Dr. Rakib's Med Academy

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11/07/2026

❤️ HOW TO START ANTIHYPERTENSIVE DRUGS — A SIMPLE STEPWISE APPROACH

📌 Goal: Reduce cardiovascular, cerebrovascular, and renal complications by achieving and maintaining target blood pressure.

💡 Golden Rule:
Confirm Hypertension → Assess Risk → Start Lifestyle Measures → Choose the Right Drug → Titrate → Add Combination Therapy if Needed → Monitor

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🩺 STEP 1: CONFIRM THE DIAGNOSIS

✅ Diagnose hypertension using repeated properly measured office BP (or confirm with home BP monitoring/ambulatory BP monitoring when feasible).

Office BP Classification
▪️ Normal:

11/07/2026

📌 APPROACH TO FEVER — A SIMPLE STEPWISE GUIDE

📌 Fever is a symptom, not a diagnosis. The key is to identify the underlying cause while recognizing patients who need urgent treatment.

💡 Golden Rule: Confirm Fever → Assess Stability → Take Focused History → Examine → Investigate → Treat the Cause → Reassess

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🌡️ STEP 1: Confirm Fever

▪️ Fever = Body temperature ≥38.0°C (100.4°F)

Measure accurately:
▪️ Oral.
▪️ Tympanic
▪️ Re**al (most accurate for core temperature)
▪️ Axillary (less reliable)

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🚨 STEP 2: Assess for Emergency (ABCDE)

Look for red flags requiring immediate management:

🔴 Hypotension/shock
🔴 Altered mental status
🔴 Respiratory distress
🔴 Severe dehydration
🔴 Seizure
🔴 Purpuric/petechial rash
🔴 Meningeal signs
🔴 Severe immunocompromise
🔴 Suspected sepsis

➡️ If unstable:
▪️ Resuscitate (ABCDE)
▪️ Obtain cultures promptly
▪️ Start empiric antimicrobials without unnecessary delay when serious bacterial infection or sepsis is suspected.

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📝 STEP 3: Focused History

Ask about:

▪️ Duration and pattern of fever
▪️ Chills/rigors
▪️ Localizing symptoms • Cough • Dysuria • Diarrhea • Headache • Rash • Joint pain ▪️ Recent travel
▪️ Animal or insect exposure
▪️ Sick contacts
▪️ Drug history (drug fever)
▪️ Vaccination status
▪️ Recent surgery or hospitalization
▪️ Immunocompromised state

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🔍 STEP 4: Physical Examination

Perform a complete examination:

▪️ Vital signs
▪️ Skin and rashes
▪️ ENT
▪️ Neck stiffness
▪️ Lymph nodes
▪️ Chest
▪️ Heart murmurs
▪️ Abdomen
▪️ Costovertebral angle tenderness
▪️ Joints
▪️ Neurological examination

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🧪 STEP 5: Investigations

Base investigations on clinical suspicion.

Common initial tests:

🩸 CBC with differential
🩸 CRP and/or ESR
🩸 Renal function
🩸 Liver function
🩸 Blood glucose
🩸 Urinalysis ± urine culture

When indicated:

▪️ Blood cultures (preferably before antibiotics if feasible)
▪️ Chest X-ray
▪️ Sputum studies
▪️ Stool examination/culture
▪️ Malaria test (endemic areas)
▪️ Dengue NS1/IgM (when appropriate)
▪️ Lumbar puncture (if meningitis suspected)
▪️ CT/Ultrasound if occult infection is suspected

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🎯 STEP 6: Identify the Cause

Common causes include:

🦠 Infections (most common)
▪️ Viral
▪️ Bacterial
▪️ Tuberculosis
▪️ Malaria
▪️ Dengue
▪️ Fungal

🔥 Non-infectious causes

▪️ Autoimmune diseases
▪️ Malignancy
▪️ Drug fever
▪️ Venous thromboembolism
▪️ Endocrine disorders (e.g., thyroid storm)

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💊 STEP 7: Management

Supportive Care

💧 Adequate hydration 🛌 Rest 🍲 Maintain nutrition

Antipyretic

✅ Paracetamol (Acetaminophen)

⚠️ Do not routinely alternate paracetamol and ibuprofen.

Antibiotics

❌ Do NOT prescribe antibiotics for every fever.

Use antibiotics only when there is evidence or strong suspicion of a bacterial infection, following local antimicrobial guidelines and culture results whenever possible.

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⏳ STEP 8: Reassess

Monitor:

▪️ Temperature trend ▪️ Vital signs ▪️ Clinical response ▪️ Laboratory results

Escalate evaluation if: ▪️ Fever persists ▪️ New symptoms develop ▪️ Patient deteriorates

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❓ Fever of Unknown Origin (FUO)

Consider FUO when fever persists despite appropriate initial evaluation.

Common categories:

▪️ Infection ▪️ Malignancy ▪️ Autoimmune/inflammatory disease ▪️ Miscellaneous causes

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💎 MediNerd Pearls

✅ Fever itself is usually not harmful; the underlying cause is what matters.

✅ Always assess for sepsis in any febrile patient with systemic illness.

✅ Obtain appropriate cultures before antibiotics whenever feasible, but never delay antibiotics in septic or unstable patients.

✅ Avoid unnecessary antibiotic use

03/06/2026

➡️ FCPS Part 1 - Medicine - June Diet Question (Topic)
➡️ Chapter 1. Clinical Decision-Making

Good clinical ethics
Doing good for patient
Accept previous error

➡️ Chapter 3. Clinical Genetics

Test to diagnose prenatal Down syndrome
Mitochondrial disorders characteristics
Imprinting disorders
Autosomal dominant

➡️ Chapter 4. Clinical Immunology

Graft rejection – Most common cause
SLE hypersensitivity
Complement deficiency er jonno kon kon organism diye infection hoy (MCQ)
Site of T cell maturation
Components of acquired immunity
NK cell - MCQ

➡️ Chapter 5. Population Health and Epidemiology

RCT
Sampling method
To confirm HIV - Specificity

➡️ Chapter 7. Oncology

CA 19-9 associated cancer
Occupational Malignancy - MCQ

➡️ Chapter 10. Poisoning

OPC Muscarinic features - SBA
Digoxin toxicity ECG - SBA
Small pupil (MCQ)
TCA - ECG

➡️ Chapter 12. Medicine in Austere Environments

Heat stroke
Hypothermia Mx

➡️ Chapter 13. Infectious Disease

Dengue myocarditis – Markers
Dengue plasma leakage – Pathophysiology
Diphtheria – Investigation
Mosquito-borne disease
Malaria despite prophylaxis / Relapsing malaria
HIV CD4

25/04/2026

New DM Management Landscape (NICE 2026 Update)

BIGGEST CHANGE: First-Line Therapy

New Standard:

Modified-release Metformin (MRM) + SGLT2 inhibitor for most patients

If Metformin not tolerated:
SGLT2 inhibitor alone

This is a major change: SGLT2 inhibitors moved from 2nd line → 1st line

COMORBIDITY-BASED PATHWAYS (Core of New NICE)

❤️ A. Heart Failure

Metformin + SGLT2 inhibitor
Avoid unnecessary escalation

❤️‍🔥 B. ASCVD (Atherosclerotic CVD)

Triple early therapy:

Metformin
SGLT2 inhibitor
GLP-1 RA (e.g., semaglutide)

Early aggressive therapy = ↓ CV events

-C. CKD (Chronic Kidney Disease)

eGFR >30 → Metformin + SGLT2
eGFR 20–30 → SGLT2 (dapagliflozin/empagliflozin) + DPP-4

eGFR

10/03/2026

Update in TB management by wHO :

Intensive phase ( 2 months) :

Isoniazide + High Dose Rifapentin + Pyrazinamide + moxifloxacin 400mg daily.

Continuation phase (2months) :

Isoniazide + High dose Rifapentin + Moxifloxacin

#গুরুত্বপূর্ন_পরিবর্তন :

1. Rifampicin এর পরিবর্তে High dose Rifapentin add করা হয়েছে।

2. সময় ৬ মাসের পরিবর্তে ৪ মাসে নামিয়ে আনা হয়েছে (যদিও এটা ১৭ সপ্তাহ বলেছে গাইডলাইনে।)

3. Ethambutol totally বাদ এবং Moxifloxacin যোগ হয়েছে ।

#বি:দ্র : বাংলাদেশে এখনো এই রেজিম চালু হয়নি। Rifapentin এর ডোজ কত ক্লিয়ার না,

INH, Pyrazinamide আগের মত ওজন হিসেব করে দিতে হবে। এভাবে আলাদা আলাদা না দিয়ে আমাদের দেশে যেরকম fixed dose combination এ পাওয়া যায় এভাবে নিয়ে আসতে পারলে ভালো হবে। দেশে Rifapicin resitance খুবই বেড়ে গেছে।

(INH + Rifampicin Resistant) Update :

BPaLM regimen for 6 months.

Bedaquiline

Pretomanid.

Linezolid 600mg ( Antibiotic)

Moxifloxacin ( antibiotic)

যদি / TB হয় অর্থাৎ Fluroquinolone Resistant থাকে তাহলে

শুধু Bedaquiline + Pretomanid + Linezolid gor 6 months.

update :

৩ টা রেজিমেন এর যেকোন ১ টা

1. Daily INH+ Rifapentin for 1 month.

2. Daily Rifampicin for 4 month.

3. Weekly once INH+ Rifapentin for 3 months. (total 12 dose.)

আমাদের দেশে Retreatment Phase এ Levofloxacin দিয়ে চিকিৎসা করা হচ্ছে।

Collected

26/01/2026

Basal (Long-Acting) Insulin: Dosing & adjustment

Starting dose
• Initiate basal insulin at 10 units once daily or 0.1–0.2 U/kg/day
• Titrate according to fasting blood glucose

Total Daily Insulin Dose (TDD) – insulin-naïve adults (Type 2 DM)
• 0.3–0.5 U/kg/day
• Lean / elderly / CKD: 0.2–0.3 U/kg
• Typical adult: 0.4–0.5 U/kg
• Obese / insulin-resistant: 0.5–0.6 U/kg

Basal insulin calculation
• Basal insulin = 40–50% of TDD

Example
TDD = 28 units → Basal dose = 14 units once daily

Important points
• Normal fasting glucose with elevated HbA1c suggests post-prandial hyperglycemia, not inadequate basal insulin
• Avoid basal doses >0.5 U/kg; if control is inadequate, consider prandial insulin or a GLP-1 receptor agonist

23/01/2026

Top 100 High-Yield Cardiology Points (2025)

(🟥 Facts / 🟩 Treatments)

1) Acute Coronary Syndromes (ACS) — 10

1. 🟥 High-sensitivity troponin (hs-cTn) is preferred for rapid rule-in/rule-out of MI.

2. 🟩 Give aspirin immediately (162–325 mg chew), then 75–100 mg daily.

3. 🟥 For STEMI, door-to-balloon ≤90 min (≤120 min if transfer) saves myocardium.

4. 🟩 Primary PCI is first-line reperfusion; fibrinolysis only if PCI delay is excessive.

5. 🟥 NSTEMI patients with high risk (e.g., GRACE) benefit from early invasive strategy.

6. 🟩 Use a P2Y12 inhibitor (ticagrelor/prasugrel preferred in most) + aspirin (DAPT).

7. 🟥 Radial access lowers bleeding and vascular complications vs femoral.

8. 🟩 Start high-intensity statin in all ACS unless contraindicated.

9. 🟥 Shorter DAPT (3–6 mo) can be reasonable after PCI in high-bleeding-risk patients.

10. 🟩 At discharge: checklist—DAPT, statin, beta-blocker (if indicated), ACEi/ARB/ARNI (LV dysfunction), SGLT2i (HF), cardiac rehab.

(Key sources: 2025 ACC/AHA ACS Guideline & slide set.)

2) Chronic Coronary Disease (CCD) & Secondary Prevention — 10

11. 🟥 Beta-blockers are not for routine long-term use after MI if LVEF >50% and no other indication.

12. 🟩 First-line antianginal: either beta-blocker or nondihydropyridine CCB; add long-acting nitrates/rano as needed.

13. 🟥 LDL-C goal is “lower is better,” with thresholds guiding add-ons in very-high risk.

14. 🟩 Add ezetimibe, then PCSK9 inhibitor if LDL-C remains above threshold on max statin.

15. 🟥 Cardiac rehab reduces mortality and rehospitalization.

16. 🟩 Refer all eligible CCD/ACS patients to supervised rehab programs.

17. 🟥 Long-term single antiplatelet therapy is standard after PCI once DAPT completed.

18. 🟩 Use PPI with DAPT in patients at ↑ GI-bleeding risk.

19. 🟥 Inclisiran/bempedoic acid can lower LDL-C when statins insufficient or intolerant.

20. 🟩 Consider inclisiran or bempedoic acid per shared decision when targets unmet.

(Key sources: 2023 CCD Guideline; 2022 ACC Non-statin ECDP.)

3) Lipids — 10

21. 🟥 High-intensity statin reduces major events ~25% per mmol/L LDL-C lowering.

22. 🟩 Aim ≥50% LDL-C reduction with high-intensity statin; check lipids 4–12 wks after start/titrate.

23. 🟥 Very-high-risk ASCVD often needs LDL-C

05/01/2026

APPROACH TO HEPATOMEGALY

Confirm TRUE hepatomegaly

Clinical
• Liver palpable >2 cm below right costal margin (mid-clavicular line)
• Increased liver span on percussion
• Normal adult: ≤12–13 cm
• Assess surface (smooth vs nodular), edge (sharp vs rounded), tenderness

Imaging
• Ultrasound (first-line)
• Increased craniocaudal length (>15–16 cm)
• CT / MRI if:
• Focal lesions
• Infiltrative disease
• Malignancy staging

Exclude pseudo-hepatomegaly
• Right pleural effusion
• Lung hyperinflation (COPD)
• Subdiaphragmatic abscess
• Riedel’s lobe (normal variant)

Decide: Tender vs Non-tender

Tender hepatomegaly Non-tender hepatomegaly

Acute hepatitis Fatty liver disease
Congestive cardiac failure Cirrhosis (early)
Liver abscess Malignancy
Budd–Chiari syndrome Storage / infiltrative

Look for ASSOCIATED CLUES

Feature Suggests
Fever Hepatitis, abscess, infection
Jaundice Hepatitis, obstruction
Weight loss Malignancy
RUQ pain Hepatitis, congestion
Ascites Portal HTN, cirrhosis
Splenomegaly Portal HTN
Stigmata of CLD Cirrhosis
Heart failure signs Congestive hepatomegaly

Categorize causes (MOST IMPORTANT STEP)

🟢 INFECTIOUS / INFLAMMATORY
• Acute viral hepatitis (A, B, C, E)
• Liver abscess (amoebic, pyogenic)
• EBV / CMV
• TB
• Sepsis-associated hepatomegaly

Tender + febrile liver → think infection

🟡 METABOLIC / STEATOTIC
• NAFLD / MAFLD (most common)
• Alcohol-associated liver disease
• Drug-induced liver injury

Smooth, soft, non-tender liver

🔵 VASCULAR / CONGESTIVE
• Right-sided heart failure
• Constrictive pericarditis
• Budd–Chiari syndrome
• Veno-occlusive disease

Tender + pulsatile liver + raised JVP → CCF

🔴 NEOPLASTIC
• Hepatocellular carcinoma
• Metastatic liver disease
• Cholangiocarcinoma
• Leukemia / lymphoma infiltration

Hard, nodular liver ± weight loss

🟣 STORAGE / INFILTRATIVE
• Hemochromatosis
• Wilson disease
• Amyloidosis
• Glycogen storage diseases
• Gaucher disease
• Sarcoidosis

Massive hepatomegaly + minimal symptoms

⚫ CHRONIC LIVER DISEASE / PORTAL HTN
• Cirrhosis (early: enlarged; late: shrunken)
• Portal vein thrombosis

Hepatosplenomegaly + ascites

INITIAL INVESTIGATIONS

Baseline
• LFTs (AST, ALT, ALP, bilirubin)
• CBC
• INR
• Albumin
• ESR / CRP

Directed
• Viral hepatitis serology
• Ultrasound abdomen ± Doppler
• AFP (if HCC suspected)
• Iron studies (hemochromatosis)
• Ceruloplasmin (young patient)
• Autoimmune markers (ANA, ASMA)
• Echocardiography (if congestive)

Assess for PORTAL HYPERTENSION

Triad
1. Hepatomegaly
2. Splenomegaly
3. Ascites / varices / thrombocytopenia

→ Think cirrhosis or portal vein pathology

20/12/2025

Rapid Review করেন:Hepatitis B Serology নিয়ে ভালো একটা আইডিয়া হবে ইনশাআল্লাহ।

HBsAg ➕ পজিটিভ মানে কী:

Current Hepatitis B infection আছে
➡️ Acute বা Chronic ,দুটোই হতে পারে 🛑

🔹 Differentiation কীভাবে করবেন?
-Anti-HBc IgM ➕ → Recent / Acute infection
-Anti-HBc IgG ➕ → Chronic infection

❌ HPV DNA থাকলে acute অনেকে মনে করেন,এটা ভুল
✅ HBV DNA acute vs chronic বোঝায় না, বরং viral replication বোঝায়

তাহলে HBsAg ❌ মানে:

No current infection

💥এখন Anti-HBc আর Anti-HBs দেখে past exposure vs vaccination বোঝা হয়।

🫵Anti-HBc:
IgM ➕ → Recent acute HBV infection
IgG ➕ → Past infection বা Chronic infection

📌 Vaccinated patient → Anti-HBc negative

HBeAg:

💥 HBeAg ➕ মানে বুঝায়:
👉 High viral replication
👉 High infectivity

💥 Anti-HBe ➕ মানে বুঝায়:
👉 Lower viral replication
👉 Seroconversion হয়েছে

HBV DNA ➕ পজিটিভ:

:Confirms active viral replication
:Disease activity, infectivity, এবং treatment monitoring-এ সবচেয়ে important marker

✅HBV DNA থাকতে পারে
-Acute infection
-Chronic active hepatitis
-Reactivation

Myocardial Infarction (MI) ❤️ MI ECG CHANGES OVER TIMEMnemonic: “T → ST → Q → T↓ → Q” • Minutes → Hyperacute T + ST ↑ • ...
19/12/2025

Myocardial Infarction (MI)
❤️ MI ECG CHANGES OVER TIME

Mnemonic: “T → ST → Q → T↓ → Q”
• Minutes → Hyperacute T + ST ↑
• Hours → ST ↑ + Q waves + T inversion
• Days → Q waves + T inversion
• Weeks → Q waves only (scar)

👉 Q wave = dead muscle

🫀 INFERIOR MI

Mnemonic: “II, III, aVF = INFERIOR”
• Leads: II, III, aVF
• Artery: RCA
• Risk: Bradycardia, heart block

🫀 ANTERIOR MI

Mnemonic: “V2–V4 = ANTERIOR”
• Leads: V2–V4
• Artery: LAD
• Worst prognosis (large area)

🫀 SEPTAL MI

Mnemonic: “V1–V2 = SEPTUM”
• Leads: V1, V2
• Artery: LAD (septal branch)

🫀 LATERAL MI

Mnemonic: “I, aVL, V5–V6 = LATERAL”
• Leads: I, aVL, V5, V6
• Artery: LCX or diagonal LAD

🫀 POSTERIOR MI

Mnemonic: “Posterior = Look Behind”
• Leads: V7–V9 (posterior leads)
• Or ST ↓ + tall R in V1–V3
• Artery: PDA (RCA or LCX)

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Gazipur

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