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Patiromer is a relatively new potassium binder and studies showed it is superior to Kayexalate which has been conventionally used to lower potassium in hyperkalemia due to various causes, especially renal failure. Patiromer works by binding to free potassium available the intestine and prevent its absorption into the bloodstream. It releases positive calcium ions which are absorbed instead of potassium if needed. As free potassium readily combines to the Patiromer, thus less potassium is available for absorption, this results in a decrease in potassium blood potassium level. Patiromer is not absorbed by the gut, thus it has no systemic side effects. The side effects are mainly related to the gut. Another advantage of Patiromer over Kayexalate is that it can be given in heart failure, hypertension, and CKD etc. Kayexalate has high sodium content and this can be potentially harmful in case of heart failure, hypertension and even in advanced chronic kidney disease. Anothe...

Coomb's test is very helpful in making a diagnosis of hemolytic anemia. Once a patient is found to have anemia, with raised bilirubin and raised retic count, hemolysis becomes the most likely possibility. Coomb's test is of two types. 1. Direct Coomb's test 2. Indirect Coomb's test. Direct Coomb's test: In case of direct Coomb's test, patient's RBC's are washed clear of plasma and are mixed with Coomb's serum (antihuman globulins), if agglutination occurs, it means the Direct Coomb's test is positive. If the direct Coomb's test is positive it means the patient has autoimmune hemolytic anemia. Indirect Coomb's test.  In indirect Coomb's test, the patient's serum is taken instead of RBCs and this serum is then mixed and incubated with RBCs with a known antigen if the patient's serum contains antibodies against the RBCs antigens then antibody-antigens complexes are formed, then coombs serum is added to the sample, if ...

Sometimes it becomes difficult to choose a drug in those patients who have multiple co-morbidities. That is are suffering from more than one disease and physician needs to choose a few out of many drugs to avoid drug-drug interactions. Anti-epileptic drugs, or the drugs which are used to treat seizures, do interact with other drugs.  Carbamazepine, phenytoin, phenobarbital, oxcarbazepine, topiramate and primidone are enzyme inducers. Enzyme inducers decrease the efficacy of a drug which is metabolized by the induced enzymes because more concentration of the enzyme will be available and the drug will be quickly metabolized and removed from the system.  Valproic acid, felbamate, rufinamide, and stiripentol, on the other hand, are enzyme inhibitors.  Therefore, we can't give these drugs to a patient who is taking a drug for any medical problem which is metabolized by the liver enzymes (eg cytochrome p450 enzyme system).  The anti-epileptic drugs which are not ...

Pericardial effusion is the collection of fluid around the heart. In this brief article, we will be discussing the signs of pericardial effusion on physical examination. Following are the 4 signs of pericardial effusion.  1. Pulsus Paradoxus.      Pulsus Paradoxus means a decrease in systolic blood pressure of more than 10mm of Hg during inspiration. The fall occurs due to increase in intrathoracic negative pressure during inspiration. In cardiac tamponade, Pulsus Paradoxus is exaggerated and a fall of more than 10 mm of Hg occurs during inspiration. An arterial line for blood pressure measurement is a good tool to measure inspiratory and expiratory blood pressures.  2. Ewart's sign     In case of a large pericardial effusion, dullness is present below the left scapular angle along with bronchial breathing. this sign is called Ewart's sign.  3. Increased Cardiac dullness.      The area of cardiac dullness increases upon the per...

Paramalignant pleural effusions and malignant pleural effusions are often used interchangeably which is wrong, these are two different types of pleural effusions, Said Dr Kausar Rehanna, assistant professor of the department of pulmonology, Shaheed Zulfiqar Ali Bhutto Medical University, Pakistan Institute of Medical Sciences, Islamabad, Pakistan. Paramalignant and malignant pleural effusions both occur in the presence of a solid tumour, but In case of a malignant effusion , there is direct pleural involvement and pleural fluid cytology shows malignant cells, therefore, an effusion which occurs as a result of metastatic pleural involvement and contains malignant cells is called a malignant effusion.  On the other hand, a paramalignant effusion does not contain malignant cells, it occurs as a result of complication of malignancy, such as hypoalbuminemia due to malnutrition or lymphatic obstruction etc. there is no pleural involvement in case of a para-malignant pleural e...

Pulmonary artery hypertension can be caused by a number of drugs. Some drugs are known to cause pulmonary arterial hypertension, while others are thought to be involved. Below is the list of drugs that may cause pulmonary arterial hypertension (PAH) Definitive causes of Pulmonary Artery Hypertension  Aminorex : A drug which was previously prescribed for weight loss, later withdrawn from the market when it was noticed that it causes pulmonary artery hypertension.  Fenfluramine : Another drug which was used in past for the purpose of weight loss, it is an anorectic drug, and decreases appetite. It was also withdrawn because it causes pulmonary artery hypertension.  Dexfenfluramine : An isomer of fenfluramine, was being used to induce weight loss.  Topical rapeseed oil : used as an anti-ageing agent.  Benfluorex : similar structure as that of fenfluramine.  Likely causes of Pulmonary Artery Hypertension.  Amphetamines : CNS stimulant Try...

A 35-year-old male presented to Emergency department of PIMS hospital complaining of intermittent hematuria, lower abdominal pain, and dysuria. Blood complete picture, Urine routine examination, and renal function tests were ordered along with an X-Ray KUB. X-Ray KUB revealed a Big Stone in the Urinary Bladder. The patient was referred to urology for further management. A Large stone in the urianry bladder. Courtesy of Dr. Adil Ramzan, MBBS, MD Internal Medicine A large stone in urinary bladder. Courtesy of Dr. Adil Ramzan MBBS, MD Internal Medicine, Pakistan Institute of Medical Sciences, SZABMU, Islamabad Pakistan Dr. Adil Ramzan, MBBS, MD Internal Medicine Pakistan Institue of Medical Sciences, Shaheed Zulfiqar Ali Bhutto Medical Univeristy Islamabad Pakistan

In this article, we will summarize the guidelines and recommendations about the initiation of enteral or tube feeding in a patient of acute stroke with dysphagia. Summary of Recommendations: When to start enteral feeding in a patient of stroke? Each patient of stroke should be evaluated for dysphagia as soon as possible. How to evaluate dysphagia in a patient of acute stroke? There are five ways of assessing dysphagia; Water swallowing test Multiple consistency test. Swallowing provocation test Videofluoroscopic swallowing study (VFSS) Fiberoptic endoscopic evaluation of swallowing (FEES) Videofluoroscopic swallowing study (VFSS) is the gold standard of swallowing evaluation.  Importance of starting early nutrition in a patient of acute stroke If a patient doesn't pass the swallowing evaluation. Then we should think about alternate modes of nutrition. As nutrition in a patient of stroke affects the outcome, decreases the risk of infections, bedsores, and also decrea...

A Patient who has a stroke commonly presents with altered sensorium, dysphagia, and weakness of a part or whole side of the body depending on the extent of infarct and area of the brain that is involved. If a patient has dysphagia or altered sensorium, then he is at risk of having aspiration. So in such situation, oral or enteral feeding shouldn't be allowed during the first 72 hours at least. Professor Dr. Rauf Niazi , explained during a teaching session at PIMS hospital, "A nasogastric tube should only be passed if needed as it may actually increase the risk of aspiration. In the presence of nasogastric tube the lower esophageal sphinctor (a valve at the lower end of esophagus which prevents reflux of stomach contents back to esophagus) can't close properly and food or gastric secretions may regurgitate back to esophagus, thus, increase the risk of aspiration. If patient is at risk of aspiration or is having recurrent aspiration, then you should pass NG tube ac...