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| No life ever grows great until it is focused, dedicated and disciplined." ~Harry E. Fosdick |
30th April to 30th May 2012
Learning objective: Basic lessons in ECG interpretation
This ECG strip is from a patient who presented with chest discomfort and breathlessness. His blood pressure was 102/70mm Hg and he had signs of mild left ventricular failure.
Learning points during this semester:
- A blood pressure above 130/80mmg Hg is the trigger to initiate antihypertensive treatment in patients with diabetes. Hence this value can be considered to define hypertension in diabetics.
- As a screening test for diabetes, a fasting plasma glucose (or a fasting capillary blood glucose) or a glycosylated hemoglobin value can be used.
- The e-GFR in any clinical situation where there is an element of acute kidney injury should not be the basis for defining ESRF. The e-GFR must be estimated when the chronic kidney disease is stable in order to grade the severity of the chronic kidney disease.
- ACE inhibitors and ARBs can be used in patients with chronic renal failure to protect kidneys from rapid deterioration in function. They help to prolong the dialysis-free interval for these patients. These drugs reduce glomerular hyperfiltration and help to slow down nephron loss. This benefit must be balanced against the risk of hyperkalemia and worsening of renal function that can occur because of these drugs. Hence we tend not to use these drugs in ESRF because of the risk of hyperkalemia and we tend not to use these drugs also in people who experience a greater than 30 percent increase in serum creatinine in the first few weeks after their initiation.
- A crucial decision in managing diabetes is when to initiate insulin in patients with Type2 diabetes. The answer will generally be: Not too early, not too late. The HbA1c is a good guide for this purpose. As a rule of thumb we can say that insulin should be initiated whenever the glycosylated hemoglobin is more than 10 percent.
- When initiating insulin for a Type 2 diabetic, start with a basal insulin in a dose of 0.2units per kg body weight given subcutaneously once a day.
- Basal insulins come as "pure" basal insulins or as a pre-mixed combination (biphasic insulin). Biphasic insulins should always be given before food.
- Metformin should be discontinued a few days before any procedure that involves the use of an iodine-containing contrast medium. This is to reduce the risk of contrast-induced nephropathy.
Dr Vela Menon, MD
Faculty of Medicine, International Medical University, Malaysia
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This is ventricular tachycardia with ventricular flutter.
VT: broad complex QRS (more than 0.12sec) with rate more than 100beats per minute.
VFL: 4th large box to 11th large box shows sine wave with rate more than 200beats per minute suggestive of ventricular flutter.
The rapid heart rate and absence of atrial filling impairs cardiac output with resultant hypotension and Left ventricular failure as seen in this patient. Ventricular flutter is an extreme form of ventricular tachycardia and usually progresses into ventricular fibrillation. Immediate management include advanced life support and cardioversion.