Causes based on signs or symptoms

1. Itching
Local causes-eczema, atopy, urticaria, scabies, lichen planus, dermatitis
herpetiformis, spinal cord tumours
Systemic causes-liver ds, uremia, malignancy, polycythemia rubra vera, IDA, old age,
pregnancy, drugs (morphine), DM, thyroid ds, HIV

2. Falls and difficulty walking

Intrinsic-RA, OA, #neck of femur, CNS ds, reduced vision, cognitive impairment,
depression, postural hypotension, peripheral neuropathy, medications (eg antiHPT,
sedatives), pain eg arthritis, parkinsonism (drugs egs chlorpherazine,
metoclopramide

Important topics need to learn before HO

Medicine
Cardio cases

ECG
interpretation
ACS STEMI
Diagnose when:
In a patient w ischemic chest pain (>30 mins) and accompanied by rise and fall in
cardiac biomarkers
i) ST elevation of >1 mm in 2 contiguous leads OR
ii) New onset of LBBB in resting ECG

In the absence of LVH and LBBB is:

i) Presence of >0.1mV ST elevation in all leads exc leads V2-V3
ii) A cut-off point of >0.25mV (in males <40 y/o), >0.2mV (in males >40 y/o)
and >0.15mV in females is used in leads V2-V3

To diff between posterior MI and NSTEMI:

If ST depression is at leads V1-V4 then it is posterior MI (+dominant R waves), if other
than that leads then it is NSTEMI.
Cardiac biomarkers: Troponin T and Troponin I, CKMB, CK, myoglobulin
 **Troponins rises within 3-4 hours of onset and more likely to be +ve 6 hours after
onset.
**CKMB peaks at 24 hours and returns to normal in 48-72 hours. Values should rise
and fall if not is never dt MI. So shud measure at first assessment and repeat 6-9
hours later.
*If reinfarction, use CKMB bcs troponins still could remain elevated for up to 2
weeks. A >20% increase between 2 samples 3-6 hours apart support dx.

Mx: Fibrinolytics or PCI

Indications of successful reperfusion by fibrinolysis: Resolution of chest pain, early
return of ST elevation to isoelectric line or decrease in height of ST elevation by 50%
within 60-90 mins of fibrinolytic therapy, early peaking of CKMB and CK levels,
restoration or maintenance of hemodynamic stability

Heart failure According to CPG: A clinical sx dt any structural or physiological abn of the heart
resulting in its inability to meet metabolic demands of the body or its ability to do so
only at a higher than normal filling pressures
Can be categorized into ACUTE and CHRONIC.

Also can be divided into LVEF;

i) HFrEF (LVEF<40%)
ii) HFmrEF (LVEF of 41-49%)
iii) HFpEF (LVEF >50%)
Special groups:
DM-better use SGLT2 inhibitor as reduced mortality and hospitalisations. SU,
biguanides (metformin) and alpha glucosidase inhibitor, acarbose is safe
IMPORTANT basic investigations
12 lead ECG Assess heart rate, rhythm, QRS morphology, duration, voltage,
evidence of ischemia, LV hypertrophy and arrythmias
CXR Assess pulmonary congestion, cardiomegaly and presence of u/l
lung pathology
*pts with HFpEF may have normal cardiac size
Blood tests FBC, RF, LFT, serum glucose, lipid profile, cardiac biomarkers
Urinalysis Proteinuria, glycosuria
Echocardiography LV chamber size, volume, systolic function, wall thickness,
scarring, RWMA, diastolic function of heart, valvular structure
and function, congenital cardiac abnormalities, pulmonary HPT
BNP/NTproBNP A rule out test for pts presenting w acute dyspnoea.
<100pg/mL for BNP and <300pg/mL for NTproBNP makes acute
HF unlikely.
**Basically if congested, give diuretics. If hypoperfused give inotropes. If adequate
perfusion don’t give inotropes.
Admit to ICU/CCU if: Hemo instability, arrythmias, hypoperfused, need for invasive
ventilatory support, O2 <90% despite given supplemental oxygen.

MANAGEMENT
1. Oxygen administration
-Supplemental O2 given when spo2 <95% or PaO2 <60mmHg. Titrated to achieve
>95% (consider HFNC also)
-NIV shud b considered early in pts w resp distress (RR>25, SpO2 <90%)
-If already resp failure consider intubation
2. Diuretics (indicated in pts who are FO)
-IV frusemide 40-100mg is DOC.
-Target 0.5-1.0kg decrease in body weight/day so if less than that indicate
inadequate diuretic dose/diuretic resistance

Vasodilators (considered when SBP >100)

-Eg nitrates, nitroprusside

Inotropes (not routinely adm if pts has adequate BP)

-Indicated in hypoperfusion despite adeq filling status
-Dopamine infusion (low dose at <2-3mcg/kg/min to improve renal flow and
promote diuresis)
-Dobutamine (start at 2-5mcg/kg/min and titrate by 1-2mcg/kg/min increments at 30
mins intervals)
-Noradrenaline also can

Morphine (co-administer w IV metoclopramide 10mg or prochlorperazine 12.5mg)

-IV 1-3mg bolus (max 10mg) reduces pulmonary venous congestion
Monitoring the vital signs and adequate response such as:
-Improvement in pts clinical conf and sx
-warm peripheries
-decrease HR
-improve O2 and UO
-watch out for cardiogenic shock eg SBP<90mmHg not improved w fluid
administration, sx of hypoperfusion, reduced UO (<20cc/hour), serum lactate
>2.0mmol/L.

Generally a SBP>90mmHg is considered adequate if pts has all of the following:

-feels well,
-has good ts perfusion such as absence of giddiness, warm skin AND
-Stable RF w good UO
Drugs in chronic HF
Respiratory cases

Asthma

COPD

Infectious disease cases

Dengue

Leptospirosis

Malaria

TB

HIV/AIDS
Endocrine cases

DKA

Hyperosmolar
hyperglycaemi
c syndrome
(HHS)
DM

Thyroid
disease

Electrolyte Hypokalemia
imbalance
Hypercalcemia

Hypocalcemia

Hyponatremia

Gastro/Hepatology cases
Chronic liver
disease

Hepatitis

PUD

Nephro cases
AKI

Fluid overload

Uremia

Hyperkalemia

ESRD

Neurology cases
Cerebrovascul
ar accident
Meningitis
Encephalitis
Acute delirium

Other common cases

Anemia

PUO
Poisoning

DVT