Chronic Kidney Disease (CKD): Individualize BP-lowering therapy and treatment targets in people with frailty, high risk of falls, very limited life expectancy, or symptomatic postural hypotension. Treatments that delay progression of CKD with a strong evidence base include RASiand SGLT2i. In people with CKD and heart failure, SGLT2i confer benefits irrespective of albuminuria. Initial dips in eGFR are expected following initiation of hemodynamically active therapies, including both RASI and SGLT2i. GFR reductions of ≥30% from baseline exceed the expected variability and warrant evaluation. CKD is not a contraindication to an invasive strategy for people with acute or unstable heart disease. Imaging studies are not necessarily contraindicated in people with CKD and the risks and benefits should be determined on an individual basis. #CKD #eGFR #Kidney

Radio-opaque shadows on ABDOMINAL X-RAY • A substance is more radiopaque if it contains atoms of high atomic number (AN) such as calcium, iodine, barium, or lead. • Bone, which contains calcium (AN 20), is more radiopaque than soft tissue, which is made up mostly of carbon (AN 6), hydrogen (AN 1), and oxygen (AN 8). • Iodine (AN 53) is the key constituent of radiocontrast material and lead (AN 82) is an effective barrier to x-rays. #calcium #stone #calculi #calculus #foreignbody #abdomen #AXR #radiology

The eye is very complex and contains various tissues and structures that work together to provide vision. Eye problems can range from benign, self-resolving processes to malignant, and possibly metastatic tumors. Eye disorders can be caused by various factors, resulting in various signs and symptoms. They can be as trivial as minor irritation or pain all the way to blurred vision or blindness. Strabismus is a visual disorder in which the eyes are misaligned and point in different directions. When the eyes are misaligned, typically one eye will fixate on objects of interest while the other eye turns in (esotropia), out (exotropia), down (hypotropia), or up (hypertropia). #Eye #eyelid #iris #pupil #Strabismus #Blepharitis #Ptosis #scleritis #melanoma

Management of Diabetes Mellitus in Patients With CKD 1. Monitor for changes in BP, serum creatinine, & serum K+ within 2–4 weeks of initiation or increase in the dose of an ACEi or ARB. 2. Continue ACEi or ARB therapy unless serum creatinine rises by > 30% within 4 weeks following initiation of treatment or an increase in dose. 3. FDA recommends, metformin should NOT be used with serum creatinine ≥ 1.5 mg/dl in men & ≥ 1.4 mg/dl in women or with decreased creatinine clearance in people > 80. 4. Recommended is treating patients with T2D, CKD, & an eGFR ≥ 30 ml/min per 1.73 m2 with metformin. ADA/KDIGO Consensus Statements: All patients with Type 1 diabetes or Type 2 diabetes and CKD should be treated with a comprehensive plan, outlined and agreed by health care professionals and the patient together, to optimize nutrition, exercise, smoking cessation, and weight, upon which are layered evidence-based pharmacologic therapies aimed at preserving organ function and other therapies selected to attain intermediate targets for glycemia, blood pressure, and lipids. #Diabetes #CKD #ADA #KDIGO #eGFR #Insulin #metformin #ACEi #ARB.

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

ACUTE CHOLANGITIS Legend says that Cholangitis was first defined in 1877 by Jean-Martin Charcot, at which time the pathognomonic triad of fever, right upper quadrant pain, and jaundice was described. Today, cholangitis is defined as the presence of increased hepatic intraductal pressure with a concurrent infection of the obstructed bile. Chole: Derived from the Greek word “cholē” meaning bile. Angio: Comes from the Greek “angeion” meaning vessel. Cholangitis: Bacterial infection of the biliary tree. The pathogens identified as causative agents of acute ascending cholangitis are gram-negative and anaerobic organisms, the most common including Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, and Citrobacter. Iatrogenic introduction of bacteria commonly occurs post- ERCP in individuals with biliary obstruction. Charcot triad has a high specificity (95.9%), while sensitivity is low (26.4%). Tokyo guidelines (2018) have a sensitivity of 100% and specificity of 87.4%. #cholangitis #biliaryobstruction #Charcottriad #Reynoldpentad

Pseudo- Conditions in Medicine: The term ‘pseudo’ means ‘false’, ‘pretended’, ‘unreal’, or ‘sham’. Likely to be of Greek origin, pseudes means false. There are a number of ‘pseudo’ terms and syndromes that we see in the common practice. Even though the meaning of pseudo is unreal or sham, however several medical conditions/ syndromes are true entities as described above. #pseudo #false #pretended #unreal #sham

Acute Pulmonary Embolism: "D" sign: In a physiologically normal heart, LV pressure > RV pressure. When viewing heart in a parasternal short axis during systole the LV maintains a circular appearance, bowing the intraventricular septum into the right ventricle. A D-shaped left ventricle or flattening of the interventricular septum with a D-shaped configuration is a feature described with significant RV overload / right heart strain such as that occurring with complications of a sizable pulmonary embolic event. McConnell's sign: An echocardiographic finding of segmental right ventricular wall‐motion abnormality with apical sparing, is highly specific in acute pulmonary embolism and may guide rapid intervention when other testing is not feasible. #Pulmonaryembolism #PE #FleischnerSign #Hamptonhump #D-sign #McConnell'ssign #S1Q3T3 #Westermarksign #knucklesign #Pallasign #Changsign

Thyroid storm is a rare and life-threatening condition characterized by an acute exacerbation of thyrotoxicosis (elevated free triiodothyronine or free thyroxine and suppressed thyrotropin) with severe clinical symptoms. It often results in multiorgan failure involving one or more organ systems such as the central nervous, cardiac, hepatic, pulmonary, respiratory, digestive, and gastrointestinal excretory systems. Specific Strategic Steps for Treatment: • Therapy to control increased adrenergic tone: Beta-blocker • Therapy to reduce thyroid hormone synthesis: Thionamide • Therapy to reduce the release of thyroid hormone: Iodine solution • Therapy to block peripheral conversion of T4 to T3: Iodinated radiocontrast agent, glucocorticoid, PTU, propranolol • Therapy to reduce enterohepatic recycling of thyroid hormone: Bile acid sequestrant #Thyroidstorm #thyroid #thyroidcrisis #beta-blocker #glucocorticoid #Thionamide #Iodine #PTU #triiodothyronine #thyroxine #thyrotropin #propylthiouracil #methimazole

Urinalysis & Urine Sodium Theophilus Protospatharius, a seventh-century physician who wrote the first manuscript focused exclusively on urine called "De Urinis", determined heating urine would precipitate proteins, documenting proteinuria as a disease state. French scholar named Gilles de Corbeil (12th century) classified 20 different types of urine, recording differences in urine sediment and color and introduced the "matula," a glass vessel in which a physician could assess color, consistency, and clarity. Following includes the complete analysis of urine: Visual exam • Color. • Clarity Dipstick test • Acidity (urine pH). • Bilirubin. • Blood (hemoglobin). • Glucose. • Ketones • Leukocyte esterase. • Nitrites. • Protein • Urine specific gravity test. Microscopic exam • Crystals. • Epithelial cells. • Bacteria, yeast and parasites (infections). • Red blood cells (RBC). • Urinary casts: • White blood cells Fractional excretion of Sodium (FE Na). [(U Na x P Cr) / (P Na x U Cr)] x 100 U = Urine, P = Plasma, Cr = Creatinine, Na = Sodium. Re-absorption and filtration accounted (Both). Should not be used with normal renal function. Acute Kidney Injury (AKI) FE Na < 1% Urine sodium < 20 mEq/L. Acute Tubular Necrosis (ATN) FE Na > 2% Urine sodium > 40 mEq/L. #Urinalysis #crystals #dipstick #nitrite #leucocyte-esterase #urine #UNa #casts #glucosuria #hematuria