Medical students remember a golden rule.
Magnesium and potassium are linked.
One of the commonest ignored cause of refractory hypokalemia is hypomagnesemia.
If magnesium and potassium both are low, replace magnesium first and then potassium.
Otherwise your everyday
Ok my med residents. Here comes the potassium replacement🥳
There is no guideline. Its a self learning process. There is no right or wrong in this but we need to be mindful of certain things and then i ll teach you my way, the Abbasi way.
Medicine residents, a very smart and easy tool to pick thallesemia minor. So please dont miss it or treat it as iron deficiency anemia.
When you see low Hb, low MCV and suspect IDA, immediately look at RBC count. In iron deficiency, RBC count should also be low. But..
Medicine residents dont be afraid of chemotherapy. 🫣
Will teach you some basics so that you can handle it with confidence 😎 meanwhile you reach a heme/oncologist.
#1
In iron deficiency DO NOT transfuse blood UNLESS the patient is symtomatic. IRRESPECTIVE of the hemoglobin level.
Hb 4.5😰, patient is not short of breath, no signs of anemic failure, proven iron deficiency, DO NOT transfuse blood. Start iron replacement and follow closely.
Medicine residents, please whoever has NG tube placed, REMEMBER their mouth is dry like hell and they really feel the thirst. Just imagine what you would feel if you are damn thirsty and no one gives you water. We are of the impression that they are getting enough replacement
Med residents... listen...
Low Hb, high mcv, associted with other cytopenias, LDH high, raised indirect bilirubin, first thing that comes in your mind is...
Medicine residents what to do with hemolytic anemia😵💫
A simple approach to make your life easy peasy.
No. 1 - establish hemolysis
No. 2 - determine the type and cause
No. 3- treat it
Lets discuss 1 by 1.
Hey medicine residents🫠
First 30 minutes - Easy management of febrile neutropenia😎
Step 1 - Dont panic. Your clinical acumen becomes zero when you panic. So think before you ink.
Medical student and residents, please dont ignore this.
Metformin, one of the commonest medicines used for the management of diabetes mellitis and for a a few other reasons, results in vitamin B12 deficiency 😲
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Medicine residents!! Medicines that may help patients with persistent hiccups are as follows:
Start with PPI lets say Omeprazole 40mg , 3-4 weeks
Not settled, Baclofen 5mg-10mg tid
Or Gabapentin 100-400mg tid
Not responsive, Metoclopramide 10mg tid
Not resolved, chlorpromazine
Medical students always remember, if patients WBC are increased and the patient is on steroids, its one of the causes.
Whats the phenomenon?
Its called....
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Hey medicine residents.
Lets simplify the commonly used blood components.
1. Whole blood collected from donor is centrifuged by a machine to seperate rbcs from the plasma(platelet rich).
Hey medicine resident, generally in hematology malignancy inpatients, dont worry about when to tranfuse blood and platelets. Generally among the hematologist the cutoff are the following:
Hb <7 or 8 for most of us.
Platelets <10, in case of infection, <20, incase of ..
Medicine residents, please REMEMBER.
Never prescribe steroids for the evening time. It disrupts the normal sleep cycle.
Even when prescribing Bid dose, give in the morning and afternoon. Rather than than morning and night.
This is very important and will really change how your
Iron deficiency anemia.
Please do not give Feso4 200mg po TID.
Give Feso4 200mg po once a day, every alternate day.
Reason- There is max limit of iron absorption. Secondly raised iron increases hepcidin further causing decreased iron absorption.
Med residents, lets learn how to replace B12 ?😰
There is no correct way.
One way practised in a number of countries is as follows:
7 injections of 1000mcg daily (ideally alternate day) for 7 doses, followed by 1 injection every week for 4 weeks..
#1
Hematology made easy
Retic count - tells you exactly if bone marrow is producing enough or less or higher hemoglobin precursors. Indirectly its a marker of healthy bone marrow.
Remember when you have anemia and retic count ia high, it means bone marrow is perfectly fine and
You prescribed iv iron to patient in iron deficiency anemia and 3 days later patient comes up with severe fatigue? Medicine residents!!!!
Very very important to know.
Low platelets 😵 emergency.
But when?
Patient is actively bleeding. Transfuse platelets irrespectively. Do the further workup after that.
Patient is in sepsis. Lactic acid, procal, d-dimer, fibrinogen will guide you.
#1
Hey medicine residents!!
If you see high hemoglobin /hematocrit in a patient in routine labs and concerned about polycythemia, do this thing first. A lot of times its false alarm.
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Magnesium is low medicine residents🤔
Easy peasy.
Normal range 1.7 to 2.2 mg/dL (0.85 to 1.10 mmol/L). Just you tease you guys. Never try to remember. Labs have range variation, follow local lab range.
Hematology made simple
How to play with MCV? And low Hb
Mcv low - think of iron deficiency anemia and/or thallesemia
MCV normal - think of mixed nutritional deficiency anemia/ bleeding
MCV high - Vitamin B12 deficiency, Folate deficiency, hemolysis, drugs such as hydroxyurea/
Remember medical residents and students.
If you want to give steroids in BID dose, give the patients in AM and max late in the afternoon. Please avoid giving steroids at later time in the day or after evening. Steroids disrupts the sleep cycle and patients specially on high dose
How to know if someone is in sepsis?
Tachycardia ( lets say >120)
Labs:
Fibrinogen < 1
D dimer > 5
Pt/Aptt deranged
Neutropenia/Leucocytosis
Thrombocytopenia
Crp/Procal raised significantly
You may not find all available markers but most of them, if present, be alert.
How to
How do you check iron deficiency??
Medicine residents!!!!
Dont waste resources.
Just do ferritin levels. It tells you stores of iron in body. Thats it. If its less than 50, replace iron oral/iv. If above expect iron levels are fine.
However as ferritin is acute phase
So medicine residents lets learn something about breaking bad news. We all have to go through this as physicians. So how do you break bad news to a patient and/or his family. There is a well known SPIKE protocol.
Medicine residents!!!!
Remember. The most dehydrated person on floor is the resident. Keep yourself hydrated specially in 12-24 hour calls. Take care of yourself as no one else will.🫠
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Hey medical students and residents, What is precisely iron deficiency?
With all the unnecessary iron profile results making you confused, here is a simple hack.
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Medicine interns and residents. How to manage fever as a symptom?
Sponging, Paracetamol, NSAIDs and steroid are the 4 commonly applied options.
Paracetamol is the best option always with least side effects.
Problem comes in the case of transaminitis or active hepatitis...
For medicine residents
Anemia> low mcv> ⬆️rbc count> rule out thalassemia minor.
Anemia>low mcv>rbc count low> consider Iron deficiency anemia
Take history : for females, menorrhagia is important. History of not eating red meat, poor diet, liking for raw rice, for ice.
#1
So medicine residents!!!!
How to manage DOACS like Rivaroxiban, apaxiban peri operatively?
When to stop, when to restart.
Here is a brief easy method.
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Hey medicine residents.
When you order a blood transfusion, a sample is asked by lab for crossmatch. What is a Xmatch?
To make it simple, patient will receieve rbcs from a donor. So we want to make sure there are no antibodies in the serum of the recepient against the rbcs ..
Always remember my dear medical students and residents.
Never keep a patient with febrile neutropenia on regular anti pyretic. Fever is like an alarm for you to react quickly. Regular antipyretics may mask fever. Likewise a patient on regular steroid will mask fever, so be on
Medicine residents, everyone of you must know about VTE prophylaxis. Any patient thats admitted on floor, needs to be assessed for VTE. If you dont have a specific tool, you can use the following and if high risk, the patient should start on prophylactic dose of enoxaparin which
So a lot of neutrophils are actually on the margins of endothelium and not in peripheral blood. When you give someone steroids, it causes "demarginalization" of the neutrophils giving you neutrophilia and raised WBC in the blood. What do you have to do about it? Nothing. Just
If the Hb and MCV is low specially MCV in 50s lets say and RBC count is high rather than low, ALWAYS rule out thallesemia minor, which is specially prevalent in Indo Pak region and some other parts of the blood. There is reactive eryhtrocytosis due to minor hemolysis going on.
Magnesium deficiency exacerbates potassium wasting by increasing distal potassium secretion. A decrease in intracellular magnesium, caused by magnesium deficiency, releases the magnesium-mediated inhibition of ROMK channels and increases potassium secretion. Magnesium deficiency
Hey Medicine residents, lets learn some basics about CMV virus. Its lesser known in non hematological settings but in heme onc it matters a lot.
Cytomegalovirus is from what species is your least concern ao leave this bookish info aside as far as medicine residency is concerned.
An open invitation to all my follower medical students, residents, if you are reading anything from the text book regarding hematology or related topics and you dont understand, feel free to send me a snap of your book page and ask what you dont understand. No hesitation please.
Be prepared for some FREE GIFTS such as medical books for my FOLLOWERS around the globe.
I may select random medical students, residents and physicians from my FOLLOWERS and inbox them to tell me the medical book of their choice which they want to buy and will try my best to
So remember Ferritin levels is the answer. See ferritin levels, less than 50, treat. Its iron deficiency.
If patient has any inflammatory condition/ chronic disease that may cause an increase in acute phase reactant , only then consider other parameters to help you.
So lets say
Remember , never give Intravenous Iron Infusions in a setting where you dont have emergency services. Patients can sometimes have severe anaphylactic reactions leading to mortality. In addition, a crash cart having epinephrine IM injection is a must. In many countries its a
What should you do? Just get hemoglobin electrophoresis ( HPLC ideally) done to see if there is element of Beta thallesemia minor. In that case, do not replace iron. The Hb in these patients will vary between 9 and 12. But no need to treat it. Just like any hemolysing disorder ..
Medical students and residents. You frequently use blood products but are not aware of their volumes. Patients can go into volume overload and other complications specially those with compromised, renal, cardiac or liver function.
Here you go with the volume. Just compare it
Uptodate is a must have resource for all heathcare professionals. I would like
@UpToDate
to give a special promo code discount for my followers. Kindly like and share to tell them you really need it. We want a very good discount for our followers specially those who are living in
Medical students, If you hear some one saying ANC, dont panic. You know wbc, its not very different. Just a subset.
anc stands for absolute neutrophilic count.
So lets say a patient wbc is 4 x 10^9/L and neutrophil % is 60%. Very simple calculation.
Wbc × % neutrophils × 10
4
Always check both folic acid levels and b12 both as very severe folate deficiency will show falsely normal levels of B12. So replace both in that case. Hb, wbc and platelets , in addition to LDH and lfts all will correct just with B12 replacement.
#3
Most of the patient in screening labs do their labs in a state of fasting, usually for lipid profile. Being dehydrated, they have a falsely high hematocrit. So always, before making big decisions and creating anxiety in patient, ask them to repeat the lab some other day after
Platelet cutoff :
Bone marrow biopsy - any counts, if less than 10, just keep platelets in hand if patient bleeds.
Lumber puncture - 40-50 k
Major Surgery - 50k
Liver biopsy - 50k
Splenic aspiration - 80k
Epidural anesthesia - 75k
Opthalmic/Neuro surgery - 100k
CVP insertion...
So remember every cell in the body originates from its stem cell. Likewise goes for blood cells. All blood cells originate from a hematopoietic stem cell > blast cell> lymphoblast and myeloblast. There are approximately 5% normal blast cells in the bone marrow. Bone marrow is the
Hey medicine residents physicians!!!
How to see a patient in a clinic?
For a better patient satisfaction, shortening consultation time, earlier diagnosis and better doctor patient relationship
Remember 2 things.
1 - Golden minute
2 - ICE
Filgastrim/GCSF/Nupogen ...
Is it a solution for every neutropenia?
Can you give it in any patient who comes under any service who has neutropenia.
Medicine residents lets learn the use and contraindication of using gcsf.
Lets start ...🫠
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Chemotherapy can cause cancer?
The answer is Yes.
#MedTwitter
BUT Chemotherapy mainly cures cancer. This is more important. Please understand what I am going to tell you now.
Whats the normal ferritin cutoff for considering IDA?
For all practical purposes, no ones ferritin level should be less than 50 ng/ml. So any patient with ferritin <50, needs to be treated. Please ignore the normal lab ranges in your lab😉.
I hope you ll remember 50🙂
Bye🫠
Potassium is mainly intracellular and there is no direct way to check intracellular potassium level. We can only check extracellular potassium which can be measured by simple chemistry. So a 4 meq/litre of K extracellularly maintains an intracellular K of 160 meq/litre.
#2
Which means that a 1 meq/l of change for example from 4 to 3 is not just 1 but a significant change in the intracellular potassium. And so replacement needs to be done to fill the intracellular potassium deficit.😎
#3
And beware cytopenias will be scary like Hb of 4, tlc of 1 and platelets 20k.
So dont worry, with the picture explained above dont forget to rule out B12 deficiency. This simple vitamin deficiency can play havoc.
Bye and take care🫠
A sincere advice to my colleagues and juniors in medicine.
Dont be around those seniors and consultants who always discourage you from being a doctor and telling that medicine has no future.
You ll see each one of them will have either a son or a daughter becoming a doctor.
So how do we know the actual deficit? There are many arbitarary formulas, and there is no right one. The one I follow is as follows. (4-K level of patient × 0.4 x weight in kg) +Wt( as daily maintainence requirement of K is 1mg/kg). So lets say your patient K is 2.5.
Potassium replacement needed = (4-2.5) x 0.4(constant) × 70 ( kg average adult male) +70 = 112 meq .
This needs to be replaced to correct potassium levels.
But how to replace such a large volume and what are the considerations.
#4
Medicine and Hematology Residents !!!
For all practical purposes, to learn coagulation and related material, the best website is
Go and read everything in detail.
In addition they have an app named EMBOLUS that covers many areas, mcq based
Ideally treat the disease. Erythropoieten works in some diseases like CKD. People are actually trying to find someone to actually handle the pirate hepcidin.
Bye guys🫠
Medicine residents. A very important advice.
Plan your vacations. Dont waste your 10-20 days of holidays.
Everyone needs a break from the routine. Our schedule is mentally very tiring.
Go to nature. Spend sometimes in the wood, cool fresh air, in the mountains and river.
What is MDS ( Myelodysplastic syndrome)? Easiest way.
In MDS there is dysplasia in cells, causing functional and quantitative defect in blood cells which include all 3 lineages, red blood cells, white blood cells and platelts. So these cells are dsyfunctional and cause
Hematologist !!!!
Hepcidin causes decreased iron absorption and utilisation. A new hepcidin mimic, named Rusfertide, not yet FDA approved has been used in a small RCT showing promising results in polycythemia vera patients with mininal side effects, eliminating the need of
1. Red packed cells 300 ml - given in max 4 hours
2. Platelet bag ( random unit) 50 ml , 6 units equavelnt to 300ml given in 30 minutes.
3. FFPs 250 ml - given over 15-30 minutes
4. Cryoprecipitate - 30ml per bag lets say you give 10 units so around 300 ml in 30 minutes.
In brief if some one has high likeness of having hypocalcemia, hypovitaminosis D or prolonged admissions, history of poor oral intake, correct the deficiencies and make sure not to ignore severe fatigue after iron replacement. As hypophosphatemia is sometimes critically low and
Story starts when iron decided to go from his home( storage site) for work( being utilised for iron related construction, hemoglobin lets say). Iron hired a ship named " ferroportin" and he left for the destination. However suddenly...
Establish hemolysis - Low hemoglobin, high mcv( not always), high retic count ( compensatory increase in immature RBCs, low haptoglobin, raise in indirect bilirubin and high LDH.
There is a well balanced production of each cell to make sure their numbers are maintained for optimal functioning. By some unlucky event, a mutation or a hit, this control is lost. When this happens at the levels of blast production, its acute leukemia and when it happens at a
Iv fluids is the corner stone of all sepsis management. Patient worsens because of hypotension and then its a sequelae of multi organ failure.
So assess if patient is hemodynamically stable or unstable. See Heart rate and blood pressures. If patient is tachycardic and ..
#3
Medicine residents!!!! Patient came with platelet counts of 30,000, with no history of bleed. You ordered a peripheral film morphology review? Here what you see. What is this?
Image: The blood project
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RETWEET this post to enter the draw to win a medical book of your choice. To maintain transparency, I will use retweet picker, which will select random person from the retweet. The winner must be a FOLLOWER to be eligible for the gift. The medical book of choice will be delivered
Medicine residents please take care of one thing.
Patients who are NPO a lot of times feel extreme dryness in mouth. The oral mucosa feels dry giving a feeling of thirst. A lot of time doctors and nurses dont respond to their request as they are NPO. Please try to alleviate..
NLR - Neutrophil to lymphocyte ratio?
To be honest I never use it.
Studies have mixed data on its use and relevance.
Used as earlier marker of sepsis, to differentiate between viral vs bacterial pneumonia etc.
My two cents. Dont waste your time with NLR.
Then how to
One last important thing is the MOA.
The process by which this deficiency develops is as follows. Vitamin B12 is derived primarily from consumed animal proteins. Upon digestion of these proteins, gastric parietal cells produce intrinsic factor (IF), which attaches to the vitamin
Category : Anthracyclines eg. Doxorubicin, Daunorubicin, Idarubicin. These medicines cause two problems mainly. Cardiomyopathy, so basically a heart failure and cytopenias post chemo. Normally the blood counts will go down and reach there lowest point(nadir) by day 7 and ..
#3
Corneal bleed or opthalmic bleed <50, in case of acute promyelocytic leukemia <30.
When not to tranfuse platelets
ITP , TTP and HITT unless patient is actively bleeding.
In sepsis and acute promyelocytic leukemia , keep d dimer <5 by transfusing FFPs,...
Never transfuse packed cell in a patient with hyperleukocytosis, it presents like the symptoms of anemia but its actually leucostasis. First reduce the leukocyte count and then transfuse.
Thats it for now.
Bye 😄