - Ringer's Lactate / Normal saline
         ↓
Blood transfusion if Hb <8 g/dL (or <10 if cardiac patient)
         ↓
IV PPI: Pantoprazole 80mg bolus, then 8mg/hr infusion
         ↓
Urgent endoscopy (within 24h, within 12h if high risk)
         ↓
If varices: IV terlipressin + antibiotics (ceftriaxone - SBP prophylaxis)

• Score >5 = high rebleed/mortality risk

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CONDITION 14 - URINARY TRACT INFECTION (UTI)

Types:

Risk Factors:

• Female sex (short urethra)
• Sexual activity ("honeymoon cystitis")
• Pregnancy (always treat even if asymptomatic)
• Urinary catheter (most common hospital infection)
• Obstruction (BPH, stones)
• Diabetes
• Immunocompromised

Diagnosis:

• Urine dipstick: Nitrites (bacteria convert nitrates) + Leucocyte esterase (WBCs) = likely UTI
• Urine microscopy: WBCs >5/HPF (pyuria), bacteria, RBCs
• Urine culture & sensitivity (C&S): Gold standard - identifies organism + antibiotic sensitivity (results take 24-48 hours)
• Send urine before starting antibiotics

Common Organisms:

• E. coli - 80% of uncomplicated UTI
• Klebsiella, Proteus, Pseudomonas (especially in hospital/catheter-associated)
• Staphylococcus saprophyticus - young sexually active women
• Enterococcus - in complicated/hospital UTI

Treatment:

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CONDITION 15 - MALARIA

Plasmodium Species:

Classic Presentation:

• Periodicity of fever: P. falciparum = irregular; P. vivax/ovale = every 48h (tertian); P. malariae = every 72h (quartan)
• Rigors (shaking chills) → high fever → profuse sweating → resolution (cold-hot-sweat cycle)
• Headache, myalgia, nausea
• Splenomegaly (chronic malaria)
• Jaundice, anemia (destruction of RBCs)

Complications of Severe Falciparum Malaria:

• Cerebral malaria: Seizures, altered consciousness, coma
• Blackwater fever: Massive hemolysis → hemoglobinuria (dark/black urine)
• Severe anemia (Hb <7)
• Hypoglycemia (especially in children, pregnant women)
• Acute lung injury / Pulmonary edema
• AKI

Diagnosis:

1. Peripheral blood smear (thick + thin smear): Gold standard; identifies species and parasite density
   • Thick film: better for detecting parasites (screening)
   • Thin film: identifies species (diagnosis)
2. Rapid diagnostic test (RDT/ICT): Quick, good for P. falciparum (HRP2 antigen)
3. Quantitative buffy coat (QBC)

Treatment:

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CONDITION 16 - DEEP VEIN THROMBOSIS (DVT) & PULMONARY EMBOLISM (PE)

DVT - Blood Clot in Deep Vein (usually leg)

Risk Factors - Virchow's Triad:

Symptoms of DVT:

• Unilateral leg swelling (one leg much bigger than other)
• Warmth, redness, tenderness along vein
• Homan's sign (calf pain on dorsiflexion) - not reliable
• Calf circumference >3 cm difference between legs = significant

Wells DVT Score:

• Score ≥2 = DVT likely → do USS
• Score <2 = DVT unlikely → D-dimer first

Diagnosis:

• Compression USS (duplex): First line - non-compressibility of vein = DVT
• D-dimer: Sensitive but not specific - negative D-dimer rules out DVT if low pre-test probability

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PE - Pulmonary Embolism (Clot in Lung Artery)

Symptoms:

• Sudden breathlessness (most common)
• Pleuritic chest pain (sharp, worse on breathing)
• Hemoptysis (blood-stained sputum)
• Tachycardia
• Tachypnea
• Syncope (massive PE)

Wells PE Score (simplified):

• Clinical signs of DVT (+3)
• PE is #1 diagnosis (+3)
• HR >100 (+1.5)
• Immobilization >3 days / surgery in past 4 weeks (+1.5)
• Previous DVT/PE (+1.5)
• Hemoptysis (+1)
• Malignancy (+1)

ECG in PE:

• Sinus tachycardia (most common finding)
• S1Q3T3 pattern (S wave in lead I, Q wave + inverted T in lead III) - classic but not common
• Right heart strain: right axis deviation, RBBB, T-wave inversion V1-V4

CTPA (CT Pulmonary Angiogram): Gold standard for PE diagnosis

Treatment:

• Enoxaparin 40mg SC once daily
• • Ted stockings / intermittent pneumatic compression
• Early mobilization

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CONDITION 17 - CELLULITIS & SKIN INFECTIONS

Presentation:

• Spreading redness, warmth, swelling, tenderness
• Fever, raised WBC
• Typically lower limbs
• Entry point: minor wound, tinea pedis (athlete's foot), insect bite

Organisms:

• Streptococcus pyogenes (Group A Strep): Most common
• Staphylococcus aureus: Especially MRSA (methicillin-resistant)
• Diabetic foot: often polymicrobial

Grading Severity:

Mark the Borders:

• Use a skin marker to draw the edge of redness when patient admitted
• Reassess in 6-12 hours: redness spreading beyond line = treatment not working
• Redness staying within line / reducing = improving

Necrotizing Fasciitis (Flesh-eating infection - Emergency):

• Rapidly spreading infection along fascial planes
• Disproportionate pain (pain much worse than appearance)
• Crepitus (gas under skin - feel crackling)
• Skin discoloration → black necrosis
• Treatment: Emergency surgical debridement + broad-spectrum IV ABx (meropenem + clindamycin + vancomycin) + ICU

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CONDITION 18 - EPILEPSY & SEIZURES

Types of Seizures (ILAE Classification):

Focal (Partial) Seizures - Start in one area of brain:

• Simple focal: Conscious throughout - twitching of one limb, abnormal smell/taste
• Complex focal: Impaired consciousness - blank staring, automatisms (lip smacking, picking)
• Focal to bilateral tonic-clonic: Starts focal, spreads to whole brain

Generalized Seizures - Involve whole brain from start:

Status Epilepticus - Medical Emergency:

Investigations after first seizure:

• BGL (hypoglycemia causes seizures)
• Na, Ca, Mg (electrolyte seizures)
• Toxicology (drug/alcohol related)
• CT brain (rule out structural cause)
• MRI brain (better for hippocampal sclerosis, cortical dysplasia)
• EEG (electroencephalogram) - identifies epileptiform activity

Common Antiepileptic Drugs (AEDs):

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CONDITION 19 - NEPHROTIC & NEPHRITIC SYNDROME

Two Key Glomerular Syndromes - Know the Difference:

Nephrotic Syndrome:

• Thrombosis (loss of antithrombin III in urine) → DVT, renal vein thrombosis
• Infections (loss of immunoglobulins) → pneumococcal, gram-negative
• Hyperlipidemia → cardiovascular risk

• Steroids (prednisolone 1mg/kg/day) - especially minimal change disease (remits well)
• ACEi/ARB (reduces proteinuria)
• Diuretics for edema
• Statins for hyperlipidemia
• Treat underlying cause

Nephritic Syndrome:

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CONDITION 20 - CHRONIC KIDNEY DISEASE (CKD)

GFR Staging:

Causes:

1. Diabetic nephropathy (most common worldwide)
2. Hypertensive nephropathy
3. Glomerulonephritis
4. Obstructive uropathy (stones, BPH)
5. Polycystic kidney disease (PKD)
6. Recurrent infections

CKD Complications - Know All:

Uremia Symptoms (End-Stage CKD):

• Nausea, anorexia, vomiting
• Pruritus (itch all over - urea deposits in skin)
• Encephalopathy (confusion, asterixis)
• Pericarditis (uremic pericarditis)
• Platelet dysfunction → bleeding tendency
• Metallic taste in mouth

Dialysis - Types:

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GENERAL MEDICINE MASTER DRUG CHART (Complete)

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DAILY CHECKLIST FOR GENERAL MEDICINE - FULL VERSION

Questions to ask yourself about EVERY PATIENT, every day:

SYSTEM-BY-SYSTEM REVIEW:

METABOLIC:
□ If diabetic: BGL checked? Insulin given? Any hypo episodes overnight?
□ Thyroid patient: On levothyroxine? TSH pending?

CARDIOVASCULAR:
□ BP controlled? Which antihypertensive? Any chest pain?
□ If heart failure: weight? Fluid balance? Diuretic response?

RESPIRATORY:
□ SpO2? On O2? How many liters? Can we wean?
□ Fever + cough + consolidation on CXR? Start antibiotics?

RENAL:
□ Urine output >0.5 mL/kg/hr?
□ Creatinine trend? Rising or falling?
□ Any nephrotoxic drugs to stop?

INFECTIONS:
□ Are cultures back? Sensitivities match current antibiotic?
□ IV to oral switch possible? (afebrile 24-48h + tolerating oral)
□ Line sites clean? IV changed in last 72h?

HAEMATOLOGICAL:
□ Anaemia: Hb? Transfusion needed?
□ Thrombocytopenia: Dengue? DIC? TTP?
□ DVT prophylaxis ordered?

GI/LIVER:
□ Bowels moving? If liver disease: any encephalopathy signs (asterixis)?
□ On lactulose? How many stools/day?

MEDICATIONS:
□ Any drug interactions? Any to stop?
□ Renal dosing adjustments needed?
□ Anticoagulation (dose, monitoring)?

SOCIAL/DISCHARGE:
□ Improving enough for discharge?
□ Follow-up appointment needed?
□ Patient knows their diagnosis and medications?

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THINGS SENIORS WILL ASK YOU ON ROUNDS (Be Ready)

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1. Diabetes (DKA, HHS, Hypoglycemia) | 2. Hypertension | 3. Pneumonia | 4. TB | 5. Dengue | 6. Anemia | 7. AKI | 8. Liver / Jaundice | 9. Asthma & COPD | 10. Sepsis | 11. Electrolytes | 12. Thyroid disease | 13. PUD & GI Bleed | 14. UTI | 15. Malaria | 16. DVT & PE | 17. Cellulitis | 18. Epilepsy | 19. Nephrotic & Nephritic | 20. CKD

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CONDITION 11 - ELECTROLYTE DISTURBANCES (COMPLETE)

Full Guide | All 7 Electrolytes

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OVERVIEW - WHY ELECTROLYTES MATTER

• Cardiac arrest (K+, Ca2+, Mg2+)
• Seizures (Na+, Ca2+, Mg2+)
• Muscle paralysis (K+, Mg2+)
• Coma (Na+)

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ELECTROLYTE 1 - SODIUM (Na+) | Normal: 136-145 mEq/L

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HYPONATREMIA (Na+ <135 mEq/L)

Symptoms (depend on speed of fall, not just level):

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Step 1: Assess the patient's VOLUME STATUS (the most important step)

Look at the patient:
- Dry mouth, low BP, tachycardia, reduced skin turgor → HYPOVOLEMIC
- Normal examination → EUVOLEMIC
- Oedema, ascites, raised JVP → HYPERVOLEMIC

Causes by Volume Status:

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SIADH (Syndrome of Inappropriate ADH Secretion):

• CNS: meningitis, stroke, subarachnoid hemorrhage, head injury
• Chest: pneumonia, TB, lung cancer (small cell - most common malignancy cause)
• Malignancy: small cell lung cancer (secretes ADH ectopically)
• Drugs: carbamazepine, SSRIs (fluoxetine), morphine, cyclophosphamide, vincristine
• Idiopathic / Post-surgery

• Serum Na <135 mEq/L (low serum osmolality <280)
• Urine osmolality >100 mOsm/kg (inappropriately concentrated)
• Urine Na >40 mEq/L (kidneys still losing Na)
• Normal thyroid and adrenal function (exclude hypothyroidism, Addison's)
• No diuretics, no volume depletion, no oedema

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Treatment of Hyponatremia:

• Myelin sheath around brainstem neurons is destroyed
• Results in: dysarthria (slurred speech), dysphagia, flaccid paralysis, coma
• Irreversible, devastating - especially in malnourished, alcoholics, elderly

• Patient seizing OR
• GCS dropping OR
• Na <115 mEq/L

• In chronic hyponatremia (>48h): max correction 8 mEq/L in 24 hours
• In acute hyponatremia (<48h): can correct up to 1-2 mEq/L per hour
• Recheck Na every 2-4 hours when giving hypertonic saline

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HYPERNATREMIA (Na+ >145 mEq/L)

Causes:

• Water loss: Fever, sweating, burns, diabetes insipidus (DI), osmotic diuresis (DKA), diarrhea
• Inadequate water intake: Elderly, unconscious, infants who can't ask for water
• Salt excess (rare): IV hypertonic saline, excess sodium bicarbonate, sea water ingestion

Symptoms:

• Thirst (if conscious)
• Confusion, lethargy, irritability
• Weakness, tremors
• Seizures, coma (severe Na >155-160)

Treatment of Hypernatremia:

Free water deficit = [(Na actual - 140) ÷ 140] × Total Body Water (TBW) TBW = 0.6 × body weight in kg

• TBW = 0.6 × 70 = 42 L
• Free water deficit = [(165-140) ÷ 140] × 42 = 7.5 L

• Mild: Encourage oral water/feeds
• If IV needed: 5% Dextrose (D5W) or 0.45% NaCl (half-normal saline)
• Never give pure water IV - causes hemolysis

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ELECTROLYTE 2 - POTASSIUM (K+) | Normal: 3.5-5.0 mEq/L

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HYPERKALEMIA (K+ >5.5 mEq/L)

Causes ("DREAD"):

• Drugs: ACEi, ARBs, spironolactone, NSAIDs, heparin, beta-blockers, digoxin toxicity
• Renal failure (AKI/CKD) - can't excrete K+
• Endocrine: Addison's disease (no aldosterone → K+ retained)
• Acidosis: H+ goes into cells, K+ comes out
• Destruction: rhabdomyolysis, tumor lysis syndrome, massive hemolysis, burns

ECG Changes (in order as K rises):

Treatment - Three Goals (from Fischer's Mastery of Surgery):

• Low potassium diet (avoid: bananas, oranges, potatoes, tomatoes, dried fruits, nuts)
• Stop ACEi/ARBs if K+ consistently >6
• Newer agents: Patiromer (8.4g daily with food) or Sodium zirconium cyclosilicate

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HYPOKALEMIA (K+ <3.5 mEq/L)

Causes:

Symptoms:

• Mild (3.0-3.5): Often asymptomatic
• Moderate (2.5-3.0): Fatigue, weakness, muscle cramps, constipation, palpitations
• Severe (<2.5): Flaccid paralysis (including respiratory muscles), rhabdomyolysis, ileus

ECG Changes in Hypokalemia:

1. Flattening of T waves
2. U waves (positive deflection after T wave - classic sign)
3. ST depression
4. Prolonged QU interval
5. Severe: ventricular tachyarrhythmias (torsades de pointes)

Treatment:

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ELECTROLYTE 3 - CALCIUM (Ca2+) | Normal: 8.5-10.3 mg/dL

Corrected Ca2+ = Measured Ca2+ + [0.8 × (4.0 - albumin)]

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HYPERCALCEMIA (Ca2+ >10.3 mg/dL)

Causes - 90% are from just 2 causes:

1. Primary hyperparathyroidism - most common in outpatients; elevated PTH, usually asymptomatic, found on routine bloods
2. Malignancy - most common in inpatients; PTH suppressed but PTHrP elevated; advanced cancer

Symptoms - "Bones, Stones, Groans, Psychic Moans":

Treatment:

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HYPOCALCEMIA (Ca2+ <8.5 mg/dL, corrected)

Causes:

• Hypoparathyroidism - most commonly after thyroid/parathyroid surgery (check for Chvostek + Trousseau after any neck surgery)
• Vitamin D deficiency (very common - especially in sun-deprived populations, malnutrition)
• Hypomagnesemia - low Mg suppresses PTH
• Pancreatitis (fat saponification consumes Ca)
• CKD (impaired vitamin D activation, high phosphate)
• Massive blood transfusion (citrate chelates Ca)

Symptoms - "Neuromuscular excitability":

• Perioral tingling (numbness around lips)
• Tingling in hands and feet
• Muscle cramps → tetany (carpopedal spasm - hands/feet clench)
• Chvostek's sign: Tap facial nerve just in front of ear → facial muscle twitching
• Trousseau's sign: Inflate BP cuff on arm >SBP for 3 min → hand goes into carpal spasm (thumb adducts, fingers extend = "main d'accoucheur")
• Prolonged QT interval on ECG → torsades de pointes
• Seizures (severe hypocalcemia)
• Laryngospasm (emergency - airway obstruction)

Treatment:

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ELECTROLYTE 4 - MAGNESIUM (Mg2+) | Normal: 1.7-2.2 mg/dL (0.7-0.9 mmol/L)

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HYPOMAGNESEMIA (Mg2+ <1.7 mg/dL)

Causes:

• Diuretics (furosemide, thiazides) - most common hospital cause
• Chronic diarrhea, malabsorption
• Alcohol abuse (renal Mg wasting)
• Diabetes mellitus (renal loss)
• Drugs: aminoglycosides (gentamicin), proton pump inhibitors (long-term), digoxin, cisplatin
• Poor intake + refeeding

Symptoms:

• Mild: Causes other electrolyte disturbances (hypokalemia, hypocalcemia) - often only finding
• Severe:
  • Neuromuscular: tremor, muscle cramps, positive Chvostek/Trousseau
  • Neurological: confusion, seizures, heightened reflexes
  • Cardiac: Torsades de Pointes (the arrhythmia most associated with low Mg - polymorphic VT with QT prolongation)

Key Point: Refractory Hypokalemia

Treatment:

• Mild/moderate: Oral magnesium oxide tablets or magnesium glycinate
• Severe / symptomatic: MgSO4 (Magnesium sulphate) 2g IV over 10-15 min (slowly, watch for bradycardia and hypotension) then maintenance infusion
• Torsades de Pointes: MgSO4 2g IV stat is first-line treatment
• Eclampsia: MgSO4 4g IV loading dose (different context - prevent seizures)

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HYPERMAGNESEMIA (Mg2+ >2.2 mg/dL)

Causes:

• Renal failure (can't excrete Mg)
• Massive Mg supplementation (especially in eclampsia treatment)
• Excessive antacids (Mg-containing: gaviscon, milk of magnesia)
• Adrenal insufficiency

Symptoms by Level:

Treatment:

• Stop Mg supplementation
• IV calcium gluconate (10 mL 10% over 3 min) - temporarily antagonizes Mg at membrane
• IV fluids + furosemide (promote renal Mg excretion)
• Severe/renal failure: Dialysis

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ELECTROLYTE 5 - PHOSPHATE (PO4) | Normal: 2.5-4.5 mg/dL

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HYPOPHOSPHATEMIA (PO4 <2.5 mg/dL)

Causes:

• Refeeding syndrome (MOST important ward cause)
• Malnutrition, malabsorption
• Antacid use (aluminum/Mg antacids bind phosphate in gut)
• DKA treatment (insulin drives PO4 into cells)
• Hyperparathyroidism

• Occurs when severely malnourished patient starts eating/receiving nutrition (oral, enteral, or parenteral)
• Carbohydrates in food → insulin release → K+, Mg2+, PO4 all rush into cells → all 3 drop suddenly
• Prevention: Feed slowly, start at 50% of target calories, supplement K/Mg/PO4 before and during feeding

Symptoms of Hypophosphatemia:

• Muscle weakness (including respiratory muscles → ventilator dependence)
• Confusion, seizures
• Hemolytic anemia
• Platelet dysfunction

Treatment:

• Mild: Oral phosphate supplements
• Severe: IV sodium/potassium phosphate infusion

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HYPERPHOSPHATEMIA (PO4 >4.5 mg/dL)

• Calcium carbonate (cheapest, also supplements Ca)
• Sevelamer (non-calcium binder - better in dialysis patients)
• Lanthanum carbonate

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ELECTROLYTE QUICK REFERENCE TABLE

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ECG SUMMARY - ELECTROLYTES AT A GLANCE

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ELECTROLYTE CORRECTION - THE CARDINAL RULES

RULE 1: SODIUM
→ Never correct Na+ faster than 8-10 mEq/L per 24 hours
→ Too fast = osmotic demyelination → permanent brain damage

RULE 2: POTASSIUM
→ NEVER push KCl IV (causes cardiac arrest)
→ Max peripheral IV rate: 10-20 mEq/hour
→ Always give Calcium gluconate FIRST if ECG changes present
→ Check Mg2+ if K+ won't correct

RULE 3: CALCIUM
→ Always correct for albumin before deciding it's abnormal
→ IV calcium gluconate (not calcium chloride) via peripheral - safer
→ Monitor for QT changes on ECG

RULE 4: MAGNESIUM
→ Check Mg2+ in any patient with unexplained hypokalemia or hypocalcemia
→ Torsades de Pointes = give MgSO4 2g IV immediately
→ Check patellar reflex before each dose in eclampsia treatment

RULE 5: PHOSPHATE
→ Refeeding syndrome - think of it in any malnourished patient getting nutrition
→ Replace K+, Mg2+, PO4 BEFORE starting feeds in malnourished patients

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