DocXus

A 24 year old was brought to the ER with a heart rate of 212 His batchmates carried him in from the hostel. Palpitations. Breathlessness. Panic Couldn’t sit still, kept grabbing the bed rail HR 212 on the monitor. Narrow complex tachycardia No prior cardiac history. No previous episodes. Completely healthy till tonight History revealed they’d been drinking. Smoking cigarettes. Normal hostel night Then someone brought a joint. Single joint. Passed around between five of them Four of them were fine Only he ended up here Same alcohol. Same cigarettes. Same joint. Same room So what was different about him? We tried a Valsalva The rhythm broke. He converted back to sinus. Once he settled down, we took the history again. Properly this time Specifically, anything in the last 48 hours. Anything at all. Even something you don’t think counts. He thought for a moment Then he said He had taken one tablet the previous day. Something small. Something he bought over the counter. Something he didn’t mention because it didn’t feel important Fluconazole 150 mg One tablet. Taken for a minor fungal issue. Available without prescription. Forgotten about completely Fluconazole is a potent CYP inhibitor. That’s one of the pathways responsible for clearing THC from the body Block that pathway and THC doesn’t metabolize normally Instead it accumulates as 11-OH-THC, its active metabolite which crosses the blood brain barrier more efficiently than THC itself and produces stronger sympathetic stimulation Fluconazole has a half life of about 30 hours It was still fully active when that joint came around His friends cleared the THC normally His liver couldn’t The same joint effectively became a much larger dose His sympathetic system fired His heart rate hit 212 Same alcohol. Same cigarettes. Same joint But one over the counter tablet had quietly changed the evening Drug interactions don’t care why you took the drug They don’t care that it was just ONE tablet Sometimes the critical detail is the one patients leave out The small thing they thought wasn’t worth mentioning.

Imaging tells you what it sees. Clinical exam tells you what’s happening!

@DipankarDoc 👏🎯

@docxusofficial Hippocrates method for reducing anterior dislocated shoulder, it's a good technique but uncouth

Name this OBSOLETE technique ______ ❓

@PerceptioApp 🎯

Hippocratic Technique Indication: Reduction of anterior shoulder dislocation. How is it performed: - The patient lies supine on a firm surface. - The physician places their heel in the patient’s axilla to act as a fulcrum. - Holding the patient’s wrist or forearm, the physician applies steady longitudinal traction to the arm. - The heel in the axilla provides counter-traction while the humeral head is guided back into the glenoid fossa. FAQs: - Why is it considered obsolete? Due to the risk of neurovascular injury and damage to the axillary structures from the heel fulcrum, safer and more controlled techniques are now preferred. - What replaced it? Techniques like the Stimson, Milch, and Kocher methods are commonly used today, offering better safety profiles. - Is it ever used now? Rarely, and typically only in resource-limited settings or emergencies where modern techniques aren’t feasible. - What are the risks? Brachial plexus injury, axillary artery compression, and soft tissue trauma

Type of gait? Most likely diagnosis ?

Heavy SMOKER presenting with this what’s the cause❓

What is the most likely diagnosis ??

Painless, soft, compressible forehead mass Diagnosis ?

@Psychiatrist42 a positive result indicates Troponin T >100 ng/L, so it’s far from “terrible” likely just a lack of exposure to such tests in your speciality!?

@docxusofficial What a terrible troponine test. You need quantification of the troponine level. Ok, this EKG is abnormal, but still..

What’s your immediate NEXT move ??

Qualitative trop exists for a reason, faster triage and to support ECG findings when time matters Studies show bedside/POC troponin can reach ~90–98% specificity and even >90% sensitivity, especially when repeated or timed properly It’s less precise than lab hs-troponin, but that’s the trade off for speed, early decision making, and real world emergency use

What’s the name of this procedure? When is it done ?

Critical OB decision Your Move: ______?

@esanum crisp summary 🎯

@docxusofficial ✅ Answer: Calcium gluconate ⚡️ ECG changes from hyperkalemia mean stabilize the myocardium first 💡 Calcium does not lower K, it buys time 🧠 Insulin with glucose shifts potassium intracellularly afterward

First line treatment ______ ❓

@DrsansariOrd 🎯

⚡ Hyperkalemia ECG → Why Calcium Gluconate is FIRST🚨 📈 Classic ECG changes in hyperkalemia 🔍 What you’re seeing Tall, peaked (“tented”) T waves → earliest sign Progressive changes: PR prolongation QRS widening Eventually → sine wave → ventricular fibrillation/asystole 👉 This is a cardiac emergency ❤️ Why Calcium Gluconate FIRST? 💡 Mechanism (high-yield) Hyperkalemia ↓ resting membrane potential → cells become more excitable Leads to dangerous arrhythmias 👉 Calcium gluconate: Raises threshold potential Restores stability between resting & threshold potential Prevents arrhythmias immediately ⏱️ Onset: 1–3 minutes 🔄 Why NOT Insulin/Glucose first? 💡 What insulin does Activates Na⁺/K⁺ ATPase Pushes K⁺ into cells Lowers serum potassium ❗ BUT: Takes 15–30 minutes Does NOT protect heart immediately 🧠 Exam Sequence (Must Remember) ✅ Stepwise approach 1. Calcium gluconate → stabilize heart ⭐ 2. Insulin + glucose → shift K⁺ intracellular 3. ± β-agonist / bicarbonate 4. Remove K⁺ → dialysis / diuretics 🎯 Final Takeaway 👉 ECG changes in hyperkalemia = Calcium gluconate FIRST Because: 🛑Protect the heart before correcting potassium