Inotrope Selection

Inotrope selection is sometimes needed but please find the cause, find the cause, FIND THE CAUSE, and find the cause before using this.

Interpreting Arterial Blood Gas

Interpreting arterial blood gas is an essential skill for the house officer. This is the outline of my framework.

Taking a past medical history or history disease known.

If the examiner request that you take a history of a patient's diabetes mellitus , one cannot use the normal methods. Instead I use the D2FMC3 framework.
You must know the:

1. Duration
2. Diagnosis
• presenting symptoms
• trigger or risk factors
• gold standard tests done
• clinical criteria used for diagnosis
• who and where was the diagnosis
3. Follow-up
• regular or irregular
• defaulted
• doctor-shopping
4. Management
• Non-pharmacological
• Pharmacological
5. Compliance
• If not, why?
6. Control
7. Complications
• disease-related
• treatment-related

For example: This 50 year old gentleman has diabetes mellitus which was diagnosed in 2015. He first presented with polyuria, polydipsia, and recurrent fungal infection of the genital area. His parents had diabetes mellitus. Both diagnosed in their 50's. Fasting blood glucose was 14.3 mmol/L and HbA1c done by his general practitioner was 9.2%. He is currently being regularly followed-up by his personal GP. He already has been screened for retinopathy, nephropathy, and polyneuropathy. He is under regular ophthalmology follow-up, has seen the foot care nurse and seen the diabetic nurse educator. He is now on metformin 1g bd and basal bolus insulin. He is compliant to his medication though sometimes not compliant to diet restriction. His latest HbA1c is 7.0% and home self-monitoring of blood glucose is between 5.0 to 8.0. He has microalbuminuria and has undergone one previous laser treatment for his left eye and cataracts removed from both eyes. He admits to hypoglycaemic episodes up to once a week usually around 3am and this has affected the compliance to his insulin somewhat.

So hopefully with this framework one can get as much relevant history as is needed.

A further elaboration of the art of history-taking

There are two forms of history-taking: that which the disease is known ("please take a history of this patient's diabetes mellitus") and that which the disease is unknown ("this gentleman is short of breath").
If the disease is known we use the D2FMC3 framework outline previously.
If unknown we use the method we most commonly use. My variation of this method will be outlined below:
First we clarify the symptoms and find out what the patient means. Most time the use the words wrongly or imprecisely.
Then we find out the duration.
Then we determine the history of presenting illness. For me there are two components: the character of the symptoms and the differentials.
For the character I use OPPA:

1. Onset
2. Progression
• frequency
• severity
• timing
3. Previous similar symptoms
4. Aggravating and alleviating factors

Then depending on what the symptoms are I will ask further questions. For example for pain, I will ask the character, site, and radiation.

The illustration is seen here.