ALLERGY & IMMUNOLOGY TiKi TaKa

________________________________

. HYPER-SENSITIVITY REACTIONS:
______________________________
______________________________

{1} Type "1" (IMMEDIATE):

__________________________
. Ex. Acute atopic dermatitis.
. Highly pruritic papules, vesicles & plaques.
. Light microscopy -> Spongiosis (edema of the epidermis).

{2} Type "2" (ANTIBODY MEDIATED):

__________________________________
. IgM or IgG + ANTIGEN.
. Ex. Immune hemolytic anemia & Rh hemolytic disease of the newborn.

{3} Type "3" (IMMUNE COMPLEX MEDIATED):

________________________________________
. Ag + Ab + COMPLEMENT.
. Ex. Serum sickness.

{4} Type "4" (CELL MEDIATED):

______________________________
. Dermal inflammation after direct contact with allergen.
. Ex. Tuberculin skin test & Allergic contact dermatitis.

. TRANSFUSION REACTIONS:
________________________
________________________

. 1 . ABO INCOMPATIBILITY:
___________________________
. Acute symptoms of hemolysis WHILE the transfusion is occuring.
. Ex -> DURING a transfusion, the pt becomes hypotensive & tachycardic.
. Back & chest pain & dark urine.
. ++ LDH & bilirubin.
. -- Haptoglobin.

. 2 . TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) = LEUKO-

AGGLUTINATION REACTION:
_________________________________________________________________________
___________
. Acute Shortness of breath from antibodies in the donor blood against
the repient WBCs.
. Ex -> 20 mins after a pt. receives a blood transfusion, the pt becomes
short of breath.
. Transient infiltrates on CXR.
. All symptoms resolve spontaneously.

. 3 . IgA DEFECIENCY:
______________________
. presents with anaphylaxis !
. In the future, use blood donations from an IgA defecient donor or
washed RBCs.
 . Ex -> As soon as the pt. received transfus., he becomes SOB,
hypotensive & tachycardic.
. NORMAL LDH & BILIRUBIN.

. 4 . MINOR BLOOD GROUP INCOMPATIBILITY:

_________________________________________
. To kell, Duffy, Lewis or Kidd antigens or Rh incompatibility !
. Delayed jaundice.
. No specific therapy.
. Ex -> A few days after transfusion, the pt becomes jaundiced.
. The hematocrit doesn't rise with transfusion & he is generally without
symptoms.

. 5 . FEBRILE NON-HEMOLYTIC REACTION:

______________________________________
. Small rise in temperature.
. No ttt required.
. Reaction against donor WBCs antigens.
. prevented by using filtered blood transfusions in the future to remove
WBCs antigens.
. Ex -> A few hours after transfusion, the pt becomes febrile with rise
1 degree in temp.
. No evidence of hemolysis.

. RHINITIS:
____________
____________

{A} ALLERGIC RHINITIS:

_______________________
. Watery rhinorrhea & sneezing with more prominent eye symptoms.
. Early age of onset.
. Identifiable trigger (animals - environmental exposure).
. Usually seasonal symptoms but can be persistent throughout year.
. Nasal mucosa can be normal, pale blue or pale on exam.
. Associated with allergic disorders e.g. eczema & asthma.
. Tx -> Allergen avoidance.
. Tx -> Topical intra-nasal glucocorticoids.

{B} NON-ALLERGIC RHINITIS = VASOMOTOR RHINITIS:

________________________________________________
. Nasal congestion - Rhinorrhea - Postnasal discharge (postnasal drip =
dry cough).
. Late age of onset > 20 ys.
. Can't identify clear trigger !
. Symptoms throughout the year but sometimes worse with seasons change.
. Nasal mucosa may be normal or erythematous.
. Less commonly associated with allergic disorders e.g. asthma or
eczema.
. Routine allergy testing isn't necessary prior to initiating empiric
ttt.
. May respond to 1st generation oral H1 antihistaminics
(Chloramphenicol),
. Never ever responds to antihistaminics without anticholinergic
properties (Loratidine)!
. Tx -> TOPICAL INTRANASAL GLUCOCORTICOIDS.

. The 3 most common causes of CHRONIC COUGH (> 8 weeks):

________________________________________________________
. UPPER AIRWAY COUGH $YNDROME (Post-nasal drip).
. BRONCHIAL ASTHMA.
. GERD.

. UPPER AIRWAY COUGH $YNDROME = POST-NASAL DRIP:

_________________________________________________
. NON-smoker.
. Caused by rhino-sinusitis conditions.
. Dry cough is most likely due to post-nasal drip associated with
allergic rhinitis.
. Dx -> Confirmed by improvement of the nasal discharge & cough with H1
Anti-histaminics.
. Chlorpheniramine is an H1 receptor blocker that decreases the allergic
response.
. Decrease in NASAL SECRETIONS is most likely to significally improve
symptoms.

. ALLERGIC REACTIONS:
_____________________
_____________________

{1} . ANAPHYLAXIS = ANAPHYLACTIC SHOCK:

________________________________________
. Type 1 hypersensitivity reaction.
. Pts usually have prior exposure to the offending substance.
. Pts have preformed Ig E -> Histamine mediated peripheral
vasodilatation.
. Bee stings - food & medications are the most common allergens.
. Acute onset of hypotension & tachycardia.
. Dangerous allergic reaction may progress to respiratory failure &
circulatory collapse.
. Allergen exposure -> Sudden onset of symptoms in more than one system,
. Cutaneous (hives - flushing - pruritis).
. GIT ( Lip / tongue swelling - vomiting).
. Respiratory (Dyspnea - wheezing - stridor - hypoxia).
. Cardiovascular (Hypotension).
. It is a medical emergency.
. Tx -> INTRA-MUSCULAR EPINEPHRINE into the THIGH.

{2} . ANGIO-EDEMA:
___________________
. H/O of ICU pt on ACEIs e.g ENALAPRIL.
. Edema in the face, mouth, lips.
. Absence of pruritis & urticaria.
. Laryngeal edema may occur causing airway obstruction.
. occurs due to BRADYKININ release.
. it may occur at any time not just at the start of drug intake.
. Dx----> Low levels of C2 & C4.
. Tx----> STOP ACEIs + FRESH FROZEN PLASMA + Secure the airway.

. HERIDITARY angioedema:
________________________
. C1 esterase inhibitor defeciency.
. usually follows an infection, dental procedure or minor trauma.
. N.B. The most common cause of acquired isolated angioedema is ACE
inhibitors use.

. N.B. C1q is NORMAL in heriditary angioedema.

. N.B. C1q is DEPRESSED in aquired angioedema.
 . C4 levels are depressed in all forms !

{3} . URTICARIA:
_________________
. Sudden swellings of the superficial layers of the skin.
. Can be caused by insects or medications.
. May be caused by pressure, cold or vibration !
. Tx -> ANTI-HISTAMINICs (Diphenhydramine & koratidine).

. GRAFT VERSUS HOST DISEASE (GVHD):

___________________________________
___________________________________
. in pts with bone marrow transplantation.
. due to activation of the DONOR "T" lymphocytes.
. Skin ---> Maculopapular rash.
. Intestine ---> Bloody diarrhea.
. Liver ---> Abnormal LFTs & jaundice.

. PRIMARY IMMUNO-DEFECIENCY DISORDERS:

_______________________________________
_______________________________________

{1} COMMON VARIABLE IMMUNODEFECIENCY (CVID):

_____________________________________________
. ADULT with recurrent sino-pulmonary infections.
. NORMAL NUMBER OF "B" cells but don't make effective amounts of
immunoglobulins.
. DECREASE in ALL subtypes of immunoglobulins (IgG, IgM & IgA).
. Frequent episodes of bronchitis, pneumonia, sinusitis & otitis media.
. CVID increases the risk of lymphoma.
. Dx -> Decreased immunoglobulins level & -- response to Ag stimulation
of B-cells.
. Tx -> Antibiotics for infections.
. Tx -> Chronic maintainance with regular infusions of I.V.
immunoglobulins.

. The clue to CVID is DECREASE in the OUTPUT of B-LYMPHOCYTES with,

. NORMAL NUMBER of B-cells & NORMAL amount of LYMPHOID TISSUE (LNs,
adenoids & tonsils).

{2} X-LINKED (BRUTON) A-GAMMA-GLOBULINEMIA:

____________________________________________
. MALE CHILDREN with recurrent sino-pulmonary infections.
. DIMINISHED B-cells & LYMPHOID TISSUES.
. ABSENCE of tonsils, adenoids & lymph nodes & spleen.
. NORMAL T-cells.
. Tx -> Antibiotics for infections.
. Tx -> Chronic maintainance with regular infusions of I.V.
immunoglobulins.

{3} SEVERE COMBINED IMMUNODEFECIENCY:

______________________________________
. Combined = Defeciency in BOTH B & T cells.
. -- B-cells -> -- immunoglobulin production -> Recuurent sinopulmonary
infections at 6ms
. -- T-cells -> AIDS related infections e.g. PCP, varicella & candida.
. Treat the infections as they rise.
 . BM transpalntation is curative.

{4} Ig"A" DEFECIENCY:

______________________
. Recurrent sinopulmonary infections + ATOPIC DISEASE + ANAPHYLAXIS to
blood transfusions
. Anaphylaxis from blood transfusions from pts with "NORMAL" levels of
IgA !
. Treat infections as they arise.
. ONLY use blood that is from Ig-A DEFECIENT donors or that has been
WASHED !
. IVIG will NOT work as the amount of IgA in the product is too small to
be therapeutic !
. The trace amounts of IgA in IVIG may provoke anaphylaxis !

{5} HYPER Ig"E" $YNDROME:

__________________________
. Recurrent SKIN infections with STAPHYLOCOCCI.
. Treat infections as they arise.
. Consider prophylactic antibiotics e.g Dicloxacillin & cephalexin.

{6} WISKOTT - ALDRICH $YNDROME:

________________________________
. IMMUNODEFECIENCY + THROMBOCYTOPENIA + ECZEMA.
. MARKED DECREASED T-LYMPHOCYTES.
. BM TRANSPLANTATION is the ONLY curative ttt.

{7} CHRONIC GRANULOMATOUS DISEASE (CGD):

_________________________________________
. Genetic disease results in extensive inflammatory reactions.
. Lymph nodes with purulent material leaking out !
. Aphthous ulcers & inflammation of the nares.
. Obstructive granulomas in the GIT or UT.
. Infections with odd combinations (Staphylococci, Bulkhorderia,
Nocardia & Aspergillus).
. Dx -> ABNORMAL TETRAZOLIUM TEST !
. -- in respiratory burst that produces hydrogen peroxide.
. -- in NADPH oxidase that generates superoxide.

Dr. Wael Tawfic Mohamed

_________________________
 CARDIOLOGY TiKi TaKa
______________________

. ISCHEMIC HEART DISEASE "IHD" = CORONARY ARTERY DISEASE "CAD":

_______________________________________________________________
_______________________________________________________________
. Risk factors:
________________
. DM (THE SINGLE WORST OR MOST DANGEROUS RISK FACTOR OF CAD is DIABETES
MELLITUS).
. HTN. (Most COMMON risk factor is hypertension).
. Smoking.
. Hyperlipidemia.
. Peripheral artery disease.
. Obesity.
. Family H/O (Family member must be young,female relative < 65ys & male
relative < 55ys).

. IHD CHEST PAIN NOT CHANGING WITH BODY POSITION or RESPIRATION !

__________________________________________________________________
. Dull pain.
. Located sub-sternally.
. Lasts 15-30 minutes.
. Occurs on exertion.
. Radiates to the lower jaw or left arm.

. Changes with respiration = Pleuritic pain (Pneumonia - pleuritis - PE

- Pneumothorax).
. Changes with position = Pericarditis.
. Tenderness on palpation = Costochondritis.

. The most common cause of chest pain that is NOT CARDIAC in origin is
GERD ACID REFLUX !
_________________________________________________________________________
_________________
. Ex: pt comes to the ER with chest pain in the epigastrium & associated
e' sore throat,
. A bad metallic taste in th mouth & cough is present.
. A proton pump inhibitor (Omeprazole) trial sh'd be done.

. D.D. of CHEST PAIN:

_____________________
_____________________

. 1 . Costochondritis:
_______________________
-> Chest wall tenderness.
-> Do physical examination.

. 2 . Aortic dissection:
_________________________
-> Radiation to the back.
-> Un-equal B.P. between both arms.
-> CXR: Widened mediastinum.
-> Confirm with Chest CT or TEE (Trans-esophageal echocardiography).

. 3 . Pericarditis:
____________________
-> Pain worse with lying flat, better when sitting up.
-> ECG -> ST elevation in all leads with PR depression.

. 4 . Duodenal ulcer disease:

______________________________
. Epigastric discomfort - pian is better on eating.
. Endoscopy is confirmatory.

. 5 . Gastro-esophageal reflux disease "GERD":

_______________________________________________
. Bad taste, cough & hoarsness.
. Response to PPIs "Omeprazole".

. 6 . Pneumonia:
_________________
. Cough, sputum & hemoptysis.
. Dx -> CXR.

. 7 . Pulmonary embolism:
__________________________
. Sudden onset SOB, hypoxia, tachycardia.
. CxR -> Clear lungs.
. Spiral CT - V/Q scan - D-Dimer.
. Most accurate: Pumonary angiography.

. 8 . Pneumothorax:
____________________
. Sharp, pleuritic pain with tracheal deviation.
. CXR is diagnostic.

. 9 . Pancreatitis:
____________________
. Alcoholic pt with chest pain radiating to the back.
. Nausea & vomiting.
. Dx -> Check amylase & lipase levels.

. 10 . Cholecystitis:
______________________
. Right upper quadrant tenderness & mild fever.
. Dx -> Abdominal U/$ for gall stones.

. EVALUATION OF CHEST PAIN IN THE EMERGENCY DEPARTMENT:

_______________________________________________________

Focused H/O & P/E

Assess vital signs
Obtain venous access
|
_______ STABLE ______________UN-STABLE_______
| |
. Obtain ECG & CXR . Stabilize
hemodynamics.
. Administer aspirin if . Check for
underlying causes
low risk of aortic dissection
|
ECG consistent with AC$ ?
|
 _______________________________________________
| |
YES NO
| |
_______________________ CXR diagnostic ??
| | |
STEMI NSTEMI __________YES_________NO___
| | | |
Treat with emergency Treat with Treat cause Assess for
Pulmonary embolism
catheterization or appropriate Assess for
pericarditis
thrombolytics anticoagulation Assess for
aortic dissection

. N.B.
. Further testing for coronary artery disease (CAD):
. sh'd NOT be done routinely in low risk pts as they frequently can've
false +ve results.
. Exercise EKG or pharmacological stress testing is most useful in
intermediate risk pts.
. High risk pts sh'd start pharmacological therapy & undergo coronary
angiography,
. if they have stable angina.

. Physical examination findings:

_________________________________
. Distressed pt with SOB & clutching chest.
. S3 gallop = Lt ventricular dilatation.
. S4 gallop = Lt ventricular hypertrophy.
. Jugulo-venous distension.
. Bilateral basal lung rales.
. LL edema.

. Diagnosis:
____________
. Best initial test -> EKG.

. N.B. If the case is very clear with diagnosis of ischemic pain & the
given choices are:
. EKG & (Aspirin - Nitrates - Oxygen - Morphine) ..
. CHOOSE TTT 1st !

. N.B. CK-MB is the best to detect RE-infarction a few days after the
initial infarction:
_________________________________________________________________________
_________________
. Both CK-MB & troponin levels rise 3-6 hs after the start of chest
pain.
. The main difference is that CK-MB only stays elevated 1-2 days.
. While troponin stays elevated 1-2 weeks.
. so, CK-MB is the best to detect RE-infarction a few days after the
initial infarction.

. N.B. MYOGLOBIN is the 1st cardiac marker to rise after chest pain:
_____________________________________________________________________
. Myoglobin elevates 1-4 hours after start of chest pain.
 . When do you order a STRESS TEST ?
____________________________________
. When the case is NOT ACUTE.
. When the initial EKG & cardiac enzymes can't establish diagnosis.
. Angiography is the next best step in case of an abnormal stress test.

. N.B.
. Ischemic cardiac pain can sometimes be mistaken for epigastric pain,
. but should remain high on differential.
. especially in the setting of symptoms worsened with exertion.
. An exercise stress test e'out imaging (Exercise EKG) is the most
reasonable 1st step,
. if the baseline resting EKG is normal.

. When do you order DIPYRIDAMOLE or ADENOSINE THALLIUM STRESS TEST or

DOBUTAMINE ECHO ?
_________________________________________________________________________
_______________
. In pts who can't exercise to a target heart rate of > 85% of maximum.
. COPD.
. Amputation.
. Weakness due to a prevous stroke.
. Morbid obesity.

. N.B.
. Dipyridamole & coronary steal phenomenon:
. Dipyridamole can be used during myocardial perfusion scanning,
. to reveal the areas of restricted myocardial perfusion.
. The redistribution of coronary blood flow to "Non-diseased" segments
by Dipyridamole,
. is called "Coronary steal phenomenon".

. When do you order EXERCISE THALLIUM TEST or STRESS ECHOCARDIOGRAPHY ?

________________________________________________________________________
. When EKG is UN-READABLE for ischemia !
. Lt BBB.
. Digitalis use.
. Pace maker is present.

. When do you order a SESTAMIBI NUCLEAR STRESS TEST ?

______________________________________________________
. Obese pts with large breasts.

. ANGIOGRAPHY is the MOST ACCURATE TEST to detect coronary artery

disease.

. ACUTE CORONARY $YNDROME (AC$) MANAGEMENT:

___________________________________________
___________________________________________
. UN-STABLE ANGINA (EKG: ST segement depression & -ve CK-MB).
. NON-ST SEGMENT ELEVATION MI "NON-STEMI" (EKG: No ST segment elevation
& +ve CK-MB).
. ST SEGMENT ELEVATION MI "STEMI" (EKG: ST sement elevation & +ve CK-
MB).

. N.B. ST segment elevation in leads 2,3,aVF -> Inferior wall MI.

. N.B. ST segment depression in leads V1,V2 -> Posterior wall MI.
 . The occluded culprit artery -> RIGHT CORONARY ARTERY.
. Inferior MI is associated weith hypotension, bradycardia & AV block.

. MI LOCATION & corresponding culprit occluded CORONARY VESSEL:

_______________________________________________________________
. Involved myocardium ___________ Blocked vessel ________ ECG leads
involved

. Anterior MI ___________ LAD ________ ST elevation

V1-V6

. Inferior MI ___________ RCA or LCX ________ ST elevation

2,3,aVF

. Posterior MI ___________ RCA or LCX ________ ST depression

V1-V3
ST elevation
1,aVL (LCX)
ST depression
1,aVL (RCA)

. Lateral MI ___________ LCX, diagonal _________ ST elevation

1,aVL,V5,V6
ST depression
2,3,aVF

{1} ASPIRIN:
_____________
. The best initial therapy for all AC$.
. ANTI-PLATELET drug.
. LOWERS MORTALITY.
. Given in addition to Nitrates, oxygen & Morphine.
. CLopidogreal or Prasugrel are given in case of containdication to
Aspirin e.g. Allergy.
. They are also given in pts under-going angioplasty or there is acute
MI.

{2} THROMBOLYTICS & ANGIOPLASTY (PCI):

_______________________________________
. Both lower mortality.
. Angioplasty must be performed within 90 minutes of arrival at the
emergeny department.
. If it can't be performed within 90 mins -> The pt sh'd receive
THROMBOLYTICS.
. Contraindications to thrombolytics (Major bleeding - Recent surgery -
Severe HTN).
. Complications of angioplasty (Rupture of coronary artery - Restenosis
- Hematoma).

{3} BB, ACEIs & ARBs:

______________________
. BB ALWAYS LOWER MOTALITY.
. ACEIs & ARBs lower mortality ONLY IF there is left ventricular
dysfunction!
. ACEIs lessens ventricular remodelling following MI.

{4} STATINS:
_____________
. Given to all pts with AC$.
. Side effect -> Liver toxicity.
 . Statins inhibit intracellular HMG-CoA reductase enzyme,
. prevent conversion of HMG coA to mevalonic acid & ++ NO of cell
membrane LDL receptors
. Statins also -- coenzyme Q10 synthesis involved in muscle cell energy
production,
. so .. It contributes to statin-induced myopathy.
. CPK levels sh'd be checked in any pt on a statin who presents with
myalgias.
. If highly elevated, the 1st step is to discontinue the statin.

. N.B. High dose Niacin therapy may cause cutaneous flushing & pruritis.
. This side effect is due to PROSTAGLANDIN INDUCED PERIPHERAL
VASODILATATION.
. Can be reduced by low dose aspirin.

. DIFFERENT THERAPIES & THEIR MORTALITY BENEFIT:

________________________________________________
* ALWAYS LOWER MORTALITY:
__________________________
. Aspirin.
. Thrombolytics.
. Primary angioplasty.
. BB "Metoprolol".
. Statins.
. Clopidogrel or prasugrel.

* LOWER MORTALITY IN CERTAIN CONDITIONS:

_________________________________________
. ACEIs & ARBs if there is low ejection fraction (Lt ventricular
dysfunction).

* DO NOT LOWER MORTALITY:

__________________________
. Oxygen.
. Morphine.
. Nitrates.
. CCBs.
. Lidocaine.
. Amiodarone.

. When do you give Calcium channel blockers "CCBs" ?

_____________________________________________________
. Intolerance to BBs (Severe asthmatic pt).
. Cocaine induced chest pain.
. Coronary vasospasm (Prinzmetal's angina).

. When do you place a pacemaker ?

__________________________________
. 3rd degree complete AV block.
. Mobitz 2 2nd degree AV block.
. New LBBB.
. SYMPTOMATIC bradycardia.

. N.B. The strongest influence on long term prognosis following an STEMI

is:
. The duration of time that passes before restoring coronary blood flow.
. PTCA -> Door to balloon time -> 90 minutes.
. Fibrinolytics -> Door to needle time -> 30 minutes.
 . N.B. Nitrates cause venodilatation which improves cardiac chest pain,
. Nitrates reduce cardiac preload thus decreasing myocardial oxygen
demand.

. N.B. The main mechanism for pain relief in pts with anginal pain ttt
with NITROGLYCERIN
. VENO-DILATATION (DILATATION of CAPACITANCE VESSELS) & -- in
ventricular pre-load.

. N.B. Following MI, ventricular emodelling occurs.

. Remodelling leads to gradual dilatation of the left ventricle with
thinning of walls.
. This can results in CHF.
. ACE inhibitors are given to lessens ventricular remodelling.
. ACEIs sh'd be initiated within 24 hours of MIin all pts without
contraindications.

. N.B.
. GERD is characterized by a retrosternal burning sensation after eating
& lying down.
. It may be accompanied by hoarseness & chronic cough especially while
recumbant.
. Initial ttt is an H2-receptor blocker or Proton pump inhibitor.

. N.B. Dihydropyridine CCB (Nifedipine) can worsen cardiac ischemia,

. Bec. they cause peripheral vasodilatation & reflex tachycardia.
. so they are contraindicated in pts with acute coronary $.

. N.B. NON-Dihydropyridine CCB (Diltiazem & Verapamil) can be used in

STEMI after BB,
. BUT .. They do NOT improve mortality.

. N.B. Ischemic damage in MI may lead to diastolic dysfunction & stiff

left ventricle,
. resulting in an atrial gallop (S4 4th heart sound).

. N.B. Pts presenting to the emergency department with chest pain &
suspected AC$,
. should be administered ASPIRIN ASAP.
. Early anti-platelet therapy with aspirin reduces the rate of MI &
overall mortality.

. COMPLICATIONS of Acute MI:

____________________________

{1} CARDIOGENIC SHOCK:

_______________________
. Dx -> Echo & SWAN-GANZ Rt heart catheterization.
. Tx -> ACEIs & urgent re-vascularization.

{2} VALVE RUPTURE:

___________________
. Dx -> ECHO.
. Tx -> ACEIs, Nitroprusside & intra-aortic balloon pump as a bridge to
surgery.

{3} MYOCARDIAL FREE WALL RUPTURE:

__________________________________
. Mechanical complication of transmural ANTERIOR wall MI.
 . Presents with profound chest pain & profound shock.
. Rupture of the Lt ventricle -> Hemopericardium & tamponade.
. Pericardial effusion & tamponade signs (Dyspnea, hypotension, JVD,
Pulsus paradoxus).
. Tamponade compresses the Lt wall ventricle& decreases stroke volume ->
-- BP & ++ HR.
. EKG -> Low voltage QRS complexes & Electrical alternans.
. Dx -> ECHO.
. Tx -> Pericardiocentesis & Supportive care & urgent surgical repair.

{4} INTERVENTRICULAR SEPTAL RUPTURE:

_____________________________________
. Around 5 days after infarction.
. Presents with profound chest pain & profound shock.
. Interventricular wall rupture causes a ventricular septal defect.
. Sudden onset of hypotension congestive biventricular failure (Right
predominant).
. Loud holosystolic murmur heard best at the lower left sternal border.
. Dx -> Echo & SWAN-GANZ Rt heart catheterization.
. Step-up in oxygen saturation from Rt atrium to Rt ventricle.
. Tx -> ACEIs, Nitroprusside & urgent surgery.

{5} PAPILLARY MUSCLE RUPTURE:

______________________________
. 3-5 days post MI.
. Mechanical complication of MI.
. Life threatening due to necrosis of the surrounding tissues.
. Acute severe mitral regurge (pan-systolic murmur heard at the apex &
axillary radation)
. Acute severe MR causes hypotension & pulmonary edema.
. No ST segment elevation.

{6} SINUS BRADYCARDIA:

_______________________
. Dx -> EKG.
. Tx -> Atropine, followed by pacemaker if symptoms are still present.

{7} COMPLETE 3rd DEGREE AV BLOCK:

__________________________________
. Dx -> EKG & Cannon "a" waves.
. Tx -> Atropine & PACEMAKER even if symptoms resolve.

{8} RIGHT VENTRICULAR INFARCTION:

__________________________________
. Associated with NEW INFERIOR WALL MI.
. due to occlusion of the Rt coronary artery.
. HYPOTENSION & Shock & JVD & Clear lung fields.
. EKG -> ST elevation in RV4-RV6 (Rt venticular leads).
. Tx -> High volume fluid replacement.
. Avoid nitroglycerin (will worsen hypotension).

{9} VENTRICULAR ANEURYSM (VA):

_______________________________
. Late complication occuring weeks to months post MI.
. Scarred or fibrotic myocardial wall due to healed transmural MI.
. may present with heart failure, refractory angina, ventricular
arrhythmia or embolism.
. HALLMARK EKG -> PERSISTENT ST segement elevation after a recent MI +
DEEEEP Q waves !
 . Large VA can lead to progressive LV enlargement, arrhythmia, mural
thrombus.
. Dx -> ECHOCARDIOGRAPHY -> Dyskinetic wall motion of a portion of the
left ventricle.

{10} ACUTE PERICARDITIS:

_________________________
. Within 1-3 days post MI.
. Sharp pleuritic or positional chest pain within the 1st several days
post MI.
. It is worse in supine position & improved by sitting up & leaning
forwards.
. A pericardial friction rub may be heard.
. Diffuse ST elevations especially with PR depressions are typical ECG
manifestations.
. Dressler's $ is post MI pericarditis (immune-mediated) occuring weeks
to months post MI
. Fever, leukocytosis & pericardial friction rub.
. Tx -> NSAIDs.

{11} POST-INFARCTION ANGINA (Recurrent cardiac ischemia):

__________________________________________________________
. Recurrent chest pain.
. New or worsening ECG changes of ischemia e.g. ST elevation.
. It may cause ventricular tachycardia or fibrillation which may
degenerate into asystole

. N.B. IWMI with Right Ventricular Infarction management:

_________________________________________________________
. Acute management of a STEMI generally includes reperfusion
(Thrombolysis or PCI),
. antiplatelet therapy, morphine, heparin, nitrates & BB.

. Nitrates & BB are contraindicated in certain circumstances.

. e.g. AS, recent phosphodiesterase inhibitor use or Right Ventricular
Infarction.

. RV MI with IWMI are associated with hypotension & JVD.

. When the Rt venticular stroke volume decreases, the COP is impaired.

. So .. Any medication that reduces preload (e.g. Nitrates or diuretics)
will WORSEN it.

. so .. The 1st step in RV MI is generally IV FLUID RESUSCITATION to ++

RV stroke volume.
. Nitrates should be avoided.

. N.B.
. Acute MR can occur due to papillary muscle dysfunction in pts with
acute MI.
. Acute MR characteristically causes a rise in LEFT ATRIAL PRESSURE.
. NO CHANGE in (Lt atrial size - Lt ventricular size - Lt ventricular
EF).

. POST-MI DISCHARGE INSTRUCTIONS:

_________________________________
. Aspirin, clopidogrel, BB, Statin & ACEIs.
. Wait 2-6 weeks before resuming sexual relation.
. Anxiety is the most common cause of erectile dysfunction post-MI.
 . Nitrates are containdicated in case of Slidenafil usage (Both ->
severe hypotension).

. NON-STEMI MANAGEMENT:
_______________________
. No thrombolytic use.
. HEPARIN is uded routinely.
. LMW heparin is preferred to the IV form.
. Glycoprotein 2b/3a inhibitors lower mortality in those undergoing
angioplasty & stent.
. Thrombolytics are used only if there is ST segment elevation or new
LBBB.

. STABLE ANGINA MANAGEMENT:

___________________________
. Beta blockers are the 1st line therapy.
. ASPIRIN & METOPROLOL are the main stay of ttt. (Both lower mortality).
. Nitrates sh'd be used in case of anginal pain but they do NOT lower
mortality.
. ACEIs & ARBs are used in case of congestive failure, systolic
dysfunction or low EF.
. Coronary angiography is used routinely to determine who is candidate
for CABG.
. CABG = Coronary artery bypass graft.
. You don't need angiography to diagnose CAD (A stress test can show
reversible ischemia)

. N.B. You don't need angiography to initiate the following:

-> Aspirin + Metoprolol "Mortality benefit".
-> Nitrates "pain".
-> ACEIs/ARBs "Low EF".
-> Clopidogrel or prasugrel "Acute MI or can't tolerate aspirin".
-> Statins "LDL > 70 - 100".

. BB are the 1st line therapy for anginal syms, improves exercise
tolerance.
. BB relieve angina by -- myocardial contractility & heart rate.
. BB improve survival rate in those with MI.

. CCB can combine BB if angina persists or there is contraindication to

BB.
. CCB improve angina by causing peripheral & coronary vasodilatation.

. Nitrates short acting form ttt are used in acute setting.

. Nitrates long acting form are used in persistent angina.

. Preventive ttt for stable angina:

-> Aspirin.
-> Statin.
-> Smoking cessation.
-> Regular exercise & weight loss.
-> Control of blood pressure & diabetes.

. N.B. The main difference between saphenous vein grafts & internal
mammary artery grafts
. is that veins grafts start to become occluded after 5 years,
. but internal mammary artery grafts are often patent at 10 ys.

. INDICATIONS for CABG:

________________________
. 3 coronary vessels with > 70 % stenosis.
. Left main coronary artery stenosis.

. CORONARY ARTERY DISEASE EQUIVALENTS:

_______________________________________
. DM - PAD - AAA - CAD.

. LIPID MANAGEMENT:
____________________
. The single strongest indication for a "statin" in a pt with AC$ & an
LDL > 130mg/dl.
. The goal of therapy in this pt will be < 100 mg/dl.
. If there is associated DM, the goal will be < 70 mg/dl.

. RISK FACTORS IN LIPID MANAGEMENT:

____________________________________
. Cigarette smoking.
. Hypertension > 140/90 mmHg on antihypertensives.
. Low LDL < 40 mg/dl.
. Family H/O of early coronary artery dis. (Female relatives < 65, Male
relatives < 55ys)
. Age (Male > 45 ys, Females > 55 ys).

. N.B. STATINS have the greatest efficacy in lowering mortality.

. The most common adverse effect of statins is LIVER TOXICITY.

. N.B. High dose Niacin therapy may cause cutaneous flushing & pruritis.
. This side effect is due to PROSTAGLANDIN INDUCED PERIPHERAL
VASODILATATION.
. Can be reduced by low dose aspirin.

. SUMMARY OF MECHANICAL COMPLICATIONS OF MI:

____________________________________________

* RIGHT VENTRICULAR FAILURE:

_____________________________
++ . Time course -> Acute.
. Culprit coronary artery -> RCA.
. Exam -> Hypotension - Clear lungs - Kussmaul's sign (++JVD on
inhalation).
. Echo -> Hypokinetic RV.

* PAPILLARY MUSCLE RUPTURE:

____________________________
. Time course -> Acute & within 3-5 days.
. Culprit coronary artery -> RCA.
. Exam -> Acute severe pulmonary edema + New holosystolic murmur.
. Echo -> Severe mitral regurgitation with flail leaflet.

* INTERVENTRICULAR SEPTUM RUPTURE/DEFECT:

__________________________________________
. Time course -> Acute & within 3-5 days.
. Culprit coronary artery -> LAD (Apical septal rupture) or RCA (Basal
septal rupture).
. Exam -> Shock & chest pain + New holosystolic murmur + Biventricular
failure.
 . Echo -> Lt to Rt shunt at ventricular level & step up of oxygen level
bet Rt AT & VT.

* VENTRICULAR FREE WALL RUPTURE:

_________________________________
. Time course -> Within 1st 5 days - 2 weeks.
. Culprit coronary artery -> LAD.
. Exam -> Shock & chest pain + JVD + Distant heart sounds (Tamponade
signs).
. Echo -> Pericardial effusion with tamponade.

. N.B. VARIANT ANGINA = PRINZMETAL's ANGINA:

____________________________________________
. Caused by temporary spasm of coronary arteries.
. Young women are classically affected.
. The greatest risk factor is smoking.
. Aside from smoking, there is absence of cardiovascular risk factors.
. Associated e' other vasospastic disorders (Raynaud's phenomenon &
Migraine headache).
. Episodes occur at the middle of the night to 8 a.m.
. Triggers -> exercise, hyperventillation, emotional stress, cold
exposure & cocaine use.
. Anginal episode is accompanied by transient ST elevations with return
to baseline.
. Tx -> CCBs "Diltiazem" or Nitrates.
. Non selective BB & Aspirin should be AVOIDED because they can promote
vasoconstriction.

. N.B. COCAINE ABUSE INDUCING VASOSPASM:

________________________________________
. Dilated pupils & blood-crusted nose suggest cocaine abuse.
. Cocaine inhibits catecholamines reuptake from neuronal synapses ->
Sympathomimetic.
. Cocaine induced vasospasm -> myocardial ischemia & or infarction.
. Pt presents with chest pain & ST elevations.
\
. Cocaine induced STEMI is ttt sameway as classic STEMI with PCI &
thrombolysis.
. Aspirin & nitrates are also appropriate.
. BB SHOULD BE AVOIDED -> WORSEN THE SPASM.
. Tx -> CCBs.

. CONGESTIVE HEART FAILURE:

___________________________
___________________________
. DYSPNEA (SOB) is the essential feature.
. Orthopnea (Worse when lying flat, relieved when sitting or standing).
. Pripheral edema.
. Bilateral lung rales.
. Jugular venous distension (JVD).
. Paroxysmal nocturnal dyspnea (PND) "Sudden worsening at night during
sleep".
. S3 GALLOP (Diastolic sound just after S2 = Left ventricular failure)

. Volume overload - Cardiac dysfunction - Pressure overload.

. Systolic dysfunction -> LOW EJECTION FRACTION + HEART DILATATION.
. Diastolic dysfunction -> PRESERVED EJECTION FRACTION.
 . HYPERTENSION causing cardiomyopathy is the most common cause of
systolic dysfunction.
. MYOCARDIAL INFARCTION causes dilated cardiomyopathy & -- EF.
. INFARCTION -> DILATATION -> REGURGITATION -> CHF.

. Dx -> Every CHF pt must undergo ECHOCARDIOGRAPHY to evaluate ejection

fraction.
. Other tests used to determine the etiology of CHF:
. EKG -> MI or heart block.
. CXR -> Dilated cardiomyopathy.
. Holter monitor -> Paroxysmal arrhythmia.
. Cardiac catheterization -> To detect valve diameters & septal
defects.
. Thyroid functions -> Both hypo & hyper thyroid states cause CHF.
. CBC -> Anemia.

. Tx -> SYSTOLIC DYSFUNCTION (LOW EF):

_______________________________________
. ACE Is & ARBS (if associated dry Cough), Both ACEIs & ARBs cause
HYPERKALEMIA !
. BBs (Metoprolol & Carvedilol).
. Spironolactone -> Anti-aldosterone -> Side effects (Gynecomastia -
Hyperkalemia).
. Diuretics (Loop diuretics e.g. Furosemide).
. Digoxin (inhibits Na-K ATPase).

. N.B. 1. Give ARBs instead of ACEIs in associated dry cough.

. N.B. 2. BB are never given in ttt of acute heart failure !

. BB are given as a chronic ttt of CHF.
. BB have anti-arrhythmic & anti-ischemic action ao they prevent sudden
death.

. N.B. 3. Most common cause of death in CHF is ARRHYTHMIA -> SUDDEN

DEATH.

. N.B. 4. Eplerenone is like spironolactone but e'out antiandrogenic SE

(NO Gynecomastia)

. N.B. 5. Digoxin (cardiac glycoside) is a medication with narrow

therapeutic window.
. Some drugs eg. VERAPAMIL ++ its concentration & -- it's clearance ->
Digitalis toxicity
. Toxicity -> (Anorexia, Nausea & vomiting) & Biventricular tachycardia
& yellow vision.
. Most common arrhythmia due to Digitalis is ATRIAL TACHYCARDIA WITH
VARIABLE AV BLOCK !
. Tx of Digoxin toxicity -> Na-K ATPASE, Lidocaine & Digibind (Abs
against Digitalis).

. N.B. 6. DRUGS LOWERING MORTALITY IN CHF -> ACEIs - ARBs - BB -

SPIRONOLACTONE & ASPIRIN
. Hydralazine & nitrates have been proven to lower mortality in CHF.
. Implantable defibrillator lowers mortality & prevents sudden death due
to arrhythmia.

. N.B. 7. Digoxin & loop diuretics "Furosemide" DO NOTTTT lower

mortality.

. N.B. 8. EJECTION FRACTION (EF):

 . Best initial test -> TRANS-THORACIC ECHOCARDIOGRAPHY (TTE).
. Most accurate test -> MUGA scan or nuclear ventriculography.

. N.B. 9. A NORMAL BNP excludes CHF !

. N.B. 10. If their is hyperkalemia 2ry to ACEIs, don't give ARBs (Also
cause ++ K)!
. Give HYDRALAZINE (DIRECT ACTING ARTERIOLAR VASODILATOR) instead.

. N.B. 11. A H/O of upper RTI followed by suuden onset cardiac failure
in a healthy pt,
. is suggestive of dilated cardiomyopathy.
. It is the end result of myocardial damage due to toxic, metabolic or
infectious agents.
. Viral myocarditis is most commonly seen following Coxsackie virus B
infection.
. Viral myocarditis may cause dilated cardiomyopathy via direct viral
damage.
. Dx -> Echocardiogram -> Dilated ventricles with diffuse hypokinesia.
. Low EF (Systolic dysfunction).

. N.B. 12. Mechanism of edema in congestive heart failure:

. In heart failure, there is defective circulating blood volume -> --
COP.
. -- COP -> Renal hypoperfusion -> Activation of Renin Angiotensin
Aldosterone system.
. ++ in concentration of both Angiotensin 2 & Aldosterone.
. Angiotensin 2 -> -- Renal blood flow by constricting the efferent
renal arteriole.
. Aldosterone -> ++ Na Reabsorption -> ++ water retention -> Edema.

. N.B. 13. HYPO-NATREMIA is a bad prognostic factor in pts with heart

failure.
. It indicates the severity of heart failure i.e. high level of
neurohumoral activation.
. -- Na is associated e' high levels of renin, aldosterone, vasopressin
& norepinephrine.
. -- water intake (Not ++ Na intake) may correct the electrolyte
imbalance.

. N.B. 14. HYPO & HYPER-KALEMIA are an imporatant electrolyte imbalance

in HF.
. It reflects the activity of RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM.
. It may be due to drug interactions.
. Hyperkalemia due to ACEIs (Enalapril), Digoxin & K sparing diuretics
(Spironolactone).
. Hypokalemia due to Thiazide diuretics (Furosemide).

. N.B. 15. AMYLOIDOSIS may cause congestive heart failure.

. It is extracellular deposition of excees proteins leading to organ
dysfunction.
. Extra-cardiac manifestations (proteinuria & easy bruisability) are the
key words!
. Common causes of amyloidosis include multiple myeloma (AL
amyloidosis).
. Chronic inflammatory diseases e.g. rheumatoid arthritis (AA
amyloidosis).
. Deposition of amyloid fibrils in the kidney -> proteinuria.
. Amyloid fibrils binding to liver-> -- coagulation factors synthesis->
Easy bruisability
 . Amyloid fibrils deposition in the heart -> Restrictive cardiomyopathy.
. Restrictive cardiomyopathy is due to thickened ventricular wall &
diastolic dysfunction . Systolic function is relatively well preserved.
. Ventricular dimensions remain unchanged.

. N.B. 16. Medications to withhold prior to cardiac stress testing: BB -

CCB - Nitrates.
. N.B. 17. Medications to continue (ACEIs - ARBs - Digoxin - Statins -
Diuretics).

. N.B. 18. Pt e' recurrent pulmonary infections, chronic cough &

significant smoking H/O.
. ++ antero-posterior diameter & wheezing on P/E.
. This is consistent with COPD.
. The associated chronic hypoxemia -> constriction of the pulmonary
arterial system,
. Constriction -> ++ PULMONARY ARTERY SYSTOLIC PRESSURE -> PULMONARY
HTN.
. Pulmonary hypertension -> Rt ventricular hypertrophy & Rt ventricular
failure.
. RVF -> ++ JVP, congestive HSM, Hepatojugular reflux & LL edema.

. N.B. 19. MASSIVE PULMONARY EMBOLISM

. is likely in post-operative pt with jugular venous distension & new
onset Rt BBB.

. N.B. 20. Diastolic dysfunction = impaired ventricular filling with

preserved EF,
. Due to poor myocardial relaxation or diminished ventricular
compliance.
. Usually due to systemic hypertension.
. Tx -> Diuretics & anti-hypertensives.
. In severe cases, diastolic dysfunction can cause decompensated heart
failure.

. N.B. 21. Measurement of serum BNP can help distinguish bet. CHF &
other dyspnea causes.
. A value > 100 pg/ml diagnoses CHF with,
. a sensitivity, specificity & predictive accuracy of 90, 76 & 83 %
respectively !!!

. N.B. 22. In otherwise healthy pts who develop CHF,

. Myocarditis should be considered high on D.D.
. Viral infection, especially with Coxsackie B virus is the most common
cause.

. N.B. 23. SYSTOLIC HEART FAILURE:

-> Depressed cardiac index (CI).
-> ICREASED TOTAL PERIPHERAL RESISTANCE (TPR).
-> LEFT VENTRICULAR END DIASTOLIC VOLUME (LVEDV).

. DIFFERENTIAL DIAGNOSIS OF DYSPNEA:

____________________________________
. Pulmonary embolism -> Sudden onset & Clear lungs.
. Bronchial asthma -> Sudden onset, wheezing & ++ expiratory phase.
. Pneumonia -> Slower, fever, sputum, UNIlateral rales or ronchi.
. Pneumothorax -> Unilateral -- in breath sounds& tracheal deviation.
. Panic attack -> Circumoral numbness, caffeine use & H/O of anxiety.
. Anemia -> Pallor, gradual over days to weeks.
 . Tamponade -> Pulsus paradoxus, faint heart sounds & JVD.
. Arrhythmia -> Palpitations & syncope.
. Pleural effusion -> Dullness to percussion at lung bases.
. COPD -> Long smoking H/O & barrel chest.
. Methemoglobinemia -> Recent anesthetic use, BROWN blood not improved
e' O2 & cyanosis.
. CO poisoning -> Burning building or car, Wood burning stove in winter,
suicide attempt.

. ALL of the previous items will lack orthopnea - PND - S3 Gallop !

. ACUTE CARDIOGENIC PULMONARY EDEMA:

____________________________________
. Due to SEVERE LEFT VENTRICULAR FAILURE.
. ACUTE ONSET SHORTNESS OF BREATH.
. Rales - JVD - S3 gallop - Edema - Orthopnea.
. May be ascites & HSM in case of associated RVF.

. Dx -> Brain natriuretic peptide BNP.

. BNP is used if the etiology of SOB is not clear !
. A normal BNP excludes pulmonary edema (BNP > 100 is diagnostic).
. CXR -> Vascular congestion - cardiomegaly - pleural effusion & Kerley
B lines.
. ABG -> Hypoxia & Respiratory alkalosis (Hyperventillation with excess
CO2 release).
. EKG -> Af, AF or V.tachycardia -> Perform synchronized cardioversion.
. Echo -> To detect if there is systolic or diastolic dysfunction.

. The BEST INITIAL TTT is LOOP DIURETIC (FUROSEMIDE).

. Furosemide removes a large volume of fluid from the vascular space.
. It causes VENODILATATION so it decreases the preload.

. PRELOAD REDUCTION -> LOOP DIURETIC "Furosemide" + MORPHINE + NITRATES

+ OXYGEN.
. POSITIVE INOTROPE -> DOBUTAMINE.
. AFTERLOAD REDUCTION -> ACEIs & ARBs.

. N.B. NITRATES "NITROGLYCERIN" (THE MOST RAPIDLY ACTIVE DRUG TO RELIEVE

SYMPTOMS).

. N.B. Dobutamine "+ve inotrope" is used if there is no response to

preload reduction.

. N.B. Amrinone & Milrinone "Phosphodiesterase inhibitors" are also +ve

inotropes.

. N.B. Nitroprusside & Hydralazine can -- afterload in acute cases.

. N.B. BB are -ve inotropes so they are contraindicated in acute

pulmonary edema.
. N.B. BB are given only in ttt of chronic heart failure.

. VALVULAR HEART DISEASES:

__________________________
__________________________

. IMPORTANT CLUES:
___________________
. Young female -> MVP.
 . Healthy young athlete -> HOCM.
. Immigrant, pregnant -> MS.
. Turner's $, Aortic coarctation -> Bicuspid Aortic valve (AS).
. Palpitations, Atypical chest pain not with exertion -> MVP.

. MURMURS:
___________
. SYSTOLIC -> AS - MR - MVP - HOCM.
. DIASTOLIC -> AR - MS.

. EFFECT OF CHANGE IN VENOUS RETURN:

_____________________________________
. Valvular lesion _____ ++ VR (Squatting & Raising legs) ____ -- VR
(Standing & Valsalva)
_________________________________________________________________________
_________________
. AS,AR,MS,MR, VSD ____ (+) ____ (-)
Give diuretics !
. HOCM & MVP __________ (-) ____ (+)

. EFFECT OF CHANGE IN AFTERLOAD:

_________________________________
. Valvular lesion _____ ++ AFTERLOAD (HAND GRIP) ____ --
AFTERLOAD (AMYL NITRATE)
_________________________________________________________________________
_________________
. AS __________________ (-) ____
(+)
. AR __________________ (+) ____
(-) Give ACEIs !
. MR __________________ (+) ____
(-) Give ACEIs !
. VSD _________________ (+) ____
(-) Give ACEIs !
. HOCM ________________ (-) ____
(+)
. MVP _________________ (-) ____
(+)

. LOCATION & RADIATION OF MURMURS:

___________________________________
. AS -> Heard best at 2nd Rt intercostal space & radiates to the carotid
arteries.
. AR, TA, TR, VSD -> Heard best at Lt lower sternal border.
. MR -> Heard best at apex & radiates into the axilla.

. DIANOSIS:
____________
. Best initial test -> ECHOCARDIOGRAPHY (Trans-Thoracic TTE > Trans-
Esophageal TEE).
. Most accurate test -> Left heart catheterization.

{1} AORTIC STENOSIS (AS):

__________________________
. Chest pain.
. Old pt with H/O of HTN.
. Syncope & HF are less common presentations.
. Syncope due to left ventricular out flow obstruction.
. Associated CAD.
. AS becomes sympomatic when it is severe (Valve areas < 1 cm2).
 . CRESCENDO DECRESCENDO SYSTOLIC MURMUR.
. Heard best at 2nd Rt intercostal space & radiates to the carotid
arteries.
. PULSUS PARVUS ET TARDUS (Week & delayed pulse stroke).
. EKG & CXR -> Lt ventricular hypertrophy.
. Tx -> Best initial ttt -> DIURETICS.
. Tx -> Failed -> AORTIC VALVE REPLACEMENT. (Give Warfarin till INR 2-
3).

. N.B.
. Aortic stenosis in young individual mostly due to CONGENITAL BICUSPID
AORTIC VALVE.
. Pts with severe aortic stenosis often have large left ventricular
mass, so..
. requiring additional oxygen.
. ++ myocardial oxygen demand -> Anginal pain.

. N.B.
. Aortic stenosis in old individual is mostly due to AGE DEPENDENT
SCLEROCALCIFIC CHANGES
. They may present with exertional syncope due to restricted COP due to
stenotic aorta.

. N.B.
. Indications for aortic valve replacement:
-> All symptomatic pts with AS (Syncope - Angina - Dyspnea).
-> Pts with severe AS undergoing CABG or other valvular surgery.
-> Asymptomatic pt with e' AS & either poor LV systolic function, LV
hypertrophy > 15mm.

. N.B.
. The 3 most common causes of aortic stenosis in the general population
are:
. senile calcific aortic stenosis - bicuspid aortic valve - rheumatic
heart disease.
. A bicuspid aortic valve is the cause of aortic stenosis in the
majority of pts < 70 ys.

{2} AORTIC REGURGITATION (AR):

_______________________________
. SOB & fatigue are the most common presentations.
. H/O of HTN, Rheumatic heart disease, endocarditis.
. Marfan's $, $yphilis & reactive arthritis are rare causes.
. DIASTOLIC DECRESCENDO MURMUR heard best at left sternal border.
. Quincke pulse -> Arterial or capillary pulsations in the finger nails.
. Corrigan's pulse -> High bounding pulses "Water-hammer pulse".
. Musset's sign -> Head bobbing up & down with each pulse.
. Duroziez's sign -> Murmur heard over the femoral artery.
. Hill sign -> Blood pressure gradient much higher in the lower limbs.
. EKG & CXR -> Lt ventricular hypertrophy.
. Tx -> Best initial therapy -> ACEIs, ARBs & Nifedipine.
. Tx -> Add loop diuretic (Furosemide).
. Tx -> Surgery (If EF < 55% or LVESD > 55mm).

. N.B.
. AR murmur is best heard along the left sternal border at the 3rd & 4th
interspaces.
. It may be heard in some pts only by applying firm pressure e' the
stethoscope diaphragm
 . while the pt is sitting up, leaning forward & holding his breath in
full expiration.

. N.B.
. In DEVELOPED countries,
. Congenital bicuspid aortic valve is the most common cause of AR in
young adults.

. N.B.
. In DEVELOPING countries,
. Rheumatic heart disease is the most common cause of AR.

. N.B.
. AR causes widening of the pulse pressure, which can be felt as "water-
hammer" pulse.
. Lying down & turning to the left brings the heart closer to the chest
wall,
. making the pt more aware of the forceful heart beat.

{3} MITRAL STENOSIS (MS):

__________________________
. Dyspnea on exertion, HEMOPTYSIS, nocturnal cough.

. Rheumatic fever is the most common cause of MS.

. Immigrants from developing countries (Cambodia) due to RF or pragnants
are more common.

. Dysphagia (Large atrium compressing the esophagus).

. Hoarseness (Large atrium compressing the recurrent laryngeal nerve).
. MS -> Lt ATRIAL DILATATION & congestion -> Cardiac emboli -> Af ->
stroke.

. LOUD S1.
. DIASTOLIC RUMBLE AFTER AN OPENING SNAP "Extra-sound in diastole".

. EKG & CXR -> LT atrial hypertrophy.

. CXR -> Lt border Straightening & Elevation of the left main bronchus.

. Tx -> Best initial therapy -> Diuretics.

. Tx -> Most effective therapy -> Balloon valvuloplasty.
. Pregnancy is not a contraindication to valvuloplasty.

. N.B. MS may be caused by INTRACARDIAC ATRIAL TUMOR (ATRIAL MYXOMA).

. Atrial myxoma may obstruct the mitral valve.
. Constitutional manifestations of the tumor (Low grade fever & weight
loss).
. Presents as a mass on echocardiography.
. May be assocaiated e' neurological symptoms "side weakness" due to
tumor embolization.
. Atrial myxoma is NOT equal to Myxomatous valve degeneration (COMMON
MISTAKE) !!!

{4} MITRAL REGURGITATION (MR):

_______________________________
. Dyspnea on exertion is the most common complaint.
. Any disease leads to heart dilatation e.g. Hypertension, ischemic
heart disease.
. HOLOSYSTOLIC MURMUR OBSCURING BOTH S2 & S2.
. S3 GALLOP due to volume overload.
. Tx -> Best initial therapy -> ACEIs, ARBs & Nifedipine.
 . Tx -> Add loop diuretic (Furosemide).
. Tx -> Surgery (If EF < 60% or LVESD > 40mm).

. N.B.
. DIASTOLIC & continous murmur as well as loud systolic murmurs on
auscultation,
. should always be investigated using TTE (Trans-thoracic Doppler
Echocardiography).

. Mid-systolic soft murmurs in an asymptomatic young pt are usually

benign,
. No further investigations are needed.

. N.B.
. AORTIC STENOSIS -> Trans-Thoracic TTE.
. AORTIC DISSECTION -> Trans-Esophageal TEE.

. N.B.
. Acute MR can occur due to papillary muscle dysfunction in pts with
acute MI.
. Acute MR characteristically causes a rise in LEFT ATRIAL PRESSURE.
. NO CHANGE in (Lt atrial size - Lt ventricular size - Lt ventricular
EF).

. MITRAL VALVE PROLAPSE (MVP):

______________________________
. Mostly a young female.
. Mostly asymptomatic.
. Absent symptoms of CHF.
. Mid-systolic click over the cardiac apex.
. An accompanying short systolic murmur if mitral regurgitation is
present.
. Squatting -> ++ VR -> ++ cardiac preload -> -- or eliminates the
prolapse.
. Atypical chest pain (Lasting 5 - 10 seconds).
. Anxiety, palpitations & hyperventilation may be present.
. Dx -> Echocardiography is the best choice.
. Tx -> BB when the pt is symptomatic.
. Valve repair in refractory cases to BB.
. A few stitches into the valve can markedly tighten up the leaflets.
. Endocarditis prophylaxis is NOT recommended even in the presence of a
murmur of MR !

. N.B. MVP is due to MYXOMATOUS DEGENERATION OF THE MITRAL VALVE

LEAFLETS !

. INFECTIVE ENDOCARDITIS:
_________________________
_________________________
. Intermittent fever.
. New murmur.
. +ve blood culture.
. Tx -> Empiric vancomycin (Covering staph, strept & enterococci).
. VIRIDANS group streptococci (Strep. Mutans) are highly susceptible to
penicillin.
. Tx Strept viridans & mutans with INTRA-VENOUS AQUEOUS PENICILLIN G or
IV CEFTRIAXONE.
 . IV Ceftriaxone is easier to administer at home due to once daily
dosing.
. Oral antibiotics are NOT recommended.

. INFECTIVE ENDOCARDITIS IN INTRAVENOUS DRUG USERS:

___________________________________________________
. HIV infection ++ infective endocarditis risk in IV drug abusers.
. STAPHYLOCOCCUS AUREUS is the most common causing organism.
. TRICUSPID valve involvement (RIGHT-sided) is more common than aortic
valve.
. HOLO-SYSTOLIC MURMUR ++ with INSPIRATION indicates tricuspid
involvement.
. AUGMENTATION OF INTENSITY WITH INSPIRATION IS VERY SENSITIVE SIGN.
. Septic pulmonary emboli are common (Cough, chest pain & hemoptysis).
. Splinter hemorrhages & Janeway lesions are common.
. Heart failure is more common in aortic valve dis. but rare in
tricuspid valve dis.

. Vascular manifestations in infective endocarditis:

____________________________________________________
. Systemic arterial emboli -> Focal neurologic deficits, renal or
splenic infarcts.
. Septic pulmonary infarcts.
. Mycotic aneurysm.
. Conjunctival hemorrhages.
. Janeway lesions -> Macular erythematous non tender lesions on the
palms & soles.

. Immunologic manifestations in infective endocarditis:

_______________________________________________________
. Osler's nodes -> Painful violaceous nodules seen on finger tips &
toes.
. Roth spots -> Edematous & hemorrhagic lesions of the retina.
. Glomerulonephritis.
. Arthritis or positive rheumatoid factor.

. Microbiology of infective endocarditis:

_________________________________________

* STAPHYLOCOCCUS AUREUS:
_________________________
. Prosthetic valves.
. Intravascular catheters.
. Implanted devices (pacemakers - Defibrillators).
. Injection drug users.

* STREPTOCOCCUS VIRIDANS:
__________________________
. Dental procedures.
. Incision & biopsy or respiratory tract.

* COAGULASE NEGATIVE STREPTOCOCCI:

___________________________________
. Intravascular catheters.
. Prosthetic valves.
. pacemakers - Defibrillators.

* ENTEROCOCCI:
_______________
. Nosocomial urinary tract infections.
 * STREPTOCOCCUS BOVIS:
_______________________
. Colon carcinoma.
. Inflammatory bowel disease.

* FUNGI:
_________
. Immunocompromized host.
. Chronic indwelling catheters.
. Prolonged antibiotic therapy.

. SEPTAL DEFECTS:
_________________
_________________

.1. VENTRICULAR SEPTAL DEFECT (VSD):

_____________________________________
. HOLOSYSTOLIC MURMUR at the lower left sternal border.
. Mostly asymptomatic.
. Large defects may cause SOB.
. Dx -> ECHOCHARDIOGRAPHY.
. Dx -> Catheterization is used to determine the degree of Lt to Rt
shunt.
. Tx -> Mild defects can be left without mechanical closure.

.2. ATRIAL SEPTAL DEFECT (ASD):

________________________________
. Mostly asymptomatic.
. Large defects may cause signs of Rt venticular failure (SOB -
parasternal heave).
. FIXED SPLITTING of S2.
. Dx -> ECHOCARDIOGRAPHY.
. Tx -> Best initial -> Percutaneous or catheter devices.
. Tx -> Repair if the shunt ratio exceeds 1.5:1.

. ARTERIO-VENOUS FISTULA (AVF):

_______________________________
. Congenital -> Patent ductus arteriosus.
. Acquired -> Femoral trauma - Iatrogenic "femoral catheterization".

. Abnormal connection between the arterial & venous systems bypassing

capillary beds.
. Shunting of large amounts of blood through the fistula -- SVR, ++
prelad & ++ COP.
. A state of high out put cardiac failure.

. Widened pulse pressure.

. Strong peripheral arterial pulsation (Brisk carotid upstroke).
. Systolic flow murmur heard over cardiac apex not affected by Valsalva
maneuver.
. Tachycardia & flushed extremities.
. Hypertrophied left ventricle -> Lt displacement of the point of
maximal impulse.

. Dx -> Doppler ultrasonography.

. Tx -> Surgery if large symptomatic AVF.
 . Other causes of high output cardiac failure:
. Thyrotoxicosis - Paget disease - Anemia - Thiamine defeciency.

. SPLITTING OF S2:
__________________
__________________
. WIDE (Delayed P2) --------> RBBB - PS - RVH - PHTN.
. PARADOXICAL (Delayed A2) -> LBBB - AS - LVH - SHTN.
. FIXED --------------------> ASD.

. CARDIOMYOPATHY:
_________________
_________________

{1} DILATED CARDIOMYOPATHY:

____________________________
. presents & managed in the same way as CHF.
. Most common causes (Ischemia - Viral - Alcohol - Adriamycin -
Radiation - Chaga's dis).
. Dx -> Best initial test -> ECHOCARDIOGRAPHY to detect EF.
. Dx -> Most accurate test -> MUGA or nuclear ventriculography.
. Tx -> ACEIs, ARBs & spironolactone.
. Digoxin -- symptoms but doesn't prolong survival.

{2} HYPERTROPHIC CARDIOMYOPATHY:

_________________________________
. SOB on exertion.
. S4 Gallop.
. Dx -> ECHOCARDIOGRAPHY -> NORMAL EF.
. Tx -> BB & Diuretics.
. ACEIs may be used.
. Digoxin & spironolactone do NOT benifit !

{3} RESTRICTIVE CARDIOMYOPATHY:

________________________________
. H/O of sarcoidosis, amyloidosis, hemochromatosis, cancer, myocardial
fibrosis.
. SOB is the main presenting complaint.
. KUSSMAUL's sign -> ++ JVP on inhalation.
. Cardiac catheterization -> Rapid x & y descent.
. EKG -> Low voltage.
. Dx -> Best initial test -> ECHOCARDIOGRAPHY is the main stay of
diagnosis.
. Dx -> Most accurate test -> Endomyocardial biopsy.
. Tx -> Diuresis & correcting the underlying cause.

{4} HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY (HOCM):

____________________________________________________
. AUTOSOMAL DOMINANT inheritance.
. African American male chid.
. H/O of sudden death in the family.

. Dyspnea & chest pain.

. Syncope & light headedness.
. Sudden death, particularly in health athlets.
 . Symptoms worsened by anything that ++ HR e.g. exercise, dehydration &
diuretics.
. Worsened by anything that -- Lt ventricular chamber size e.g. ACEIs.

. Dx -> ECHOCARDIOGRAPHY (The septum is 1.5 times the thickness of the

posterior wall).

. Tx -> BETA BLOCKERS ARE THE BEST INITIAL THERAPY for both HOCM & HCM.
. DIURETICS ARE CONTRAINDICATED in HOCM but they are useful in ordinary
HCM.

. N.B. Systolic anterior motion (SAM) of the mitral valve is classic for
HOCM.

. N.B. Catheterization is the most accurate test to detect precise

gradients of pressure.

. N.B. EKG -> Non-specific ST & T wave changes are common.

. N.B. Left ventricular hypertrophy is common.

. N.B. Septal Q waves in the inferior & lateral leads are common in HOCM
(Absent in MI).

. N.B. Digoxin & spironolactone are definitely always wrong in HOCM.

. N.B. Surgical myomectomy is the therapy only if all medical ttt fails.

. N.B. A H/O of upper RTI followed by suuden onset cardiac failure in a

healthy pt,
. is suggestive of dilated cardiomyopathy.
. It is the end result of myocardial damage due to toxic, metabolic or
infectious agents.
. Viral myocarditis is most commonly seen following Coxsackie virus B
infection.
. Viral myocarditis may cause dilated cardiomyopathy via direct viral
damage.
. Dx -> Echocardiogram -> Dilated ventricles with diffuse hypokinesia.
. Low EF (Systolic dysfunction).

. N.B. Excessive alcohol consumption leads to DILATED cardiomyopathy.

. Preserved ventricular dimensions RULES OUT dilated cardiomyopathy !

. N.B. Hemochromatosis causes RESTRICTIVE cardiomyopathy.

. Classic findings (Pancreatic dysfunction - Bronzed skin -
Hepatomegaly).

. N.B. Sarcoidosis causes RESTRICTIVE cardiomyopathy.

. More common in African Americans bet 20 - 3- ys.
. Classic findings (Bilateral hilar adenopathy & erythema nodosum).

. N.B. Constrictive pericarditis is difficult to distinguished from

restrictive myopathy
. BUT .. INCREASE WALL THICKNESS rules out constrictive pericarditis.

. N.B. Hemochromatosis leads to restrictive cardiomyopathy & cardiac

conduction problems.
. It does NOT cause endocardial fibroelastosis !!! (Common mistake).

. N.B. Dilated cardiomyopathy 2ry to Alcoholism:

 . Thrombocytopenia - Macrocytosis - ++ Transaminases are suggestive of
alcoholism.
. Total abstinence from alcohol is the mainstay of alcoholic
cardiomyopathy management.

. Differences in therapy between hypertrophic cardiomyopathy & dilated

cardiomyopathy:
_________________________________________________________________________
______________
. BB, diuretics, ACEIs & ARBS, Spironolactone & Digoxin are all used in
DILATED type.
. ONLY BBs & diuretics only are used in hypertrophic type.

. PERICARDIAL DISEASES:
_______________________
_______________________

{1} PERICARDITIS:
__________________
. Sharp & brief pleuritic chest pain (changes with respiration).
. Positional (Relieved by sitting up & leaning forwards).
. Viral in origin in most cases.
. Friction rub.
. Dx -> EKG -> ST segment elevation in ALL leads.
. Dx -> EKG -> PR segment is pathognomonic but isn't always present.
. Tx -> Best initial therapy -> NSAIDs (Indomethacin).
. Tx -> Add oral steroids (prednisone) in refractory cases.

. N.B.
. UREMIC PERICARDITIS (UP) occurs in 10 % of renal failure pts.
. Typically those with BUN > 60 mg/dl.
. Most pts do NOT present with the classic ECG changes of pericarditis
(Diffuse ST elev.)
. Tx -> HEMODIALYSIS -> Rapid resolution of chest pain & -- size of
effusion.

. N.B. Pericardial effusions appear as an enlarged, "water bottle"

shaped on CXR.
. P/E of pericardial effusion without a tamponade -> Diminished heart
sounds &
. Difficulty to palpate the point of maximal impulse.

{2} PERICARDIAL TAMPONADE:

___________________________
. SOB + Beck's triad (Hypotension + JVD + Muffled heart sounds).
. May follow viral pericarditis after an URT infection.
. Tamponade is due to fluid accumulation in the pericardial cavity
leading to,
. restricting venous return to heart -> Impaired ventricular filling ->
-- LV preload.***
. & due to exaggerated shift of interventricular septum into the left
ventricular cavity
. Clear lungs.
. PULSUS PARADOXUS -> -- in BP < 10 mmHg on inhalation.
. Dx: ECHOCARDIOGRAPHY (MOST ACCURATE)-> Diastolic collapse of the Rt
atrium & ventricle.
 . Dx -> EKG -> Low voltage & ELECTRICAL ALTERNANS (Variation in the QRS
complexes height)
. Rt heart catheterization Equalization of all the pressures in heart
during diastole.
. Tx -> best initial therapy -> PERICARDIOCENTESIS.
. Most effective long term therapy -> Pericardial window placement.
. Most dangerous therapy -> Diuretics !

. N.B. Pulsus paradoxus -> Exaggerated fall in blood pressure > 10 mmHg
on INSPIRATION.
. It is a frequent finding in cardiac tamponade.
. Other causes severe asthma & COPD.

{3} CONSTRICTIVE PERICARDITIS:

_______________________________
. The pericardium is thickened or scarred -> Restriction of diastolic
filling.
. The heart is unable to fill properly during diastole -> Compromized
COP
. Venous pressure becomes chronically elevated -> JVD, ascites & liver
congestion.
. USA most common causes (Post-cardiac surgery - viral pericarditis -
Radiation therapy).
. Out-side USA -> Tuberculous pericarditis is common in endemic areas
(China - Africa).
. Fatigue or dyspnea on exertion.
. Signs of chronic RIGHT heart failure (Edema - JVD - HSM - Ascites).
. KUSSMAUL's sign -> ++ Jugular venous pressure on inhalation.
. Pericardial knock-> Extradiastolic sound: Heart hitting calcified
thickened pericardium
. Dx -> CXR -> Calcification.
. Dx -> EKG -> Low voltage.
. Dx -> JVP tracing -> Prominent x & y descents.
. Dx -> CT & MRI -> Thickening of pericardium.
. Tx -> Best initial ttt -> Diuretics.
. Tx -> Most effective ttt -> Surgical removal of the pericardium
"pericardiectomy".

. AORTIC DISEASES:
__________________
__________________

. AORTIC DISSECTION:
_____________________
. Dissection of the THORACIC aorta.
. Most common cause is SYSTEMIC HYPETENSION.
. Marfan's & Ehlers-Danlos $yndromes may cause dissection in YOUNG
population.

. Tearing chest pain radiating to the back between the scapulae.

. Very severe "Ripping".

. Dissection may extend to:

. carotid arteries -> stroke & AMI?.
. renal arteries -> Acute renal failure.
. aortic valve -> Aortic regurgitation: Early diastolic decrescendo
murmur at the sternum
 . pericardial cavity -> Tamponade (Hypotension - ++JVP - pulsus
paradoxus).
. pleural cavity -> Hemothorax.
. superior cervical sympathetic ganglion -> Horner's $.
. spinal or common iliac arteries -> lower extremity weakness or
ischemia.
. abdominal pain -> mesenteric artery.

. > 20 mmHg difference bet. blood pressures of the Rt & Lt arms.

. Dx -> Best initial test -> CXR -> Widened mediastinum.

. Dx -> Most accurate test -> CT ANGIOGRAPHY = Trans-Esophageal ECHO TEE
= MRA.
. Dx -> TEE NOT TTE (COMMON MISTAKE).

. Tx -> BB & Nitroprusside.

. Tx -> ICU with surgical correction.

. N.B. Aortic dissection is the most dangerous complication of Marfan's

$.
. Tall pt with long extremities - high extensibility of hand joints -
pectus carinatum.

. N.B. BB is the most important initial intervention for acute aortic

dissection.
. Type "A" dissections involve the ascending aorta -> Tx: Medical
therapy & surgery.
. Type " B" dissections involve only the descending aorta -> Tx: Medical
therapy alone.

. AORTIC COARCTATION:
_____________________
. Narrowing of DESCENDING aorta distal to Lt subclavian artery at
ligamentum arteriosum.

. Pts present with hypertension & may be asymptomatic.

. Headaches, epistaxis, blurred vision or heart failure due to severe
hypertension.

. BRACHIAL / FEMORAL DELAY.

. Differential blood pressure in the upper & lower extremeties.
. Well developed upper body compared to lower body.
. Continous cardiac murmur.

. ECG -> Lt ventricular hypertrophy.

. High voltage QRS complexes, ST depression & T wave inversion in leads
V5 & V6.

. CXR -> Notching of the 3rd - 8th ribs due to erosion by enlarged
intercostal arteries.
. Classic 3 sign caused by indentation of the aorta at the site of
coarctation.
. with pre & post stenotic dilatation.

. Dx -> ECHOCARDIOGRAPHY, CT & MRI.

. Associated conditions -> Bicuspid aortic valve, PDA, VSD & Turner's $.

. ABDOMINAL AORTIC ANEURYSM (AAA):

___________________________________
. Portion of the abdominal aorta grows to 1.5 times its normal size,
 . or exceeds the normal diameter by more than 50 % through dilatation.
. It is a true anurysm since it involves all layers of the arterial
wall.
. Dx -> CT or MRI to detect relation with surroundings.
. Dx -> U/$ must be done to monitor its size.
. Screening with U/$ for all smokers > 65ys.
. Small AAA < 5 cm -> Observation & monitoring.
. Large AAA > 5 cm -> Surical repaired.
. The strongest predictors of AAA expansion & rupture are:
. large aneurysm diameter, rapid rate of expansion & current cigarette
smoking.
. Operative or endovascular repair indications:
-> Aneurysm size > 5 cm.
-> Rapid rate of expansion > 0.5 cm in 6 months or > 1cm per year.
-> Presence of syms (Abdominal, back or flank pain & limb ischemia)
regardless its size.

. N.B.
. ASCENDING aortic aneurysms are due to cystic medial necrosis or
connective tissue dis.
. DESCENDING aortic aneurysms are due to atherosclerosis.
. CXR can suggest thoracic (descending) aortic aneurysm by showing:
. widened mediastinal silhouette, increased aortic knob & tracheal
deviation.

. PERIPHERAL ARTERY DISEASE (PAD):

__________________________________
. CLAUDICATION (Pain in the calfs on exertion).

. Smooth, shiny skin with loss of hair & sweat glands & loss of pulses
in the feet.
. PAIN + PALLOR + PULSELESSNESS = ARTERIAL OCCLUSION.

. Dx -> Best initial test -> ANKLE - BRACHIAL INDEX (ABI) "Normal ABI >
0.9".
. LL BP should be EQUAL to UL BP (Difference > 10 % = Obstruction).
. Dx -> Most accurate test -> ANGIOGRAPHY.
. Tx -> Best initial ttt (Aspirin - ACEIs for BP control - Exercise -
Cilostazole).

. N.B. SPINAL STENOSIS is an imp. D.D. for PAD.

. Spinal stenosis will give pain that is worse with walking downhill &
. less with walking uphill, or while cycling or sitting.
. Pulses & skin exam will be NORMAL with spinal stenosis.

. Acute arterial embolus is very sudden in onset with loss of pulse & a
cold extremity.
. It is also quite painful.
. H/O of AS or Af is present.

. BB are not contraindicated with PAD.

. If the pt needs them for ischemic disease, they sh'd be used.

. ARRHYTHMIAS:
_______________
_______________
 . INITIAL MANAGEMENT OF CARDIAC ARREST:
________________________________________
. The 1st step is to make sure that the pt is truely unresponsive.
. Exclude sleeping or syncopal episode !!
. Open the airway -> Head tilt, chin lift & jaw thrust.
. Five rescue breaths if not breathing.
. Check pulse & start chest compressions if pulseless.
. CPR doesn't restart the heart; it keeps the pt alive until
cardioversion is performed.

. The most iportant factors in improving survival in pts with sudden

cardiac arrest:
-> ADEQUATE BYSTANDER CPR.
-> PROMPT RHYTHM ANALYSIS.
-> DEFIBRILLATION in pts found to be in ventricular fibrillation.

. i.e. The most imp. item is TIME TO RHYTHM ANALYSIS & DEFIBRILLATION.

. PULSELESSNESS -> Sudden loss of a pulse can be caused by asystole, VF,

VT & PEA:
_________________________________________________________________________
__________
_________________________________________________________________________
__________

. (1) ASYSTOLE:
________________
. Besides CPR, therapy for asystole is with epinephrine & atropine.
. Vasopressin is an alternative to epinephrine (Both constrict bl. vs.
in tissues).
. This shunts blood into critical central circulation e.g. heart &
brain.
. Managaed with un-interrupted cardiopulmonary resuscitation CPR &
vasopressor therapy,
. in order to maintain adequate cerebral & coronary perfusion.
. Defibrillation or synchronized cardioversion has no role in management
!

. (2) VENTRICULAR FIBRILLATION (VF):

_____________________________________
. One of the most dangerous MI complications.
. Best initial ttt -> Immediate un-synchronized cardioversion =
Defibrillation.
. Perform CPR if cardioversion is not effective.
. The most important next step after cardioversion is epinephrine or
vasopressin.
. They don't restart the heart. They make the next attempt of
defibrillation succeed.
. Amiodarone or lidocaine is given next to try to get subsequent shocks
successful.
. MAGNESIUM is mandatory.
. VF is managed by shock, drugs, shock, drugs, shock, drug & CPR at all
times inbetween.

. (3) VENTRICULAR TACHYCARDIA (VT):

____________________________________
. Wide complex tachycardia with a regular rate.
. Management is based on hemodynamic stability:
. Pulseless VT -> Same as VF.
 . Hemodynamically STABLE -> Amiodarone then lidocaine then procainamide.
. Cardiovert the pt. if medications failed.
. Hemodynamically UN-stable -> Electrical cardioversion several times
followed by drugs.
. N.B. Hemodynamic instability = Chest pain - Dyspnea - CHF -
Hypotension - Confusion.
. N.B. Direct intracardiac medication is always a wrong answer.

. (4) PULSELESS ELECTRICAL ACTIVITY (PEA):

___________________________________________
. PEA = Electrical mechanical dissociation (EMD).
. The heart is electrically NORMAL but there is NO motor contraction.
. Sometimes, the heart may still be contracting but without blood inside
.. No COP !
. Dx -> NORMAL EKG & NO PULSE !!!!
. Tx -> Correct the underlying cause (Tamponade, pneumothorax, Massive
PE, K disorders).
. Managaed with un-interrupted cardiopulmonary resuscitation CPR &
vasopressor therapy,
. in order to maintain adequate cerebral & coronary perfusion.
. Defibrillation or synchronized cardioversion has no role in management
!

. ATRIAL ARRHYTHMIAS:
______________________
______________________
. Rarely associated with hemodynamic instability bec. COP is dependent
upon ventricles.
. H/O of palpitations, dizziness or lightheadedness.
. H/O of exercise intolerance or dyspnea.
. H/O of embolic stroke.

. N.B. An irregularly irregular rhythm suggests Af even before an EKG is

done !
. Af is the most common arrhythmia in the US.

{1} & {2} . ATRIAL FIBRILLATION (Af) & ATRIAL FLUTTER (AF):
____________________________________________________________
. Both have identical management .. Only 2 differences:
. 1 -> Flutter is a regular rhythm while fibrillation is irregular.
. 2 -> Flutter usually goes back into sinus rhytm or deteriorates into
fibrillation.

{1} . Atrial fibrillation (Af):

________________________________
. IRREGULAR pulse (R-R interval) with ABSENT "P" waves & narrow QRS
complexes.
. Af is a common complication after CABG.
. The most common cause of Af is HYPERTHYROIDISM.
. Tx -> Hemodynamically UN-stable -> Synchronized DC cardioversion.
. Synchronization helps to prevent deterioration into VT or VF.

. CHRONIC Af:
______________
. Af lasting more than 2 days.
. It takes several days to be a risk of clot formation.
. The majority of those who are converted to sinus rhythm will not stay
in sinus.
 . Af & AF are mostly caused by anatomic abnormalities of the atria from
HTN or valve dis.
. Shocking the pt. into sinus rhythm doesn't correct a dilated left
atrium.
. Over 90% will revert to fibrillation.

. SLOW THE RATE & COAGULATE "WARFARIN" are the STANDARD CARE for chronic
Af.

. The best initial therapy is to control the rate with BB, CCB or
Digoxin.
. Once the rate is under 100/min -> Give WARFARIN until the INR is
between 2-3.
. CCBs used (Diltiazem & verapamil) -> Block the AV node.
. You need to use heparin only if there is a current clot in the atrium.

. N.B. Rate control drugs don't convert the pt. into sinus rhythm.
. N.B. Heparin is not necessary before starting a pt on warfarin.

. N.B. Controlling the rhythm or rate in pts with prolonged

tachysystolic Af,
. usually improves the LV function significantly, sometimes even
dramatically.

. Af CLASSIFICATION:
_____________________
. FIRST DETECTED -> Initial diagnosis, independent of duration.
. PAROXYSMAL -> Recurrent > 2 episodes that terminate spontaneously in <
7days.
. PERSISTENT -> Episodes lasting > 7days.
. LONGSTANDING PERSISTENT -> Persistent > 1 year duration.
. PERMANENT -> Persistent with no further plans for rhythm control.

. LONE Af:
___________
. LONE = paroxysmal, persistent or permanent Af with no structural heart
disease.
. Pts e' low risk of stroke can safely prevent it e' using ASPIRIN alone
e'out warfarin.

. Criteria of low risk of stroke from Af:

-> No cardiomyopathy, CHF or atherosclerosis.
-> No hypertension.
-> Age 75 or younger.
-> No DM.
-> No past stroke.

. When all the previous risk factors are absent, this is called "LONE
Af".
. Tx of lone Af -> ASPIRIN & rate control with BB.

. CHADS2 SCORING:
__________________
. C -> Congestive heart failure.
. H -> Hypertension (BP > 140/90 mmHg).
. A -> Age > 75 ys.
. D -> DM.
. S -> Previous stroke or TIA.

. ANTICAGULATION ttt in Af according to CHADS2 score:

______________________________________________________
. CHADS2 score -> Stroke risk -> Anti-thrombotic ttt.
. 0 -> Low -> No anticoagulation (preferred) or
Aspirin.
. 1 -> Intermediate -> Anticoagulation (preferred) or
Aspirin.
. 2 -> High -> Anticagulation.

. N.B.
. Antiarrhythmic drugs are reserved for pts with recurrent symptomatic
Af episodes,
. or those with Lt ventricular systolic dysfunction thought to be 2ry to
uncontolled Af.
. Long term use of antiarrhythmic drugs has significant side effects.

. N.B.
. Amiodarone cause pulmonary toxicity & sh'd be avoided in pts with
preexisting lung dis.
. So .. RESTRICTIVE lung disease pts can NOT be given Amiodarone.
. Amiodarone is ABSOLUTELY CONTRAINDICATED.

. N.B.
. BBs causes bronchoconstriction.
. So .. OBSTRUCTIVE lung disease (Asthma - COPD) pts can NOT be given
BBs.
. BBs are RELATIVELY CONTRAINDICATED in obstructive lung diseases.
. BBs can be used SAFELY in RESTRICTIVE lung diseases.

. N.B.
. Af pts with past H/O of Wolf-Parkinson-White $yndrome,
. Should be treated with cardioversion or anti-arrhythmics like
procainamide.
. AV nodal blockers (BB - CCB - Digoxin - Adenosine) should be AVOIDED,
. because they ++ conductance through the accessory pathway after AVN
blockage.

. N.B.
. Pts e' new-onset Af sh'd've TSH & free T4 levels measured to rule out
hyperthyroidism.

{3} . SUPRA-VENTRICULAR TACHYCARDIA (SVT):

___________________________________________
. Palpitations in a pt who is usually hemodynamically stable.
. No structural heart disease.
. Heart rate 160-220/min.
. Mechanism of SVT -> "RE-ENTRY into the AV NODE."
. Narrow QRS complex tachycardia.
. No regular P waves as they are burried within the QRS complexes.
. PSVT most commonly results from accessory conduction pathways through
the AV node.
. Vagal maneuvers & medications that -- conduction through the AV node
reslove the attack
. Cold water therapy affects the AV conductivity. (VVVVVVV. imp.).
. The best initial step is vagal maneuvers (carotid message, valsalva &
ice immersion).
. ADENOSINE if vagal maneuvers don't work.
. BB (Metoprolol), CCB (Diltiazem) or Digoxin if adenosine is not
effective.
. If hemodynamically UNSTABLE -> DC CARDIOVERSION.
 . N.B. you sh'd differentiate bet SVT & sinus tachycardia due to panic
attacks,
. Sinus tachycardia has normal P wave morphology & relationship with QRS
complex.
. Tx of sinus tachycardia due to anxiet -> Alprazolam.

. N.B. You sh'd differentiate bet SVT & ventricular tachycardia (VT),
. Ventricular tachycardia has WIDE QRS COMPLEXES,
. while SVT have NARROW QRS complexes.
. Tx of VT if hemodynamically stable -> Amiodarone.

. N.B. You sh'd differentiate bet SVT & Af with rapid ventricular
response (AF with RVR),
. SVT presents as sudden onset, REGULAR, narrow complex tachycardias.
. SVT HR 160 - 220 beats/min.
. Can be managed by vagal maneuvers as carotid massage or Adenosine.
. But Af with RVR has IRREGULARLY IRREGULAR RHYTHM with narrow complex
tachycardia,
. in addition to absence of P waves.
. Af with RVR is managed by rate control (BB metoprolo or CCB
Diltiazem),
. if hemodynamically stable (No hypotension).

{4} . WOLFF - PARKINSON - WHITE $YNDROME (WPW):

________________________________________________
. Anatomic abnormaily in the conduction pathway.
. Supraventricular tachycardia alternating with ventricular tachycardia.
. Supraventricular tachycardia that gets worse after diltiazem or
digoxin.
. DELTA waves on EKG.
. Dx -> Most accurate test -> Cardiac electrophysiology (EP) studies.
. Tx -> Acute therapy -> Procainamide or Amiodarone. (Only if there is
current WPW).
. Tx -> Chronic therapy -> Radiofrequency catheter ablation is curative.
. Digoxin & CCB are DANGEROUS "they block the normal pathway forcing
abnormal conduction"

. N.B. Pts with Wolf-Parkinson-White $yndrome who develop Atrial

fibrillation with RVR,
. Should be treated with cardioversion or anti-arrhythmics like
procainamide.
. AV nodal blockers (BB - CCB - Digoxin - Adenosine) should be AVOIDED,
. because they ++ conductance through the accessory pathway after AVN
blockage.

{5} MULTI-FOCAL ATRIAL TACHYCARDIA (MAT):

__________________________________________
. Associated with chronic lung disease e.g. COPD.
. Treat the underlying lung disease.
. Treat MAT as Af (But avoid BB because of the lung disease).

. N.B.
. AMIODARONE SIDE EFFECTS -> pulmonary fibrosis - Hepatotoxicity -
Hypothyroidism.
. Always do pulmonary, liver & thyroid function tests.

. N.B.
. Amiodarone-induced hypothyroidism:
. progressively worsening fatigue - difficulty concentrating & ++
forgetfulness.
 . Unintensional weight gain & dry skin.

. N.B.
. Pre-mature atrial beats are benign.
. Neither require follow up nor treatment.
. May be due to anxiety, CHF, hypoxia, Caffeine or electrolyte
imbalance.

. N.B.
. Don't ONLY reassure the pt without advising him !!
. Tobacco & alcohol are reversible risk factors for PACs.
. BBs are helpful in those who are symptomatic.

. N.B.
. Heriditary hemochromatosis > Abnormal iron deposition -> Multisystem
end-organ damage.
. Iron deposition within the myocardium can lead to Dilated
cardiomyopathy, heart failure
. May lead to conduction abnormalities e.g. Sick sinus $yndrome.
. Manifestations of hemochromatosis (DM, -- libido, hepatomegaly &
testicular atrophy).
. Sick sinus $ = Tachycardia-Bradycardia $ = Bursts of atrial tachy then
bradyarrhythmias

. N.B.
. Multiple premature ventricular complexes (PVCs)
. Identified by a wide QRS > 120 msec.
. Bizarre morphology.
. Compensatory pause.
. PVCs can be seen in normal individuals.
. They may follow a myocardial infections.
. No ttt indicated if pt is asymptomatic.
. BB are the 1st line of ttt in symptomatic pts.

. N.B.
. Grave's disease (insomnia - fatigability - weight loss - lid lag -
tremor).
. Atrial fibrillation is a common complication of hyperthyroidism.
. Best initial ttt is BB "propranolol".
. BB not only control Af, but alsodiminishes hyperthyroism symptoms.

. N.B.
. Ventricular premature beats (VPBs)
. If associated with Acute coronary $,
. You sh'd n't give LIDOCAINE (Class 1B anti-arrhythmic)!!
. Although Lidocaine use deceases the risk of ventricualar fibrillation,
. It may ++ risk of asystole !!
. Loidocaine is not used prophylactically in pts with AC$.
. Overall prognosis is not affected.

. N.B.
. Absence of P waves is characteristic for Af.
. PULMONARY VEINS are the most common frequent origin of ectopic foci
that cause Af.

. N.B.
. DELTA waves are characteristic for WPW $.

. N.B.
. FLUTTER waves are characteristic for AF.
 . TRICUSPID ANNULUS is the most common frequent of ectopic foci causing
AF.

. N.B.
. HIGH RATE REGULAR RHYTHM NARROW QRS COMPLEXES TACHYCARDIA = PSVT.
. It mostly involves formation of a re-entry circuit within AV node or
accessory pathway.

. BRADYCARDIA & AV BLOCK:

__________________________
__________________________
. HR < 60/min.
. EKG is mandatory to detect the cause of bradycardia.

. {1} SINUS BRADYCARDIA:

_________________________
. HR < 60/min with REGULAR rhythm & constant PR interval.
. May be associated with exaggerated vagal activity, hypoglycemia & sick
sinus $yndrome.
. May be induced by some medications (Digitalis, BB & CCB).
. Mostly asymptomatic.
. May be dizziness - lightheadedness - syncope - fatigue & worsened
angina.
. No ttt if asymptomatic no matter how low the heart rate is.
. If symptomatic -> Atropine is best initial ttt & PACE MAKER is the
most effective ttt.
. Atropine ++ HR by -- vagal input.

. {2} FIRST DEGREE AV BLOCK:

_____________________________
. Delayed impulse transmission from atria to ventricles.
. Prolonged PR interval > 0.20 seconds i.e. > 5 small squares i.e. > 1
big square.
. The PR interval remains constant.
. There is a QRS complex present for every P wave.
. Same management.

. {3} SECOND DEGREE AV BLOCK:

______________________________

. {a} MOBITZ "1" = WENCKEBACH BLOCK:

_____________________________________
. Intermittent AV nodal block.
. Progressively lenghtening PR interval that results in dropped beat.
. PR interval longer than previously conducted beat until dropped QRS.
. Grouped QRS complexes followed by dropped complex.
. Low risk for complete heart block.
. Normal sign in aging population.
. No ttt either symptomatic or asymptomatic !!

. {b} MOBITZ "2":

__________________
. Bundle block below the AV node.
. No PR interval prolongation.
. Drops a beat with-OUT the progressive lenghthening of the PR interval.
. i.e. PR interval is constant until dropped QRS complex.
. P waves are episodic & unpredictable dropped QRS complex.
. High risk of progression to 3rd degree AV block.
. Tx -> Pacemaker even if asymptomatic.
 . {4} THIRD DEGREE AV BLOCK:
_____________________________
. The atria & ventricles beat separately.
. Complete failure of impulse conduction from atria to ventricles.
. P-P waves intervals are constant (Some P waves may be burried inside
QRS complexes).
. R-R waves are constant.
. PACEMAKER is mandatory.

. N.B.
. The most common cause of death in the 72 hours post AMI is VENTRICULAR
ARRHYTHMIA.
. Manage arrhythmia from ischemia by correcting the ischemia.
. Don't put in an implantable defibrillator for an arrhythmia u can fix
the its cause !

. N.B.
. To determine the risk of recurrence of arrhythmia, do
ECHOCARDIOGRAPHY.
. If the echo shows a normal EF, the risk of recurrnce of arrhythmia is
small.

. N.B.
. In pts with recurrent syncopes due to arrhythmia, Put an implantable
defibrillator.
. An implantable defibrillator will prevent the next episode of syncope
or sudden death.

. N.B.
. Torsades de pointes = polymorphic ventricular tachycardia + prolonged
QT interval.
. H/O of alcoholism + Recent fluconazole or Moxifloxacin ttt.
. Tx -> Mg So4 (Alcohol is associated with -- Mg).

. N.B.
. Loop diuretics "Furosemide" cause hypokalemia & hypomagnesemia.
. These electrolyte abnormalities can cause ventricular taachycardia.
. so .. You should measure serum electrolytes before treating
ventricular arrhythmia.

. N.B.
. Anti-arrhythmic medications with the property of use-dependence,
. are more effective at higher rates because,
. there is no time between heart beats for the medication to dissociate
from its receptor
. This phenomenon is seen with class 1C anti-arrhythmics e.g
"FLECAINIDE" & class 4.
. Class 1C prolong the QRS complex whereas class 4 don't.

. N.B. APPROACH TO WIDE-COMPLEX TACHYCARDIA:

_____________________________________________

AV DISSOCIATION ?
___________________
FUSION/CAPTURE BEATS?
_______________________
|
______YES_____________NO________
| |
 VENTRICULAR TACHYCARDIA SUPRAVENTRICULAR
TACHYCARDIA With ABERRANCY
_________________________
_____________________________________________
| |
_________________________
_____________________________
| | |
|
STABLE UN-STABLE
STABLE
________ ___________
_________
| |
|
. IV AMIODARONE . HYPOTENSION . VAGAL MAEUVERS
(Carotid massage) . Altered mentation
. Adenosin - BB - CCB - Digoxin.
. Respiratory distress
|
. SYNCHRONIZED CARDIOVERSION

. SYNCOPE MANAGEMENT:
______________________
______________________
. Management of syncope is based on 3 criteria:
________________________________________________
. Was the loss of consciousness sudden or gradual ?
. Was the regaining of consciousness sudden or gradual ?
. Cardiac examination normal or abnormal ?

{1} Was the loss of consciousness sudden or gradual ?

______________________________________________________
. Sudden -> Cardiac or neurologic etiology "seizures".
. Gradual -> Toxic metabolic problem - Drug toxicity - Hypoxia - Anemia
- Hypoglycemia.

{2} Was the regaining of consciousness sudden or gradual ?

___________________________________________________________
. Sudden -> Cardiac etiology (Rhyhtm disorder or structural heart
disease).
. Gradual -> Neuorologic "Siezures".

{3} Cardiac examination normal or abnormal ?

_____________________________________________
. Normal -> Ventricular arrhythmia.
. Abnormal -> Structural heart disease (AS - HOCM - MS - MVP).

. DIFFERENTIAL DIAGNOSIS OF SYNCOPE:

_____________________________________

.1. VASO-VAGAL = NEURALLY MEDIATED SYNCOPE = NEUROCARDIOGENIC SYNCOPE:

_______________________________________________________________________
. Most common type of syncope.
. Due to excessive vagal stimulation -> Profound hypotension &
bradycardia.
. Triggers -> Prolonged standing - emotional stress - painful stimuli.
. Situations like medical needles & urination can precipiatate it.
 . Prodromal symptoms -> Nausea - warmth - Diaphoresis.
. symptoms improve with supine position.
. Dx -> UPRIGHT TILT TABLE TESTING (in uncertain cases).

.2. ORTHOSTATIC HYPOTENSION:

_____________________________
. Postural changes in heart rate or blood pressure after standing
suddenly.
. > 20 mmHg difference in BP bet standing & supine positions.
. DUE TO DECREASED BARORECEPTORS RESPONSIVENESS !

.3. AORTIC STENOSIS - HYPERTROPHIC CARDIOMYOPATHY - ANOMALOUS

CORONARIES:
_________________________________________________________________________
_
. Syncope with exertion or during exercise.

.4. VENTRICULAR ARRHYTHMIAS:

_____________________________
. Prior H/O of coronary artery disease, MI, cardiomyopathy or reduced
EF.

.5. SICK SINUS $YNDROME - BRADYARRHYTHMIAS - ATRIOVENTRICULAR BLOCK:

_____________________________________________________________________
. Sinus pauses on monitor, prolonged PR interval or QRS duration. (vvv.
imp.).

.6. TORSADES DE POINTES = ACQUIRED LONG QT $YNDROME:

_____________________________________________________
. Hypokalemia, hypomagnesemia, medications causing prolonged QT
interval.

.7. CONGENITAL LONG QT $YNDROME:

_________________________________
. Family H/O of sudden death, prolonged QT interval on ECG.
. Syncope with triggers (exercise, swimming, sudden noise, during
sleep).

.8. SITUATIONAL SYNCOPE:

_________________________
. Middle aged or older male with prostatic hypertrophy,
. who lost his consciousness after awakening & voiding at night.
. Pathophysiology -> Autonomic dysregulation.

. Treatment of syncope is based on etiology.

. Majority of cases never get a specific diagnosis.
. The most important is to EXCLUDE cardiac etiology e.g. arrhythmia.
. The majority (> 80%) of mortality from syncope involves a cardiac
etiology.
. If a ventricular dysrrhthmia is diagnosed -> Implantable
cardioverter/defibrillator.

. N.B. Elderly pts are very sensitive to fluid loss.

. Even mild hypovolemia may predispose them to orthostatic hypotension &
syncope.
. A recent episode of diarrhea with -- fluid intake due to -- appetite
is a risk factor.
. Patients on diuretics therapy are liable to syncope due to
hypovolemia.
. Mucosal dryness is a sign of hypovolemia.
 . Mostly noticed upon getting up in the morning.
. BUN/Creatinine ratio is the best indicator of dehydration.

. N.B. Syncope may be due to pericadial tamponade.

. Tamponade is due to viral pericarditis following an URT viral
infection.
. Hypotension, jugular venous distension & distant heart sounds.
. Electrical alternans (Varying QRS amplitudes on EKG).
. CXR -> Cardiac silhouette enlargement.

. COMPARISON BETWEEN SEIZURES & SYNCOPE:

_________________________________________

. P.O.C. _______ SEIZURES _______ SYNCOPE

* Circumstances: . Sleep loss. . Upright

position.
. Emotions. . Emotions.
. Alcohol withdrawal. . Heat.
. Flashing light. . Crowded
places.

* Clues: . Aura (Olfactory hallucinations). . Pre-syncope

lightheadedness.
. occur with sleeping or sitting position.. NO
. Head deviations. . Pallor &
diaphoresis.
. Tongue biting & laceration. . Weak & slow
pulse.
. Rapid strong pulse.
. Unusual body posturing.

* Sequelae . Delayed return to baseline.

. Post ictal state (sleepy confused). . IMMEDIATE
SPONTANEOUS RETURN.

. N.B.
. Clonic jerks may occur during any syncope if it is prolonged due to
brain hypoxia.
. Absence of previous H/O of seizure & presence of structural heart
disease,
. excludes seizure & makes a diagnosis of syncope due to arrhythmia more
reliable.

. SYSTEMIC HYPERTENSION:
________________________
________________________
. Systolic blood pressure > 140 mmHg.
. Diastolic blood pressure > 90 mmHg.

. A diabetic pt or chronic renal disease pt > 130/80 mmHg.

. Hypertension is the most common risk factor for MI (Death most common
risk factor).

. 95% of cases of HTN has no clear etiology "Essential hypertension".

 . Commonest cause of essential HTN is RIGIDITY OF ARTERIAL WALL
"Atherosclerosis".
. 5 % of cases has definite etiology (Mostly YOUNG population) ->
"Secondary HTN".

. Causes of SECONDARY HYPERTENSION:

-> Renal artery stenosis "systolic diastolic abdominal periumbilical
bruit".
-> Glomerulonephritis.
-> Coarctation of the aorta "Upper extremity BP > Lower extremity BP".
-> Acromegaly.
-> Pheochromocytoma "Episodic HTN - flushing - Palpitations - Headache -
Part of MEN 2".
-> Hyperaldosteronism "++Na,--K, Weakness, Metabolic alkalosis,--
Renin,++ Aldosterone".
-> Cushing $ (Central obesity - Abdominal striae - Facial plethora).
-> Exogenous therapeutic glucocorticoids.
-> Congenital adrenal hyperplasia.
-> Hyperparathyroidism (HTN - Hypercalcemia - renal stones -
Neuropsychiatric symptoms).
-> Oral contraceptive pills "Stoppage of OCPs intake may correct the
problem".

. Dx -> ROUTINE OFFICE TESTS -> Urinalysis - Lipid profile - Glucose

level - EKG.

. Tx -> Best initial therapy -> LIFE STYLE MODIFICATION:

_________________________________________________________
-> Obese pts -> Weight loss (Most effective).
-> Thin pts -> ++ fruit & vegetables = DASH DIET.
-> Sodium restriction.
-> Dietary modification (Less fat & red meat, More fish & vegetables).
-> Exercise.
-> Tobacco cessation does NOT stop HTN but important to prevent
cardiovascular diseases.
-> Councel for reduction of alcohol intake.

. Tx -> DRUG THERAPY:

______________________
. The best initial drug therapy is THIAZIDE DIURETICS.

. If BP is very high on presentation (above 160/100), 2 medications

should be given.

. If diuretics don't control BP, the most important next step in

management is:
. ACEI - ARB - BB - CCB.

. Medications that are not considered as 1st or 2nd line therapy are:
-> Central acting alpha agonists (Alpha methyl dopa - Clonidine).
-> Peripheral acting alpha antagonists (Prazosin - terazosin -
doxazosin).
-> Direct acting vasodilator (Hydralazine - Minoxidil).

. Compelling indications for specific drugs:

_____________________________________________
-> Coronary artery disease -> BB - ACEI - ARB.
-> Diabetes mellitus -> ACE - ARB.
-> Benign prostatic hyperplasia -> Alpha blockers (Prazocin).
-> Depression & Asthma -> Avoid BB.
 -> Hyperthyroidism -> BB 1st.
-> Osteoporosis -> Thiazides.
-> Essential tremors -> BB.

. N.B.
. Benign essential tremor are tremors occuring with posture "movement".
. They are unlike Parkinson's disease which is characterized by resting
tremors.
. It usually disturbs the fine motor tasks e.g. handling a newspaper or
pouring tea.
. Inhibition of the tremor by a small amount of alcohol is typical.
. Tx -> Propranolol.

. N.B.
. Isolated systolic hypertension (ISH) is an important cause of
hypertension in elderly,
. it is due to DECREASED ELASTICITY OF THE ARTERIAL WALL.
. It sh'd be ttt due to strong association with ++ risk of
cardiovascular events.
. Initial ttt -> Monotherapy with a low dose thiazide, an ACEI or long
acting CCB.

. N.B. 2ry hypertension due to Cushing's $,

. ++ cortisol -> ++ vasoconstriction, insulin resistance &
mineralocorticoid activity.
. ++ Vasoconstriction -> Hypertension.
. ++ insulin resistance -> Hyperglycemia & weight gain.
. ++ mineralocorticoid activity -> Hypokalemia.
. Proximal ms weakness, central adeposity, thinning of skin, weight gain
are common.
. Psychiatric problems (Sleep disturbances, depression & psychosis) are
also common.
. Cushing's $ may be due to ADRENAL CORTICAL (Not medullary)
HYPERPLASIA,
. ACTH producing pituitary adenoma (Cushing's disease), ectopic ACTH
production,
. or exogenous steroids.

. N.B.
. Renovascular hypertension
. sh'd be suspected in all pts with resisant hypertension in addition to
. diffuse atherosclerosis - asymmetric kidney size - recurrent flash
pulmonary edema.
. or elevation in serum creatinine > 30 % from baseline after starting
ACEIs or ARBs.
. The presence of continous abdominal bruit has a high specificity for
renovascular HTN.

. N.B.
. POLYCYSTIC KIDNEY DISEASE (PKD) -> Autosomal dominant inheritance.
. Bilateral cystic dilatation of the renal tubules.
. Hypertension is one of the earliest manifestations.
. Hematuria is often present.
. Flank or abdominal masses with pain & 2ry eryhthrocytosis.
. PKD is associated with cerebral aneurysms.
. Family H/O of stroke or sudden death.
. Dx -> Abdominal U/$.

. HYPERTENSIVE CRISIS:
______________________
 . Hypertensive crisis is not defined as a specific level of blood
pressure !
. It is defined as hypertension associated with END-ORGAN DAMAGE.
. End organ damage = CONFUSION - BLURRY VISION - DYSPNEA - CHEST PAIN.

{1} HYPERTENSIVE URGENCY:

__________________________
. Severe hypertension (> 180/120 mmHg) .. BUT .. No symptoms or acute
end organ damage.

{2} HYPERTENSIVE EMERGENCY:

____________________________
. Severe hypertension (> 180/120 mmHg) + Acute, life threatening end
organ complications.
. Malignant hypertension -> Severe HTN + Retinal hemorrhages + exudates
+ Papilledema.
. Hypertensive encephalopathy -> Severe HTN + cerebral edema + Non
localizing neuro signs

. The best initial therapy for hypertensive crisis is LABETALOL or

NITROPRUSSIDE.

. INTRAVENOUS LABETALOL is preferred to Nitroprusside (Needs

monitoring).

. Do NOT lower blood pressure in HTN crisis to NORMAL, or you may

PROVOKE A STROKE.

. N.B. ANTI-HYPERTENSIVE DRUGS SIDE EFFECTS:

____________________________________________

. THIAZIDE DIURETICS "HYDROCHLOROTHIAZIDE":

____________________________________________
. Metabolic side effects -> Hyperglycemia, ++ triglycerides & ++ LDL
cholesterol.
. Electrolyte side effects -> Hyponatremia, hypokalemia & hypercalcemia.

. DIRECT RENIN INHIBITOR:

__________________________
. Enhances natriuresis.
. -- serum angiotensin 2 concentration.
. -- Aldosterone production.

. N.B. CLUES FOR CAUSES OF SECONDARY HYPERTENSION:

__________________________________________________

* RENAL PARENCHYMAL DISEASE:

_____________________________
. ++ serum creatinine.
. Abnormal urinalysis (proteinuria & RBCs casts).

* RENO-VASCULAR DISEASE:
_________________________
. Severe hypertension (> 180 mmHg systolic & 120 mmHg diastolic) after
age 55.
. Possible recurrent flash pulmonary edema or resistant heart failure.
. Unexplained rise in serum creatinine.
 . Abdominal bruit.

* PRIMARY HYPERALDOSTERONISM = CONN's $:

_________________________________________
. Due to adrenal adenoma or bilateral adrenal hyperplasia.
. Easily provoked hypokalemia.
. Slight hypernatremia.
. Metabolic alkalosis (High serum BICARBONATE HCO3).
. ++ ALDOSTERONE & -- RENIN.
. Hypertension with adrenal incidentaloma.

* PHEOCHROMOCYTOMA:
____________________
. Paroxysmal ++ Blood pressure with tachycardia.
. Pounding headaches, palpitations & diaphoresis.
. Hypertension with adrenal incidentaloma.

* CUSHING's $YNDROME:
______________________
. Central obesity & facial plethora.
. Proximal muscle weakness.
. Ecchymosis, amenorrhea & erectile dysfunction.
. Hypertension with adrenal incidentaloma.

* HYPOTHYROIDISM:
__________________
. Fatigue, dry skin & cold intolerance.
. Constipation, weight gain & bradycardia.

* PRIMARY HYPERPARATHYROIDISM:
_______________________________
. Hypercalcemia (Polyuria & polydipsia).
. Renal stones.
. Neuropsychiatric (Confusion, depression & psychosis).

* AORTIC COARCTATION:
______________________
. Differential hypertension with brachial femoral pulse delay.

. MISCELLANEOUS TOPICS:
_______________________
_______________________

. NOREPINEPHRINE INDUCED VASOSPASM:

___________________________________
. Caused by vasopressors used in emergency bleeding episodes.
. Norepinephrine is an alpha 1 agonist causing vasoconstriction.
. Norepinephrine causes ischemia of the distal fingers & toes 2ry to
vasospasm.
. SYMMETRICAL duskiness & coolness of all fingertips.
. A similar condition may occur in intestines (Mesenteric ischemia) or
kidneys (RF).

. BLUE TOE $YNDROME:

____________________
. Due to cholesterol emboli in pts with atherosclerosis.
. Affect the distal portions of the digits.
 . ABSENCE of symmetry of digital involvement.

. SUBCLAVIAN VEIN THROMBOSIS:

_____________________________
. Used for total parenteral nutrition.
. Continous irritating hyperosmolar fluid can traumatize the veins
leading to thrombosis.
. Prolonged placement of central lines can lead to subclavian vein
thrombosis.
. It results in arm swelling & pallor.
. CATHETER REMOVAL IS MANDATORY.
. Duplex is ordered to document thrombus & the need for anticoagulation.

. HEAT STROKE:
______________
. Temperature above 40.5 c (105 F).
. Exertional heat stroke occurs in healthy individuals exercising in
extreme heat.
. Dehydration, hypotension, tachycardia & tachypnea are common.
. Systemic effects like seizures, ARD$, DIC & hepatic or renal failure
may occur.

. COCAINE USE:
______________
. Atrophic nasal mucosa.
. Sympathetic hyperactivity (Tachycardia, hypertension, dilated pupils).
. Chest pain due to coronary vasospasm.
. Psychomotor agitation & siezures.
. Complications (Acute MI - Aortic dissection - Intracranial
hemorrhage).
. Management of chest pain:
-> IV BENZODIAZEPINES for blood pressure & anxiety.
-> Aspirin.
-> Nitroglycerin & CCBs for pain.
-> BBs are CONTRAINDICATED.
-> Fibrinolytics are NOT PREFERRED due to ++ risk of intracranial
hemorrhage.
-> Immediate cardiac catheterization with reperfusion when indicated.

. LATEX ANAPHYLACTIC SHOCK:

___________________________
. Exposure to latex-containing products such as surgical gloves &
condoms.
. Development of hives after protected sex due to sensitization to latex
condoms.
. Latex gloves used by surgeonsprovokes anaphylactic reaction with
hypotension & rash.
. Health care workers & pts with atopic disease are at high risk of
latex allergy.

. CHAGAS DISEASE:
_________________
. A potozoal disease caused by Trypanosoma cruzi.
. It is endemic to Latin America "Brazil".
. Two primary manifestations -> MEGACOLON/MEGAESOPHAGUS & CARDIAC
DISEASE.
. Megacolon or megaesophagus (focal GI dilatation) is 2ry t destruction
of the nerves,
. controlloing the gastrointestinal smooth muscles leading dialatation.
 . Congestive heart failure occurs (Pedal edema - JVD - S3 gallop -
cardiomegaly).

. ACUTE LIMB ISCHEMIA:

______________________
. Pain - Pulselessness - Paresthesia - Poikilothermia "Coldness" -&
Pallor.
. Angiography -> Abrupt cut-off of arterial blood flow.
. IV Heparin sh'd be started immediately upon suspicion.
. Definitive ttt -> Surgical embolectomy,
. or Intra-arterial fibrinolysis & mechanical embolectomy.

. ARD$:
_______
. Acute onset.
. Bilateral patchy airsapce disease on CXR.
. PCWP < 18.
. No ++ in LVEDP.
. PaO2/FiO2 < 200.

. GASTRO-ESOPHAGEAL MURAL INJURY CHARACTERISTICS:

_________________________________________________
_________________________________________________

(A) MALLORY WEISS $YNDROME:

____________________________
. Upper gastro-intestinal MUCOSAL TEAR.
. Caused by forceful retching (++ pressure).
. Submucosal arterial or venule plexus bleeding.
. Vomiting, retching, hematemesis & epigastric pain.
. Dx -> EGD confirms diagnosis.
. Most tears heal spontaneously.
. Endoscopic therapy for continous bleeding.

(B) BOERHAAVE $YNDROME:

________________________
. Esophageal TANS-MURAL tear.
. Caused by forceful retching (++ pressure).
. ESOPHAGEAL AIR/FLUID LEAKAGE into nearby areas e.g. pleura.
. Vomiting, retching, chest & upper abdominal pain.
. Odynophagia, fever, dyspnea & septic shock may occur.
. Subcutaneous emphysema may be seen.
. Dx -> CT or CONTRAST ESOPHAGOGRAPHY with GASTROGRAFIN confirms
diagnosis.
. CXR -> Pneumo-mediastinum & pleural effusion.
. Pleural fluid analysis -> EXUDATIVE, LOW pH, VERY HIGH AMYLASE > 2500
IU.
. Tx -> Surgery for thoracic perforations.
. Conservative measures e.g. antibiotics for cervical perforation.

. IMPORTANT AUSCULTATORY MEDIA Qs:

__________________________________
__________________________________

. S3
. Extra-sound heared just after S2.
. (ken-tuc-"KY") -> With S3 corresponding to the last syllabus.
. Result when inflow from Lt atrium strikes blood already in Lt
ventricle.
. It is a sign of Lt ventricular failure.
 . Best initial ttt of LVF is IV diuretics.

. S4
. Additional diastolic sound
. ("TEN"-nes-see) -> With S4
. It is indicator of a stiff
. Causes: prolonged systemic
just prior to S1.
corresponding to the first syllabus.
left ventricle.
hypertension or restrictive cardiomyopathy.

. AR MURMUR
. Early diastolic murmur.
. Associated clinical finding -> Water hammer pulse = Bounding pulse.

. MR MURMUR
. Holo-systolic murmur.
. Heard best over the apex with radiation to the axilla.

. IMPORTANT KEY WORDS:

______________________
. FIXED SPLITTING od S2 = ASD.
. PULSUS PARADOXUS (Fall in BP > 10 mmHg with inspiration) = CARDIAC
TAMPONADE.
. PULSUS PARVUS ET TARDUS (Week & delayed pulse stroke) = Aortic
stenosis.
. OPENING SNAP with loud S1 = MS.
. CAPILLARY PULSATIONS in fingers & lips = AR.

. PERIPHERAL EDEMA DIFFERENTIAL DIAGNOSIS:

__________________________________________
__________________________________________

{1} CARDIAC:
_____________
. Bilateral.
. Congestive heart failure.
. Dyspnea & orthopnea.
. Jugular venous distension & hepatomegaly.

{2} HEPATIC:
_____________
. Bilateral.
. Hepatic cell failure.
. Ascites dominates over LL edema.
. Abnormal liver function tests (++ ALT & AST)
. Hypoalbunimea & hyperbilirubinemia.
. Spider nevi, gynecomastia, palmer erythema.

{3} RENAL:
___________
. Bilateral.
. Nephrotic $yndrome (Due to massive proteinuria).
. Nephritic $yndrome (Due to fluid retention).
. Proteinuria, hypoalbuminemia.
. Abnormal renal function tests (++ urea & creatinine).

{4} NUTRITIONAL:
_________________
. Bilateral.
. H/O of metabolic problems.
. Rare in adults.
 {5} MEDICATIONS SIDE EFFECTS:
______________________________
. Bilateral.
. Ex. Dihydropyridine Ca channel antagonists (Amlodipine).
. Amlodipine dilate peripheral blood vessels.

{6} VENOUS INSUFFECIENCY:

__________________________
. Unilateral.
. Varicose veins.
. Skin changes & ulcers.

. N.B. TRICKY CASE:

___________________
. 53 ys old pt - 2 days H/O of Rt calf pain & swelling.
. Constant pain - exacerbated by knee flexion.
. H/O of past IV drug abuse, endocarditis & stroke.
. He is currently wheel-chair bound 2ry to stroke related Lt sided
hemiparesis.
. BP 140/90 - HR 100/mon.
. No JVD - No hepato-jugular reflux.
. Clear chest on ausculatation.
. Enlarged abdomen with shifting dullness & fluid wave suggestive of
ascites.
. Palpable liver 3 cm below the Rt. costal margin - splenomegaly.
. Rt sided calf swelling & tendrness.
. What is the cause of ascites ??
. Pulmonary embolism/paradoxical embolism/Rt sided HF/Chronic liver
disease/Nephrotic $ ?

. The answer is -> CHRONIC LIVER DISEASE.

. The pt's H/O of IV drug abuse ++ risk for cirrhosis 2ry to infection
e' HBV & HCV.
. The findings of hepatosplenomegaly & ascites point toward the
diagnosis.
. Most common cause of ascites is hepatic cirrhosis.
. The pt's leg swelling may be due to DVT resulting from impaired
mobility.
. ASCITES is NOT related to DVT !!

. N.B. Hepato-jugular reflux:

. A useful clinical tool that can differentiate bet. cardiac & liver
causes of LL edema.
. Cardiac cause (Heart failure) -> ++ Jugular venous pressure & +ve
Hepatojugular reflux.
. Hepatic cause (Liver cirrhosis) -> -- or Normal JVP & -ve
Hepatojugular reflex.

. N.B.
. Chronic venous insuffeciency is a common cause of peripheral edema.
. Sh'd be suspected in pts with isolated lower limb edema & or dilated
veins,
. with otherwise normal physical examination.
. Initial ttt -> Conservative measures with leg elevation, exercise &
compression therapy
. PATHO-PHYSIOLOGY of CAUSES of PERIPHERAL EDEMA:
_________________________________________________

. ++ CAPILLARY HYDROSTATIC PRSSURE:

____________________________________
. Heart failure (Lt ventricular & cor pulmonale).
. Primary renal Na retention (Renal diseases & drugs).
. Venous obstruction (Cirrhosis & venous insuffeciency).

. -- CAPILLARY ONCOTIC PRESSURE = HYPOALBUMINEMIA:

___________________________________________________
. Protein loss (Nephrotic $).
. -- Albumin synthesis (Cirrhosis & Malnutrition).

. ++ CAPILLARY PERMEABILITY:
_____________________________
. Burns, trauma & sepsis.
. Allergic reactions.
. ARD$.
. Malignant ascites.

. ++ INTERSTITIAL ONCOTIC PRESSURE = LYMPHATIC OBSTRUCTION:

____________________________________________________________
. Malignant ascites.
. Hypothyroidism.
. Lymph node dissection.

. PARAMETERS OF DIFFERENT TYPES OF SHOCKS:

__________________________________________
__________________________________________

. TYPE OF SCOCK __ COP __ SVR __ BP __ HR __ PCWP(CVP) __ Tx

. CARDIOGENIC __ - __ + __ - __ + __ + __ TTT cardiac

problem

. HYPOVOLEMIC __ - __ + __ - __ + __ - __ Fuids &

pressors

. SEPTIC __ + __ - __ - __ + __ - __ Fluids,
pressors & Antibiotics

. NEUROGENIC __ - __ - __ - __ + __ - __ Fluids &

pressors

. BP -- in all types of shock.

. HR ++ in all types of shock.

. PCWP ++ only in cardiogenic shock.

. COP ++ only in septic shock.

. SVR ++ in hypovolemic & cardiogenic shocks.

. Skin is pale & cool in hypovolemic & cardiogenic shocks.

. Skin is warm & faint in septic shock.
 . The most common cause of cardiogenic shock is myocardial infarction.
. The most common cause of hypovolemic shock is massive hemorrhage.
. The most common cause of septic shock is E-coli & staphylococcal
infection.
. The most common cause of nerogenic shock is cervical or thoracic
spinal cord injury.

Dr. Wael Tawfic Mohamed

_________________________
 DERMATOLOGY TIKI TAKA
-----------------------

. CELLULITIS:
------------
. Cellulitis with systemic manifestations e.g. fever,rigors,chills &
confusion is ttt by I.V. NAFICILLIN or Cefazolin.
. caused by staph or strept.
. Generalized swelling which is erythematous "linear streaks", warm,
tender but less well demarcated than Erysipelas.
. An associated fungal infection may acts as a portal of entry.

. Tinea Corporis:
-----------------
. Ring shaped scaly patches with central clearin & scaly borders.
. Dx: KOH -----> Hyphae. . Tx: Local Terbinafine or systemic
Griseofluvin.

. Tinea Versicolor:
-------------------
. Pale velvety pink or whitish hypopigmented macules that DON'T TAN !
. SCALE ON SCRAPING.
. Dx: KOH preparation ----> Spaghetti & meat ball appearance.
. Tx: Selenium sulfide.

. NECROTIZING FASCIITIS:
------------------------
. Severe pain & swelling.
. H/O of recent trauma.
. High fever > 39 c.
. Edematous limb with PURPLISH DISCOLORATION of the injured area
"denoting start of gangrene!".
. Surgical debridement of all necrotic tissue.
. Empiric IV Antibiotics e.g AMPICILLIN + SULBACTAM + CLINDAMYCIN.
. Bullae & seroanguinous discharge.

. Seborrheic dermatitis:
------------------------
. Fine loose waxy scales with underlying erythema.
. On scalp, eye brows.
. Associated with HIV or parkinsonism.

. PRIMARY BILIARY CIRRHOSIS:

----------------------------
. Pruritis, jaundice, steatorrhea, HSM, ++ ALP, ++ Bilirubin.
. +ve Anti-mitochondrial Antibodies.
. Immune mediated destruction of intra hepatic bile ducts ---> Bile
stasis & cirrhosis.
. Cutaneous association ---> XANTHELASMA
"Yellowish, soft plaques on the medial aspects of the eyelids
bilaterally".

. CHALAZION:
------------
. Painful swelling that progresses to a nodular rubbery lesion.
. due to MEIBOMIAN gland obstruction.
. Recurrent chalazion may be due to meibomian gland carcinoma !
 . U can't differentiate bet. PERSISTENT CHALAZION & BASAL CELL CARCINOMA
except through HISTOPATHOLOGICAL exam.

. MOLLUSCUM CONTAGIOSUM is caused by POX VIRUS not HPV !!!!!!! (REPEATED

FAULT) !!

. BASAL CELL CARCINOMA:

-----------------------
. Fair skinned individual.
. Prolonged sun exposure.
. Slowly growing nodule with rolled border.
. SHINY PEARL.
. Most common location is the lower eyelid margin.

. Seborrheic Keratosis:
-----------------------
. OLD AGE.
. WAXY - "STUCK ON" - well circumscribed lesion.
. Not pre-cancerous.
. No therapy is required.
. Surgical removal for cosmetic purpose.

. MELANOMA -----------> Excisional biopsy " FULL THICKNESS".

. Varicella Zoster virus = Shingles:

------------------------------------
. Vesicular eruption that occurs in a dermatomal distribution.
. Preceided by pain.
. The 1ry disease in children is termed "chickenpox".

. ANGIO-EDEMA:
--------------
. H/O of ICU pt on ACEIs e.g ENALAPRIL.
. Edema in the face, mouth, lips.
. Laryngeal edema may occur causing airway obstruction.
. occurs due to BRADYKININ release.
. it may occur at any time not just at the start of drug intake.
. Dx----> Low levels of C2 & C4.
. Tx----> STOP ACEIs + FRESH FROZEN PLASMA + Secure the airway.

. HERIDITARY angioedema:
------------------------
. C1 esterase inhibitor defeciency.

. Drug induced PHOTOTOXICITY:

-----------------------------
. The most common drug is DOXYCYCLINE (TETRACYCLINE).
. Manifest as exaggerated sunburn reactions with erythema ,edema &
vesicles over sun- exposed areas.

. WARFARIN induced skin necrosis:

---------------------------------
. More common in females.
. Common sites: Breasts, buttocks, thighs & abdomen.
. Initial complaint is pain followed by bullae formation & skin
necrosis.
. Occurs within weeks after starting therapy.
. Tx: Discontinue WARFARIN & Give Vit. K & maintain anticoagulation
using Heparin.
. Dermatitis Herpetiformis:
---------------------------
. Pruritic papules & vesicles over the extensor surfaces.
. Presence of anti-endomysial antibodies.
. Tx----------------> DAPSONE.

. Dermatitis Herpetiformis:
---------------------------
. Ass. with celiac disease.
. Erythematous papules, vesicles & bullae that occur bilaterally,
symmetrically & in groups "herpetiform" arrangement.
. On the extensor sufraces of the elbows,knees,buttocks.
. Tx: Gluten free diet & DAPSONE.

. Pemphigus Vulgaris:
---------------------
. Thin & fragile large wide bullae.
. +ve Nikolsky sign.
. Mouth is involved.
. H/O of ACE Is use.
. Deposition of IgG in the epidermis.

. Bullous Pemphigoid:
---------------------
. Thick & intact small & narrow bullae.
. Bullae don't rupture easily.
. No mouth involvement.
. H/O of SULFA drugs use.
. Deposition of IgG & C3 in the epidermis.

. ROSACEA:
----------
. 30 - 60 ys old pt.
. TELANGECTASIA over the cheeks, nose & chin.
. Flushing of these area is precipitated by hot drinks,heat,emotion.
. Tx: initial ttt is METRONIDAZOLE.

. Toxic Epidermal Necrolysis "TEN":

----------------------------------
. Much more surface area involved.
. Higher mortality rate.
. +ve NIKOLOSKY sign.
. Although the most common cause of death is sepsis, Anitibiotics is not
indicated.
. TEN has similar features to SSSS, however, TEN is DRUG INDUCED but
SSSS is caused by a toxin.

. Vilitiligo (Leukoderma):
--------------------------
. Young 20-30 ys.
. Pale whitish macules with hyperpigmented borders.
. Around body orifices.
. Auto-immine destruction of melanocytes.

. STEVENS JOHNS $YNDROME:

-------------------------
. Immune complex mediated hypersensitivity.
. H/O of SULFONAMIDES, NSAIDs & PHENYTOIN intake.
. Characteristic "TARGET" appearance.
 . Fever, conjunctivitis, ++HR, --BP, altered consciousness, coma,
convulsions may occur.

. RUBELLA:
---------
. Middle aged female.
. Maculo-papular rash starting on the face & extends to involve the
trunk & extremeties (Not involving th palms & soles).
. Tender lymphadenopathy (Post. auricular & post. cervical LNs).
. Poly-arthritis.

. Secondary $yhphilis:
----------------------
. Maculopapular rash (involving the palms & soles).
. The papules may coalese to form CONDYLOMA LATA in severe cases!

. NICKEL jewelry can cause allergic contact dermatitis (Type 4

hypersensitivity).

. Frost-bite injury:
--------------------
. Rapid re-warming with warm water.
. Dead Tissue debridement is WRONG.
. Rapid re-warming with fry heat or fan is WRONG.

. SQUAMOUS CELL CARCINOMA:

--------------------------
. Non-melanoma skin cancer.
. Second most common skin cancer after Basal cell carcinoma.
. Aggressive due to distant mateastasis.
. EXPOSURE to SUN LIGHT is the most imp. risk factor.

. MILD ACNE & NON-INFLAMMATORY COMEDONES -----> Topical retinoids.

. MILD INFLAMMATORY ACNE ---------------------> Topical benzyl peroxide.
. MODERATE to SEVERE ACNE (NODULO-CYSTIC) ----> ORAL ISOTRETINOIN.

. GRAFT VERSUS HOST DISEASE (GVHD):

-----------------------------------
. in pts with bone marrow transplantation.
. due to activation of the DONOR "T" lymphocytes.
. Skin ---> Maculopapular rash.
. Intestine ---> Bloody diarrhea.
. Liver ---> Abnormal LFTs & jaundice.

. Drug induced type 1 hypersensitivity reaction:

-----------------------------------------------
. IMMEDIATE ONSET.
. Mediated by IgE & Mast cells.
. Urticaria & pruritis without systemic symptoms.
. Tx: ANTI-HISTAMINICS & dis-continue the offending drug !

. MELANOMA criteria (ABCDEs):

-----------------------------
. Assymetry.
. Border irregularities.
. Color variation.
. Diameter > 6mm.
. Evolving: lesion changing in size, shape or color; new lesion.
. The most concerning sign for malignancy is ZONES OF DIFFERENT SKIN
COLORS !

. PORPHYRIA CUTANEA TARDA:

--------------------------
. photosensitivity reaction to accumulating porphyrins.
. Painless blisters on the dorsum of the hand.
. Hypertichosis on the face & Hyperpigmentation.
. H/O of liver disease (HCV) or OCP use.
. Dx: Urinary uroporphyrins.
. Tx: Phlebotomy & Deferoxamine.

. SQUAMOUS CELL CARCINOMA:

--------------------------
. isolated solitary ulcer.
. in the Vermilion area of the lip.
. H/O of sun exposure (FARMER).
. Histologically: INVASIVE CORDS OF SQUAMOUS CELLS WITH KERATIN PEARLS.

. BASAL CELL CARCINOMA:

-----------------------
. INVASIVE CLUSTERS OF SPINDLE CELLS SURROUNDED BY PALISADED BASAL
CELLS.

. CHERRY HEMANGIOMA:
--------------------
. Small vascular bright red papular lesion.
. 30-40 ys & ++ in no with age "Senile hemangioms".
. Don't regress spontaneously.
. Sharply circumscribed areas of congested capillaries.

. ACTINIC KERATOSIS:
--------------------
. Erythematous papule with a central scaling.
. Sand paper like texture.
. H/O of chronic sun exposure.
. Pre-cancerous ----> may convert to squamous cell carcinoma.

. Molluscum Contagiosum (Pox virus):

------------------------------------
. Firm, flesh colored, dome-shaped, umbilicated papules.
. Transmitted through sexual contact.
. Due to CELLULAR immunodefeciency.
. Associated with HIV.

. SHINGLES (HZV) may develop due to "INFLIXIMAB" therapy causing

immunodefeciency.

. Allergic contact dermatitis:

------------------------------
. Type 4 hypersensitivity reaction.
. Prurutic erythematous rash with vesicles.
. Bilateral distribution.
. H/O of cutting woods (Poison Sumac).
. Vesicular fluid is sterile and grows coagulase -ve staphylococci (S.
Epidermidis).
. May be 2ry infected staph or strept !

. ACANTHOSIS NIGRICANS:
-----------------------
 . Symmetrical, hyperpigmented, velvety plaques in the axilla, groin &
neck !
. Ass. with INSULIN RESISTANCE in YOUNG pts e.g. DM & PCO.
. Ass. with GIT malignancy in OLD pts.
 ENDOCRINOLOGY TiKi TaKa
_________________________

. THYROID DISEASES:
___________________
___________________

. P.O.C. ___________________ HYPOthyroidism ______________

HYPERthyroidism
---------------- ----
-------------
* Labs ___________________ -- T4 & ++ TSH ______________ ++
T4 & -- TSH
* Weight ___________________ Gain ______________
Loss
* Intolerance ___________________ Cold ______________
Heat
* Hair ___________________ Coarse ______________
Fine
* Skin ___________________ Dry ______________
Moist
* Mental ___________________ Depressed ______________
Anxious
* Heart ___________________ Bradycardia ______________
Tachycardia & Af
* Muscles ___________________ Week ______________
Week
* Reflexes ___________________ Diminished ______________
Hyperactive
* Fatigue ___________________ Yes ______________ Yes
* Menstrual changes ___________________ Yes ______________ Yes

. HYPOTHYROIDISM:
_________________
* PRIMARY Hypothyroidism * * Secondary Hypothyroidism * * TERTIARY
Hypothyroidism *
________________________ _________________________
_________________________
. -- T3 & T4. . -- T3 & T4. . -- T3 &
T4.
. ++ TSH. . -- or normal TSH. . -- or
normal TSH.
. Ex: Auto-immune Hashimoto's.

. HASHIMOTO's THYROIDITIS:
__________________________
. Hypothyroidism symptoms: Slow, tired, fatigued pt with weight gain.
. Anti-TPO Abs (Anti-thyroid peroxidase antibodies).
. -- T4 & ++ TSH.
. Tx -> T4 or thyroxine replacement.
. High risk of developing THYROID LYMPHOMA.

. GENERALIZED RESISTANCE to thyroid hormones:

_____________________________________________
. ++ T3 & T4 levels.
. ++ or Normal TSH level.
. features of HYPO-thyroidism despite having ++ free T3 & T4.
. N.B. HYPOTHYROIDISM & MYOPATHY:
_________________________________
. Un-explained ++ ofe serum CPK creatinine kinase.
. ANA Anti-nuclear antibodies may be +ve in HASHIMOTO's thyroiditis.
. Serum TSH level is the most sensitive test to diagnose hypothyroidism.

. HYPERTHYROIDISM -> "Grave's disease" - "Silent" - "Subacute" -

"Pituitary adenoma":
_________________________________________________________________________
_________________
. Physical findings: . Eye,skin,nails - Not tender - Tender gland -
None.
. RAIU scan: . (++) - (--) - (--) -
(++).
. TTT: . Iodine ablation - None - Aspirin -
Surgical removal.

.1. GRAVE's DISEASE:

____________________
. Symptoms of thyrotoxicosis (weight loss - insomnia - hperactivity -
tachycardia).
. Ophthalmopathy (Exophthalmos & proptosis - Abs against the extra-
ocular muscles).
. Dermopathy (Thickening & redness of the skin just below the knee).
. Onycolysis (Separation of the nail from the nailbed).
. Peri-orbital lymphocytic infiltration -> Gritty sandy sensation.
. Fibroblast proliferation, hyaluronic acid deposition, edema &
fibrosis.
. Throid stimulating immunoglobulins.
. RAIU -> HIGH.
. Tx -> Propylthiouracil (PTU) or methimazole.
. Use radioactive iodine to ablate the gland (May cause permanent HYPO-
thyroidism).
. BB (propranolo) to treat sympathetic symptoms, such as tremos &
palpitations.

.2. SILENT Thyroiditis:

_______________________
. Auto-immune process.
. Symptoms of thyrotoxicosis (weight loss - insomnia - hperactivity -
tachycardia).
. NON-tender gland.
. No skin, eye or nail diseases.
. RAIU -> NORMAL.
. Tx -> NONE !

.3. SUB-ACUTE Thyroiditis = De QUERVAIN's THYROIDITIS:

______________________________________________________
. Viral etiology.
. ++ ESR > 50 mm/hr.
. Thyroid TENDRNESS.
. Syms last for < 8 wks due to thyroid depletion.
. RAIU -> LOW.
. Tx -> ASPIRIN to relieve pain.

.4. PITUITARY ADENOMA:

______________________
. THE ONLY CAUSE OF HYPERTHYROIDISM WITH ++ T4 & ++ TSH !
. Dx -> Brain MRI.
. Tx -> Surgical removal.
.N.B. EXOGENOUS THYROID HORMONE ABUSE:
______________________________________
. ++ T4 & -- TSH.
. The galnd will atrophy to the degree of non-palpability on exam.

. N.B. THYROID STORM:

_____________________
. Acute, severe life threatening hyperthyroidism.
. Tx -> IODINE -> Blocks uptake of iodine into the gland.
. Tx -> Propylthiouracil or methimazole -> Blocks the production of
thyroxine.
. Tx -> Dexamethazone -> Blocks peripheral conversion of T4 to T3.
. Tx -> Propranolol -> Blocks target organ effect.

# THYROID NODULE APPROACH:

__________________________

A . 1st step -> Cilinical evaluation - TSH level & thyroid ULTRA$OUND.
______________________________________________________________________

B . CANCER risk factors or suspicious U$ findings ??

____________________________________________________
. YES -> FNAB (Fine Needle Aspiration Biopsy).
. NO -> C. (TSH level).

C . TSH LEVEL ??
________________
. Normal or ++ -> FNAB.
. -- Low -------> D. (I 123 scintigraphy).

D . I - 123 scintigraphy:
_________________________
. HYPER-functional (HOT) nodule -> Treat hyperthyroidism.
. HYPO-functional (COLD) nodule -> FNAB.

. MOST thyroid nodules are BENIGN COLLOID nodules.

__________________________________________________

. SICK EUTHYROID $YNDROME = LOW T3 $YNDROME:

____________________________________________
. Abnormal thyroid function tests with an acute severe illness.
. May be due to caloric deprivation.
. Fall in total & free T3 levels with NORMAL T4 & TSH.

. FACTITIOUS THYROTOXICOSIS:
____________________________
. Due to exogenous thyroid hormone.
. H/O of psychiatric illness or attempted weight loss (Herbal remedy!).
. Thyrotoxicosis syms (Palpitations - sweating - weight loss -
hyperactivity & diarrhea).
. Lid lag may be present but NO exophthalmos (Excluding Grave's dis.).
. The ingested thyroid hormone disturbs the native thyroid axis !
. RAIU is decreased (-- Radio Active Iodine Uptake).
. Dx -> "LOW SERUM THYROGLOBULIN" is the main stay of diagnosis.
. Dx -> -- TSH & ++ T3 &/or T4.

. TOXIC ADENOMA:
________________
. ++ T4 & -- TSH levels.
 . Symptoms suggestive of thyrotoxicosis.
. Radioactive uptake in the nodule & suppression of uptake ith rest of
the thyroid gland.
. No infiltrative ophthalmopathy.

. THYROID RADIOACTIVE IODINE SCAN:

__________________________________
. HASHIMOTO's THYROIDITIS -> Heterogenous pattern.
. GRAVE's DISEASE ---------> Diffusely ++ uptake.
. MULTINODULAR GOITER -----> PATCHY.
. PAINLESS THYROIDITIS ----> -- markedly reduced uptake.

. SIDE EFFECTS OF RADIO-IODINE THERAPY -> HYPO or HYPER thyroidism !!

_____________________________________________________________________
. HYPOTHYROIDISM:
_________________
. Destruction of thyroid flollicles by radioactive iodine.
. Tx of hypothyroidism is Levo-thyroxine.
. Ophthalmopathy may worsen in 10 % of cases.
. THYROTOXICOSIS:
_________________
. may be a side effect of RADIO-IODINE theray !!
. I - 131 is taken up by thyroid follicles & then destroys them by
emitting B-rays.
. Dying thyroid cells may release excess thyroid hormone into the
circulation.
. Aggravating the hyperthyroid state.

. CONTRA-INDICATIONS to RADIO-ACTIVE IODINE THERAPY:

____________________________________________________
. PREGNANCY.
. VERY SEVERE OPHTHALMOPATHY.

. SIDE EFFECTS of ANTI-THYROID DRUGS (PROPYLTHIOURACIL):

________________________________________________________
. AGRANULOCYTOSIS (fever & sore throat) -> Stop the drug !

. SURGERY SIDE EFFECTS:

_______________________
. Permanent hypothyroidism.
. Risk of recurrent laryngeal nerve damage.

. COMPLICATIONS of UN-TREATED HYPER-THYROID PATIENTS:

_____________________________________________________
-> RAPID BONE LOSS -> due to ++ osteoclastic activity .
-> CARDIAC TACHYARRHYTMIA (Af).

. N.B. HYPERTENSION in pts with THYROTOXICOSIS:

_______________________________________________
. is predominantly SYSTOLIC.
. caused by HYPERDYNAMIC CIRCULATION.

. N.B. INDICATIONS OF THYROID FUNCTION TESTS:

_____________________________________________
-> HYPERLIPIDEMIA.
-> Un-explained hyponatremia.
-> Un-exlained ++ CPK.

# THYROID MALIGNANCIES:
_______________________
 1 * PAPILLARY CARCINOMA:
________________________
-> MOST COMMON TYPE & BEST PROGNOSIS.
-> Slow infiltrative local spread.
-> Presence of PSAMMOMA bodies.

2 * MEDULLARY CARCINOMA:
________________________
-> CALCITONIN secretion.

3 * FOLLICULAR CARCINOMA:
_________________________
-> Invasion of the tumor capsule & blood vessels.
-> Early metastasis to distant organs.

. BIOCHEMISTERY IMPORTANT INFO:

_______________________________
. GLUCONEOGENESIS main substrates:
__________________________________
. Alanine - Lactate - Glycerol 3 phosphate.
. PYRUVATE is an INTERMEDIATE of Alaninie.

. MULTIPLE ENDOCRINE NEOPLASIA (MEN):

_____________________________________

* MEN TYPE 1:
______________
. Parathyroid adenoma.
. Pituitary tumor.
. Pancreatic tumor.
. {Mutation in the MEN 1 tumor suppressor gene}.

* MEN TYPE 2A:

______________
. Medullary thyroid cancer (HARD NODULE - ++ Calcitonin - Malignant
cells on FNAB).
. Pheochromocytoma.
. Parathyroid hyperplasia.
. Less aggressive (No associated cancers).

* MEN TYPE 2B:

______________
. Medullary thyroid cancer (HARD NODULE - ++ Calcitonin - Malignant
cells on FNAB).
. Pheochromocytoma (++ urinary metanephrines & nor-epinephrines levels).
. Neuromas (mucosal & intestinal).
. Marfanoid habitus (-- upper to lower body ratio - hypermobile joints -
scoliosis).
. {Mutation in the RET proto-oncogene located on chromosome 10}.
. DNA testing is used for screening.
. More aggressive (Associated cancers).

. DM SCREENING TESTS:
_____________________

.1. GLYCOSYLATED HEMOGLOBIN Hb A 1C:

_____________________________________
. It is used to monitor chronic glycemic control.
. It is reflective of the pt's average glucose levels over the past 100-
120 days.
 . Preferred test in non fasting state.
. > 6.5 -> DM.
. < 5.7 -> Normal.

.2. FASTING BLOOD GLUCOSE:

___________________________
. No caloric intake for 8 hours.
. > 126 mg/dl -----> DM.
. 100 - 125 mg/dl -> Impaired fasting glucose.
. 70 - 99 mg/dl ---> NORMAL.

.3. RANDOM GLUCOSE LEVEL:

__________________________
. > 200 mg/dl with symptoms of hyperglycemia.

.4. ORAL GLUCOSE TOLERANCE TEST:

_________________________________
. MOST SENSITIVE TEST.
. 75 g glucose load with glucose testing for 2 hours.
. > 200 mg/dl -----> DM.
. 140 - 199 mg/dl -> Impaired glucose tolerance.

. DKA DIABETIC KETOACIDOSIS:

____________________________
. Blood glucose level > 250.
. pH < 7.3
. Low serum HCO3 < 15-20
. Detection of plasma ketones.
. ++ ANION GAP {(Na) - (Cl+HCO3)} ----> AG > 8-12.
. H/O of previous stressor e.g. recent GIT infection.
. H/O of weight loss, ployurea & polydipsia.
. Deep rapid breathing (Kussmaul's respiration).
. Osmotic diuresis -- total body K (But : Serum K may be elevated!).
. ++ in K level due to EXTRA-CELLULAR SHIFT.
. PARADOXICAL HYPERKALEMIA (The body potassium reserves are actually
depleted!)

. 1st initial simple step to detect DKA --> FINGER-STICK GLUCOSE !

. DKA MANAGEMENT:
_________________
.1. RAPID INTRAVENOUS NORMAL SALINE (0.9% SALINE).
.2. RAPID INTRAVENOUS REGULAR INSULIN.
.3. K correction.
.4. TTT of infections e.g. Abs.

. ARTERIAL pH or ANION GAP is the most reliable indicator of metabolic

recovery in DKA.
_________________________________________________________________________
______________

. HYPER-GLYCEMIC HYPER-OSMOLAR NON-KETOTIC COMA:

________________________________________________
-> Very high glucose levels.
-> Very high plasma osmolality.
-> NORMAL ANION GAP.
-> NEGATIVE SERUM KETONES.

. Non ketotic - Hyperglycemic coma management:

______________________________________________
 . Fluid replacement with NORMAL SALINE.

_______________________________
________________________________
. DIABETIC KETOACIDOSIS (DKA)
HYPERGLYCEMIC STATE
________________________________
________________________________
. Type (1) DM usually.
. YOUNGER age.
. LESS confusion.
. Hyperventillation MORE common
. Abdominal pain MORE common.
....................
.................... HYPEROSMOLAR
....................
____________________ . Type (2) DM.
____________________ . Older.
____________________ . MORE confusion.
____________________ . Less common.
____________________ . LESS common.

_________________________________________________________________________
_____________
. Glucose 250 - 500 mg/dl. ____________________ . > 600
. HCO3 < 18 meq/L. ____________________ . > 18
. +++++ ANION GAP. ____________________ . NORMAL.
. POSITIVE serum ketones. ____________________ . NEGATIVE.
. Serum osmolality < 320 ____________________ . > 320.

. DIABETIC NEPHROPATHY:
_______________________
. Begins with HYPERFILTRATION (++GFR) & MICROALBUMINURIA.
. If not ttt well .. Micro becomes Macroalbumiuria > 300 mg/dl.
. INTENSIVE BLOOD PRESSURE CONTROL to prevent worsenening of the
condition.
. Use ACE Is with blood pressure goal 130/80 mmHg.
. Most sensitive screening test is -> RANDOM URINE MICRO-
ALBUMIN/CREATININE RATIO.

. DIABETIC NEUROPATHY:
______________________
. DISTAL SYMMETRIC SENSORIMOTOR PLOYNEUROPATHY.
. STOCKING GLOVE pattern.
. It is the most common risk factor of foot ulcerations in diabetics.
. Tx -> TCAs (Amitriptyline - Gabapentin).

. DIABETIC GASTROPATHY:
_______________________
. Autonomic neuropathy of the GIT.
. Symptoms of delayed gastric emptying & gastroparesis.
. -- Esophageal dysmotility -> Dysphagia.
. -- Gastric emptying -------> Gastroparesis.
. Gastroparesis (Nausea - vomiting - early satiety - postprandial
fullness).
. -- intestinal function ----> diarrhea - constipation - incontinence.
. Tx -> DN control - SMALL FREQUENT MEALS - METOCLOPROMIDE (prokinetic &
Antiemitic).
. SEs of Metoclopromide -> Extrapyramidal syms -> Tardive dyskinesia
(Give Erythromycin).

. ERECTILE DYSFUNCTION in D.M.:

_______________________________
. Due to vascular complications & neuropathy.
. 1st line of ttt is phosphodiesterase inhibitor (Sildenafil).
. Contr'd in pts being ttt with NITRATES.
. Sildenafil may predispose to PRIAPISM.
 . When combined with an Alpha blocker (Prazosin), it is imp. to give
them 4 hrs apart,,
. to avoid SEVERE HYPOTENSION.

. DIABETIC FOOT management -> DEBRIDEMENT & proper wound care.

______________________________________________________________

. CAUSES OF HYPOGLYCEMIA in NON-DIABETIC pts:

_____________________________________________
1 - INSULINOMA (BETA cell tumor).
2 - SURREPTITIOUS use of insulin or sulfonylurea.

. INSULINOMA:
_____________
. BETA CELL TUMOR.
. Normally, blood glucose < 60 mg/dl result in complete suppression of
insulin secretion.
. Hypoglycemia in the presence of inappropriately ++ serum insulin
levels = insulinoma.
. ++ C-peptide level.
. ++ Pro-insulin.

. DIABETES INSIPIDUS:
_____________________
. Due to ADH defeciency or resistance.
. Urine osmolality is < serum osmolality.
. Polyurea & polydipsia.
. H/O of tendency to COLD BEVERAGES to QUENCH THIRST.
. Exclude psychogenic polydipsia using water deprivation test.
. Differentiate bet. central & nephrogenic DI using ARGININE
VASOPRESSIN.
. Tx -> NORMAL SALINE.
. Tx -> CENTRAL -> INTRANASAL SPRAY DDAVP.
. Tx -> NEPHROGENIC -> NSAIDs & HCZ.

. HOW CAN U DIFFERENTIATE BET. DI & PSYCHOGENIC POLYDIPSIA:

___________________________________________________________
. WATER DEPRIVATION TEST:
__________________________
. Failure to concentrate urine after deprivation -> DI.
. Production of concentrated urine ---------------> Psychogenic
polydipsia.

. HOW CAN U DIFFERENTIATE BET. CENTRAL & NEPHROGENIC DI:

________________________________________________________
. ARGININE VASOPRESSIN (AVP) or DESMOPRESSIN adminstration:
____________________________________________________________
. CENTRAL DI -----> ++ in urine osmolality.
. NEPHROGENIC DI -> No significant ++ !

. SYNDROME OF INAPPROPRIATE ADH SECRETION (SIADH):

__________________________________________________
. ++ ADH levels without stimuli of its release.
. NORMAL SERUM osmolality -> 275 - 295 mOsm.
. NORMAL URINE osmolality -> 50 - 1400 mOsm.
. Dx -> Simultaneous measurment of urine & plasma osmolality.
. The normal response to hypotonicity (low plasma osmolality) is ,
. the production of maximally diluted urine (low urine osmolality -> <
100 mOsm.)
 . LOW plasma osmolal. (<280 mOsm.) & HIGH urine osmolality (>100-
150mOsm) is diagnostic.
. Tx of SIADH:
-> Mild symptoms (forgetfulness & unstable gait) -> Fluid restriction.
-> Moderate symptoms (Confusion & lethargy) -> HYPERTONIC SALINE (3%).
-> Severe symptoms (seizures & coma) -> Hypertonic saline + Conivaptan.

. BOTTOM LINE:
______________
* Diabetes insipidus:
______________________
. Polyurea - polydipsia - excretion of diluted urine with ++ serum
osmolality.

* 1ry (Psychogenic) polydipsia:

________________________________
. Excessive water drinking -> BOTH plasma & urine are diluted.

* SIADH:
_________
. Hyponatremia - LOW serum osmolality & inappropriately high urine
osmolality.

. P.O.C.------- # DIABETES INSIPIDUS -------- # PSYCHOGENIC POLYDIPSIA --

-------# SIADH
_____ __________________ ______________________
_____
-> SERUM osm. ---> (+) (-)
(-)
-> URINE osm. ---> (-) (-)
(+)

. HYPER-VITAMINOSIS "D":
________________________
. H/O of trials of weight loss with vitamin supplementations.
. Vit. D ++ Ca absorption -> Hypercalcemia.
. Constipation - Abd. pain - Polyurea - Polydipsia.

. METABOLIC $YNDROME:
_____________________
1- ABDOMINAL OBESITY -> Waist circumference (Men > 40 & Women > 35
inches).
2- DIABETIS MELLITIS -> Fasting glucose > 100 - 110 mg/dl.
3- HYPERTENSION ------> Blood pressure > 130/80 mmHg.
4- HYPERLIPIDEMIA ----> Triglycerides > 150 mg/dl & HDL (Men < 40 &
Women < 50 mg/dl).

. The main mechanism of DM development in metabolic $ is INSULIN

RESISTANCE.

. ACROMEGALY:
_____________
. ++ GROWTH hormone by SOMATOtroph PITUITARY ADENOMA.
. GH -> ++ IGF-1.
. IGF-1 ++ growth of bones & soft tissues.
. Coarse facial features - arthralgia - uncontrolled HTN - skin tags.
. Carpal tunnel $.
. Dx -> The MOST SENSITIVE TEST is -> IGF-1 level (GH level fluctuations
is deceiving).
. Suppression of GH by giving glucose excludes acromegaly.
 . MRI -> Pituitary lesion.
. Tx -> Surgical resection with trans-sphenoidal removal.
. Tx -> Somatostatin - Cabergoline or bromocriptine.
. MOST COMMON CAUSE OF DEATH is CONGESTVE HEART FAILURE.
. Non cardiac causes of death: stroke - cancer colon - renal failure.

. ANDROGEN PRODUCING ADRENAL TUMOR in FEMALES:

______________________________________________
. Best indicator is DHEA-S = De-Hydro Epi-Androsterone Sulfate.

. PROLACTINOMA:
_______________
. Prolactin secreting micro-adenoma.
. Pituitary tumor < 10 mm in diameter is called micro-adenoma.
. Amenorrhea & galactorrhea in females.
. Hypogonadism in males.
. Its small size can't lead to mass effects of ++ ICT.
. Tx -> 1st line is medical ttt with Dopamine agonists (CABERGOLINE or
BROMOCRIPTINE).
. Cabergoline normalizes the prolactin level & shrinks the tumor's size.

# CALCIUM HOMEOSTASIS:
______________________
. 3 forms of calcium (ionized Ca 45% - Albumin bound Ca 40% - Inorganic
anions bound Ca).
. Albumin plays an imp. role !
. Pts with hypo-albuminemia can have a low level of total plasma ca,
. However ,, They may NOT present with clinical hypocalcemia,
. Because their level of ionized calcium (physilologically active form)
remained normal.
. So .. it is imp. to calculate the CORRECTED SERUM CALCIUM LEVEL.
. CORRECTED SERUM CALCIUM LEVEL = TOTAL Ca + 0.8 (4 - Serum Albumin).
. Another rough method,
. With every 1 g/dl change in serum albumin level from 4 g/dl,
. there is a change in total plasma Ca level by 0.8 mg/dl.

# ++ Ca (Hyperclacemia) Approach -> Measure Parathormone (PTH):

_______________________________________________________________
* ++ Ca & ++ PTH -> 1ry hyperparathyroidism (abd. groans - renal stones
- bones - moans).
________________
* ++ Ca & -- PTH -> Malignancy - vit. D toxicity - Sarcoidosis.
________________

# -- Ca & ++ PO4 causes -> CRF & Primary hypothyroidism.

________________________________________________________
. CHRONIC RENAL FAILURE:
________________________
. -- Ca & ++ PO4 & ++ PTH.
. Exclude CRF by NORMAL renal function tests (urea & creatinine).

. PRIMARY HYPO-THYROIDISM:
__________________________
. Causes -> post-surgical- congenital absence - autoimmune.
. Post surgical may occur after thyroidectomy & removal of 3.5 out of 4
parathyroids.
. -- Ca -> perioral tingling - numbness - ms cramps - carpopedal spasms
- seizures.
. EKG -> prolongation of the QT interval.
# Causes of ++ Ca & + PTH: 1ry Hyperparathyroidism & familial
hypocalciuric hypercalcemia:
_________________________________________________________________________
_________________
. Differentiated by 24 hour urinary calcium:
____________________________________________
. Primary Hyper-parathyroidism ---------> > 250 mg.
. Familial hypocalciuric hypercalcemia -> < 100 mg.

. PRIMARY HYPER-PARA-THYROIDISM:
________________________________
. Causes -> Parathyroid adenoma (90%) - hyperplasia (6%) & carcinoma
(2%).
. Associated with MEN 1 & 2A.
. 80 % of pts are asymptomatic.
. Abdominal groans, renal stones, bones #s & psychic moans.
. ++ Ca & -- PO4 & ++ or normal PTH.
. 24 hours urinary calcium > 250 mg.
. Urinary calcium/creatinine > 0.02 (To rule out familial hypo-calciuric
hyper-calcemia).
. Dx -> 3Ds SESTAMIBI scan + U/$ to locate the hyperactive parathyroid
tissue presurgery.
. Tx -> Parathyroidectomy for symptomatic pts.
. Surgery indications:
_____________________
-> Serum Ca level > 1 mg/dl above the upper limit of normal (11mg/dl).
-> Young age < 50 ys.
-> Bone mineral density < T-2.5 at any stage.
-> -- Renal function (GFR < 60ml/min.).

. HYPERCALCEMIA of MALIGNANCY:
______________________________
. ++ Ca -> confusion - lethargy - fatigue - anorexia - polyuria &
constipation.
. Associated with SQUAMOUS cell lung cancer.
. CXR finding of lung cancer (lobar mass & perihilar lymphadenopathy).
. Malignancy produces PTH related peptide PTHrP -> ++ Ca & -- PO4.

. HYPERCALCEMIA (++Ca) ALGORITHM:

_________________________________
.(++Ca)
.|
.Measure PTH level
__________________
.|
.____________________________________________________
.| .|
.(+++) .(---)
.(PTH dependent) . (PTH-
INdependent)
________________
___________________
.| .|
.Measure urinary Ca
._______________________________________________
.| .| .| .|
.|
.________________ .+PTHrP .+1,25(OH)D .+25(OH)D
.NORMAL LABs
 .| .| .| .| .|
.|
.> 250 .< 100 .TUMOR .Lymphoma-Sarcoid .Vit.D
toxicity.HYPERTHYROIDISM
.| .|
.MULTIP. MYELOMA
1ry or 3ry .Familial
.Adrenal tumor
Hyperpara- .Hypercalcemic
.Acromegaly
thyroidism .Hypocalciuria
.Vit.A toxicity

.Immobilization

. IMPORTANT CASE SCENARIO:

__________________________
. Rapid ascent to a height of 10000 feet -> HYPO-calcemia ! HOW ?? (++
Albumin bound Ca).
_________________________________________________________________________
_________________
. Respiratory alkalosis = ++ pH level -> ++ the affinity of serum
albumin to calcium.
. ++ the levels of ALBUMIN-bound Ca -> -- the level of IONIZED Ca
(Active form).
. -- Ionized Ca (Active form) -> Hypocalcemia manifestations.

. PAN-HYPO-PITUITARISM:
_______________________
* Pituitary tumors are the most common cause by exerting pressure on
pituitary cells.

* ACTH defeciency (2ry adrenal insuffeciency): "-- Glucocorticoids":

____________________________________________________________________
-> Postural hypotension & tachycardia.
-> Fatigue & weight loss.
-> -- libido, hypoglycemia & eosinophilia.

* HYPOTHYROIDISM (Central):
___________________________
-> Fatigue, cold intolerance, -- appetite, constipation & dry skin.
-> Bradycardia, delayed relaxation phase of DTRs & anemia.

* -- GONADOTROPINS:
___________________
-> Women -> Amenorrhea, infertility & hot flashes.
-> Men -> -- energy & libido.

. OSTEOPOROSIS:
_______________
. Postmenopausal woman.
. presenting with multiple bony #s.
. NORMAL serum Ca - PO4 & PTH.

. OSTEOMALACIA:
_______________
. Vit. D defeciency in ADULTS.
. Bony pain & tendrness.
. -- serum Ca & PO4.
 . -- urinary Ca.
. ++ ALP & ++ PTH.
. -- 25 OH-D.
. X-ray -> BILATERAL SYMMETRIC PSEUDO-FRACTURES (LOOSER ZONES).

. PAGET's DISEASE:
__________________
. NORMAL serum Ca - PO4 & PTH.
. INCREASED ++ ALKALINE PHOSPHATASE.
. Tx -> BIPHOSPHONATES -> inhibit OsteoCLASTs asctivity.

. CAUSES of HYPOKALEMIA & --BICARBONATE HCO3 {Metabolic Alkalosis} ->

(Check RENIN):
_________________________________________________________________________
___________

.. CAUSES of HYPOKALEMIA & ++ ALDOSTERONE & -- RENIN -> PRIMARY HYPER-

ALDOSTERONISM.
_____________________________________________________

.. CAUSES of HYPOKALEMIA & ++ BOTH ALDOSTERONE & RENIN -> (Check Cl):
_____________________________________________________________________

(A) WITH ++ CHLORIDE (Check Na): (B) WITH -- CHLORIDE:

_________________________________ _____________________
1- -- Na -----> (Diuretic use). 1- Surreptitious
vomiting.
2- Normal Na -> (Bartter's $). 2- Factitious
diarrhea.
3- ++ Na -----> (Renin secreting tumor).

. SURREPTITIOUS VOMITING:
_________________________
. Scars & calluses on the dorsum of the hands & dental erosions.
. Result from chemical & mechanical injury as the pt uses his hands to
induce vomiting.
. Dental erosions result due to ++ exposure to gastric acid..
. May lead to hypovolemia & hypochloremia -> Low urine Cl level.

. CAUSES OF HYPERTENSION & HYPOKALEMIA:

_______________________________________
. Primary hyperaldosteronism & Reno-vascular hypertension.
. Check the PLASMA RENIN ACTIVITY (PRA).
. Primary hyperaldosteronism -> LOW PRA.
. Reno-vascular hypertension -> HIGH PRA.

# ADRENAL DISORDERS:
____________________
____________________

.1. CUSHING $YNDROME = HYPER-Corticolism:

_________________________________________
. ++ Cortisol.
. Fat redistribution -> Truncal obesity - moon face - buffalo hump -
thin arms & legs.
. Easy bruising & striae -> Cortisol leads to loss of collagen.
. Hypertension -> From salt & water retention.
. Ms wasting.
. Hirsutism -> due to ++ adrenal androgen levels.
. Hyperglycemia - Hyperlipidemia - Leukocytosis - Metabolic alkalosis.
 . Dx -> 1 mg over-night dexamethasone suppression test:
_______________________________________________________
. Give dexamethasone at 11 a.m. the night before.
. A normal person will will suppress the 8 a.m. level.
. A NORMAL 1 mg overnight dexamethasone suppression test EXCLUDES
hypercorticolism.
. Abnormal test may be false elevated due to stress or alcoholism.
. Dx -> 24 hour urine cortisol:
_______________________________
. Done to confirm that an overnight dexamethasone suppression test is
not falsely ++.

_________________________________________________________________________
_______
. Sources of Cushing $ ------> Pituitary tumor - Ectopic - ACTH Adrenal
adenoma:

_________________________________________________________________________
_______
. ACTH ----------------------> HIGH - HIGH - LOW.
. High dose dexamethazone ---> Suppression - No - No.
. Specific tests ------------> MRI - CT - CT adrenals.
. Tx ------------------------> Removal - Removal - Removal.

. TO DIAGNOSE THE PRESENCE OF CUSHINNG $, Do the following tests:

__________________________________________________________________
1- 24 hour urine cortisol.
2- 1 mg over night dexamethasone test.

. To diagnose the origin of CUSHING $, Check the ACTH level:

_____________________________________________________________
* ACTH -> HIGH -> PITUITARY or ECTOPIC source.
* ACTH -> LOW -> ADRENAL source.

.2. ADRENAL INSUFFECIENCY = ADDISON DISEASE:

____________________________________________
. Fatigue, anorexia, weight loss, weakness & hypotension.
. Thin pt with hyperpigmented skin.
. Labs -> ++ K, -- Na, -- BP & EOSINOPHILIA.
. Dx -> COSYNOTROPIN (Synthetic ACTH) stimulation test:
_______________________________________________________
. Measure the level of cortisol bef. & aft. cosynotropin adminstration.
. NO RISE IN CORTISOL -> Adrenal insuffeciency.
. Dx -> CT adrenals.
. Tx -> FLUIDS + Steroid replacement (IV HYDROCORTISONE).
. CAUSES:
__________
. 1- Auto-immune adrenalitis -> Responsible of 80% of cases in developed
countries.
. 2- Adrenal Tuberculosis -> CT: CALCIFICATION of both glands.

. CENTRAL (TERTIARY) ADRENAL INSUFFECIENCY:

___________________________________________
. Due to long term supra-physiologic doses of prednisone.
. Suppressing the hypothalamic pituitary adrenal (HPA) axis.
. Glucocorticoids suppress Corticotropin Releasing Hormone secretion
from hypothalamus,
 . Also .. Block the action of of CRH on the anterior pituitary to
release ACTH.
. ACTH acts on adrenal cortex & is responsible for the secretion of
cortisol & androgen.
. ACTH has mild stimulatory effect on Aldosterone secretion,
. so .. Aldosterone level is relatively normal in ACTH defeciency in
central adrenal def.

. NORMALLY, Cortisol suppresses ADH production by the posterior

pituitary.
. In case of central adrenal def. -> -- cortisol -> ++ ADH secretion.
. ++ ADH -> Water retention -> Hyponatremia.

. TYPES OF ADRENAL INSUFFECIENCY ALGORITHM:

___________________________________________

.Symptoms & signs of adrenal insuffeciency

__________________________________________
.|
. 250Mg COSYNOTROPIN stimulation test with CORTISOL & ACTH
levels

.________________________________________________________________
.|
. Minimal response
._________________
|
._________________________________________________
.| |
. Basal cortisol LOW . Basal
cortisol LOW
. ACTH HIGH . ACTH LOW
.____________________
.____________________
.| .|
. PRIMARY AI . SECONDARY or
TERTIARY AI

.3. PRIMARY HYPER-ALDOSTERONISM:

________________________________
. Hypokalemia + Hypertension + Proximal muscle weakness & numbness.
. Hypernatremia + metbaolic alkalosis.

. Dx -> Measure (PA:PRA) -> Plasma Aldosterone : Plasma Renin Activity

ratio.
. Result -> ++ Plasma Aldosterone & -- Plasma Renin Activity i.e. Ratio
> 30 !
. (PA:PRA) -> is the most specific test.

. Confirm the diagnosis -> Aldosterone suppression test.

. Give oral or IV NaCl then measure 24 hs urinary or plasma aldosterone
level.
. If Aldosterone level > 14 mg/24 hs despite Na loading -> So Dx is
confirmed.

. Once u confirm the diagnosis -> Detect the cause,

. CT scan of the adrenals -> Adrenal mass -> Adrenal vein sampling.

. EVALUATION OF SUSPECTED HYPERALDOSTERONISM:

_____________________________________________

. HYPERTENSION & HYPOKALEMIA

_____________________________
|
. Measure PLASMA RENIN ACTIVITY (PRA)
______________________________________
.& PLASMA ALDOSTERONE CONCENTRATION (PAC)
_________________________________________
|
______________________________________________________
| | |
. + PRA & + PAC . - PRA & + PAC . - PRA & -
PAC
________________ ________________
________________
| | |
SECONDARY HYPERALDOSTERONISM PRIMARY HYPERALDOSTERONISM Other causes
of ++ Aldosterone
____________________________ __________________________
______________________________
* Diuretic use. * Do a CT ADRENAL to *Congenital
adrenal hyperplasia
* Liver cirrhosis. * detect the etiology ! *
Glucocorticoid resistance.
* Congestive heart failure. * Exogenous
mineralocorticoid.
* Reno-vascular hypertension. * Cushing's
$yndrome.
* Renin secreting tumor.
* Malignant hypertension.
* Coarctation of the aorta.

.4. PHEOCHROMOCYTOMA:
_____________________
. Headache, palpitations, tremors, anxiety & flushing.
. Episodic elevations of blood pressue.
. Dx -> BEST INITIAL -> ++ catecholamines level in plasma & urine.
. Dx -> BEST INITIAL -> ++ metanephrines & VMA levels.
. Dx -> MOST ACCURATE -> CT or MRI or MIBG of the adrenal glands.
. Tx -> PHENOXYBENZAMINE (Alpha blocker) "FIRST" to control blood
pressure.
. e'out Alpha blockage, BB may lead to CATASTROPHIC ++ in BP due to
unopposed Alpha stim.
. Tx -> Propranolol is used "AFTER" an alpha blocker .
. Tx -> Surgical resection.
. N.B. It is a part of MEN type 2 A & B (DNA testing is imp. RET PROTO-
ONCOGENE).

.5. CONGENITAL ADRENAL HYPERPLASIA (CAH):

_________________________________________
. ++ ACTH.
. -- Aldosterone & cortisol.
. Tx -> Prednisone.
. Types of CAH:
_______________
____________________________ ___________________________
_____________________________
* 21 hydroxylase defeciency - * 11 hydroxylase defeciency - * 17
hydroxylase defeciency
 ____________________________ ___________________________
_____________________________
* ++ Adrenal androgens - * ++ Adrenal androgens - * -- Adrenal
androgens
* Hirsutism - * Hirsutism - * NO
hirsutism
* ++ 17 hydroxy-progesterone- * NO - * NO
* NO hypertension - * HYPERTENSION - *
HYPERTENSION

. LEYDIG CELL TUMORS:

_____________________
. Most common type of testicular sex cord tumors.
. ++ ESTROGEN & -- FSH & LH.

. ANDROGEN SECRETING NEOPLASM of the OVARY or ADRENAL:

______________________________________________________
. Rapidly developing hyper-androgenism with verilization.
. Serum TESTOSTERONE & DHEAS levels are diagnostic.
. ++ TESTOSTERONE & NORMAL DHEAS -> OVARIAN source.
. NORMAL TESTOSTERONE & ++ DHEAS -> ADRENAL source.

. PATHOLOGY of bone diseases:

_____________________________
. OSTEOMALACIA -> -- Mineralization of the bone.
. RICKETS ------> -- Mineralization of the bone & CARTILAGE.
. PAGET's ------> Disordered remodeling.
. OSTEOPOROSIS -> NORMAL mineralization but low bone mass.

. ERECTILE DYSFUNCTION:
_______________________
. Failure to achieve a spontaneous erection.
. Causes:
. * NEUROGENIC -> injury of the parasympathetic nerve fibers (# pelvis
or urethral tear).
. * VENOGENIC -> Disruption of tunica albuginea (# penis).
. * ENDOCRINOLOGIC -> ++ prolactin & -- Testosterone.
. * SITUATIONAL -> Anxiety (Nighttime & morning erctions are preserved).

. N.B. NOCTURNAL PENILE TUMESCENCE:

___________________________________
. helps to differentiate psychogenic from organic causes of male
erectile dysfunction.
. +ve in psychogenic causes.
. -ve in organic causes.

. PROLACTINOMA = LACTO-TROPH ADENOMA:

_____________________________________
. The MOST COMMON pituitary tumor.
. ++ PRL.
. Hypogoandism & galactorrhea.

Dr. Wael Tawfic Mohamed

_________________________
 ENT
-----

. TEMPORO-MANDIBULAR JOINT DYSFUNCTION:

---------------------------------------
. H/O of teeth grinding at night.
. Referred pain to ear.
. Worse with eating.

. Peri-tonsillar abscess:
-------------------------
. Muffled voice make one consider other diagnosis than simple
tonsillitis or pharyngitis. . Deviation of the Uvula + Unilateral
lymphadenopathy = Peri-tonsillar abscess.
. Tx: URGENT NEEDLE ASPIRATION + IV Antibiotics.

. PRESBYCUSIS:
--------------
. Old pt in 60s.
. Sensori-neural hearing loss.
. HIGH frequency BILATERAL hearing loss.
. Difficult hearing in noisy crowded places.

. OTOTOXIC drugs:
-----------------
. Aminoglycosides antibiotics.
. Loop diuretics e.g. Furosemide. NOT THIAZIDEs !!
. Aspirin.

. REMEMBER:
-----------
. SE of BBs -------> Bronchoconstriction - Bradycardia - fatigue -
depression.
. SE of ACEIs -----> Cough - Hyperkalemia - Angioedema.
. SE of Aspirin ---> Tinnitus.
. SE of Thiazides -> Orthostatic Hypotension - photosensitivity -
hypercalcemia.

. Serous O.M.
-------------
. is associated with HIV pts manifesting as middle ear effusion without
infection.
. causing dull hypomobile tympanic membrane.

. NASAL POLYP:
--------------
. is associated with chronic rhino-sinusitis, asthma.
. H/O of aspirin or NSAIDs induced broncho-spasm
. (ASPIRIN EXACERBATED RESPIRATORY DISEASE).
. Symptoms of bilateral nasal obstruction, nasal discharge & anosmia.

. LEKOPLAKIA:
-------------
. Hard to remove white patches in the floor of the mouth.
. due to chronic irritation by smoking or alcohol.
. May lead to squamous cell carcinoma.

. CANDIDIASIS:
--------------
 . Diabetic pt. with poor control.
. Whitish plaques with underlying erythema.
. Easily scrapped off with a tongue depressor.

. Epiglottitis:
---------------
. High fever.
. Severe sore throat.
. Odynophagia.
. DROOOOOOOOOOOOOOOOLING.
. Progressive airway obstruction.
. HARSH SHRILL.
. Causative organisms: Haemophilus influenzae & Streptococcus pyogenes.

. Retro-pharyngeal space is the most common neck space susceptible to

infection.

. Otosclerosis:
---------------
. is the most common cause of conductive hearing loss in middle aged
adults 20-30s.
. AMINOGLYCOSIDES - GENTAMYCIN is the most common cause of sensorineural
hearing loss.

. Retro-pharyngeal abscess:
---------------------------
. Fever & sore throat.
. Dysphagia & Odynophagia.
. Trismus (pain on mouth opening).
. Pain on neck EXTENSION (pain on neck flexion = Meningitis).
. H/O of local trauma to the pharynx e.g. FISH BONE.

. MENIERE's disease:
--------------------
. Vertigo = Severe spinning sensation + nausea.
. The type of vertigo is peripheral not central as it last just for 1-2
hours with the presence of ear fullness & H/O of excessive cell
phone use.
. EAR FULLNESS suggests Meniere's disease
. from an abnormal accumulation of endo-lymph within the inner ear.
. Meniere's dis. is an INNER ear disease.
. Simply exclude CEREBELLAR dis. by absence of inco-ordination or gait
disturbances!

. MALIGNANT OTITIS EXTERNA:

---------------------------
. caused by PSEUDOMONAS AERUGINOSA.
. Elderly with poorly controlled DM.
. Ear pain, discharge.
. GRANULATION TISSUE within the ear canal on otoscopy.
. Progression to the base of the skull may damaga the facial nerve
causing facial palsy. . Dx: CT skull base.
. Tx: IV CIPROFLOXACIN. not surgery !!

. Meniere's disease:
--------------------
. Vertigo + Ear fullness + Hearing loss.
. 1st line ttt ----> LOW SALT DIET.

. ASSESSMENT a case of hearing loss:

------------------------------------
. A louder tone is heard when a TF is placed on the pt's Rt mastoid
process
& a softer tone when the TF is placed near her Rt. external auditory
meatus
-> Abnormal Rinne
-> CONDUCTIVE hearing loss
-> bec. the diseased ear hears better due to obscuring of the external
noise.

. When the TF is placed on the middle of the forehead, she feals the
vibration better in her Rt ear than the Lt
-> Abnormal Weber test
-> The sound lateralizes to the diseased ear due to better bone
conduction.
-> CONDUCTIVE hearing loss.

. APHTHOUS ULCERS:
-----------------
. CROHN's disease can involve any part of the GIT from the MOUTH to the
ANUS.
. APTHOUS ulcers in the mouth can be seen as extra-intestinal
manifestation.
. Pathology: GRANULOMATOUS inflammation.
 GASTROENTEROLOGY TiKi TaKa
----------------------------

. U should exclude MI with AS in a pt with epigastric pain radiating to

the mid-scapulae.
-----------------------------------------------------------------------
-----------------
. When u r given a complaint of acute epigastric pain,
. radiating to the back inbet. the scapulae,
. with H/O of coronary artery disease,
. in addition to suspicion in pancreatitis & PUD,
. the 1st step to do is EKG to exclude MI !!!!!!!!!

. Chronic mesenteric ischemia:

----------------------------
. Un-explained chronic abd. pain.
. weight loss.
. Food fear & avoidance of eating.
. Associated atherosclerotic disease.
. Abd. ex. may reveal a bruit.
. Dx: Doppler U/S.

. Mallory Weiss $:
-----------------
. is hematemesis due to ++ intra-abd. pressure with vomiting,
. leading to rupture of submucosal ARTERIES at the distal esophagus.

. Portal hypertension:
---------------------
. leads to hematemesis due to rupture of esophageal varices (submucosal
VEINS).

. Diverticulitis:
----------------
. LLQ pain + Constipation + Fevr + vomiting.
. The most appropriate test to confirm acute diverticulitis is Abd. CT.
. Sigmoidoscopy is contra-indicated for fear of perforation.

. ULCERATIVE COLITIS:
--------------------
. Young pt.
. Abd. pain.
. Bloody diarrhea.
. Rectal urgency.
. Anemia & reactive thrombocytopenia.
. Rectal tenderness.
. Stool mixed with mucous & blood.
. ++ WBCS with nausea ----> Toxemia.
. U should suspect TOXIC MEGACOLON.
. DO ABDOMINAL X-rays to search for Toxic Megacolon.

. Chron's disease:
------------------
. Young pt.
. Chronic diarrhea.
. Abd. pain.
. Weight loss.
 . Mouth ulcers.
. Rt upper Q. tenderness without rebound.
. Gas in small & large intestines.
. Reactive thrombocytosis & anemia.

. DIVERTICULOSIS:
----------------
. Old pt.
. is associated with constipation not diarrhea,
. with Left lower Q. pain.

. CANCER HEAD PANCREAS:

-----------------------
. Enlarged (NON TENDER) Gall bladder.
. Weight loss.
. evidence of biliary obstuction (++ALP disproportionate with +AST &
+ALT).
. Dx: Abd. CT !

. The most common cause of iron defeciency anemia in an elderly pt is

GIT bleeding.
------------------------------------------------------------------------
-----------
. The next step is COLONOSCOPY.
. A single -ve occult blood test doesn't exclude GIT bleeding.

. DYSPHAGIA:
------------
. Both sloids & liquids = Motility disorder e.g. ACHALASIA.
. Solids then progressing to liquids = Obstructing lesion e.g.
esophageal adenocarcinoma. . so .. You should perform BARIUM
SWALLOW 1st before endoscopy.

. Spontaneous bacterial peritonitis:

------------------------------------
. should be considered in any pt. with cirrhosis & ascites,
. accompanied by fever or change in mental status.
. Paracentesis is the test of choice, with a +ve ascitic fluid cultue &
PMN > 250 cells.

. Step wise approach of ttt of Ascites:

---------------------------------------
1. Sodium & water retention.
2. Spironolactone.
3. Loop diuretic (Furosemide).. But not more than 1 L/day of diuresis.
4. Frequent abd. paracentesis (2-4 L/day).

. Aggressive diuresis > 1 L/day may worsen encephalopathy or

precipitate hepato-renal $.

. Liver cirrhosis ----> Renal hypo-perfusion -----> Hepato-Renal $ !

-------------------------------------------------------------------
. manifested by HIGH UREA & CREATININE.
. Very low urine Na < 10 meq = Pre-renal cause.
. No protein & No blood in dipstick urine = Not intrinsic glomerular
cause.

. CARCINOID $ triad:
-------------------
. Flushing.
 . Valvular heart disease.
. Diarrhea.
. Ass. e' hepatic metastasis.
. ++ Serotonin & 5 HIAA in blood & urine.
. The precursor of Serotonin is Tryptophan,
. which is also utilized in the synthesis of Niacin.
. -- Niacin ----> PELLAGRA 4 Ds (Diarrhea-Dermatitis-Dementia-Death).

. Neutrophilic cryptitis is seen on bowel biopsy in pts with IBD.

. CARCINOID $ = Flushing + secretory diarrhea + Wheezing + cardiac

problem.

. Intra-abdominal malignancy obstructing the biliary system:

------------------------------------------------------------
. Painless jaundice.
. Conjucated hyper-bilirubinemia.
. Elevated Alkaline phosphatase.
. ex. pancreatic adenocarcinoma.

. Pancreatic choleraa = VIPoma.

-------------------------------
. The pancreas secretes vaso-active intestinal peptide.
. Hypokalemia (leg cramps).
. chronic diarrhea --> dehydration.
. Abd. pain.
. weight loss.
. facial flushing & redness.
. Dx: Abd. CT.

. FOLIC ACID DEFECIENCY:

------------------------
. A tea & toast type of diet is associated with folic acid defeciency.
. Folic acid is heat sensitive.
. Folic acid defeciency causes macrocytic anemia.

. Corn based diets -> NIACIN defeciency -> PELLAGRA (4Ds):

----------------------------------------------------------
. Diarrhea + Dementia + Dermatitis + Death.

. DIVERTICULITIS:
----------------
. H/O of costipation & little fiber in diet.
. Left lower quadrant pain & fever.
. Tx: IV Antibiotics.
. If no improvement ---> Abd. CT to detect complications.

. Tropical sprue:
-----------------
. Endemic tropical area e.g. Puertorico.
. Biopsy of S.I ---> Blunting of villi,
. with infiltration of chronic infl. cells e.g. lymphocytes, plasma
cells & eosinophils. . Malabsorption to Vit. B12 & folic acid --->
Megaloblastic anemia.
. Other signs of malabsorption e.g. glossitis - cheilosis - pallor.

. WHIPPLE's disease:
--------------------
. PAS +ve material in the lamina propria of the small intestine is
diagnostic.
 . Primary HIV infection:
------------------------
. can present with a mononucleosis like syndrome,
. consisting of fever, night sweats, lymphadenopathy, arthralgia &
diarrhea.

. JAUNDICE:
-----------
.Abd. U/S is the best initial investigation for JAUNDICE.
.But .. once u suspect pancreatic cancer , then the best inv. is Abd.
CT.
.Manif. of cancer include weight loss , pressure obstruction of CBD,
.leading to ++ direct bilirubin & ++ ALP.

. MEN 1 = 3 Ps:
---------------
. Primary Hyperparathyroidism.
. Pituitary tumors.
. Pancreatic tumors (insulinoma-gastrinoma-VIPoma).
. GASTRINOMA = ZOLLINGER ELLISON's $ (Non B-cell pancreatic tumor).
. Endoscopy--> Multiple ulcerations & prominent gastric folds.

. MEN 2 A:
----------
. Medullary thyroid cancer & Pheochromocytoma.

. MEN 2 B:
----------
. Neuromas & Marfanoid habitus & Pheochromoytoma.

. Pts aged > 55ys with new onset dyspepsia with ALARM SYMPTOMS: -------
--------------------------------------------------------
* weight loss.
* dysphagia.
* persistent vomiting.
* should be evaluated with UPPER ENDOSCOPY.

. Pts < 55ys with no alarm symptoms:

------------------------------------
. should have 1st H.Pylori serology test,
. followed by empiric ttt with PPIs e.g. Omeprazole.
. If failed ----> ENDOSCOPY.

. Hemorrhage is the most common complication of peptic ulcer.

. CRYPTOSPORIDIUM PARVUM:
-------------------------
. HIV pt. with chronic severe diarrhea with CD4 cells < 100.

. ZOLLINGER ELLISON's $YNDROME:

-------------------------------
. Endoscopic findings of prominent gastric folds.
. Chronic duodenal ulcer.
. upper jejunal ulcer.
. Serum GASTRIN conc. < 1000 is diagnostic.

. Bacterial overgrowth:
-----------------------
. Malabsorption in a pt. with a H/O of abdominal surgery.
 . Vit. D def. = Hypocalcemia.
. Vit. A def. = Night blinness.
. Vit. B12 def. = Neuropathy.

. LACTOSE INTOLERANCE:
--------------------
. Asian American.
. +ve Hydrogen breath test.
. +ve stool test for reducing substance.
. ++ stool osmotic gap.
. -- stool pH.
. No steatorrhea.

. ESOPHAGUS:
----------
. ADENO-carcinoma ------------> Chronic GERD & Barret's esophagus.
. Squamous cell carcinoma ----> Smoking & Alcohol.

. Acute Appendicitis:
-------------------
. VS-VS-VS-VS-VS-VS-VS-VS-VS-VS-VS-VS Visceral followed by somatic pain
!!

. ACUTE EROSIVE GASTRITIS:

--------------------------
. Massive doses of Aspirin & NSAIDS can cause upper GI bleeding.
. Alcohol can aggravate its effect.

. Mallory Weiss $:
------------------
. occur in the distal esophagus at the gastro-esohageal junction,
. after repeated bouts of retching & vomiting.

. Zinc defeciency:
------------------
. may result from total parenteral nutrition or malabsorption.
. Alopecia,skin lesions,abnormal taste,impaired wound healing.

. Drug induced pancreatitis:

----------------------------
. Pts with H/O of VALPROIC ACID ttt for seizure disorder.

. Ulcerative colitis:
---------------------
. presents as diarrhea & bloody stools.
. The condition may be complicated by systemic toxicity : fever &
weight loss,
. with dilated colon on CXR "TOXIC MEGA-COLON".
. Tx: I.V. fluids + Antibiotics + Bowel rest + I.V. corticosteroids.
. If failed: Emergency surgery with sub-total colectomy with end
ileostomy.

. Minimal bleeding per rectum or scant hematochezia:

----------------------------------------------------
. Dx -> Office based ANOSCOPY or PROCTOSCOPY.

. GIARDIASIS:
-------------
. Foul smelling stool.
. Abd. cramps.
 . Bloating = MALABSORPTION diarrhea.
. H/O of developing country e.g. South America.
. Tx: METRONIDAZOLE.

. MALIGNANT criteria of a colonic polyp:

---------------------------------------
. Villous adenoma.
. Sessile adenoma.
. Size > 2.5 cm.

. MULTIPLE MYELOMA:
-------------------
. Back pain + Renal dysfunction + High ESR + Anemia.
. MM ----> ++ Ca Hypercalcemia.
. ++ Ca ----> Constipation.
. so .. The cause of constipation in a pt. with MM is ELECTROLYTE
DISTURBANCE (++ Ca).

. NON-CASEATING GRANULOMA ----> PATHOGNOMONIC to CHRON's disease !

. N.B. UC always involves the rectum while it is spared in CD.

. Angiodysplasia:
----------------
. Pt. > 60 ys. with anemia.
. Painless GIT bleeding.
. Murmur of Aortic stenosis.

. DIVERTICULOSIS:
----------------
. The most common cause of painless GIT bleeding.
. Not associated with AS.
. Endoscopy: Multiple out-pouchings of the mucosa through the
hypertrophied muscular layer.

. ZOLLINGER ELLISON's $:
------------------------
. Multiple duodenal ulcers + Single jejunal ulcer resistant to H2
blockers & PPIs.
. GASTRIN producing PANCREATIC TUMOR.
. Un-controlled gastrin production
. ---> Parietal cell hyperplasia
. ----> +++ Stomach acid production
. ----> Inactivation of pancreatic enzymes
. ----> Steatorrhea.

. Inflammatory Bowel disease:

-----------------------------
. Bloody diarrhea + anemia + elevated ESR + Reactive thrombocytosis.
. The type of diarrhea is INFLAMMATORY.

. Newly diagnosed gastric carcinoma transformation in a gastric ulcer by

an endoscopy warrants an abdominal CT scan to evaluate the extent of
the cancer.

. Pharyngo-esophageal (ZENKER's) diverticulum:

----------------------------------------------
. is due to motor dysfunction.
. Pt. < 50 ys.
. with oro-pharyngeal dysphagia & neck mass.
 . Tx: Crico-pharyngeal Myotomy.

. Diffuse esophageal spasm:

--------------------------
. Young female.
. intermittent episodes of chest pain & dysphagia.
. Ba swallow: Cork screw esophagus.

. Causes of ++ BUN / Creatinine ratio:

--------------------------------------
. Pre-renal RF.
. GIT bleeding due to reabsorption of blood from the GIT.
. Steroid adminstration.

. Esophageal dysmotility due to SCLERODERMA:

--------------------------------------------
. Sticking sensation in the throat.
. Significant -- in LES tone.
. Absence of peristaltic waves in the lower 2/3s of the esophagus.

. CHRONIC PANCREATITIS:
----------------------
. H/O of ALCOHOL use.
. Epigastric chronic abd. pain.
. Malabsorption (Steatorrhea & chronic diarrhea).
. Weight loss.
. Type 2 D.M.
. Amylase & Lipase may be normal (Not diagnostic).
. Dx: Abd. CT showing pancreatic calcifications.

.Duodenal ulcers:
------------------
. typically presents with epigastric pain that improves with eating.
. OVER 90% of duodenal ulcers are infected with H. Pylori.
. Tx of H. Pylori ass. ulcers is acid suppression & organism
eradication with antibiotis. . 1st line regimen is OCA = OMEPRAZOLE
+ CLARITHROMYCIN + AMOXICILLIN.

. In upper GIT bleeding:

----------------------
. If Hb < 10 ----> PACKED RBCs transf.
. If Ht < 30 ----> PACKED RBCs transf.

. Upper bleeding with coagulopathy:

-----------------------------------
. is most likely to ruptured gastro-esophageal varices.
. Tx: FRESH FROZEN PLASMA: bec.FFP contains all the clotting factors &
plasma proteins.
. We never use whole blood transfusion.
. Cryoppt contains Factor 8, Fibrinogen, Von Willebrand factor & factor
10.
. FFP is preferred to cryoppt as it contains all clotting factors.
. Platelet transfusion is done when platelets < 50,000 !!

. Achalasia Manometry:
---------------------
. esophageal body peristalsis.
. Failure of relaxation of LES.

. Achalasia Ba Swallow:
 ----------------------
. Dilated esophagus.
. Bird's beak deformity of LES.

. HERPES ZOSTER (SHINGLES):

--------------------------
. Pt. with Rt. sided abd. pain.
. Light touch to the skin to the Rt. of the Umbilicus elicits intense
pain.
. Immunocompromized pt. 2ry to chemotherapy.

. Digoxin side effects:

----------------------
. GIT-------> Anorexia, Nause & vomiting.
. Cardiac---> Biventricular Arrhythmia.
. VERAPAMIL ++ the Digoxin's toxicity.
. N.B. Mesenteric ischemia presents with severe abd. pain out of prop.
to exam. !!

. Ulcerative colitis:
--------------------
. Bloody diarrhea + tenesmus + abd. cramps + weight loss + anemia.
. Extraitestinal manifestations:
------------------------------
.Sclerosing colangitis.
. Uveitis.
. Erythema nodosum.
. Spondyloarthropathy.
. Complications:
--------------
. Toxic Megacolon.
. Colon cancer.
. Yearly colonoscopies is recommended for pts with UC,
. beginning 8-10 ys after diagnosis for prevention of cancer colon.

. Irritable bowel $yndrome:

---------------------------
. Abd. pain + diarrhea and/or constipation.
. Endoscopy ---> NORMAL COLONIC MUCOSA!

. Dark melanotic stools = Upper GI bleeding.

--------------------------------------------
. The most common cause of upper GI bleeding is PUD.
. Duodenal ulcer's pain gets better with eating.
. while Gastric ulcer worsens with eating.

. PEPTIC STRICTURE:
-------------------
. Slowly progressive dysphagia to solids without anorexia & weight
loss.
. As stricture progresses , it can actually block reflux,
. leading to improvement of heart burn symptoms.
. ENDOSCOPY --> SYMMETRIC circumferential narrowing.

. ADENO-CARCINOMA:
----------------
. Pt with GERD < 20 ys.
. Weight loss.
. ASYMMETRIC narrowing of the esophageal lumen.
. REMEMBER:
-----------
. Pt. with fever + chills + Lt upper Q. pain + splenic fluid collection
. = Lt. sided endocarditis with septic emboli to the spleen,
. causing splenic abscess.
. H/O of incarerated pt. with ++ liver enzymes (possible HCV),
. suggesting IV drug use as the cause of infective endocarditis.

. NERD FAULT !!
---------------
. Pt. with upper GI bleeding (Hematemesis)
. who have depressed conscioussness level should be intubated with ??
. ENDO-TRACHEAL tube not naso-gastric tube to secure the airway.

. KCL Potassium chloride ----> Drug induced esophagitis.

Dr. Wael Tawfic Mohamed

-------------------------
 GENITOURINARY TIKI TAKA
_________________________

. GLOMERULONEPHRITIS common criteria:

_____________________________________
1- RBCs in urine.
2- Red cell casts in urine.
3- Mild degree of proteinuria (< 2 g. / 24 hs.).
4- Edema.
5- May lead to nephrotic $.
6- Most accurate diagnosis by --> RENAL BIOPSY.

* GOOD PASTURE's $YNDROME:

___________________________
. Cough, hemoptysis, shortness of breath & lung findings.
. Dx: Best initial test: Anti-basement membrane Abs.
. Dx: Most accurate test: Renal biopsy -> Linear deposits.
. Tx: PLASMAPHARESIS & steroids.

* CHURG STRAUSS $YNDROME:

__________________________
. ASTHMA, cough, EOSINOPHILIA + Renal abnormalities.
. Dx: Best initial test: CBC for eosinophil count.
. Dx: Most accurate test: Renal biopsy.
. Tx: Glucocorticoids "prednisone".

* WEGENER's GRANULOMATOSIS:
____________________________
. URT infections + LRT infections.
. URT infections -> sinusitis & otitis.
. LRT infections -> cough, hemoptysis, Abnormal CXR.
. It is a systemic vasculitis so it may involve the joint, skin, eye.
. Dx: Best initial test: C-ANCA "Anti-neutrophil cytoplasmic Ab".
. Dx: Most accurate test: Renal biopsy.
. Tx: Steroids & cyclophosphamide.

* POLYARTERITIS NODOSA:
________________________
. Systemic vasculitis.
. Involvement of all organs EXCEPT LUNGS !!!!!
. Renal - myalgia - GI bleeding - purpura - stroke - uveitis -
neuropathy.
. MULTIPLE MOTOR & SENSORY NEUROPATHY + PAIN.
. Dx: Best initial test: ESR & inflammation markers.
. Dx: Most accurate test: Renal biopsy or SURAL N. biopsy.
. Test for HEPATITIS B & C (Ass. e' PAN).
. ANGIOGRAPHY showing BEADING can spare the need for biopsy.
. Tx: Steroids & cyclophosphamide.

* IgA NEPHROPATHY = BERGER's DISEASE:

______________________________________
. Painless recurrent hematuria.
. ASIAN pt.
. H/O of very recent viral upper RTI.
. Dx: Best initial test: ++ IgA !
. Dx: Most accurate test: RENAL BIOPSY IS ESSENTIAL !
. Normal complement levels.
. Tx: Steroids.
 * HENOCH - SCONLEIN PURPURA:
_____________________________
. Adolescent or child.
. Raised, non-tender purpuric skin lesions "buttocks".
. Abdominal pain.
. Possible bleeding.
. Joint pain.
. Renal involvement.
. Dx: Best initial test: CLINICAL SUSPENSE !
. Dx: Most accurate test: R. biopsy "Not necessary".
. Tx: No ttt - Resolves spontaneously.

* POST-STREPTOCOCCAL GLOMERULONEPHRITIS = PSGN:

________________________________________________
. Dark urine "Tea-colored or cola-colored".
. Periorbital edema & hypertension.
. H/O of Throat or skin infections 10 - 20 days ago.
. Dx: Best initial test: Anti-streptolysin O test "ASLO",
. Anti-DNase & Antihyaluronidase.
. Low complement levels.
. Dx: Most accurate test: R. biopsy sh'd n't be done bec. blood tests r
suffecient.
. Tx: Antibiotics e.g. PENICILLIN.
. CONTROL HYPERTENSION & FLUID OVERLOAD with diuretics.

* CRYOGLOBULINEMIA:
____________________
. H/O of HEPATITIS "C" with renal involvement.
. Joint pain & pruritic skin lesions & Hepatosplenomegaly.
. Dx: Best initial test: Serum cryoglobulin componet levels,
. immunoglobulins & light chains, IgM.
. Low complement levels esp. "C4".
. Dx: Most accurate test: R. biopsy.
. Tx: Treat HEPATITIS C with INTERFERON + RIBAVIRIN.

* LUPUS (SLE) NEPHRITIS:

_________________________
. H/O of SLE !!
. N.B. Drug induced lupus spares the kidneys & the brain "V.V.V. imp.".
. Dx: Best initial test: ANA & Anti-Ds DNA.
. Dx: Most accurate test: RENAL BIOPSY.
. R. biopsy is v. imp. in cases of SLE to determine the extent of the
disease & ttt.
. Tx:
----- Sclerosis only -------------------------------> No ttt.
----- Mild dis., early stage, NON proliferative ----> Steroids.
----- Severe dis. late stage, PROLIFERATIVE --------> MYCOPHENOLATE.

* ALPORT $YNDROME:
___________________
. CONGENITAL with family H/O of renal failure.
. Recurrent episodes of hematuria.
. Eye & ear problems e.g. deafness.
. No specific therapy.

* HEMOLYTIC UREMIC $YNDROME:

____________________________
. H/O of E-coli 0157:H7
. Intra-vascular hemolysis (fragmented cells on smear).
 . ++ Creatinine.
. -- platelets.

* THROMBOTIC THROMBOCYTOPENIC PURPURA "TTP":

_____________________________________________
. HU$ +
. Fever +
. Neurological abnormalities.
. Tx: Plasmapharesis in severe cases.

___________________________
. ARF : PRE-RENAL AZOTEMIA:
___________________________

.. Presentation:
_________________
... Elderly pt with poor oral intake living in nursing homes taking
medications e.g.,
... NSAIDs, ACE Is & diuretics causing intravascular volume depletion.
... leading to renal glomerular vasoconstriction.

.. Causes:
___________
. 1- Hypotension "SBP <90 mmHg".
. 2- Hypovolemia "dehydration or blood loss".
. 3- Low oncotic pressure " -- Albumin".
. 4- Congestive heart failure.
. 5- Constrictive pericarditis.
. 6- Renal artery stenosis.

.. Dx:
_______
... BUN:Creatinine ratio > 20:1.
... Urinary Na is low < 20.
... Fe Na < 1.
... Urine osmolality > 500.

___________________________________________________
. ARF : POST-RENAL AZOTEMIA = OBSTRUCTIVE UROPATHY:
___________________________________________________

.. Causes:
___________
. 1- Stone in the bladder or ureter.
. 2- Strictures.
. 3- Cancer of the bladder, prostate or cervix.
. 4- Neurogenic bladder "Atonic or non-contracting due to MS or DM".

.. Dx:
_______
... Similar to pre-renal azotemia.
... Distended bladder on exam.
... Large volume diuresis after passing a urinary catheter.
... Bilateral hydronephrosis on U/$.

______________________________________________________
. ARF : INTRA-RENAL AZOTEMIA = ACUTE TUBULAR NECROSIS:
______________________________________________________

.. Dx:
_______
... BUN/Creatinine ratio 10:1.
... Urinary Na > 40.
... Urine osmolality < 350.

* TOXIN INDUCED RENAL INSUFFECIENCY:

_____________________________________
. Aminoglycosides: Gentamycin, tobramycin, Amikacin (--Mg is
suggestive).
. Amphotericin.
. Contrast agents (--Mg is suggestive).
. Chemotherapy e.g Cisplatin.
. Urinalysis: MUDDY BROWN or GRANULAR CASTS.

* ALLERGIC INTERSTITIAL NEPHRITIS:

___________________________________
. Hypersensitivity reaction to medications e.g. Penicillin or Sulfa
drugs.
. Phenytoin, Allopurinol, Cyclosporin, Quinidine & Rifampin.
. FEVER & RASH & ARTHRALGIA.
. Dx: WRIGHT stain or HANSEL's STAIN of the urine ---> EOSINOPHILIA.
. WBCs casts are common but RBCs cast are rare.
. Tx: Discontinue the offending drug.

* RHABDOMYOLYSIS:
__________________
. Large volume muscular necrosis.
. causes direct toxic effect of myoglobin on the kidney tubule.
. H/O of crush injury or seizure.
. H/O of prolonged immobility.
. H/O of recent start of STATIN for hyperlipidemia.
. Best initial test: Urinalysis -> Large amounts of blood with no cells.
. Relative absence of RBCs on urine microscopy.
. ++ CPK (MOST SPECIFIC FINDING).
. Most accurate test: Urine myoglobin > 20000.
. Rhabdomyolysis --> ++ K & -- Ca.
. In case of hyperkalemia .. Do EKG to exclude arrhythmia.
. Tx hyperkalemia with IV Ca gluconate, insulin & glucose.
. Tx: BOLUS OF NORMAL SALINE, MANNITOL.
. ALKALINIZATION OF URINE.

* OXALATE CRYSTAL INDUCED RENAL FAILURE:

_________________________________________
. H/O of suicide trial by anti-freeze ingestion "ethylene glycol".
. intoxication due to metabolic acidosis & ++ in anion gap.
. Best initial Dx: Urinalysis --> ENVELOPE SHAPED OXALATE CRYSTALS.
. Best initial Tx: ETHANOL or FOMEPIZOLE with immediate dialysis.

* URIC ACID CRYSTAL INDUCED RENAL FAILURE:

___________________________________________
. H/O of chemotherapy for lymphoma causing tumor lysis $.

* CONTRAST INDUCED RENAL FAILURE:

__________________________________
. H/O of radiological procedure with contrast.
. H/O of elderly pt with DM or HTN.
. CREATININE just above normal 1.5 - 2.5.
. Tx: HYDRATION with Normal saline & Bicarbonate & N-Acetyl cysteine.
 . NON-IONIC contrast agent is associated with less severity of
nephropathy.

* NSAIDs INDUCED NEPHROPATHY Mechanism:

________________________________________
. Direct toxicity & ATN.
. Allergic interstitial nephritis with eosinophils in the urine.
. Nephrotic $.
. Afferent arteriolar VC.

. NEPHROTIC $YNDROMES & THEIR ASSOCIATIONS:

___________________________________________
. CHILDREN -------------------------------> Minimal change disease.
. ADULTS & CANCERS "LYMPHOMA" ------------> MEMBRANOUS.
. HEPATITIS C ----------------------------> MEMBRANOPROLIFERATIVE.
. HIV, HEROIN USE ------------------------> FOCAL SEGMENTAL.
. UN-CLEAR -------------------------------> MESANGIAL.

. STEPS FOR PROTEINURIA EVALUATION:

___________________________________
. Repeat the urine analysis.
. Evaluate for orthostatic proteinuria.
. Get a protein/creatinine ratio.
. Perform a renal biopsy.

. INDICATIONS OF DIALYSIS:
__________________________
. Hyperkalemia.
. Metabolic acidosis.
. Uremia with encephalopathy.
. Fluid overload.
. Uremia with pericarditis.
. Toxicity with a dialyzable drug e.g. Lithium , ethylene glycol or
Aspirin.

. URGE INCONTINENCE:
____________________
. Pain followed by urge to urinate.
. Not related to coughing, laughing or standing.
. Dx: Urodynamic pressure monitoring.
. Tx: Behaviour modification + Anti-cholinergics.

. STRESS INCONTINENCE:
______________________
. NO PAIN.
. Follow coughing or laughing.
. Dx: Observe leakage with coughing.
. Tx: KEGEL exercise + Estrogen cream.

. SEVERE HYPERKALEMIA:
______________________
. Denoted by PEAKED T waves on EKG.
. Tx: I.V. CALCIUM GLUCONATE.

. NEPHROLITHIASIS:
__________________
. Sudden onset flank pain.
. Colicky, may be referred to the scrotum.
. Nause, vomiting.
. Cola colored urine.
 . Dx: Non contrast CT Abdomen (Preferred to X-ray as it detects Radio-
lucent stones).
. Tx: Relieve the pain by NSAIDs.
. Tx: Stones < 5 mm -> pass spontaneously with conservative ttt.
. Best conservative ttt is FLUID INTAKE > 2 LITERS / day.

. DEHYDRATION:
______________
. Altered mental status.
. Dry oral mucosa.
. ++ Na & ++ K.
. BUN / Creatinine > 20 "Pre-renal azotemia".
. More common in old age due to -- thirst response to dehydration.
. Tx: I.V. sodium containing CTYSTALLOIDS = NORMAL SALINE = 0.9 % NaCl.

. HERNIATED INTERVERTEBRAL DISK may cause URINE RTENTION due to SEVERE

PAIN:
_________________________________________________________________________
___
. Unilateral radicular pain in a dermatomal distribution.
. Bk tendrness due to spasm of the paraspinous muscles.
. Cauda Equina $ can be excluded by absence of saddle anesthesia &
intact sphincter tone.
. There will be pain on coughing or chest movement.
. So, severe pain in a pt.with a mild urinary obstruction, such as BPH,
. may cause urinary retention due to inability to Valsalva.

. CHLAMYDIAL URETHRITIS:
________________________
. Middle aged female.
. H/O of mutliple sex parteners.
. Dysuria & urinary frequency.
. Urinalysis: Absent bacteriuria.
. Urine culture < 100 colonies.

. HONEYMOON CYSTITIS:
_____________________
. Urinary infection most commonly arises by an ascending route.
. Sexual intercourse is one of the most imp. risk factors of un-
complicated UTIs.
. due to its mechanical effect of introducing uropathogens into the
bladder.

. RENAL CELL CARCINOMA:

_______________________
. Triad of flank pain, hematuria & palpable abdominal renal mass.
. Scrotal varicoceles "Lt sided" r seen in 10 % of pts.
. Varicoceles typically fail to empty when the pt is recumbent due to
tumor obstruction.
. So presence of non emptying varicocele make you suspect mass
obstruction by a tumor !
. Para-neoplastic symptoms e.g. Thrombocytosis, hypercalcemia &
cachexia.
. Dx: Abd. CT .

. BENIGN PROSTATIC HYPERPLASIA = BPH:

_____________________________________
. Lower urinary tract symptoms e.g. frequency. nocturia, hesitancy &
weak stream.
. Hypertrophy usually starts at the CENTRAL part of the prostate.
 . Rectal exam: Smooth & firm enlargement of the prostate.
. N.B. prostate cancer rectal ex: (prostate nodules - induration -
asymmetry).
. 1st initial step of management is placement of a FOLEY's catheter.
. Tx of BPH: Alpha blockers.
. Tx of severe cases: Surgery TURP.
. Current recommendations: All BPH pts sh'd have urinalysis & serum
creatinine,
. to assess for urinary infection, obstruction or hematuria.
. If there is woresening of creatinine,
. Abdomial ULTRA$OUND is the initial test of choice to assess for
HYDRONEPHROSIS.
. Hydronephrosis is caused by urinary obstruction & renal failure.

. HYPERKALEMIA (++ K > 5):

__________________________
. Drugs ++ K (ACE Is - NSAIDs - K sparing diuretics e.g. spironolcatone
& Amiloride).
. Pseudohyperkalemia (Hemolyzed sample during venipuncture).
. Hyperkalemia (K > 6.5) may cause cardiac toxicity .
. EKG -> Peaked T waves & progressive widening of the QRS complex.
. Tx: IV CALCIUM GUCONATE.
. Tx: Insulin - B2 agonists.
. Tx: Na HCO3.
. Dialysis in severe cases.
. REMOVAL OF K FROM THE BODY -----> KAYEXALATE !

. The most common cause of death in RENAL DALYSIS & TRANSPLANTATION:

____________________________________________________________________
. is CARDIOVASCULAR complications.

. ANALGESIC NEPHROPATHY:
________________________
. Woman with chronic headaches on NSAIDs.
. Presenting with painless hematuria.
. NSAIDs -> VC of renal medulla vessels -> RENAL PAPILLARY NECROSIS.
. CHRONIC TUBULO-INTERSTITIAL NEPHRITIS.

. AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE (ADPCKD):

________________________________________________________
. HYPERTENSION + PALPABLE kidneys "BILATERALLY".
. Multiple renal cysts & intermittent flank pain.
. Liver enlargement due to cystic involvement "Most common extra-renal
manifestation".
. Hematuria, UTIs & nephrolithiasis.
. Death may occur due to intracranial bleeding caused by rupture of
berry anurysm.

. GLOMERULOPATHY associated diseases:

_____________________________________
. Lymphoma ----------------------------> Membranous nephropathy.
. Lymphoma complicated by nephrotic $ -> Minimal change nephropathy.
. HIV ---------------------------------> Focal & segmental
glomerulosclerosis.
. AFRICAN AMERICANS -------------------> Focal & segmental
glomerulosclerosis.
. OBESE -------------------------------> Focal & segmental
glomerulosclerosis.
. HEROIN ADDICTS ----------------------> Focal & segmental
glomerulosclerosis.
. MULTIPLE MYELOMA:
___________________
. Old age pt 65 ys with anemia, fatigue & bony pains (back & chest).
. Renal insuffeciency due to obstruction of the distal & collecting
tubules by,
. BENCE JONES PROTEINS "PARA-PROTEINS".
. Old pt + bony pain + renal failure + Hypercalcemia = Multiple myeloma.

. AMITRIPTYLINE INDUCED URINE RETENTION:

________________________________________
. Amitriptyline is TCA with anticholinergic properties,
. it will lead to -- dterusor ms contraction & prevent urethral
sphincter relaxation.
. leading to urine retention.
. Tx: Discontinue Amitriptyline + urinary catheterization.

. OVER-FLOW IN-CONTINENCE:
__________________________
. May be due to DM autonomic neuropathy causing a denervated bladder ->
urine retention.
. The a-contractile hypotonic bladder gradually overdistends,
. When the bladder pressure rises above the urethral pressure,
. Urine is lost until the pressure equalizes !
. These events occur in a cyclic manner occuring at day & night.
. Exam may reveal a distended bladder.
. post-voidal residual urine volume is high.
. Associated other D.M. manifestations e.g. gastropathy, nephropathy &
retinopathy.

. D.M. is the 1st leading cause of nephropathy, kidney biopsy will show:
________________________________________________________________________
. GLOMERULAR HYPERFILTRATION is the EARLIEST renal abnormality detected.
(UW Q!).
. ++ extracellular matrix, basement membrane thickening, mesangial
expansion & fibrosis.
. DIABETIC MICRO-ANGIOPATHY. (UW Q!)
. Proteinuria & progressive -- in GFR.
. Glomerulosclerosis. (UW Q!).

. HTN is the 2nd leading cause of nephropathy, kidney biopsy will show:
_______________________________________________________________________
. Arterio-sclerotic lesions of the afferent & efferent renal arterioles
& capillaries.
. NO proteinuria.

. HEMATURIA:
____________
. Initial "Beginning of urination" -----> Urethral lesion e.g.
Urethritis.
. Terminal "At the end of voiding" -----> Prostatic or Bladder
lesion e.g. cystitis.
. Total "during the entire process" ------> Ureters or kidneys
lesion.

. The presence of clots in urine is more consistent with bladder not

renal lesion.

_______________________
. URINARY TRACT STONES:
_______________________

1.CALCIUM OXALATE STONES:

__________________________
. Radio-opaque.
. envelope shaped on microscopy.
. Small bowel disease, surgical resection or chronic diarrhea,
. may lead to malabsorption of fatty acids & bile salts,
. which are important for chelating calcium,
. so, when Calcium is free, it binds with oxalic acid,
. forming Ca Oxalate stones.

2.CALCIUM PHOSPHATE STONES:

____________________________
. common in primary hyperparathyroidism.

3.URIC ACID STONES:

____________________
. When urine is acidic.
. When there is ++ cell turnover.
. Radio-lucent on X-ray.
. Tx: Hydration.
. Tx: Alkalinization of urine to pH > 6.5 by oral POTASSIUM CITRATE.

4.CYSTEINE STONES:
___________________
. ++ cysteine "Inborn error of metabolism".
. +ve family H/O.
. Recurrent stones since childhood.
. HARD & RADIO-OPAQUE stones.
. HEXAGONAL CRYSTALS on urine analysis.
. +ve Urinary cyanide nitroprusside test.

5.STRUVITE STONES:
___________________
. Formed when urine is ALKALINE.
. Bec. of infection with urease producing bacteria e.g. PROTEUS.
. H/O of recurrent UTI.

. NEPHROTIC $YNDROME:
______________________
. Proteinuria ( > 3- 3.5 g/day - most imp. criterion).
. Hypoalbuminemia.
. Edema.
. Hyperlipidemia & lipiduria.
. Pathology: Altered permeability of the glomerular membrane.
. Children : Minimal change disease.
. Adults : Membranous glomerulopathy.
. Complicated by HYPERCOAGULABILITY -> Thrombo-embolic manifestations.
. Accelerated atherosclerosis.
. Venous or arterial thrombosis & even pulmonary embolism.
. Other complications: Ptn malnutrition - iron resistant microcytic
hypochromic anemia.
. Other complications: ++ susceptibility to infections & vitamin D
defeciency.

. POST-OPERATIVE OLIGURIA:
__________________________
. Low urine out-put volume with lower abdominal pain.
 . Most common cause is post-renal i.e. bladder out-let obstruction.
. Placement of a bladder catheter can rapidly improve symptoms "1st step
done".
. Never to start fluids before catheterization as it may worsen the
condition.

. BLUE TOE $YNDROME = CHOLESTEROL EMBOLIZATION:

_______________________________________________
. H/O of cardiovascular disease with recent surgical intervention or
angiography.
. Atherosclerotic plaque may break off & enter the circulation.
. Abdominal pain & nausea.
. Livedo reticularis = cyanotic dicolouration of the skin
. ARF may occur due to renal artery embolization.
. ++ urea & creatinine levels.
. -- complement levels.
. ++ eosinophils.

. N.B. BLUE TOE $ sh'd n't be mis-diagnosed with CONTRAST INDUCED

NEPHROPATHY:
_________________________________________________________________________
_____
. Absence of livedo reticularis, abd. symptoms, high eosinophils & --
complement.

. ACUTE PYELONEPHRITIS:
_______________________
. Acute febrile illness.
. Costo-vertebral angle tendrness.
. Pyuria & bacteriuria.
. Initial ttt -> Blood cultures followed by Empirical I.V. Antibiotics.
. No response within 72 hours -> Do imaging e.g. U/$ or CT,
. to search for underlying pathologies (e.g.obstruction) or
complications (e.g.abscess).

. Prazosin & TRAZODONE cause PRIAPISM !

. Diabetic pts with renal failure on METFORMIN should stop it as it ++

lactic acidosis.

. SIMPLE RENAL CYST:

____________________
. Age > 50 ys.
. Benign, don't require ttt.
. Reassurance.

. Both IgA Nephropathy & PSGN are major causes of hematuria after an
upper RTI:
_________________________________________________________________________
______
. IgA nephropathy: begins (1-5days) after URTI with normal serum
complement.
. PSGN : begins 10-15 days after URTI with low serum complement.

. MEMBRANO-PROLIFERATIVE GLOMERULONEPHRITIS:
____________________________________________
. caused by persistent activation of the alternative complement pathway.
. Microscopy: Dense intra-membranous deposits that stain for C3.

. Dipsticks findings in case of UTI:

____________________________________
. Leukocyte esterase -> Pyuria.
. Positive nitrites -> Enterobacteriaceae.
. The most common culprit organism in UTIs is E-Coli.

. ERYTHROPOIETIN THERAPY in cases of ESKD:

__________________________________________
. ESKD presents with normocytic normochromic anemia due to --
erythropoietin.
. Tx of choice is recombinant erythropoietin.
. Started if Hb < 10 g/dl.
. Most common side effect is WORSENING OF HYPERTENSION.
. Other SE: Headaches & flu-like symptoms.

. ESKD ttt options:

___________________
. Dialysis or renal transplantation.
. Renal transplantation is more preferred due to better survival rate.
. A living related donor is always preferred.

. Management of CALCIUM OXALATE STONES:

_______________________________________
. 1- ++ fluid intake.
. 2- -- Na intake.
. 3- THIAZIDE DIURETIC.
. 4- -- protein & oxalate intake.
. GUESS WHAT ???!!------------> Calcium restriction is not required

. ACUTE EPIDIDYMITIS:
_____________________
. Fever.
. Painful enlargement of the testes.
. Irritative voiding symptoms.

. Two types of epididymitis: Sex-transmitted related & non-related.

. Sex-transmitted: more common in young pts & associated with

urethritis.
. Sex-transmitted: pain at the tip of the penis & urethral discharge.
. Sex-transmitted: caused by Chlamydia trachomatis & Neisseria
Gonorrhea.

. NON-sex-transm.: more common in elderly & associated with a UTI.

. NON-sex-transm.: No pain at the penile tip - No urethral discharge.
. NON-sex-transm.: caused by gram -ve rods e.g. E-coli.

. ACUTE PROSTATITIS:
____________________
. Fever, chills, ++ WBCs with bandemia.
. Urinary urgency, dysuria & +ve leukocyte esterase.
. Pain in the perineal region.
. Tender boggy prostate..
. Obtaining a mid-stream urine sample is the 1st step sh'd be done.
. Prostatic massage sh'd be avoided as it may lead to infectious spread.

. EXOGENOUS ANABOLIC STEROID USE can produce INFERTILITY in MEN:

________________________________________________________________
.By suppressing the production of GnRH, LH & FSH.

. ACYCLOVIR -> CRYSTALLURIA with RENAL TUBULAR OBSTRUCTION:

___________________________________________________________
. Acyclovir doesn't produce interstitial nephritis. (Take care - common
mistake).
. Acyclovir is poorly soluble in urine & easily precipitates in renal
tubules.
. It causes tubular obstruction with acute renal failure.
. It is due to large parenteral doses of Acyclovir.
. Inadequate hydration is a common predisposing factor.

. FIBROMUSCULAR DYSPLASIA -> RENAL ARTERY STENOSIS -> RENOVASCULAR

HYPERTENSION:
_________________________________________________________________________
_______
. Young adult.
. Headache, hypertension & renal bruit.
. Medical therapy only with ACEIs is NOT effective.
. Tx of choice is: Percutaneous ANGIOPLASTY + STENT.

. PERICARDITIS is a common complication of UREMIA (RF):

_______________________________________________________
. Chest pain (Non radiating - Retrosternal - Relieved by leaning
forward).
. EKG (Diffuse ST elevation - PR segment depression).
. Pericardial friction rub.
. Tx: Hemodialysis.

. CASTS in NEPHROLOGY:
______________________
. Muddy brown granular ca?sts -> Acute tubular necrosis.
21Broad & waxy casts ---------> Chronic renal failure.
. RBCs casts -----------------> Glomerulonephritis.
. WBCs casts -----------------> Interstitial nephritis & pyelonephritis.
. Fatty casts ----------------> Nephrotic $.

. RENAL AMYLOIDOSIS:
____________________
. H/O of Rheumatoid arthritis (predisposes to amyloidosis).
. Enlarged kidneys & hepatomegaly.
. Renal biopsy -> Amyloid deposits with APPLE GREEN BIREFRINGENCE under
polarized light.

. RENAL DISEASE -----> RENAL BIOPSY FINDING:

____________________________________________
. AMYLOIDOSIS -> Amyloid deposits with APPLE GREEN BIREFRINGENCE under
polarized light.
. RPGN "Rapid progressive GN" -> Crescent formation.
. GOOD PASTURE's $ -> Linear immunoglobulin deposits (Ani-glomerulat b.
membrane Abs).
. LUPUS NEPHRITIS -> Granular deposits.
. NEPHROTIC $ "MINIMAL CHANGE DISEASE" -> NORMAL LIGHT MICROSCOPY.

. IMPORTANT DRUG SIDE EFFECTS:

______________________________
. TACROLIMUS: Nephrotoxicity - hyperkalemia - hypertension - tremors.
. CYCLOSPORINE: Same as Tacrolimus + Hirsutism & Gum hypertrophy.
. AZATHIOPORINE: Diarrhea - leukopenia - hepatotoxicity.
. "M"YCOPHENOLATE -> Bone "M"arrow depression.

. RENAL VEIN THROMBOSIS:

________________________
 . Important complication of Nephrotic $.
. caused by MEMBRANOUS GLOMERULONEPHRITIS (Not minimal change dis.).
. Due to loss of ANTITHROMBIN 3 in urine.
. Sudden onset of abdominal pain, fever & hematuria.

. ACUTE CYSTITIS:
_________________
. Healthy, young, non-pregnant woman. " Un-complicated".
. Pregnant, v.young, v.old, D.M.,immunocompromized,anatomical
abnormality. "Complicated".
. Dysuria, frequency, supra-pubic pain & or hematuria (Hemorrhagic
cystitis).
. Tx of un-complicated cystitis: NITROFURANTOIN or Oral TMP-SMX.
. Tx of complicated cystitis: Levofloxacin or ciprofloxacin.

. RENAL TRANSPLANT DYSFUNCTION:

_______________________________
. Oliguria - hypertension - ++ creatinine/urea.
. Causes:
_________
1- Ureteral obstruction.
2- Acute rejection.
3- Cyclosporine toxicity.
4- Vascular obstruction.
5- Acute tubular necrosis.

. Acute rejection is best treated with INTRAVENOUS STEROIDS.

. NON-INFLAMMATORY CHRONIC PROSTATITIS:

_______________________________________
. Afebrile pts.
. Irritative voiding symptoms (frequency, urgency, suprapubic or
perineal discomfort).
. Normal physical exam.
. Normal urine analysis.
. Expressed prostatic secretions show NORMAL number of leukocytes.
. culture of the expressed secretionsis NEGATIVE for bacteria.
. No past H/O of UTIs.

. HEPATO-RENAL $YNDROME:
________________________
. Complication of end stage LIVER disease (e.g. Cirrhosis).
. -- GFR in absence of shock, proteinuria or other causes of renal
dysfunction.
. Failure to respond to 1.5 liters of normal saline.
. Most common causes of death are infection & hemorrhage.
. Tx: LIVER "NOT KIDNEY" TRANSPLANTATION.

. RIRFAMPICIN (Anti-Tuberculous drug):

______________________________________
. Reddish discolouration of urine, saliva, sweat & tears.
. Benign drug effect.
. Reassure the patient.

. UREMIC COAGULOPATHY:
______________________
. Complication of CRF.
. Echymosis & epistaxis are the most common presentations.
. The main cause is PLATELET DYSFUNCTION.
. PT,PTT,Platelet count -> NORMAL.
 . Bleeding time is prolonged.
. Tx: DDAVP ++ the release of factor 8 (Von Willebrand f) from
endothelial storage sites.
. PLATELET TRENSFUSION has NOOOOOO EFFECT as they quickly become
INACTIVE.

. SICKLE CELL TRAIT:

____________________
. YOUNG BLACK MALE with PAINLESS HEMATURIA.
. Painless hematuria in EPISODES !
. Caused by PAPILLARY ISCHEMIA.
. Reassurance.

. DETRUSOR MUSCLE INACTIVITY:

_____________________________
. May be caused by 1st generation ANTI-HISTAMINICs due to their ANTI-
CHOLINERGIC effects.
. They inhibit the action of Acetyl-choline on Muscarinic receptors.
. Urine retention occurs due to detrusor ms. failure of contraction.
. Other SEs: Dryness of eyes, oral mucosa & rspiratory passags.

. GROSS PAINLESS HEMATURIA in an ADULT = BLADDER MASS TUMOR:

____________________________________________________________
. Do a contrast CT abominal scan or IVP to detect the mass.
. The presence of erythrocytes in urine sh'd be confirmed
microscopically,
. to exclude myoglobinuria, hemoglobinuria or porphyria.
. Other causes: BEETS large amounts ingestion or Rifampicin ttt.

Dr. Wael Tawfic Mohamed

_________________________
 HEMATOLOGY & ONCOLOGY TiKi TaKa
_________________________________

. ANEMIA presentations:
_______________________
. Mild -> Fatigue - loss of energy - tiredness - malaise.
. Severe -> Shortness of breath - lightheadedness - confusion.
. Diseases with similar presentations (Hypoxia - CO poisoning -
Methemoglobinemia).
. Pallor - flow murmur - pale conjunctiva.

. MICROCYTIC ANEMIA:
____________________
____________________

(1) IRON DEFECIENCY ANEMIA:

____________________________
. The most common cause is chronic blood loss (Bleeding ulcer).
. ++ platelet count.
. Dx -> Best initial test -> IRON STUDIES:
- ____________________________________________
- | -- iron. .|
- | -- ferritin. .|
- | -- iron saturation. .|
- | ++ TIBC (Total iron binding capacity). .|
|--------------------------------------- .|
- | ++ Red cell distribution of width (++ RDW).|
- ____________________________________________
. Dx -> Most accurate test -> Bone marrow biopsy.
. Tx -> Ferrous sulfate orally (May turn the stool BLACK but Guaiac test
-ve).
. PICA -> Appetite for non-nutritive substances (ice - clay - dirt).

(2) ANEMIA OF CHRONIC DISEASE:

_______________________________
. Rheumatoid arthritis.
. End Stage Kidney Disease (ESKD).
. Any chronic infectious, inflammatory or connective tissue disease.
. . Dx -> Best initial test -> IRON STUDIES:
- _______________________________________
- | -- iron. .|
- | ++ ferritin. .|
- | Normal or -- iron saturation. .|
- | -- TIBC (Total iron binding capacity).|
|--------------------------------------.|
- _______________________________________
* IRON IS LOCKED IN STORAGE OR TRAPPED IN MACROPHAGES OR IN FERRITIN.
. Osteoarthritis doesn't cause anemia of chronic disease !
. Exclude anemia of chronic disease if there is NORMAL ESR !
. The only form of anemia that responds to erythropoietin is ESKD.
. Tx -> tt the underlying cause e.g. (METHOTREXATE or INFLIXIMAB for
RA).
. Although iron concentration is low, Iron supplementation is not
benificial.
. IRON IS LOCKED IN STORAGE OR TRAPPED IN MACROPHAGES OR IN FERRITIN.

(3) THALASSEMIA:
_________________
 . Very small MCV with few or no symptoms. (55 - 75 ml).
. TARGET cells.
. Dx -> NORMAL iron studies.
. Most accurate test -> HEMOGLOBIN ELECTROPHORESIS:
- Beta -> ++ Hg A2 & Hg F.
- Alpha -> Normal (Most accurately diagnosed by DNA sequencing).
- Hg H has Beta 4 tetrads with 3 gene deleted Alpha thalassemia.
. B thalassemia major -> Both B hemoglobin are deffective.
. Characterized by severe anemia & transfusion dependence at an early
age).
. B thalassemia minor occurs in people heterozygous for the B hemoglobin
gene.
. The only microcytic anemia with a HIGH reticulocytic count is Hg H.
. Microcytic anemia non responsive to iron supplementation.
. No ttt !

(4) SIDEROBLASTIC ANEMIA:

__________________________
. Defect in heme-synthesis.
. Alcoholic pt.
. Isoniazid intake without Vit. B6 "pryridoxine" supplementation.
. Lead exposure.
. Dx -> Iron studies -> HIGH IRON & -- TIBC.
. Dx -> Bone marrow biopsy -> RINGED SIDEROBLASTs.
. Most accurate test -> PRUSSIAN BLUE STAIN.
. Tx -> Minor -> Pyridoxine replacement.
. Tx -> Major -> Remove the toxin exposure.

. "IRON DEFECIENCY ANEMIA" - "ALPHA THALASSEMIA MINOR" - "BETA

THALASSEMIA MINOR":
_________________________________________________________________________
_____________
. Hematocrit < 30 % - Hematocrit > 30 % - Hematocrit >
30 %
. RDW ++ - RDW normal - RDW normal
. RBC count -- - RBC count normal - RBC count
normal to ++
. No target cells - TARGET cells on smear - TARGET cells
on smear
. -- serum iron & ferritin - Nor. to ++ iron & ferritin - Nor. to ++
iron & ferritin
. ++ TIBC - Normal TIBC - Normal TIBC
. Responds to iron supplem. - No response to iron supplementation
. Normal Hb Electrophoresis - Normal Hb Electrophoresis - ++ Hb A2 on
Hb Electrophor.

. N.B. MECHANISMS OF ANEMIA IN MICROCYTIC HYPOCHROMIC DISEASES:

_______________________________________________________________
. -- fe intake & ++ blood loss -> IRON DEFECIENCY ANEMIA.
. Defective utilization of storage iron -> ANEMIA OF CHRONIC DISEASES.
. -- globin production -> THALASSEMIA.
. -- Heme synthesis -> LEAD POISONING & SIDEROBLASTIC ANEMIA.

. MICROCYTIC HYPOCHROMIC DISEASE -> FINDINGS IN IRON STUDIES:

_____________________________________________________________
. IRON DEFECIENCY ANEMIA -> -- fe, -- ferritin & ++ TIBC.
. THALASSEMIA -> Normal to ++ fe & ferritin levels.
. ANEMIA OF CHRONIC DISEASE -> -- TIBC.
. SIDEROBLASTIC ANEMIA -> Normal to ++ fe & ferritin levels.
. MACROCYTIC ANEMIA:
____________________
____________________
. Extravascular hemolysis occurs in spleen & liver so u can't see it on
a smear !
. Caused by Vit. B12 or floate defeciency.
. Vit. B12 def. -> neurological findings (Mostly peripheral neuropathy-
Least dementia).
. Folate defeciency is NOT associated with neurological findings.
. Suspect Vit B12 def. in STRICT VEGETERIANS with anemia & neurologic
complications.
. METFORMIN blocks B12 absorption.
. B12 def. -> Smooth tongue (Glossitis) & diarrhea.
. -- B12 -> -- production of INTRINSIC FACTOR by gastric parietal cells,
. -- B12 -> Atrohic gastritis -> DOUBLE RISK of GASTRIC CANCER.
. Dx -> Best initial test -> CBC with peripheral smear -> HYPERSEGMENTED
NEUTROPHILs.
. Dx -> Hypersegmented neutrophils + Large MCV = Megaloblastic anemia.
. Dx -> Anisocytosis - poikilocytosis - basophilic stippling.
. Dx -> ++ Bilirubin & LDH.
. Dx -> -- Reticulocytic count.
. Dx -> Most accurate test -> -- Vit. B12 & Folic acid levels.
. If u suspect B12 defeciency but B12 level is normal -> Order Methyl
Malonic acid (MMA).
. Dx -> HOMOCYSTEINE is ++ in both Vit. B12 & folate defeciency.
. Dx -> Most accurate test -> Anti-parietal cell Abs & anti-intrinsic
factor Abs.
. Tx -> REPLACEMENT of Vit B12 & folate.
. Tx -> Folic acid will correct the hematological problems.
. Tx -> Vit. B12 will correct the neurological problems.
. Watch for low potassium after ttt B12 def. !

. N.B. (1):
___________
. Folate & cobalamine (B12) are involved in the conversion of
homocysteine to methionine.
. -- Vit. B12 or folic acid -> ++ Homocysteine level.

. N.B. (2):
___________
. Folic acid & vit. B12 defeciency can be distinguished by measuring
Methyl Malonic acid!
. Vit B12 (Not folic acid) is involved in the conversion of MMA to
succinyl coA.
. -- Vitamin B12 -> ++ MMA.
. -- Folic acid -> NORMAL MMA.

. N.B. (3):
___________
. Laboratory tests ------------> Prinicious anemia -------------> Folic
acid defeciency
_________________________________________________________________________
_______________
. Serum B12 level -------------> (--) ------------->
Normal.
. Serum folic acid level ------> (Normal) -------------> (--).
. Serum LDH level -------------> (++) ------------->
Normal.
 . Achlorhydria ----------------> present ------------->
Absent.
. Schilling test --------------> +ve -------------> -ve.
. Methyl malonyl acid MMA -----> ++ ------------->
Absent.
. Neurological signs ----------> ++ ------------->
Absent.

. N.B. (4):
___________
. Alcohol abuse is the most common cause of nutritional folate
defeciency in USA.

. N.B. (5):
___________
. Anemia of chronic kidney disease is due to erythropoietin defeciency.
. One must be careful to ensure adequate iron stores prior to
erthropoietin replacement,
. Bec. the erythropoietin induced surge in RBCs production may consume
much iron,
. precipitating an iron defecient state.

. N.B. (6):
___________
. A case of microcytic hypochromic anemia with -- iron & ferritin,
. The most common cause of iron defeciency anemia is GIT blood loss.
. Dietary iron defeciency & malabsorption of iron are rare causes.
. Iron supplementation helps to restore iron reserves but u must detect
the cause !
. So .. perform test for occult blood in the stool.

. N.B. (7):
___________
. The most common cause of folic acid defeciency is NUTRITIONAL.
. Either due to poor diet or Alcoholism.
. May be caused by some drugs either by impairing its absorption
(PHENYTOIN),
. or antagonizing its physiologic effect (Methotrexate - Trimethoprim).

. N.B. (8):
___________
. PERINICIOUS ANEMIA:
______________________
. Most common cause of vit. B12 defeciency.
. Auto-antibodies against the gastric intrinsic factor required for B12
absorption.
. More in Northern Europeans.
. Associated other auto-immune diseases e.g. Autoimmune thyroiditis &
Vitiligo.
. Shiny tongue due to atrophic glossitis.
. Shuffling broad-based gait ataxia.
. Neurological abnormalities with loss of pain & vibration sense.
. Peripheral blood smear -> Macro-ovalocytes, megaloblasts & hyper-
segmented neutrophils.
. Dx -> Detection of Anti-intrinsic factor Abs.

. N.B. (9):
___________
. Total body stores of Vit.B12 in humans are 2-5 mg with min. daily
requirement 6-9 micg.
 . Animal products (meat & dairy) are the only dietary sources of vit.
B12.
. It would take 4-5 years of a pure vegan diet to cause dietary
defeciency.
. In contrast, Folate stores are smaller, clinical defeciency occur
within 4-5 months.

. N.B. (10):
____________
. SCHILLING TEST:
__________________
. Used to detect the cause of vit. B12 defeciency.
. Used to differentiate dietary defeciency from perinicious anemia &
malabsorption.
. In dietary defeciency,
. Oral radiolabelled Vit B12 is absorbed in the gut & excr. by kidneys
in NORMAL amounts.
. But In Malabsorption,
. Oral radio-labelled Vit B12 is excreted in sub-normal amounts.

. HEMOLYTIC ANEMIA:
___________________
___________________
. SUDDEN ONSET of hematological manifestations.
. Dx -> Hemolysis ->
-> ++ indirect bilirubin.
-> ++ reticulocyte count.
-> ++ LDH level.
-> -- Haptoglobin.
. Dx -> Intravascular hemolysis ->
-> Abnormal peripheral smear (schistocytes - helmet cells - fragmented
cells).
-> Hemoglobinuria.
-> Hemosiderinuria.

(1) SICKLE CELL ANEMIA:

________________________
. Very severe pain in the back, chest & thighs.
. Retinal infarction.
. Flow murmur from anemia.
. Splenomegaly in children & asplenia in adults.
. Rales or consolidation from lung infection or infarction.
. Skin ulcers.
. Aseptic necrosis of hip.
. Neurological strokes.

. Cause of Osteomyelitis in sickle cell anemia is SALMONELLA !

. Cause of BM suppression in sickle cell anemia is PARVO B19 !

. Tx -> OXYGEN - HYDRATION with NORMAL SALINE - Pain relief.

. If there is fever -> (Emergency - No spleen) -> Ceftriaxone -
levofloxacin.

. Tx -> EXCHANGE TRANSFUSION if ->

-> Eye -> Visual disturbance from retinal infarction.
-> Lungs -> Pulmonary infarction with pleuritic pain.
-> Penis -> Priapism from infarction of prostatic plexus of veins.
-> Brain -> Stroke (weakness & aphasia due to sludging & occlusion of
cerebral vessels).
 . N.B. -> SUDDEN DROP IN HEMATOCRIT can be caused by FOLATE DEFECIENCY
or PARVO B19 INF:
. Folate defeciency in SCD due to ++ RBCs turnover & consumption of
folate in the BM.
. Daily folic acid supplementation is recommended in all SCD.
. If the pt is already on Folate replacement -> The cause is PARVO B19
viral infection !
. PARVO B19 may invade the bone marrow & causes aplastic anemia.
. Detect Parvo B19 infection by PCR for DNA of Parvo B19.

. On discharge -> Give folate replacement - Pneumococcal vaccine.

. Hydroxyurea (++ Hb F) is given to prevent further crisis.

(2) HEMOGLOBIN SICKLE CELL DISEASE:

____________________________________
. African American pt.
. Family H/O of blood disrder.
. Mild version of sickle cell anemia.
. Visual distrurbance is frequent.
. No painful crisis.
. RENAL problems are common,
. (Hematuria - Isosthenuria "inablility to dilute urine or concentrate
urine" - UTIs).
. Isosthenuria due to RBCs sickling in the vasa rectae of the inner
renal medulla.
. The pt have to wake to urinate 2 - 3 times per night despite
restricting fluid intake.
. No ttt.

(3) AUTOIMMUNE HEMOLYSIS:

__________________________
. H/O of other autoimmune diseases e.g. SLE (peripheral immune
destruction of all cells).
. H/O of CLL or lymphoma (Enlarged Non tender axillary LNs
bilaterally!).
. H/O of penicillin - alpha methyl dopa - quinine or sulfa drug intake.
. Dx -> ++ LDH - ++ indirect bilirubin - ++ reticulocyte count - --
Haptoglobin.
. Dx -> peripheral smear -> spherocytes.
. Dx -> Most accurate test -> Coombs test. (WARM Abs = IgG Abs).
. Tx -> Best initial ttt -> Steroids e.g. prednisone.
. If there is recurrent episodes of hemolysis -> SPLENECTOMY is the most
effective ttt.
. If no response to prednisone or splenectomy -> Give IVIG.

(4) COLD INDUCED HEMOLYSIS = COLD AGGLUTININs:

_______________________________________________
. H/O of mycoplasma or EBV infection.
. Coomb's test -> -ve.
. Complement test-> +ve.
. No response to prednisone, spenectomy or IVIG.
. Tx -> RITUXIMAB.

(5) GLUCOSE - 6 - PHOSPHATE DEFECIENCY (G6PD):

_______________________________________________
. X-linked disorder - Only MALE pt. (African American).
. ENZYME defeciency (Glucose 6-phosphate dehydrogenase).
. Sudden onset of hemolysis.
. INFECTION is the most common predisposing factor.
. H/O of intake of Oxidizing drugs (Sulfa - primaquine - Dapsone).
 . H/O of ingestion of FAVA BEANS.
. Mechanism of cell damage -> OXIDATIVE STRESS.
. Dx -> Best initial test -> Heinz body test & BITE CELLs.
. +ve prussian blue is indicative of hemosiderin found in urine during
hemolytic episode.
. Heinz bodies are collections of oxidized precipitated Hb embedded in
the RBC membrane.
. Bite cells appear when pieces of the red cell membrane have been
removed by the spleen.
. Most accurate test -> G6PD level after 2 months of symptoms !
. A normal level of G6PD immediately after an episode of hemolysis
doesn't exclude it !
. Tx -> AVOID OXIDANT STRESS.

. N.B. PYRUVATE KINASE DEFECIENCY:

___________________________________
-> can lead to similar presentation as G6PDD .. BUT:
-> Hemolysis not precipitated by sulfa drugs !
-> No bite cells on peripheral smear !

(6) HERIDITARY SPHEROCYTOSIS:

______________________________
. Northern European descent.
. TRIAD of HEMOLYTIC ANEMIA + JAUNDICE + SPLENOMEGALY.
. Autosomal dominant disorder of spectrin (Ptn that provides scaffolding
for RBCs).
. RBCs are not deformable -> Gets trapped in the fenesterations of the
spleen's red pulp.
. Recurrent episodes of hemolysis.
. Splenomegaly.
. Bilirubin gall stones (pigmented Ca bilirubinate) -> Acute
cholecystitis.
. Dx -> +++ MCHC (Mean cell hemoglobin concentration = RBC membrane loss
& dehydration).
. Dx -> Peripheral smear -> Spherocytes.
. Dx -> -ve Coomb's test (+ve in AIHA = Autoimmune hemolytic anemia).
. Dx -> Most accurate test -> OSMOTIC FRAGILITY test.
. Tx -> SPLENECTOMY will prevent hemolysis as spherocytes are destroyed
in the spleen.
. Folate supplementation is important.
. There is a risk for infection with Parvovirus B19 causing aplastic
anemia.

(7) HEMOLYTIC UREMIC $YNDROME (HU$):

_____________________________________
. H/O of E-coli 0157:H7 infection.
. HUS TRIAD (ART):
-> Autoimmune hemolysis -> intravascular hemolysis (Anemia - indirect
hyperbilirubinemia)
-> Renal failure -> ++ BUN & creatinine.
-> Thrombocytopenia -> -- platelets.
. Dx -> Peripheral smear -> Schistocytes.
. Tx -> Most cases resolve on their own.
. Tx -> Severe cases are ttt with plasmapharesis or plasma exchange.
. Steroids don't help !
. Antibiotics worsen the case !
. Platelet transfusion worsen the case !

(8) THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP):

_______________________________________________
 . H/O of TICLOPIDINE use.
. HUS TRIAD + FN (Fever & Neurolgical abnormailities).
. Dx -> Peripheral smear -> Schistocytes.
. Same ttt as HUS (PLASMAPHARESIS or PLASMA EXCHANGE).

(9) PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH):

_______________________________________________
. Pancytopenia.
. Recurrent attacks of dark urine "Specially in the morning !".
. Most common cause of death -> LARGE VESSEL VENOUS THROMBOSIS "PORTAL
VEIN THROMBOSIS".
. PNH may transform to alpastic anemia or acute myelogenous leukemia
(AML).
. PORTAL VEIN THROMBOSIS may be the key to answer PNH case !
. Dx -> Most accurate test -> Flow cytometry -> Cd 55 & CD 59
antibodies.
. Tx -> Best initial ttt -> Glucocorticoids (prednisone).
. Transfusion dependent pts may be ttt with Eculizomab -> inhibit C5
complement.
. Hemolytic anemia + Venous thrombosis = PNH.

(10) MACROVASCULAR TRAUMATIC HEMOLYSIS:

________________________________________
. ++ reticulocytes - ++ LDH - -- Haptoglobin ("intra-vascular hemolytic
anemia).
. Fragmented RBCs.
. Chronic hemolysis -> iron loss -> Microcytic anemia.
. Due to mechanical trauma from artificial valves or calcified aortic
valves.

. N.B. HERIDITARY SPHEROCYTOSIS & AUTOIMMUNE HEMOLYTIC ANEMIA:

______________________________________________________________
. Peripheral blood smerar in both conditions -> Spherocytes without
central pallor.
. Both cause extravascular hemolytic anemia.
. Heriditary spherocytosis -> Autosomal dominant heriditary condition.
. AIHA -> Acquired condition.
. Spherocytosis -> +ve family H/O & -ve Coomb's test.
. AIHA -> -ve family H/O & +ve Coomb's test.

. N.B. PATHO-PHYSIOLOGIC MECHANISMS of ANEMIA in variable diseases:

___________________________________________________________________
. Impaired DNA & purine synthesis -> Vitamin B12 defeciency.
. RBC membrane instability -> Heriditary spherocytosis.
. Impaired Hb synthesis -> Iron defeciency anemia, sickle cell anemia &
Thalassemia.
. Impaired glutathione synthesis -> G6PDD.
. Mechanical injury to RBCs -> Hemolysis with artificial heart valves.

. MET-HEMOGOLBINEMIA:
_____________________
. Shortness of breath for no clear reason.
. Clear lungs on examination.
. Blood locked up in an oxidized state that can't pick up oxygen.
. H/O of exposure to drugs such as nitroglycerin, amyl nitrate,
nitroprusside & dapsone.
. H/O of exposure to anesthetic drugs e.g lidocaine.
. H/O of brown blood !!
. Tx -> Methylene blue !!
. CARBOXYHEMOGLOBINEMIA = CARBON MONOXIDE (CO) POISONING:
_________________________________________________________
. H/O of environmental risk (Pt working in an enclosed space ->
underground parking lot).
. Present with headache, nausea & dizziness.
. Exposure to CO from automobile exhaust.
. CO binds Hb with an affinity app. 250 times that of oxygen.
. -- in blood carrying oxygen capacity.
. As a compensation -> the body ++ RBCs production (++ HCT).

. OBSTRUCTIVE SLEEP APNEA (OSA) -> ++ ERYTHROPOIETIN PRODUCTION:

________________________________________________________________
. Recurrent transient obstruction of the upper airway due to pharyngeal
collapse.
. Obese or over-weight pts have excessive snoring, day time sleeping &
morning headaches.
. Transient episodes of hypoxia -> sensed by the kidneys -> ++
Erythropoietin production.
. Erythropoietin ++ RBCs -> Polycythemia.
. OSA doesn't cause carboxyhemoglobinemia ! xxxxxxxxxxxxxx

. LEUKEMIA:
___________
___________

(A) ACUTE LEUKEMIA:

____________________
. Pancytopenia (Fatigue - bleeding - infections).
. Excess WBCS but don't work (Functional immunodefeciency).
. Dx -> Peripheral smear -> BLASTS.
. AUER RODS = AML ACUTE MYELOID LEUKEMIA.
. DIC is asscociated with M3 (Acute pro-myelocytic leukemia).
. Cytogenetics is used for prognosis & relapse prediction.
. If the pt is at high risk for relapse after chemotherapy,
. BM transplantation sh'd be performed as chemotherapy induces
remission.
. Tx -> Chemotherapy (idarubicin & daunorubicin) -> Acute myelogenous
leukemia.
. Tx -> Add ATRA (All Trans-Retinoic Acid) for -> M3 Acute pro-
myelocytic leukemia.
. Tx -> Ass intra-thecal Methotrexate for ALL Acute Lymphocytic
leukemia.

. N.B. Acute leukemia can sometimes present with extremely HIGH WBCs
count,
. When the WBCs > 100000 -> sludging of WBCs in the blood vessels of eye
& lungs & brain.
. LEUKOSTASIS is ttt with LEKOPHARESIS (Removing of WBCs via blood
centrifugation).
. Hydroxyurea is used to lower the cell count.

(B) MYELODYSPLASIA:
____________________
. Mild slowly progressive pre-leukemia $.
. May progress to acute leukemia.
. MOST COMMON CAUSE OF DEATH -> INFECTION or BLEEDING.
. Elderly pt.
. Pancytopenia (Fatigue - bleeding - infections).
. ++ MCV (Macro-ovalocytes).
. -- Reticulocyte count.
 . Dx -> Special neutrophil with 2 lobes (PELGER-HUET) cells.
. Tx -> Supportive with transfusions as needed & AZAcitadine.
. Those with 5q minus $ are ttt with Lenalidomide.
QSZA `
. MYELO-PROLIFEARTIVE DISORDERS:
________________________________

(A) CHRONIC MYELOGENOUS LEUKEMIA (CML):

________________________________________
. ++ WBCs (NEUTROPHILs predominant).
. SPLENOMEGALY.
. Dx -> Best initial -> -- Leukocyte Alkaline Phosphatase (LAP).
. Dx -> Most accurate -> PHILADELPHIA CHROMOSOME (Cytogenic
study:Abnormal chromosome 22)
. formed by reciprocal translocation of chromosom 9 & 22.
. Reciprocal translocation -> BCR-ABL fusion gene -> ABNORMAL TYROSINE
KINASE ACTIVITY !
. {-- LAP} + {++ WBCs} = CML.
. {++ LAP} + {++ WBCs} = LEUKEMOID REACTION = Reactivity from infection.
. Tx -> Best initial -> IMATINIB (Gleevac) " Tyrosine kinase inhibitor".
. BMT is the only way to cure CML (Never best initial ttt).

(B) CHRONIC LYMPHOCYTIC LEUKEMIA (CLL):

________________________________________
. ++ WBCs (LYMPHOCYTES predominant).
. Pt > 50 ys.
. Asymptomatic - found on routine testing.
. Dx -> Peripheral blood smear -> SMUDGE cells "Ruptured nuclei of
lymphocytes".

. Stage 0 -> ++ WBCs.

. Stage 1 -> Enlarged LNs.
. Stage 2 -> Enlarged Spleen.
. Stage 3 -> Anemia.
. Stage 4 -> -- platelets.

.THE PRESENCE OF THROMBOCYTOPENIA = STAGE 4 -> POOR PROGNOSIS.

. Tx -> Stage 0 & 1 -> No ttt.

. Other stages -> FLUDARABINE + RITUXIMAB.

(C) HAIRY CELL LEUKEMIA:

_________________________
. Middle aged pt with Pancytopenia & massive splenomegaly.
. Dx -> Tartarate resistant acid phosphatase (TRAP) smear -> HAIRY CELLS
!
. Named so bec. the lymphocytes have fine hair like irregular
projections.
. The bone marrow may be become fibrotic -> Un-successful aspirates
(DRY-TAP).
. Tx -> CLADRIBINE.

(D) MYELOFIBROSIS:
___________________
. Same as hairy cell leukemia -> BUT -> NORMAL TRAP level !
. Dx -> TEAR DROP shaped cells on smear.
. Tx -> LENALIDOMIDE or THALIDOMIDE , BMT.

(E) POLYCYATHEMIA VERA (Pvera):

________________________________
 . Plethoric face.
. Headache - Blurring of vision - dizziness - fatigue.
. Pruritis happening after a hot bath or shower.
. pruritis due to release of histamine from basophils.
. Hypertension can be one of the presentations of polycythemia.
. ++ incidence of peptic ulcerations (++ Histamine release from
basophils).
. ++ incidence of gouty arthritis ( ++ cell turnover).
. Dx -> CBC "MARKEDLY HIGH HEMATOCRITE & low MCV" !!!
. Dx -> ABG " Absence of hypoxia".
. Dx -> -- Erythropoietin (Most important).
. ++ WBCs & ++ Platelets.
. ++ B 12 & ++ LAP levels.
. MARKEDLY HIGH HEMATOCRITE may lead to THROMBOSIS.
. Ass. with JAK 2 mutation.
. Tx -> PHLEBOTOMY. (HCT < 45%).
. Tx -> Hydroxyurea to -- cell count.
. Tx -> Give daily Aspirin to prevent Thrombosis.
. High risk of thrombosis -> Due to ++ platelet count.
. High risk of bleeding -> Due to impaired platelet function

. N.B. . HERIDITARY TELANGIECTASIA = OSLER - WEBER - RENDU $YNDROME:

____________________________________________________________________
. Diffuse telangiectasia + Recurrent epistaxis + Wide spread AV
MALFORMATIONs.
. AV malformations in lung -> Blood shunt from Rt to Lt side of the
heart.
. AV shunts -> Chronic hypoxemia -> Reactive polycythemia (++ HCT).

(F) ESSENTIAL THROMBOCYTOPENIA:

________________________________
. ++ PLATELET cell count.
. Headache - visual disturbances - pain in hands (Erythromyelalgia).
. Most common cause of death -> Bleeding & thrombosis.
. Tx -> Hydroxyurea to -- cell count.
. Tx -> Give daily Aspirin to prevent Thrombosis.

. PLASMA CELL DISORDERS:

________________________
. ALL are characterized by ++ serum protein with normal albumin (GAMMA
GAP).
_________________________________________________________________________
____

(A) MULTIPLE MYELOMA:

______________________
. Monoclonal proliferation of plasma cells.
. CRAB -> Calcium ++ & Renal impairment & Anemia & Bones pain, lytic
lesions & #s.
-> Skeletal survey -> Punched out osteolytic lesions (if osteoblastic =
Prostate cancer).
-> Serum immune electrophoresis -> Abnormal M spike.
-> Serum protein electrophoresis (SPEP) -> ++ Mono-clonal Antibodies
(IgG).
-> Urine protein electrophoresis (UPEP) -> BENCE-JONES proteins.
-> Peripheral smear -> ROULEEAUX formation of blood cells.
-> ++ Ca.
-> ++ ESR > 100.
-> B2 micro-globulin (detect prognosis).
-> ++ BUN & Creatinine (RF).
 -> Most specific test -> Bone marrow biopsy -> ++ PLASMA cells > 10 % !
. Most common cause of death -> INFECTIONS & RENAL FAILURE.
. susceptible to infections due to -- WBCs & -- ability to produce
effective antibodies,
. due to BM infiltration with malignant plasma cells.
. Tx -> Melphalan & steroids.
. Tx -> Most effective ttt -> Autologous stem cells bone marrow
transplantation.
. Tx -> Hypercalcemia -> Hydration & diuresis.
. Tx -> Bone #s -> Biphosphonates.
. Tx -> RF -> hydration.
. Tx -> Anemia -> Erythropoietin.
. Tx -> Prophylaxis against infections with vaccinations (Pnemovax).

(B) MONO-CLONAL GAMMOPATHY OF UNKNOWN SIGNIFICANCE (MGUS):

___________________________________________________________
. Asymptomatic ++ of IgG on SPEP. (due to ++ ptn in old age).
. Elderly pt > 70 ys.
. MGUS require METASTATIC SKELETAL BONE X-RAY to exclude lytic lesions
sugesting MM !
. No ttt.

(C) WALDENSTROM's MACRO-GLOBULINEMIA:

______________________________________
. ++ Ig M -> Hyperviscosity.
. Blurry vision (Dilated segmented tortuous retinal veins)
. confusion & headache.
. Enlarged Lns & Hepatosplenomegaly.
. Dx -> Serum viscosity level -> ++.
. Dx -> SPEP -> ++ Ig M SPIKE !
. Tx -> PLASMAPHARESIS.
. Same ttt as CLL -> Fludarabaine.

(D) APLASTIC ANEMIA:

_____________________
. PANCYTOPENIA with no identified etiology.
. Tx -> Pt < 50 ys & has a match - > BMT.
. Tx -> Pt > 50 ys & NO match -> Anti-thymocyte globulin & cyclosporine.

. N.B. MONO-CLONAL GAMMOPATHY OF UNKNOWN SIGNIFICANCE Vs MULTIPLE

MYELOMA:
_________________________________________________________________________
_
(MGUS) (MM)

. Absence of anemia. . Anemia.

. Hypercalcemia. . Hypercalcemia.
. Renal insuffeciency. . Renal insuffeciency.
. Lytic lesions in bones. . Lytic lesions in
bones.
. Serum monoclonal protein < 3 g/dl. . Serum monoclonal
protein > 3 g/dl.
. < 10 % plasma cells in the bone marrow. . > 10 % plasma cells in
the bone marrow.
. ++ B 2 microglobulin.

. MGUS require METASTATIC SKELETAL BONE X-RAY to exclude lytic lesions

sugesting MM !
. LYMPHOMA:
___________
. ENLARGED LNs (Mostly CERVICAL).
. Anemia due to BONE MARROW INFILTRATION by CANCEROUS CELLS !

. Two types_________________________________
|
____________________________________________________
| |
.HODGKIN's LYMPHOMA .NON-
HODGKIN's LYMPHOMA
.__________________
._______________________

. Best initial test -> EXCISIONAL LN BIOPSY. . SAME.

. REED STERNBERG CELSS. . NO !
. STAGING by Contrast CT & CXR & BM biopsy: . SAME.
-> 1 -> Single LN group.
-> 2 -> 2 LN groups on one side of diaphragm.
-> 3 -> LN invovement on both sides of diaphragm.
-> 4 -> Wide-spread disease = B symptoms (fever - weight loss - Night
sweats).
. 90 % of cases present with Stages 1 & 2. . 90 % of cases present
with stages 3 & 4.
. Tx -> Stages 1 & 2 with no B symptoms -> radiotherapy.
. Tx -> Stages 3 & 4 with B symptoms ----> chemotherapy.
. "ABVD" -> . "CHOP" ->
- Adriamycin. - Cyclophosphamide.
- Bleomycin. - Hydroxyadriamycin.
- Vinblastine. - Oncovin.
- Dacarbazine. - Prednisone.

. TUMOR LYSIS $YNDROME:

_______________________
. Ass. with tumors with high cell turn-over.
. Ex: Poorly differentiated lymphoma "Burkitt's lymphoma" & Leukemias
"ALL".
. HYPER {phosphatemia - kalemia - uricemia}.
. HYPO {Calcemia}.
. Both potassium & phosphate r intra-cellular ions, so cell break down -
> their release.
. Released phosphate binds calcium leading to hypocalcemia.
. Degradation of cell proteins -> ++ uric acid levels.
. TL$ may lead to fatal arrhythmias, ARF & sudden death.
. Tx -> Allopurinol greatly reduces the possibility of acute urate
nephropathy.

. ASYMPTOMATIC LOCALIZED LYMPHADENOPATHY:

_________________________________________
. Several non-tender rubbery cervical Lymph nodes.
. Most commonly in upper respiratory tract infection.
. Commonly observed in children & youn adults.
. Tx -> OBSERVATION !

. GASTRIC MALT = MUCOSA ASSOCIATED LYMPHOID TISSUE MANAGEMENT:

______________________________________________________________
. ERADICATION OF HELICOBACTER-PYLORI !
. TRIPLE THERAPY (OMEPRAZOLE - CLARITHROMYCIN - AMOXICILLIN).
. INFECTIOUS MONONUCLEOSIS (IM):
________________________________
. Acute, benign, self limiting lymphoproliferative condition.
. Caused by Epstein Barr virus (EBV).
. EBV is transmitted by close contact to infected oro-tracheal
secretions.
. Extreme fatigue - malaise - sore throat - fever - generalized
maculopapular rash.
. Posterior cervical lymphadenopathy & palatal petichae.
. Splenomegaly is common.
. Contact sports sh'd be avoided to prevent splenic rupture.
. Leukocytosis with variant lymphocytes (Atypical lymphocytes).
. Dx -> HETEROPHIL ANTIBODIES (SENSITIVE & SPECIFIC).
. HETEROPHIL ANTIBODIES may be NEGATIVE in EARLY disease.
. -ve HETEROPHIL ANTIBODIES doesn't exclude IM.

. COAGULATION DISORDERS:
________________________
________________________

. 1 . VON WILLEBRAND's DISEASE (VWD):

______________________________________
. NORMAL PALTELET COUNT & ABNORMAL PLATELET FUNCTION.
. -- VWF -> -- platelet activation.
. Superficial bleeding from the skin & mucosal surfaces e.g. gingiva,
gums & vagina.
. Epistaxis is a common presentation & worsens with the use of aspirin.
. -- VWF -> destabilizes factor 8 -> ++ aPTT.
. Dx -> Most accurate -> RISTOCETIN COFACTOR ASSAY & VWF level.
. If the level of VWF is normal -> RISTOCETIN test will tell if it is
working properly.
. Tx -> DESMPORESSIN or DDAVP -> Will release sub-endolthelial stores of
VWF & factor 8.
. If DDAVP failed -> Factor 8 replacement.

. TYPES OF BLEEDING:
____________________
____________________

. A -> PLATELET TYPE BLEEDING:

______________________________
. petichae - epistaxis - purpura - gingiva - gums - vagina.

. B -> FACTOR TYPE BLEEDING:

____________________________
. Hemoarthrosis - Hematoma.

. A -> PLATELET TYPE BLEEDING:

______________________________
. 1 . IDIOPATHIC IMMUNE THROMBOCYTOPENIA (ITP):
________________________________________________
. Immune destruction of platelets.
. Platelets count < 50000.
. Ig G auto-antibodies against the paltelet membrane glycoproteins 2B &
3A receptors.
. Mostly occur in children.
. Pt may be asymptomatic.
. Mucocutaneous bleeding, ecchymosis & or petichiae.
. May follow acute viral infection.
 . Dx -> ISOLATED THROMBOCYTOPENIA < 100000/ml.
. Dx -> Peripheral smear sh'd be done to exclude other causes e.g. TTP.
. Dx -> Bone marrow -> ++ Megakaryocytes (platelet precursors).
. Dx -> U/$ -> NORMAL SPLEEN.
. Dx -> Check for hepatitis C & HIV infections.
. Dx -> Diagnosis of exclusion.
. Tx -> Platelets > 30000 , without bleeding -> Observe !
. Tx -> Platelets < 30000 , or bleeding -> Corticosteroids Prednisone
(1st line therapy).
. Tx -> Platelets < 20000 ! with eistaxis, melena & intracranial
hemorrhage -> IVIG.
. IVIG: INTRAVENOUS IMMUNOGLOBULIN -> when platelet < 20000 & life
threatening condition.
. Recurrent episodes -> SPLENECTOMY.
. No response to splenectomy -> Romiplostim.
. N.B. HCV & HIV tests as ITP may be the initial presentation of HIV
infection.

. 2 . UREMIA INDUCED PLATELET DYSFUNCTION:

___________________________________________
. Uremia prevents palatelets from degranulation.
. NORMAL PLATELET COUNT + PLATELET TYPR BLEEDING + RENAL FAILURE PT.
. NORMAL Ristocetin test & VWF level.
. Tx -> Desmopressin - DDAVP.

. B -> FACTOR TYPE BLEEDING = COLTTING FACTOR DEFECIENCIES:

___________________________________________________________
* FACTOR 8 = HEMOPHILIA A:
___________________________
. Joint bleeding (Hemarthrosis) or hematoma on a MALE child.
. Dx -> Mixing study then specific factor level.
. Tx -> Minor defeciency -> DDAVP.
. Tx -> Severe defeciency -> Factor 8 replacement.

* FACTOR 9 = HEMOPHILIA B:
___________________________
. Joint bleeding (Hemarthrosis) or hematoma (less common than factor 8
def.).
. Dx -> SAME.
. Tx -> Factor 9 replacement.

* FACTOR 11:
_____________
. Rare bleeding with trauma or surgery.
. Dx -> Same.
. Tx -> FFP Fresh frozen plasma.

. FACTOR 12:
____________
. No bleeding.
. Dx -> Same.
. Tx -> No ttt necessary.

. SENILE PURPURA:
_________________
. occurs in areas susceptible to traumas in elderly (Dorsum of the hands
& forearms).
. Due to PERIVASCULAR CONNECTIVE TISSUE ATROPHY .
. Lesions rapidly resolve leaving a brownish discolouration from
hemosiderin deposition.
 . Requires no ttt.

. HEPARIN INDUCED THROMBOCYTOPENIA (HIT):

___________________________________________
. HEPARIN exposure > 5 days then,
. Platelet count reduction > 50 % from baseline.
. Despite -- platelet count ->HIT is highly thrombogenic -> Arterial &
venous thrombosis.
. Necrotic skin lesions at heparin injection sites.
. Acute systemic anaphylactoid recation after heparin.
. Dx -> SEROTONIN RELEASE ASSAY (GOLD STANDARD).
. TTT is started on clinical suspicion before serotonin assay.
. Tx -> CESSATION OF ALL HEPARIN PRODUCTS !
. Tx -> Start Argatroban (direct thrombin inhibitor).

. WARFARIN INDUCED SKIN NECROSIS:

_________________________________
. More common in females.
. Common sites: breasts , buttocks, thighs & abdomen.
. Initial complaint is PAIN FOLLOWED BY BULLAE FORMATION & SKIN
NECROSIS.
. Occurs within weeks after starting therapy.
. Tx -> Discontinue warfarin - Give heparin to continue anticoagulation
- Give Vit. K.
. Acetaminophen, NSAIDs & Amiodarone may potentiate the anticoagulant
effect of warfarin.

. VITAMIN K DEFECIENCY BLEEDING:

________________________________
. Pt kept NPO NOTHING PER ORAL for a prolonged period of time &
receiving Antibiotics.
. OR Newborn hadn't received prophylactic vit. K (Home-born) for
prevention of hemorrhage
. ++++ PT > ++ PTT.

. THROMBOPHILIA = HYPERCOAGULABLE STATES:

_________________________________________
_________________________________________

(1) LUPUS ANTI-COAGULANT or ANTI-CARDIOLIPINS ANTIBODIES:

__________________________________________________________
. Venous thrombosis.
. ++ aPTT (PROLONGED PARTIAL THROMBOPLASTIN TIME).
. Normal PT, BT, platelet count & VWF.
. Spontaneous abortion. (Due to promotion of arterial & venous
thrombosis).
. False +ve VDRL & True -ve FTA-ABS (Excluding $yphilis as a cause of
recurrent abortions
. Dx -> Mixing study.
. Dx -> Russel Viper venom test (Most accurate).
. Tx -> Heparin (LMWH) followed by warfarin.

(2) PROTEIN C DEFECIENCY:

__________________________
. Skin necrosis with the use of Warfarin.
. Dx -> Ptn C level.
. Tx -> Heparin followed by Warfarin.

(3) FACTOR 5 LEIDEN MUTATION:

______________________________
. Most common cause of thrombophilia.
. Dx -> Factor 5 mutation test.
. Tx -> Heparin followed by Warfarin.

(4) ANTI-THROMBIN DEFECIENCY:

______________________________
. No change in the aPTT with a blous of IV heparin !
. Dx -> Anti-thrombin 3 level.
. Tx -> Large amounts of heparin or direct thrombin inhibitor followed
by warfarin.

. DIC = DISSEMINATED INTRAVASCULAR COAGULATION:

_______________________________________________
. Doesn't occur in healthy pts.
. Ass. with sepsis - burns - snake bites - cancer - Abruptio placenta or
AF Embolism.
. BLEEDING related to CLOTTING FACTORS DEFECIENCY & THROMBOCYTOPENIA !!
. ++ both PT & PTT.
. -- platelet count.
. ++ D-dimer & FDP (fibrin degradation products).
. -- fibrinogen level (consumed).
. Tx -> REPLACEMENT by FFP FRESH FROZEN PLASMA (Contains both palatelets
& clot.factors).

. TRANSFUSION REACTIONS:
________________________
________________________

. 1 . ABO INCOMPATIBILITY:
___________________________
. Acute symptoms of hemolysis WHILE the transfusion is occuring.
. Ex -> DURING a transfusion, the pt becomes hypotensive & tachycardic.
. Back & chest pain & dark urine.
. ++ LDH & bilirubin.
. -- Haptoglobin.

. 2 . TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) = LEUKO-

AGGLUTINATION REACTION:
_________________________________________________________________________
___________
. Acute Shortness of breath from antibodies in the donor blood against
the repient WBCs.
. Ex -> 20 mins after a pt. receives a blood transfusion, the pt becomes
short of breath.
. Transient infiltrates on CXR.
. All symptoms resolve spontaneously.

. 3 . IgA DEFECIENCY:
______________________
. presents with anaphylaxis !
. In the future, use blood donations from an IgA defecient donor or
washed RBCs.
. Ex -> As soon as the pt. received transfus., he becomes SOB,
hypotensive & tachycardic.
. NORMAL LDH & BILIRUBIN.

. 4 . MINOR BLOOD GROUP INCOMPATIBILITY:

_________________________________________
. To kell, Duffy, Lewis or Kidd antigens or Rh incompatibility !
 . Delayed jaundice.
. No specific therapy.
. Ex -> A few days after transfusion, the pt becomes jaundiced.
. The hematocrit doesn't rise with transfusion & he is generally without
symptoms.

. 5 . FEBRILE NON-HEMOLYTIC REACTION:

______________________________________
. Small rise in temperature.
. No ttt required.
. Reaction against donor WBCs antigens.
. prevented by using filtered blood transfusions in the future to remove
WBCs antigens.
. Ex -> A few hours after transfusion, the pt becomes febrile with rise
1 degree in temp.
. No evidence of hemolysis.

. N.B. HYPOCALCEMIA MANIFESTATIONS (PARESTHESIA) AFTER BLOOD TRANSFUSION:

_________________________________________________________________________
. Occurs in pts who receive more than one blood volume of blood
transfusion or packed RBCs over 24 hours may develop ++ plasma level of
CITRATE (A SUBSTANCE ADDED TO STORED BLOOD) -> CHELATION of Ca & Mg by
citrate -> -- Ca -> Paresthesia.

. MIGRATORY SUPERFICIAL THROMBOPHLEBITIS = TROUSSEAU's $YNDROME:

________________________________________________________________
. Hypercoagulable disorder.
. Un-explained superficial venous thrombosis at un-usual sites e.g. arm
& chest area.
. Associated with OCCULT VISCERAL MALIGNANCY !
. Ex. Cancer involving the pancreas "most common".
. The tumor releases mucin that react with platelets forming platelet
rich micro-thrombi.
. H/O of heavy smoking - abdominal pain - migrattory thrombophlebitis.
. Dx -> CT Abdomen -> searching for an occult tumor (pancreatic
carcinoma).

. GLUCAGONOMA:
______________
. Necrolytic migratory erythema:
---------------------------------
-> Erythematous papules / plaques on face, perineum & extremities.
-> Enlarge & coalese with central clearing & blistering & crusting &
scaling.
. Diabetes Mellitis:
---------------------
-> Mild hyperglycemia easily controlled with diet & oral agents.
-> Don't require insulin !
. GIT symptoms:
----------------
-> Diarrhea - anorexia abdominal pain - occasional constipation.
. Other findings:
------------------
-> Weight loss.
-> Neuropsychiatric (ataxia - dementia - proximal ms weakness).
-> Associated wih venous thrombosis !
. Dx -> Hyperglycemia with ++ GLUCAGON > 500 mg/dl.
. Dx -> Normocytic Normochromic anemia.
. Dx -> CT or MRI to detect the tumor.
. SMOKER + HORNER's $ = LUNG CANCER:
____________________________________
. Horner's $ -> Miosis, ptosis & anhydrosis.
. Simple CXR is the best next step to detect lung cancer.

. SMALL CELL (OAT) LUNG CARCINOMA:

__________________________________
. associated with $yndrome of inappropriate ADH secretion & ACTH
production.

. SIADH (Hyponatremia & -- serum osmolality & ++ urine osmolality).

. Metastasis is already present at the time of diagnosis !
. Tx of SIADH -> Mild (Fluid restriction) or Severe (Hypertonic saline).

. ++ ACTH -> Hypertension - Hypokalemia - Metabolic alkalosis -

Hyperpigmentation.
. e'out other manifests of Cushing $ (Moon face - Dorsal hump - central
obesity - striae)

. SQUAMOUS CELL CARCINOMA OF THE LUNG:

______________________________________
. Significant smoking H/O.
. HYPERCALCEMIA ++ Ca -> (sCa++mous) !
. Hilar mass.

. ADENOCARCINOMA OF THE LUNG:

_____________________________
. Least association with smoking.
. Located peripherally.
. Consists of columnar cells growing along the septa.
. Presents as a sloitary nodule !
. May be detected incidentally.

. FEBRILE NEUTROPENIA:
______________________
. Single temperature > 38.3c or sustained temp. > 28 c for > 1 hour in a
neutropenic pt.
. Neutropenia = Absolute neutrophil count < 1500 cells/ml.
. Mild (<1500) - Moderate (<1000) - Severe (<500).
. All require antibiotics.
. Moderate & severe neutropenia require hospitalization.
. The most common invading organism is PSEUDOMNAS AERUGINOSA.
. Tx -> HOSPITALIZATION,
. BLOOD CULTURES followed by IV CEFEPIME or PIPERACILLIN TAZOBACTAM.

. SQUAMOUS CELL CARCINOMA OF THE MUCOSA OF THE HEAD & NECK:

___________________________________________________________
. ALCOHOLIC SMOKER.
. HARD UNILATERAL NON-TENDER CERVICAL OR SUBMANDIBULAR lymph node.
. Dx -> Best initial -> PAN-ENDOSCOPY.
. Tx -> Radical neck dissection.

. TESTICULAR TUMOR:
___________________
. Painless hard mass in testicle.
. Suggestive ultrasound.
. Tx -> Orchiectomy (Removal of the testicle & its associated cord).
. FNAC or trans-rectal biopsy are contr'd bec. the risk of spillage of
cancer cells.
. FIBROCYSTIC DISEASE OF THE BREAST:
____________________________________
. Rubbery, firm, mobile & pinful mass in a young pt.
. More pain during menses.
. Aspiration of the cyst -> Clear fluid with diasppearance of the mass.
. Tx -> Observation of the pt 4 - 6 weeks.
. Only send the fluid for cytology if their is blood or foul smelling.

. INVASIVE DUCTAL BREAST CARCINOMA:

___________________________________
. TNM staging is the single most important prognostic tool for breast
cancer.
. Prognosis is best detected using ONCOGENE AMPLIFICATION by FISH !
. FISH = Fluorescent in situ hybridization.
. Over-expression of the oncogene HER2 can be detected by FISH = (Worse
prognosis).
. Positivity predicts a +ve response to TRASTUZUMAB & ANTHRACYCLINE
chemotherapy.
. ER +ve & PR +ve are GOOD prognostic features.
. Tx -> TRASTUZUMAB (Herceptin) is used to ttt breast cancer that is
HER2 +ve.
. Trastuzumab side effect -> CARDIOTOXICITY.
. ECHOCARDIOGRAPHY is recommended before ttt to assess the ejection
fraction.

. INFLAMMATORY CARCINOMA OF THE BREAST:

_______________________________________
. Breast cancer sh'd be considered whenever a pt. without a prior H/O of
skin disease,
. develops a breast rash that is non-responsive to standard ttt !
. When invasive ductal carcinoma is severe, it can infiltrate into the
dermal lymphatics,
. resulting edema - erythema - warmth of the entire breast (inflammatory
carcinoma).
. When the rash is localized to the nipple & has an ulcerating
eczymatous appearance,
. the primary cosideration should be PAGET's DISEASE of the breast.
. 5 % of pts with PAGET's disease have an underlying breast cancer
"ADENO-CARCINOMA".
. Skin biopsy -> Large cells surrounded by clear halos.

. TAMOXIFEN:
____________
. Has mixed agonist & antagonist activity on Estrogen receptors.
. It is used as an adjuvant therapy for early stage breast cancer,
. It reduces the risk of recurrence of the original cancer,, BUT,,
. ++ risk of developing of another cancer in the other breast !
. Estrogenic effects ++ risk of ENDOMETRIAL cancer & Venous thrombosis.

. SQUAMOUS CELL CARCINOMA of the SKIN:

______________________________________
. Any scar that develops into a non-healing, painless, bleeding ulcer.
. Sun-exposed or burned areas are typically involved.
. Rough scaly nodules that can ulcerate & metastasize.
. Tar derivatives (tobacco smoke) & chronic radiation exposure are
predisposing factors. . Dx -> PUNCH BIOPSY.
. Tx -> Surgical removal with wide excision of the skin around the
tumor.

. BASAL CELL CARCINOMA of the SKIN:

___________________________________
. Most common form of skin cancers in USA.
. Open sore that bleeds, oozes or crusts & remains open for 3 or more
weeks.
. Reddish patch or irritated area, shiny, waxy, scar like with elevated
rolled borders.
. Remains local - Never spreads.
. Tx -> Mohs surgery (Microscopic shaving) -> 1-2 mm of clear margins
are excised.
. Highest cure rate with Mohs surgery.
. Indicated in lesions located at critical areas e.g. perioral region,
nose, lips & ears.

. ESOPHAGEAL CARCINOMA:
_______________________
. Heart burn - significant weight loss - Regurgitation of food - fatigue
- smoking H/O.
. Age > 50 ys.
. Histological types -> Squamous cell carcinoma & Adenocarcinoma.
. SCC -> Ass. with smoking & alcohol consumption.
. Adenocarcinoma -> Barret's esophagus (GERD complication).
. Dx -> BARIUM SWALLOW followed by ENDOSCOPY.

. MYASTHENIA GRAVIS:
____________________
. Ptosis & double vision by the end of the day.
. Dx -> EMG -> Decremental response in compound action potential.
. Dx -> Acetyl choline receptor antibody test +ve.
. Dx -> CT scan chest sh'd be done in all newly diagnosed MG pts
searching for a THYMOMA.

. COLON CANCER SCREENING:

_________________________

* ROUTINE:
___________
-> Colonoscopy at 50 ys then every 10 ys.

* SINGLE FAMILY MEMBER WITH COLON CANCER:

__________________________________________
-> Colonoscopy at 40 ys,
-> or .. 10 ys earlier than the age at which the family member had
cancer,
-> whichever is earlier then every 10 ys.

* HNPCC 3 family members & 2 generations & 1 premature (<50ys):

________________________________________________________________
. Colonoscopy at 25 then every 1-2 ys.
. HNPCC is ass. with high risk of extra-colonic tumors (ENDOMETRIAL
CARCINOMA).
. It is a part of LYNCH $ type 2.

* FAMILIAL ADENOMATOUS POLYPOSIS:

__________________________________
. Sigmoidoscoy at 12 then every 1-2 ys.
. 100 % risk of cancer.
. ELECTIVE PROCTO-COLECTOMY sh'd be done.

* JUVENILE POLYPOSIS - PEUTZ JEHGERs - TURCOT's $ - GARDNER's $:

_________________________________________________________________
 . No additional screening.

. ULCERATIVE COLITIS:
_____________________
. Colonoscopy once the diagnosis is established for 8 ys then repeated
every 1 - 2 ys.

. MEN 1 = MULTIPLE ENDOCRINE NEOPLASIA 1:

_________________________________________
. Paratyhroid (>90%) -> parathyroid hyperplasia -> primary
hyperparathyroidism -> ++ Ca.
. Pituitary -> prolactinoma.
. Pancreas / GIT -> Gastrinoma "ZE $" - insulinoma - VIPoma -
Glucagonoma.
. KEY WORDS-> INTRACTABLE ULCERATION + HYPERCALCEMIA -> ZE$ &
Hyperparathyroidism = MEN1.

. POST-SPLENECTOMY SEPSIS:
__________________________
. Asplenic pt have defective PHAGOCYTOSIS !
. impaired antibody mediated opsonization in phagocytosis.
. High risk of overwhelming infection by encapsulated organisms,
. e.g. Strept. pneumoniae, N. menengitidis & H. influenzae.

. DEEP VENOUS THROMBOSIS = DVT MANAGEMENT:

__________________________________________
. Presents with pain, swelling & discoloration.
. D.D. -> Ruptured Baker's cyst - venous insuffeciency - post-thrombotic
$ & cellulitis.
. Failure to anti-coagulate the pt may lead to pulmanary embolism.
. Modified Wells criteria is a pretest propability of DVT:
-> Previous DVT.
-> Active cancer.
-> Recent immobilization.
-> Localized tendrness along vein distribution.
-> Swollen leg.
-> Pitting edema.
. . Pre-test propability of DVT using WELLs criteria
.__________________________________________________
.|
._________________________________________
.| .|
. Not likely . Likely
.____________ .________
| .|
. D-Dimer test (+)--------------->. Compression
Ultrasonography
.______________
._____________________________
.| .|
.|
._________________________________
.| .|
.|
(-) (+)
(-)
.| .|
.|
. Un-likely to have DVT ! (TTT with Heparin & Warfarin)
(Contrast Venography)
. Clinical features of METASTATIC BRAIN CANCER:
_______________________________________________
. Incidence -> Lung > Breast > Un-known primary > Melanoma > Colon.
. Primary solitary brain metastases -> BREAST - COLON - RENAL CELL
CARCINOMA.
. Multiple brain metastasis -> LUNG - MALIGNANT MELANOMA.
. Brain metastasis are the most common intracranial tumors.
. Headache - nausea&vomiting - seizures & focal neurological symptoms
(weakness-aphasia).

. TYPES OF THERAPIES !
______________________
. ADJUVANT -> TTT given in addition to standard therapy.
. INDUCTION -> Initial dose of ttt to rapidly kill tumor cells.
. CONSOLIDATION -> TTT given after induction therapy to -- the tumor
burden.
. MAINTENANCE -> Given after induction & consolidation ttt to kill
residual tumor cells.
. NEO-ADJUVANT -> Given before the standard therapy for a particular
disease.
. SALVAGE -> TTT for a disease when the standard ttt fails.

. MECHANISM OF ACTION of IMP. DRUGS:

____________________________________
. HEPARIN -> "Anti-coagulant" -> ++ ANTI-THROMBIN 3 -> -- Thrombin, 9 &
10.
. WARFARIN -> "Anti-coagulant" -> -- synthesis of Vit. K dep. factors
1972, ptn C & S.
. ASPIRIN -> "Anti-platelet" -> -- cyclo-oxygenase 1 -> -- TXA 2
synthesis.
. CLOPIDOGREL ->"Anti-platelet" -> block platelet sufrace receptors -> -
- platelet activ.

. ANDROGEN ABUSE:
_________________
. Atheletes commonly abuse androgen to enhance performance in
competetive sports.
. Ex: testosterone & synthetic androgen.
. ++ Muscle mass & strength & ++ physical exercise intolerance.
. Men SEs -> -- testicular function - -- sperm production - testicular
atrophy.
. Men SEs -> Gynecomastia - mood distaurbance - agrressive behavior.
. Women SEs -> ++ Acne - Hirsutism - deepening of voice - menstrual
irregularities.
. Labs -> Erythrocytosis & ++ HCT - Hepatotoxicity - Dyslipidemia ( --
HDL & ++ LDL).

. SOLITARY PULMONARY NODULE APPROACH:

_____________________________________
. 3 cm or less coin-shaped lesion,
. in the middle to lateral one third of the lung.
. Surrounded by normal parenchyma.
. Most of them are benign !
. Calcifications of the nodule favors a benign lesion !
. POP CORN calcification -> Hamartoma.
. BULLS EYE -> Granuloma.
. Low risk pts (< 40 ys & non smokers) -> Not a sign of immediate alarm.
. Best approach -> ASKING FOR AN OLD X-RAY !
 . If no change in it for the last 12 months -> Benign.
. Followed by CXR every 3 months for the next 12 months -> If no growth
or syms -> Leave!
. High risk pts (> 40 ys & smokers) -> Full investigation work up !

. GIANT CELL TUMOR OF BONE:

___________________________
. Dx -> X-ray -> Expansile & eccentric lytic area with SOAP & BUBBLE
APPEARANCE.
. Benign but locally aggressive skeletal neoplasm.
. Young adults.
. pain, swelling & -- range of motion at the involved site.
. Pathologic #s are common due to thinning of the bone cortex in weight
bearing areas.
. Affect the epiphysis of the long bones (distal femur & proximal
tibia).
. MRI -> Tumor containing both cystic & hemorrhagic regions.
. Tx -> Surgery.

. COMPRESSION OF THE THECAL SAC or SPINAL CORD by a TUMOR:

__________________________________________________________
. Ex -> H/O of prostatic cancer + Acute onset back pain.
. Rapid recognition is crucial to avoid paralysis.
. Point tenderness over the spine process L5 & S1.
. Imbalance, ms weakness & week rectal sphincter tone.
. Dx -> MRI spine BUTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
. Initial management with glucocorticoids (dexamethasone) is crucial to
-- swelling,
. as an attempt to preserve neurological function while awaiting the
results of imaging.

. POST-SPLENECTOMY RECOMMENDATIONS:
___________________________________
. Risk for sepsis after splenectomy is present UP TO 30 years & more !
. Anti-pneumococcal, Haemophilus & meningococcal vaccine sh'd be given,
. several weeks before splenectomy.
. Daily oral penicillin prophylaxis for 3 - 5ys following splenectomy.

. CANCER OVARY:
_______________
. NO screening tests !
. Serum CA 125 & pelvic U/$ may help in diagnosis.

. ++ HOMOCYSTEINE levels -> HYPERCOAGULABILITY:

_______________________________________________
. Vit. B6, Folate & Vit. B12 are involved in the metabolism of
homocysteine.
. Vit. B6 lowers homocysteine levels by acting as a cofactor for
cystathionine B-synthase
. which metabolizes homocysteine to cystathionine.

. PAIN CONTROL IN CANCER PATIENTS:

__________________________________
. Give the appropriate pain medication to cancer pts e.g. Ibuprofen.
. If no response .. Use a narcotic drug if it is the most appropriate.
. Use SHORT ACING IV MORPHINE.

. MANAGEMENT OF CHEMOTHERAPY INDUCED NAUSEA & VOMITING:

_______________________________________________________
. Volume repletion + SEROTONIN ANTAGONIST (Block 5HT3 recptors).
. MANAGEMENT OF CANCER RELATED ANOREXIA & CACHEXIA:
___________________________________________________
. PROGESTERONE ANALOG -> ++ Appetite & ++ weight gain.

. PROSTATE CANCER with BONE METASTASIS:

_______________________________________
. Tx -> FOCAL EXTERNAL BEAM RADIATION (If the pt under-went orchiectomy
!).

. BRAIN METASTASIS:
___________________
. SOLITARY -> SURGICAL RESECTION followed by whole brain radiation.
. Multiple -> Palliative whole brain radiation.

. MANAGEMENT OF HYPERCALCEMIA DUE TO UNDERLYING MALIGNANCY:

___________________________________________________________
. Asymptomatic or mild -> Ca < 12 mg/dl:
_________________________________________
. Just avoid thiazides, lithium use, volume depletion or prolonged bed
rest.

. Severe -> Ca > 14 mg/dl:

___________________________
. Immediate ttt -> Normal saline hydration + Calcitonin.
. Long term ttt -> Biphosphonate (Zoledronic acid).

. D.D. of ANTERIOR MEDIASTINAL MASS (4 Ts):

___________________________________________
. Thymoma - Teratoma - Thyroid neoplasm - Terrible lymphoma.
. Germ cell tumors are classified into seminomatous & non-seminomatous.
. Non-seminomatous (Yolk sac tumor - choriocarcinoma - embryonal
carcinoma).
. A mixture of all types of non seminomatous germ cell tumors = MIXED
GERM CELL TUMOR.
. Seminoma -> ++ B-HCG & Normal AFP.
. Non seminoma (MIXED) -> ++ B-HCG & ++ AFP.

. HEMOCHROMATOSIS:
__________________
. NEW-ONSET DIABETES MELLITUS + ARTHROPATHY + HEPATOMEGALY.
. Due to abnormal ++ intestinal absorption of iron -> ++ iron deposition
in tissues.
. Damage to organs ex. liver, pancreas , heart & pituitary.
. Liver -> Hepatomegaly -> Liver cirrhosis -> Hepatocellular carcinoma.
. Pancreas -> Bronze D.M.
. Pituitary -> Hypogonadism.
. Heart -> Restrictive heart failure.
. Joints -> Arthropathy.
. Skin -> Hyperpigmentation.
. Dx -> Iron studies -> ++ fe, ++ ferritin, ++ transferrin saturation.
. Dx -> Liver biopsy -> confirm the diagnosis.

. LEAD POISONING:
_________________
. Lead bind to erythrocytes & disrupts hemoglobin synthesis ->
Microcytic anemia.
. Due to chronic lead exposure & toxicity.
. Acute exposure -> Abdominal pain & constipation.
. Chronic exposure -> Fatigue, iiritability & insomnia.
 . Hypertension - Sensori-motor neuropathies - Neuropsychiatric
disturbances - Nephropathy
. OCCUPATIONAL HISTORY IS VERY IMPORTANT !
. BATTERY MANUFACTURING - PLUMBING - MINING - PAINTING - PAPER HANGING &
AUTO-REPAIR.
. Dx -> Blood Lead level.
. Dx -> Peripheral smear -> BASOPHILIC STIPPLING.
. Tx -> CHELATION THERAPY.

Dr. Wael Tawfic Mohamed

_________________________
 HEPATOLOGY TiKi TaKa
______________________

. LIVER DISEASES:
_________________
_________________

. ACUTE HEPATITIS:
__________________
__________________

. Jaundice - fatigue - weight loss - drak urine (bilirubin in urine).

. Hepatitis B & C present with serum sickness phenomena (arthralgia -
urticaria - fever).

. HBV is associated with polyarteritis nodosa (PAN) !

. HCV is associated with Cryoglobulinema.
. HEV is most severe in PREGNANT WOMEN .. It can be fatal.

. Dx -> ++ CONJUGATED (DIRECT) BILIRUBIN.

. Dx -> ++ ALLLLLLLLT -> VIRALLLLLLLLL hepatitis.

. Dx -> ++ ASSSSSSSST -> DRUGSSSSSSSSS hepatitis.

. Dx -> AST:ALT = 2:1 -> ALCOHOLIC hepatitis.

. Dx -> Most accurate test -> Serology (IgG & IgM).

. N.B. EVALUATION OF LIVER DAMAGE:

___________________________________
-> ACUTE HEPATITIS -> Liver function tests & Viral serology.
-> CHRONIC HEPATITIS -> Liver biopsy.

# HEPATITIS B:
_______________

. HEPATITIS B DIAGNOSIS -> SEROLOGY:

____________________________________

. The 1st test to become ABNORMAL in ACUTE HB infection is SURFACE

ANTIGEN (HBsAg).
. ++ ALT, e-antigen & symptoms all occur after the appearance of HBsAg.

...................... Surface Ag ........ e-Ag ......... Core Ab

.......... Surface Ab

. ACUTE disease -----> ++ ........ ++ ......... ++

.......... (--)

. WINDOW PHASE ------> -- ........ -- ......... (++)

.......... --
(RECOVERING)

. VACCINATED --------> -- ........ -- .......... --

........... (++)

. HEALED RECOVERED --> -- ........ -- .......... (++)

........... (++)
 . CHRONIC disease ---> Same as acute disease but based on persistance of
HbsAg > 6 months

. Anti HBc Ig "G" Ab -> Denotes CHRONICITY !

. Best means of screening for HBV infection -> HBsAg & IgM Hbc Ab.

. N.B. ACUTE VIRAL REPLICATION indicators:

__________________________________________
. Hepatitis B DNA plymerase = e-Antigen = Hepatitis B PCR for DNA.

. CHRONIC HEPATITIS B TREATMENT:

________________________________
. Chronicity = More than 6 months with +ve serology.
. Tx -> Anti-viral therapy -> LAMIVUDINE + INTERFERON.

# HEPATITIS C:
______________

. HEPATITIS C DIAGNOSIS:
________________________
. Best initial test -> Hepatitis C antibody.
. Most accurate test ->
1 - Hepatitis C PCR for RNA:determine the degree of viral activity &
response to therapy.
2 - Liver biopsy: determine the seriousness of the disease i.e. extent
of liver damage.

. Chronic HCV classically presents with waxing & waning transaminases

levels & few syms.
. Pts may complain of arthralgias or myalgias.
. Extra-hepatic sequlae: Cryoglobulinemia - porphyria cutanea tarda &
glomerulonephritis.

. CHRONIC HEPATITIS C TREATMENT:

________________________________
. All chronic hepatitis C pts with ++ ALT, detectable HCV RNA &
histologic evidence.
. Tx -> Anti-viral therapy -> RIBAVIRIN + INTERFERON.

. Chronic HCV pts with persistently NORMAL liver enzymes & MINIMAL
histological findings,
. NO NEED TO BE TTT WITH INTERFERON OR ANTI-VIRAL DRUGS.
. JUST follow up with yearly liver function tests.

. All chronic HCV pts sh'd receive vaccinations to Hepatitis A & B if

not already immune.
. Both vaccinations are safe during pregnancy.
. Incidence of vertical transmission is very low 2-5 % (No need for C.S.
for pregnants).
. HCV infected mothers should NORMALLY BREAST-FEED their babies.

. SE of Ribavirin -> Anemia.

____________________________

. SE of Interferon -> Arthralgia - myalgia - flu-like $ -

thrombocytopenia - depression.
_________________________________________________________________________
_______________
. VACCINATION:
______________
. Vaccination for both hepatitis A & B are done universally in
childhood.
. No vaccine & No post-exposure prophylaxis for hepatitis C.

. INDICATIONS for HEPATITIS A & B:

___________________________________
1 - CHRONIC LIVER DISEASE -> Cirrhosis.
2 - HOUSE HOLD CONTACTS -> of pts with hepatitis A & B.
3 - HOMOSEXUAL MEN !
4 - Chronic recepients of blood products.
5 - Injection drug users.

. SPECIFIC INDICATIONs FOR HEPATITIS A & B VACCINE:

___________________________________________________
. A -> TRAVELERS.
. B -> Health care workers & patients on dialysis.

. POST-EXPOSURE PROPHYLAXIS FOR HEPATITIS B:

____________________________________________
. Health care worker got stucked with a needle contaminated with blood
from HBV pt.
. A child born to a mother with chronic hepatitis B.
. GIVE -> HEPATITIS B IMMUNOGLOBULIN + HEPATITIS B VACCINE.

. If the person had already been vaccinated,

. Check the levels of protective HBsAb (surface antibodies).
. If protective antibodies are ALREADY present -> No further ttt.

. FULMINANT HEPATIC FAILURE:

____________________________
. Hepatic encephalopathy developing within 8 weeks of the onset of acute
liver failure.
. More common in pts using heavily using acet5aminophens & alcohols.
. Mostly their is co-infection of hepatitis B & D.
. Markedly ++ ALT, ++ PT & coagulopathy.
. HIGH PRIORITY CANDIDATES FOR LIVER TRANSPLANTATION. (The only
effective ttt!).

. N.B. PROTHROMBIN TIME IS THE SINGLE MOST IMPORTANT TEST TO ASSESS LIVER
FUNCTION !
_________________________________________________________________________
____________

. ASYMPTOMATIC ++ OF LIVER FUCTION TESTS (AST & ALT) APPROACH:

______________________________________________________________
.1. Ask for H/O of drug or alcohol intake, travel outside USA, blood
transfusion or sex.
.2. Drugs (NSAIDs - Antibiotics - Anti-epileptic - Anti-tuberculous).
.3. Repeat the tests again to confirm the elevations !
.4. If elevation persists > 6 months -> Chronic.
.5. So .. test for HBV & HCV, Hemochromatosis & fatty liver.

. INH (ISONIAZID) INDUCED HEPATITIS:

____________________________________
. INH may induce sub-clinical hepatitis.
. Mild elevation of ALT & AST (< 100 IU/L).
. The hepatic injury is typicall self-limited.
 . No ttt is needed .. The condition will resolve spontaneously.

. CHRONIC HEPATITIS -> CIRRHOSIS:

_________________________________
_________________________________
. CHRONIC ALCOHOL ABUSE & VIRAL HEPATITIS ARE THE MOST COMMON CAUSES.

. GENERAL FEATURES OF CIRRHOSIS:

_________________________________
1 - Edema -> from low oncotic pressure -> Tx: Spironolactone &
diuretics.
2 - Gynecomastia.
3 - Palamar erythema.
4 - Splenomegaly.
5 - Thrombocytopenia (Caused by splenic sequestration).
6 - Encephalopathy (Tx: lactulose).
7 - Ascites (Tx: spironolactone).
8 - Esophageal varices (Tx: propranolol will prevent bleeding - Banding
if rebleed).

. HYPER-ESTROGENISM in Cirrhosis:
_________________________________
. Due to -- clearance of Estrogen due to ++ portosystemic shunt.
. -- sex hormone binding globulin synthesis.
. Gynecomastia - testicular atrophy - spider angiomata - palmar eryhtema
& -- body hair.

. ASCITES:
___________
. Paracentesis if (New ascites - pain, fever & tenderness).

. SERUM TO ASCITES ALBUMIN GRADIENT (SAAG):

___________________________________________
-> < 1.1 -> EXUDATE -> NO portal hypertension.
-> > 1.1 -> TRANSUDATE -> PORTAL HYPERTENSION (++ Capillary hydrostatic
pressure).

. SPONTANEOUS BACTERIAL PERITONITIS:

____________________________________
-> Pt with cirrhosis & ascites presenting with low grade fever, abd.
pain & or confusion.
-> Dx -> Best initial test -> Cell count > 250 neutrophils.
-> Dx -> Most accurate -> Fluid culture.
-> Tx -> CEFOTAXIME.
-> Prevent recurrence -> TMP-SMX.

. HEPATIC HYDRO-THORAX:
_______________________
. Transudative pleural effusions in pts with cirrhosis,
. who have no underlying cardiac or pulmonary disease.
. Results in a RT-sided pleural effusion.
. Tx -> Salt restrictions & diuretics.
. TIPS "Trans-jugular Intra-hepatic Porto-systemic Shunt" placement in
refractory cases.

. CHRONIC LIVER DISEASES (CAUSES OF CIRRHOSIS):

_______________________________________________

{1} ALCOHOLIC CIRRHOSIS:

_________________________
 . Diagnosis of exclusion !!
. H/O of long-standing alcohol abuse.

{2} PRIMARY BILIARY CIRRHOSIS (PBC):

_____________________________________
. Not related to IBD !!
. Middle-aged woman.
. ITCHING !
. XANTHELASMA (Cholesterol deposits).
. H/O of other autoimmune diseases.
. Best initial test -> ++ ALP Alkaline phosphatase with NORMAL BILIRUBIN
level.
. ++ IgM.
. Most accurate test -> Anti-mitochondrial antibody (AMA) & Liver
biopsy.
. Tx -> Ursodeoxycholic acid.

{3} PRIMARY SCLEROSING CHOLANGITIS (PSC):

__________________________________________
. Inflammatory bowel disease (IBD) accounts for 80% of causes (UC > CD).
. ITCHING !
. Best initial test -> ++ ALP Alkaline phosphatase with ++ BILIRUBIN
level.
. Most accurate test -> ERCP -> BEADING of the biliary system.
. +ve ASMA (Anti-smooth muscle antibody).
. +ve ANCA.
. Tx -> Ursodeoxycholic acid.

{4} WILSON's DISEASE = HEPATO-LENTICULAR DEGENERATION:

_______________________________________________________
. -- Ceruloplasmin -> ++ Copper.
. Abnormal Copper deposition in liver, basal ganglia & cornea.
. Young pt < 30 ys.
. Cirrhosis + Choreiform movement disorder + Neuropsychiatric
abnormalities.
. May present with hemolysis.
. Best initial test -> Slit lamp (Keiser Fleischer rings) & --
Ceruloplasmin level < 20mg
. Most accurate test -> Liver biopsy -> Copper level > 250 mcg/gram.
. Tx -> Penicillamine.

{5} HEMOCHROMATOSIS:
_____________________
. Genetic disorder -> over-absorption of copper.
. Iron deposits in various body tissues.
. Heart -> Restrictive cardiomyopathy.
. Skin -> Darkening & pigmentation.
. Joint -> Psedogout & CPPD.
. Pancreas -> Bronze Diabetes.
. Pituitary -> Panhypopituitarism.
. Genitalia -> Infertility.
. Infections -> LISTERIA, VIBRIO VULNIFICUS & YERSINIA ENTEROCOLITICA.
. Liver -> HEPATOMA & cirrhosis -> HEPATOCELLULAR CARCINOMA (Most common
cause of death).
. Dx -> Best initial test -> ++ serum iron & ferritin levels & -- TIBC.
. Dx -> Most accurate test -> Liver biopsy - MRI liver - HFe gene
mutation detection.
. Tx -> Phlebotomy.

{6} AUTO-IMMUNE HEPATITIS:

___________________________
. Young woman with other auto-immune diseases (Coomb's +ve AIHA,
thyroiditis & ITP).
. Best initial test -> ANA & ASMA & Liver/kidney microsomal antibody.
. Serum protein electrophoresis (SPEP) -> Hyper-gamma globulinemia.
. Most accurate test -> Liver biopsy.
. Tx -> prednisone.

{7} NON-ALCOHOLIC STEATOHEPATITIS (NASH):

__________________________________________
. Associated with obesity - DM - Hyperlipidemia.
. Hepatomegaly.
. Patho-physiology -> INSULIN RESISTANCE.
. Dx -> Best initial test -> ALT > AST.
. Dx-> Most accurate test -> Liver biopsy (Fatty infiltration).
. The liver biopsy looks alike Alcoholic liver disease !!
. Tx -> No specific therapy.
. Control the underlying cause e.g. weight loss - DM control.

{8} ALPHA - 1 ANTI-TRYPSIN DEFECIENCY:

_______________________________________
. PAN-ACINAR EMPHYSEMA + CIRRHOSIS.
. Co-existing lung involvement.
. Family H/O of cirrhosis.

{9} CARDIAC CIRRHOSIS:

_______________________
. Co-existing right-sided heart failure.

. MANAGEMENT OF CIRRHOSIS:
__________________________
__________________________

{A} . PERIODIC SURVEILLANCE OF Liver Function Tests (INR - Albumin -

Bilirubin):
_________________________________________________________________________
________

{B} . COMPENSATED:
___________________
. U/$ surveillance for Hepatocellular carcinoma & Alpha feto-protein
every 6 months.
. Esophageal endoscopy for varices surveillance.

{C} . DECOMPENSATED -> ASSESS COMPLICATIONS:

_____________________________________________
. VARICEAL HEMORRHAGE -> Start non selective BB - Repeat esophageal
endoscopy every year.
. Ascites -> Dietary sodium restriction, diuretics, paracentesis &
Alcohol abstinence.
. Hepatic encephalopathy -> identify the cause (infection - GIT
bleeding) & Lactulose.

. VARICEAL BLEEDING MANAGEMENT:

_______________________________
. The 1st step in ttt of ACUTE VARICEAL BLEADING is to establish
vascular access,
. with TWO LARGE BORE INTRAVENOUS NEEDLES OR CENTRAL LINE.
. Then .. Control the bleeding itself !
 . In 50 % of cases, bleeding ceases on its own.
. Other 50 % -> Vasoconstrictors (Terlipressin) = Synthetic analogue of
vasopressin.

. HEPATIC ENCEPHALOPATHY MANAGEMENT:

____________________________________
. Decline in neurologic function due to hepatic damage.
. Due to ++ AMMONIA level in circulation & production of false
neurotransmitters.
. TTT principles -> Correction of ppt factor & lowering of blood ammonia
concentration.
. PPT factors -> hypovolemia - GIT bleeding - infection - hypoxia -
hypoglycemia & -- K.
. Lower blood ammonia using DISACCHARIDE (LACTULOSE) -> Ammonia trap.
. Add NEOMYCIN -> Destroy ammonia producing colonic bacteria (OTO &
NEPHRO-TOXIC).
. Lower protein in diet (BUT .. NOT PTN FREE DIET xxxx) !

. COAGULOPATHY MANAGEMENT:
__________________________
. Bleeding disorders occur as the liver synthesizes all clotting factors
except factor 8.
. Chief among these are Vit. K dependent factors 1972.
. Acute bleeding is best ttt with FFP FRESH FROZEN PLASMA.
. FFP contains all clotting factors.

* AMEBIC LIVER ABSCESS:

_______________________
. Amebiasis is aprotozoal disease caused by ENTAMOEBA HISTOLYTICA.
. H/O of travel to endemic area e.g. MEXICO.
. Followed by dysentery, RUQ. pain & diarrhea.
. The primary infection is the colon leading to bloody diarrhea,
. Ameba may be transported to the liver by portal circulation -> Amebic
liver abscess.
. Fever up to 39.5 c.
. ++ WBCs & ++ ALP.
. Generally SINGLE & located in the RT lobe.
. Dx -> Stool exam. -> trophozites.
. CT -> Liver mass (cystic not solid lesion).
. Needle aspiration is not performed due to risk of bleeding &
peritonitis.
. The fluid inside is called "anchovy paste" - STERILE & odourless
unless 2ry infected.
. Tx -> ORAL METRONIDAZOLE. (NOT SURGICAL RESECTION!).

* HYDATID DISEASE:
___________________
. Hydatid cyst in liver.
. Caused by ECHINOCOCCUS GRANULOSUS.
. Defnitive host is DOG.
. Unilocular cystic lesions in liver, lungs, muscles & bones.
. Most pts are asymptomatic.
. Symptoms are due to compression of the surrounding tissues.
. CT -> EGG SHELL CALCIFICATION of hepatic cyst.
. Aspiration isn't indicated -> anaphylactic shock 2ry to spelling of
cyst contents.
. Tx -> Surgical resection under the cover of ALBENDAZOLE.

* ISCHEMIC HEPATIC INJURY = SHOCK LIVER:

_________________________________________
. Accompanies severe hypotension or shock.
. Rapid massive +++ in transaminases.
. Minimal ++ in bilirubin & ALP.
. Once the predisposing factor disappears, the transaminases return to
normal.

. LIVER MALIGNANCIES:
_____________________
_____________________

* LIVER METASTASIS:
____________________
. 20 times more common than HCC.
. Tumors of GIT, lung & breast are the most common culprits.
. May be asymptomatic & discovered accidentally.
. If symptomatic: Hepatomegaly, jaundice, cholestasis & ++ alkaline
phosphatase (ALP).
. NORMAL ALPHA FETO-PROTEIN (AFP).
. Dx -> CT -> Multiple hepatic nodules of varying sizes.
. Confirmed by liver biopsy.
. Multiple liver masses are much more likely to be the result of a
metastatic disease.
. Mostly -> CANCER COLON -> DO COLONOSCOPY.

* HEPATOCELLULAR CARCINOMA (HCC):

__________________________________
. Less common than metastasis.
. ++++ ALPHA FETOPROTEIN.
. CT -> SOLITARY large lesion.

* HEPATIC ADENOMA:
___________________
. Benign rare liver tumor.
. Young & middle aged women with H/O of OCP intake.
. Palpable liver mass.
. Liver biopsy -> Mildly atypical hepatocytes containing glycogen &
lipid deposits.
. Normal liver finction tests.
. Normal AFP.
. ++ ALP & GGT.
. Complications -> Severe intra-tumor hemorrhage & malignant
transformation.

. ALCOHOLIC LIVER DISEASES:

___________________________
. Females are more susceptible than males to alcoholic liver diseases !!
. Alcoholic fatty liver is reversible condition.
. AST:ALT -> 2:1.

. 80 % of alcoholics will develop fatty liver.

. 20 % of alcoholics will develop hepatitis.
. 50 % of alcoholics will develop cirrhosis.

. H/O of heavy alcohol use.

. Hepatomegaly (Liver span > 12 cm in MCL).
. ++ MCV.
. ++ AST : ALT = 2:1.
 . Stages -> 1. Fatty liver "steatosis" - 2. Hepatitis - 3. Fibrosis
"Cirrhosis".
. Fatty liver is due to short alcohol use.
. Hepatitis & cirrhosis require long term use.

. Alcohol Hepatitis is characterized by:

-> MALLORY BODIES.
-> Neutrophils infiltration.
-> Liver cell necrosis.
-> Peri-venular inflammation.

. On CESSATION of alcohol intake:

-> Steatosis & hepatitis & early fibrosis are REVERSIBLE.
-> True cirrhosis (with generation nodules) are IRREVERSIBLE, regardless
of abstinence.

. HYPER-BILIRUBINEMIA APPROACH:
_______________________________
_______________________________

{A} MAINLY UN-CONJUGATED:

__________________________
. Over-production (hemolysis).
. Reduced up-take (drugs & porto-systemic shunt).
. Conjugation defect (Gilbert's $).

{B} MAINLY CONJUGATED -> EVALUATE LIVER ENZYME PATTERN:

________________________________________________________
. {1} Predominantly ++ AST & ALT:
__________________________________
. Viral Hepatitis.
. Autoimmune hepatitis.
. Drug induced hepatitis.
. Hemochromatosis.
. Ischemic hepatitis.
. Alcoholic hepatitis.

. {2} NORMAL AST & ALT & ALP:

______________________________
. DUBIN JOHNSON's $YNDROME.
. ROTOR's $YNDROME.

. {3} Predominantly ++ ALP -> Do abdominal imaging U$ or CT &

Antimitochondial Abs:
_________________________________________________________________________
___________
. Cholestasis of pregnancy.
. Malignancy (pancreas - ampullary).
. Cholangiocarcinoma.
. Primary biliary cirrhosis.
. Primary sclerosing cholangitis.
. Choledocholithiasis.

. N.B. U/$ -> Biliary dilatation = Extra-hepatic cholestasis.

. N.B. U/$ -> No biliary dilatation = Intra-hepatic cholestasis.

. UN-CONJUGATED HYPER-BILIRUBINEMIA FAMILIAL DISORDERS:

_______________________________________________________
 {1} GILBERT's $YNDROME:
________________________
. Disorder in conjugation.
. -- Glucuronyl transferase (enzyme that mediates glucuronidation).
. Mild jaundice.
. In-direct bilirubin < 3 mg/dl.
. Tx -> Un-necessary.

{2} CRIGLER NAJJAR TYPE - 1 $YNDROME:

______________________________________
. Disorder in metabolism.
. Severe jaundice.
. Bilirubin encephalopathy (Kernicterus).
. In-direct bilirubin 20 - 25 mg/dl. may reach 50 mg/dl.
. Normal liver enzymes & liver histology.
. IV PHENOBARBITAL -> NO CHANGE in serum bilirubin.
. Tx -> Phototherapy or plasmapharesis the LIVER TRANSPLANT.

{3} CRIGLER NAJJAR TYPE - 2 $YNDROME:

______________________________________
. Disorder in metabolism.
. Severe jaundice (less severe than type 1).
. NOOOO Bilirubin encephalopathy (Kernicterus).
. In-direct bilirubin <<<< 20 mg/dl.
. Normal liver enzymes & liver histology.
. IV PHENOBARBITAL -> ----------- in serum bilirubin.
. Tx -> Not necessary (just phenobarbital to -- bilirubin).

. CONJUGATED HYPER-BILIRUBINEMIA FAMILIAL DISORDERS:

____________________________________________________

{1} ROTOR's $YNDROME:

______________________
. Defect in hepatic storage of conjugated bilirubin.
. Normal liver function tests.
. TTT is not necessary.

{2} DUBIN JOHNSON's $YNDROME:

______________________________
. Defect in hepatic bile secretion.
. Liver biopsy -> dark granular pigment in hepatocytes (Not seen in
Rotor's $).

. PANCREATIC DISEASES:
______________________
______________________

. ACUTE PANCREATITIS:
_____________________
. Severe mid-epigastric abdominal pain radiating to the back.
. Vomiting without blood - Anorexia - Tendrness in the epigastric area.
. Main causes are ALCOHOLISM & GALL STONES.
. Other causes -> Hypertiglyceridemia - trauma - infection - iatrogenic
ERCP.
. Dx -> Best initial test ->
* ++ Amylase & lipase (most sensitive & specific) -> ++
Amylase/lipase 3 times.
 * ABDOMINAL ULTRA$OUND -> Diffusely enlarged hypoechoic
pancreas.
. Dx -> Most accurate test -> Abdominal CT scan:
* Detect dilated common bile ducts.
* Comment on intra-hepatic ducts.
. Dx -> N.B. -> ++ ALT > 150 & ++ ALP -> Biliary pancreatitis.
. MRCP -> Detects causes of biliary & pancreatic duct obstruction not
found on CT scan.
. ERCP -> If there is dilatation of the common bile duct without a
pancreatic head mass.
. ERCP -> Detect stones or strictures in the pancreatic duct system &
remove them.
. Tx -> NPO - Bowel rest - Hydration - pain medications.

. N.B. (1):
____________
. If the cause of acute pancreatitis was gall stones not alcoholism,
. Once the pt. recovers with normalization of the pancreatic enzymes &
medically stable,
. CLOLECYSTECTOMY IS A MUST !

. N.B. (2):
____________
. Acute pancreatitis in pts without gall stones or a H/O of alcohol use.
. HYPER-TRIGLYCERIDEMIA > 1000 mg/dl -> Acute pancreatitis.
. Eruptive xanthoma on exam.
. Dx -> FASTING LIPID PROFILE.

. COMPLICATIONS OF SEVERE PANCREATITIS:

________________________________________
. 1 . Pseudocyst.
. 2 . Peri-pancreatic fluid collection.
. 3 . Necrotizing pancreatitis.
. 4 . ARD$.
. 5 . ARF.
. 6 . GIT bleeding.

. SEVERE PANCREATITIS:
______________________
. Pancreatitis with failure of at least 1 organ !
. Predisposing factors: Age > 75 ys, Alcoholism & obesity.
. CULLEN SIGN -> Peri-umbilical bluish coloration indicating
hemoperitoneum.
. GREY-TURNER SIGN -> Reddish brown coloration around flanks =
retroperitoneal bleeding.
. ++ CRP > 150 mg/dl in the 1st 48 hs.
. ++ Urea & creatinine in the 1st 48 hs.
. Severe cases -> (-- BP, -- Ca, -- O2, -- pH) & (++ WBCs, ++ glucose).
. Hypotension, Hypoxia, Metabolic Acidosis, Hypocalcemia, Leukocytosis &
Hyperglycemia.
. Hypocalcemia due to fat malabsorption.
. severe pancreatitis may lead to release of activated pancreatic
enzymes,
. that enter the vascular system & ++ the vascular permeability,
. so, large volumes of fluid migrate from the vascular system to
surrounding peritoneum,
. resulting in widespread vasodilatation, capillary leak, shock & end
organ damage.
. Dx -> CT or MRCP to detect pancreatic necrosis & extra-pancreatic
inflammation.
 . Tx -> Supportive with several liters of IV fluids.

. NECROTIZING PANCREATITIS:
___________________________
. Dx -> CT.
. Tx -> If > 30 % necrosis -> IV Antibiotics (Imipenem) & CT guided
biopsy.
. If the biopsy showed infected necrotic pancreatitis -> SURGICAL
DEBRIDEMENT.
. Surgical debridement is done to prevent ARD$ & death.

. PANCREATIC PSEUDOCYST:
________________________
. Palpable mass in the epigastrium 4 weeks after the onset of acute
pancreatitis.
. Not true cysts as they lack an epithelial lining just walled by a
thick fibrous capsule
. The pseudocyst is compromized of inflammatory fluid, tissues & debris.
. The fluid contains high levels of amylase, lipase & enterokinase.
. Dx -> U/$.
. Tx -> Usually resolves spontaneously.
. Tx -> Drainage if persisting > 6 weeks or > 5 cm in diameter or
becomes 2rly infected.
. May be complicated by severe hemorrhage if eroded into a blood vessel.

. DRUG INDUCED PANCREATITIS:

____________________________
. Mild & usually resolves with supportive care !
. CT scan is diagnostic.
. Pt on diuretics -> Furosemide & thiazides.
. Pt on antibiotics -> Metronidazole & tetracyclines.
. Pt with IBD -> Sulfasalazine.
. Pt on immunosuppressives -> Azathioporine.
. Pt with seizures or bipolar disorder -> Valproic acid.
. Pt with AIDS -> Didanosine & pentamidine.

. CHRONIC PANCREATITIS:
_______________________
. Due to alcohol abuse - cystic fibrosis (Children) - Autoimmune causes.
. Epigastric chronic abdominal pain.
. Intermittent pain free intervals.
. Malabsorption -> chronic diarrhea & steatorrhea.
. Weight loss & DM may occur lately.
. AMYLASE & LIPASE may be normal .. Non diagnostic.
. Plain film or CT scan -> Pancreatic calcifications. (DIAGNOSTIC).
. If x-ray & CT are -ve for calcifications -> ERCP or MRCP.
. Tx -> Pain management with frequent small meals & pancreatic enzymes
supplement.
. Alcohol & smoking cessation.

. PANCREATIC CARCINOMA:
_______________________
. More in males & black race & age > 50 ys.
. Risk factors -> Chronic pancreatitis, smoking & DM.
. CIGARETTE SMOKING is the MOST CONSISTENT RISK FACTOR.
. Dull upper abdominal pain radiating to the back, weight loss &
jaundice.
. Tumors located in pancreatic body or tail -> pain & weight loss.
. Tumors located in pancreatic head -> Steatorrhea, weight loss &
jaundice.
 . COURVOISIER's sign -> Palpable, non tender gall bladder at the Rt.
costal margin.
. VIRCHOW's NODE -> Left supra-clavicular adenopathy.
. ++ serum bilirubin & ++ ALP.
. ++ CA 19-9 levels (Serum cancer associated antigen).
. Dx -> ABDOMINAL U/$ & CT (if U$ is not diagnostic).
. Tx -> Resection of the involved tissue.
. GUESS WHAT -> ALCOHOLISM & GALL STONES ARE NOT RISK FACTORS OF
PANCREATIC CANCER !!

. PANCREATIC CANCER VS CHRONIC PANCREATITIS:

____________________________________________
. Both may present with epigastric pain.
. (Old age, jaundice & weight loss) favors malignancy.
. Mild elevation of amylase & lipase are consistent with chronic
pancreatitis.
. ++ serum Bilirubin & ALP = compression of the intra-pancreatic bile
duct = Malignancy.
. Best initial test -> ABDOMINAL U/$ -> DILATED BILE DUCTS & MASS IN
HEAD OF PANCREAS.
. CT abdomen is more specific than U/$.
. If CT failed -> i.e. No mass lesion -> Do ERCP.
. If ERCP failed -> due to pancreatic duct obstruction -> Do MRI.

. GALL BLADDER DISEASES:

________________________
________________________

. GALL STONE DISEASE = CHOLELITHIASIS:

______________________________________
. Types of gall stones (Cholesterol - Pigment "Ca bilirubinate" -
Mixed).
. Msot common is Cholesterol stone & least common is pigment "Ca
bilirubinate".
. 80 % of stones are RADIO-OPAQUE.
. FAT - FERTILE - FEMALE - FORTY - FILTHY !
. Native American - DM - Obesity - OCP & pregnancy are common
predisposing factors.
. Bloating & dyspepsia after eating fatty foods.
. RUQ abdominal pain.
. Dx -> Abdominal U/$.
. Tx -> LAPAROSCOPIC CHOLECYSTECTOMY.
. If refused the operation -> Give ursodeoxycholic acid & advise to
avoid fatty foods.
. Asymptomatic gall stones should NOT be treated.
. Symptomatic gall stones -> LAPAROSCOPIC CHOLECYSTECTOMY.

. ACUTE CHOLECYSTITIS = ACUTE GALL BLADDER INFLAMMATION:

________________________________________________________
. CHARCOT's TRIAD -> Fever + severe jaundice + RUQ abd pain radiating to
the Rt shoulder.
. REYNOLD's PENTAD -> + Confusion + Hypotension -> (Suppurative
cholangitis).
. Most commonly due to obstruction of the common bile duct by stone.
. The original incinting event is a gall stone obstructing the CYSTIC
DUCT (Not CBD) !!!
. MURPHY's SIGN -> pain on palpation of area of gall bladder fossa on
deep inspiration.
. ++ WBCs & ++ ALP (cholestasis & obstruction).
 . Dx -> U/$.
. Tx -> Supportive care & broad spectrum antibiotics.
. Most pts recover completely, but despite adequate fluids &
antibiotics,
. Some pts continue to have persistent abd. pain, hypotension, high
fever & confusion.
. This is an indication of URGENT BILIARY DECOMPRESSION by ERCP.
. ERCP -> Sphincterotomy & stone removal or stent insertion.
. Lap. cholecystectomy won't accomplish drainage of the biliary tree
"main concern" !
. Pt will undergo cholecystectomy later on but drainage of the biliary
tree is more imp.

. EMPHYSEMATOUS CHOLECYSTITIS:
______________________________
. Due to 2ry infection of the gall bladder with gas forming bacteria
e.g. Clostridium.
. Mostly diabetic male pts aged 50 - 70 ys.
. Vascular predisposing factor e.g. obstruction or stenosis of the
cystic artery.
. Right upper quadrant pain - nausea - vomiting - low grade fever.
. Crepitus in the abdominal wall adjacent to the gall bladder.
. Complications -> Gangrene & perforation.
. Dx -> Abdominal radiograph -> Air fluid level in the gall bladder.
. Dx -> Abdominal ultrasound -> Curvilinear gas shadowing in the gall
bladder.
. Tx -> Immediate fluid & electrolyte resuscitation, cholycystectomy &
antibiotics.

. A-CALCULOUS CHOLECYSTITIS:
____________________________
. Acute inflammation of the gall bladder in absence of gall stones.
. Most commonly seen in hospitalized pts wit the following conditions:
. Extensive burns - severe trauma - Prolonged TPN or fasting &
mechanical ventillation.
. pathophysiology -> ischemia - biliary stasis - infection or external
compression.
. Complications -> Gangrene - perforation - emphysematous cholecystitis.
. Dx -> U/$ -> Signs of cholecystitis but No gall stones.
. CT & HIDA scan are more sensitive & specific.

. PORCELAIN GALL BLADDER:

_________________________
. Due to chronic cholecystitis.
. Calcium laden gall bladder.
. Calcium salts are deposited intra-murally 2ry to chronic irritation
from gall stones.
. RUQ. pain with firm non tender mass in the RUQ.
. X-ray -> Rim like calcification in the area of gall bladder.
. CT -> Calcified rim with central bile-filled dark area.
. Mostly develop to GALL BLADDER CARCINOMA.
. Tx -> CHOLECYSTECTOMY.

. GALL BLADDER CARCINOMA = CHOLANGIOCARCINOMA:

______________________________________________
. Rare malignancy.
. More in hispanic or Native american females who have H/O of gall
stones.
. Typicallu diagnosed during or after chlecystectomy !
. Can NOT be easily diagnosed pre-operatively.
 . CA 19-9 is NOT a specific marker.

. POST-OPERATIVE CHOLESTASIS:
_____________________________
. Benign condition developing after a major surgery.
. Major = Hypotension - extensive blood loss into tissues - massive
blood replacement.
. Jaundice by the 2nd or 3rd post-operative day.
. Bilirubin peaks at 10 - 40 mg/dl by the 10th day.
. ALP may be elevated.
. AST & ALT NORMAL.

. POST-CHOLECYSTECTOMY $YNDROME:
________________________________
. Persistent abdominal pain, nause & dyspepsia after cholecystectomy.
. Biliary causes -> Retained common bile duct - cystic duct stone.
. Extra-biliary causes -> Pancreatitis - PUD.
. Dx -> U/$ followed by ERCP.

. POST-CHOLECYSTECTOMY PAIN:
____________________________
. Due to functional etiology e.g. SPHINCTER OF ODDI DYSFUNCTION or CBD
stone.
. Normal ERCP & U/$ can rule out CBD stones.
. It is a diagnosis of exclusion.
. Tx of sphincter of Oddi dysfunction -> ERCP with sphincterotomy.

. VANISHING BILE DUCT $YNDROME:

_______________________________
. progressive destruction of the intra-hepatic bile ducts.
. Histological hallmark -> Ductopenia.
. Primary bilary cirrhosis is the most common cause of ductopenia in
adults.
. Primary scerosing cholangitis is not related to ductopenia.

. DIFFERENT DIAGNOSTIC TOOLS USED FOR GALL BLADDER DISEASES:

____________________________________________________________

{1} * ABDOMINAL ULTRA$OUND:

____________________________
. Best initial investigation of gall bladder diseases.

{2} * ERCP = ENDOSCOPIC RETRO-GRADE CHOLANGIO-PANCREATOGRAPHY:

_______________________________________________________________
. Best diagnostic & therapeutic tool in evaluation of chronic
pancreatitis & CBD disease.
. Most accurate test of detecting causes, location & extent of bile duct
obstruction.
. Therapeutic: Stone extraction, sphincterotomy, balloon dilatation &
stent placement.
. TTT of choice in case of sphincter of Oddi dysfunction.

{3} * ABDOMINAL RADIOGRAPHS:

_____________________________
. Neither sensitive nor specific.
. > 80 % of gall stones are radio-lucent so can't be visualized.

{4} * HIDA SCAN:

_________________
 . Use technitium labelled compounds to demonstarate bile duct
obstruction & GB diseases.
. It is superior to U/$ in confirming suspected acute cholecystitis
(Acalculus type).

{5} * PTC = PER-CUTANEOUS TRANS-HEPATIC CHOLANGIOGRAPHY:

_________________________________________________________
. study the intra & extra hepatic biliary tree.

. IMMUNOLOGIC BLOOD TRANSFUSION REACTIONS:

__________________________________________
__________________________________________

. 1 . FEBRILE NON-HEMOLYTIC:
_____________________________
. Most common reaction.
. Fever & chills.
. Within 1 - 6 hours of transfusion.
. Caused by cytokine accumulation during blood storage.

. 2 . ACUTE HEMOLYTIC:
_______________________
. Fever, flank pain, hemoglobinuria, renal failure & DIC.
. Within 1st hour of transfusion.
. +ve direct Coomb's test & pink plasma.
. Caused by ABO INCOMPATIBILITY.

. 3 . DELAYED HEMOLYTIC:
_________________________
. Mild fever & hemolytic anemia.
. Within 2 - 10 days of transfuion.
. +ve direct Coomb's test & +ve new antibody screen.
. caused by ANAMNESTIC ANTIBODY RESPONSE.

. 4 . ANAPHYLACTIC:
____________________
. Rapid onset of shock, angioedema, urticaria & respiratory distress.
. Within a few seconds to minutes of the transfusion.
. Caused by RECEPIENT anti-Ig"A" Abs.

. 5 . URTICARIAL = ALLERGIC:
_____________________________
. Urticaria - flushing - angioedema & pruritis.
. Within 2 - 3 hours of transfusion.
. Caused by RECEPIENT Ig"E" Abs & mast cell activation.

. 6 . TRANSFUSION RELATED ACUTE LUNG INJURY:

_____________________________________________
. Respiratory distress & signs of non-cardiogenic pulmonary edema.
. Within 6 hours of transfusion.
. Caused by DONOR ANTI-LEUKOCYTE ANTIBODIES.

. N.B. Individuals who received blood transfusions before 1992 sh'd be

screened for HCV.

. N.B. Individuals who received blood transfusions before 1986 sh'd be

screened for HBV.
 Dr. Wael Tawfic Mohamed
_________________________
 INFECTIONS TiKi TaKa
----------------------

. Isoniazid side effect:

-------------------------
. Peripheral neuropathy .. Tx: Vit. B 6 (Pyridoxine)

. CEREBRAL TOXOPLASMOSIS:
-------------------------
. Multiple ring enhancing lesions causing headache & hemiparesis.
. Prohphylaxis = TMP-SMX = Trimethoprim - Sulfamethoxazole.
. Treatment = SDZ-PMT = Sulfadiazine - Pyrimethamine.

. MYCO-BACTERIAL AVIUM "MAV" complex:

-------------------------------------

. HIV pt with un-explained fever & cough with CD 4 count < 50.
. AZITHROMYCIN is the best prophylaxis for HIV with MAV.

. FEBRILE NEUTROPENIA:
----------------------
. Fever > 38.3 + Neutrophils < 1500.
. Management: Admission + CEFEPIME I.V.

. Mucormycosis:
---------------
. caused by fungus RHIZOPUS.
. require aggressive surgical debridement + I.V. AMPHOTERICIN B.

. ASPERGILLOSIS:
----------------
. Immunocompromized pt. with pulmonary symptoms.
. CXR: consolidation in the upper lobe.
. CT: HALO sign.

. HISTOPLASMOSIS:
-----------------
. Pulm. symps.
. CXR: Hilar adenopathy.
. Triad of palatal ulcers + splenomegaly + Thrombocytopenia.

. COCCIDIODIOMYCOSIS:
--------------------
. Pulm. symps.
. erythema multiforme or erythema nodosum.

. BLASTOMYCOSIS:
----------------
. Immunodefecient pt. with pulm. symps.
. YEAST :)

. COCCIDIOMYCOSIS:
-----------------
. ARIZONA.
. Non specific lung syms + erythema multiforme + erythema nodosum +
Arthralgia.

. Any dog bite .. An attempt to capture the dog is tried 1st.

-------------------------------------------------------------
 . If the dog is not captyred .. It is assumed RABID .
. Give post-exposure prophylaxis.

. If the dog is captured .. but doesn't show any features of Rabies .

. Observe for 10 days .
. If it developed any Rabies features.
. Give post-exp. prophylaxis.

. If the bite involves the head & neck.

. Post exposure prophylaxis is indicated IMMEDIATELY.

. Viral (HSV) Encephalitis:

---------------------------
. Fever + confusion.
. Hemiparesis + Hyperreflexia.
. Cranial n. palsies + focal deficits.
. CSF: ++ ptn , ++ WBCS , ++ Lymphocytes.
. Normal glucose.
. Dx: PCR.
. Tx: I.V. ACYCLOVIR.

. Rt. sided endocarditis:

-------------------------
. should be considered in pts. with H/O of I.V. drug abuse.
. Tx ----------------> VANCOMYCIN.
. directed against MRSA & Streptococci.

. BABESIOSIS:
-------------
. Tick borne disease.
. Parasite enters the RBC causing hemolysis.
. Symptoms: JAUNDICE .. HEMOGLOBINURIA .. RENAL FAILURE .. DEATH.
. Typical pt: > 40 ys .. without a spleen or immunocompromized.
. LABS: INTRAVASCULAR HEMOLYSIS:
................................ * -- RBCs,--WBCs,--Platelets.
................................ * -- Serum complement.
................................ * ++ ESR, ++ Lymphocytes.
. Dx: GIEMSA stain.
. Tx: qunidine-clindamycin, ATOVAQUONE - AZITHROMYCIN.

. Any transplant pt. should have TMP-SMX for prophylaxis against (PCP)
pnemo-cystis carinii pneumonia.

. "AIHI" Auto-immune Hemolytic Anemia is one of the complications of

INFECTIOUS MONONUCLEOSIS.

. Empiric antibiotics for bacterial meningitis:

-----------------------------------------------
. VANCOMYCIN + AMPICILLIN + CEFEPIME + CORTICOSTEROIDS.

. HIV +ve pts are at high risk for T.B.

---------------------------------------
. A pt with +ve PPD Tuberculin test i.e. > 5mm induration:
. should have INH (Isoniazid) & Vit.B6 (Pyridoxine) for 9 months as a
prophylaxis.

. EHRILICHIOSIS:
----------------
. SPOTLESS RMSF.
. TICK BITE.
 . Sysytemic symptoms.
. LEUKOPENIA & THROMBOCYTOPENIA.
. ++ ALT & AST.
. Tx: DOXYCYCLINE.

. ENTERO-HEMORRHAGIC E-COLI:
----------------------------
. Bloody diarrhea.
. Abd. pain.
. NO FEVER.
. No travel H/O.

. E-Coli = TRAVELER's diarrhea.

. Whenever a health care worker is exposed to HIV:

--------------------------------------------------
. Draw his blood for HIV serology.
. Start anti-retro-viral therapy with 3 drugs without delay
. while awaiting the results of HIV serology.

. HIV pts with CD 4 cell count < 50:

------------------------------------
. require prophylaxis against MAV complex with AZITHROMYCIN.

. CRYPTO-COCCAL meningitis:
---------------------------
. caused by encapsulated yeast
. HIV pt. with meningitis
. Tx: IV Amphotericin + FLUCYTOSINE.

. Tx of primary syphilis:
-------------------------
. Single I.M. BENZATHINE PENICILLIN.
. If the pt is allergic to penicillin.
. Give either single dose of AZITHROMYCIN or 2 weeks course of
DOXYCYCLINE.

. Lyme dis. pt. if pregnant , lactating or child < 8ys:

-------------------------------------------------------
. Don't give DOXYCYCLINE but give AMOXICILLIN.

. Malignant Otitis externa:

---------------------------
. D.M. pt. with ear pain & granulation tissue at the auditory canal.
. caused by pseudomonas Aeruginosa.

. Recall of a tick bite is not the main stay of the diagnosis of LYME
disease caused by BORRELIA BURGDORFERI !

. UTI INFECTION:
----------------
. Acidic urine = E-Coli.
. Alkaline urine = Proteus.

. Rash of measles & Rubella r za same ... BUT:

----------------------------------------------
. Measles is accompanied by KOPLIK's spots.
. Rubella is associated with ARTHRITIS.

. TRICHINELLOSIS:
-----------------
. GIT complaints.
. + Triad of ---> Peri-orbital edema + Myositis + Eosinophilia.
. other clues .. Splinter or sub-ungal hemorrhages.

. Actinomycosis:
----------------
. Infection at the neck in a diabetic pt.
. Serosanguinous fluid draining from a defect in the center of the
lesion.
. Culture : Gram +ve branching bacteria.
. Tx: I.V. Penicillin.
. Actinomycosis is a bacteria not a fungus so don't ttt it with
Amphotericin !!
. Lesion: Slowly progressive non tender indurated mass
. evolving into multiple abscesses with draining sinus tracts.
. with sulfur yellowish granules !

. CMV Pneumonitis !!!!

---------------------
. 45 days post Bone Marrow transplant recepients.
. CXR: Multi-focal diffuse patch infiltrates.
. Oral thrush.
. CMV colitis: Abdominal tenderness

. Toxic scock $yndrome:

-----------------------
. H/O of NASAL PACKING or MENSTRUATION TAMPOONS.
. Fever < 38.9 c.
. Hypotension < 90/60 mmHg.
. Rash & thrombocytopenia.
. Multisystem involvemet (Vomiting & Diarrhea & Myalgia).

. PCP = PNEUMOCYSTIS CARINII PNEUMONIA:

--------------------------------------
. HIV pt. with CD4 < 200.
. Non prod. cough, dyspnea, fever, hypoxia.
. Bilateral interstitial infiltrates on CXR.
. Tx: TMP-SMX.
. Use steroids if: PaO2 < 70 mmHg or A-a gradient > 35 mmHg.

. NOCARDIOSIS:
--------------
. Crooked , branching , beaded , gram +ve partially acid fast filaments
on microscopy.
. Tx: TMP-SMX.

. Symptomatic CAT scratch disease:

----------------------------------
. Lymphadenopathy & Systemic symptoms.
. Tx: AZITHROMYCIN.

. PSEUDOMONAS AERUGINOSA:
-------------------------
. Gram -ve bacilli in the sputum of an intubated ICU pt. + fever +
leukocytosis.
. Tx: CEFEPIME (4th g. cephalosporin) or PIPERACILLIN - TAZOBACTAM !
. Ceftriaxone is not effective against Pseudomonas.
. U should STOP it !
. Valvular diseases:
--------------------
. MR is the most common valvular abnormality not related to IV drug
abuse.
. If IV drug abuser .. TR is the the most common.

. D.M. pts with foot ulcer who developed osteo-myelitis:

--------------------------------------------------------
. The route of infection is CONTAGIOUS SPREAD.

. A nail puncture wound resulting in Osteomyelitis in an adult:

---------------------------------------------------------------
. is due to Pseudomonas Aeruginosa.

. Bacterial Meningitis with meningococcemia:

--------------------------------------------
. Sudden onset fever + Neck stiffness + Nause + Headache + Myalgias.
. Hypotension + Tachycardia + Myalgia + Purpuric skin lesions.
. CSF findings of BACTERIAL cause:
=================================
** ++ WBCs .. 2000 (N: 0-5).
** Glucose .. 20 (N: 40-70).
** ++ Protein .. 175 (N: <40).

. Lyme disease:
----------------
. is not associated with purpura.
. but associated with erythema migrans.
. with characteristic bull's eye appearance !

. INFLUENZA MANAGEMENT:
-----------------------
. Most pts with INFLUENZA r ttt with BED REST & SIMPLE ANALGESIA e.g.
ACETAMINOPHEN.
. Anti-viral medications reduce the duration of influenza,
. but they r only effective if administered within 48 hours of the onset
of illness. . Amantadine & Rimantadine r only effective against type A.
. Zanamivir & Oseltamivir r only effective against both type A & B.

. INDINAVIR (Protease inhibitor):

---------------------------------
. Anti-retroviral therapy.
. causing high creatinine & hematuria.
. Needle shaped crystals in sediment : causing crystal induced
nephropathy!

. BACILLARY ANGIOMATOSIS:
--------------------------
. caused by BARTONELLA HENSELAE.
. Manifest as several cutaneous & visceral angioma like blood vessels.
. EXOPHYTIC PURPLE SKIN LESIONS.

. I.V. drug abusers r more prone to developing tricuspid endocarditis:

----------------------------------------------------------------------
. caused by STAPHYLOCOCCAL AUREUS.
. Fragments of the vgetation can embolize to the lungs,
. causing the characteristic nodular infiltrate with cavitation.

. PID PELVIC INFLAMMATORY DISEASE :

-----------------------------------
 . Any PID .. Give .. Chlamydia (Azithromycin) + Gonorrhea (Ceftriazone).
. Any PID pt sh'd be routinely screened for $yphilis .. HIV .. HBV ..
PAP smear.

. 2ry SYPHILIS:
---------------
. Maculo-papular rash involving the palms & soles + Generalized
lymphadenopathy. . Spirochete infection.

. PNEUMONIAS:
-------------
. POST-INFLUENZA ---------------> STAPH. AUREUS.
. HIV---------------------------> PCP.
. D.M. & Alcoholics-------------> KLEBSIELLA.
. C.F. & Bronchiectasis---------> PSEUDOMONAS.
. Atypical $ dry cough----------> MYCOPLASMA.
. Aspiration--------------------> ANAEROBES.

. o"H"io----> "H"ISTOPLASMOSIS:
-------------------------------
. HIV pt with CD 4 cell count <100.
. T.B. like pulm. syms with FHMA & weight loss.
. HEPATOSPLENOMEGOLY + Palatal ulcers.
. CXR: Bilateral reticulonodular opacities.
. Dx: URINE ANTIGEN.
. Tx: ITRACONAZOLE.

Dr. Wael Tawfic Mohamed

-------------------------
 NEUROLOGY TiKi TaKa
_____________________

. HEMORRHAGE -> HYPER-dense areas on CT. (WHITE).

. INFARCTIONS -> HYPO-dense areas on CT. (BLACK).

. GAITS IN NEUROLOGY:
_____________________

1. FESTINATING ----> PARKINSONISM:

___________________________________
(Mask face - bradykinesia - resting tremor - rigidity).
. N.B. PARKINSONISM's gait -> FESTINATING = HYPOKINETIC = SHUFFLING.

2. HIGH STEPPAGE --> TABES DORSALIS:

_____________________________________
(Neuro$ - Loss of proprioception - +ve Romberg sign).

3. SEMI-CIRCLE ----> STROKE HEMIPLEGIA:

_______________________________________
(Adducted affected arm & Extended affected leg).

4. WADDLING -------> MUSCULAR DYSTROPHY:

_________________________________________
(Weakness of gluteal muscles).

5. WIDE BASED & SHUFFLING -> NORMAL PRSSURE HYDROCEPHALUS:

___________________________________________________________
(Urine incontinence & dementia).

6. IPSILATERAL ATAXIA -> CEREBELLAR ATAXIA:

____________________________________________
The pt tends to fall towards the side of the lesion,
(Nystagmus-Hypotonia-Dysarthria-Loss of coordination-Dysdiadokokinesia).

7. SPASTIC ----> UMNL UPPER MOTOR NEURON LESION:

_________________________________________________
(Spinal cord injury or cerebral palsy).

8. STAGGERING -> VESTIBULAR ATAXIA:

____________________________________
(Ass. with nausea & vomiting).

. TREMORS IN NEUROLOGY:
_______________________

1. RESTING TREMORS (PARKINSON):

________________________________
* At rest - improves e' activity.
* High frequency tremors 5-7 Hz.
* Ass. e' rigidity & bradykinesia.
* Pill rolling quality.
* NOT ivolving the entire head.

2. ESSENTIAL TREMORS:
______________________
* Familial in up to 50 % of cases.
* Starts with fine movement in the upper extremity.
 * Worst at the end of the goal directed activity (e.g. reaching a pen).
* Involving the entire head.

3. CEREBELLAR TREMORS:
_______________________
* Intension tremors.
* low fequency 3-4 Hz.
* Affect the extremity & the Whole head.
* Nystagmus & ataxia are present.

. TRIGEMINAL NEURALGIA:
_______________________
. Paroxysmal, LIGHTENING PAIN on the face.
. Severe intense burning or electric shock like.
. Tx: CARBAMAZEPINE.

. CEREBELLAR TUMORS:
____________________
. Ipsi-lateral ataxia (The pt. falls towards the side of the lesion).
. Ipsi-lateral muscular hypotonia.
. Titubation (Forward & backward movement of the trunk).
. Nystagmus.
. Intention tremors.
. Dysdiadokokinesia (Difficulty in performing rapid & alternating
movements).

. INTRA-CRANIAL HEMORRHAGE:
___________________________
. HYPERTENSION is the most imp. risk factor.
. Focal neurological signs develop suddenly & gradually worsen over mins
to hours.
. The degree of symptoms is not maximal at onset (# SAH or embolic
stroke).
. Symptoms start during normal activity (may be ppt by sex).

. Site of INTRA-CRANIAL HEMORRHAGE ------> NEUROLOGICAL FINDINGS:

_________________________________________________________________

1- BASAL GANGLIA (PUTAMEN):

___________________________
* Hemi-plegia, hemi-sensory loss.
* Homonymous hemianopsia, gaze palsy.
* Stupor & coma.

2- "T"HALAMUS:
______________
* Hemi-paresis, hemi-sensory loss.
* Eyes deviate "T"owards hemiparesis.
* UP-GAZE palsy.
* (Non-reactive) miotic pupils.

3- CEREBELLUM:
______________
* NO hemiparesis.
* GAIT ATAXIA.
* OCCIPITAL HEADACHE (+nausea & vomiting).
* Gaze palsy (6th CN. paralysis)
* Facial weakness.

4- "P"ONS:
__________
* COMPLETE PARAPLEGIA.
* Followed by deep coma in a few mins.
* (REACTIVE) "P"IN POINT PUPILS.

5- CEREBRAL:
____________
* May be associated with seizures.
* Eyes deviate AWAY from the hemi-paresis.

. GUILLAIN BARRE' $YNDROME:

___________________________
. Acute idiopathic polyneuropathy.
. Ascending paralysis (i.e. affects LL 1st then involve the rest of the
ms upwards!).
. Preceided by infection or vaccination.
. weakness in both legs then ascends to involve the arms, respiratory ms
& face.
. Reflexes are diminished or symptoms.
. Distal paresthesia may occur.
. Dx: CSF ANALYSIS -> HIGH PROTEIN CONCENTRATION with NORMAL CELL COUNT.
. ++ PROTEIN & NORMAL (WBCs - RBCs - GLUCOSE) !
. i.e. CYTO-ALBUMINOUS DISSOCIATION.
. Tx: Supportive care, IVIG (Intravenous immunoglobulins) &
plasmapharesis.
. GB$ may lead to respiratory failure.
. LUNG VITAL CAPACITY is the best way to monitor the respiratory
function.

. N.B. TICK BORNE PARALYSIS:

____________________________
. Progressive ascending paralysis.
. Over hours - days.
. NO fever.
. Normal sensations.
. Normal CSF analysis.
. Meticulous search & removal of the tick results in improvement &
complete recovery.

# PARA-NEOPLASTIC $YNDROMES !
_____________________________

.1. MYASTHENIA GRAVIS:

______________________
. Female 18 - 25 ys.
. NEURO-MUSCULAR JUNCTION DISEASE.
. Muscle weakness after a period of muscle use.
. Dysarthria - Dysphagia.
. Drooping eyelids (Ptosis) - Diplopia (Double vision). {Extraocular ms
involvement}.
. Generalized weakness may develop (trunks - arms - legs). {Bulbar ms
involvement}.
. RESOLUTION OF MUSCULAR WEAKNESS with REST is the HALLMARK of
Myasthenia gravis.
. Dx: CT SCAN CHEST is MANDATORY to exclude THYMOMA.
. Tx: Oral ANTI-CHOLINESTERASES e.g. PYRIDOSTIGMINE & NEOSTIGMINE.
. Immunosuppressive agents & thymectomy may induce remission.
. MYASTHENIC CRISIS may occur resulting in severe weakness of the
respiratory muscles.
. Tx with ENDOTRACHEAL INTUBATION & withdrawal of anti-cholinesterases.
.2. LAMBERT EATON $YNDROME:
___________________________
. H/O of cancer mostly LUNG CANCER (Heavy smoking - weight loss -
malaise - lung mass).
. Small cell carcinoma.
. Proximal ms weakness.
. Auto-antibodies directed against the voltage gated calcium channels,
. leading to -- Acetylcholine release with proximal ms weakness.
. Dx: Electro-physiological studies.
. Tx: Plasmapharesis & immunosuppressive therapy.

. N.B. MYASTHENIA GRAVIS:

_________________________
. Auto-antibodies against the (post)-synaptic receptors.
. INTACT deep tendon reflexes.

. N.B. LAMBERT-EATON $:
________________________
. Auto-antibodies against the (pre) - synaptic receptors.
. LOSS of deep tendon reflexes.

.3. DERMATOMYOSITIS/POLYMYOSITIS:
___________________________________
. MUSCLE FIBER INJURY.
. Symmetric & more proximal ms weakness.
. Ass. ILD, esophageal dysmotility, Raynaud's phenomenon &
polyarthritis.
. SKIN FINDINGS (Gottron's papules & Heliotrope rash).

. N.B. STEROID INDUCED MYOPATHY:

________________________________
. Due to ttt with HIGH doses of steroids over a prolonged period of
time.
. ex: ttt of Temporal arteritis with high dose steroids.
. Proximal muscle weakness (LL before UL).
. No pain.
. Difficulty getting up from a chair - climbing stairs or brushing hair.
. Muscle power improves after discontinuation of the drug.

. SUB-ARACHNOID HEMORRHAGE:
___________________________
. Caused by rupture of arterial saccular "Berry" aneyrysm.
. Sudden severe headache (WORST HEADACHE EVER).
. Meningeal irritation may occur (Neck stiffness).
. Dx -> NON CONTRAST HEAD CT.
. Dx -> is imp. to rule out SAH.
. Dx -> Xanthochromia in CSF confirms the diagnosis.
. Dx -> CT cerebral Angiography is imp. to identify the bleeding source.
. Tx -> Coiling or restenting (Endovascular therapy).
. Tx -> Nimodipine (CCB) to -- the vasospasm.
. Complications:
. ______________
. 1 - Re-bleeding (1st 24 hours).
. 2 - Vasospasm (after 3 days).
. 3 - Hydrocephalus (++ ICT).
. 4 - Seizures.
. 5 - HYPO-NATREMIA (--Na due to SIADH).

. NEURO-FIBROMATOSIS TYPE 2:
____________________________
. YOUNG pt.
. S.C. neurofibromas + Cafe' au lait spots + Bilateral acoustic neuromas
(Deafness).
. Family H/O.
. Autosomal dominant dis. caused by a mutation in chromosome 22.
. NON-SENSE or frame shift mutations are the cause.
. N.B. Silent (Same sense) mutations don't affect the structure of the
protein.
. Dx: MRI with GADOLINIUM.

. PRONATOR DRIFT:
_________________
. It denotes UMNL.
. When the pt. closes his eyes & extends his arms with the palms up,
. The affected arm will tend to pronate.
. Bec. UMNL causes weakness in supination with dominance of the pronator
muscles.

. ESSENTIAL TREMOR:
___________________
. ACTION tremor.
. Absence of other neurological signs.
. Suppressed at rest (# parkinsonism).
. Noticed when the pt. attempts a task that requires fine motor movement
!
. Tx: BB (Propranolol) is the 1st line of ttt.
. Primidone may be used (Anti-convulsant which may ppt acute
intermittent Porphyria,
. manifested as abdominal pain, neurologic & psychiatric abnormalities.

. MULTIPLE SCLEROSIS:
_____________________
. Affects women in child bearing peiod (15-50 ys).
. Multiple neurological deficits that can't be explained by single
lesion.
. "PATCHY" neurological manifestations.
. Optic neuritis (painful loss of vision) & diplopia.
. Sensory symptoms -> Numbness & paresthesia.
. Motor symptoms -> Paraparesis & spasticity.
. Bowel/bladder dysfunction.
. "UHTHOFF phenomenon" Exacerbated by hot weather or exercise !
. "LHERMITTE's sign" Electric shock-like sensation down the spine on
flexion of the neck.
. INTER-NUCLEAR OPHTHALMOPLEGIA (INO) is characteristic:
_______________________________________________________
* On attempted left gaze, the left eye abducts & exhibits horizontal
jerk nystagmus,
* but the right eye remains stationary.
* On attempted right gaze, the right eye abducts & exhibits horizontal
jerk nystagmus,
* but the left eye remains stationary.
* caused by demyelination of the MEDIAL LONGITUDINAL FASCICULUS.
. Dx: BRAIN MRI with & without GADOLINIUM.
. MRI:Multiple bilatreal asymmetric hyperintense lesions in
periventricular white matter.
. CSF analysis: OLIGOCLONAL IgG bands - Normal pressure.
. Tx of acute exacerbation -----> HIGH DOSE IV GLUCOCORTICOIDS.
. Tx to prevent future attacks -> B-interferon or Glatiramer acetate.
. N.B. YOUNG FEMALE with BILATERAL TRIGEMINAL NEURALGIA = MS.
. AMYOTROPHIC LATERAL SCLEROSIS:
________________________________
. UPPER + LOWER motor neuron lesions.
. UMNL (Spasticity - bulbar symptoms - exagerrated deep tendon
reflexes).
. LMNL (Fasciculations, wasting).
. Tx: RILUZOLE (Glutamate inhibitor) - Steroids are WRONGGGGGGGGGGGGGGG
!

. CARPAL TUNNEL $YNDROME = MEDIAN NERVE ENTRAPPMENT $YNDROME:

_____________________________________________________________
. At WRIST !
. Numbness & pain in the palm.
. Thenar eminence atrophy.
. Paresthesia of the 1st three & a half digits

. ULNAR NERVE ENTRAPMENT $YNDROME:

___________________________________
. -- sensation over the 4th & 5th fingers with weak grip.
. due to involvement of the interosseus muscles of the hand.
. entrapment at the medial epicondylar groove.
. Leaning on the elbows while working at a desk or table is the typical
scenario.

. VESTIBULO-TOXICITY by AMINO-GLYCOSIDES:
_________________________________________
. Gentamycin & Amikacin.
. Vertigo & gait imbalance.
. due to damage of the motion sensitive hair cells in the inner ear.

. TORTICOLLIS:
______________
. Example of FOCAL DYSTONIA.
. Dystonia -> Sustained ms contraction.
. Focal -> Affecting one muscle.
. Involuntary head turning & fixation to one side.
. Hypertrophy of the opposite side sterno-cleido-mastoid ms.
. It is a common side effect of Anti-psychotic drugs.

. UN-PROVOKED FIRST SEIZURE -> HEAD CT WITHOUT CONTRAST is the 1st

initial step done:
_________________________________________________________________________
____________
. To exclude intracranial or subarachnoid bleeding requiring urgent
intervention.
. MRI is the best diagnostic modality in elective situations for
seizures cases.

. LIMB ISCHEMIA:
________________
. Mostly due to migration of arterial emboli from the heart.
. The emboli source may be Af or recent MI.
. 5 Ps (Pain - Pallor - Paresthesia - Pulselessness & Paralysis).
. Tx: IV HEPARIN BOLUS followed by continous heparin infusion.
. Referral for emergency vascular surgery.

. METOCLOPRAMIDE:
_________________
 . It is a pro-kinetic agent used to treat nausea , vomiting & gastro-
paresis.
. Pts sh'd be monitored closely for the development of drug induced
extra-pyramidal syms.
. Ex: Tardive dyskinesia - Dystonic reactions & prkinsonism.
. Manifested by stiff painful neck.

_________________________________________________________________________
________________
_________________________________________________________________________
________________

# MAIN CAUSES OF STROKE:

_________________________

. 1 . ISCHEMIC THROMBOTIC:
__________________________
-> H/O of previous TIAs (Transient ischemic attacks).
-> Atherosclerotic risk factors (Uncotrolled HTN & DM).
-> Local in-situ obstruction of an artery.
-> Symptoms may progress or regress with time.

. 2 . ISCHEMIC EMBOLIC:
_______________________
-> H/O of cardiac disease (Af, endocarditis or carotid atherosclerosis
"Bruit").
-> Onset of symptoms is ABRUPT & usually MAXIMAL at the start.
-> Multiple infarcts within different territiories.
-> NO headache or impaired consciousness.

. 3 . HEMORRHAGIC:
__________________
-> H/O of uncontrolled HTN, co-agulopathy, illicit drug use e.g
amphetamines & cocaine.
-> Sudden development of focal neurological signs.
-> Followed by ++ ICT symptoms (vomiting & headache).
-> Worsens gradually over mins to hours.
-> Symptoms may start with normal activity.
-> Hypertension is the most imp. risk factor.

. 4 . SPONTANEOUS SUB-ARCHNOID HEMORRHAGE:

__________________________________________
-> Rupture of an arterial saccular berry aneurysm or AV malformation.
-> Sudden dramatic onset of severe headache (WORST HEADACHE EVER).
-> Meningeal irritation e.g. neck stiffness.
-> Focal deficits are uncommon.

# The 1st step in STROKE management is NON CONTRAST HEAD CT.

_____________________________________________________________

# TOPOGRAPHY of the lesions in stroke pts (ACCORDING TO THE AFFECTED

ARTERY):
_________________________________________________________________________
_____

* POSTERIOR LIMB OF INTERNAL CAPSULE (LACUNAR INFARCT):

________________________________________________________
. Motor impairment without any higher cortical dysfunction.
. No visual field abnormalities.
 * MIDDLE CEREBRAL ARTERY OCCLUSION:
____________________________________
. Contralateral hemiplegia.
. Contralateral hemianesthesia.
. Conjugate eye deviation toward the side of stroke.
. Homonymous hemianopia.
. Aphasia (dominant hemisphere).
. Hemi-neglect (Non dominant hemisphere).

* ANTRIOR CEREBRAL ARTERY OCCLUSION:

_____________________________________
. Contralateral weakness that predominantly affects the LLs.
. Abulia (loss of willing).
. Akinetic mutism.
. Emotional disturbances.
. Deviation of head & eyes towards the side of the lesion.
. Sphincter incontinence.

* VERTEBRO-BASILAR SYSTEM LESION (BRAIN STEM):

_______________________________________________
. Alternate $ with contralateral hemiplegia & ipsilateral CN
involvement.

# Presentations according to the AFFECTED LOBE:

________________________________________________

. DOMINANT FRONTAL LOBE STROKE:

_______________________________
. Expressive (BROCA's) aphasia.
. Contralateral hemiparesis (due to involvement of the primary motor
cortex).
. Contralateral apraxia (due to involvement of the supplementary motor
cortex).

. DOMINANT PARIETAL LOBE STROKE:

________________________________
. Contralateral sensory loss (pain, vibration, agraphesthesia &
astereognosis).
. Contralateral inferior homonymous quadrantanopsia (Superior optic
radiation lesion).

. DOMINANT TEMPORAL LOBE STROKE:

________________________________
. APHASIAS due to ARCUATE FASCICULUS involvement.
. Reception aphasia (Affect comprehension).
. Anomic aphasia (inability to speak nouns).
. Conductive aphasia (Repitition)
. Contralateral inferior homonymous quadrantanopsia (Superior optic
radiation lesion).

# PRESENTATION ACCORDING TO TEH AFFECTED PART OF THE BRAIN:

____________________________________________________________

.1. BRAIN STEM LESIONS:

________________________
. involve the cranial nerves.
. sensory loss of one half of the face & contralateral half of the body.

.2. THALAMUS LESIONS:

______________________
 . Hemi-sensory loss with severe dysesthesia (THALAMIC PAIN PHENOMENON).

.3. CORTICAL LESIONS:

______________________
. sensory loss of one half of the face & ipsilateral half of the body.
. Aphasia - Neglect - Abnormal graphesthesia or stereognosis.

.4. MEDIAL MEDULLARY $YNDROME:

_______________________________
. Due to occlusion of the vertebral artery or one of its branches.
. Contralateral paralysis of the arm & leg.
. Contralateral loss of tactile, vibratory & position sensation.
. Ipsilateral Tongue deviation.

# THE MOST COMMON RISK FACTOR OF STROKE IS HYPERTENSION.

_________________________________________________________

# LACUNAR STROKES:
___________________
. Most common site is in the POSTERIOR LIMB OF THE INTERNAL CAPSULE.
. Most common cause is HYPERTENSION & DM.
. Lipo-hyalinotic thickening of the small vessels.
. Micro-atheromas.
. LIMITED neurological deficit.
. Pure motor or sensory stroke - Ataxic hemiparesis - Dysarthria with
clumsy hand $.
. May be missed on CT due to their small size.

1. PURE MOTOR HEMIPARESIS:

__________________________
. Lacunar infarct in the POSTERIOR LIMB OF THE INTERNAL CAPSULE.
. Unilateral motor deficit (face, arm & to a lesser extent leg).
. Mild dysarthria (Slurred speech).
. NO sensory, visual or higher cortical dysfunction.

2. PURE SENSORY STROKE:

_______________________
. Lacunar infarct in the ventro-postero-lateral of the THALAMUS.
. Unilateral numbness, paresthesia.
. Hemisensory deficit in the face, arm, trunk & leg.

3. ATAXIC HEMIPARESIS:
______________________
. Lacunar infarct in the ANTERIOR LIMB OF THE INTERNAL CAPSULE.
. Weakness more prominent in LL extremity.
. Ipsi-lateral arm & leg incoordination.

4. DYSARTHRIA CLUMSY HAND $YNDROME:

___________________________________
. Lacunar stroke at the basis pontis.
. Hand weakness, mild motor aphasia.
. NO sensory deficits.

# STROKE MANAGEMENT:
_____________________
1- NON contrast head CT to rule out hemorrhagic stroke.
2- Ischemic stroke -> Give fibrinolytic therapy (if the pt comes within
3-4 hs of onset).
3- Make sure that the pt. has no contraindications to the fibrinolysins.
4- If there is contraindication -> Give Antiplatelets (ASPIRIN).
. Clinical presentation "ischemic stroke case" -> Anti-platelet/Anti-
thrombotic therapy:
_________________________________________________________________________
_______________
. Presenting within 3 - 4.5 hs of symptoms onset with no cont'ds -> I.V.
Alteplase.
. Stroke with no prior anti-platelet therapy -> Aspirin.
. Stroke on Aspirin therapy ->(Aspirin + dipyridamole) OR (Clopidogrel).
. Stroke on Aspirin therapy + intracranial large art. sclerosis ->
Aspirin + Clopidogrel.
. Stroke with evidence of atrial fibrillation -> LONG TERM
ANTICOAGULATION e.g. WARFARIN.

# THROMBOLYTICS = TISSUE PLASMINOGEN ACTIVATOR (t-PA) = ALTEPLASE:

___________________________________________________________________

# THROMBOLYTICS INDICATIONS & CONTRAINDICATIONS:

_________________________________________________

# THROMBOLYTICS INDICATIONS:
_____________________________
.1. Non hemorrhagic ischemic stroke.
.2. Symptoms onset < 3 - 4.5 hours before treatment initiation.

# THROMBOLYTICS CONTRA-INDICATIONS:
____________________________________
.1. Stroke or head trauma in the past 3 months.
.2. H/O of intracranial hemorrhage.
.3. Major surgery in the past 2 weeks.
.4. GI,GU or active bleeding in the past 3 weeks.
.5. Seizure at the onset of stroke.
.6. SBP > 185 mmHg or DBP > 110 mmHg.
.7. Platelets < 100000/mm3 , Glucose < 50 mg/dl , INR > 1.7.

_________________________________________________________________________
_________________
_________________________________________________________________________
_________________

. HEMI-NEGLECT $YNDROME = LESION in the (RIGHT PARIETAL LOBE CORTEX):

_____________________________________________________________________
. Lesion of the RIGHT (NON)-dominant hemi-sphere.
. which is responsible for spatial organization.
. So, In this disease, The pt ignores the left side of a space.
. Responds only to the stimuli coming from the RIGHT side.
. Pt may shave only the Right side of their face.
. Comb the Right side of his hair.
. Ignore the subject located in the left side of a space.
. Dx: Ask the pt to fill in the numbers o a clock !

. EXERTIONAL HEAT STROKE:

_________________________
. Severe exertion under direct sun light.
. Acute confusion, hyperthermia, tachycardia & persistent epistaxis.
. Due to FAILURE OF THERMO-REGULATORY CENTER to maintain a euthermic
state.
. Core temperature > 40 with altered mental status.
. Factory workers, Military recruits exposed to hot humid environment.
 . Complications: Rhabdomyolysis - RF - ARDS - Coagulopathic bleeding.
. Tx ->immersion in cold water

. MALIGNANT HYPERTHERMIA:
_________________________
. Genetically susceptible pt during anesthesia.
. Ass. with halothane & succinyl choline.
. Uncotrolled efflux of calcium from the sarcoplasmic reticulum.

. CAVERNOUS SINUS THROMBOSIS:

_____________________________
. Un-controlled infection of the skin, sinuses & orbit may spread to he
cavernous sinus.
. Bec. the facial / ophthalmic venous system is valveless !
. Cav. sinus inflammation may lead to cav. sinus thrombosis &
intracranial hypertension.
. HEADACHE (INTOLERABLE) is the most common symptom.
. Vomiting is common due to ++ ICT.
. Fundoscopy will reveal papilledema.
. Binocular palsies, periorbital edema with hypo/hperesthesia.
. Dx: MRI.
. Tx: Broad spectrum Antibiotics.

. RESTLESS LEG $YNDROME:

________________________
. Uncomfortable "Crawling" sensation or urge to move the legs.
. Discomfort which worsens in the evening or during sleep.
. Discomfort which worsens at rest.
. Discomfort alleviated by movement of the affected limb.
. Tx : Dopaminergic agonists e.g. L-dopa.

. WERNICKE's ENCEPHALOPATHY:
____________________________
. Alcoholic pt.
. Altered mental status + Gait instability + Nystagmus + Conjugate gaze
palsy.
. Due to Vit. B "1" defeciency 2ry to long term alcohol use.
. Triad of ecephalopathy, oculomotor dysfunction & gait ataxia is
diagnostic.

. DECUBITUS ULCER:
__________________
. H/O of old pt in a care giver facility.
. Continued pressure on a bony prominence for a long period.
. Ischemic necrosis of the overlying ms, S.C. tissue & skin.
. Preveted by repositioning of the pt every 2-4 hours.

. LEVO-DOPA / CARBI-DOPA Side effects:

_____________________________________
. Dopamine precursors.
. Most common side effect is HALLUCINATIONS.
. Others: Dizziness, Headaches & agitation.
. Involuntary movements may occur.

. TRI-HEXY-PHENIDYL side effects ( VERY IMPORTANT .. ASKED TWICE in UW):

________________________________________________________________________
. It is an Anti-cholinergic drugs used for ttt of Parkinsonism.
. Red as beet, dry as bone, hot as hare, blind as bat, mad as hatter &
full as a flask.
. Red as beet : Flushing.
 . Dry as bone : Anhydrosis - dry mouth.
. Hot as hare : Hyperthermia.
. Blind as bat : Mydriasis - vision changes.
. Mad as hatter : Delirium - cofusion.
. Full as a flask : Urine retention - constipation.

# DEMENTIAS:
_____________

.1. FRONTO-TEMPORAL DEMENTIA (Pick's disease):

______________________________________________
. Personality changes (euphoria - disinhibition - apathy).
. Compulsive behavior (peculiar eating habits - hyperorality).
. Impaired memory.
. Family H/O of the disease is common.

.2. LEWY BODIES DEMENTIA:

_______________________
. Fluctuating cognitive impairment.
. Bizarre visual hallucinations.

.3. ALZHEIMER's DISEASE:

______________________
. Progressive dementia.
. Age, female gender, +ve family H/O, head trauma are common risk
factors.
. Subtle memory loss, language difficulties & apraxia.
. Impaired judgement & personality changes.

. N.B. HYPOTHYROIDISM is an imp. cause of reversible changes in memory &

mentation:
_________________________________________________________________________
__________
. Accompanied by systemic changes e.g. weight gain, fatigue, hoarseness
& constipation.

.4. HUNTINGTON's DISEASE:

_________________________
. Triad of mood disturbances + Choreiform movements + Dementia.
. Due to ATROPHY of the CAUDATE NUCLEUS.
. Autosomal dominant (Gene defect on chromosome 4).
. Affects both sexes equally.
. Family H/O of the disease is present.
. Age 30 - 50 ys.
. Mood disturbances (Depression & apathy).
. Choreiform movements (facial grimacing, ataxia, dystonia, tongue
protrusion).
. Writhing movements of the extremeties.

.5. CREUTZFELDT - JAKOB DISEASE:

______________________________
. Age 50 - 70 ys.
. It is a spongiform encephalopathy caused by a prion.
. Rapidly progressive dementia & myoclonus.
. EEG -> SHARP TRI-PHASIC SYNCHRONOUS DISCHARGES.
. Pts die within one year of onset.

.6. NORMAL PRESSURE HYDROCEPHALUS:

________________________________
. Triad of Urine incontinence + Abnormal gait + Dementia.
 . Gait -> Broad based & shuffling
. ++ in ventricular size without persistent ++ in ICT.
. Symptoms due to distortion of the periventricular brain matter.
. The cause is -- CSF ABSORPTION.
. Dx: CT or MRI -> ENLARGED VENTRICLES.
. Dx: LP -> NORMAL OPENING PRESSURE.
. Tx: VENTRICULO-PERITONEAL SHUNT.

.7. PSEUDO-DEMENTIA:
____________________
. Major depressive episode may present as pseudo-dementia.
. Elderly pts who r severely depressed may present with memory loss.
. H/O of emotional situation with the pt. (e.g. Pt's son moving out !).
. Symptoms coincides with the emotional situation.
. Tx -> Anti-depressants e.g. SSRIs (SLECTIVE SEROTONIN RE-UPTAK
INHIBITORS).

.N.B. NORMAL AGING:

___________________
. Tiredness.
. occasional forgetfulness.
. occasional word finding difficulty
. Trouble falling asleep.
. Absence of functional impairments.
. Normal performance on mental status examination.

. BRAIN DEATH:
_______________
. Irreversible cessation of the brain activities.
. Absent cortical & brain stem functions.
. Absent corneal reflex.
. Absent gag reflex.
. Absent oculovestibular rflex.
. FIXED DILATED PUPILS.
. No spontaneous breathing when the ventillator is off for 10 mins.
. Spinal cord may be still functioning, so, DEEP TENDON REFLEXES may be
STILL PRESENT.
. MUST BE CONFIRMED BY TWO PHYSICIANS.

. SHY DRAGER $YNDROME:

______________________
. MULTIPLE SYSTEM ATROPHY.
. PARKINSONISM pt.
+ Autonomic dysfunction (postural hypotension - bowel&bladder loss of
control-impotence).
+ Widespread neurological signs (cerebellar, pyramidal or lower motor
neuron).

. Chronic alcohol abuse -> Cerebellar damage:

_____________________________________________
. loss of co-ordiated movement.
. Ataxia.
. Broad based gait.
. Dysmetria.
. Intention tremors.
. Dysdiadokokinesia.
. Nystagmus.
. Ms hypotonia (pendular knee reflex).

. BELL's PALSY:
_______________
. Facial 7th cranial nerve peripheral neuropathy.
. Sudden onset of unilateral facial paralysis.
. Inability to close the eye on the affected side.
. Inability to raise the eye brow on the affected side.
. Drooping of the mouth corner with disappearnce of the nasolabial fold,
. so, the mouth is drawn to the spared side.
. Diminished tearing.
. Hyperacusis.
. Loss of taste sensation over the anterior 2/3s of the tongue.
. If the lesion in the CNS occuring above the facial nucleus,
. it will typically CONTRALATERAL LOWER FACIAL WEAKNESS SPARING THE
FOREHEAD.

. AMAUROSIS FUGAX:
__________________
. Painless loss of vision.
. Cholesterol particles may be seen in the eye.
. It is a warning sign of impending stroke.
. An underlying embolic disease is most always present.
. Emboli occur at the carotid bifurcation.
. Dx: NECK DUPLEX ULTRA$OUND.

. SUB-DURAL HEMATOMA:
_____________________
. Due to BLUNT or shearing trauma tearing the BRIDGING VEINS.
. causing them to slowly bleed into the subdural space.
. Headache & gradual loss of consciousness occur gradually.
. More common in older pts & alcoholics due to brain atrophy & vessel
fragility.
. NON contrast head CT -> WHITE CRESCENT..
. Mass effect with mid line shift may be seen.
. Emergent neurosurgical consultation for hematoma evacuation is
necessary.

. EPI-DURAL HEMATOMA:
_____________________
. Trauma to the TEPORAL bone.
. Injury to the MIDDLE MENINGEAL ARTERY.
. Non contrast head CT -> BICONVEX HEMATOMA.

. SYRINGOMYELIA = CORD CAVITATION:

__________________________________
. Idiopathic Cavitary expansion of the spinal cord.
. Affets the upper limbs in a CAPE like distribution.
. Areflexic weakness in the upper extremeties.
. Dissociated anesthesia (Loss of pain & temperature with intact
position & vibration).
. A cord cavity is present !
. Lower cervical or upper thoracic are the most common affected sites.

. DIABETIC NEUROPATHY:
______________________
. Symmetric peripheral polyneuropathy, mononeuropathy or autonomic
neuropathy.
. Mononeuropathies either cranial or somatic.
. CN 3 (Oculomotor) is the most common affected.
. The cause of neuropathy is ISCHEMIC.
. Somatic & parasympathetic fibers in CN 3 have separate blood supplies.
 . So .. Only somatic fibers are affected while the parasympathetic
fibers are intact.
. Manifested by PTOSIS & DOWN & OUT GAZE.
. Accomodation & light reflex are intact.

. SPINAL CORD COMPRESSION:

__________________________
. isolated, symmetric, lower extremity symptoms.
. Loss of sensations & signs of upper motor neuron lesion.
. Weakness without fasciculations, hyperreflexia & +ve Babinski sign.
. Possible etiologies: (Disk herniation - Epidural absess & malignancy).
. It is a medical emergency !
. Dx: MRI Spine .. NOT CT !!

. ALZHEIMER's DISEASE:
______________________
* It is the most common cause of dementia.
* NO disturbance in consciousness.
* Age group > 60.

* EARLY FINDINGS:
__________________
. Anterograde memory loss (immediate recall affected, distant memory
preserved).
. Visuospatial deficits (lost in own neighborhood).
. Language difficulties (difficulty finding words).
. Cognitive impairment with progressive decline.

* LATE FINDINGS:
_________________
. Neuropsychiatric (hallucinations & wandering).
. Dyspraxia (difficulty performing learned motor tasks).
. Lack of insight regarding deficits.
. Non-cognitive neurological deficits (pyramidal & extra-pyramidal
motor, myoclonus).
. Urinary incontinence.

* Dx: CT -> Diffuse cortical & subcortical atrophy,

which is disappropriately greater in the temporal & parietal lobes.

. GLIOBLASTOMA MULTIFORME (GBM) = HIGH GRADE ASTROCYTOMA:

_________________________________________________________
. Symptoms of ++ ICT (Nausea-vomiting-headache worsening with change in
position).
. ++ ICT = Space occupying lesion.
. Personality changes & strange behavior (Due to involvement of the
frontal lobe).
. Dx: CT or MRI -> BUTTERFLY appearance with central necrosis,
. with HETEROGENOUS SERPIGINOUS CONTRAST ENHANCEMENT.

. CRANIOPHARYNGIOMA = Hypopituitarism signs + Headaches + Bitemporal

blindness:
_________________________________________________________________________
______
. Benign tumors arising from Rathke's pouch.
. Bimodal age distribution i.e. children & 55-65 ys age group.
. It is located above sella turcica.
. Consists of multiple cysts filled with oily fluid.
. Presents with symptoms of hypothyroidism.
. In children (Retarded growth due to -- GH & TSH).
 . In adults (Sexual dysfunction).
. Women may present with amenorrhea.
. It compresses the optic chiasma -> BITEMPORAL BLINDNESS.
. Headaches occur due to ++ ICT.
. Dx: MRI or CT.
. Tx: Surgery or radiotherapy.

. CAUDA EQUINA $YNDROME:

________________________
. Compression of the spinal nerve roots.
. Causes (Tumor - Herniated disk - Abscess - Trauma).
. Low bk pain.
. Bowel & bladder dysfunction.
. Saddle anesthesia.
. Sciatica.
. Lower extremity sensory & motor loss.
. Dx: Emergent MRI.

# HIV associated lesions on MRI:

________________________________

.1. PRIMARY CNS LYMPHOMA:

_________________________
. Solitary.
. {WEAKLY} ring enhancing peri-ventricular mass.
. Altered mental status.
. Associated EBV DNA in the CSF.

.2. TOXOPLASMOSIS:
__________________
. Multiple.
. {Ring - enhancing} spherical lesions in the basal ganglia.
. +ve serology is not specific !
. TMP-SMX is preventive.

.3. PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY:

_______________________________________________
. {Non - enhancing}.
. No mass effects.
. Opportunistic viral infection (JC virus).

.4. AIDS DEMENTIA COMPLEX:

__________________________
. Cortical & sub-cortical atrophy.
. 2ry ventricular enlargement.

.5. ABSCESS:
____________
. Solitary.
. {Ring enhancing}.
. Isolated, round with smooth borders.
. H/O of known extra-cranial infections.
. Fluid collection in the maxillary sinus.
. The most common causative organisms are AEROBIC & ANAEROBIC
STREPTOCOCCI & BACTEROIDES.

# CAROTID ARTERY STENOSIS:

__________________________
. May progress to embolic stroke or TIAs.
. May be silent with no symptoms.
 . Symptomatic -> sudden onset of focal neuro. syms ipsilateral to the
blocked artery.
. Dx: NECK DUPLEX U/$.
. Tx: CEA or CAS.
. CAROTID END ARTERECTOMY (CEA) is recommended if:
_________________________________________________
. * Symptomatic pts with carotid stenosis 70 - 99 %.
. * Low surgical risk.
. * Good 5 year predicted survival.
. * Surgically accessible carotid lesion.
. CAROTID ANGIOPLASTY WITH STENTING (CAS) is recommended if:
___________________________________________________________
. * High surgical risk.
. * Poor 5 year predicted survival.
. * Lesion not amenable to surgery.

# IMPORTANT CRANIAL NERVES & THEIR FUNCTIONS:

_____________________________________________

* OPTIC NERVE (CN 2):

_____________________
. VISION.

* OCULOMOTOR (CN 3):

____________________
. Eye movement (Most).
. Adduction with medial rectus.
. Elevation with superior rectus.
. Depression with inferior rectus.
. Eye lid opening.
. Pupil constriction.

* TRIGEMINAL (CN 5):

____________________
. Three branches with both motor & sensory fibers.
. The 1st branch is called the Ophthalmic nerve,
. It carries sensory fibers to the scalp, forehead, upper eyelid, cornea
& nose.

* FACIAL (CN 7):

________________
. Facial movement.
. Taste in the anterior 2/3s of the tongue.
. Lacrimation.
. Salivation.
. Eye closing.

* VAGUS (CN 10):

________________
. Swallowing.
. Palate elevation.
. Monitoring baro & chemo receptors of the aortic arch.

. IMPAIRED DAILY FUNCTIONING:

_____________________________
. is essential to distinguish between dementia & normal aging.
. Pts with dementia have functional impairment.
. Normal aging is not ass. with impairment.

. ACUTE GLAUCOMA:
_________________
. Occurs when a pre-existing narrow anterior chamber angle is closed,
. in response to pupillary dilatation from medications or another
stimiulus.
. PPt by direct bright light e.g. watching TV.
. ++ IOP may lead to nausea & vomiting & tearing pain.
. Complain of seeing halos around light.
. Damage of the optic nerve is common & may lead to visual loss.
. Sudden onset of photophobia, eye pain, headache & nausea.
. Palpation -> very hard eye.
. NON REACTIVE MID DILATED PUPIL.
. Dx: TONOMETRY.

# HEADACHES:
____________

.1. MIGRAINE HEADACHE:

_______________________
. Unilateral.
. Pulsating quality.
. Attacks last from 4 - 72 hs.
. Photophobia.
. Common in younger females.
. AURA of neurological syms preceiding headache.
. Tx: TRIPTANS (Efficient only before the start of the attack) + NSAIDs.
. I.V. Anti-emetics e.g. (PRO-CHLOR-PERAZINE) or Metoclopramide {SEVERE
VOMITING CASES}.

.2. CLUSTER HEADACHE:

______________________
. Intense unilateral retro-orbital pain.
. Starts suddenly (usually at night).
. More common in men.
. Redness of the ipsilateral eye.
. Tearing eye pain.
. Stuffed or runny nose.
. Ipsilateral Horner's $.
. Attacks occur in clusers.
. Prophylaxis is the key to management (Verapamil - Lithium -
Ergotamine).
. Tx of acute attack -> 100 % OXYGEN & S.C. Sumatriptan.

.3. BENIGN IDIOPATHIC INTACRANIAL HYPERTENSION = PSEUDOTUMOR CEREBRI:

______________________________________________________________________
. Over-weight female in the child bearing period.
. H/O of OCPs intake or hypervitaminosis A.
. Headache - transient loss of vision - pulastaile tinnitus - diplopia.
. Ex: papilledema - peripheral visual defects.
. Dx: MRI & LP (CSF opening pressure > 250 mmHg with NORMAL analysis).
. Tx: Stop the offending medications, weight loss & Acetazolamide.
. ACETAZOLAMIDE +/- FUROSEMIDE is the 1st line therapy.
. Acetazolamide -> inhibits choroid plexus carbonic anhydrase -> -- CSF
production.
. Most common complication is BLINDNESS !
. Shunting or optic nerve sheath fenestration is done to prevent
blindness.

.4. SUB-ARACHNOID HEMORRHAGE:

______________________________
. WORST HEADACHE EVER !!
 .

. BROWN SEQUARD $YNDROME:

_________________________
. Damage to the lateral spinothalamic tract.
. Causing contra-lateral loss of pain & temperature sensation,
. beginning two levels below the level of the lesion.
. N.B. The spino-thalamic tract crosses on very early in the spinal cord
!
. so .. A lesion of the Rt-sided spino-thalamic tract at T10,
. will result in a Lt-sided loss of pain & temperature sensation
beginning at T12.

. L5 RADICULOPATHY -> Foot drop -> Compensated by HIGH STEPPAGE GAIT:

_____________________________________________________________________
. Foot drop due to failure of the foot dorsiflexion.
. caused by trauma to the common peroneal nerve
. or one of the spinal roots contributing to it (L4 - S2).
. To compensate, HIGH STEPPAGE GAIT is done.
. Pts have to overly flex the hip & knee to bring the foot forward.
. The toes of the affected foot may drag on the ground.
. caused by peripheral neuropathy.
. Foot drop may be congenital (Charcot - Marie - Tooth disease).

. HERPES ENCEPHALITIS:
______________________
. Caused by HSV-1.
. Mainly affects the TEMPORAL lobe of the brain.
. Acute onset < 1 week duration.
. Altered mentation - focal neuro. deficits - hemiparesis - dysphasia -
aphasia - ataxia.
. May present with seizures !
. FEVER is present in 90 % of cases.
. CSF analysis -> LYMPHOCYTIC PLEOCYTOSIS.
. .............-> ++ RBCs (Hemorrhagic destruction of the temporal
lobes).
. .............-> ++ Ptn level.
. .............-> -- Glucose level
. Dx : HSV POLYMERASE CHAIN REACTION IS THE GOLD STANDARD.
. Tx : IV ACYCLOVIR.

. ETHICAL PROBLEM:
__________________
. REGARDLESS OF H/O OF DRUG ABUSE,,
. Pts with acute severe pain sh'd receive the same standard of pain
management !!
. IV MORPHINE is the best ttt for acute severe pain.
. Physicians sh'd NEVER undertreat pain even if there is a risk for
abuse.

. SITE OF THE LESION ----> DEFICIT:

___________________________________
. UPPER THORACIC SPINAL CORD ---> Paraplegia - Bladder & fecal
incontinence,
. ............................... + Absent sensation from the (NIPPLE)
downwards.
. LOWER THORACIC SPINAL CORD ---> Absent sensation from the (UMBILICUS)
downwards.

. PARKINSON DISEASE = TREMORS + RIGIDITY + BRADYKINESIA:

________________________________________________________
. Neurodegenerative disorder.
. Caused by accumulation of alpha synuclein within the neurons of
SUBSTANCIA NEGRA.
. The most common presenting symptom is asymmetric resting tremor in the
upper extremity.

.1 * TREMOR:
___________
. A resting 4 to 6 Hz tremor with a pill-rolling quality.
. Frequently first manifests in one hand.
. May slowly generalize to involve the other side of the body & the
lower extremity.

.2 * RIGIDITY:
______________
. Baseline ++ resistance to passive movement (Lead pipe or cog wheel).

.3 * BRADYKINESIA:
__________________
. Difficulty initiating movements as when starting to walk or rising
from a chair.
. Narrow based, shuffling gait with short strides without arm swing
(FESTINATING).
. Micrographia (Small hand writing).
. Hypomimia (-- facial expression).
. Hypophonia (soft speech).

.4 * POSTURAL INSTABILITY:
__________________________
. Flexed axial posture.
. Loss of balance during turning or stopping.
. Loss of balance when pushed slightly.
. Frequent falls.

. NO SPECIAL TEST FOR EXACT DIAGNOSIS.

. ONLY PHYSICAL EXAMINATION CAN LEAD TO THE Dx.

. STATUS EPILEPTICUS:
_____________________
. Single seizure lasting > 30 mins.
. H/O of seizure disorder with no compliance to anti-convulsant therapy.
. A brain seizing > 5 mins is at ++ risk of permanent injury : CORTICAL
LAMINAR NECROSIS.
. Tx -> BENZODIAZEPINE -> IV DIAZEPAM.
. Failed -> ADD FOSPHENOTOIN.
. Failed -> ADD PHENOBARBITAL.
. Failed -> ADD SUCCINYL CHOLINE.

. DELIRIUM:
___________
. Acute confusion state.
. Reduced oe fluctuating level of consciousness.
. Inability to sustain attention.
. Anxiety, agitation & hallucinations.
. Common ppt factors (infections: UTI).
. Polypharmacy, medication side effects, volume depletion & electrolyte
imbalance.
. SERUM ELECTROLYTES & URINALYSIS sh'd be done to detect the cause.
. Tx-> Typical & atypical anti-psychotics (HALOPERIDOL).
 . Benzodiazepines (Lorazepam) are not recommended in old age.

. ONCE MORE: DIFFERENT CEREBRAL ARTERY OCCLUSIONS & THEIR EFFECTS:

__________________________________________________________________

* MIDDLE cerebral artery occlusion:

____________________________________
. Contralateral motor & sensory deficits.
. More pronounced in the {upper limb} than the lower limb.
. Homonymous hemianopia.
. If the dominant lobe (LEFT) is involved ------> APHASIA.
. If the NON dominant lobe (RIGHT) is involved -> HEMI NEGLECT $.

* ANTERIOR cerebral artery occlusion:

______________________________________
. Contralateral motor & sensory deficits.
. More pronounced in the {lower limb} than the upper limb.
. Urinary incontinence.
. Gait apraxia.

* POSTERIOR cerebral artery occlusion:

_______________________________________
. Homonymous hemianopia.
. Alexia without agraphia (dominant hemisphere).
. Visual hallucinations (cortex).
. Sensory symptoms (Thalamus).

. INTRACRANIAL HYPERTENSION:
____________________________
. ++ intra-cranial pressure > 20 mmHg.
. Causes: Trauma - space occupying lesion - hydrocephalus - impaired CSF
outflow.
. Symptoms: Diffuse headache worse in the morning - Nausea & vomiting.
. Vision changes - papilledema - cranial nerve deficis.
. Somnolence - cofusion - Unsteadiness.
. Cushing's reflex: Hypertension & bradycardia.
. Dx: CT or MRI.

. CEREBRAL HEMORRHAGE due to EXCESS ANTI-COAGULATION:

_____________________________________________________
. Anti-coagulation therapy is the most common bleeding disorded causing
brain hemorrhage.
. So .. Pts on anti-coagulants (e.g. Warfarin) sh'd be monitored
regularly with INR.
. Risk of bleeding ++ with INR ++ !
. Correction of excess anti-coagulation is dependent upon the INR value:
. INR < 5 , NO significant bleeding -> Omit next Warfarin dose.
. INR 5-9 , NO significant bleeding -> Stop Warfarin temporarily.
. INR > 9 ---------------------------> Stop Warfarin, Give oral Vit. K.
. SERIOUS INTRA-CRANIAL BLEEDING -> FRESH FROZEN PLASMA (FFP).
. FFP reverses the actio of warfarin , works immediately & lasts for few
hours.

. HYPOKALEMIA -> WEAKNESS, FATIGUE & MUSCLE CRAMPS:

___________________________________________________
. Electrolyte disturbance with K < 2.5 mEq/L.
. Flaccid paralysis, hyporeflexia, tetany, rhabdomyolysis & arrhythmia
may occur.
. ECG -> BROAD FLAT T-waves, U waves & pre-mature ventricular beats.
. Af, Torsades de points & VF may occur.
 . H/O of K wasting diuretic is common (Hydrochlorothiazide).
. Other causes -> Diarrhea - vomiting - anorexia - hyperaldosterinism.
. Symptoms resolve with K supplementation.

. TAKE CARE: Differentiate bet IIH & NPH:

_________________________________________
. NORMAL PRESSURE HYDROCEPHALUS = Triad of Urine incontinence + Abnormal
gait + Dementia.

_________________________________________________________________________
________________
. BENIGN IDIOPATHIC INTACRANIAL HYPERTENSION = PSEUDOTUMOR CEREBRI:
___________________________________________________________________
. Over-weight female in the child bearing period.
. H/O of OCPs intake or hypervitaminosis A.
. Headache - transient loss of vision - pulastaile tinnitus - diplopia.
. Dx: MRI & LP (CSF opening pressure > 250 mmHg with NORMAL analysis).

=========================
. KEY-WORDS to RE-MEMBER:
=========================

. OLIGO-CLONAL BANDS -> MS.

. CYTO-ALBUMINOUS DISSOCIATION -> GB$.

. HEMORRHAGE -> HYPER-dense areas on CT. (WHITE).

. INFARCTIONS -> HYPO-dense areas on CT. (BLACK).

. GAITS
. FESTINATING = HYPOKINETIC = SHUFFLING -> PARKINSONISM.
. HIGH STEPPAGE -------------------------> TABES DORSALIS or L5
Radiculopathy.
. SEMI-CIRCLE ---------------------------> STROKE HEMIPLEGIA.
. WADDLING ------------------------------> MUSCULAR DYSTROPHY.
. WIDE BASED & SHUFFLING ----------------> NORMAL PRSSURE HYDROCEPHALUS.
. IPSILATERAL ATAXIA --------------------> CEREBELLAR ATAXIA.
. SPASTIC -------------------------------> UMNL UPPER MOTOR NEURON
LESION:
. STAGGERING ----------------------------> VESTIBULAR ATAXIA.

. TREMORS
. RESTING TREMORS (PARKINSON)-> At rest,imp. e' activity,High frequency
tremors 5-7 Hz.
. ESSENTIAL TREMORS-> Worst at the end of the goal directed activity
(reaching a pen).
. CEREBELLAR TREMORS -> Intension tremors - low fequency 3-4 Hz -
Nystagmus & ataxia.

. TRIGEMINAL NEURALGIA: LIGHTENING PAIN on the face - electric shock -

Tx: CARBAMAZEPINE.

. GUILLAIN BARRE'$: Ascending paralysis - Pre.by infection -

CYTOALBUMINOUS DISSOCIATION.

. TICK BORNE PARALYSIS: Ascending paralysi - NO fever - Normal CSF - Tx:

Tick removal.
 . MYASTHENIA GRAVIS: Ptosis,Diplopia RESOLUTION OF MUSCULAR WEAKNESS
WITH REST.

. LAMBERT EATON $YNDROME: LUNG CANCER H/O, Auto-Abs against voltage

gated Ca channels.

. N.B. MYASTHENIA GRAVIS: AutoAbs against (post)synaptic recs - INTACT

DTRs.
. N.B. LAMBERT-EATON $: AutoAbs against (pre)synaptic receptors - LOST
DTRs.

. DERMATOMYOSITIS: Sym. prox. ms weakness - SKIN (Gottron's papules &

Heliotrope rash).

. STEROID INDUCED MYOPATHY: Prox. ms weakness (LL before UL) - No pain.

. SUB-ARACHNOID HEMORRHAGE: Rupture of "Berry" aneyrysm - WORST HEADACHE

EVER.

. NEURO-FIBROMATOSIS "2": S.C. neurofibromas + Cafe' au lait spots +

acoustic neuromas.

. PRONATOR DRIFT = UMNL.

. ESSENTIAL TREMOR: Tx: BB "Propranolol".

. MULTIPLE SCLEROSIS = Optic neuritis (painful loss of vision) &

diplopia.
. MULTIPLE SCLEROSIS = INTER-NUCLEAR OPHTHALMOPLEGIA (INO).
. MULTIPLE SCLEROSIS = Dx: BRAIN MRI with & without GADOLINIUM.
. MULTIPLE SCLEROSIS = CSF analysis: OLIGOCLONAL IgG bands - Normal
pressure.
. MULTIPLE SCLEROSIS = Tx of acute exacerbation -----> HIGH DOSE IV
GLUCOCORTICOIDS.
. MULTIPLE SCLEROSIS = prevent future attacks -> B-interferon or
Glatiramer acetate.
. MULTIPLE SCLEROSIS = YOUNG FEMALE with BILATERAL TRIGEMINAL NEURALGIA.

. AMYOTROPHIC LATERAL SCLEROSIS: UPPER + LOWER motor neuron lesions.

. CT$: MEDIAN N. - At WRIST - Thenar eminence atrophy - Paresthesia 1st

3.5 fingers

. ULNAR N. ENT. $: paresthesia of 4th & 5th fingers - ent.at medial

epicondylar groove.

. VESTIBULO-TOXICITY by AMINOGLYCOSIDES: Gentamycin-Amikacin - Vertigo &

gait imbalance.

. TORTICOLLIS: Example of FOCAL DYSTONIA.

. UN-PROVOKED FIRST SEIZURE -> HEAD CT WITHOUT CONTRAST is the 1st

initial step done.

. LIMB ISCHEMIA: 5 Ps (Pain - Pallor - Paresthesia - Pulselessness &

Paralysis).

. METOCLOPRAMIDE: Side effect Dystonia - Manifested by stiff painful

neck.
 . HEMI-NEGLECT $YNDROME: RIGHT PARIETAL LOBE CORTEX lesion - (NON)-
dominant hemi-sphere.

. EXERTIONAL HEAT STROKE: Tx -> EVAPORATION COOLING (NOT immersion in

cold water xxx).

. CAVERNOUS SINUS THROMBOSIS: Dx: MRI - Tx: Broad spectrum Antibiotics.

. RESTLESS LEG $YNDROME: "Crawling" sensation - Tx : Dopaminergic

agonists e.g. L-dopa.

. WERNICKE's ENCEPHALOPATHY: ecephalopathy,oculomotor dysf. & gait

ataxia.(--Vit B1).

. DECUBITUS ULCER: Preveted by repositioning of the pt every 2-4 hours.

. LEVO-DOPA / CARBI-DOPA Side effects: Most common side effect is

HALLUCINATIONS.

. TRI-HEXY-PHENIDYL:
Red as beet, dry as bone, hot as hare, blind as bat, mad as hatter &
full as a flask.

. DEMENTIAS
. FRONTO-TEMPORAL : Personality changes (euphoria - disinhibition -
apathy).
. LEWY BODIES DEMENTIA: Bizarre visual hallucinations.
. ALZHEIMER's DISEASE: Progressive dementia - Impaired judgement &
personality changes.
. HUNTINGTON's DISEASE: Triad of mood disturbances + Choreiform
movements + Dementia.
. CREUTZFELDT - JAKOB DISEASE: EEG -> SHARP TRI-PHASIC SYNCHRONOUS
DISCHARGES.
. NORMAL PRESSURE HYDROCEPHALUS: Triad of Urine incontinence + Abnormal
gait + Dementia.
. PSEUDO-DEMENTIA: Tx -> SSRIs.
. NORMAL AGING: Absence of functional impairments.

. BRAIN DEATH: DTRs may be STILL PRESENT - MUST BE CONFIRMED BY TWO

PHYSICIANS.

. SHY DRAGER $YNDROME: MULTIPLE SYSTEM ATROPHY - PARKINSON pt. + bladder

loss of control.

. Chronic alcohol abuse -> Cerebellar damage.

. BELL's PALSY: Facial 7th cranial nerve peripheral neuropathy.

. AMAUROSIS FUGAX: BLACK CURTAIN FALLING - impending stroke - NECK

DUPLEX ULTRA$OUND.

. SUB-DURAL HEMATOMA: Tearing the BRIDGING VEINS .. CT -> WHITE

CRESCENT.

. EPI-DURAL HEMATOMA: Injury to the MIDDLE MENINGEAL ARTERY .. CT ->

BICONVEX HEMATOMA.

. SYRINGOMYELIA: CAPE like - Loss of pain & temperature with intact

position & vibration.
 . SPINAL CORD COMPRESSION: It is a medical emergency - Dx: MRI Spine.

. ALZHEIMER's DISEASE: CT -> Diffuse cortical & subcortical atrophy.

. GLIOBLASTOMA MULTIFORM: BUTTERFLY appearance with central necrosis on

VT or MRI.

. CRANIOPHARYNGIOMA = Hypopituitarism signs + Headaches + Bitemporal

blindness.

. CAUDA EQUINA $YNDROME: LBP - bladder dys. - Saddle anesthesia - Dx:

Emergent MRI.

. HIV associated lesions on MRI:

. PRIMARY CNS LYMPHOMA: Solitary - {WEAKLY} ring enhancing - Ass. EBV
DNA.
. TOXOPLASMOSIS: Multiple - {Ring - enhancing} spherical - TMP-SMX is
preventive.
. PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY: {Non - enhancing} - No
mass effects.
. ABSCESS: Solitary - {Ring enhancing} - caused by ANEROBES

. CAROTID ARTERY STENOSIS: NECK DUPLEX U/$.- CAROTID END ARTERECTOMY if

stenosis 70-99 %.

. ACUTE GLAUCOMA: Palpation -> very hard eye - NON REACTIVE MID DILATED
PUPIL.

. HEADACHES
. MIGRAINE HEADACHE: female Unilateral Pulsating, AURA of neuro syms
preceiding headache.
. CLUSTER HEADACHE: unilateral 5tearing retro-orbital pain .. Tx -> 100
% OXYGEN.
. PSEUDOTUMOR CEREBRI: Obese female- Vit A - OCPs - Most common
complication is BLINDNESS
. SUB-ARACHNOID HEMORRHAGE: WORST HEADACHE EVER !!

. BROWN SEQUARD $YNDROME: contra-lateral loss of pain & temperature

sensation,
. BROWN SEQUARD $YNDROME: beginning two levels below the level of the
lesion.

. L5 RADICULOPATHY -> Foot drop -> Compensated by HIGH STEPPAGE GAIT:

. HERPES ENCEPHALITIS: CSF analysis -> LYMPHOCYTIC PLEOCYTOSIS - Tx : IV

ACYCLOVIR.

. PARKINSON DISEASE = TREMORS + RIGIDITY + BRADYKINESIA.

. DELIRIUM: Tx -> Typical & atypical anti-psychotics (HALOPERIDOL).

. ABSENCE seizures -> ETHOSUXIMIDE.

Dr. Wael Tawfic Mohamed

_________________________
 OPHTHALMOLOGY TiKi TaKa
-------------------------

. PAPILLAEDEMA:
---------------
. Transient loss of vision lasting few seconds with change in head
psition.
. caused by ++ ICT manifested by morning headaches or change in headache
intensity with head position.

. Optic neuritis:
-----------------
. Associated with multiple sclerosis.
. Unilateral eye pain & visual loss.

. Exrenal hordeolum = Syte :

----------------------------
. Staphylococclal abscess of the eyelid.
. Tx: Warm compresses.
. If not resolved within 48 hours ---> incision & drainage.

. Allergic conjunctivitis:
--------------------------
. Intense itching - hyperemia - tearing - conjunctival oedema & eye lid
edema.

. CATARACT:
-----------
. Progressive thickening of the lens.
. Blurred vision & glare.
. Tx: Lens extraction.

. Acute angle closure glaucoma:

-------------------------------
. Old pts 55 - 70 ys.
. Acute severe eye pain.
. Blurred vision , nausea & vomiting.
. Fixed dilated pupil non reactive to light.

. Open angle closure glaucoma:

------------------------------
. Loss of peripheral vision.
. preserved central tunnel vision.
. More common in AFRICAN AMERICANs.

. Macular degeneration:
-----------------------
. Loss of central vision.
. More common in OLD AGE.

. Post-operative ENDOPHTHALMITIS:
---------------------------------
. H/O of recent ocular operation.
. symptoms manifest within 6 weeks of surgery.
. pain & -- visual acuity.
. swollen eyelids, corneal edema & infection.

. Herpes Zoster Ophthalmicus:

-----------------------------
 . Dendriform ulcers.
. Vesicular rash in the trigeminal distribution.

. CMV Retinitis:
----------------
. HIV pt with CD4 < 50.
. Fundoscopy: Yellow - white patches of retinal opacification &
hemorrhages are diagnostic.

. Optic neuritis:
-----------------
. Central scotoma.
. Afferent pupillary defect.
. Change in colour perception.
. -- visual acuity.
. Ass. e' Multiple sclerosis.

. Vitreous hemorrhage :
-----------------------
. Sudden loss of vision.
. Floaters in the visual field.
. Diabetic retinopathy is the most common cause.
. Fundus is hard to be visualized with obscured details.

. HSV ---> dendriTIC ulcers.

. HZV ---> dendriFORM ulcers.

. Amaurosis Fugax:
------------------
. Curtain falling down.
. Whitened edematous retina following the distribution of the retinal
arterioles.
. caused by retinal emboli from the ipsi-lateral carotid artery.

. CRAO = CENTRAL RETINAL ARTERY OCCLUSION:

-----------------------------------------
. Sudden unilateral painless loss of vision.
. Pallor of the optic disc + CHERRY RED FOVEA + Boxcar segmentation.

. CRVO = CENTRAL RETINAL VEIN OCCLUSION:

---------------------------------------
. Sudden painless unilateral loss of vision.
. THUNDER & BLOOD appearance.

. Vitreous hemorrhage:
---------------------
. Black curtain coming down infront of eyes = Retinal detachment.
. Photopsia (Flashes of light).
. Floaters (Spots in the visual field).

. Central retinal vein occlusion:

---------------------------------
. Sudden monocular loss of vision.
. Blood & thunder appearance.
. Optic disc swelling.
. Retinal hemorrhage.
. Dilated veins.
. Cotton wool spots.

. Central Retinal Artery Occlusion:

-----------------------------------
. Sudden painless loss of vision.
. Pallor of the optic disc.
. Cherry red fovea.
. Boxcar segmentation of blood in the retinal veins.

. Diabetic retinopathy:
-----------------------
. H/O of D.M.
. -- visual acuity in both eyes.
. Micro-aneurysms.
. Dot & blot hemorrhages.
. Hard exudates.
. Macular edema.
. Tx ARGON laser photocoagulation to prevent complications.

. Presbyopia:
------------
. Difficulty in near vision.
. Prespyobia is due to -- in lens elasticity not due to macular
degeneration !!
. A history of middle aged individual who has to hold books at an arms
length to read is classic.

. On Tx of Acute glaucome , ATROPINE is contraindicated. . 1st line Tx:

I.V. MANNITOL.

. Multiple Sclerosis :
----------------------
. FEMALE with multiple neurological presentations.
. Associated optic neuritis can lead to blurring of vision & retro-
bulbar pain.

. Sub-conjunctival hemorrhage ---> No ttt .. Just Observation.

. CRAO Tx: ocular massage + High flow Oxygen.

. Sympathetic Ophthalmia:
-------------------------
. Damage of one eye (sympathetic eye) after a penetrating injury to the
other eye.
. Due to UN-COVERING OF HIDDEN ANTIGENS !

. In HIV pts:
-------------
.. HSV & HZV :
--------------
... Pain-ful.
... Ass. with karatitis & conjunctivitis.
... Fundus: Peripheral pain lesions & central necrosis.

.. CMV :
--------
... Pain-less.
... Not ass. e'keratitis or. conjunctivitis.
... Fundus: Hemorrhages & fluffy or granular lesions around retinal
vessels.

. Neuro-fibramatosis type 1 = Axillary freckling + Cafe' au lait patches

+ Optic glioma.
 ---------------------------

. Diabetic pt with blurry vision:

---------------------------------
. Type 2 D.M. with HYPEROSMOLAR HYPERKETOTIC state without ketoacidosis.
. Glucose in urine with NO KETONES.
. NKHS = Non Ketotic Hyperosmolar $
so, the cause of blurring of vision is HYPEROSMOLARITY !

. Macular degeneration:
-----------------------
. Grid test: distortion of the straight lines that appear wavy !

-------------------------
Dr. Wael Tawfic Mohamed
-------------------------
 POISONING TiKi TaKa
_____________________

. OPIOID INTOXICATION:
______________________
. -- RESPIRATORY RATE is the most reliable & predictive sign.
. -- Bowel sounds.
. -- BP.
. -- Temp.
. H/O of heroin injection (Needle marks on extremities by P/E).
. Tx: NALOXONE.
. The goal of ttt is ++ RR from 6 to 12/min with improving Oxygen
saturation.
. N.B. PUPIL EXAMINATION is NOT RELIABLE !!
. Opioid intoxication doesn't always present with miosis.
. Co-ingestions can lead to normal pupillary size or even mydriasis !!!

. OPIOID WITHDRAWAL:
____________________
. Symptoms develop within 6-12 hs after the last dose of short acting
opioid.
. H/O of heroin injection (Needle marks on extremities by P/E).
. Nausea - vomiting - Abdominal pain - Diarrhea - Restlessness -
Arthralgia & myalgia.
. Rhinorrhea - Lacrimation.
. Mydriasis - Piloerection & hyperactive bowel sounds.
. Tx -> METHADONE.

. METHANOL INTOXICATION:
________________________
. "ALCOHOL's SUBSTITUTE".
. H/O of homeless man.
. 1st 24 hs -> Headache, nausea, vomiting & epigastric pain.
. Later -----> Vision loss & coma.
. Optic disc hyperemia.
. ++ ANION GAP METABOLIC ACIDOSIS { (Na) - (Cl + HCO3) }. (Normal AG 8-
12).
. ++ OSMOLAR GAP.
. Very low HCO3.

. ETHYLENE GLYCOL INTOXICATION:

_______________________________
. "ALCOHOL's SUBSTITUTE".
. H/O of homeless man.
. 1st 24 hs -> Headache, nausea, vomiting & epigastric pain.
. Later -> Flank pain, hematuria, oliguria, Acute renal failure.
. Glycolic acid (Metabolite) injuries the renal tubules.
. Oxalic acid binds calcium & deposits in the kidneys.
. Tx: FOMEPIZOLE or ETHANOL to prevent ethylene glycol to its harmful
metabolites.

. N.B. METHANOL & ETHYLENE GLYCOL MAY HAVE SIMILAR PRESENTATIONS ! BUT !!
_________________________________________________________________________
. METHANOL DAMAGES THE EYES.
. ETHYLENE GLYCOL DAMAGES THE KIDNEYS.

. BETA-BLOCKERS BB INTOXICATION:
________________________________
. -- HR.
. -- BP.
. AV BLOCK.
. BRONCHOSPASM -> WHEEZES (MOST SPECIFIC).
. Cardiogenic shock may occur (Cold & clammy extremities).
. Neurological effects (Delirium & seizures).
. 1st line TTT -> ATROPINE + IV FLUIDS.
. FAILED -------> GLUCAGON ++ c-AMP -> ++ Ca -> ++ cardiac
contractility.

. CANNABIS = MARIJUANA INTOXICATION:

____________________________________
. +++++++ APPETITE.
. DRY MOUTH.
. CONJUNCTIVAL INJECTION.
. ++ HR.
. ++ BP.
. ++ RR.
. -- concentration & short time memory.
. -- reaction time & impairs attention.
. ++ the risk of vehicle accidents.

. ALCOHOL INTOXICATION:
_______________________
. Slurred speech.
. Unsteady gait.
. Incoordination.
. Disinhibited behavior.
. Memory impairment.
. Nystagmus.

. ALCOHOL WITHDRAWAL:
_____________________
. Due to reflex hyperactivity of certain parts of the brain.
. Anxiety, insomnia, tremors & diaphoresis in the 1st 6-24 hs after
alcohol cessation.
. Hallucinations & withdrawal seizures may occur.
. DELIRIUM TREMENS may occur in 5% of pts after 48 - 72 hs.
. Hypertension, agitation, tachycardia, hallucinations & fever.
. Tx -> CNS depressant -> Benzodiazepenes -> Chlordiazepoxide.

. BENZODIAZEPINE OVERDOSE:
__________________________
. Slurred speech.
. Unsteady gait.
. Incoordination.
. Respiratory compromise, stupor & coma.
. Distinguished from opioid overdose by lack of severe respiratory
depression & miosis.
. Distinguished from alcohol & phenytoin toxicity by lack of nystagmus.

. BARBITURATE (SEDATIVES) INTOXICATION:

_______________________________________
. Slurred speech.
. Unsteady gait.
. Incoordination.

. COCAINE INTOXICATION:
_______________________
 . SYMPATHETIC STIMULATION (++HR, ++BP, MYSRIASIS).
. Euphoria.
. Sense of self confidence.
. ++ arousal.
. improved performance.

. CAUSTICS "LYE" (SODIUM HYDROXIDE) INGESTION:

______________________________________________
. A strong alkaline solution.
. Mostly due to suicidal attempt.
. SEVERE ESOPHAGEAL DAMAGE due to LIQUEFACTIVE NECROSIS.
. May lead to perforation & mediastinitis.
. Retrosternal or epigastric pain - hypersalivation - Odynophagia &
dysphagia.
. Tx -> HOSPITALIZATION + IV HYDRATION.
. ENDOSCOPY IS MANDATORY to determine the extent of esophageal damage !
. If perforation is suspected -> A gastrograffin study sh'd be
performed.
. NEVER to neutralize the alkali with ana acid !!
. NEVER to induce vomiting !!
. Charcoal isn't effective !!
. N.B. NO ALTERATION IN CONSCIOUSNESS.

. CARDIOLOGICAL PROBLEM RELATED TO TOXICOLOGY !

_______________________________________________
. TORSADES DE POINTS -> Tx: MgSO4 !
____________________________________
. Polymorphic ventricular tachycardia.
. Occurs in the setting of a prolonged QT interval.
. Seen in pts with familial long QT $yndrome.
. Malnourished pts predisposed to hypomagnesemia (Alcoholics).
. Pts on TCAs (Tricyclic anti-depressants).
. Pts on anti-arrhythmics (Amiodarone - Sotalol).
. Anti-infective agents (Moxifloxacin - Fluconazole).
. Tx -> Cessation of the offending drug & MgSO4.

. PHENCYCLIDINE INTOXICATION:
_____________________________
. HALLUCINOGENIC STREET DRUG.
. VERTICAL NYSTAGMUS.
. VIOLENT BEHAVIOR.
. Agitation - confusion - Pupillary dilatation - tachycardia.
. Severe hypertension & hyperthermia may occur.
. Tx -> Benzodiazepines.

. CHEMICALS IN THE EYE:

_______________________
. FLUSH THE EYE WITH WATER (EYE UNDER A FAUCET OF RUNNING WATER FOR AT
LEAST 15 mins) !

. DIPHENHYDRAMINE POISONING:
____________________________
. Anti-histaminic used in ttt of allergic rhinitis - insect bites &
motion sickness.
. Mixture of anti-cholinergic symptoms.
. Drowsiness & confusion.
. Dry mouth - dilated pupils - blurred vision - Reduced bowel sounds &
urine retention.
. Tx -> PHYSOSTIGMINE (Cholinesterase inhibitor).
. SALICYLATE INTOXICATION:
__________________________
. TINNITUS.
. Nausea & vomiting.
. Fever.
. Altered mental status & acid-base abnormalities.
. Tx -> ALKALINIZATION OF URINE with SODIUM BICARBONATE (Na HCO3).

. CARBON MONOXIDE (CO) POISONING:

_________________________________
. HISTORY is the most ipmortant clue to diagnosis.
. SMOKE INHALATION - BARBEQUE PARTY !!
. CO is a colorless - odorless gas.
. Emitted by automobiles, furnaces & charcoal grills.
. When inhaled, it prevents the body from utilizing Oxygen.
. Headache - Nausea - Vomiting - Abd. discomfort - confusion - coma.
. PINKISH RED SKIN HUE.
. Dx -> Obtain CARBOXYHEMOGLOBIN levels.
. Tx -> HYBERBARIC OXYGEN.

. ACETAMINOPHEN POISONING:
__________________________
. Rumack - Matthew Nomogram is a curve used to assess its hepatotoxic
effects.
. It also provides the need for N-acetylcysteine as an antidote.
. The 1st data point on the curve is at 4 hours !
. The decision of whether or not to take the antidote can be made after
4 hours.
. Studies proved zat their is no correlation bet. z amount ingested & z
toxicity level!
. So .. If a pt. came to u with H/O of ingestion of 14 pills 2 hours ago
,,
. You should wait 2 hours then obtain the acetaminophen level.

. ORGANO-PHOSPHATE POISONING:
_____________________________
. Organophosphates antagonizes acetylcholinesterase -> Cholinergic
excess.
. -- HR - miosis - muscle fasciculations.
. Bronchorrhea - salivation - lacrimation - diarrhea - urination.
. Tx -> ATROPINE (Compete with acetylcholine at the muscarinic
receptors).
. IMMEDIATE REMOVAL OF THE PT's CLOTHING (SOAKED with secretions),
. thus .. preventing continued absorption of organophosphates through
the skin.

. TRI-CYCLIC ANTI-DEPRESSANTS (TCA) INTOXICATION:

_________________________________________________
. Hyperthermia - seizures - Hypotension.
. Anticholinergic effects (mydriasis - flushed dry skin - intestinal
ileus).
. TCAs -> -- conductivity -> QRS prolongation -> Ventricular arrhythmia.
. THE BEST INDICATOR OF THE EXTENT OF THE OVERDOSE is the QRS COMPLEX
DURATION.
. Tx -> NaHCO3 -> Narrows the QRS complex & -- the incidence of VT.
. NaHCO3 Mechanism -> Sodium load will alleviate the depressant action
on Na channels.

. NEUROLEPTIC MALIGNANT $YNDROME:

_________________________________
 . DRUG INDUCED IDIOSYNCRATIC REACTION.
. Sudden onset of confusion, fever, muscle rigidity & diaphoresis.
. Mostly caused by dopaminergic antagonists (HALOPERIDOL) for
hallucinations ttt.
. Rigidity & hyperthermia may lead to ms necrosis & ++ CPK > 50000.
. Tx -> DANTROLENE (Muscle relaxant).

. FLUPHENAZINE OVERDOSE -> HYPOTHERMIA:

_______________________________________
. High potency "typical" anti-psychotic drug.
. It disrupts thermoregulation & body's shivering mechanism.
. Pts sh'd be advised to avoid prolonged exposure to extreme
temperatures.

Dr. Wael Tawfic Mohamed

_________________________
 PSYCHIATRY & ETHICS TiKi TaKa
_______________________________

. PSYCHOTIC DISORDERS:
_______________________
_______________________

. Combination of positive &/or negative symptoms.

. POSITIVE SYMPTOMS (Associated e' DOPAMINE receptors):

________________________________________________________
-> Delusions (Mostly bizarre).
-> Disorganized speech/behavior.
-> Hallucinations.
-> Agitation.
-> Impairment of baseline functions.

. NEGATIVE SYMPTOMS (Associated e' MUSCARINIC receptors):

__________________________________________________________
-> Flattened affect.
-> Social withdrawal.
-> Anhedonia.
-> Apathy.
-> Poverty of thought.

. N.B. Atypical anti-psychotics are the most effective ttt for -ve
symptoms.

. N.B. The key differentiating feature is the DURATION of symptoms:

____________________________________________________________________

. SCHIZO-PHRENIA: > 6 MONTHS.

. SCHIZO-PHRENI-FORM DISORDER: < 6 MONTHS BUT > 1 MONTH.

. BRIEF PSYCOTIC DISORDER: < 1 MONTH (Look for a stressful life event
precipitating it).

. SCIZO-AFFECTIVE DISORDER:
-> Distinguished from schizophrenia by the presence of mood symptoms
-> (mania or depression) during the course of the disease.

. N.B.
. Disorganized speech & CIRCUMSTANTIALITY is common in pts with
schizophrenia;
. They deviate from the original subject but eventually returns to it !

. N.B.
. Schizophrenic pts have ++ ventricular size on CT !!

. N.B.
. When there is H/O of syms for many years e' NO IMPROVEMENT OF BASELINE
FUNCTIONING,
. think of:

* DELUSIONAL DISORDER:
-> Key is that delusions are NON-bizarre.
-> Delusions may occur normally in daily life.
 -> Delusions are false beliefs in high functioning person.

* PERSONALITY DISORDERS (Especially SCHIZOTYPAL PERSONALITY DISORDER):

-> Prsents with peculiar thinking & social isolation.
-> No psychosis.

. The previous two types of pts (DELUSIONS & PERSONALTY DISORDERS):

-> Don't respond to anti-psychotics.
-> PSYCHOTHERAPY is the preferred therapy.

. N.B.
. A DELUSION is a fixed, false belief not consistent with cultural
norms.
. Individuals with GRANDIOSE DELUSIONS typically believe they have
. special powers extraordinary accomplishments or a special relationship
e' god.

. RULE OUT other forms of psychosis that are NOT schizophrenia:

-> Get a DRUG SCREEN to rule our SUBSTANCE ABUSE.
-> Look for signs & symptoms of SEIZURE !
-> TEMPORAL LOBE EPILEPSY can present with hallucinations (Auditory &
Olfactory).

. N.B.
. Watch out for SUICIDAL IDEATION in schizophrenia pts &
schizophreniform pts.
. 50 % of them attempt suicide & 10 % are successful.
. 1st stepin management is always to HOSPITALIZE if there is risk of
suicide.

. The 1st step in management of any acute psychiatric condition is:

. to determine if the pt needs hospitalization !
. Hospitalize if the pt at risk of harm to self or to others.
. Hospitalize against the pt's will if the pt has suicidal or homicidal
ideation.

. The greatest risk factor for progression to schizophrenia is

SCHIZOFRENIFORM DISORDER.

. Prognosis:
-> Females have a better prognosis & respond better to ttt than males.
-> Pts e' paranoid schizophrenia are more responsive to ttt.

. The prognosis is poor if there is:

-> Early age of onset.
-> Negative symptoms.
-> Poor premorbid functioning.
-> Family H/O of schizophrenia.
-> Disorganized or deficit subtype.

. Treatment:
-> If there is bizarre or paranoid syms -> HOSPITALIZE the pt.
-> Give BENZODIAZEPINES for agitation & start ANTI-PSYCHOTICS.
-> Anti-psychotic medications are given for 6 months.
-> They are most effective to prevent further episodes.
-> Long term anti-psychotics are ONLy given if there is H/O of REPEATED
episodes.
-> Initiate log-term psychotherapy.

. ANTI-PSYCHOTICS:
___________________
___________________
. Have an IMMEDIATE QUIETING EFFECT in acute atacks.
. Delay relapse.
. Used for sedation when benzodiazepines are cont'd or as an adjunct
during anesthesia.
. Used for ttt of movement disorders (Huntington's disease & Tourette
$),
. to suppress tics & vocalization

. N.B. In ttt of Tourette $ -> We use TYPICAL antipsychotics

(Haloperidol & PIMOZIDE).

. N.B. Antipsychotics are chosen based on side effect profile, NOT

efficacy !

. A . CONVENTIONAL (TYPICAL) ANTIPSYCHOTICS:

_____________________________________________

(1) HIGH POTENCY {FLUPHENAZINE DECANOATE - HALOPERIDOL}:

__________________________________________________________
-> Less sedating - Fewer anticholinergic effects - Less hypotension.
-> Useful as depot injections (Haloperidol decanoate) for non-compliant
pts.
-> Give IM route for acute psychosis when pt is unable or unwilling to
take PO.
-> GREATEST ASSOCIATION WITH EXTRAPYRAMIDAL SYSTEMS (EPS).
-> ++ PROLACTIN.

(2) LOW POTENCY {THIORIDAZINE - CHLORPROMAZINE):

_________________________________________________
-> Less likely to cause EPS.
-> Greater anticholinergic effects - More sedation - More postural
hypotension.

. B . ATYPICAL ANTIPSYCHOTICS (RISPERIDONE - OLANZAPINE - QUETIAPINE -

CLOZAPINE):
_________________________________________________________________________
__________
-> OLANZAPINE is the best.
-> Drug of choice in initial therapy.
-> Greater effect on negative symptoms.
-> Little or no risk of EPS.

. N.B. SIDE EFFECTS of ATYPICAL ANTIPSYCHOTICS:

________________________________________________
. Clozapine -> Agranuloctosis (Order CBC before initiatin ttt & one week
after).
. Quetiapine -> Cataracts.
. Olanzapine -> Weight gain - Hyperglycemia - Dyslipidemia.
. Respiredone -> Hyperprolactinemia.

. N.B. Anti-psychotic medications -> Dopamine receptor blockage ->

Hyperprolactinemia.
. ++ PRL > 200 ng/ml -> Gynecomastia - Galactorrhea - Menstrual
dysfunction & -- libido.

. N.B. Antipsychotics -- dopamine activity in the TUBERO-INFUNDIBULAR

pathway.
. NOOOOOOOOTTTTTTTTT the mesolimbic pathway xxxxxxxx !
 . LOW potency antipsychotics have the highest risk of causing
ORTHOSTATIC HYPOTENSION
. Due to (ALPHA BLOCKAGE).

. LOW potency antipsychotics have the highest risk of causing

ANTICHOLINERGIC SYMPTOMS
. Acute urine retention - Dry mouth - Blurry vision - Delirium.

. Thioridazine is associated with prolonged QT & arrhythmias.

. Order an EKG if there is chest pain - SOB - plapitations.

. Thioridazine is associated with abnormal retinal pigmentation.

. Routine eye exam is important.

. NONcompliance in males -> IMPOTENCE & INHIBITION OF EJACULATION.

. NONcompliance in females -> WEIGHT GAIN - HYPERPROLACTINEMIA -

GALACTORRHEA &AMENORRHEA

. Olanzapine - Quetiapine are 1st choice medications when INSOMNIA is a

problem !

. RISPERIDONE is the 1st choice medication when SEDATION is a problem !

_________________________________________________________________________
_________________

. MOVEMENT DISORDERS:
______________________
______________________

. Extra-pyramidal symptoms (EPS) are the most common reason for failure
to comply e' ttt.
. Acute dystonia - Bradykinesia - Tardive dyskinesia - Neuroleptic
malignant $.
. Most common culprit atypical antipsychotic is RISPERIDONE -> Switch to
CLOZAPINE.

{1} ACUTE DYSTONIA:

____________________
. Occurs in the 1st week.
. Muscle spasms (Torticollis) & difficulty swallowing.
. Young men are at higher risk.
. Tx -> Reduce the dose.
. Tx -> ANTICHOLINERGICS (Benztropine - Diphenhydramine -
Trihexiphenidyl).

{2} BRADYKINESIA (PARKINSONISM):

_________________________________
. Within weeks.
. Bradykinesia - tremors - rigidity & other signs of parkinsonism.
. Elderly are at higher risk.
. Tx -> Reduce the dose.
. Tx -> ANTICHOLINERGICS (Benztropine - Diphenhydramine -
Trihexiphenidyl).
. Tx -> Amantadine (Dopamine agonist).

{3} AKATHISIA:
_______________
 . Weeks to chronic use.
. Motor restlessness (Do NOt nistake for anxiety or agitation).
. Tx -> Reduce the dose.
. Tx -> Add benzodiazepines or BBs (Propranolol).

{4} TARDIVE DYSKINESIA:

________________________
. Months to years.
. Choreoathtosis & other involuntary movements after chronic use.
. Often irreversible.
. Circumoral movements.
. Tx -> Stop older antipsychotics.
. Tx -> Switch to newer antipsychotics (Clozapine).
. It can be ttt with BENZTROPINE.
. Symptoms commonly worsen after medication discontinuation.

. N.B.
. Chronic use of dopamine antagonists eg. antiemetics (Metoclopramide &
Prochlorperazine)
. can result in tardive dyskinesia.

{5} NEUROLEPTIC MALIGNANT $YNDROME:

____________________________________
. Any time !
. Muscle rigidity - Hyperthermia - Volatile vital signs - Altered
consciousness.
. ++ WBCs & ++ Creatinine kinase level.
. Tx -> Stop antipsychotics.
. Tx -> DANTROLENE (Muscle relaxant).
. Transfer to ICU for monitoring.
. Mortality rate 20 %.

. N.B.
. CLOZAPINE is the most effective anti-psychotic for schizophrenia.
. CLOZAPINE has NO incidence of movement disorders.
. CLOZAPINE is a 2nd line therapy bec. of the risk of seizures &
agranulocytosis.
. Remember to monitor CBC to watch for bone marrow suppression.

. N.B.
. BENZTROPINE (Anticholinergic)
. is the 1st line ttt in management of acute dystonia & bradykinesia
(parkinsonism).

. N.B.
. BBs (Propranlol) is the 1st line ttt of akathisia.
_________________________________________________________________________
_________________

. ANXIETY DISORDERS (ÇÖØÑÇÈÇÊ ÇáÞáÞ):

_______________________________
_______________________________

. Anxiety that interferes e' daytime functioning not due to any other
identifiable cause.

. Medical causes:
. Hyperthyroidism - Pheochromocytoma - Excess cortisol - Heart failure.
. Arrhythmia - Asthma - COPD.
 . Drugs:
. Corticosterids - Cocaine - Amphetamines - Caffeine.
. Withdrawal from alcohol & sedatives.

{1} ADJUSTEMENT DISORDER (ÇÖØÑÇÈ ÇáÊßíÝ):

____________________________________
. Normal psychological reaction (anxiety - depression - irritability).
. occurs soon after profound changes in a person's life.
. such as divorce - migration - birth of handicapped child.
. Symptoms are not severe enough to be classified in another category.
. It is NOT a true anxiety disorder.
. Tx -> Psychotherapy & counselling to help with the pt adjust to the
life stressor.
. NO medications.

{2} PANIC DISORDER (ÇÖØÑÇÈ ÇáåáÚ):

______________________________
. Brief attacks of intense anxiety with autonomic symptoms;
. tachycardia - hyperventillation - dizziness - sweating.
. Episodes occur REGULARLY without an obvious precipitant.
. Absence of any other psychiatric ilness.
. Tx -> COGNITIVE BEHAVIORAL THERAPY.
. Tx -> Relaxation training & desensitization.
. Tx -> Acute panic attack -> Benzodiazepines (Alprazolam - Clonazepam).
. Tx -> Long term symptomatic relief -> SSRIs (Fluoxetine).
. Tx -> Imipramine & MAOIs (Phenelzine) may be used.

. N.B. Panic disorder pts have ++ risk of depression !

{3} PHOBIC DISORDERS (ÇÖØÑÇÈÇÊ ÇáÑåÈÉ):

_________________________________
. Persistent, unreasonable intense fear of situations, circumstances or
objects.
. No known eliciting events in phobic disorders associated with the
onset of symptoms.

. D.D. -> Post-traumatic stress diorder (PTSD) & Acute stress diorder
(AST);
. which have a HISTORY OF TRAUMATIC EVENT (Threat to life).

(a) AGORAPHOBIA (ÑåÈÉ ÇáÎáÇÁ):

_________________________
. Fear of avoidance of places due to anxiety about non being able to
escape;
. public spaces - being outside alone - public transportation - crowds.
. It is more common in women.

(b) SOCIAL PHOBIA (ÑåÈÉ ÇáãÌÊãÚ):

____________________________
. Fear of humiliation or embarrasement in either general or specific
social situations;
. public speaking - stage fright - Urinating in public restrooms.
. The pt knows that the response is excessive & unreasonable.

. D.D. AVOIDANT PERSONALITY DISORDER:

. The person does NOT believe the avoidance is excessive or
unreasonable.

. Tx of generalized social anxiety disorder:

-> SSRIs (Paroxetine) & cognitive behavioral therapy.
 (c) SPECIFIC PHOBIAS:
______________________
. Most common type of phobias.
. Animals (Carnivores or spiders) - Natural environments (Storms).
. Injury (Injection - Blood) - Situations (Heights - Darkness).
. Tx -> Exposure therapy -> ++ exposure to stimulus to induce
habituation & -- anxiety.
. Benzodiazepenes & Beta blockers are helpful when given prior to
exposure.
. BBs are useful in performance related anxiety.

{4} OBSESSIVE COMPULSIVE DISORDER (OCD) (ÇÖØÑÇÈ ÇáæÓæÇÓ ÇáÞåÑí):

________________________________________________________
. Recurrent obsessions or compulsions.
. The pt recognizes that the behavior is unreasonable & excessive (there
is insight).
. Obsessions are anxiety provoking; thoughts are intrusive.
. Related to contamination, doubt, guilt, aggression & sex.
. Compulsions are peculiar behaviors that reduce the anxiety.
. Most commonly habitual hand washing, organizing, checking, counting &
praying.
. Pts with Tourette $ often also have OCD !!
. Depression & substance abuse are common.
. Tx -> 1st line of ttt is SSRIs (Paroxetine & Sertaline).
. SSRIs alter neurotransmitter serotonin level.
. Behavioral therapy is useful.

. N.B.
. Obsessive symptoms in psychotic disorders may be misdiagnosed as OCD.
. You can differentiate psychosis from OCD by looking for:
. a lack insight & loss of contact to reality.

. N.B.
. Pts with Tourette $ have a high risk of developing ADHD or OCD !

{5} ACUTE STRESS DISORDER (ASD) & POST-TRAUMATIC STRESS DISORDER (PTSD):
_________________________________________________________________________
. ACUTE STRESS DISORDER (ASD) -> ÇÖØÑÇÈ ÇáÊæÊÑ ÇáÍÇÏ
. POST-TRAUMATIC STRESS DISORDER (PTSD) -> ÇÖØÑÇÈ ãÇ ÈÚÏ ÇáÕÏãÉ

. Anxiety symptoms that follow a life threatening event.

. ASD -> Symptoms last LESS THAN ONE MONTH & occur within 1 month of
stressor.
. PTSD -> Symptoms last MORE THAN ONE MONTH.

. Re-experiencing of the traumatic event: Dreams, flashbacks or

intrusive recollections.
. Avoidance of stimuli associated e' trauma or numbing of general
responsiveness.
. Increased arousal: Anxiety, sleep disturbances, hypervigilance &
impulsiveness.

. Tx -> Benzodiazepines acutely for anxiety symptoms.

. SSRIs & anti-depressants can be helpful for long term therapy.

. N.B.
. GROUP COUNSELING is the most effective to prevent PTSD following a
traumatic event.
 {6} GENERALIZED ANXIETY DISORDER (GAD):
________________________________________
. Excessive, poorly controlled anxiety that occurs daily for more than 6
months.
. No single event or focus is related to anxiety.
. It often coexists e' major depression, specific phobi, social phobia &
panic disorder.
. Tx -> SUPPORTIVE PSYCHOTHERAPY.
. Tx -> SSRIs, Venlafaxine, buspirone & benzodiazepenes may be used.

. N.B.
. Distinguish GAD from panic attack or social phobiaby what is causing
the anxiety.
. If the question describes persistent worry of a panic attack or social
encounter,
. then GAD is NOT the answer.
. In GAD, multiple life circumstances, not just one, are causing the
anxiety.

. ANXIOLYTIC MEDICATIONS:
__________________________
__________________________

. Adjustment disorder with anxious mood:

. Tx -> Benzodiazepines with brief psychotherapy.
. Rapid onset to therapy.

. Panic disorder:
. Tx -> SSRIs, Alprazolam & Clonazepam.
. They -- intensity & frequency of panic attacks.

. GAD: Tx -> Venlafaxine (-- overall anxiety).

. OCD: Tx -> SSRI (-- obsessional thinking).

. Social phobia -> SSRIs (-- fear ass. e' social situations).

. Benzodiazepines:
-> Don't change dosages abruptly.
-> Use the lowest dose in the elderly.
-> Advise against using machinery or driving.
-> Half life -> ALPRAZOLAM < LORAZEPAM < DIAZEPAM.

. N.B.
. Abrupt cessation of Alprazolam (used in sleeping difficuties),
. which is a short acting benzodiazepine lead to withdrawal symptoms;
. in the form of generalized tonic clonic seizures.

. BUSPIRONE:
-> Therapeutic effect can take up to 1 week.
-> No sedation or cognitive impairment.
-> Best option for people with occupations where driving or machinery
is involved.
-> No withdrawal syndrome.

_________________________________________________________________________
_________________

. MOOD DISORDERS (ÇÖØÑÇÈÇÊ ÇáãÒÇÌ):

_____________________________
_____________________________

{1} MAJOR DEPRESSIVE DISORDER (ÇÖØÑÇÈ ÇáÇßÊÆÇÈ):

__________________________________________
. Depressed mood or anhedonia & depressive symptoms lasting at least 2
weeks.
. Major depressive disorder = Depressed mood + SIGECAPS.

. S -> changes in (S)leep.

. I -> loss of (I)nterest.
. G -> thoughts of worthlessness or (G)uilt.
. E -> loss of (E)nergy.
. C -> trouble (C)oncentrating.
. A -> changes in (A)ppetite or weight.
. P -> changes in (P)sychomotor activity.
. S -> thoughts about death & (S)uicide.

. All depressed pts sh'd be asked about death or suicideal thoughts.

. Look for other causes of depression where the 1st step in management
is different:
-> Hypothyroidism (Check TSH).
-> Parkinson's disease.
-> Medications (Corticosteroids, BBs, antipsychotics).
-> Substance abuse (Alcohol - Amphetamines).

. Tx -> Admit the pt if there is suicidal/homicidal ideation or

paranoia.
. Begin antidepressant medications (SSRI is the 1st drug of choice).
. Give benzodiazepines if agitated.
. Electroconvulsive therapy (ECT) is the best choice if the pt is
acutely suicidal.

. N.B.
. The antidepressant of choice for depressed pts who don't respond to
1st line ttt
. with an SSRI (e.g. Paroxetine) is another medication of the same class
(Citalopram).

. N.B.
. In management of single episode of major depression,
. the antidepressant sh'd be continued for a period of 6 months.

{2} DYSTHYMIC DISORDER (ÇÖØÑÇÈ ÇáÇßÊÆÇÈ ÇáÌÒÆí):

_______________________________________
. DYSTHYMIA = PERSISTENT DEPRESSIVE DISORDER.
. The pt is depressed over entire life.
. Low level depression symptoms on most days for at least 2 years.
. Superimposed acute major depressions may occur.
. Don't hospitalize the pt unless there's suicidal ideation.
. Tx -> Long term individual, insight oriented psychotherapy.
. Tx -> If failed, a trial of SSRIs may be done.

{3} SEASONAL AFFECTIVE DISORDER (ÇáÇÖØÑÇÈÇÊ ÇáÚÇØÝíÉ ÇáãæÓãíÉ):

__________________________________________________
. Depressive symptoms in the winter months (Shorter daylight hours).
. Absence of depressive symptoms during summer months (Longer daylight
hours).
. Tx -> Psychotherapy or sleep deprivation.
 {4} BIPOLAR DISORDER (ÇáÇÖØÑÇÈ ËäÇÆí ÇáÞØÈ : ÇáÇßÊÆÇÈ æÇáåæÓ):
______________________________________________
. Episodes of depression, mania or mixed symptoms for at least 1 week.
. H/O of both manic syms & depressive syms as well as periods of normal
mood.
. RAPID CYCLIC BIPOLAR is indicated by > 4 episodes of mania per year.

. Risk of bipolar disorder in general population is 1 %.

. It is 10 % risk in those with 1st degree relative H/O.

. MANIA SYMPTOMS:
-> Grandiosity - Less need for sleep - Excessive talking - Pressured
speech.
-> Racing thoughts - Flight of ideas - Distractability - Sexual
promiscuity.
-> Goal focused activity at home or at work.

. MAJOR DEPRESSIVE SYMOTOMS:

-> Depressed mood - Loss of pressure or interest.

. BIPOLAR TYPE (1) DISORDER: MANIC episodes; pts may or may not 've
depressive episodes.

. BIPOLAR TYPE (2) DISORDER: Major depression + Hypomania.

. MANAGAEMENT:

*1* HOSPITALIZE (in case of severe manic symptoms despite mood

stabilizer therapy).

*2* Mood stabilizers are used to induce remission.

. Lithium is the drug of choice (takes 1 week for effect).

*3* Antipsychotics are used until acute mania is controlled.

. Risperidone is the drug of choice.

*4* Give IM depot phenothiazine in non-compliant severely manic

patients.

*5* Give antidepressants only when there's a H/O of recurrent episodes

of depression,
. Given ONLY TOGETHER with mood stabilizers (to prevent including
manic episode).

. N.B.
. The long term therapy of bipolar disorder is mood stabilizer
(Lithium).
. Lithium is NEPHROTOXIC.
. If the pt has renal problems (++ urea & creat) -> Give VALPROIC ACID.

. N.B.
. Lithium in the 1st trimester of pregnancy is very dangerous.
. It causes cardiac malformations.
. Septal defects & Ebstein's anomaly (Atrialization of right ventricle).
. In 2nd & 3rd trimesters, it causes goiter & neuromuscular dysfunction.

. N.B.
. Choose electro-convulsive therapy (ECT) for 1st trimester pts with
manic episodes.
 . LAMOTRIGENE may be used in 2nd or 3rd trimester.

. N.B.
. Pts who are extremely agitated, psychotic or manic, sh'd be initially
managed with
. an antipsychotic medication such as "Haloperidol".

{5} CYCLOTHYMIA (ÏæÑæíÉ ÇáãÒÇÌ):

__________________________
. H/O of recurrent episodes of depressed mood & hypomanic mood for at
least 2 years.
. It is a mild form of bipolar affective disorder.
. Tx -> Psychotherapy is the 1st line of ttt.
. DIVALPROEX is used when functioning is impaired (More effective than
Lithium).

{6} GRIEF & DEPRESSION (ÇáÍÒä æÇáÇßÊÆÇÈ):

__________________________________

. < GRIEF > < DEPRESSION >

. Sadness - Tearfulness - -- Sleep - -- Appetite - -- interest in the

world.

. Symptoms wax & wane. . Symptoms are pervasive

& unremitting.
. Shame & guilt are less common. . More common.
. Suicidal ideation is less common. . More common.
. Symptoms can last up to 1 year. . Symptoms continue for
more than 1 year.
. Pt returns to normal functioning in 2 months . No return to base line
functioning.
. Tx -> SUPPORTIVE therapy. . Tx -> ANTI-DEPREESANTs.

. N.B.
. BEREAVEMENT is a normal reaction o the loss of beloved one !
. PERSISTENT COMPLEX BEREAVEMENT DISORDER -> Severe impairment >12
months after the loss!

. N.B.
. COMPLICATED GRIEF / EXTENDED BEREAVEMENT can present e' syms of major
depression.
. Bereaved pts who have at least 2 weeks of syms of depression,
. 6-8 weeks after a major loss, sh'd be considered for ttt with:
. BOTH PSYCHOTHERAPY & TRIAL OF ANTIDEPRESSANTs.

. N.B.
. Pts e' both mood & psychotic symptoms respond to both antidepressants
& antipsychotics.
. However, you must treat the worst symptoms first.

. N.B.
. Auditory hallucinations e'out other psychotic symptoms are normal in
grief reaction.

{7} POST-PARTUM DEPRESSION:

____________________________

. A . POSTPARTUM BLUES = BABY BLUES:

_____________________________________
 . After any birth.
. Mother cares about the baby.
. Mild depressive symptoms.
. Self limited, no ttt necessary.

. B . POSTPARTUM DEPRESSION:
_____________________________
. Usually after 2nd birth.
. Many have thoughts about hurting the baby.
. Severe depressive symptoms.
. Tx -> Antidepressants.

. C . POSTPARTUM PSYCHOSIS:
____________________________
. Usually after 1st birth.
. Mothers have thoughts about hurting the baby.
. Psychotic symptoms along with severe depressive symptoms.
. Tx -> Mood stabilizers or antipsychotics & antidepressants.
. Avoid medications if the pt is breastfeeding; use ECT instead !

{8} SUICIDE & SUICIDAL IDEATION:

_________________________________

* RISK FACTORS:
________________
. History of suicide threats & attempts is the most important predictor
of suicide.
. Family H/O of suicide.
. Perceived hopelessness (Demoralization).
. Scizophrenia, borderline or antisocial personality.
. Drug use, especially alcohol.
. Males.
. Age > 65 ys.
. Socially isolated, recently divorced or widowed.
. Chronic physical illness.
. Low job satisfaction or unemployment.

* EMERGENCY ASSESSMENT:
________________________
. Take all suicide threats seriously.
. Detain & hospitalize (Usually 2 weeks).
. Never transport patient to emergency depratment without medically
trained personnel.
. Don't identify with the pt.
. Tx of choice -> PSYCHOTHERAPY + ANTIDEPRESSANTs (SSRIs are the 1st
choice).
. For acute severe risk of self-harm -> Tx of choice is ECT.

. N.B.
. Minors with suicidal attempts must be admitted to hospital ,
. even against their parents will (Their consent is NOT mandatory).

* INDICATIONS FOR ELECTROCONVULSIVE THERAPY (ECT):

___________________________________________________
. Major depressive episodes that are unresponsive to medications.
. High risk of immediate suicide.
. Contraindications to using antidepressants.
. Good response to ECT in the past.

. The biggest complication of ECT is TRANSIENT MEMORY LOSS,

 . which worsens with prolonged therapy & resolves after several weeks.

. Use of ECT is cautioned in pts with space occupying intracranial

lesions.
. ECT ++ ICT.

* ANTIDEPRESSANTs & MOOD STABILIZERs:

______________________________________
. SSRIs are the 1st line of therapy.
. TCAs are avoided bec. of risk of toxicity (U sh'd monitor BP).
. MAOIs are more helpful in atypical depressive disorders.
. Switch to another antidepressant if there is no response after 8
weeks.
. Treat the pt for 6 months then taper the dose gradually.

. SSRIs are the 1st line of therapy in the following disorders:

-> Major depressive disorder.
-> Bipolar disorder.
-> Anxiety disorders (Panic disorder - OCD - Social phobia - GAD).
-> Bulimia nervosa.

. When the Q. describes a pt concerned about weight gain or sexual side

effects,
. Give Bupropion (causes modest weight loss).
. Bupropion is associated with SEIZURES !!

. When the Q. describes a pt who has poor appetite, loos of weight or

insomnia,
. Give MIRTAZAPINE (Ass. e' weight gain).

. AMITRIPTYLINE is used to treat chronic pain (Neuropathic pain).

. Amitriptyline is ass. e' antichlinergic effects (If severe switch to
SSIs).

. IMIPRAMINE is useful in noctunal enuresis (DESMOPRESSIN is the 1st

choice).

. TRAZADONE is strongly sedating used in ttt of pts with insomnia.

. Trazadone causes PROLONGED ERECTION !

. SSRIs & TCAs are SAFE in pregnancy except for PAROXETINE !

. Seizures are common with TCAs & Bupropion.

. These medications sh'd be avoided in pts with seizures disorders.
. The best 1st line of ttt in pts with seizures is SSRIs.

. TCAs have anticholinergic effects & are an Alpha blocker,

. causing peripheral vasodilatation & hypotension.
. TCAs affect the sodium channels in the cardiac tissue.

. EKG is the single most important test to guide TCAs therapy.

. Watch out for prolonged QRS, QT & PR intervals.
. Most serious complication is ventricular tachycardia & fibrillation.

. SODIUM BICARBONATE Na HCO3 attenuates TCA cardiotoxicity by

alkalinization of blood,
. which uncouples TCA from myocardial sodium channels & ++ extracellular
Na concentration
 . Lithium is the 1st line of ttt for BIPOLAR & SCHIZOAFFECTIVE
disorders.
. Side effects:
-> Acne & weight gain are the most common problems.
-> Tremors, GI distress & headaches.
-> Hypothyroidism (Order TSH level).
-> Polyurea 2ry to lithium induced DI (Order Creinine level).
-> Fetal cardiac defects & Ebstein's anomaly if used in 1st trimester.

. DIVALPROEX is the 1st line of choice for rapid cyclic bipolar

disorder.

. CARBAMAZEPINE is the SECOND line of ttt for bipolar disorder.

. Used when lithium is ineffective or contraindicated.
. Not used due to severe agranulocytosis & sedation side effects.

. Lithium for life time !!

. Pts who've experienced 2 episodes of acute mania sh'd be considered
for long time
. if previous manic episodes were severe or there is family H/O.
. Pts with 3 or more relapses are recomended to have life time lithium
therapy.

. Q. What is the 1st assessment prior to prescribing antidepressants ?

. A. Suicidal ideation.

_________________________________________________________________________
_________________

. MEDICATION OVERDOSES:
________________________
________________________

{1} LITHIUM TOXICITY:

______________________
. Elderly p who takes lithium with renal failure or hyponatremia.
. May be induced by diuretics, vomiting or dehydration.
. Nausea - vomiting - acute disorientation - tremors - ++ DTRs -
seizures.
. Tx -> DIALYSIS.

{2} NEUROLEPTIC MALIGNANT $YNDROME:

____________________________________
. H/O of recent start with antipsychotics (Specially HALOPERIDOL).
. H/O of Parkinson's pt who has recently stopped Levo dopa.
. High fever - Tachycardia - Ms rigidity - Altered consciousness -
Autonomic dysfunction.
. It is unrelated to dosage or previous drug exposure.
. 20 % mortality rate.
. Tx -> Transfer to ICU.
. Tx -> Discontinue antipsychotic.
. Tx -> Bromocriptine to overcome dopamine receptor blockage.
. Tx -> Ms relaxants (DANTROLENE or DIAZEPAM) to reduce ms rigidity.

{3} SEROTONIN $YNDROME:

________________________
. H/O of SSRIs use or migraine medication (triptans) or MAOIs.
. Agitation - Hyperreflexia - Hyperthermia - Muscle rigidity.
. Volume contraction 2ry to sweating & insensible fluid loss.
. Tx -> IV fluids.
 . Tx -> Cryptoheptadine to -- serotonin production.
. Tx -> Benzodiazepine to -- muscle rigidity.

{4} MAOIs INDUCED HYPERTENSIVE CRISIS:

_______________________________________
. H/O of MAOI use with acute hypertension.
. H/O of antihistaminics or nasal decongestants may be a cause.
. H/O of consumption of tyramine rich foods (Cheeses - Pickled foods).
. May also be seen in pts who take a MAOI (Phenelzine) & a TCA
concurrently.
. Tx -> As hypertensive crisis.

_________________________________________________________________________
_________________

. SOMATOFORM DISORDERS = ÇáÇÖØÑÇÈÇÊ ÌÓÏíÉ ÇáÔßá:

______________________________________
. Physical symptoms without medical explanation.
. Severe enough to interfere with the pt's ability to function.

{1} SOMATIZATION DISORDER = ÇÖØÑÇÈ ÇáÌÓÏäÉ:

_____________________________________
. 4 pain symptoms + 2 GIT symptoms + 1 Sexual symptom + 1
psudoneurologic symptom
. Tx -> Maintain a single physician as the primary care giver.
. Tx -> Schedule brief monthly visits.
. Tx -> Avoid diagnosting tests or therapies.
. Tx -> Schedule individual psychotherapy.
. Tx -> Do NOT hospitalize the pt.

{2} CONVERSION DISORDER = ÇÖØÑÇÈ ÇáÊÍæá:

___________________________________
. One or more neurological symptoms that,
. can't be explained by any medical or neurological disorder.
. Most common syms (Blindness - Mutism - Paralysis - Anesthesia -
Paresthesia).
. Look for psychologic factors associated with the onset of syms.
. THE PATIENTS ARE UNCONCERNED ABOUT THEIR IMPAIRMENT (LA BELLE
INDIFFERENCE).
. You must first rule out other medical conditions.
. Tx -> Supportive physician-patient relationship.
. Tx -> Psychotherapy.

. N.B.
. Somatization disorder or conversion disorder are NEVER the correct
diagnosis if:
. symptoms are produced intentionally or feigned.

{3} HYPOCHONDRIASIS = ÇáãÑÇÞ:

___________________________
. The pt has false belief that he has a specific disease,
. despite repeated negative medical tests & work up.
. Symptoms must have been present for at least 6 months.
. Physician's reassurance has failed to relief concerns.
. Tx -> Identify one primary care giver.
. Tx -> Schedule regular routine visits.
. Psychotherapy ( Initiate a discussion about current emotional
stressors).
 {4} FACTITIOUS & MALINGERING DISORDERS = ÇáÇÖØÑÇÈÇÊ ÇáÇÕØäÇÚíÉ
æÇáÊãÇÑÖíÉ:
__________________________________________________________
. INTENTIONALLY FEIGNED SYMPTOMS !
. A pt that has seen many doctors & visited many hospitals.
. A pt that has large amount of medical knowledge (e.g. Health care
workers).
. A pt who demands a treatment.
. Always agitated & threatens litigation if tests return -ve !!
. No secondary gain (Unlike malingering).

. Factitious disorder by proxy:

-> If the signs & syms are faked by another person.
-> As in a mother making up symptoms in her child.
-> The motivation is to assume the caretaker role.

. Malingering:
-> When obvious gain results from feigned symptoms.
-> Ex: Shelter - medications - disability insurance.
-> Pts are more occupied with rewards or gain than alleviation of
presenting symptoms.

. N.B.
. Factitious disorder -> The pt wants sick role.
. Malingering disorder -> The pt wants secondary gain.

. Tx -> Supportive psychotherapy.

. Do NOT confront or accuse the pt (The pt will become angry, more
guarded & suspicious).
. Only provide the minimum amount of treatment & work up needed.

_________________________________________________________________________
_________________

. EATING DISORDERS = ÇÖØÑÇÈÇÊ ÇáÊÛÐíÉ:

______________________________
______________________________

{1} ANOREXIA NERVOSA = ÝÞÏÇä ÇáÔåíÉ ÇáÚÕÈí:

_________________________________
. YOUNG FEMALE - UNDERWEIGHT.
. Food restriction & excessive exercise.
. No menstrual period for 3 months or more.
. H/O of purging (ÊÓåíá æÊáííä ãÇ ÈÚÏ ÇáÃßá).

. N.B.
. REFEEDING $YNDROME:
-> Fluids & electrolytes shift -> Electrolyte depletion, arrhythmias &
heart failure.

. N.B.
. ANOREXIA COMPLICATIONS:
-> Osteoporosis.
-> ++ Cholesterol & carotene levels.
-> Cardiac arrhythmias (Prolonged QT interval).
-> Euthyroid sick $.
-> Hypothalamic - pituitary axis dysfunction -> Anovulation.
-> Hyponatremia secondary to excess water intake.
-> Pregnants (Miscarriage - Hyperemesis gravidarum - postpartum
depression - C.S.).
 -> Fetus (IUGR - Prematurity).

{2} BULIMIA NERVOSA = ÇáÔÑå ÇáÚÕÈí:

______________________________
. YOUNG FEMALE - NORMAL WEIGHT RANGE.
. Frequent episodes of binge eating follwed by guilt, anxiety.
. Self induced vomiting, laxative, diuretics or enema use.
. Food restriction is NOT a feature of bulimia nervosa.
. Painless parotid gland enlargement.
. Dental enamel erosions.
. Metabolic alkalosis with hypochloremia & hypokalemia caused by emesis.
. Metabolic acidosis caused by laxative abuse.
. Risk of cardiomyopathy with excessice syrup of epicac use.

. MANAGEMENT of ANOREXIA NERVOSA & BULIMIA NERVOSA:

____________________________________________________
. HOSPITALIZE for IV hydration if electrolyte disturbance are present.
. OLANZAPINE in anorexia nervosa helps with weight gain.
. SSRI antidepressants (esp. FLUOXETINE) prevent relapses.
. Behavioral therapy.

{3} BODY DYSMORPHIC DISORDER = ÇÖØÑÇÈ ÊÔæå ÇáÌÓÏ:

__________________________________________
. YOUNG FEMALE - Preoccupied with an imagined or slight defect in
appearance.
. causing an impaired ability to function in a social or occupational
life.
. Distress is most commonly related to facial features.
. The pt is often isolated & housebound.
. Tx -> High doses of SSRIs are the 1st line of ttt.

. N.B.
. If the only concern is body shape & weight -> ANOREXIA NERVOSA is more
accurate Dx.
. If the only concern is sex characteristics -> GENDER IDENTITY DISORDER
is more acc.

_________________________________________________________________________
_________________

. IMPULSE CONTROL DISORDERS = ÇÖØÑÇÈÇÊ ÇáÓíØÑÉ Úáì ÇáÇäÝÚÇáÇÊ:

______________________________________________
______________________________________________
. People who are unable to resist impulses.
. Anxiety prior to the impulse that is relieved after the pt acts on it.

. Pts do NOT believe their actions or out of proportion.

. Pts lack insight (Unlike OCD).

{1} INTERMITTENT EXPLOSIVE DISORDER = ÇáÎáá ÇáÇäÝÚÇáí ÇáãÊÞØÚ:

_________________________________________________
. Episodes of aggression out of proportion to the stressor.
. H/O of head trauma.
. If there is a H/O of drug intake -> Intermittent explosive diorder is
NOT the Dx !
. Tx -> SSRIs & mood stabilizers.

{2} KLEPTOMANIA = åæÓ ÇáÓÑÞÉ:

_________________________
. Individual who repeatedly steals items to relieve anxiety.
 . The person doesn't steal because he needs the object.
. The person often secretely replaces the object after stealing it.
. Tx -> COGNITIVE BEHAVIORAL THERAPY.

{3} PYROMANIA = åæÓ ÇÖÑÇã ÇáäíÑÇä:

__________________________
. Individual who repeatedly lights fires.
. Pyromania is NOT the diagnosis if the motive is personal gain
(insurance money),
. or when the motive is to show anger (Differenting it from CONDUCT
DISORDER).

{4} PATHOLOGIC GAMBLING = ÇáãÞÇãÑÉ ÇáãÑÖíÉ:

___________________________________
. Obsession with gambling despite the consequences.
. Tx -> Group psychotherapy (GAMBLING ANONYMOUS).

{5} TRICHOTILLOMANIA:
______________________
. Uncontrollable urge to pull out the hair -> Alopecic areas.
. These areas still contain hair of varying lenghts.

_________________________________________________________________________
_________________

. TYPES OF ABUSE:
__________________
__________________

{1} CHILD ABUSE:

_________________
. PHYSICAL is the most common.
. Look for bruises - burns - lacerations - broken bones.
. Shaken baby $ -> Do eye exam !!
. Neglect.
. Sexual exploitation (STDs).
. Mental cruelty.

. MANDATORY REPORTING UP TO AGE 18.

. You must report ALL suspected cases.
. Protect the child (Separate from parents) & consider admission to
hospital.

. Those who are younger than 1 year are at risk.

. Step children, premature, very active & defective children are at
risk.

. Be careful not to mistake BENIGN CULTURAL PRACTICES (Coining -

Moxibustion) for abuse.
. Treat FEMALE CIRCUMCISION as ABUSE !!

{2} ADULT MALTREATMENT = ELDER ABUSE:

______________________________________
. NEGLECT is the most common (50 % of all reported cases).
. Physical, psychological & financial are another forms.

. You must report ALL suspected cases.

. Protect pt from abuser & consider admission to hospital.
 . Caretaker is the most likely source of abuse; spouses are often
caretakers.

{3} SPOUSAL ABUSE:

___________________
. PHYSICAL is the most common.
. It is the number 1 cause of injury to American women.
. Psychological & financial are another forms.

. Reporting is NOOOOOTTTTT indicated !

. Provide information about local shelters & counseling.

. High risk categories:

-> More frequent in families with drug abuse, esp. Alcoholism.
-> Victim often grew up in a violent home (about 50 %).
-> Married at a young age.
-> Dependent personalities.
-> Pregnant, last trimester (Highest risk).

. MANAGEMENT OF ABUSE:
_______________________
1 - Complete physical examination.
2 - Radiographic skeletal survey.
3 - Coagulation profile (If multiple bruises).
4 - Report to child protective services.
5 - Admission of the child to hospital.
6 - Consultation with a psychiatrist & evaluation of family dynamics.

_________________________________________________________________________
_________________

. PERSONALITY DISORDERS (PD):

______________________________
______________________________

{A} CLUSTER A -> Peculiar thought processes & Inappropriate affect !

_____________________________________________________________________

(1) PARANOID PD:

_________________
. Mistrustful & suspiciousness of the motivations & actions of others.
. Secretive & isolated.
. Emotionally cold & odd.
. Often take legal action against other people.
. Often confused with paranoid schizophrenia.
. Main defense mechanism is projection.

. Ex. 62 ys old man lives in an apartment,

. constantly acuses his neighbors of stealing his mail & prying into his
apartment.
. He believes that all his neighbors are conspiring to have him removed
from the building

(2) SCHIZOID PD:

_________________
. Emotionally distant & fear intimacy with others.
. Absorbed in their own thoughts & feelings.
. Always disinterested.
. Main defense mechanism is projection.
 . Ex. 68 ys old man lives in the country-side manning a lighthouse near
a remote village.
. He is seen in town 2-3 times a year to purchase supplies.
. He has no known friends or family.

(3) SCHIZOTYPAL PD:

____________________
. Like schizoid PD except they also have MAGICAL THINKING.
. They have clairvoyance, ideas of reference & paranoid ideation.

. Ex. 28 ys old man lives in a small coastal town,

. attempting to start his own internet herbal business.
. He believes that the herbs have magical power of healing.
. He believes that spirits are guiding him to wealth.

{B} CLUSTER B -> Mood lability, dissociative symptoms & preoccupation

with rejection:
_________________________________________________________________________
_____________

(1) HISTRIONIC PD:

___________________
. Colorful exagerrated behavior & excitable.
. Shallow expression of emotions.
. Use of physical appearance to draw attention to self.
. Sexually seductive.
. Discomfort in situatios where not the center of attention.

. Ex. 30 ys old woman presents to the doctor's office,

. dressed in a sexually seductive manner,
. insisting taht the doctor comment on her appearance.
. When the doctor refuses to do so, she becomes upset.

(2) BORDERLINE PD:

___________________
. Unstable affect, mood swings, marked impulsivity, unstable
relationships.
. Recurrent suicidal behaviors, chronic feelings of emptiness & identity
disturbance.
. Inappropriate anger (Become intensily angered if they feel abondened).
. Main defense mechanism is SPLITTING.

. Ex. 30 ys old woman reports that she has been to many doctors,
. They were all wonderful until they started ignoring her or cutting her
visits short,
. then she realized what terrible doctors they were.
. She startes the visit saying that the assistant at the front desk is
the worst ever,
. because she didn't smile at her.
. The other assistant was just wonderful according to her !

(3) ANTISOCIAL PD:

___________________
. Continous anti-social or criminal acts.
. Inability to conform to social rules, impulsivity & aggressiveness.
. Disregard for the rights of others.
. Lack of remorse & deceitfullness.
 . Ex. 26 ys old man is caught lighting forest fires during a recent
spate.
. H/O of legal problems since childhood.
. He reports that his mother is to blame.
. He denies feeling regret.
. He has no friends & is found to be hostile to everyone at the police
station.

(4) NARCISSISTIC PD:

_____________________
. Sense of self-importance, grandiosity & pre-occupation with fantasies
of success.
. Belief of being special, requires excessive admiration.
. Reacts with rage when criticized.
. Lacks empathy, is envious of others & is interpersonally exploitative.

. Ex. Pt in hospital for chest pain & becomes very agitated,

. because he feels he is not getting enough attention.
. He reports that he is an important CEO.
. Demands a special VIP room, more consideration & a dedicated nurse to
attend his needs.

{C} CLUSTER C -> Anxiety, preoccupation with criticism or rigidity:

____________________________________________________________________

(1) AVOIDANT PD:

_________________
. Social inhibition, feelings of inadequacy & hypersensitivity to
criticism.
. They shy away from starting anything new or attending social
gatherings.
. Always fear of failure or rejection.
. They desire affection & acceptance.
. They are open about their isolation & inability to interact with
others.

. Ex. 45 ys old singl man fears an upcoming social party being hosted by
his parents.
. He dreads having to meet other people & doesn't feel comfortable
speaking e' others.
. He is planning on staying at home to avoid speaking to others.

(2) DEPENDENT PD:

__________________
. Submissive & clinging behavior related to a need to be taken care of.
. They are always worry about abandonment.
. They feel inadquate & helpless & avoid disagreements with others.
. They usually focus dependency on a family member or a spouse.

. Ex. 28 ys old woman seeks counseling bec. of a recent relationship

breakup.
. They were dating for 6 months.
. She continues to call her ex 15 - 20 times a day eventhough he doesn't
pick up.
. She says she can't understand why they broke up bec. she never
disagreed with him.
. She never left the house without him & she always asked his opinion.
. She can't imagine life without him.
 (3) OBSESSIVE COMPULSIVE PD:
_____________________________
. They are preoccupied with orderliness, perfectionism & control.
. They are always consumed by details of everything & lose their sense
of overall goals.
. They are strict & perfectionistic, overconscientious & inflexible.
. Associated with difficult interpersonal relationships.

. Ex. 38 ys old man presents with his wife for marital counseling.
. The wife reorts that he is inflexible & has unrealistic demands of
orderliness.
. Both partners agree that his demands are causing marital problems.

_________________________________________________________________________
_________________

. SUBSTANCE USE DISORDERS:

___________________________
___________________________

(1) ALCOHOL DEPENDENCE = ALCOHOLISM:

_____________________________________
. Frequent use of alcohol -> Tolerance & physical & psycholical
dependence.
. Alcohol abuse -> Failure to fulfill obligations, legal troubles.
. Tolerance is NOT included in the diagnosis of alcohol abuse.
. Dx -> CAGE QUESTIONNAIRE (Lab tests are never included in the
diagnosis).

. CAGE -> An answer of YES to any 2 of the following Qs is suggestive of

abuse:
-> Have you ever felt that you should CUT down your drinking ?
-> Have you ever felt ANNOYED by others who have criticized your
drinking ?
-> Have you ever felt GUILTY about your drinking ?
-> Have you ever had an EYE-OPENER to steady your nerves or alleviate a
hangover ?

. Order toxicology to look for another drugs: breath, blood & urine drug
screens.
. Look for 2ry effects of alcohol use: ++ GGTP, AST, ALT & LDH.
. If there is suggestion of IV drug use (treack marks) -> Order HIV,
HBV, HCV & PPD.

. Management of abuse or prevention of relapse -> ALCOHICS ANONYMOUS

(AA).

. ACUTE OUT-PATIENT MANAGEMENT OF ALCOHOL DEPENDENCE:

-> Prevent further ETOH intake.
-> Prevent individual from driving a car, operating machinery.
-> Sedate pt if he or she becomes agitated.
-> Transfer to inpatient.

. ACUTE IN-PATIENT MANAGEMENT PAERLS:

-> Look for withdrawal symptoms.
-> Prevent Wernicke-Korsakoff (ataxia - nystagmus - ophthalmoplegia -
amnesia).
-> Give IV or IM thiamine & Mg ASAP plus vit. B12 & folate.
-> Benzodiazepine of choice is CHLORDIAZEPOXIDE or DIAZEPAM.
 -> Choose short-acting benzodiazepam if there is H/O of severe liver
disease: LORAZEPAM
-> Do NOT give seizure prophylaxis; repaeted seizures sh'd be ttt e'
diazepam.
-> Haldol is NEVER the answer (It reduces seizure threshold).

. CHRONIC MAINTENANCE MANAGEMENT:

-> Refer to inpatient rehabilitation or outpatient group therapy (AA).
-> Never give drug therapy without group psychotherapy.
-> Naloxone & acamprosate -- relapse rate only when given with
psychotherapy.
-> Disulfiram has poor compliance and hasn't been shown to be
effective.

. WITHDRAWAL $ MANIFESTATIONS:
_______________________________

(1) MINOR WITHDRAWAL SYMPTOMS:

_______________________________
-> Onset after last drink -> 6 hours.
-> Syms -> insomnia, tremulousness, mild anxiety, headache, diaphoresis
& palpitations.
-> Exam tips -> Give thiamine, folate, multivitamin & glucose.

(2) ALCOHOLIC HALLUCINOSIS:

____________________________
-> Onset after last drink -> 12 - 24 hours.
-> Symptoms -> Visual, auditory & tactile hallucinations.
-> Exam tips -> If there are hallucinations with disorientation &
altered mental status
-> then alcoholic hallucinosis is NOT the answer.

(3) WITHDRAWAL SEIZURES:

_________________________
-> Onset after last drink -> 48 hours.
-> Symptoms -> Tonic clonic seizures.
-> Exam tips -> Perform CT scan if repeated seizures to rule out
structural causes.

(4) DELIRIUM TREMENS:

______________________
-> Onset after last drink -> 48 - 96 hours.
-> Symptoms -> Hallucinations, disorientation, tachycardia,
hypertension.
-> Symptoms -> Low grade fever, agitation & diaphoresis.
-> Exam tips -> Time of onset is important.
-> This is the diagnosis if the case describes symptoms 2 DAYS after
last drink.

_________________________________________________________________________
_________________

. SUBSTANCE ABUSE:
___________________
___________________

{1} ALCOHOL:
_____________
. Intoxication syms -> Talkative, sullen, gregarious & moody.
. Intoxication ttt -> Mechanical ventillation if severe.
 . Withdrawal syms -> Tremors, hallucinations, seizures & delirium.
. Withdrawal ttt -> Long acting benzodiazepeines (Chlordiazepoxide).

. No seizure prophylaxis.
. Disulfiram or naloxone for adjunct to supervised therapy after acute
withdrawal.

{2} AMPHETAMINES & COCAINE:

____________________________
. Intoxication syms -> Euphoria, hypervigilance, autonomic hyperactivity
& weight loss.
. Intoxication syms -> Pupil dilatation, disturbed perception, stroke &
MI !
. Intoxication syms -> -- appetite (Picky eater).
. Intoxication syms -> Erythema of turbinates & nasal septum.
. Intoxication ttt -> Antipsychotics, benzodiazepines, inderal & vit C
to ++ excretion.

. Withdrawal syms -> Anxiety, tremors, headache, ++ appetite, depression

& suicide risk.
. Withdrawal ttt -> Antidepressants.

{3} CANNABIS:
______________
. Intoxication syms -> Impaired motor coordination, impaired time
perception.
. Intoxication syms -> Social withdrawal, ++ appetite, dry mouth,
tachycardia.
. Intoxication syms -> Conjunctival redness.
. Intoxication ttt -> NONE.

. Withdrawal syms -> NONE.

. Withdrawal ttt -> NONE.

{4} HALLUCINOGENS (LSD = LYSERGIC ACID):

_________________________________________
. Intoxication syms -> Visual hallucinations & intensified perception.
. Intoxication syms -> Ideas of reference, impaired judgment &
dissociative syms.
. Intoxication syms -> Pupillary dilatation, panic, tremors &
incoordination.
. Intoxication ttt -> Supportive counseling (talking down),
antipsychotics & benzos.

. Withdrawal syms -> NONE.

. Withdrawal ttt -> NONE.

{5} INHALANTS:
_______________
. Intoxication syms -> Belligerence, apathy, assaultiveness & impaired
judgement.
. Intoxication syms -> Blurred vision, stupor & coma.
. Intoxication ttt -> Antipsychotics if delirious or agitated.

. Withdrawal syms -> NONE.

. Withdrawal ttt -> NONE.

{6} OPIATES (HEROIN):

______________________
 . Intoxication syms -> Respiratory depression, pin point pupils & CNS
depression (Coma).
. Intoxication syms -> Apathy, dysphoria, drowsiness, slurred speech.
. Intoxication syms -> Impaired memory, coma & death.
. Intoxication ttt -> NALOXONE.

. Withdrawal syms -> Fever, chills, lacrimation, runny nose, abdominal

cramps.
. Withdrawal syms -> Muscle spasms, insomnia, yawning & secretions from
all openings !
. Withdrawal ttt -> METHADONE & clonidine.

{7} PHENYLCYCLIDINE (PCP):

___________________________
. Intoxication syms -> Panic reactions, assaultiveness & agitations.
. Intoxication syms -> Nystagmus, HTN, seizures, coma & hyperacusis.
. Intoxication ttt -> Talking down, benzodiazepines, antipsychotics &
resp. support.

. Withdrawal syms -> NONE.

. Withdrawal ttt -> NONE.

{8} BARBITURATES & BENZODIAZEPINES:

____________________________________
. Intoxication syms -> Inappropriate sexual or aggressive behavior.
. Intoxication syms -> Impaired memory & concentrations.
. Intoxication ttt -> FLUMAZENIL.

. Withdrawal syms -> Autonomic hyperactivity, tremors, insomnia,

seizures & anxiety.
. Withdrawal ttt -> Substitute short with long acting barbiturates
(chlordiazepoxide).

_________________________________________________________________________
_________________

. HUMAN SEXUALITY:
___________________
___________________

{1} HOMOSEXUALITY:
___________________
. It is NOT a mental illness.

{2} GENDER IDENTITY DISORDER & TRANS-SEXUALISM:

________________________________________________
. An individual who insists that he/she is the opposite gender.
. Intense discomfort about his or her sex.
. It is NOT the Dx when the Q. describes an individual who desires to be
another gender
. because of the perceived advantages of the other sex.
. e.g. a boy who wants to be a girl so that he will receive the same
special ttt as his younger sister.

{3} PARAPHILIAS:
_________________
. Recurrent, sexually arousing preoccupations which are usually focused
on humiliation,
. The use of non-living objects & non-consenting partners.
 . Occurs for more than 6 months & causes impairment in pt's level of
functioning.
. Tx -> Individual psychotherapy & averse conditioning.
. If severe impairment -> Give antiandrogens or SSRIs to help reduce
pt's sexual drive.

. TYPES OF PARAPHILIAS:
________________________
________________________

.1. VOYEURISM:
_______________
. Recurrent urges to observe an unsuspecting person who is engaging in
sexual activity or disrobing.
. This is the earliest paraphilia to develop.

.2. PEDOPHILIA:
________________
. Recurrent urges or arousal toward prepubescent children.
. This is the most common paraphilia.

.3. EXHIBITIONISM:
___________________
. Recurrent urge to expose oneself to strangers.

.4. FETISHISM:
_______________
. Use of non-living objects usually associated with the human body.

.5. FROTTEURISM:
_________________
. Recurrent urge involving touching or rubbing against a non-consenting
partner.

.6. MASOCHISM:
_______________
. Recurrent urge or behavior involving the act of humiliation.

.7. SADISM:
____________
. Recurrent urge or behavior involving acts in which ..
. physical or psychological suffering of a victim is exciting to the
patient.

. PHARMACOLOGICAL AGENTS THAT CAUSE SEXUAL DYSFUNCTION:

________________________________________________________
________________________________________________________

. Alpha 1 blockers -> Impaired ejaculation.

. Beta blockers -> Erectile dysfunction.
. Neuroleptics -> Erectile dysfunction.
. SSRIs -> Inhibited orgasm.
. Trazodone -> Priapism.
. Dopamine agonists -> ++ Erection & libido.

. N.B. POOR SLEEP HYGIENE:

___________________________
 -> can be associated with insomnia.
-> Due to performance of bad daily living activities.
-> that are inconsistent with maintainance of sleep.
-> Poor sleep scheduling with variable wake & sleep times.
-> Frequent day time naping.
-> Routine use of caffeine, Alcohol, Nicotine in period preceiding
sleep.
-> Engaging in mentally or physically stimulating activities too close
to bed time.
-> Frequent use of the bed for activities other than sleep.

. N.B. DELAYED SLEEP PHASE $YNDROME:

_____________________________________
-> Circadian rhythm disorder.
-> Inability to fall asleep at normal bed times such as 10 p.m. to
midnight.
-> These pts often can't fall asleep until 4-5 a.m. BUTTTTTT ..
-> their sleep is normal if they are allowed to sleep until late
morning.

=========================================================================
=================
=========================================================================
=================

ETHICS TiKi TaKa

__________________

. AUTONOMY:
____________
. An adult e' capacity to understand his/her medical problems can refuse
any ttt or test
. It doesn't matter if the ttt or test is simple, safe & risk free.
. It doesn't matter if the person will die without the ttt or the test.
. Respecting autonomy is MORE IMPORTANT to do the right thing for a pt !

. Even though an adult pt e' capacity can refuse anything,

. USMLE wants u to discuss things 1st.
. Eventhough u may eventually honor his wishes,
. if an answer says "meet", "confer", or "discuss", the do that first !

. CAPACITY:
____________
. Capacity is determined by physicians.
. Competence is a legal term & is determined by courts & judges.
. An adult who is alert & not mentally handicapped is deemed to have
capacity.

. PSYCHIATRY CONSULTATION:
___________________________
. is the answer when a pt's capacity to understand is NOT clear.
. It is NOT necessary if the pt is clearly competent or clearly in coma
!
_________________________________________________________________________
_________________

. MINORS:
__________
. Minors aren't determined to have the capacity to understand their
medical problems,
 . until the age of 18.

. Emancipation means that although the pt is under 18, he can make his
own decisions.
. Emancipated minors are living independently & self supporting, married
or in military.
. Partial emancipation is considered for (Sex - Reproductive health -
Substance abuse).

. If the pt is a minor & seeks ttt for contraception, STDs, HIV or

prenatal care,
. she is partially emancipated.
. i.e. she can make these decisions on her own,
. her privacy sh'd be resprected like that of an adult.

. An exception is ABORTION: 36 states have parental notification laws

for abortion.

. MINOR STATUS
|
______________________________________________
| |
UN-emancipated
Emancipated
| (Can consent for
care)
| |
. Age < 17 ys & must have consent . Married
from parent or legal guardian . In the
military
. Lives
separately from parents
& manages own
financies.

. N.B. Parents can NOT refuse lifesaving therapy for minors.

. Ex. If a blood transfusion w'd be lifesaving, the parents can't
refuse.
. Doing so w'd be considered child abuse.
. JEHOVAH's WITNESSES may refuse therapy for themselves but not for a
child.

. In an emergency, family members or friends of a Jehovah's witness who

suggest that a pt
. would not accept blood transfusion should be asked to provide
documentary evidence,
. such as an advance directive.
. Without this documentation or when uncertainity remains,
. it is advisable NOT to withhold blood in life threatening conditions.
_________________________________________________________________________
_________________

. INFORMED CONSENT:
____________________
. It is based on autonomy.
. Only a fully informed pt e' the capacity to understand the issues can
grant it.
. The pt must be informed of the benifits & the risks of the procedure.
. Alternatives of the procedure must be given.
 . The information is in a language the pt can understand.
. The informed consent must be given for each procedure.

. For emergency procedures, consent is implied in an emergency,

. when there isn't suffecient time to determine capacity or prior
wishes.
. If prior wishes are fully known, then this information takes
precedence.
. Consent obtained via telephone is considered valid.
. If the pt's proxy isn't present at the time of the procedure, then,
. consent via telephone counts.

. Pregnant women can refuse therapy, even if the life of the fetus is at
risk !!
. Until the fetus comes out of the body, it is considered part of the
woman's body.
. Ex. A woman can refuse a blood transfusion while pregnant.
. She can refuse antiretroviral ttt during prgnancy, even if the fetal's
life is at risk.
. Once the baby comes out, she can't refuse ttt for the baby.
_________________________________________________________________________
_________________

. CONFIDENTIALITY:
___________________
. The pt has an absolute right to privacy concerning his own medical
information.
. The following persons do NOT have a right to any of the medical
information of the pt:
-> Relatives, employers, friends & spouses.
-> Other physicians -> U can't release it without the express consent
of the pt.
-> Members of law enforcement: U can't release medical information to
courts or police without a court order or subpoena.

. BREAKING CONFIDENTIALITY TO PREVENT HARM TO OTHERS:

______________________________________________________
. If a pt has a TRANSMISSIBLE disease, such as T.B. or HIV,
. the physician can violate the pt's confidentiality to protect innocent
3rd parties.
. If u have T.B., your doctr can contact your close associates with OUT
your consent.
. If u have $, HIV or gonorrhea, your doctor can safely inform others
e'OUT your consent.

. The classic ex. is of a pt e' a psychiatric illness who may be

planning to harm others.
. The physician has the right to alert the person at risk to prevent
harm.
_________________________________________________________________________
_________________

. END OF LIDE ISSUES:

______________________
______________________
. An adult with capacity can withhold or withdraw any form of therapy.
. If the pt begins ttt, he or she has the right to withdraw any form of
ttt.
. The reasons for the withdrawal or withholding of care are not
important.
 . An advice directive is a set of instructions from an adult pt.
. with capacity directing the care of himself or herslf prior to losing
capacity.

. HEALTH CARE PROXY:

_____________________
. The strongest advance directive is a health care proxy.
. The proxy is both a document describing the care the person desire,
. as well as the appointment of an agent to be the decision maker.
. The agent as a decision maker doesn't take hold until the pt loses the
capacity.
. If I appoint a proxy but I'm still here, alert & communicative,
. you can't ask the agent for consent for my procedures.

. LIVING WILL:
_______________
. It is a writen document outlining the care desired by the patient.
. If a pt doesn't have a health care proxy, the living will can be very
useful.
. If the pt writes out "I never want to be intubated", this is valid.
. If he writes "No heroic measures", this is not valid.
. To be useful, a living will must be clear & precise.

. If a pt's family members disagree with a living will,

. and demand care that contradicts the pt's written wishes,
. the best initial step is -> DISCUSS THE MATTER WITH THEM.
. If discussion fails o resolve the condition -> consult the hospital's
ETHICS COMMITTEE.

. DO NOT RESUSCITATE (DNR) ORDERS:

___________________________________
. It means the refusal of endotracheal intubation & cardiopulmonary
resuscitation,
. in the event of the loss of the ability to breathe or the heart
stopping.
. A DNR doesn't mean the elimination of testing or medical therapy.

. PATIENT WITH NO CAPACITY & NO ADVANCE DIRECTIVE (PROXY OR LIVING

WILL):
_________________________________________________________________________
_
. This is the most complex & the most common circumstance.
. The care is based on the best understanding of the pt's wishes for
himself.
. Family & friends attempt to outline what they heard the pt say he
wanted.
. This is not the same as saying "This is what is best for the pt".
. Decisions are based on the best possible understanding of clearly
expressed wishes.
. If there is no clear expression of wishes,
. the the weakest basis on which to act is the "best interests of the
pt".

. ETHICS COMMITTEE:
____________________
. The ethics committee is used for cases in which the following are
true:
-> The pt is not an adult with capacity.
-> There are no clearly stated wishes on the part of the pt.
 . Also, the ethics committee is the answer if:
-> the caregivers, such as family, are split or in disagreement about
the nature of care.
-> If some family members say "He never wanted to be on a ventilator,
ever".
-> and some family members say "He might have wanted a ventilator
sometime",
-> then this a case for an ethics committee.

. COURT ORDER:
_______________
. It is the option when all the other options haven't given clarity.
. If their is disagreement after all the other steps, including an
ethics committee.
. You don't need a court order if the proxy clearly states wishes or
family in agreement.

. If parents refuse to consent to ttt of their child for a non-emergent

but ..
. potentially fatal medical case, the physician sh'd seek a court order
mandating ttt.

. FLUID & NUTRITION ISSUES:

____________________________
. An adult pt with capacity may refuse all forms of nutrition.
. There is no ethical basis for forcing fluids or nutrition upon a pt.
. If the pt is not an adult with the capacity to understand,
. the proxy or living will can direct the removal of fluid & nutrition,
. provided the pt's clearly expressed wishes while competent stated
that:
. "No artificial nutrition be started".
. In absence of clearly stated wishes on the issue fluids & nutrition,
they sh'd be given

. PHYSICIAN-ASSISTED SUICIDE & EUTHANASIA:

___________________________________________
. It means providing the pt with the means to end his own life.
. THIS IS ALWAYS WRONG !
. Euthanasia means the physician directly administers the means of
ending the pt's life.
. THIS IS ALWAYS WRONG !

. These are not the same as providing pain medications that may end the
pt's life.
. It is ethical to give pain medication, even if the only way to relieve
pain,
. may result in shortenening of life !

. The primary difference is clear:

-> In physician assisted suicide, the 1ry intent is to end life.
-> With a life shortened by pain medication, the 1ry intent is to
relieve suffering.

. FUTILE CARE:
_______________
. There is NO obligation on the part of the physician to provide care
that won't work !
. There is NO obligation to provide treatment without possible benifit.
 . Ex. A pt with widely metastatic cervical cancer develops renal
failure,
. the family members insist that dialysis be started. What do u tell
them ??!
-> You don't have to provide dialysis to a person who will certainly die
!!

. BRAIN DEATH:
_______________
. You are NOT obliged to provide care for a brain-dead patient.
. Brain death = Dead.

_________________________________________________________________________
_________________

. REPRODUCTIVE ISSUES:
_______________________
_______________________

. 1 . ABORTION:
________________
. A woman's right to an abortion varies by trimester of pregnancy:
-> 1st trimester -> A woman has UNRESTRICTED right to an abortion.
-> 2nd trimester -> A woman has access, but her rights are LESS CLEAR.
-> 3rd trimester -> NO CLEAR ACCESS to abortion (The fetus is
potentially viable).

. N.B. YOU DO NOT NEED THE CONSENT OF THE FATHER FOR THE ABORTION.

. 2 . DONATION OF GAMETES:
___________________________
. Pts have UNRESTRICTED RIGHT to donate sperm & eggs.
. There is no ethical problem with being a PAID DONOR for sperm & eggs.
. Note that one can't be a paid donor for organs, such as the kidneys or
the cornea.
_________________________________________________________________________
_________________

. HIV ISSUES:
______________
. A pt has a right to confidentiality of his HIV status.
. However, this confidentiality can be broken to prtect the uninfected,
. such as sexual & needle-sharing partners.

. No obligation for HIV +ve health care workers to disclose their HIV
status.
. This include surgeons.
. A surgeon doesn't have to disclose her HIV status to patient.

. Physicians have the legal right to refuse to treat any patient.

. It is not legal to refuse to take care of HIV +ve persons.
. It is unethical to refuse care to HIV +ve pts simply as they are HIV
+ve, BUT .....
. It is legal to do so !
_________________________________________________________________________
_________________

. DOCTOR PATIENT RELATIONSHIP:

_______________________________
_______________________________
 . ACCEPTING A PATIENT:
_______________________
. A physician doesn't have an obligation to accept a patient.
. The need of a person doesn't compel the physician to accept that
person as a pt.
. Ex. if there is only 1 neurosurgeon at a hospital & a pt needs
neurosurgery,
. this situation does NOT compel the physician to accept the pt.

. Once having accepted a pt, however, the physician can NOT simply
abandon the pt.
. The physician has an obligation to inform the pt that he must find
another physician,
. and the physician must render care until a substitute caregiver can be
identified.

. GIFTS:
_________
. Ethically acceptable -> Small gifts not tied to specific ttt or tests.
. Ethically UNacceptable -> Gifts given e' intention of getting a
specific prescription.

. SEXUAL CONTACT:
__________________
. Psychiatrists -> NEVER acceptable.
. Other physicians -> They must end the doctor-patient relationship
FIRST !

. ELDER ABUSE:
_______________
. Can be reported even against the will of the patient.
. Doesn't imply a specific age; it has to do e' the FRAGILITY of the pt.
. If the pt is frail & vulnerable, the abuse can be reported even
against the pt's will.

. IMPAIRED DRIVERS:
____________________
. Such as pts suffering from a seizure disorder,
. can NOT have their license taken away by a physician.
. Only the department of motor vehicles can remove or restrict a
license.

. TORTURE:
___________
. Physician participation in torture, on any level, is always WRONG.
. You can't even agree to certify the patient dead !
_________________________________________________________________________
_________________

. IMPAIRED PHYSICIANS:
_______________________
. Must be reported to an authority figure.
-> Physicians in training -> Reported to program director ar department
chair.
-> Faculty -> Reported to the department chair or the dean of the
medical school.
-> Those in practice -> Reported to the state medical board.

. The impairment must involve potential danger to medical care.

 . If u c a physician stealing a car, behavior is NOT reportable to the
department chair.

. If u c a physician at a bar dancing naked on the table top,

. but her medical performance is not impaired, this is NOT reportable.
_________________________________________________________________________
_________________

. TIPS & TRICKS:

_________________
_________________

. Tx of Alzheimer's dementia -> Acetylcholinesterase inhibitors

(Donepezil, Rivostigmine)

. Pts with homicidal thoughts sh'd be admitted at the psychiatric ward.

. Pt with meningitis -> Admit him against his will & start ttt.

. PASSIVE AGGRESSIVE BEHAVIOR:

. Individual expresses his aggression toward another person,
. with repeated passive failures to meet the other person's needs.

. When dealing with an angry pt, the most appropriate response is to:
. encourage a discussion about the source of feelings.
. ex. You seem to be angry about something, May I ask what is bothering
u so I can help?!

. If a pt is interested in alternative therapy, the physician sh'd 1st

inquire as to why?
. If a pt refuses ttt after being informed about cancer, he sh'd be
asked why u refuse ?

. DISPLACEMENT DEFENSE MECHANISM:

-> Shifting of emotions associated with an upsetting person to a safer
alternate object,
-> that represent the original.
-> Ex. Husband angry with his wife, breaks the car she gave to him !

. INTELLECTUALIZATION DEFENSE MECHANISM:

-> Transformation of an unpleasant event into a purely intellectual
problem - No emotions -> Ex. A doctor received the results of his
investigations & discovered that has cancer,
-> He went home & surfed the net for the most recent ways of ttt of
cancer.

. REACTION FORMATION DEFENSE MECHANISM:

-> Transformation of unwanted thought or feeling into its opposite.
-> REACTION FORMATION is NEITHER a splitting, NOR a dissociation.

. Genito-pelvic pain (Vaginismus) -> Pain with intercourse or attempted

penetration.

. Treatment response
-> When a pt demonstrates significant improvement with or without
remission.
-> Generally defined as a 50 % reduction in base line of severity.
 Dr. Wael Tawfic Mohamed
_________________________
 PULMONOLOGY TIKI TAKA
_______________________

. BRONCHIAL ASTHMA:
___________________
___________________

. SHORTNESS OF BREATH (SOB) + EXPIRATORY WHEEZES.

. Severe asthma -> Use of accessory muscles & inability of speaking
complete sentence.

. SEVERE ASTHMA EXACERBATION manifestations:

_____________________________________________
-> ++ RR = Hyperventillation.
-> -- in peak flow.
-> -- O2 = Hypoxia.
-> -- pH = Respiratory acidosis.
-> Possible absence of wheezes (To wheeze, one must have air flow!).

. Dx -> Pt with SOB & unclear if the cause is BA:

__________________________________________________
-> Do "PULMONARY FUNCTION TESTS" (PFTs) before & after INHALED
BRONCHODILATORS:
-> ++ in FEV1 > 12 % -> Confirmed BA.

. Dx -> Asymptomatic pt now i.e. H/O of intermittent SOB episodes but

now he is normal:
_________________________________________________________________________
_______________
-> Do "METACHOLINE STIMULATION TEST":
-> -- in FEV1 in response to synthetic acetylcholine (if the pt has BA).

. Tx -> ACUTE ASTHMA:

______________________
-> INHALED BRONCHODILATORS (SABA) -> ALBUTEROL.
-> BOLUS "Not inhaled" of steroids (Methyl prednisone).
-> INHALED IPRATROPIUM.
-> OXYGEN.
-> Magnesium.

. N.B. Any BA pt. with RESPIRATORY ACIDOSIS & CO2 RETENTION sh'd be
placed in the ICU.
-> Persistent resp. acidosis is an indication of INTUBATION & MECHANICAL
VENTILLATION.

. The following therapies have "NO BENIFIT" in acute asthma

exacerbation:
-> Theophylline - Cromolyn - Montelukast - INHALED steroids - LABA
"Salmeterol".

. NON-ACUTE BA:
________________
-> Best initial -> INHALED BRONCHODILATORs (ALBUTEROL).
-> Not controlled -> ADD + INHALED STEROIDs.
-> Not controlled -> ADD + INHALED LABA (SALMETEROL).

. Extrinsic allergies (HAY FEVER) -> Cromolyn or nedocromil.

. High Ig E levels not controlled with Cromolyn -> Omalizumab.
 . Atopic disease -> Montelukast.
. COPD -> Ipratropium.

. N.B. VVVVVVVVVVVVVV. imp. GERD can exacerbate airflow obstruction in

asthmatics:
_________________________________________________________________________
__________
. Due to ++ vagal tone & micro-aspiration of gastric contents into the
upper airway.
. Risk factors: Obesity, supine position after meals, laryngitis.
. Manifestations: Change in voice & NOCTURNAL COUGH. (ACE Is lead to day
& night cough!).
. Anti-GERD life style modification.
. Give a trial of a proton pump inhibitor (Esomeprazole).

. GERD is present in 75% of asthma pts & may be the trigger of many
cases.
. Adult onset asthma with GERD (Worsening syms after meals or with lying
down).
. Obesity, hoarsness, pharyngitis & laryngitis tend towards GERD.
. A trial of proton pump inhibitors (Omeprazole) can be both diagnostic
& therapeutic.

. N.B. Efficacy of BETA blockers for mortality in cases of MI & CHF is

more important than its adverse effects e.g. Asthma & COPD.

. N.B. Exercise induced asthma -> Tx with INHALED BRONCHODILARORS prior

to exercise.

. N.B. All pts with SOB sh'd 've -> O2 - pulse oximeter - CXR & ABG.

. TREATMENT OF BRONCHIAL ASTHMA DEPENDS ON ITS SEVERITY:

_________________________________________________________

* INTERMITTENT -> CONTINUE CURRENT REGIMEN SABA (B-agonists: ALBUTEROL):

_________________________________________________________________________
. Day time syms < 2 /week.
. Night time awakenings < 2 / month.
. B-agnists < 2 / week.
. Normal PFTs.
. No limitations on daily activities.

* MILD PERSISTENT -> ADD INHALED CORTICOSTEROIDS:

__________________________________________________
. Day time syms > 2 /week.
. Night time awakenings 3-4 / month.
. Normal PFTs.
. MINOR limitations on daily activities.

* MODERATE PERSISTENT -> ADD INHALED LABA (SALMETEROL):

________________________________________________________
. Daily symptoms.
. Weekly Night time awakenings.
. FEV1 <60 - 80 % of predicted.
. Moderate limitations on daily activities.

* SEVERE PERSISTENT -> ADD ORAL PREDNISONE:

____________________________________________
 . Symptoms through out the day.
. Frequent night time awakenings.
. FEV1 < 60 % of predicted.
. Severe limitation on daily activity.

. IMPORTANT DRUG SIDE EFFECTS:

______________________________
______________________________
. N.B. The most common adverse effect of INHALED CORTICOSTEROIDS is
OROPHARYNGEAL THRUSH.

. N.B. The most common adverse effect of "IV" CORTICOSTEROIDS is -- WBCs

"NEUTROPHILIA".
. Glucocorticoids ++ bone marrow release of of neutrophils.
. Glucocorticoids mobilize the marginated neutrophilic pool.
. Eosinophils & lymphocytes are decreased.

. N.B. High doses of B2 agonists may develop HYPOKALEMIA !

. Hypokalemia may present as ms weakness, arrhythmia & EKG
abnormalities.

. N.B. Theophylline toxicity:

. CNS stimulation (Headache, insomnia & seizures).
. GIT disturbances (Nausea & vomiting).
. Cardiac toxicity (Arrhythmia - Multifocal atrial tachycardia &
premature beat).
. Dx -> Measure serum theophylline levels.

. INDICATORS OF SEVERE ASTHMATIC ATTACK:

________________________________________
. NORMAL or INCREASED CO2 is the worst sign indicating acute severe
attack.
. CO2 retention is due to severe airway obstruction (air trapping) &
respirat. ms fatigue
. Speech difficulties.
. Diaphoresis.
. Altered sensorium.
. Cyanosis.
. SILENT lungs.

. ACUTE EPISODES of SOB MANAGEMENT:

___________________________________
-> Oxygen & ABG.
-> CXR.
-> SABA "ALBUTERL" INHALED.
-> IPRATROPIUM INHALED.
-> BOLUS of steroids (Methyl prednisone).-------> VVVVVVVVVVV. imp.
-> Chest, heart, extremity & nerological exam.
-> If fever, sputum & or new infiltrate is present on CXR:
ADD CEFTRIAXONE & AZITHROMYCIN for community acquired pneumonia.

. N.B. In pts with acute asthma exacerbation, an ELEVATED or even NORMAL

PCO2 = RF.
. Respiratory failure due to -- respiratory drive due to respiratory
muscle fatigue.
. ENDO-TRACEAL INTUBATION & MECHANICAL VENTILLATION is MANDATORY.
. Add inhaled SABA (Albeterol) & inhaled ipratropium & systemic
corticosteroids.
. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD):
_______________________________________________
_______________________________________________

. H/O of long term smoker with ++ SOB & -- exercise tolerance.

. Barrel shaped chest.

. Clubbing of fingers.
. ++ A-P diameter of the chest.
. Loud P2 heart sound (Sign of pulmonary hypertension).
. Edema (Sign of -- Rt ventricular out put).

. EKG -> Rt. axis deviation - Rt atrial & ventricular hypertrophy.

. CXR -> Elongated heart - Flattenning of the diaphragm due to
hyperinflated lungs.
. N.B. FLATTENING OF THE DIAPHRAGM ++ The WORK OF BREATHING.
. CBC -> ++ Hematocrit & reactive microcytic eryhthrocytosis due to
chronic hypoxia.
. ABG -> ++ pCO2 & -- pO2 & -- pH (Respiratory acidosis).
. Chemistry -> ++ serum bicarbonate as metabolic compensation for
respiratory acidosis.

. N.B. (1):
. ABG is critical in acute SOB due to COPD (No other way to assess for
CO2 retention !).

. N.B. (2):
. ABG is important to assess for CO2 retention.
. ABG is important to assess for the need for chronic home oxygen based
on pO2.

. N.B. (3):
. In moderate & severe cases of COPD, pts may become members of the
50/50 club !!
. Both pO2 & pCO2 are around 50s !
. Ex -> pH. 7.35 - pCO2 49 - pO2 52 - HCO3 32.

. PULMONARY FUNCTION TESTS in COPD -> OBSTRUCTIVE PATTERN:

___________________________________________________________
-> -- FEV1.
-> -- FVC (Loss of elastic recoil of the lung).
-> -- FEV1/FVC ratio.
-> ++ Total Lung Capacity (++ TLC due to air trapping ..
VVVVVVVVVVVV.imp.).
-> ++ Residual Volume.
-> -- Diffusion capacity lung CO (-- DLCO due to destruction of lung
interstitium).

-> INCOMPLETE IMPROVEMENT WITH ALBUTEROL (# Asthma).

-> LITTLE OR NO IMPROVEMENT WITH METACHOLINE (# Asthma).

. N.B. A bronchodilator response test to differentiate COPD from BA:

____________________________________________________________________
. Measuring FEV1 before & after adminstration of bronchodilator (B2
agonist).
. Significant improvement in FEV1 (> 15%) after bronchodilator ->
Reversibility = Asthma.
. Little or no improvement in FEV1 after bronchodilator ->
Irreversibility = COPD.
. N.B. Chronic hypercapneic respiratory failure due to COPD:
____________________________________________________________
. Marked acidosis should be the result of respiratory failure in COPD.
. But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 ->
Respiratory acidosis.
. To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption
instead !

. BOTTOM LINE -> The body compensates for chronic hypercapnea by ++

bicarbonate retention.

. CHRONIC MEDICAL THERAPY of COPD:

___________________________________
. IPRATROPIUM or TIOTROPIUM INHALED (Most effective therapy to reduce
syms in COPD).
. SABA ALBUTEROL INHALED.
. Pneumococcal vaccine -> Hepatavalent vaccine (Pneumovax).
. Influenza vaccine yearly.
. Long term home oxygen therapy (If pO2 < 55 or SO2 < 88%).

. N.B. Long term O2 therapy in a pulmonary hypertension pt or HCT > 55% -

> PaO2 < 60 mmHg.

. N.B. Both smoking cessation & home oxygen therapy & vaccines lower
mortality in COPD.

. N.B. SABA (Albuterol), Anticholinergic (Anti-muscarinic

ipratropium),LABA & STEROIDS:
improve symptoms only without -- mortality rate.

. N.B. INHALED ANTI-CHOLINERGICS = INHALED MUSCARINIC ANTAGONISTS -

INHALED IPRATROPIUM
are the most effective in COPD.

. N.B. Cromolyn & Montelukast have no benefit in COPD.

. ACUTE EXACERBATION OF COPD TTT:

_________________________________
. Acute worsening of symptoms in a pt. with COPD.
. Caused by upper respiratory tract infection.
. May be preceided by cough & fever.
. Exam -> Bilateral wheezes.
. ABG -> Respiratory acidosis & hypoxia.

. Inhaled bronchodilators (B2 agonists = Albuterol).

. Inhaled anti-cholinergics (Ipratropium).
. Broad spectrum antibiotics.
. INHALED CORTICOSTEROIDS for 2 weeks then tapered gradually.
. Smoking cessation.
. Oxygen (If pO2 < 55 mmHg or SO2 < 88%).

. N.B. Pts with acute on chronic respiratory failure ttt with high flow
supplemental O2,
. are at risk for developing worsening HYPERCAPNIA & CO2 NARCOSIS,
. due to a combination of reduced alveolar ventillation & ++ dead space
ventillation,
. causing ventillation perfusion mis-match & -- Hb affinity for CO2.
 . The goal oxy-hemoglobin saturation in these pts is 90 - 94 % (Not >
95%)!

. NON INVASIVE POSITIVE PRESSURE VENTILLATION (NIPPV):

_______________________________________________________
. Used in acute exacerbations of COPD REFRACTORY to ttt with B-agonist &
inhaed steroids.
. Used before intubation to avoid its side effects e.g. infection.
. Recommended in pt e' respiratory distress with a pH<7.35 or
pCO2>45mmHg or RR>25/min.
. It is contraindicated in septic, hypotensive or dysrhythmic pts.
. NIPPV will provide more O2 & wash out excess CO2.
. If the pt. is refractory to NIPPV -> Intubate with mechanical
ventillation !

. SPONTANEOUS PNEUMOTHORAX (A complication of COPD):

____________________________________________________
. COPD pt presenting with catastrophic worsening of respiratory
symptoms.
. Cigarette smoking markedly ++ risk of pneumothorax.
. It leads to chronic airway inflammation & respiratory bronchiolitis.
. The chronic destruction of the alveolar sacs -> Formation of large
alveolar blebs.
. which can rupture & leak air into the pleural space.
. presents with acute onset of chest pain & shortness of breath.
. Breath sounds are markedly reduced & hyperresonance to percussion on
affected side.

. VVVVVVVVV. IMP. TWO PRIMARY SUB-TYPES OF COPD: CHRONIC BRONCHITIS &

EMPHYSEMA:
_________________________________________________________________________
________

{A} . COPD with EMPHYSEMA pre-dominance -> (-- DLCO):

______________________________________________________
. Thin pts with severe dyspnea, hyperinflated chest.
. DECREASED vascular markings.
. SEVERE flattening of diaphragm.
. DECREASED DLCO -> due to alveolar destruction.

{B} . COPD with CHRONIC BRONCHITIS pre-dominance -> (NORMAL DLCO):

___________________________________________________________________
. Chronic productive cough for > 3months over 2 consecutive years.
. Due to hypersecretion of mucus & structural changes in the tracheo-
bronchial tree.
. PROMINENT vascular markings.
. MILD flattening of diaphragm.
. NORMAL DLCO.

. EXACERBATION OF CONGESTIVE HEART FAILURE:

___________________________________________
. H/O of coronary artery disease -> Lt ventricular dysfunction -> Heart
failure.
. Un-controlled hypertension & smoking H/O are risk factors for coronary
vascular disease
. LVF -> Tachypnea -> fluid pooling in the lungs -> pleural effusion ->
Hypoventillation.
. Hypoventillation -> Hypoxemia.
. Tachypnea -> Hypocapnia & respiratory alkalosis.
 . Signs of fluid overload - S3 & S4 gallops & cardiomegaly.
. Lung exam -> Bi-basilar crackles.
. Lung exam -> -- breath sounds at lung bases due to pleural effusion
from CHF.
. Wheezing can occasionally be present (Cardiac asthma).
. ABG -> HYPOXIA - HYPOCAPNIA - RESPIRATORY ALKALOSIS (COPD ->
Respiratoy ACIDOSIS).
. Dx -> BNP & PCWP.

. ALPHA 1 ANTI-TRYPSIN DEFECIENCY:

__________________________________
__________________________________
. Genetic disorder.
. Liver cirrhosis + COPD.
. NON-smoker.
. Early age < 40 ys NON-smoker having BULLAE at the base of the lungs.
. Dx -> CXR -> Findings of COPD (Bullae - Barrel chest - Flat
diaphragm).
. Dx -> Blood test -> -- ALBUMIN & ++ PT (Cirrhosis).
. Dx -> -- Alpha-1 antitrypsin level.
. Tx -> Alpha-1 antitrypsin infusion !

. BRONCHIECTASIS:
_________________
_________________
. Cough - mucopurulent sputum - hemoptysis.
. Profound dilatation of the bronchi.
. due to anatomic defect in the lungs mostly due to infection in
childhood.
. Episodes of lung infection with high volume of sputum.
. Hemoptysis & fever may occur.
. Dx -> CXR -> Dilated bronchi (TRMA TRACKING).
. Dx -> CT Chest -> Most accurate test.
. Tx -> No curative therapy.
. Just ttt the infectious episodes with rotating antibiotics to avoid
resistance.

. CYSTIC FIBROSIS:
__________________
__________________
. Young pt.
. Mutation in the Chloride transporter protein CFTR.
. Abnormally thick secretions.
. Affect the respiratory tract - sinuses - pancreas - intestines &
reproductive systems.
. Respiratory tract -> Chronic cough e' frequent exacerbations &
superimposed infections.
. Most pts develop BRONCHIECTASIS leading to HEMOPTYSIS.
. Pancreas -> Fat malabsorption with bloating & greasy, floating stools.
. Dx -> CT -> Atrophic pancreas with calcifications.

. INTERSTITISAL LUNG DISEASES (ILD):

____________________________________
____________________________________

. Pulmonary fibrosis 2ry to environmental or occupational exposure

(Pneumoconiosis).
. Also caused by medications (NITROFURANTOIN & TMP-SMX "BACTRIM").
. If the etiology is unknown (IDIOPATHIC PULMONARY FIBROSIS).
 . ASBESTOSIS -> Shipyard - Mining - Construction workers - Pipe
fitters).
. SILICOSIS -> Glass workers - Mining - Sandblasting & Brickyards.
. COAL WORKER's PNEUMONIA -> Coal worker !
. BYSSINOSIS -> COTTON.
. BERYLLIOSIS -> Electronics - Ceramics - Fluorescent & Light bulbs.
. PULMONARY FIBROSIS -> Mercury.

. Shortness of breath.
. "DRY" = NON productive cough & chronic hypoxia.
. Dry rales - Bi-basilar end-inspiratory crackles.
. Loud P2 (Sign of pulmonary hypertension).
. Digital clubbing.
. NOOOO FEVER - NOOOO systemic findings.

. Dx -> CXR -> Interstitial fibrosis & Honeycombing.

. Dx -> CXR -> Pulmonary vascular congestion at the hilum.
. Dx -> CT -> PLEURAL PLAQES ARE PATHOGNOMONIC (Pneumoconiosis)!
. Dx -> Lung biopsy.
. Dx -> PFTs -> ALL MEASURES ARE DECREASED but PROPORTIONATELY.

. PULMONARY FUNCTION TESTS in ILD -> RESTRICTIVE PATTERN:

__________________________________________________________
-> -- FEV1.
-> -- FVC.
-> NORMAL FEV1/FVC ratio.
-> -- TLC.
-> -- RV.
-> -- DLCO (VVVVVVVVVV. imp.).

-> VVVVVVVVVV. imp. -> ILF -> +++ A-a gradient !

. Tx -> No specific therapy to reverse any of ILD forms.

. If the lung biopsy shows an inflammatory infiltrate, a trial of
steroids is used.
. The only form of ILD that responds to steroids is BERYLLIOSIS
(Granulomatous disease).

. N.B. The most common type of cancer in ASBESTOSIS is LUNG CANCER not
mesothelioma.

. N.B. ILD may be complicated by COR PULMONALE:

-> peripheral edema - Hepatojugular reflex - Jugular venous distension -
Rt ventr. heave.

. COMPARISON BETWEEN PFTs in COPD & ILD:

________________________________________
. COPD -> OBSTRUCTIVE PATTERN & ILD -> RESTRICTIVE PATTERN:
___________________________________________________________

. PFTs ___________ COPD __________ ILD

. FEV1 ___________ ---- __________ --

. FVC ___________ -- __________ --
. FEV1/FVC _______ -- __________ NORMAL
. TLC ____________ ++ __________ --
. RV _____________ ++ __________ --
. DLCO ___________ -- __________ --
. BRONCHILOTIS OBLITERANS ORGANIZING PNEUMONIA BOOP / CRYPTOGENIC
ORGANZING PNEUMONIA COP:
_________________________________________________________________________
_________________
_________________________________________________________________________
_________________
. Inflammation of the small airways with a chronic alveolitis of an
unkown origin !
. Associated with Rheumatoid arthritis.
. Resembles ILD but more acute presentation (Over weeks to months).
. (SOB - Cough - rales) + FEVER + MALAISE + MYALGIA.
. No occupational exposure in history !
. CXR -> Bilateral PATCHY infiltrates.
. CT -> Inerstitial disease & alveolitis.
. Most accurate -> OPEN LUNG BIOPSY !
. Tx -> Steroids (No response to antibiotics).

. COMPARISON BETWEEN BOOP/COP & ILD:

____________________________________

. BOOP/COP _______________________________ . ILD

. Fever- myalgia - malaise _______________ . NO.

. Presents over days to weeks ____________ . 6 months or more of
symptoms.
. PATCHY infiltrates _____________________ . INTERSTITIAL infiltrates.
. STEROIDs EFFECTIVE _____________________ . Only BERYLLIOSIS may
respond to steroids.

. SARCOIDOSIS:
______________
. AFRICAN AMERICAN WOMEN.
. Age < 40s.
. SOB - Cough & fatigue over a few weeks to months.
. Lung - > Rales.
. Eye -> ANTERIOR UVEITIS (Sight threatening).
. Neural -> Facial palsy (7th cranial nerve).
. Skin -> ERYTHEMA NODOSUM.
. Joint -> Polyarthralgia.
. Heart -> RESTRICTIVE CARDIOMYOPATHY.
. HYPERCALCEMIA (2ry to Vit.D production by the granulomas).

. Dx -> Best initial test -> CXR.

. CXR -> BILATERAL HILAR LYMPHADENOPATHY & diffuse interstitial
infiltrates.

. Dx -> Most accurate test -> LUNG or LN biopsy -> NON-CASEATING

GRANULOMA.
. Dx -> ++ Ca & ++ ACE levels
. Dx -> BAL -> ++ helper cells.

. Tx -> STEROIDs.

. SYSTEMIC SCLEROSIS:
_____________________
. Pulmonary symptoms (Due to interstitial fibrosis).
. Dysphagia.
. Raynaud's phenomenon.
 . Hypertension.
. Telangiectasia.

. PULMONARY HYPERTENSION:
_________________________
. Mean pulmonary arterial blood pressure > 25 mmHg.
. Overgrowth & obliteration of pulmonary vasculature -> -- outflow of
the Rt ventricle.
. SOB more often in young women.
. May be 2ry to (MS - COPD - PCV - ILD & chronic pulmonary emboli).
. Physical findings (Loud P2 - TR - RV heave).
. Dx -> TRANS-THORACIC ECHOCARDIOGRAM (TTE) -> Rt atrial & ventricular
hypertrophy.
. Dx -> EKG -> Rt axis deviation.
. Dx -> CXR -> Pulmonary arteries enlarg. & RVE & tapering of distal
vessels (Pruning).
. Most accurate -> RIGHT HEART SWAN GANZ CATHETERIZATION -> ++ PULMONARY
ARTERY pressure.
. Tx -> BOSENTAN -> Endothelial inhibitor.
. May be complicated by RVF (Rt ventricular heave - JVD - Tender
hepatomegaly - Ascites).

. COR PULMONALE:
________________
. Rt sided heart failure due to pulmonary disease.
. Jugular venous distension.
. Right sided S3 gallop.
. Right ventricular heave.
. Hepatomegaly.
. Ascites.
. Dependent LL edema.
. Most commonly caused by COPD (Flattened diaphragm - prominent
pulmonary vessels on CXR)
. CXR -> Prominent right ventricle & pulmonary artery.

. PULMONARY EMBOLISM:
_____________________
_____________________
. PERFUSION DEFECT & NO VENTILLATION DEFECT.
. ++++++++++++++++++++++++++++ A-a gradient.

. SUDDEN onset SOB + CLEAR LUNGs.

. Risk factors of DVT (Immobility - Malignancy - Trauma - Surgery -
Thrombophilia).
. H/O of recent orthopedic surgery followed by bed rest.
. No specific physical finding for PE.

. MODIFIED WELL'S CRITERIA for PRE-TEST PROPABILITY of PE:

___________________________________________________________
-> Score + 3 points (Clinical signs of DVT).
-> Score + 1.5 points (Prev PE/DVT - HR>100 - Recent surgery <4wks -
Immobilization>3ds)
-> Score + 1 point (Hemoptysis - cancer).
-> Total score for clinical propability (< 4 -> PE UN-likely .. > 4 ->
PE likely).

. . Clinical assessment for pulmonary embolism

.____________________________________________
 .< Modified Well's criteria>
.____________________________
|
.________________________________
.| .|
. PE UN-likely . PE likely
.______________ .___________
.| .|
. D-dimer assay .|
._______________ .|
.| .|
.___________________ .|
.| .|
.(< 500 ng/ml) .(> 500 ng/ml)-->. CT PULMONARY
ANGIOGRAPHY
.|
.____________________________
. PE EXCLUDED .|
.(-ve = PE EXCLUDED BUT +ve =
PE CONFIRMED)

. INITIAL DIAGNOSTIC TESTS -> CXR - EKG - ABG.

. CONFIRMATORY TESTS -> Spiral CT - V/Q scan - LL Doppler - D-Dimer.
. MOST ACCURATE TEST -> PULMONARY ANGIOGRAPHY = CHEST CT ANGIOGRAPHY
with IV CONTRAST.

. 1 . CXR:
___________
. Most common result -> NORMAL.
. Most common abnormailty -> Atelectasis.
. Wedge shaped infarction & pleural humps are rare.

. 2 . EKG:
___________
. Most common showing -> SINUS TACHYCARDIA.
. Most common abnormality -> NON-SPECIFIC ST-T WAVE CHANGES.
. Right axis deviation & Rt BBB are rare.

. 3 . ABG:
___________
. HYPOXIA -> ++ A-a gradient.
. Mild respiratory alkalosis.

. 4 . SPIRAL CT -> TEST OF CHOICE if the CXR is ABNORMAL:

__________________________________________________________
. Standard to confirm the presence of a pulmonary embolus.
. Excellent if +ve being specific.
. Not specific as it can miss some emboli if they are small & in the
periphery.
. Chest CT showing a WEDGE SHAPED infarction is PATHOGNOMONIC for
pulmonary embolism.

. 5 . VENTILLATION PERFUSION V/Q SCAN -> TEST OF CHOICE if the CXR is

NORMAL:
_________________________________________________________________________
_____
. PERFUSION DEFECT with NO VENTILLATION DEFECT.
. NORMAL V/Q scan excludes pulmonary embolism.
 . 6 . LOWER EXTREMITY DOPPLER:
_______________________________
. If +ve -> No further tests are needed to confirm PE.
. The problem is that 30 % of PEs originate in pelvic veins, so the LL
Doppler is NORMAL.
. So it has low sensitivity i.e. can't exclude PE.

. 7 . D-DIMER TESTING = FIBRIN SPLIT PRODUCTS TESTING:

_______________________________________________________
. SINGLE TEST TO EXCLUDE PE.
. Very sensitive test with poor specificity.
. D-DIMER -> NEGATIVE -> NO PULMONARY EMBOLISM.
. D-DIMER -> Not specific -> May be other causes.
. The best use of D-DIMER test is in a pt with LOW propability of PE,
. & u want a single test to exclude PE !!

. 8 . ANGIOGRAPHY -> SINGLE MOST ACCURATE TEST FOR PE:

______________________________________________________
. ANGIOGRAPHY = CHEST CT ANGIOGRAPHY WITH INTRAVENOUS CONTRAST (VVVVVV.
imp.).
. INVASIVE with risk of death (0.5%).

. MANAGEMENT of PULMONARY EMBOLISM:

___________________________________
{1} HEPARIN & OXYGEN -> Standard of care.
{2} Warfarin -> Sh'd be used at least for 6 months after Heparin.
{3} IVC filter -> in case of contraindication to Anticoagulants (e.g.
hematoma).
{4} Thrombolytics -> used in pts who r hemodynamically UN-stable (e.g.
hypotension).
{5} Embolectomy is rarely done (High risk of death).

. N.B. When the case so clearly suggests a pulmonary embolism,

. i.e. Pt presenting with sudden onset of SOB & clear lungs with H/O of
major surgery,
. the 1st thing to do is CXR & ABG followed by HEPARIN.
. Don't wait the results of V/Q scan or spiral CT to start heparin !!

. When there is a contraindication to anticoagulation e.g. hematoma,

. Don't use heparin ! Place an IVC filter.

. For anticoagulation, "Un-fractionated" heparin is preferred in pts

with -- GFR !
. LMW heparin (Enoxaparin) can't be given as it causes severe renal
insuffeciency.

. Warfarin can be thrombogenic without heparin as a bridge !

. It sh'd be given after initiating heparin with PTT goal 1.5-2 times of
normal.
. Warfarin takes up to 5-6 days to reach its therapeutic level.
. After reaching therapeutic INR level (2-3), heparin can be stopped.

. VVVVVV. imp. N.B. A PROGRESSING CLOT in a pt with sub-therapeutic INR

(ex. 1.2),
. requires BRIDGING HEPARIN until the INR is therapeutic (2-3),
. Example .. A pt recently hospitalized for LL DVT then discharged,
. After 5 days, U$ reveals popliteal vein thrombosis extending into the
deep femoral vein
. So .. U sh'd START INTRAVENOUS UNFRACTIONATED HEPARIN & CONTINUE
WARFARIN.
. The proximal deep leg veins are the most common source of symptomatic
pulmonary embolism
. Less common sources of emboli include calf, pelvic & upper evtremity
veins & Rt heart.

. "Factor V Leiden" is the most common genetic disorder causing

hypercoagulability & DVT.

. N.B. Acute massive pulmonary embolism can present initially with

syncope & shock.
. e.g. sudden loss of consciousness at work, BP:80/40 & HR:120/min with
cold clammy skin.
. Rt heart catheterization -> ++ Right atrial & pulmonary artery
pressures.
. Normal PCWP Pulmonary artery capillary wedge pressure.

. N.B. Massive pulmonary embolism usually presents with signs of low

arterial perfusion,
. Hypotension, acute dyspnea, pleuritic chest pain, tachycardia &
syncope.
. The thrombus ++ pulmonary vascular resistance & Rt ventricular
pressure,
. causing Rt ventricular hypokinesis -> Rt ventricular dilatation.

. APPROACH TO MANAGEMENT OF PATIENT WITH SUSPECTED PULMONARY EMBOLISM:

______________________________________________________________________
______________________________________________________________________

. Stabilize the pt with Oxygen & IV fluids

._________________________________________
.|
. CONTRAINDICATIONS to Anticoagulate ?
._____________________________________
.|

._______________________________________________
.|
.|
. YES = Diagnostic tests to evaluate for PE . NO = MODIFIED
WELL's CRITERIA
.__________________________________________
._______________________________
.|
.|
._____________________
._______________
.| .| .|
.|
. +ve PE . -ve PE . PE Un-likely
. PE likely
.________ .________
.______________ .___________
.| .| .|
.|
. IVC FILTER . No further tests .| .
START anticoagulation
.|
.______________________
 .|
.|
. D-DIMER
TESTING for PE

.________________________

.|

._____________________________________________________________________
.|
.|
. +ve
. -ve
. Start or continue anticoagulation, . STOP
anticoagulation
. consider surgery or thrombolysis if indicated.

. PLEURAL EFFUSION:
___________________
___________________

. Best initial test -> CXR.

. Decubitus films (Pt lying on one side) sh'd be done next to assess the
fluid mobility.

. Most accurate test -> THORAC-CENTESIS.

. Un-diagnosed pleural effusion is best evaluated with THORACOCENTESIS,
. To detect whether it is a transudate or an exudate.
. Except in pts with clear-cut evidence of congestive heart failure,
. Associated fluid overgain, pedal edema & bilateral lung base crackles.
. Diuretics & echo sh'd be done not thoracocentesis.

. COMPARISON BETWEEN EXUDATE & TRANSUDATE (VVVVVVVVVVV. imp.):

_______________________________________________________________

. EXUDATE PLEURAL EFFUSION ______________________ . TRANSUDATE PLEURAL

EFFUSION

. Cancer & infection & Pulmonary embolism _______ . Congestive heart

failure & cirrhosis.

. High ptn level > 50 % of serum level __________ . Low ptn level < 50 %
of serum level.
. High LDH level > 60 % of serum level __________ . Low LDH level < 60 %
of serum level.
. LDH > 2/3 upper limit of normal serum LDH (250) . < 2/3 !

. pH > 7.3 (Normal 7.6) ______________________ . pH < 7.3 (++ acid prod.
by bacteria).

. NO CHANGE IN GLUCOSE OR AMYLASE LEVELS IN BOTH TYPES !

. Tx -> Small pleural effusions don't need therapy !

. Diuretics can be used for those caused by congestive heart failure.
. Larger effusions esp. those caused by empyema -> Drain by CHEST TUBE.
. Large recurrent effusion from an un-correctable cause -> PLEURODESIS.
. If pleurodesis failed -> Decortication.
 . N.B. 1 -> EXUDATE -> MALIGNANCY OR INFECTION -> ++ Capillary
permeability.
. N.B. 2 -> TRANSUDATE -> CONGESTIVE HEART FAILURE -> ++ HYDROSTATIC
PRESSURE.
. N.B. 3 -> TRANSUDATE -> CIRRHOTIC LIVER FAILURE -> -- PLASMA ONCOTIC
PRESSURE.

. COMPLICATED PARA-PNEUMONIC EFFUSION CRITERIA:

________________________________________________
. Exudative pleural effusion.
. Pleural fluid acidosis.
. Low pleural fluid glucose < 60 mg/dl(High metabolic activity of
leukocytes or bacteria)

. INDICATIONS OF TUBE THORACOTOMY in PARA-PNEUMONIC FLUID ACCUMULATION:

________________________________________________________________________
1- pH of the pleural fluid < 7.2.
2- Glucose < 60 mg/dl.

. EMPYEMA = INFECTION OF THE PLEURAL SPACE:

___________________________________________
. Due to untreated pneumonia cased by bacterial invasion of a pleural
effusion.
. or contamination of the pleural space by rupture of a lung abscess.
. Others: Bronchopleural fistula - penetrating trauma - thoracotomy or
ruptured viscus.
. May complicate hemothorax, the residual blood is an excellent medium
for bacteria.
. A mixed aerobic & anaerobic bacterial infection (Strept. - Staph. -
Klebsilella).
. Low grade fever.
. Dx -> CT scan.
. Tx -> Drainage & antibiotics.
. Tx -> SURGERY (If localized - complex or having thick rim).

. SLEEP APNEA:
______________
. Obese pt complaining of daytime somnolence.
. The pt's partener will report severe snoring.
. Hypertension - Headache - Erectile dysfunction & fat neck.

. Obstructive sleep apnea from fatty tissues of the neck blocking

breathing.
. Central sleep apnea due to -- respiratory drive from the CNS.

. Dx -> NOCTURNAL POLYSOMNOGRAPHY (GOLD STANDARD OF DIAGNOSIS).

. Mild sleep apnea -> 5 - 20 apneic periods per hour.

. Severe sleep apnea -> > 30 apneic periods per hour.

. Tx of obstructive sleep apnea -> Weight loss & CPAP:Continous positive

airway pressure
. If not effective -> Uvulo-palato-pharyngo-plasty.

. Tx of central sleep apnea -> Avoid alcohol & sedatives.

. Medroxyprogesterone -> Central respiratory stimulant.

. OBESITY HYPOVENTILLATION $YNDROME (OH$) = PICKWICKIAN $YNDROME:

_________________________________________________________________
 . Severe obesity (Greater then 150% of ideal body weight -> BMI = 55!).
. Thin neck & hypersomnolence.
. Obesity -> Distant heart sounds & Low voltage QRS complexes on EKG.
. Alveolar hypoventillation during WAKEFULLNESS !
. Polycythemia secondary to alveolar hypoventillation.
. ABG -> Hypoxemia & Hypercapnia & Respiratory acidosis.
. Due to DECREASED LUNG & CHEST WALL COMPLIANCE ! (Not resp. ms weakness
xxx).
. Tx -> Weight loss - Ventilator support - Oxygen - Avoid supine posture
during sleep.

. COMPLICATIONS of long-standing OSA or OH$:

____________________________________________
. Pulmonary hypertension with cor pulmonale.
. Secondary erythrocytosis.
. Hypoxia, chronic hypercapnea & respiratory acidosis (Due to chronic
hypoventillation).

. N.B. Chronic hypercapneic respiratory failure due to OH$:

___________________________________________________________
. Marked acidosis should be the result of respiratory failure in OH$.
. But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 ->
Respiratory acidosis.
. To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption
instead !

. HOW TO DIFFERENTIATE BETWEEN OBSTRUCTIVE SLEEP APNEA & OBESITY

HYPOVENTILLATION $:
_________________________________________________________________________
___________
_________________________________________________________________________
___________

.{1}. OBSTRUCTIVE SLEEP APNEA:

_______________________________
. Air flow is impeded by AIRWAY OBSTRUCTION,
. due to POOR ORO-PHARYNGEAL TONE.
. NORMAL ABG !

.{2}. OBESITY HYPOVENTILLATION $:

__________________________________
. Air flow is impeded by diminished expansion of chest & abdominal wall
due to obesity.
. ABG -> HYPO-ventillation -> Chronic hyoxia & hypercapnia.

. ALLERGIC BRONCHO-PUMONARY ASPERGILLOSIS (ABPA):

_________________________________________________
. Asthmatic pt with worsening asthma symptoms.
. Coughing of brownish mucous plugs with recurrent infiltrates.
. Peripheral eosinophilia.
. ++ Ig E levels.
. Central bronchiectasis may be seen.
. Tx -> ORAL (Not inhaled) corticosteroids.

. PULMONARY EDEMA:
__________________
. Hypoxia - SOB - Tachypnea.
. CXR -> Diffuse alveolar infiltrates.
 . May be cardiogenic (LVF) or non cardiogenic (ARD$).
. Differentiate bet. the two types using pulmonary capillary wedge
pressue (PCWP).
. PCWP > 18 -> Cardiogenic pulmonary edema.
. PCWP < 18 -> Non cardiogenic = ARD$.

. ACUTE RESPIRATORY DISTRESS $YNDROME (ARD$) = NON-CARDIOGENIC PULMONARY

EDEMA:
_________________________________________________________________________
______
. Sudden severe respiratory failure resulting from diffuse lung injury,
. secondary to a number of overwheming systemic injuries e.g.
. Sepsis - Aspiration of gastric contents - shock - severe infections,
. Lung contusion - trauma - toxic inhalation - drowning - pancrestitis -
burns.

. CXR -> Diffuse patchy infiltrates.

. NORMAL wedge pressure -> i.e. < 18.
. pO2/FiO2 ratio < 200.

. Tx -> Ventilatory support with low tidal volume of 6 ml/kg.

. PEEP to keep the alveoli open. (Sh'd reach 15 cm H2O).
. ++ FiO2 (Never exceed 60 %).
. Prone positioning of the pt's body.
. Possible use of diuretics & +ve inotropes such as dobutamine.
. Transfer the pt to the ICU if not already there !
. STEROIDS ARE NOTTTTTTT EFFECIVE !

. ARD$ pts on MECHANICAL VENTILLATION:

_______________________________________
. Mechanical ventillation includes two components FiO2 & PEEP.
. FiO2 = Fraction of inspired oxygen.
. PEEP = Positive end expiratory pressure.
. ++ FiO2 -> Improves oxygenation.
. PEEP -> Prevent alveolar collapse.

. Arterial pO2 is influenced by FiO2 & PEEP.

. Arterial pCO2 is influenced by RR & TV.

. When you find a given ABF with pO2 55 mmHg = Low oxygenation. & FiO2 =
70%
. So .. You should add PEEP 1st to improve oxygenation.
. Don't decrease the FiO2 before adding PEEP or you will worsen the
condition !

. When you find a given ABG with pO2 105 mmHg = TOXIC OXYGEN LEVEL.
. You should decrease the fractionated oxygen level FiO2 to non toxic
value < 60% !
. PEEP may be ++ as needed to maintain adequate oxygenation but avoid
tension pneumothx.

. When you are given an ABG with respiratory alkalosis (pH > 7.4) &
hypocapnia (--CO2),
. With appropriate tidal volume < 6 ml/kg (pt. 70 kg -> 420 ml).
. With appropriate FiO2 (Ex. 40 %),
. With appropriate PEEP (Ex. 5 cm H2O),
. Look at the respiratory rate (If it is high e.g. 18),
. This respiratory alkalosis will be due to HYPER-ventillation.
. So .. Decreasing the respiratory rate is the most appropriate step.
 . Ventillation = RR x TV.
. Respiratory alkalosis results from hyperventillation.
. The RR sh'd be lowered.
. -- in TV can trigger ++ in RR -> worsening the condition.

. POSITIVE END-EXPIRATORY PRESSURE (PEEP):

__________________________________________
. Used in cases of hypoxemic respiratory failue e.g. ARD$ & cardiogenic
edema.
. Helps to maintain air way pressure above atmospheric pressure at the
end of expiration.
. Complications -> Alveolar damage - tension pneumothorax & hypotension.
. Sudden SOB - --BP & ++ HR - tracheal deviation & unilateral absence of
breath sounds.

. SWAN-GANZ (PULMONARY ARTERY) CATHETERIZATION:

_______________________________________________
-> Hypovolemic shock -> -- COP & -- CPWP & ++ TPR.
-> Cardiogenic shock -> -- COP & ++ CPWP & ++ TPR.
-> SEPTIC SHOCK ------> ++ COP & -- CPWP & -- TPR.

. COP -> LOW except in septic shock (High).

. PCWP -> LOW except in cardiogenic shock (High).
. TPR -> HIGH except in septic shock (Low).

. PCWP is NORMAL in ARD$. (VVVVVVVVVV. imp.).

. PCWP is NORMAL in PE. (VVVVVVVVVVVV. imp.).

. PNEUMONIA:
____________
. Fever, cough & sputum.
. Severe illness -> SOB.

. COMMUNITY ACQUIRED PNEUMONIA (CAP) -> PNEUMOCOCCUS.

. HOSPITAL ACQUIRED PNEUMONIA (HAP) -> Gram -ve bacilli.

. PPI ++ the risk of hospital acquired pneumonia.

. Pts > 65ys with chronic dis. of lungs or liver are more prone to
respiratory failure.
. DM - HIV - Steroid use - Asplenia -> Worse prognosis.
. ELDERLY HYPOXIC PT WITH OR WITHOUT FEVER SHOUL BE ADMITTED !

. Dx -> Best initial test -> CXR.

. Dx -> Most accurate test -> Sputum gram stain & culture.

. N.B. All pts with suspected pneumonia sh'd have a CXR done as the 1st
step.
. Antibiotics sh'd be adminstered ASAP without waiting for sputum gram
stain or culture.

. Tx -> OUT-PATIENT PNEUMONIA:

_______________________________
-> Macrolide (Azithromycin - Doxycycline - Clarithromycin).
-> Respiratory fluoroquinolone (Levofloxacin - Moxifloxacin).

. Tx -> IN-PATIENT PNEUMONIA:

______________________________
-> Ceftriaxone & Azithromycin.
-> Fluoroquinolone as a single agent.
 . REASONS TO HOSPITALIZE pts with pneumonia:
_____________________________________________
. Hypotension -> SBP < 90 mmHg.
. Tachycardia -> HR > 125/min.
. Temperature -> T -> 104 F.
. Respiratory rate -> RR > 30/min.
. PO2 < 60 mmHg.
. pH < 7.35
. BUN > 30 mg/dl.
. Na < 130.
. Glucose > 250.
. Confusion.
. Age > 65 ys or older.
. Co-morbidities eg. cancer, COPD, CHF & RF or liver disease.

. HYPOXIA & HYPOTENSION as single factors are a reason to hospitalize !

. Tx -> VENTILLATOR ASSOCIATED PNEUMONIA (VAP):

________________________________________________
. VAP -> Fever - Hypoxia - New infiltrate & ++ secretions.
-> Imipenim - Cefepime or Piperacillin/Tazobactam.
-> Gentamycin & Vancomycin.

. INDICATIONS OF TUBE THORACOTOMY in PARA-PNEUMONIC FLUID ACCUMULATION:

________________________________________________________________________
1- pH of the pleural fluid < 7.2.
2- Glucose < 60 mg/dl.

. SPECIFIC ASSOCIATIONS:
_________________________
* Recent viral infection -> Staphylococcus.
* Alcoholics -> Klebsiella.
* GIT syms & confusion -> Legionella.
* Young healthy pts -> Mycoplasma.
* Animal contact -> Coxiella Burnetii.
* Arizona construction workers -> Coccidioidmycosis.
* HIV with < 200 CD4 cells -> Pneumocystis carinii PCP.

. MYCOPLASMA PNEUMONIAE:
________________________
. Most common cause of atypical pneumonia.
. Non productive i.e. dry cough.
. Many extra-pulmonary symptoms (Headache - sore throat - skin rash).
. ERYTHEMA MULTIFORME -> Dusky red TARGET shaped skin lesions on
extremities.
. CXR -> Lower lobe interstitial infiltrates.
. No cell wall (Only polymorphnuclear cells will appear on gram stain).

. MYCOBACTERIAL PNEUMONIA:
__________________________
. HIV pts have a higher risk of reactivation of tuberculosis.
. Non specific symptoms (Cough - Weight loss - Fatigue - Low grade fever
& Night sweats).
. CXR -> UPPER LOBE INFILTRATES WITH CAVITATION.

. ASPIRATION PNEUMONIA = ANAEROBIC PNEUMONIA:

_____________________________________________
. Impaired swallowing due to IMPAIRED EPIGLOTTIC REFLEX is the most imp.
predisp. factor.
 . Aspiration of oro-pharyngeal secretions.
. May be a complication of upper GI endoscopy.
. Usually caused by ANAEROBES & Streptococcal viridans.
. Advanced age, poor dentition, dementia, alcohol addiction are
predisposing factors.
. Pt presents with systemic syms e.g. fever & malaise & FOUL SMELLING
SPUTUM.
. Tx -> CLINDAMYCIN.

. KLEBSIELLA PNEUMONIA = FRIEDLANDER's PNEUMONIA:

_________________________________________________
. Gram -ve bacilli.
. More associated with ALCOHOLICS & immunocomprized pts with
neutropenia.
. Mechanism -> Colonization in the oropharynx followed by
microaspiration of secretions.
. Mostly affect the UPPER lobes.
. produce CURRANT JELLY sputum.
. Sputum culture -> Mucoid colonies.

. PNEUMOCYSTIS CARINII PNEUMONIA (PCP):

_______________________________________
. Almost exclusively in AIDS pts with CD4 count < 200.
. The HIV pt is usually not on prophylaxis for PCP!
. Immunocompromized pt due to chemotherapy.
. Dyspnea on exertion, dry cough & fever.
. Dx -> Best initial test -> CXR -> Bilateral interstitial infiltrates
(CHARACTERISTIC).
. Dx -> ABG -> Hypoxia & ++ A-a gradient. (VVVVVVV imp.).
. Dx -> ++ LDH level (Normal LDH level excludes PCP).
. Dx -> Most accurate test -> BRONCHO-ALVEOLAR LAVAGE. (VVVVVVVVV.
imp.).
. Dx -> Sputum stain -> if +ve -> Confirm PCP & if -ve -> Bronchoscopy.
. Tx -> Best initial therapy for treatment & prophylaxis -> TMP-SMX.
. If PCP is severe (pO2 < 70 or A-a gradient > 35) -> Add STEROIDS to --
mortality.
. If there is toxicity from TMP-SMX (Rash - BM depression) ->
PENTAMIDINE or Primaquine.
. If the pt is African American with G6PD (Bite cells on smear) -> Don't
give Primaquine.
. For PCP prophylaxis -> TMP-SMX .. if there is a rash or neutropenia ->
Atovaquone.
. If CD4 count is ++ & maintained above 200 for several months -> Stop
prophylaxis.
. But, NEVER to stop the anti-retroviral medications against HIV !

. LEGIONNAIRE's DISEASE:
________________________
. H/O of recent TRAVEL or trip (BAHAMAS).
. Linked to cruise ship & hotel water supplies.
. HIGH GRADE FEVER > 39 c.
. GIT symptoms (Nausea & vomiting & loose stools).
. Mild ++ LFTs.
. HYPONATREMIA (PATHOGNOMONIC for LEGIONELLA).
. CXR -> Focal lobular consolidation.
. Gram -ve stain rod & stains poorly (Intracellular organism).
. So.. Gram stain will show many neutrophils but no organisms is
chracteristic.
. Most accurate test -> Urine antigen test.
. Tx -> AZITHROMYCIN or Levofloxacin.
 . N.B. ACUTE PNEUMONIA WITH CONSOLIDATION & PHYSILOGIC SHUNT:
______________________________________________________________
. -- Breath sounds, ++ Tactile vocal fremitus.
. Alveoli of the affected lung become filled with exudative fluid &
cellular debris.
. These alveoli may have persistent blood flow to areas with impaired
ventillation.
. Leading to a physiologic intra-pulmonary shunt & arterial hypoxemia.
. Positioning of the pt. with the affected lung in dependent position
can worsen the case
. i.e. his SO2 will drop for example from 94% when lying on one side to
84% on other side

. RECURRENT PNEUMONIA:
______________________

. {A} INVOLVING SAME REGION OF THE LUNG:

_________________________________________

.1. Local anatomic obstruction:

________________________________
.. Bronchial compression (Neoplasm).
.. Bronchial obstruction (Bronchiectasis - Retained FB).

.2. Recurrent aspiration:

__________________________
.. Seizures.
.. Ethanol or drug use.
.. GERD.

. {B} INVOLVING DIFFERENT REGION OF THE LUNG:

______________________________________________
. Sino-pulmonary disease (Cystic fibrosis).
. Non-infectious (BOOP).
. Immunodefeciency (HIV - Leukemia - --immunoglobulins).

. BRONCHOGENIC CARCINOMA is the most common cause of recurrent pneumonia

in same region.
. Associated H/O of old age & prolonged smoking H/O
. Dx -> CT chest. (If CT is -ve -> Bronchoscopy).

. HYPERSENSITIVITY PNEUMONITIS (HP):

____________________________________
. Inflammation of the lung parenchyma caused by antigen exposure.
. Ex: Fancier's lung -> Inhalation of aerosolized bird droppings.
. Ex: Farmer's lung -> Inhalation of molds associated with farming.
. Acute episodes of cough, breathlessness, fever & malaise within 4-6 hs
of Ag exposure.
. Chronic exposue may lead to weight loss, clubbing & honey-combing of
the lung.
. The cornerstone of HP management is AVOIDANCE OF THE RESPONSIBLE
ANTIGEN !

. TUBERCULOSIS (T.B):
_____________________
. Immigrants - HIV - Homeless - Prisoners & Alcoholics.
. Most important epidemiologic factor is FOREIGN BORN INDIVIDUAL (Not US
born: MEXICO!).
 . Fever - cough - sputum - weight loss & night sweats.
. Dx -> CXR & Sputum acid fast stain & culture to confirm TB.

. If culture is +ve -> Start 6 months course of ANTI-TUBERCULOUS

THERAPY.
. ISONIAZID 6 m - RIFAMPIN 6m - PYRAZINAMIDE & ETHAMBUTOL stop after 2
months.

. All of them can lead to liver toxicity.

. TB medications sh'd be stopped if the transaminases raised up to 5
times of normal.

. Isoniazid -> Peripheral neuropathy (Give Vit.B6).

. Rifampin -> Red colored bodily secretions.
. Pyrazinamide -> Hyperuricemia.
. Ethambutol -> Optic neuritis.

. Conditions need ttt > 6ms: Osteomyelitis, Meningitis, Miliary -

cavitary TB & pregnancy

. LATENT T.B.
_____________
. PPD -> PURIFIED PROTEIN DERIVATIVE TEST:
___________________________________________
. PPD is a screening test for high risk groups.
. POSITIVE TEST IF:
-> 5 mm -> Close contacts, steroid users, HIV +ve.
-> 10 mm -> Homeless - Immigrants - Alcoholics - Health care workers &
prisoners.
-> 15 mm -> Those without any risks.

. If PPD is +ve -> Proceed as follows:

______________________________________
. CXR -> to make sure that occult active disease hasn't been detected.
. If CXR is abnormal -> Sputum staining for TB is done.
. If sputum staining is +ve -> Give full dose 4 drug therapy.

. ISONIAZID alone is used for 9 months to treat a +ve PPD.

. It -- the risk of developing TB from 99% to 1%.
. Once a PPD is +ve, the test sh'd never be repeated.

. RHINITIS:
___________
{A} ALLERGIC RHINITIS:
_______________________
. Watery rhinorrhea & sneezing with more prominent eye symptoms.
. Early age of onset.
. Identifiable trigger (animals - environmental exposure).
. Usually seasonal symptoms but can be persistent throughout year.
. Nasal mucosa can be normal, pale blue or pale on exam.
. Associated with allergic disorders e.g. eczema & asthma.
. Tx -> Allergen avoidance.
. Tx -> Topical intra-nasal glucocorticoids.

{B} NON-ALLERGIC RHINITIS = VASOMOTOR RHINITIS:

________________________________________________
. Nasal congestion - Rhinorrhea - Postnasal discharge (postnasal drip =
dry cough).
. Late age of onset > 20 ys.
. Can't identify clear trigger !
 . Symptoms throughout the year but sometimes worse with seasons change.
. Nasal mucosa may be normal or erythematous.
. Less commonly associated with allergic disorders e.g. asthma or
eczema.
. Routine allergy testing isn't necessary prior to initiating empiric
ttt.
. May respond to 1st generation oral H1 antihistaminics
(Chloramphenicol),
. Never ever responds to antihistaminics without anticholinergic
properties (Loratidine)!
. Tx -> TOPICAL INTRANASAL GLUCOCORTICOIDS.

. The 3 most common causes of CHRONIC COUGH (> 8 weeks):

________________________________________________________
. UPPER AIRWAY COUGH $YNDROME (Post-nasal drip).
. BRONCHIAL ASTHMA.
. GERD.

. UPPER AIRWAY COUGH $YNDROME = POST-NASAL DRIP:

_________________________________________________
. NON-smoker.
. Caused by rhino-sinusitis conditions.
. Dry cough is most likely due to post-nasal drip associated with
allergic rhinitis.
. Dx -> Confirmed by improvement of the nasal discharge & cough with H1
Anti-histaminics.
. Chlorpheniramine is an H1 receptor blocker that decreases the allergic
response.
. Decrease in NASAL SECRETIONS is most likely to significally improve
symptoms.

. ANAPHYLAXIS = ANAPHYLACTIC SHOCK:

___________________________________
. Type 1 hypersensitivity reaction.
. Pts usually have prior exposure to the offending substance.
. Pts have preformed Ig E -> Histamine mediated peripheral
vasodilatation.
. Bee stings - food & medications are the most common allergens.
. Acute onset of hypotension & tachycardia.
. Dangerous allergic reaction may progress to respiratory failure &
circulatory collapse.
. Allergen exposure -> Sudden onset of symptoms in more than one system,
. Cutaneous (hives - flushing - pruritis).
. GIT ( Lip / tongue swelling - vomiting).
. Respiratory (Dyspnea - wheezing - stridor - hypoxia).
. Cardiovascular (Hypotension).
. It is a medical emergency.
. Tx -> INTRA-MUSCULAR EPINEPHRINE into the THIGH.

. ASPIRIN SENSITIVITY $YNDROME:

_______________________________
. Aspirin ingestion - persistent nasal blockage - Episodes of
bronchoconstriction.
. Pathogenesis -> Psudo-allergic reaction.
. Aspirin -> PGs/LKs imbalance.
. Tx -> Avoid NSAIDs & Leukotriene recptor antagonists (Drug of choice).

. MEDIASTINAL TUMORS:
_____________________
_____________________
. Dx -> Helical CT CHEST.
. ANTERIOR mediastinum --> THYMOMA & GERM CELL TUMORS.
. MIDDLE mediastinum ----> BRONCHOGENIC CYST.
. POSTERIOR mediastinum -> Neurogenic tumors e.g. Meningocele.

. GERM CELL TUMORS:

___________________
. Affect young adults.
. Present as large ANTERIOR mediastinal mass.
. Two types of germ cell tumors (Seminomatous & Non-seminomatous).
. Both types produce B-HCG (B-Human chorionic gonadotropin).
. ONLY "NON"-seminomatous type produces Alpha-feto protein (AFP).

. CHORIOCARCINOMA:
__________________
. Metastatic form of gestational trophoblastic disease.
. It may occur after molar pregnancy or normal gestation.
. The lungs are the most frequent site of metastatic spread.
. Any postpartum woman e' pulmonary sympotms & multiple nodules on CXR =
CHORIOCARCINOMA.
. Dx -> ++++++ B-HCG levels.

. INCIDENTALLY DISCOVERED SOLITARY PULMONARY NODULE:

____________________________________________________
. May be BENIGN -> Infectious granuloma or hamartoma.
. May be MALIGNANT -> Bronchogenic carcinoma & metastasis.

. BIOPSY is the only way to definitively detect whether a nodule is

benign or malignant.

. Clinical characteristics favoring malignancy:

. Age > 50 - H/O of smoking - Weight loss - Previous malignancy.

. Radiographic characteristics of malignancy:

. Large size - Low density - Spiculated borders - Absence of
calcifications.

. Rate of lesion growth is an important parameter:

. Malignant nodules tend to double in size bet. one month & one year.

. OBTAINING PREVIOUS X-RAY if possible is the FIRST BEST STEP in

management.
. If a previous x-ray demonstrates that the lesion has been stable in
size > 2 ys,
. Malignancy is effectively ruled out & no further testing is necessary.

. LOW propability nodules are followed by serial high resolution CT

CHEST.
. INTERMEDIATE propability nodules are followed by PET SCAN or BIOPSY.
. HIGH propability nodules are removed surgically.

. PULMONARY - RENAL ASSOCIATIONS:

_________________________________

.1. WEGENER's GRANULOMATOSIS WITH POLYANGIITIS:

________________________________________________
. SYSTEMIC VASCULITIS + UPPER & LOWER RESPIRATORY TRACT INFECTION +
GLOMERULONEPHRITIS.
. Age around 40s.
 . URT symptoms (Bloody or purulent nasal discharge - oral ulcers -
sinusitis).
. LRT symptoms (Dyspnea - cough - Hemoptysis).
. Renal symptoms (Microscopic hematuria - RBC casts).
. Granulomatous inflammation of nasopharynx (Epistaxis - Rhinorrhea -
Otitis - sinusitis)
. Saddle nose deformity due to destruction of the nasal cartilage.
. Cutaneous manifestations (Painful SC nodules - palpable purpura -
pyoderma gangrenosum)
. BEST INITIAL TEST -> +ve C-ANCA = serum anti-neutrophilic cytoplasmic
antibody.
. CXR -> Bilateral multiple nodular opacities.
. Urinalysis -> RBCs casts - proteinuria & sterile pyuria.
. Tx -> CYCLOPHOSPHAMIDE & High dose corticosteroids.

.2. GOODPASTURE's DISEASE:

___________________________
. Due to renal basement membrane antibodies !
. Young male.
. Lungs (cough - dyspnes - hemoptysis).
. Kidneys (Nephritic proteinuria - ARF - Dysmorphic RBCs & red cell
casts on urinalysis).
. Systemic symptoms are un common.
. Dx -> Renal biopsy -> LINEAR IgG antibodies along the glomerular
basement membrane.

. EFFECTS OF ARTERIAL OXYGENATION & VENTILATION IN VARIOUS ENVIRONMENTS:

________________________________________________________________________
_____________________________ Example ________ A-a gradient ____ Pa CO2
___ Corrects e' O2

. -- inspired O2 tension = HIGH ALTITUDE:

_________________________________________
. A-a gradient -> Normal.
. Pa CO2 -> Normal.
. Corrects with supplemental O2 -> YES.

. Hypoventillation = CNS DEPRESSION:

____________________________________
. A-a gradient -> Normal.
. Pa CO2 -> +++++.
. Corrects with supplemental O2 -> YES.

. Diffusion limitation = INTERSTITIAL LUNG DISEASES:

______________________________________________________
. A-a gradient -> +++++.
. Pa CO2 -> Normal.
. Corrects with supplemental O2 -> YES.

. Shunt = Intracardiac shunt or extensive ARD$:

_______________________________________________
. A-a gradient -> +++++.
. Pa CO2 -> Normal.
. Corrects with supplemental O2 -> NOOOOOO.

. V/Q mis-match = Obstructive diseases, atelectasis, pulmonary edema &

pneumonia:
_________________________________________________________________________
________
. A-a gradient -> ++++++.
 . Pa CO2 -> Normal.
. Corrects with supplemental O2 -> YES.
. Low lung compliance.

. UPPER AIRWAY OBSTRUCTION WITH LARYNGEAL EDEMA:

________________________________________________
. ACUTE ONSET dyspnea & difficulty swallowing.
. Agitation & gasping of breath.
. Excessive accessory respiratory muscle use.
. Retraction of the subclavicular fossae during inspiration.
. H/O of previous food allergy.
. Identifiable precipitating event e.g. peanut ingestion.
. Physical exam. may reveal stridor & harsh respiratory sounds from
trachea.
. Wheezing is generally absent on lung auscultation.
. A fixed upper airway obstruction will -- air flowrate in all
inspiration & expiration.

* NORMAL LUNG EXAMINATION:

__________________________
. Percussion -> Resonant.
. Auscultation -> Vesicular breathing.

* LUNG CONSOLIDATION EXAM:

__________________________
. Percussion -> Dullness.
. Auscultation -> LOUDER vesicular breathing if airways are patent
(Faint if blocked).
. Bronchial breathing with full expiratory phase.
. ++ TVF.
. Bronchophony.
. Egophony (Ask the pt to say "E", it will sounds like "A").
. Widespread pectoriloquy.

* PLEURAL EFFUSION EXAM:

________________________
. Inspection -> -- movements of ipsilateral chest.
. Percussion -> Dullness.
. Auscultation -> Decreased breath sounds.
. -- TVF.

* PNEUMOTHORAX EXAM:
____________________
. Percussion -> Hyper-resonance.
. Auscultation -> Decreased breath sounds (Will be absent entirely if
large pneumothorax)
. -- TVF.
. JVD, Hypotension & Tracheal deviation to the opposite side.

* EMPHYSEMA EXAM:
_________________
. Percussion -> bilateral resonance.
. Auscultation -> Vesicuar breathing with fine crackles at inspiration.

. N.B. Recurrent bacterial infections in an adult may indicate a HUMORAL

IMMUNITY defect.
. Recurrent sino-pulmonary & gastro-intestinal infections.
. Dx -> Quantitative measurment of serum immunoglobulin "G" levels ->
DECREASED.
. Cystic fibrosis may have similar presentation BUT (Earlier in life &
e'out GIT infects).

. ACE INHIBITORS & DRY COUGH:

_____________________________
. Always consider ACE Is as a potential cause of chronic cough.
. Pathogenesis -> Accumulation of bradykinins & prostaglandins.
. Simple discontinuation of the drug sh'd precede any diagnostic tests !

. SINGLE PULMONARY NODULE APPROACH:

___________________________________

. SOLITARY PULMONARY NODULE = Lesion < 3 cm completely surrounded by

pulmonary parenchyma
.________________________________________________________________________
_________________
.|
._______________________________________________
.| .| .|
. HIGH MALIGNANCY RISK . INTERMEDIATE RISK . LOW
MALIGNANCY RISK
._____________________ .___________________
._____________________
.| .| .|
. Surgical excision. . NODULE SIZE ? . SERIAL CT
SCANS
. < 1cm: Serial CTs.
. > 1cm: PET scan.

* FUNGAL INFECTIONS OF THE LUNG:

________________________________

.1. HISTOPLASMOSIS:
___________________
. Asymptomatic pulmonary nodule.
. Residence in suburban Mississippi or o"H"io river valleys !
. Absence of any complaints.
. Absence of significant past H/O.
. Absence of any cavitary lesions.
. Calcified nodes in the lung may be seen.
. It is a dimorphic fungus found in soil with high concentration of bird
or bat droppings
. Infection through inhalation of the spores of Histoplasma capsulatum
fungus.

.2. BLASTOMYCOSIS -> ULCERATED SKIN LESIONS & LYTIC BONE LESIONS:
_________________________________________________________________
. Fungal infection of the lung..
. Residence in great lakes, Mississippi, Ohio river & Wisconsin.
. Pulmonary symptoms resembling T.B. & Histoplasmosis.
. ULCERATED SKIN LESIONS & LYTIC BONE LESIONS (Characteristic!).
. Skin lesions -> Multiple well circuscribed verrucus crusted lesions.
. Bone lesions -> Lytic lesions in the anterior ribs.
. Dx -> Sputum culture -> BROAD BASED BUDDING YEAST.
. Tx -> ITRACONAZOLE or Amphotericin B.

.3. COCCIDIOIDOMYCOSIS:
_______________________
. Fungal infection of the lung.
. Residence in Southwestern US.
. Fever, cough & night sweats.
. Extra-pulmonary -> skin, meninges & skeleton.

.4. ASPERGILLOSIS = A MOBILE LUNG CAVITARY MASS + INTERMITTENT

HEMOPTYSIS:
_________________________________________________________________________
_
. Fungal infection of the lung.
. Coarse fragmented septae.
. Hyphae are typically seen.
. CXR -> Radio-lucency next to a rounded mass.
. Cavitary lesion may form due to destruction of the underlying
pulmonary parenchyma.
. Debris & hyphae may coalese forming a FUNGUS BALL.
. The ball lies freely in the cavity & moves around with position
change.
. A MOBILE CAVITARY MASS + INTERMITTENT HEMOPTYSIS = ASPERGILLOMA.

. SUPERIOR SULCUS TUMOR:

________________________
. Apical lung tumor causing compression effects.
. Superior vena cava -> SVC $yndrome.
. Sympathetic trunk -> Horner $yndrome.
. Brachial plexus -> Pancoast $yndrome (Pain - paresthesia - weakness of
arm).
. Rt recurrent laryngeal nerve -> Hoarsness of voice.

. PANCOAST $YNDROME:
____________________
. Apical lung tumor at the thoracic inlet.
. Compress the inferior portion of the brachial plexus.
. Shoulder pain radiating in an ulnar distribution.

. SUPERIOR VENA CAVA $YNDROME (SVC):

____________________________________
. Obstruction of SVC impedes venous return from the head, neck, face &
arms to the heart.
. Dyspnea - Venous congestion & swelling of the head, neck & arms.
. Malignancy is the most common cause of obstruction (Lung cancer -
Hodgkin's lymphoma).
. H/O of chronic heavy smoker with recent un-intentional weight loss ->
Lung cancer.
. Best initial test -> CXR -> If abnormal -> Follow up with Ct chest.

. HYPERTROPHIC OSTEOARTHROPATHY:
________________________________
. Development of clubbing & sudden onset joint arthropathy in a chronic
smoker.
. Bilateral wrist tendrness, thickening of distal fingers & convex nail
beds.
. Associated with lung cancer.
. CXR is mandatory to rule out malignancy.

. FINGER CLUBBING:
__________________
. Thickening of the nail bed that causes a devrease in the angle bet the
nail bed & fold.
 . In severe cluccing, the terminal parts of the fingers appear swollen
like drumsticks.
. It is NOT a feature of simple COPD.
. NEW CLUBBING in COPD pts indicates the development of lung cancer or
occult malignancy.

. GOLDEN SCHEME:
________________
________________

. . SPIROMETRY
.____________
.|
.____________________________________________________
.| .|
. LOW FEV1/FVC . NORMAL OR HIGH
FEV1/FVC
.______________
._________________________
.| .|
. OBSTRUCTIVE DISEASE . RESTRICTIVE
DISEASE
._____________________
._____________________
.| .|
. BRONCHO-DILATOR CHALLENGE . DLCO
____________________________ .______
.| .|
._________
.________________
.| .| .|
.|
. ++ FEV1 . No ++ in FEV1 . NORMAL .
-- DLCO
._________ ._______________ ._______
._________
. ASTHMA. . COPD. . CHEST WALL WEAKNESS .
ILD.
.|
. DLCO
._____________________
.| .|
. (--) -> Emphysema . (++) -> Chronic bronchitis.

. N.B. RIGHT MAIN STEM BRONCHUS INTUBATION:

___________________________________________
. Relative complication of endotracheal intubation.
. It causes asymmetric chest expansion during inspiration.
. Markedly decreased or absent breath sounds on the left side on
auscultation.
. Solve the problem by repositioning of the tube,
. Tx -> Pull it back slightly, this will move its tip between the carina
& vocal cords.

. N.B. 2ry MALIGNANCY AFTER CHEMOTHERAPY !

__________________________________________
. Up to 4% of pts with HODGKIN's disease wil develop a 2ry malignancy
(Lung - breast)
 . After being treated with chemotherapy & radiation !

. N.B. POST-ICTAL STATE ABG:

____________________________
. Repiratory ACIDOSIS.
. Acisosis (-- pH).
. Hypercarbia (++ CO2).
. Normal or ++ HCO3 !
. HYPO-ventillation is a major cause of respiratory acidosis.

. N.B. MOST COMMON CAUSE OF HEMOPTYSIS is -> CHRONIC BRONCHITIS:

________________________________________________________________
. Chronic productive cough for 3 months in 2 successive years with
ciagarette smoking.
. Other important causes -> BRONCHOGENIC CARCINOMA & BRONCHIECTASIS.
. CXR is mandatory to exclude malignancy.

. N.B. Acute bronchitis is a common cause of blood-tinged sputum.

. It is usually viral in etiology.
. In an "A"FEBRILE pt with NEW-ONSET BLOOD TINGED SPUTUM e'OUT
significant serious signs,
. OBSERVATION & CLOSE CLINICAL FOLLOW UP is the best ttt strategy.

. MITRAL STENOSIS:
__________________
. Most common cause is rheumatic fever.
. Pt. 40 - 50ys.
. presents with gradual & progressively worsening dyspnea on exertion.
. Orthopnea & hemoptysis due to pulmonary edema.
. Auscultation -> Loud S1 & Opening snap after S2 at apex.
. Low pitched diastolic rumble at apex (When pt lies on left side with
breath holding).
. Atrial fibrillation is a common complication.
. Af causes rapid decompensation in a previously asymptomatic pt.
. Long-standing MS can cause Left atrial enlargement -> Elevation of
left main bronchus.

. ACE inhibitors side effect -> Dry cough:

__________________________________________
. Pathophysiology -> Accumulation of KININs due to activation of
arachidonic acid pathway

. N.B. ACID-BASE BALANCE in two different situations:

_____________________________________________________
_____________________________________________________

. 1 . Chronic hypercapneic respiratory failure due to COPD:

___________________________________________________________
. Marked acidosis should be the result of respiratory failure in COPD.
. But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 ->
Respiratory acidosis.
. To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption
instead !

. BOTTOM LINE -> The body compensates for chronic hypercapnea by ++

bicarbonate retention.
. 2 . Mechanically vetillated pt following head trauma:
_______________________________________________________
. Hyper-ventillation (Due to ++ TV or RR) -> Excessive CO2 loss &
Respiratory Alkalosis.
. Hypo-ventillation (Due to -- TV or RR) -> Excess CO2 Retention &
Respiratory Acidosis.

. Respiratory alkalosis:
-> ++ pH (N = 7.4).
-> -- PCO2 (N = 40 mmHg).
-> -- HCO3 (N= 24) -> DECREASED due to attempted renal compensation for
resp. alkalosis.
-> The kidneys retain increased amounts of Hydrogen H (protons)
-> & excrete ++ amounts of bicarbonate (HCO3) in attempt to normalize
serum pH.
-> The ++ amount of HCO3 in urine ALKALIZES the urine.

Dr. Wael Tawfic Mohamed

__________________________
 RHEUMATOLOGY TiKi TaKa
------------------------

. Systemic lupus erythematosus "SLE":

------------------------------------
. Female 20-30 ys.
. Malar "Butter fly" rash.
. Arthritis.
. Painless oral ulcers.
. Renal disease.
. +ve Ds DNA.
. Newly diagnosed "Lupus Nephritis" ----> RENAL BIOPSY to detect the
type of pathology.
. Grading from class 1 "Minimal mesangial" up to class 4 "Advanced
Sclerosis".

. Then the immunosuppressive therapy is given accordingly.

. BLUE TOE $YNDROME:

-------------------
. Due to CHOLESTEROL EMBOLISM.
. Cardiac catheterization may cause atheroembolism.
. BLUE TOES " But intact paulse".
. ++ CREATININE.
. Abdominal tendrness.
. Accompanied e' Livedo reticularis.

. SLE:
-----
. Young, African American woman.
. Aged 20 - 40 ys.
. Fatigue "Anemia".
. Painful oral ulcers.
. Non deforming arthritis.
. Hematologic abnormalities "pancytopenia".
. Low grade fever.
. Weight loss.
. Malar or discoid rash.
. Lupus Arthritis as RA involves MCP & PIP BUT "NO DEFORMITIES".

. REMEMBER ---> LUMBAR SPINAL STENOSIS Dx ----> Spinal MRI.

-----------------------------------------------------------
. Ankle brachial index is used to diagnose peripheral artery disease.

. ERYTHEMA NODOSUM:
-------------------
. Painful S.C. pre-tibial nodules.
. Associated with SARCOIDOSIS.
. Ask for a CXR to detect sarcoidosis.
. CXR: Bilateral hilar adenopathy.
. AFRICAN AMERICAN FEMALE !
. Cough, Arthritis & uveitis.

. Disease --------------------------> Best initial Tx:

------------------------------------------------------
. Rheumatoid arthritis --------------> Methotrxate.
. Osteoarthritis --------------------> Weight loss & Acetaminophen.
. Gout acute attack -----------------> NSAIDs, Indomethacin.
 . Gout prevent. of new attack -------> Colchicine.
. CPPD ------------------------------> NSAIDs.
. Disk herniation -------------------> NSAIDs.
. Epidural abscess ------------------> Abs "Vancomycin".
. Cord compression ------------------> Steroids.
. Spinal stenosis -------------------> Weight loss & Steroid injection.
. Fibromyalgia ----------------------> Amitriptyline.
. Carpal Tunnel. $ ------------------> Wrist splint & NSAIDs.
. Polymyositis ----------------------> HIGH dose steroids.
. Rotator cuff injury ---------------> NSAIDs.
. SLE -------------------------------> High dose steroids.
. Sjogren $ -------------------------> Water the mouth & atrificial
tears.
. Polymyalgia Rheumatica ------------> LOW dose steroids.
. Temporal "Giant cell" arteritis ---> HIGH dose steroids.
. Ankylosing Spondylitis ------------> NSAIDs.
. Psoriatic arthritis ---------------> NSAIDs.
. Reactive arthritis "Reiter's $" ---> NSAIDs.
. Septic arthritis ------------------> CEFTRIAXONE & VANCOMYCIN.
. Gonococcal arthritis --------------> Ceftriaxone or cefotaxime.

. D.D. of CALF SWELLINGS:

-------------------------

.. Cellulitis:
--------------
... Infection of skin & S.C. tissue.
... Risk factors: Obesity & Tinea pedis !
... Red, edematous skin that is hot to touch.
... Regional lymphadenopathy.
... Caused by STAPH & STREPT Group A.

.. DVT = Deep Venous Thrombosis:

--------------------------------
... Same presentation as cellulitis .
... BUT .. FEVER never exceeds 38.5 c.
... No regional lymphadenopathy.
... Ruptured BAKER's CYST.

. OSTEO-ARTHRITIS (OA):
-----------------------
. Old age.
. Affects hands & weight bearing joints.
. Mild morning stiffness < 30 mins (RA > 1 hour).
. Pain ++ with exercise & -- by rest.
. Bony crepitus, bony enlargement.
. Painful & - range of motion.
. Synovial fluid analysis: 200-2000 WBCs,
. (Normal 0-200 & Inflammatory 2000-50000 & Septic arthritis >50000).
. X-ray: -> NARROWED JOINT SPACE.
. X-ray: -> OSTEPHYTE FORMATION.
. X-ray: -> SUBCHONDRAL CYSTS.

. GOUTY ARTHRITIS:
------------------
. Middle aged male.
. Acute joint pain (1st Metatarsophalangeal joint is the most common).
. Swelling & -- range of motion.
. Low grade fever.
 . Synovial fluid analysis is cirtical for diagnosis,
. WBCs 2000-50000,
. NEEDLE shaped, NEGATIVELY bireferingent crystals under polarized
light.
. NEGATIVE gram stain & culture.
. ++ serum Uric acid is neither sensitive nor specific !!
. Tx of acute attack --> INDOMETHACIN (Cot'd in RF or GIT bleeding) &
COLCHICINE.
. TREATMENT ----> NSAIDs, Colchicine & steroids.
. PREVENTION ---> Allopurinol & probenicid.

. PSEUDO-GOUT:
--------------
. Calcium pyrophosphate dihydrate (CPPD) deposition.
. Acute onset, pinful , monoarthropathy affecting the knee.
. Synovial fluid ---> RHOMBOID shaped with POSITIVE +ve birefringence.
. Ass. with HYPERPARATHYROIDISM:
.. ++ Ca & -- PO4 --> constipation & excess urination.
.. Disease of GROANS (Abd. pain), STONES (urinary) & Psychic MOANS.

. GONOCOCCAL SEPTIC ARTHRITIS:

------------------------------
. YOUNG, SEXUALLY ACTIVE FEMALE.
. Fever > 38.5 c.
. Redness, hotness, swelling, pain, limitation of movement.
. Synovial fluid analysis: ++ WBCs > 50000.
. Asymmetric polyarthritis.
. May be associated with tenosynovitis or rash.

. OSTEO-ARTHRITIS:
------------------
. Narrowed joint space.
. Osteophytes.
. Suchondral sclerosis or cysts.
. Obesity is the most common risk factor.
. Weight loss is the best initial ttt.

. LUMBAR SPINAL STENOSIS:

-------------------------
. Old pt.
. Combined low back & leg pain.
. Posture dependent --> Flexion of the back causes widening of the
spinal canal,
. while extension causes narrowing of the spinal canal.
. So, the leg pain is exacerbated by extension of the spine (Standing &
walking),
. but improved by flexion (Sitting & lying down).
. Called "Neurological Claudication".
. Differentiated from claudication of peripheral vascular disease by
normal pulses!
. Normal Ankle / Brachial index.
. Normal neurological examination.
. -ve Straight leg test.
. Dx: MRI.
. Tx: Conservative or Laminectomy.

. TEMPORAL = GIANT CELL ARTERITIS:

----------------------------------
. Age > 50 ys.
. New headache.
 . Jaw claudication.
. Scalp pain.
. Visual loss.
. ++ ESR.
. Dx: TEMPORAL ARTERY BIOPSY.
. Tx: HIGH dose steroids.

. ANKYLOSING SPONDYLITIS TIPS & TRICKS:

---------------------------------------
. Not only in young males, may affect females !
. BILATERAL SACRO-ILIITIS is DIAGNOSTIC.
. Most imp. extra-articular manifestation is ANTERIOT UVEITIS !!
. May be associated with Aortic insuffeciency with AV Block.
. (Not ass. with Aortic Aneurysm xxxxx).

. N.B. Apophyseal joint arthritis = Ankylosing spodylitis:

---------------------------------------------------------
. "Sero-negative spondylo-arthropathies".

. HERNIATED DISC:
-----------------
. Pain worsens with sitting.
. Low bk pain & sciatica.
. +ve stress leg test.

. VERTEBRAL METASTASIS:
-----------------------
. Low bk pain.
. H/O of malignancy.
. Weight loss.
. CONSTANT DULL PAIN.
. Failure to improve with conservative therapy.

. Osteomyelitis:
---------------
. Caused by STAPH. AUREUS.
. Tx-> Ox, Clox, Dicloxacillin.

. ROTATOR CUFF TENDONITIS:

--------------------------
. Due to repititive activity above shoulder height e.g. Painter.
. Passive motion of the arm above the head cause pain & guarding
confirming impingement.
. Lidocaine injection cause pain relief,
. in contrast to persistence of pain with NO relief in case of ROTATOR
CUFF TEAR,
. Rotator cuff tear is due to fall on out stretched hand.

. CYCLOPHOSPHAMIDE side effect ---> Hemorrhagic cystitis & Bladder

carcinoma.

. ROTATOR CUFF TEAR:

--------------------
. results from chronic tendonitis & shoulder trauma.
. Shoulder pain & weakness when lifting the arm above the head.
. Lidocaine injection relieves the pain in case of R.C. Tendonitis,
. while it persists in case of R.C. Tear.
. Dx----> MRI Shoulder.

. VIRAL ARTHRITIS:
 ------------------
. Secondary to PARVO-virus 19 infection.
. Similar presentation as Rheumatic arthritis !
. Arthritis --> PCP & PIP & wrists.
. Resolves within just 2 months !!
. H/O of frequent contact with children e.g. day care workers.

. so the diff. bet viral & RA are:

----------------------------------
. . ACUTE ONSET.
. . Lack of inflammatory markers "Anti-CCP & RF".
. . Resolution within 2 months !

. SE of HYDROXYCHLOROQUINE ---> RETINOPATHY.

. SE of CYCLOPHOSPHAMIDE ---> BLADDER CARCINOMA.

. SARCOIDOSIS:
--------------
. AFRICAN AMERICAN FEMALE.
. Lung involvement --> Cough & dyspnea.
. Erythema nodosum.
. Anterior uveitis.
. Acute polyarthritis.
. Parahilar adenopathy.
. ++ ACE enzymes (Give ACE Is)!
. Biopsy: Non caseating granuloma.
. Tx: SYSTEMIC GLUCOCORTICOIDs.

. CARPAL TUNNEL $YNDROME:

-------------------------
. Compression of the median nerve within the carpal tunnel in the wrist.
. Pain & paresthesia in the median nerve distribution.
. Worse with wrist flexion (+ve PHALEN test).
. May be due to HYPOTHYROIDISM (Fatigue, constipation, menorrhagia & dry
skin).
. PATHOLOGY ----> Deposition of MUCOPOLYSACCHARIDE PROTEIN COMPLEXES
(MATRIX SUBSTANCE).
. HYPOTHYROIDISM ---> BILATERAL CT$.

. FIBRO-MYALGIA:
----------------
. WOMEN 20-50 ys.
. Point tenderness in at least 11 - 18 points !!
. H/O of generalized musculoskeletal pain not related to another
illness.
. Disturbed sleep, easy fatiguability.
. Normal lab values.
. Tx: TCAs e.g AMITRIPTYLINE.

. DERMATOMYOSITIS:
------------------
. Proximal extensor ms inflammatory myopathy.
. Violaceous poikiloderma.
. Periorbital edema with rash "Heliotrope sign".
. Rash on chest & lateral neck "Shawl sign".
. Rash on the knuckles, elbows & knees "Gottron's sign".
. Lichenoid papules "Gottron's papules".
. Anti-Mi-2 Abs.
. Ass. with internal malignancies "Most common is OVARIAN CANCER" !
. POLYMYOSITIS:
---------------
. Slowly progressive proximal muscle weakness of the lower limbs.
. Difficulty with stair climbing.
. Difficulty with rising from a seat.
. Muscle tendrness.
. Best diagnostic test ---> MUSCLE BIOPSY.

. Metastatic disease of the vertebrae:

--------------------------------------
. H/O of Lung cancer (Non small cell lung carcinoma).
. Most common causing cancers: Lung, breast, prostate & thyroid.
. CONSTANT pain, worse at night.

. LUMBAR STRAIN:
---------------
. Follow twisting of the bk while lifting heavy objects.
. ++ by activity & -- by rest.
. No point tendrness.

. SPINAL STENOSIS:
-----------------
. Low bk pain at lumbar spine,
. ++ with activity.

. DISK HERNIATION:
-----------------
. LBP radiating down the buttock,
. +ve straight leg raise test.

. ANSERINE BURSITIS:
--------------------
. Anserine bursa is located antero-medially over the tibial plateau,
. just below the joint line of the knee.
. Inflammation may be due to overuse or trauma.
. LOCALIZED pain over the ANTEROMEDIAL tibia.
. Valgus stress test -->-ve. "Ruling out Medial collateral ligament
injury".
. NORMAL X-ray.
. Tx: Cortico-steroids injection into the bursa.

. Pre-patellar bursitis:
------------------------
. Pain & swelling directly over the patella.

. Disease ---> Specific Antibodies:

-----------------------------------
. Rhematoid Arthritis "RA" ------------> Anti-Cyclic Citrulinated
Peptide "CCP".
. Systemic Lupus Erythematosus "SLE" --> Anti-Double Stranded DNA "DS
DNA".
. Scleroderma -------------------------> Anti-topoisomerase "Scl 70".
. CREST $ -----------------------------> Anti-centromere.
. Sjogren $ ---------------------------> SS-A "Ro" & SS-B "La".
. Wegener's granulomatosis ------------> Anti-neutrophil cytoplasmic
Antibody "C-ANCA".
. Chrug-Strauss -----------------------> Anti-myeloperoxidase antibody
"P-ANCA".

. WHIPPLE's disease:
 --------------------
. H/O of malabsortion diarrhea (Steatorrhea, flatulence, abd.
distension).
. Weight loss.
. Migratory arthritis.
. caused by Tropheryma Whippelii.
. Dx: Small intestinal biopsy ---> PAS +ve macrophages in the lamina
propria.

. Celiac disease = Celiac sprue = GLUTEN SENSITIVE ENTEROPATHY :

---------------------------------------------------------------
. Malabsorptive diarrhea.
. Anti-endomysial & Anti-transglutaminase Antibodies.
. Biopsy --> Effacement of SI villi.

. ANKYLOSING SPONDYLITIS & IBD are associated !

----------------------------------------------
. Both are associated with HLA B27.
. Both are associated with P-ANCA.
. IBD (UC): Bloody diarrhea, anemia & -ve stool culture, erythema
nodosum.
. AS: SACROILIITIS.

. REACTIVE ARTHRITIS = 3 Can't ( see, pee, climb a tree):

--------------------------------------------------------
. Following infectious diarrhea,
. caused by shigella, salmonella, Yersinia, Campylobacter or C.dificile.
. Conjunctivitis "Can't see".
. Urethritis "Can't Pee".
. Arthritis "Can't climb a tree"

. POLY-MYALGIA RHEUMATICA (PMR):

--------------------------------
. Age > 50 ys.
. Aching pain in neck, shoulders & pelvic girdle lasting at least 1
month.
. Morning stiffness > 1 hour !
. ESR < 40 mm/hr.
. No pain with active or passive range of movement.
. Tx: LOW DOSE PREDNISONE.
. When do u give HIGH dose prednisone ?
. -> If associated with GIANT CELL TEMPORAL ARTERITISto prevent visual
loss.
. It is diagnosed by Temporal artery biopsy.

. RHEUMATOID ARTHRITIS MANAGEMENT:

----------------------------------
. All pts should be started on DMARDs ASAP as joint damge begins early !
. METHOTREXATE is the best initial therapy.
. NSAIDs are adjunctive therapy for symptomatic relief,
. NSAIDs don't -- disease progression.
. Gucocorticoids may reveal symptoms temporarily but they don't prevent
future worsening.
. Pts sh'd be tested for HEPATITIS B & C & T.B. bef. starting MTx.
. MTx sh'dn't be used in pregnants !

. Disseminated Gonococcemia:
----------------------------
. Migratory polyarthritis.
. Skin lesions (Pustules) on the extremeties.
 . Tenosynovitis.
. High fever & chills.
. Blood & pustule culture --> NEGATIVE (Need specific growth
requirements).

. SJOGREN $YNDROME:
-------------------
. Women 50 - 60 ys.
. Kerato-conjunctivitis sicca (Xerophthalmia & dry eyes).
. XEROSTOMIA (dry mouth).
. Lack of normal amount of saliva -> Dental carries & dysphagia.
. Enlargement & firmness of the salivary glands.
. Histology -> Lymphocytic infiltration of the salivary glands.
. +ve Anti-SSA(Ro) & or Anti-SSB(La).

. SYSTEMIC SCLEROSIS:
---------------------
. AFRICAN AMERICAN FEMALE.
. Widespread organ involvement.
. Esophagus -->GERD.
. Heart ------> Rt Heart failure.
. Kidney -----> hypertension.
. Most common cause of death is PULMONARY ARTERIAL HYPERTENSION.
. +ve Anti-topo-isomerase-I Abs = +ve Anti-Scl70.

. CREST $ = LIMITED scleroderma:

-------------------------------
. Calcinosis cutis.
. Raynaud's phenomenon.
. Esophageal dysmotility.
. Sclerodactyly.
. Telangiectasia.
. +ve Anti-Centromere Abs.

. PAGET DISEASE OF BONE = OSTEITIS DEFORMANS:

--------------------------------------------
. ++ Osteoclastic activity ---> Bone RESORPTION.
. Distorted bone formation.
. Common sites: Femur & skull & vertebra.
. Hypertrophy of the skull -----> Vestibulocochlear nerve compression,
. 8th cranial n. compression ---> Deafness "Sensorineural hearing loss".
. NORMAL CALCIUM & PHOSPHATE LEVELS.
. HIGH ALKALINE PHOSPHATASE LEVEL.
. HIGH HYDROXYPROLINE LEVEL "Bone marker".

. SUB-ACROMIAL BURSITIS:
-----------------------
. Subacromial bursa lies between the acromion & the tendon of the
supraspinatous ms.
. caused by chronic microtrauma to the supraspinatous tendon.
. e.g. overhead work or tennis playing.
. Tendrness hen the arm is internally rotated & forward flexed at the
shoulder.
. No signs of deltoid atrophy.

. LATERAL EPICONDYLITIS = TENNIS ELBOW:

--------------------------------------
. Due to repeated forceful wrist extension & supination.
. ex: Backhand in tennis or use of a screw driver.
. Point tendrness near the lateral epicondyle.
 . Due to degeneration of extensor carpi radialis brevis.

. ROTATOR CUFF INJURY:

----------------------
. Shoulder pain, weakness & -- range of motion.
. Due to impingement of the supraspinatous tendon.

. De QUERVAIN TENO-SYNOVITIS:
-----------------------------
. NEW MOTHERS who hold their babies with out-stretched thumb (ABDUCTED &
EXTENDED).
. Affects tendons of abductor pollicis longus & extensor pollicis
brevis.
. Passive stretch of these tendons elicits pain.

. Chronic Tophaceous Gout:

-------------------------
. Metatarsophalangeal joint is the most affected.
. Severe swelling & pain in the big toe.
. Due to deposition of the monosodium urate crystals "PODAGRA".
. U.A. crystals ---> Nephrolithiasis.
. Urate crystals may deposit in the soft tissues forming tumors "TOPHI".
. Tophi may ulcerate & drain a chalky material.
. H/O of water-pills intake for hypertension "THIAZIDEs".
. Hydrochlorothiazide ---> Hypovolemia ---> ++ U.acid reabsorption.

. BEHCET's $YNDROME:
-------------------
. Recurrent oral ulcers.
. Recurrent genital ulcers.
. Eye lesions: Anterior uveitis.
. Skin lesions: Erythema nodosum.
. Tx: Corticosteroids.
. More common in TURKISH, ASIAN & MIDDLE EASTERN population.

. Main mechanism of kidney damage in SLE is IMMUNE COMPLEX MEDIATED.

. Best initial ttt in cases of DISK HERNIATION is NSAIDs & EARLY

MOBILIZATION.

. SLE ARTHRITIS:
---------------
. Cortico-steroid induced "AVASCULAR NECROSIS" of the femoral head.
. Progressive hip or groin pain.
. without restriction of motion range.
. Normal radiograph on early stages.
. Dx: MRI is the gold standard.

. LUMBOSACRAL STRAIN:
--------------------
. Most common cause of pain.
. Pain starts acutely after physical exertion.
. Pain concentrated in the lumbar area.
. No radiation to thighs.
. Paraspinal tendrness.
. Normal neurological exam.
. -ve straight leg raising test.
. Tx: NSAIDs & early mobilization.

. HERNIATED DISK:
 ----------------
. Pain radiation to thighs.
. +ve straight leg raising test.

. COMPRESSION # of the VERTEBRA:

-------------------------------
. OLD age.
. Acute onset of pain without an obvious trauma.
. H/O of osteoporosis.
. H/O of steroids intake.
. Normal neurological exam (Absent Babinski reflex is considered NORMAL
in elderly).
. -ve Straight leg raise test (+ve with DISK HERNIATION).

. VERTEBRAL OSTEOMYELITIS:
-------------------------
. Lumbar spine.
. Back pain.
. Low grade fever.
. ++ ESR.
. Local tendrness on percussion.
. Paravertebral muscular spasm.
. Dx: MRI.

. CERVICAL SPONDYLOSIS:
----------------------
. Due to BONY SPUR.+999999
. Age > 50ys.
. H/O of CHRONIC NECK PAIN is TYPICAL.
. Limited neck rotation & Lateral bending.
. Sensory deficits due to osteophyte induced radiculopathy.
. X-ray --> ** BONY SPURS & sclerotic facet joints.
. X-ray --> ** Narrowing of disk spaces.
. X-ray --> ** Hypertrophic vertebral bodies.

. ACUTE GOUTY ATTACK:

--------------------
. Tx: NSAIDs "INDOMETHACIN" ,COLCHICINE or steroids.
. ALCOHOL CESSATION & LOW PURINE DIET are imp. to prevent future
attacks.

. LUMBAR STRAIN:
---------------
. Related to lifting a heavy object.
. No radicular signs.
. Good response to conservative therapy.
. Pt education -----> KEEP THE BACK STRAIGHT WHILE LIFTING AN OBJECT !

. DMARDs Disease Modyfying Anti-Rheumatic Drugs:

-----------------------------------------------

.METHOTREXATE:
--------------
. inhibits dihydrofolate reductase.
. SE: Macrocytic anemia (MCV > 100 & -- Hb).
. Other SEs: Nausea, stomatitis, rash, hepatotoxicity, Alopecia.

. HYDROXYCHLOROQUINE:
---------------------
. GI distress.
 . Visual disturbances.
. Hemolysis in G6PD defeciency.

. CYCLOPHOSPHAMIDE:
------------------
. Nephrotoxicity & Bladder carcinoma.

. RED FLAGS of LOW BACK PAIN:

-----------------------------
. = SYSTEMIC DISORDER or HERNIATED DISC,
. or BONY ABNORMALITIES such as LYTIC LESIONS or Compression #s.
. Age > 50ys.
. H/O of previous cancer.
. Unexplained weight loss.
. Pain > 1 month duration.
. Nighttime pain causing difficulty with sleep.
. No response to previous therapy.
. Neurological symptoms.
. Pain to palpation of the vertebra = spinal infection or lytic lesions
in the spine.
. 1st step is X-RAY PLAIN FILM then MRI.

. SPINAL STENOSIS:
-----------------
. Bk pain radiating to the buttocks & thighs.
. Numbness & paresthesia may occur.
. Symptoms r worse during walking & lumbar extension,
. while lumbar flexion alleviates the pain.
. Dx: MRI.

. ILIAC ARTERY ATHEROSCLEROSIS:

-------------------------------
. Claudication in the buttocks & thighs.
. Pain ++ with activity & -- by rest.
. Not affected by lumbar flexion or extension.

. LUMBAR DISK HERNIATION:

-------------------------
. Acute onset bk pain.
. e' or e' out radiation to one leg.
. Pt recalls an incinting event e.g. lifting heavy objects.
. +ve straight leg raise test.

. ANKYLOSING SPONDYLITIS:
------------------------
. Young men < 40 ys.
. Low bk pain & stiffness.
. Worse in the morning & improves as the day progress.
. Ass. e' anterior Uveitis (Monocular pain,blurring,photophobia).
. X-ray pelvis --> SACRO-ILIITIS.
. -ve RF & +ve ESR.
. +ve HLA B 27.
. Tx: Pain relief & TNF Alpha antagonists.

. VERTEBRAL OSTEOMYELITIS:
-------------------------
. Injection drug user.
. Pts with sickle cell disease.
. immunocompromized pts.
. STAPHYLOCOCCUS AUREUS.
 . TENDERNESS to GENTLE PERCUSSION.
. Pain not relieved by rest.
. Fever & ++WBCs --> UN-RELIABLE !
. ++ Platelet count.
. ++ ESR > 100 mm/hr.
. Dx: MRI.
. Tx: Long term IV Antibiotics.

. EPIDURAL ABSCESS:
------------------
. Enclosed infection in the epidural space.
. Bk pain, fever, chills & leukocytosis.
. More common in injection drug users.
. It may cause SPINAL CORD COMPRESSION.
. LL weakness & Urinary incontinence.
. Acute epidural abscess requires immediate surgical debridement.

. COMPRESSION #:
---------------
. due to VERTEBRAL BODY DEMYELINIZATION.
. Intense focal pain.
. Without neurological symptoms.
. Occur in cases of osteomalacia or osteoporosis.

. ACUTE GOUTY ATTACK = PODAGRA:

------------------------------
. May be due to MYELO-PROLIFERATIVE disorder,
. e.g. POLYTHYCEMIA (SPLENOMEGALY & PRURITIS AFTER HOT BATHS).
. MPD "polythycemia" -> ++ Catabolism & turn over of proteins -> ++ uric
acid production.

. GIANT CELL "TEMPORAL" ARTERITIS:

---------------------------------
. Headache.
. Jaw claudication.
. Muscle fatigue.
. Visual disturbance.
. Scalp tenderness.
. -- Temporal artery pulse.
. ++ ESR > 50 mm/hr.
. May involve the branches of the AORTA ----> AORTIC ANEURYSM.
. Serial CXRs are imp. to exclude Aortic aneurysm.

. REMEMBER AGAIN OA "Matet5ene2sh :)

-----------------------------------
. Degenerative Joint disease.
. Wear & Tear Arthritis.
. ++ by walking & -- by rest.
. Morning stiffness < 30 mins.
. limited range of movement.
. Tenderness on passive movement.
. Due to destruction of the articular cartilage --> Bone on bone
friction.
. Most common risk factor is OBESITY !

. AVASCULAR NECROSIS = ASEPTIC NECROSIS = ISCHEMIC NECROSIS =

OSTEOCHONDRITIS DESSICANS:
------------------------------------------------------------------------
---------------
. Disruption of bone vasculature.
 . Corticosteroid related osteonecrosis of the right femoral head.
. H/O Excessive Alcohol ingestion.
. Slowly progressive anterior hip pain with limitation of range of
motion.
. Dx: MRI.

. D.D. of INFLAMMATORY MONOARTHRITIS: (RED HOT SWOLLEN PAINFUL LIMITED

MOVEMENT):
------------------------------------------------------------------------
--------
. Septic arthritis.
. Crystal induced arthritis.
. Trauma.
. Pts with RA are at high risk of developing septic arthritis esp. with
STAPH. AUREUS.

. RA cause osteopenia & osteoporosis "NOT osteomalacia caused by Ca &

Vit. D defeciency".

. MTx side effects:

------------------
. Stomatitis.
. Nausea.
. Anemia.
. Hepatotoxicity.
. Tx: Give FOLIC ACID !

. RA:
----
. MORNING STIFFNESS > 1 hour.
. Small joints (MCP & PIP).
. Spares DIP "Unlike OA".
. Tenosynovitis (Trigger finger).
. Rheumatoid nodules (Elbow).
. Cervical joint involvement ---> Spine sublaxation ---> Spinal cord
compression.
. +ve Anti-CCP Abs.
. +ve RF.
. ++ CRP & ESR.
. X-ray: Soft tissue swelling , joint sapce narrowing & bone erosions.

. Both Obstructive & Restrictive lung disease cause -- in FEV & FEV 1 !
----------------------------------------------------------------------
. But .. RESTRICTIVE lung disease cause much more -- in FEV 1 than
Obstructive type.
. So .. In RESTRICTIVE lung dis. FEV 1 / FEV is > 80 %.
. Examples of RESTRICTIVE causes:
--------------------------------
.. Interstitial lung disease.
.. Neuromuscular diseases.
.. Chest wall abnormalities.
. Ankylosing spondylitis -> costovertebral joint fusion -> chest wall
motion restriction.

. ENTHESITIS:
------------
. Inflammation & pain at ligaments & tendons attached to bone.
. Associted with Negative spondylo-arthropathies,
. e.g. ANKYLOSING SPONDYLITIS, psoriatic arthritis & reactive arthritis.
. Associated with HLA B 27.
 . Most common sites are shoulder & hip.

. REACTIVE ARTHRITIS = Seronegative spondyloarthropathy:

-------------------------------------------------------
. TRIAD of: CAN'T SEE, CAN'T PEE, CAN'T CLIMB A TREE !!
. 1- CONJUNCTIVITIS "CAN'T SEE".
. 2- NON GONOCOCCAL URETHRITIS "CAN'T PEE".
. 3- ASYMMETRIC OLIGOARTHRITIS "CAN'T CLIMB A TREE".
. Mucocutaneous lesions.
. Enthesitis "Achilles tendon pain".
. STERILE Synovial fluid analysis.
. Tx: NSAIDs.

. Pts with prolonged H/O of ANKYLOSING SPONDYLITIS:

--------------------------------------------------
. are at ++ risk of VERTEBRAL #,
. due to -- bone mineral density & may occur with minimal trauma !!

. FIBROMYALGIA:
--------------
. Women 20 - 50 ys.
. Generalized musculoskeletal pain in absence of joint swelling or lab
abnormalities.
. Excessive tendrness on palpation of at least 11 of 18 soft tissue
locations.
. The sites include the upper quadrants of the buttocks & medial aspect
of the knees.
. As well as Sternocleidomastoid & Trapezius muscles.
. Absent of joint swelling or ms weakness.

. PSORIATIC ARTHRITIS:
---------------------
. DIP.
. Dactylitis --> SAUSAGE shaped digits = diffusely swollen fingers.
. Nail involvement: pitting & oncholysis "separation of nail bed".
. Well demarcated red palques with silvery scaling.
. Tx: NSAIDs & MTx.
. Steroids are contraindicated.

. N.B. RA ----> MCP & PIP.

. N.B. OA ----> DIP.

. PSEUDO-GOUT = CHONDRO-CALCINOSIS:
----------------------------------
. Acute arthritis.
. Due to CPPD Calcium pyrophosphate dehydrate crystals deposition.
. H/O of recent surgery or medical illness.
. Synovial fluid analysis --> RHOMBOID shaped, POSITIVELY birefringent
crystals.
. GOUT synovial fluid analysis --> NEEDLE shaped, NEGATIVELY
birefringent crystals.

. BAKER CYST:
------------
. Due to excessive fluid production by an inflammed synovium.
. Occurs in cases of Rheumatoid Arthritis.
. Excess fluid accumulates in the popliteal bursa which expands,
. creating a tender mass in the popliteal fossa.
. May burst & release their contents into the calf,
. resulting in an appearance similar to DVT.
. AMYLOIDOSIS:
-------------
. Ass. with Nephrotic $ (facial swelling, LL edema, massive
proteinuria).
. Palpable kidneys.
. Hepatomegaly.
. Cardiomegaly (Audible S4).
. H/O of chronic infections e.g. Bronchiectasis & recurrent pulm.
infections.
. Tx: COLCHICINE.

. OSTEO-ARTHRITIS:
-----------------
. Age > 50 ys.
. Morning stiffness < 30 mins.
. Bony tendrness.
. Bony enlargement.
. CREPITUS on active motion.
. No warmth i.e. COOL joint !

. SLE Arthritis:
---------------
. Like RA but --------> NO PERMANENT DEFORMITIES.

. SEPTIC ARTHRITIS:
------------------
. H/O of PROSTHETIC joint.
. Red, hot, swollen, painful joint with limited range of motion.
. ++ WBCs > 50000.
. STAPH. AUREUS is the most common causative organism.

. Disseminated Gonococcemia:
---------------------------
. H/O of recent unprotected sex with a new partener.
. A triad of Polyarthralgia + Tenosyvovitis + Vesiculo-pustular skin
lesions.

. PAGET's disease of bone:

-------------------------
. Age > 40 ys.
. ++ bone turn over.
. ++ OSTEOCLAST ACTIVITY.
. Mosaic pattern of lamellar bone.
. Enlarged cranial bone --> ++ hat size.
. Entrapment of 8th cranial nerve --> Deafness.
. X-ray --> Femoral bowing.
. NORMAL CALCIUM & PHOSPHOROUS LEVELS.
. ++ ALKALINE PHOSPHATASE LEVEL.

. NEUROGENIC ARTHROPATHY = CHARCOT's JOINT:

------------------------------------------
. Due to DIABETIC NEUROPATHY.
. H/O of DM is the key word.
. -- pain, proprioception & temperature.
. caused by D.M., peripheral nerve damage, syringomyelia & B12
defeciency.
. X-ray ---> Loss of cartilage, osteophytes formation & loose bodies.
. Tx: ttt the cause & special shoes !
 . GOUT X-ray ---> PUNCHED OUT EROSIONS + Overhanging rim of cortical
bone.

Dr. Wael Tawfic Mohamed

-------------------------
 SURGERY TIKI TAKA
___________________

. TRAUMA:
__________
__________

(1) AIRWAY:
____________
. Establishing & securing the airway is always the 1st step in
management.
. Altered mental status is the most common indication for intubation in
a trauma pt.
. As an unconscious pt can't maintain his airway.
. The preferred method of securing an airway -> OROTRACHEAL INTUBATION.
. Trauma with cervical spine injury -> FLEXIBLE BRONCHOSCPE.
. Extensive facial trauma & bleeding into airway -> CRICOTHYROIDOTOMY or
TRACHEOSTOMY.

. N.B.
. Pts with cervical spine injury should 1st have stabilization of the
cervical spine.
. Oro-tracheal intubation with rapid sequence intubation is the
preferred way,
. to secure an airway in an apnein pt with a cervical spine injury.

. N.B.
. In burn victims, clinical indicators of thermal inhalation injury to
the upper airway,
. or smoke inhalation injury to the lungs include burns on face, singing
of eye brows,
. oropharyngeal inflammation & blistering, oropharyngeal carbon
deposits,
. carbonaceous sputum, stridor, carboxyhemoglobin level > 10 %.
. H/O of confinement in a burnung buiding.
. The presence of one or more of these indicators warrants early
intubation,
. to prevent upper airway obstruction by edema.

(2) BREATHING:
_______________
. Check oxygen saturation, if SpO2 < 90 %:
-> ++ oxygen concentration & flow rate.
-> Obtain an ABG.
-> Determine the likely cause of hypoxia from H/O.

(3) CIRCULATION:
_________________

* CHEST TRAUMA (Hypovolemic shock - Pericardial tamponade - Tension

pneumothorax):
_________________________________________________________________________
__________
_________________________________________________________________________
__________

-> HYPOVOLEMIC SHOCK:

______________________
. The most common type of shock.
. Pale, cold , shivering pt with diaphoresis, hypotension & tachycardia.
. Look for a source of bleeding.
. The pt may lose a large volume of blood in the abdomen or thigh
following femur #.

. N.B.
. When hemorrhage occurs, tachycardia & peripheral vasoconstriction are
the 1st changes.
. These responses act to maintain the blood pressure within normal
limits.
. PULSE CHANGE IS THE FIRST INDICATOR FOR HYPOVOLEMIA.

-> Pericardial tamponade:

__________________________
. Cause distended neck veins & high central venous pressure.
. Enlarged heart on CXR (May be normal cardiac silhouette).
. Electrical alternans on EKG.
. Pulsus paradoxus on vital signs.
. Tx -> immediate pericardiocentesis tap or pericardial window.

. N.B.
. Acute cardiac tamponade:
. occurs due to a sudden rise in intra-pericardial pressure.
. Should be suspected in all adult pts with blunt chest trauma.
. Jugular venous distension, Tachycardia & Hypotension despite
aggressive fluid resusc.
. CXR findings typically reveal a normal cardiac silhouette without
tension pneumothorax.

-> Tension pneumothorax:

_________________________
. Cause distended neck veins & high central venous pressure.
. Respiratory distress, tracheal deviation, absent breath sounds.
. Hyperresonance to percussion.
. Tx -> immediate placing of a large-bore needle or IV catheter into the
pleural space.
. Chest tube placement.
. Never wait for a CXR for diagnosis.

. N.B.
. Don't be distracted by head trauma or dilated pupils in a hypotensive
trauma pt.
. Intracranial bleeds are never the cause of hypotensive shock.
. The 1st step in management is to identify & control the site of
bleeding.

. N.B.
. Most causes of shock in the setting of trauma are 2ry to hypovolemia
from blood loss.
. However, ++ CVP/PCWP or failure of hypotension to resolve after a
bolus of IV fluids,
. should suggest an alternative diagnosis.
. Myocardial contusion sh'd be suspected in pts with evidence of injury
to anterior chest
. MI can be confirmed with +ve cardiac markers & EKG changes.

. Tension pneumothorax is excluded if there is no tracheal deviation.

 . Hypovolemia is excluded if there is failure to respond to an IV fluid
bolus.

. N.B.
. High energy blunt trauma to the chest commonly causes aortic injury.
. In most cases of aortic rupture, death is the immediate result.
. Widened mediatinum, large left sided hemothorax & mediastinal
deviation to right side.
. Disruption of the normal aortic contour..
. Bilateral COLLAPSED neck veins.

. Cardiac contusion & rupture cause pericardial tamponade only.

. Muffled heart sounds - Hypotension - DISTENDED NECK VEINS.

. N.B. PULMONARY CONTUSION:

____________________________
. Represents pulmonary bruising of the lung.
. Common after high-speed car accidents.
. Clinical manifestations develop in the 1st 24 hours (Often within few
minutes).
. Tachypnea - Tachycardia - Hypoxia.
. P/E -> Chest wall bruising & -- breath sounds on the side of pulmonary
contusion.
. CXR -> Patchy irregular alveolar infiltrate.
. ABG -> Hypoxemia.

. It is very important to differentiate pulmonary contusuion from ARD$.

. ARD$ manifests 24 - 48 hours from the trauma & BILATERAL involvement.
. Pulmonary contusion manifests in the 1st 24 hours.

. N.B. PNEUMOTHORAX:
. Primary spontaneous pneumothorax -> No preceiding event & No H/O of
lung disease.
. Secondary spontaneous pneumothorax -> Complication of underlying COPD.
. Tx -> Small ( < 2cm between lung & chest wall on CXR) -> Observation &
oxygen.
. Tx -> Large (Stable) -> Needle aspiration or chest tube.

. Tension pneumothorax:
________________________
. Life threatening; trapped air with mediastinal shift.
. Compromised cardiopulmonary function.
. Chest pain or dyspnea.
. -- Breath sounds / -- TVF / -- chest movement.
. Hyperresonance to percussion on the affected side.
. Tachycardia, hypotension.
. Tracheal deviation away from the affected side.
. Imaging -> Notable visceral pleural line.
. Imaging -> Air in hemithorax -> Contralateral mediastinal shift.
. Imaging -> Radiolucent costophrenic sulcus.
. Tx -> Urgent needle decompression then chest tube placement (Tube
thoracostomy).
. Tx -> IV lines & fluid resuscitation follow urgent needle
decompression.

. N.B.
. ONLY TWO CAUSES OF DISTENDED NECK VEINS -> TENSION PNEUMOTHORAX &
CARDIAC TAMPONADE.

. N.B.
 . In HEMOTHORAX -> Neck veins are COLLAPSED !

. N.B. FLAIL CHEST:

____________________
. Follows major thoracic trauma.
. Multiple contigious ribs are fracutred in two or more locations.
. Causing a segment of rins losing its continuity with the rest of
thoracic wall.
. The pt takes shallow breaths due to severe pain.
. The pt compensates for the hypoxemia by hyperventillation.
. Tachypnea & PARADOXICAL THORACIC WALL MOVEMENTS.
. Paradox is corrected with positive pressure mechanical ventillation.
. The isolated thoracic wall segment exhibits paradoxical motion,
. inward motion on inspiration & outward motion during expiration !
. Tx -> Pain control & supplemental oxygen are the most important steps.
. Positive pressure mechanical ventillation replaces the negative
intrapleural pressure.
. so the flail chest movement will be normal with the rest of the rib
cage on inspiration

. N.B. HEMO-THORAX:
____________________
. After blunt chest trauma, hemorrhagic shock associated e'
. decreased breath sounds & dullness to percussion over one hemithorax.
. & contralateral tracheal deviation.
. COLLAPSED NECK VEINS.
. Most common cause is damage to intercostal or internal mmamary artery.

* ABDOMINAL TRAUMA:
____________________
. The 1st step in management is always to control the site of bleeding
if known.
-> Apply direct pressure when the site is visible (e.g. extremity).
-> Blind clamping & the use of tourniquet is NEVER the answer.

. The next priority is FLUID RESUSCITATION.

. Do several things at once in preparation for immediate exploratory

laparotomy:
-> Set up 2 large gauge IV lines.
-> Give fluids & blood.
-> Insert Foley catheter.
-> Administer IV antibiotics.

. If surgery isn't needed (blunt trauma),

. fluid resuscitation is the 1st step in management (Also diagnostic).
. If the pt responds promptly, then he's propably no longer bleeding.

. N.B.
. Intraosseous cannulation in the proximal tibia is used in children
(generally < 6ys).
. Give an initial bolus of Ringer's lactate at 20 ml/kg of body weight.

. N.B. BLUNT ABDOMINAL TRAUMA (BAT):

_____________________________________
. After a car accident of a restrained driver.
. Usually occurs when a lap belt (without shoulder attachment)
compresses the abdomen,
. and lacerates solid organs most commonly the spleen & liver.
 . Hypotension, tachycardia, facial lacerations & abdominal wall
ecchymosis.
. Most reliable symptoms -> Abdominal pain, tendrness & peritoneal
signs.
. Intraabdominal injury sh'd be suspected in pts with:
. abdominal wall ecchymosis,abdominal distension & hyperactive bowel
sounds.

. 1st step after fluid resuscitation to determine if the pt needs

exploratory laparotomy.
. All pts with BAT sh'd 1st be assessed for intraperitoneal free fluid
or hemorrhage.
. Best test is -> BEDSIDE ULTRASONOGRAPHY to detect free intraperitoneal
fluid,
. in hepatorenal space, splenorenal recess & inferior portion of
intraperitoneal cavity.
. When combined with pericardial evaluation -> known as FAST.
. FAST exam -> (Focused assessment with sonography for trauma).
. It is the best to detect hemoperitoneum, pericardial effusion or
intraperitoneal fluid.

. If FAST exam is limited or equivocal -> A diagnostic peritoneal lavage

(DPL) is done.
. DPL is done to evaluate for hemoperitoneum.

. Pts with +ve findings on either FAST or DPL -> should undergo
exploratory laparotomy.

. Hemodynamically stable pts with -ve findings on FAST may undergo

abdominal CT,
. to determine need for laparotomy.

. Hemodynamically un-stable -> FAST or DPL.

. N.B.
. Blunt abdominal trauma to the upper abdomen can cause pancreatic
contusion,
. crush injury, laceration or transection to the pancreas.
. Pancreatic injuries may be MISSED by CT scan during the 1st 6 hours
following trauma.
. Untreated pancreatic injury can be complicated by retroperitoneal
abscess or pseudocyst

. N.B.
. The spleen is the most commonly injured organ following blunt
abdominal trauma.
. Left upper quadrant abdominal pain.
. Abdominal wall contusion, Lt lower chest wall tendrness.
. Lt shoulder pain referred from splenic hemorrhage irritating phrenic
nerve & diaphragm.
. It is called "KEHR" sign.
. Splenic rupture causes acute left upper quadrant abdominal pain.
. Delayed hypotension may result due to blood loss.
. No signs of sepsis will be present.
. Dx -> Abdominal CT with IV contrast.

. N.B.
. Blunt deceleration trauma (Motor vehicle accident or fall from > 10
feet):
. Blunt aortic trauma must be ruled out.
 . CXR is the initial screening test -> WIDENING of the mediastinum.

. N.B.
. Duodenal hematoma:
_____________________
. mostly follow abdominal blunt trauma in children.
. The hematoma may cause duodenal obstruction with nausea & vomiting.
. Epigastric pain & vomiting due to failure to pass gastric secretions
past obstruction.
. Tx -> NASOGASTRIC SUCTION & PARENTERAL NUTRITION.
. Most hematomas will resolve spontaneously in 1-2 weeks.

. N.B.
. Any gun shot wound below the 4th intercostal space (level of the
nipple) is:
. considered to involve the abdomen & requires an exploratory laparotomy
in unstable pts.

. N.B.
. All hemodynamically UN-STABLE pts with penetrating abdominal trauma,
. must undergo immediate exploratory laparotomy to diagnose & treat
source of bleeding
. as well as to diagnose & treat perforation of any abdominal viscus to
prevent sepsis.

. N.B.
. Abdominal CT used to detect intra-abdominal injury in hemodynamically
stable trauma pts
. In hemodynamically un-stable pts, a FAST U/$ should be the initial
test.
. DPL Diagnostic peritoneal lavage is used in hemodynamically unstable
pts if -ve FAST.

. N.B.
. DIAPHRAGMATIC TRAUMA:
________________________
. Blunt abdominal trauma -> Mild respiratory distress & Abnormal CXR.
. Sudden ++ in intra-abdominal pressure -> Large radial tears in the
diaphragm.
. Rupture is more common on LEFT side bec. the right side is protected
by the liver.
. Dx -> CXR -> Hemi-diaphragmatic elevation.
. Dx -> CXR -> Naso-gastric tube in the pulmonary cavity = Diaphragmatic
hernia.
. Dx -> CT is the next best step (to Confirm).
. The small bowel may be present in the thoracic cavity.
. Tx -> Surgical repair & exploration for other traumatic injuries.

. N.B.
. TRACHEO-BRONCHIAL RUPTURE:
_____________________________
. Due to rapid decceleration blunt chest trauma.
. 1st manage the ABCs.
. Dx -> CXR -> Persistent pneumothorax & pneumomediastinum despite chest
tube placement !
. Subcutaneous emphysema (Palpable crepitus below the skin).
. The RIGHT MAIN BRONCHUS is the most commonly injured.
. Dx -> High resolution CT scan (Confirm).
. Tx -> Surgical repair.
 . BLUNT ABDOMINAL TRAUMA MANAGEMENT:
_____________________________________
_____________________________________

. HEMODYNAMICALLY UN-STABLE PATIENT:

_____________________________________
-> Cervical spine immobilization.
-> Intravenous hydration.
-> FAST (Focused assessment with sonography for trauma).
-> If FAST is +ve for blood & pt is still UNSTABLE AFTER A TRIAL OF
FLUID RESUSCITATION,
-> URGENT LAPAROTOMY with surgical repair is indicated.

. HEMODYNAMICALLY STABLE PATIENT:

__________________________________
-> CT scan abdomen with contrast (to detect the amount of bleeding & the
site of injury).
-> The surgeon can then select either laparotomy or admission &
observation.

. MANAGEMENT OF BLUNT ABDOMINAL TRAUMA

_______________________________________
. in HEMODYNAMICALLY UN-STABLE PT
__________________________________
|
FAST EXAMINATION
________________
|
____________________________________________
| | |
+ve inconclusive -ve
| | |
LAPAROTOMY <--POSITIVE--- DPL ----NEGATIVE---> Signs of
____________ _____ extra-
abdominal
hemorrhage
(Pelvic/long bone #)
|

___YES_____________NO_____
|
|
STABILIZE
STABILIZE
ANGIOGRAPHY & SPLINT
then CT ABDOMEN

* VASOMOTOR SHOCK:
___________________
. Hypotension & tachycardia in pts who are warm & flushed (Not pale &
cold!).
. Look for a H/O of medication use (penicillin allergy).
. H/O of spinal anesthesia or exposure to allergen (bee stings).
 * TRAUMA TO LOCALIZED SITES:
_____________________________
. All penetrating wounds with damage to internal organs will need to go
to the OR.
. If the case describes an object embedded in the pt, NEVER to remove
it.
. Never remove it in the ER or at the scene of the accident (Only in the
operating room).

* HEAD TRAUMA:
_______________
. "No" surgical intervention is needed for ..
. an asymptomatic head injury with a closed skull # (No overlying wound)
alone.
. The next step of management is to clean any lacerations.

. Surgery "Repair or craniotomy" is always done for ..

. COMMINUTED or DEPRESSED SKULL # even if the pt is asymptomatic !
. Send the pt to the OR.

. For head trauma & loss of cosciousness

. The 1st step of management is ordering a HEAD & NECK CT with "OUT"
contrast.
. If the head CT & neurological exam are normal,
. he can go home if someone can closely observe him over the next 24
hours.
. i.e. wake him up frequently & watch for changes in mentation.

. Give tetanus toxoid & prophylactic antibiotics to all pts with open
skull #s.

* BASAL SKULL #:
_________________
. Ecchymosis around both eyes (Racoon eyes).
. Ecchymosis behind the ear (Battle's sign).
. Clear fluid drippling from the ear or nose (CSF leak).
. CT scan of head & neck -> Basal skull #. "X-ray is a wrong answer".
. A CSF leak will stop by itself & requires no specific management.
. Prophylactic antibiotics are NOT indicated !!
. Facial palsy may occur 2-3 days later due to neuroapraxia (Use
Steroids).

* EPI-DURAL HEMATOMA:
______________________
. Side head trauma & rupture of middle meningeal artery in the foramen
spinosum.
. H/O of head trauma & SUDDEN LOSS OF CONSCIOUSNESS.
. Accumulation of blood in the potential space inbetween the cranium &
dura matter.
. Honeymoon period (The period when the pt immediately awakes & appears
normal).
. Pt typically has ipsilateral pupil dilatation due to oculomotor nerve
compression.
. Then the pt quickly deteriorates, so .. It is important to manage
quickly.
. Dx -> CT scan -> BICONVEX LENS shaped hematoma with or without midline
deviation.
 . Tx -> EMERGENCY CRANIOTOMY.
. If the pt is treated, the prognosis is good.
. If not, the prognosis is fatal within hours.

. Epidural hematoma results from rupture of middle meningeal artery,

. higher arterial pressure can rapidly expand the hematoma -> Compress
the temporal lobe.
. Fluid resuscitation ++ the rate at which the epidural hematoma
expanded.
. Hypertension, bradycardia & respiratory depression (Cushing's reflex)
= ++ ICP.
. The uncus is the innermost part of the temporal lobe & herniated
through the tentorium,
. leading to the following pressure effects:

. TRANS-TENTORIAL (UNCAL) HERNIATION:

______________________________________
______________________________________

. Compression of the contralateral crus cerebri against the tentorial

edge:
_________________________________________________________________________
___
. Ipsilateral hemiparesis.

. Compression of the ipsilateral oculomotor nerve (CN 3) by the

herniated uncus:
_________________________________________________________________________
________
. Loss of parasympathetic innervation causes mydriasis.
. Loss of motor innervation causes ptosis & down-outwards gaze of the
ipsilateral pupil,
. due to un-opposed trochlear (CN 5) & abducent (CN 6).

. Compression of the ipsilateral posterior cerebral artery:

____________________________________________________________
. causes ischemia of the visual cortex -> Contralateral homonymous
hemianopia.

. Compression of the reticular formation:

__________________________________________
. Altered level of consciousness; coma.

* "S"UB-DURAL HEMATOMA:
________________________
. Low pressure bleeding from the "VENOUS SYSTEM".
. Accumulation of blood in the subdural space between the dura &
arachinoid membrane.
. Head trauma with FLUCTUATING CONSCIOUSNESS i.e.
. gradual headaches, memory loss, personality changes, dementia,
cofusion & drowsiness.
. Dx -> CT scan -> "S"EMILUNAR, CRESCENT shaped hematoma e' or e'out
midline deviation.
. Tx -> CONSERVATIVE management with STEROIDS.
. Emergency craniotomy is done if there are lateralizing signs & midline
displacement.

* DIFFUSE AXONAL INJURY:

_________________________
. Results from ACCELERATION-DECELERATION injuries to the head.
. The pt will be deeply unconscious.
. Dx -> CT -> Normal or diffuse small bleeds at the junctions of the
grey & white matter.
. CT -> Numerous punctate hemorrhages.
. Prognosis is terrible !
. Surgery can't help.
. Therapy is directed at preventing further injury from ++ ICT.

* ELEVATED INTRACRANIAL PRESSURE (++ ICP):

___________________________________________
. Briefly depressed consciousness after head trauma.
. Improvement.
. Progressive drowsiness.
. ++ ICT is a medical emergency.
. GRADUAL DILATATION OF ONE PUPIL & DECREASING RESPONSIVENESS TO LIGHT
is an imp. sign.
. It indicates clot expansion on the ipsilateral hemisphere.
. Dx -> Head CT -> Midline shift or dilated ventricles.
. Don't think about performing a lumbar tap in any pt before getting a
head CT 1st !
. If you perform a lumbar puncture on a person with ++ ICT, you''
herniate the brain !
. Tx -> Head elevation - Hyperventillation - Avoid fluid overload.
. Tx -> Mannitol & furosemide (use very cautiously as they can reduce
cerbral perfusion).
. Tx -> sedation & hypothermia may lower oxygen demand.

. N.B. Lowering ICP is not the ultimate goal; preserving brain perfusion
is.
. Systemic hypotension or excessive cerebral vasoconstriction may be
counterproductive.

. N.B. Steroids are good for cerebral edema 2ry to tumors & abscesses,
. But they have no role in head trauma pts !

. N.B. Pts with mild to moderate traumatic brain injury:

. can be discharged under the care of an adult if they have a NORMAL CT.
. The caretaker sh'd be given printed instructions detailing signs &
symptoms that,
. warrant immediate return to the hospital.
_________________________________________________________________________
_________________

. ACUTE ABDOMEN:
_________________
_________________

. 4 main causes -> Perforation - Obstruction - Inflammation/Infection -

Ischemia.

. When is "SURGEY" the answer ?

________________________________
1. Peritonitis (Exclude primary peritonitis).
2. Abdominal pain/tendrness + sepsis signs.
3. Acute intestinal ischemia.
4. Pneumoperitoneum.
 . In all of the above cases, make sure pancreatitis is 1st ruled out !

. N.B. Primary peritonitis is spontaneous inflammation with nephrosis in

children.
. or .. An adult with ascites & mild abdominal pain (even there is fever
& leukocytosis).

. When is "MEDICAL ttt" the answer ?

_____________________________________
1. Primary peritonitis.
2. Pancreatitis.
3. Cholangitis.
4. Urinary stones (Look for stones on X-ray).
5. Things that can mimic an acute abdomen:
-> Lower lobe pneumonia (Look for infiltrate on CXR).
-> Myocardial ischemia (Look for EKG changes).
-> Pulmonary embolism (Look for immobilized pt).
6. Ruptured ovarian cyst.

. N.B.
. Cholangitis is a GIT medical emergency & intervention with ERCP is the
ttt of choice.

. NON-surgical causes of an acute abdomen:

___________________________________________
1. Myocardial infarction - acute pericarditis.
2. Lower lobe pneumonia - pulmonary infarction.
3. Hepatitis - GERD.
4. DKA - Adrenal insuffeciency.
5. Pyelonephritis - Acute salpingitis.
6. Sickle cell crisis.
7. Acute porphyria.

. N.B.
. Be sure to differentiate GERD from peptic ulcer perforation (surgical
emergency).

* 1 * PERFORATION:
___________________
___________________

(1) GASTRO-INTESTINAL PERFORATION:

__________________________________
. Acute abdominal pain that is sudden, severe, constant & generalized.
. Pain is excruciating with any movement (may be blunted in elderly
pts).
. Most common causes of GIT perforations:

(a) Diverticulitis: Elderly pt with lower abdominal pain & fever.

(b) Perforated peptic ulcer: Epigastric pain waking up the pt at night.
(c) Chron's disease.

. Dx -> Supine & erect abdominal x-ray (free air under diaphragm).
. Tx -> Nothing by mouth (NPO) & IV fluid hydration.
. Tx -> IV antibiotics such as flagyl & gentamycin.
. Tx -> IV 2nd generation cephalosporins (Cefotetan or cefoxitin).
. Tx -> Emergency surgery.

(2) ESOPHAGEAL PERFORATION:

___________________________
. Most common cause is IATROGENIC.
. Pain in chest or upper abdomen.
. Dysphagia or odynophagia.
. S.C. emphysema shortly after endoscopy.
. It is a surgical emergency.
. Dx -> GASTROGRAFFIN CONTRAST ESOPHAGOGRAM is the best (Do NOT use
Barium xx).

* 2 * OBSTRUCTION:
___________________
___________________
. Severe colicky pain.
. Absence of flatus or feces.
. Nausea & vomiting.
. Constant movement as the pt tries to find a comfort position.

. H/O of prior surgery (Think adhesions).

. H/O of elderly pt with anemia, weight loss & melanotic stools (Think
tumor).
. H/O of recuurent lower abdominal pain (Think diverticulitis).
. H/O of hernia (incarcerated hernia).
. H/O of sudden abdominal pain in elderly pt (Think volvulus).

. Dx -> CBC & ++ lactate level.

. Dx -> Supine & erect abdominal X-ray:
-> Dilated loops of bowel, absence of gas in rectum, bird's beak
sign for volvulus.
. Tx -> NPO, (NG) suction & IV fluid hydration.
. Consider Gastrograffin contrast study (Until perforation has been
ruled out).

. Volvuls -> Perform procto-sigmoidoscop with rigid instrument.

-> Leave the rectal tube in place.
-> Perform sigmoid resection for recurrent cases.

. Abdominal hernia -> Perform elective repair for all abdominal hernias.
-> except umbilical hernia in pts < 2 ys.
-> except esophageal sliding hernia.

. All other obstructions -> Perform emergency surgery.

. N.B.
. In a pt with a hernia, immediate surgery is the answer if the case
describes:
. fever, leukocytosis, constant pain & signs of peritoneal irritation
(Strangulation).

. N.B.
. Complete small bowel obstruction
. Nausea - vomiting - Abdominal bloating - Dilated loops of bowel on
abdominal x-ray.
. Adhesions are the most common etiology.

. N.B.
. SMALL BOWEL OBSTRUCTION:
___________________________
. Colicky abdominal pain & vomiting.
. No bowel movement or passing gas (Obstipation), abd. distension &
diffuse tendernesss.
 . The contents of the vomitus are typically bilious in proximal SBO.
. The contents of the vomitus are feculent with more distal
obstructions.
. Hyperactive bowel sounds due to peristaltic rush.
. Dx -> Abd. x-ray -> DILATED BOWEL LOOPS with MULTIPLE AIR FLUID
LEVELS.
. Tx -> Complete bowel rest - Decompression e' nasogastric tube.
. Tx -> Pain control - Fluid resuscitation.
. Tx -> If no improvement -> Surgical intervention to avoid
strangulation.
. Strangulation signs (fever - tachycardia - leukocytosis - Metabolic
acidosis).

. N.B.
. Immediate surgical intervention is indicated for pts with intestinal
obstruction who,
. develop clinical or hemodynamic instability, fail to improve after
conservative ttt,
. or develop syms of strangulation (fever-tachycardia-leukocytosis-
Metabolic acidosis).

* 3 * INFLAMMATION:
____________________
____________________
. Causes (Acute diverticulitis - Acute pancreatitis - Acute
appendicitis).
. Gradual onset of constant abdominal pain that slowly builds up over
several hours.
. Initially ill defined pain that becomes localized to the site of
inflammation.
. Note that signs of peritoneal irritation are ABSENT in pancreatitis.

(1) ACUTE DIVERTICULITIS:

__________________________
. Acute abdominal pain in the LEFT LOWER QUADRANT (LLQ).
. Middle age or older pt with fever, leukocytosis & peritoneal
irritation in the LLQ.
. Palpable tender mass in the LLQ.
. In women, think about fallopian tubes & ovaries as potential sources.
. Dx -> CT -> Abscess & free air.
. Never order contrast studies or endoscopy in acute phase.
. Tx -> If there is no peritoneal signs -> Manage as outpatient with
antibiotics.
. Localized peritoneal signs & abscess -> Admit pt - NPO - IV fluids -
IV antibiotics.
. Generalized peritonitis or perforation -> Emergency surgery.
. Recurrent attacks of diverticulitis -> Elective surgery.

. N.B. When diagnosing acute diverticulitis,

. don't forget to order a urine pregnancy test on all women of
childbearing age.

. Complicated diverticulitis: Associated e' abscess, perforation,

obstruction or fistula.
. Fluid collection < 3cm -> IV antibiotics & observation.
. Fluid collection > 3cm -> CT guided percutaneous drainage.
. If no response within 5 days -> Surgery for drainage & debridement.

(2) ACUTE PANCREATITIS:

________________________
. Alcoholic pt who develops an acute (over several hours) upper
abdominal pain,
. radiating to the back, with nausea & vomiting.
. It may be edematous, hemorrhagic or suppurative (pancreatic abscess).
. Late complications include pancreatic pseudocyst & chronic
pancreatitis.
. Dx -> Serum or urinary amylase or lipase (serum 12 - 48 hs, urinary
3rd - 6th day).
. Dx -> CT if diagnosis is uncertain.
. Tx -> NPO, NG suction & IV fluids.

. N.B. Look out for the risk factors for acute pancreatitis:
-> Alcoholism.
-> Gall stones.
-> Medications (Didanosine, pentamidine, Flagyl, Tetracycline, Thiazides
& Furosemide).
-> Hypertriglyceridemia.
-> Trauma.
-> Post-ERCP.

. N.B. COMPLICATIONS:

-> Abscess:
. Often appears 10 days after onset with persistent fever & high WBC
count.
. Surgical drainage is the ttt.

-> Pseudocyst:
. Appears 5 weeks after initial symptoms.
. when a collection of pancreatic juice causes anorexia, pain & a
palpable mass.
. If < 6 cm & present < 6 weeks -> OBSERVATION.
. If > 6 cm or present > 6 weeks -> Percutaneous drainage or endoscopic
drainage.

-> Chronic damage:

. causes diabetes & steatorrhea.
. Treat with insulin & pancreatic enzyme supplementation.

. N.B. The most common causes of acute pancreatitis are gallstones &
alcohol use.
. Identifying the underlying cause can prevent recurrent pancreatitis.
. ULTRASOUND is the preferred test to detect gall stones.
. Stable pts sh'd undergo cholecystectomy for biliary pancreatitis prior
to discharge.

(3) ACUTE APPENDICITIS:

________________________
. Begins with anorexia.
. Followed by vague peri-umbilical pain.
. several hours later, it becomes sharp, severe, constant & localized to
RLQ of abdomen.
. RIGHT LOWER QUADRANT PAIN.
. Tenderness, guarding & rebound tendrness are found on the right &
below the umbilicus.
. Dx -> Fever, leukocytosis 10000 - 15000 with neutrophilia & immature
forms.
. Dx -> Reactive thrombocytosis.
 . Dx -> Abdominal U/$ or CT scan if clinically unclear.
. Tx -> IV antibiotics before appendectomy.
. Tx -> If appendix is perforated -> Continue IV until fever & WBC count
normalize.

. N.B. APEENDICEAL PERFORATION complicated by PSOAS ABSCESS:

_____________________________________________________________
. Localized Rt lower quadrant findings > 5days after onset of
appendicitis.
. perforation occurs with abscees formation.
. Psoas abscess -> Flexion of the hip against resistance (Psoas sign).
. Tx -> IV hydration - Antibiotics - Bowel rest - Interval appendectomy
after 6-8 weeks.

. N.B. APPENDICEAL PERFORATION complicated by PELVIC ABSCESS:

______________________________________________________________
. Rupture of appendix with pelvic abscess formation.
. Drainage of fluid into the dependent recto-vesical pouch.
. Tender, fluctuant mass palpable only e' the tip of finger = recto-
vesical pouch abscess
. Fever, lukocytosis, painful defecation & diarrhea.
. Tx -> Abscess drainage.

. N.B. CHRONIC ULCERATIVE COLITIS (CUC):

_________________________________________
. CUC is managed medically.
. Elective surgery is done in the following conditions:
-> Disease is present > 20 ys "High incidence of malignant
degeneration".
-> Multiple hospitalizations.
-> Pt needs chronic high dose steroids or immunosuppressants.
-> Toxic megacolon (Abd. pain - fever - leukocytosis - epigastric
tendrness).
-> Massively distended transverse colon on X-rays with gas within the
wall of the colon.

* 4 * ISCHEMIA:
________________
________________
. Acute mesenteric ischemia in older pts.
. H/O of arrhythmia (Af -> Absence of P waves with irregular rhythm).
. Coronary artery disease.
. Recent MI.
. Severe acute onset abdominal pain that is out of proportion to exam.
. Dx is clinical but look for acidosis & sepsis signs.
. If ischemia is suspected, don't w8 for lab findings (acidosis or ++
lactate),
. Go straight to surgery or order angiography.
. If diagnosis is during SURGERY -> Perform embolectomy &
revascularization or resection.
. If diagnosis is during ANGIOGRAPHY -> Give vasodilators or
thrombolysis.
. Acute embolic mesenteric ischemia may progress to bowel infarction.

. N.B. INTRA-ABDOMINAL ABSCESS:

________________________________
. H/O of previous operation, trauma or intra-abdominal
infection/inflammation.
. Abscesses can occur anywhere in the abdomen or retroperitoneum.
 . Dx -> CBC & contrast CT of abdomen or pelvis.
. Tx -> Drain an intraabdominal abscess (either surgically or
percutaneously).
. Tx -> Give antibiotics to prevent spread of infection (Doesn't cure
abscess).

. Ex. PSOAS ABSCESS:

. It is not an exclusive complication of appendicitis.
. It may present alone (Absence of rebound tenderness of appendicitis
!).
. Presence of multiple furuncles on the inner thighs is a clue of septic
focus !
. Dx -> CT Abdomen.
. Tx -> Surgical or percutaneous drainage.

. N.B. BOWEL ISCHEMIA:

_______________________
. One of the complications of abdominal aortic aneurysm repair surgery.
. Due to inadequate colonic collateral arterial perfusion to the left &
sigmoid colon.
. Due to loss of the inferior mesenteric artery during aortic graft
placement.
. Abdominal pain (Dull pain over ischemic bowel) & bloody diarrhea
(Hematochezia).
. Fever & leukocytosis.
. Colonoscopy -> Discrete segment of cyanotic & ulcerated bowel.
. Prevention -> Checking sigmoid colon perfusion following graft
placement.

. SURGICAL JAUNDICE:
____________________
____________________

* OBSTRUCTIVE JAUNDICE CAUSED BY STONES:

_________________________________________
. Obese, fecund woman in her 40s.
. Recurrent episodes of abdominal pain.
. High alkaline phosphatase.
. Dilated ducts on sonogram.
. Non-dilated gall bladder full of stones.
. Dx -> Abdominal U/$.
. Dx -> Confirm e' endoscopic ultrasound (EU$).
. Dx -> Confirm e' Magnetic resonance cholangiopancreatography (MRCP).
. Tx -> Perform Endoscopic retrograde cholangiopancreatography (ERCP).
. Tx -> Cholecystectomy sh'd follow ERCP.

. N.B. ERCP & EU$ are never the 1st step in diagnosis.
. N.B. ERCP is mostly a management step on exam.

* OBSTRUCTIVE JAUNDICE CAUSED BY TUMOR:

________________________________________
. Progressive symptoms in the preceeding weeks & weight loss.
. Adenocarcinoma at the head of pancreas.
. Adenocarcinoma at the ampulla of Vater.
. Cholangiocarcinoma arising in the common bile duct itself.
. Dx -> Abdominal U/$.
. Dx -> CT scan.
. Dx -> For lesions on CT -> Obtain a tissue diagnosis via EU$.
. Dx -> If no lesions on CT -> Order MRCP.
 . MRCP -> will show the ampullary or common bile duct tumors not seen on
CT scan.
. Obtain tissue diagnosis via ERCP.
. Tx -> Surgical resection.

. GALL STONES:
_______________
_______________

(1) BILIARY COLIC:

___________________
. TEMPORARY occlusion of the CYSTIC DUCT.
. Colicky pain in the upper right quadrant RUQ.
. Radiating to the right shoulder & back.
. Often triggered by fatty food.
. Episodes are brief (20 mins).
. No signs of peritoneal irritation or systemic signs.
. Dx -> U/$.
. Tx -> Elective cholecystectomy.

. N.B. Ingestion of a fatty meal causes the gall bladder to contract.

. so .. it presses the gall stones against the cystic duct opening,
. increasing the intra gall bladder pressure causing VISCUS DISTENSION &
colicky pain.
. Subsequent gall bladder relaxation alows the stone to fall back from
the duct,
. causin the pain to resolve completely.
. Biliary colic pain may be referred to right shoulder.

. N.B. Pain of biliary colic is distinguished from that of acute

cholecystitis by:
. its intermittent nature & relation to meals as well as absence of
fever.

(2) ACUTE CHOLECYSTITIS:

_________________________
. PERSISTENT occlusion of the CYSTIC DUCT.
. Caused by a stone.
. Constant pain.
. Fver, leukocytosis & peritoneal irritation in the RUQ.
. Dx -> U/$ (Gall stones - Thick walled gall bladder - Pericholecystic
fluid).
. Tx -> NG suction - NPO - IV fluids - IV antibiotics.
. Tx -> Followed by elective cholecystectomy after 6 - 12 wks.
. Tx -> Emergency cholecystectomy is needed if there is:
. generalized peritonitis or ephysematous cholecystitis (i.e.
perforation or gangrene).

(3) ACUTE ASCENDING CHOLANGITIS:

_________________________________
. Obstruction of the COMMON BILE DUCT causes obstruction & ASCENDING
INFECTION.
. High fever & very high WBC count.
. High levels of alkaline phosphatase.
. High levels of total & DIRECT bilirubin.
. Mild elevation of transaminases.
. Tx -> IV antibiotics.
. Tx -> Emergency decompression of the common bile duct is life saving !
 . Decompression by ERCP or PTC (Percutaneous transhepatic cholangiogram)
or surgery.
. Tx -> Cholecystectomy must follow.

. N.B.
. A pregnancy test sh'd be performed in any woman of childbearing period
age before,
. ordering diagnostic tests such as x-rays or computed tomography scans.

. PRE-OPERATIVE & POST-OPERATIVE CARE:

______________________________________
______________________________________

* PRE-OPERATIVE ASSESSMENT:
____________________________

{1} CARDIAC RISK:

__________________
. Ejection fraction < 35 % -> Prohibits non-cardiac surgery.
. JVD (sign of CHF) -> Give ACEIs, BB, Digitalis & Diuretics prior to
surgery.
. Recent MI -> Defer surgery for 6 months post MI.
. Severe progressive angina -> Cardiac catheterization for coronary
revascularization.

{2} PULMONARY RISK:

____________________
. Smoking (Compromised ventillation = High pCO2 & FEV1 < 1.5):
-> Order PFTs to evaluate for FEV1.
-> If FEV1 is abnormal -> Obtain ABG.
-> Cessation of smoking 8 weeks prior to surgery.

{3} HEPATIC RISK:

__________________
. Bilirubin > 2 mg/dl.
. Prothrombin time > 16.
. Serum albumin < 3.
. Encephalopathy.

-> 40 % mortality with any single risk factors.

-> 80 % mortality if 3 or more risk factors are present.

{4} NUTRITIONAL RISK:

______________________
. Loss of 20 % of body weight over several months.
. Serum albumin < 3.
. Anergy to skin antignes.
. Serum transferrin < 200 mg/dl.

-> Provide 5-10 days of nutritional supplements (preferrably via gut)

before surgery.

. N.B. DIABETIC COMA is an ABSOLUTE contraindication to surgery.

. 1st stabilize diabetes.
. Rehydrate & normalize acidosis prior to surgery.

. N.B.
 . If a pt presents with an acute abdomen due to perforation of hollow
abdominal viscus,
. (Rebound tendrness & subdiaphragmatic free intraperitoneal air on
abdominal x-ray),
. the pt will require IMMEDIATE LAPARATOMY !
. Pre-operative naso-gastric tube decompression is a must.
. Give IV fluids & IV antibiotics.

. In a pt on warfarin due to Af, Warfarin induced anti-coagulation must

be reversed !
. Bec. if it isn't reversed, it will lead to intra & postoperative
bleeding complications
. The most rapid mean of normalizing PT: restoration of vit K dependent
clotting factors.
. through infusion of FRESH FROZEN PLASMA.

. POST-OPERATIVE COMPLICATIONS & MANAGEMENT:

____________________________________________
____________________________________________

{1} MALIGNANT HYPERTHERMIA (Exceeding 104 F):

______________________________________________
. Shortly after the onset of the anesthetic (Halothane or succinyl
choline).
. Tx -> IV DANTROLENE, 100% oxygen, Acidosis correction & cooling
blankets.
. Watch for development of myoglobinuria.

{2} BACTEREMIA (Exceeding 104 F):

__________________________________
. Within 30-45 mins of invasive procedures (UTI instrumentation).
. 3 successive blood cultures.
. Start empiric antibiotics.

{3} POST-OPERATIVE FEVER (101 - 103 F):

________________________________________

* ATELECTASIS (Day 1):

________________________
-> Lobar or segmental collapse of the lung -> -- lung volume.
-> Due to impaired cough & shallow breathing.
-> Due to accumulation of pharyngeal secretions.
-> Due to the tongue prolapsing posteriorly into the pharynx.
-> Due to airway tissue edema or residual anesthetic effects.
-> Causes significant ventillation - perfusion mis-match -> hypoxemia &
++ breathing work
-> Atelectasis is MOST SEVERE at the SECOND POSTOPERATIVE DAY NIGHT.
-> As a compensation for hypoxia -> Hyperventilation -> Respiratory
alkalosis & -- pCO2.
-> Ex -> pH 7.49, pO2 70 mmHg, pCO2 50 mmHg.
-> Prevention: Breathing exercises - Incentive spirometry - Forced
expiratory techniques.

. N.B.
. Moving from supine to sitting position ++ the functional residual
capacity FRC by 25%.
. ++ FRC prevents post-operative atelectasis.

* "WIND" PNEUMONIA (Day 3):

____________________________
-> CXR -> Infiltrate.
-> Sputum culture.
-> Antibiotics (Hospital acquired pneumonia).
-> Prevention : Post-operative breathing exercises & incentive
spirometry.

* "WATER" URINARY TRACT INFECTION (Day 3):

___________________________________________
-> Urinalysis & urinary culture.
-> Antibiotics.

* "WALKING" DEEP VENOUS THROMBOPHLEBITIS (Day 5):

__________________________________________________
-> Doppler U/$ of deep veins of legs & pelvis.
-> Anticoagulation.

* "WOUND" WOUND INFECTION (Day 7):

___________________________________
-> Antibiotics if only cellulitis.
-> Incision & drainage if abscess is present.

* DEEP ABSCESSES (SUBPHRENIC - PELVIC - SUBHEPATIC) (Day 10 - 15):

___________________________________________________________________
-> CT scan of the appropriate body cavity is diagnostic.
-> Percutaneous radiologically guided drainage is therapeutic.

{4} PERIOPERATIVE MYOCARDIAL INFARCTION:

_________________________________________
. Precipitated by hypotension when intraoperative.
. Postoperative MI seldom presents with chest pain.
. Thrombolytics are contraindicated even in postoperative setting !
. Mortality rate is higher than for non surgery related MI.

{5} PULMONARY EMBOLUS (Day 7):

_______________________________
. Tachycardia - SOB - Hypoxia & ++ A-a gradient.
. Dx -> CT angiogram.
. Tx -> Anticoagulate with heparin.
. IVC filter if recurrent PE.

{6} ASPIRATION:
________________
. SOB - Hypoxia - Infiltrates on CXR.
. Lavage & remove gastric contents.
. Bronchodilators & respiratory support.
. Steroids don't help.

{7} INTRA-OPERATIVE TENSION PNEUMOTHORAX:

__________________________________________
. Positive pressure breathing; pt becomes progressively more difficult
to bag.
. BP steadily declines & CVP steadily rises.
. Insert needle to decompress & place chest tube later.

{8} POST-OPERATIVE CONFUSION:

______________________________
. Suspect hypoxia 1st ! (Check ABG).
. Consider sepsis then ! (Get blood cultures & CBC).
 {9} ACUTE RESPIRATORY DISTRESS $YNDROME (ARD$):
________________________________________________
. Bilateral pulmonary infiltrates & hypoxia with no evidence of CHF.
. Tx -> PEEP = Positive end expiratory pressure.

{10} DELIRIUM TREMENS (Day 2-3):

_________________________________
. Tachycardia - Hyperthermia - Hypertension - Altered mental status.
. Give benzodiazepines (Barbiturates are 2nd line agents due to low
therapeutic range).
. Watch for seizures & rhabdomyolysis.

. N.B.
. Post-operative oliguria & azotemia:
______________________________________
. Oliguria (< 400 cc) of urine output per day.
. Azotemia ( ++ BUN/Creatinine ratio > 20:1) = Acute Pre-renal failure
from HYPOVOLEMIA !
. Urinary catheter obstruction should be ruled out 1st.
. Next step is an IV FLUID CHALLENGE.

. N.B.
. Post-operative ileus:
________________________
. An ileus is a functional defect in the bowel motility without physical
obstruction.
. Following most abdominal surgeries.
. Nausea, vomiting, abdominal distension, failure to pass flatus or
stools.
. Hypoactive or absent bowel sounds.
. In contrast (Mechanical obstruction e.g. adehsions cause "HYPERactive"
bowel sounds).
. Causes of ileus:
-> ++ splanchnic nerve sympathetic tone following violation of the
peritoneum.
-> Local release of inflammatory mediators.
-> Postoperative narcotic (opiate) analgesics e.g Morphine causes
disordered peristalsis.

. N.B.
. Post-operative DVT:
______________________
. DVT occurs due to Virchow triad (Stasis - endothelial injury -
Hypercoagulability).
. Major surgery is a significant risk factor.
. Pts sh'd be ttt with LMW HEPARIN acutely & warfarin for several
months.
. Stable pts can be ttt with anticoagulation as early as 48 - 72 hours
after surgery.

. N.B.
. Transfusion reactions:
_________________________
. occur acutely during or immediately following transfusion of blood
products.
. They are immune mediated;
. preformed host antibody reacts with antigens on transfused blood
products,
. causing the release of inflammatory mediators & complement activation.
 . They may be HEMOLYTIC -> Severe reaction that may cause death.
. or NON-HEMOLYTIC -> Dose dependent self limited reaction with fever &
rigors.

. N.B.
. CATHETER (CENTRAL LINE) ASSOCIATED INFECTIONS:
_________________________________________________
. Intra-venous catheters are one of the most common causes of nosocomial
infections.
. Femoral central venous catheters carry a higher risk of bacteremia
than subclavian cath
. IV catheter infections are mostly caused by cutaneous organisms such
as STAPHYLOCOCCI.
. Femoral catheters may also cause gram -ve bacteremia.

. N.B. Post-operative ACUTE ADRENAL INSUFFECIENCY:

___________________________________________________
. Acute onset of nausea, vomiting, abdominal pain, hypoglycemia &
hypotension.
. follows a stressful event e.g. surgical procedure.
. Preoperative steroid use -> A steroid sependent pt is a common
scenario (H/O of lupus)!
. Exogenous steroids depress the pituitary-adrenal axis.

. N.B.
. POST-OPERATIVE MEDIASTINITIS:
________________________________
. May follow a cardiac surgery due ti intra-operative wound
contamination.
. Complicates 5 % of sternotomies.
. 14 days postoperative.
. Fever, tachycardia, chest pain, leukocytosis.
. Sternal wound drainage drainage of purulent discharge.
. CXR -> WIDENED MEDIASTINUM.
. Tx -> Drainage, surgical debridement with immediate closure &
prolonged antibiotic ttt.
. High mortality rate.

_________________________________________________________________________
_________________

. PEDIATRIC SURGERY:
_____________________
_____________________

. CONDITIONS THAT NEED SURGERY AT BIRTH:

_________________________________________
_________________________________________
. Congenital anomalies constitute the conditions that need surgery at
birth.
. The most imp. step is to rule out other associated congenital
anomalies.
. VACTER -> Vertebral, Anal, Cardiac, Tracheal, Esophageal, Renal &
Radial anomalies.

{1} ESOPHAGEAL ATRESIA:

________________________
. Excessive salivation is noted shortly after birth.
. Chocking spells are noticed when 1st feeding is attempted.
 . Confirm the diagnosis with an NG tube -> Coiled in the upper chest on
CXR.
. Tx -> Primary surgical repair.
. If surgery needs to be delayed for further workup,
. perform gastrotomy to protect the lungs from acid reflux.

{2} IMPERFORATED ANUS:

_______________________
. ABSENCE of flatus or stools.
. Look for a fistula near by (to vagina or perineum).
. If present, delay repair until further growth (but before toilet
training time).
. If not present, a colostomy needs to be done for high rectal pouches.

{3} CONGENITAL DIAPHRAGMATIC HERNIA:

_____________________________________
. Dyspnea is noted at birth !
. Loops of bowel in left chest are seen on x-ray.
. The primary abnormality is the HYPOPLASTIC LUNG with FETAL TYPE
CIRCULATION.
. Tx -> Endotracheal intubation, low pressure ventillation, sedation &
NG suction.
. Delay repair 3-4 days to allow lung maturation.

{4} GASTROSCHISIS & OMPHALOCELE:

_________________________________

* GASTROSCHISIS:
_________________
. The umbilical cord is NORMAL.
. The defect is to the right of the cord where is no protective
membrane.
. The bowel looks angry & matted.

* OMPHALOCELE:
_______________
. The umbilical cord goes to the defect.
. The defect has a thin membrane (one can see normal looking bowel &
little liver slice).

. Tx -> Small defects -> Close small defects primarily.

. Tx -> large defects -> Silastic "silo" to protect the bowel.
. Manual replacement of the bowel daily until complete closure (in about
1 week).
. Give parenteral nutrition (The bowel will not work in gastrochisis).

{5} EXSTROPHY OF THE URINARY BLADDER:

______________________________________
. This is an abdominal wall defect over te pubis.
. Refer to a specialized center offering surgical repair in 1st 1-2 days
of life.
. Do NOT delay surgery.

{6} INTESTINAL ATRESIA:

________________________
. Like annular pancreas, it presents with green vomiting.
. But, instead of double-bubble sign, there are multiple air-fluid
levels in the abdomen.
. There is no need to suspect other congenital anomalies,
. because this condition results from a vascular accident in utero !
 . SURGICAL CONDITIONS IN THE FIRST TWO MONTHS OF LIFE:
_______________________________________________________
_______________________________________________________

{1} NECROTIZING ENTEROCOLITIS:

_______________________________
. This shows up as feeding intolerance in premature infants when they
are 1st fed.
. There is abdominal distension.
. Rapid drop in platelet count (A sign of sepsis in babies).
. Tx -> Stop all feeds.
. Tx -> Broad spectrum IV antibiotics.
. Tx -> IV fluids & nutrition.
. Tx -> Surgery if there are signs of necrosis or perforation:
. (Abdominal wall erythema - Portal vein gas - Bowel wall gas).

{2} MECONIUM ILEUS:

____________________
. Feeding intolerance & bilious vomiting.
. Family H/O of cystic fibrosis.
. Dx -> X-ray -> Multiple dilated loops of small bowel.
. Dx -> X-ray -> Ground glass appearance in lower abdomen.
. Gastrograffin enema is both diagnostic & therapeutic.
. Diagnostic -> Microcolon & inspissated pellets of meconium in the
terminal ileum.
. Therapeutic -> Gastrograffin draws fluid in & dissolves the pellets.

{3} HYPERTROPHIC PYLORIC STENOSIS:

___________________________________
. Approximately at 3 weeks of age.
. NON-bilious projectile vomiting after each feeding.
. Look for gastric peristaltic waves.
. Palpable "olive-size" mass in the RUQ.
. Dx -> Abd. U/$.
. Tx -> Correct dehydration & associated hypochloremic hypokalemic
metabloic alkalosis.
. Follow this with Ramstedt pyloromyotomy.

{4} BILIARY ATRESIA:

_____________________
. 6 - 8 weeks old babies.
. Persistent progressively increasing jaundice Conjugated bilirubin).
. Dx -> Conduct serologies & sweat chloride test to rule out other
problems.
. Dx -> HIDA scan after 1 week of phenobarbital (A powerful choleretic).
. If no bile reaches duodenum even e' phenobarbital stimulation: Do
surgical exploration.

{5} HIRSCHSPRUNG's DISEASE = AGANGLIONIC MEGACOLON:

____________________________________________________
. The most important clue is chronic constipation.
. A rectal exam may lead to explosive expulsion of stool & flatus,
. followed by relief of abdominal distension.
. Dx -> Full thickness biopsy of rectal mucosa.

. SURGICAL CONDITIONS LATER IN INFANCY:

________________________________________
________________________________________
 {1} INTUSSUSCEPTION:
_____________________
. 6 - 12 months old chubby, healthy-looking kids.
. Brief episodes of colicky abdominal pain that makes them double up &
squat !
. A vague mass on the right side of the abdomen.
. An empty right lower quadrant.
. CURRANT JELLY STOOLS.
. Dx -> Barium or air enema -> Both diagnostic & therapeutic.
. Tx -> Perform surgery if enema fails to achieve reduction.

{2} MECKEL's DIVERTICULUM:

___________________________
. Lower GI bleeding in a child of pediatric age.
. Dx -> Radioisotope scan -> to look for gastric mucosa in the lower
abdomen.

_________________________________________________________________________
_________________

. ORTHOPEDICS:
_______________
_______________

. GENERAL RULES ABOUT #s:

__________________________
. When you suspect a #, order 2 views at 90 to one another.
. Always iclude the joints above & below the #.

. CLOSED REDUCTION -> for #s that are not badly displaced or angulated.
. OPEN REDUCTION & INTERNAL FIXATION -> for severely displaced or
angulated #s.

. Open #s (The broken bone sticking out through a wound) require

cleaning in the OR,
. & reduction within 6 hours from time of injury.

. Always worry about gas gangrene in any deep penetrating or dirty

wounds.
. 3 days later, the pt will be septic with gas crepitus.
. Tx -> Large doses of IV penicillin & hyperbaric oxygen.

. Always perform cervical spine films in any pt with facial injury.

. MANAGEMENT OF COMMON ADULT ORTHOPEDIC #s:

____________________________________________
____________________________________________

{1} CLAVICULAR #:
__________________
. # of the MIDDLE 1/3 -> Brace (Figure 8 sling), rest & ice.
. # of the DISTAL 1/3 -> Open reduction & internal fixation to prevent
malunion.
. All pts sh'd've a creful neurovascular examination to rule out injury
to:
. the underlying brachial plexus & subclavian artery.
. Hearing a loud bruit warrants an angiogram to rule out subclavian
artery injury.
 {2} COLLE's #:
_______________
. Closed reduction & casting.
. Elderly woman falling on an out-stretched hand.
. Painful wrist.
. Dinner fork deformity.

{3} DIRECT BLOW TO ULNE (MONTEGGIA #) or RADIUS (GALEAZZI #):

______________________________________________________________
. Combination of diaphyseal # & displaced dislocation of the nearby
joint.
. Open reduction & internal fixation is needed for the diaphyseal
reduction.
. Closed reduction for the displaced joint.

{4} SCAPHOID #:
________________
. Young adult with fall on an out-stretched hand.
. Persistent pain in the anatomical snuff box.
. Takes > 3 weeks to be seen on x-ray.
. If the initial x-ray is -ve, subsequent x-ray is done in 7-10 days.
. Wrist x-ray -> Fine radiolucent lines in nondisplaced scaphoid #.
. Tx -> Wrist immobilization for 6 - 10 weeks.
. Place thumb spica cast to help to prevent non-union.

{5} HIP #:
___________
. Any elderly pt who sustains a fall.
. Look for externally rotated & shortened leg.
. Femoral neck # -> High risk of avascular necrosis - Tx: Femoral head
replacement.
. Intertrochanteric # -> Open reduction & pinning.
. Femoral shaft # -> Intra-medullary rod fixation.

{6} TRIGGER FINGER:

____________________
. Woman who awakens at night with an acutely flexed finger,
. that snaps when forcibly extended.

{7} DE QUERVAIN TENOSYNOVITIS:

_______________________________
. Young mother carrying baby,
. with flexed wrist & extended thumb to stabilize the baby's head.
. Steroid injection is the best therapy.

{8} DUPUYTREN CONTRACTURE:

___________________________
. Contracture of the palm & palmar fascial nodules.
. Surgery is the only ttt.

{9} POSTERIOR HIP DISLOCATION:

_______________________________
. H/O of head-on car collision where the knees hit the dashboard
(Orthopedic emergency).
. Differentiate it from hip # by an internally rotated leg (The leg is
also shortened).
. Emergency ruduction is needed to avoid avascular necrosis.

{10} KNEE INJURIES:

____________________

(a) Medial & lateral collateral ligament injury:

__________________________________________________
. Caused by a direct blow to the opposite side of the joint.
. Casting if isolated ligament injury.
. Surgical repair if multiple ligaments injured.

. Medial -> Due to abduction injury to knee - Dx -> VALGUS stress test.
. Lateral -> Due to adduction injury to knee - Dx -> VARUS stress test.

(b) Anterior & posterior cruciate ligament injury:

____________________________________________________
. Swelling & pain.
. Anterior / posterior drawer sign.
. Young athletes need arthroscopic repair.
. Older pts need immobilization & rehabilitation.

. Anterior -> H/O of forceful hyperextension injury to knee.

. Effusion is seen rapidly following injury.
. Dx -> Lachman's test, ANTERIOR drawer test & pivot shift test.

. Posterior -> H/O of dashboard injury.

. Forceful posterior-directed force on the tibia with knee flexed at 90
dgrees.
. Dx -> POSTERIOR drawe test, REVERSE pivot test & posterior sag test.

(c) Meniscal injury:

______________________
. Twisting injuries with the foot flexed.
. Medial meniscus is more commonly injured than the lateral meniscus.
. POPPING SOUND followed by severe pain at time of injury.
. Prolonged pain & swelling.
. Localized tendrness at the side of the knee.
. Catching & locking of knee koint on extension (BUCKET HANDLE TEARS).
. Palpable or audible snap while extending the leg from full flexion
(McMurray's sign).
. Tx -> Arthroscopic repair.

{11} TIBIAL STRESS INJURY:

___________________________
. H/O of military or cadet marches.
. X-ray may be -ve initially.
. Tx -> Cast.
. Order the pt not to bear weight.
. Repeat x-ray in 2 weeks.

{12} ACHILLES TENDON RUPTURE:

______________________________
. Middle-aged man overdoes it at tennis or basketball match.
. Pt with H/O of fluoroquinolone use.
. Complaining of sudden "POPPING" & limping.
. Tx -> Casting in equinous position or surgical repair.

{13} ANTERIOR SHOULDER DISLOCATION:

____________________________________
. Most common form of shoulder dislocation.
. Direct blow or fall on out-stretched arm.
. Adducted arm & (EXTERNALLY) rotated forearm.
. Numbness over deltoid (Axillary nerve is stretched).
 . Easily seen on erect postero-anterior (PA) & lateral views.

{14} POSTERIOR SHOULDER DISLOCATION:

_____________________________________
. Pt with recent seizure or electrical burn.
. H/O of an eclampsic pt is common.
. Due to violent muscle contractions during a tonic-clonic seizure.
. Flattening of the anterior shoulder & prominent coracoid process.
. Axillary or scapular view x-ray.
. Adducted arm & (INTERNALLY) rotated forearm.
. Inability of external rotation.
. Tx -> Closed reduction.

{15} FEMORAL #:
________________
. Femoral shaft # is an orthopedic emergency.
. Can result in massive blood loss & high rate of infection.
. Immediate surgery & cleaning within 6 hours is needed.

. N.B.
. Hip #s are common in the elderly,
. 1st -> Stabilization & treatment for pain control & DVT prophylaxis.
. Next -> Discover the etiology of the pt's fall with appropriate
investigations.
. Do EKG , CXR & cardiac enzymes !

. N.B.
. Acute shoulder pain after forceful abduction & external rotation at
glenohumeral joint,
. suggests an anterior shoulder dislocation -> AXILLARY NERVE INJURY.

{16} NURSEMAID ELBOW:

______________________
. common injury in pre-school children.
. SUBLAXATION of HEAD of RADIUS at ELBOW joint.
. Due to swinging a young child by the arms or pulling a child arm while
in a hurry.
. The child will be calm but will cry on an attempt to flex the elbow or
supinate forearm
. Dx -> Clinically (Radiographs are often normal).
. Tx -> GENTLE PASSIVE ELBOW FLEXION & FOREARM SUPINATION.
. 1st -> Extend & distract the elbow.
. Next -> Supinate the forearm.
. Hyperflex the elbow with your thumb over he radial head to feel
reduction.
. No post reduction films are needed.
. The child will resume the use of the previously unused extremity
without crying.

* COMPARTMENT $YNDROME:
________________________
. Most frequent in the forearm or lower leg.
. H/O of prolonged ischemia followed by reperfusion, crushing injuries
or other traumas.
. Pain & tightness & tenderness to palpation at the affected area.
. EXCRUCIATING PAIN with PASSIVE EXTENSION.
. Pulses may be normal !!
. Tx -> 1st step is emergent fasciotomy.

. N.B. When a pt complains of pain at the site of a cast,

 . Always remove the cast & examine for compartment $.

. N.B. ISCHEMIA REPERFUSION $YNDROME:

. A form of compartment $.
. Extremeties subjected to at least 4-6 hours of ischemia,
. suffer from intracellular & interstitial edema upon reperfusion (SOFT
TISSUE SWELLING).
. When edema causes the pressure within a muscular fascial compartment
to rise > 30 mmHg
. compartment $ occurs leading to further ischemic injury to the
confined tissue.

. N.B.
. Escharotomy is indicated for circumferential full thickness burns of
an extremity,
. with an eschar causing significant edema & constriction of the
vascular supply.
. Pts sh'd be evaluated for clinical signs of adequate perfusion after
escharotomy.
. Fasciotomy sh'd be done if there is NO signs of relef.

* NEURO-VASCULAR INJURIES:
___________________________
___________________________

. OBLIQUE DISTAL HUMERUS #:

____________________________
. Radial nerve injury.
. Inability to dorsiflex (extend) the wrist.
. Function regained after reduction.
. Surgery is indicated if paralysis persists after reduction.

. POSTERIOR KNEE DISLOCATION:

______________________________
. Popliteal artery injury.
. Decreased distal pilses.
. Doppler studies or arteriogram.
. Prophylactic fasciotomy if reduction is delayed.

. BACK PAIN:
_____________
_____________

{1} DISC HERNIATION:

_____________________
. Sudden onset severe back pain after lifting heavy object.
. Electric shock like pain shooting down the leg.
. Straight leg raising test gives excruciating pain.
. Mostly lumbar in origin L4, L5 & S1.
. Peak age 43-46 ys.
. Tx -> Anti-inflammatories & brief bed rest.
. Immediate surgical compression is needed if the H/O suggests Cauda
equina $.
. (Bowel/Bladder incontinence - flaccid anal sphincter - Saddle
anesthesia).
. MRI -> Confirm both disc herniation & causa equina.
. Trial of anti-inflammatories is always the 1st step in management.
 {2} ANKYLOSING SPONDYLITIS:
____________________________
. Man in his 30s or early 40s.
. Chronic back pain.
. Morning stiffness improving with activity.
. X-ray -> Bamboo spine.
. Associated with HLA B-27 antigen (Screen for uveitis & IBD).
. Tx -> Anti-inflammatory agents & physical therapy.

{3} METASTATIC MALIGNANCY:

___________________________
. Elderly pt with progressive & constant back pain.
. Worse at night & unrelieved by rest.
. H/O of weight loss.
. X-ray -> Lytic lesions or blastic lesions.
. Blastic metastatic lesions -> Prostate cancer & breast cancer.
. Lytic metastatic lesions -> Lung, renal, breast, thyroid & multiple
myeloma.
. Hypercalcemia & ++ ALP.
. 1st -> Order plain radiographs (Especially important in multiple
myeloma).
. Bone scan is most sensitive in early disease.
. MRI shows the greatest amount of details.
. MRI -> test of choice if there are any neurologic syms to rule out
cord compression.
. Bone scan will not be helpful in purely lytic lesions (Multiple
Myeloma).
. Instead order plain radiographs or MRI.

* FOOT PAIN:
_____________
_____________

. PLANTAR FASCIITIS:
_____________________
. Older, overweight pts with sharp heel pain every time their foot
strikes to the ground.
. Pain is worse with walking & in the mornings.
. X-ray -> Bony spur matching the location of the pain.
. Exquisite tenderness to palpation over the spur.
. Burning pain in nature.
. More common in runners with repeated microtrauma,
. who develop local point tendrness on plantar aspect of foot.
. However, surgical resection of the bony spur is not indicated !

. MORTON NEUROMA:
__________________
. Inflammation of the common digital nerve at the 3rd interspace.
. Between the 3rd & 4th toes.
. Mechanically induced neuropathic degeneration.
. Numbness & burning of the toes, aching & burning in the distal
forefoot.
. Pain radiates forward from the metatarsal heads to the 3rd & 4th toes.
. PALPATION & SQUEEZING the metatarsal joints -> CLICKING SENSATION
(MULDER SIGN).
. Caused by wearing pointy-toed shoes.
. The neuroma is palpable with very tender spot there.
. Management is analgesics & appropriate foot wear.
 . STRESS # = HAIR LINE #:
__________________________
. Sudden ++ in repeated tension or compression without adequate rest.
. Sharp localized pain over a bony surface that is worse with palpation.
. The tibia is the most common bone in the body to be affected by stress
#s.
. Occur in the anterior part of the middle 1/3 of the shin of tibia in
jumping sport pts.
. Occur in the postero-medial part of the distal 1/3 of the tibia in
runners.
. X-ray are frequently normal during initial evaluation.
. Stress # of the meta-tarsals are common in atheletes & military
recruits.
. The 2nd metatarsal is the most commonly injured.
. Tx -> Rest, analgesia & a hrd soled shoe.

. TARSAL TUNNEL $YNDROME:

__________________________
. Compression of the tibial nerve as it passes through the ankle.
. Usually caused by a # of the bones around the ankle.
. Burning, numbness & aching of the distal plantar surface of foot or
toes.
. Pain may radiate up to the calf.

_________________________________________________________________________
_________________

* UROLOGY:
___________
___________

. VARICOCELE:
______________
. Tortuous dilatation of pampiniform plexus of veins surrounding
spermatic cord & testis.
. Results from incompetence of the valves of the testicular vein.
. Occurs most frequently on the left side, bec.
. Lt testicular vein enters Lt renal vein inferiorly at right angle ->
impaired drainage.
. Dull or dragging discomfort scrotal pain that becomes worse on
standing.
. Examination -> Bag of worms (Enlarge with Valsalva maneuver).
. NEGATIVE TRANSILLUMINATION.

. HYDROCELE:
_____________
. Due to fluid accumulation in tunica vaginalis.
. POSITIVE TRANSILLUMINATION.

. TESTICULAR NEOPLASIA:
________________________
. Painless testicular mass with negative transillumination.

. SPERMATOCELE:
________________
. Cystic dilatations of the efferent ductules.
. Painless fluif-filled cysts containing sperms.
. Located on superior pole of testis in relation to epididymis.
. +ve transillumination.
 . TESTICULAR TORSION:
______________________
. Severe, sudden onset testicular pain.
. NO fever - NO pyuria.
. The testis is swollen & exquisitely tender.
. High riding testicle with transverse lie.
. Dx -> U/$.
. Tx -> Immediate surgical intervention with bilateral orchipexy.

. ACUTE EPIDIDYMITIS:
______________________
. Acute scrotal pain (may be referred to abdomen).
. FEVER & urinary symptoms.
. Dx -> Urinalysis & urine cultures & discharge culture if present.
. Tx -> Males < 35 ys -> Treat for gonorrhea & chlamydia ->
Ciprofloxacin & Doxycycline.
. Tx -> Older males -> Treat as UTI (E-coli) with Levofloxacin.

. UROLOGIC OBSTRUCTIONS:
_________________________
. Combination of obstruction & infection is a urologic emergency.
. It can lead to destruction of the kidney in few hours.
. Tx -> Immediate decompression of the urinary tract above the
obstruction.
. Tx -> IV antibiotics are given to prevent infection.
. Tx -> A ureteral stent or percutaneous nephrostomy is the most
important intervention.

. N.B.
. Urinary calculi present as flank or abdominal pain radiating to the
groin.
. Nausea & vomiting is common.
. Unlikepts with an acute abdomen, pts with urinary stones are WRITHING
in pain.
. Unable to sit still in exam room (No peritoneal irritation so
movements don't ++ pain).
. Dx -> A NON-contrast spiral CT of the abdomen & pelvis is the most
accurate test.
. Dx -> X-ray can miss radio-lucent urinary stones (15 % of stones).

. N.B.
. Nephrolithiasis
. Flank pain & hematuria accompanied by nausea & vomiting.
. Pts with Chron's disease or small bowel dis -> Fat malabsorption.
. Fat malabsorption -> predispose to hyperoxaluria.
. Oxalate is obtained from diet & is a normal product of human
metabolism.
. Symptomatic hyperoxaluria is the result of ++ oxalate absorption in
the gut.
. Under normal circumstances: Calcium binds oxalate in the gut
preventing its absorption.
. In pts with fat malabsorption, Ca is bound by fat leaving oxalate free
& unbound.
. Failure to adequately absorb bile salts in cases of fat malabsorption,
. leads to -- bile salt reabsorption in small intestine.
. Excess bile salts may damage colonic mucosa -> ++ oxalate absorption.

. CONGENITAL UROLOGIC DISEASES:

________________________________
________________________________

{1} POSTERIOR URETHRAL VALVE:

______________________________
. The most common cause for a new born boy not to urinate during the 1st
day of life.
. Dx -> Voiding cystourethrogram.
. Tx -> Catheterize to empty the bladder.

{2} HYDROCELE:
_______________
. Fluid collection within the processus vaginalis or tunica vaginalis.
. Peritoneal fluid accumulation -> hydrocele
. POSITIVE TRANSILLUMINATION.
. Tx -> REASSURANCE -> Will resolve spontaneously by the age of 12
months.
. Tx -> If not resloved by 12 months -> Surgical removal to avoid
inguinal hernia.

{3} HYPOSPADIUS:
_________________
. Urethral opening at the ventral side of the penis.
. Never to perform circumcision on this child.
. The prepuce will be needed for the plastic reconstruction.

. N.B. A child who has HEMATURIA from TRIVIAL TRAUMA,

. has an undiagnosed congenital anomaly until proven otherwise.

. N.B. A child who has URINARY TRACT INFECTION,

. has an undiagnosed congenital anomaly until proven otherwise.
. e.g. vesico-ureteral reflux.
. Dx -> Voiding cystourethrogram.
. Tx -> Long term antibiotics.

{4} LOW IMPLANTATION OF A URETER:

__________________________________
. A girl who void appropriately but also found to be constantly wet,
. due to urinating into vagina.

{5} URETERO-PELVIC JUNCTION (UPJ) OBSTRUCTION:

_______________________________________________
. Only symptomatic when diuresis occurs.
. A teenager who drinks large volumes of beer & develops colicky flank
pain.

_________________________________________________________________________
_________________

. VASCULAR SURGERY:
____________________
____________________

{1} SUBCLAVIAN STEAL $YNDROME:

_______________________________
. Due to an arteriosclerotic stenotic plaque at the origin of subclavian
artery.
. This allows enough blood to reach the arm for normal activity, but,
 . Not enough to meet the ++ demands of an exercised arm,
. resulting in BLOOD BEING STOLEN FROM THE VERTEBRAL ARTERY.
. Posterior neurological signs (Visual symptoms - Equilibrium problems).
. Claudication in the arm during arm exercises.
. Don't confuse this condition with thoracic outlet $!
. Thoracic outlet $ causes vascular symptoms only with-OUT neurological
signs.
. Dx -> Angiography.
. Tx -> Bypass surgery.

{2} AORTIC ANEURYSM:

_____________________
. Size & symptoms are key to management of "ABDOMINAL" aortic aneurysm:
-> Aneurysms < 5cm -> Observe with serial annual imaging.
-> Aneurysms > 5cm -> Elective surgical repair.

. More urgent surgery is needed if:

-> A TENDER AAA will rupture within a day or two requiring urgent
repair.
-> Excruciating back pain in a pt e' large AAA means that,
. the aneurysm is already leaking, necessitating emergency surgery.

. N.B. The following contributes to the development of "THORACIC" aortic

aneurysm:
-> Chronic hypertension.
-> Hyperlipidemia.
-> Smoking.
-> Marfan $.
-> Untreated tertiary $yphilis.

. N.B. The most imp. modifiable risk to prevent worsening of existing

aneurysms is:
-> UNCONTROLLED HYPERTENSION.

. N.B. Asymptomatic lesions -> BLOOD PRESSURE MANAGEMENT is the most

important.
. N.B. Symptomatic lesions (including active dissection) -> Surgical
intervention.
. (Look for sudden onset tearing pain in the back).

{3} ARTERIOSCLEROTIC OCCLUSIVE DISEASE OF THE LOWER EXTREMETIES:

_________________________________________________________________
. Pain in the legs on exercise that is relieved by rest (intermittent
claudication).

. If the claudication doesn't affect the pt's life style -> No

intervention is needed.
. The only management indicated is CESSATION OF SMOKING & THE USE OF
CILOSTAZOL.

. If the pain is more severe,

. Dx -> Doppler studies (Pressure gradient ABI < 0.9).
. Dx -> Arterigram to identify stenosis.

. If there is DISABLING symptoms (Affect work or daily life activity),

. or there is impending ischemia to the extremity,
. Tx -> SURGERY (Angioplasty & stenting for stenotic segments).
. More extensive disease requires bypass grafts or sequential stents.
 . N.B. PAIN AT REST indicates END STAGE DISEASE (Pt complains of calf
pain at night).

. N.B. VVVVVVVVVVVVVVVVV. imp.

. The 1st step in evaluating a pt with suspected peripheral artery
disease (PAD) is:
. to obtain an ANKLE-BRACHIAL INDEX (ABI) to confirm the diagnosis.

. Aspirin & cilostazol are antiplatelet agents that can be given after
confirming PAD.
. They are not given upon clinical suspicion !

. Pts with significant symptoms & NORMAL ABI may have MILD diesase at
rest.
. They sh'd undergo EXERCISE TESTING with pre & post exercise ABI
measurment to confirm.

. ABI (1.0 - 1.3) -> Normal.

. ABI < 0.9 -> > 50 % occlusion of a major vessel.
. ABI < 0.4 -> Limb ischemia.

. N.B. ISCHEMIA REPERFUSION $YNDROME:

. A form of compartment $.
. Extremeties subjected to at least 4-6 hours of ischemia,
. suffer from intracellular & interstitial edema upon reperfusion (SOFT
TISSUE SWELLING).
. When edema causes the pressure within a muscular fascial compartment
to rise > 30 mmHg
. compartment $ occurs leading to further ischemic injury to the
confined tissue.

. N.B. COMPARTMENT $ 5 "P"s:

____________________________
. May be caused by direct trauma (Hemorrhage), prolonged compression of
an extremity.
. May be caused after revascularization of an acutely ischemic limb.
. Muscles of extremity are encased in fascial compartments preventing
tissue expansion.
. The ++ pressure interferes with perfusion leading to muscle necrosis.
. Pressure > 30 mmHg leads to cessation of blood flow through
capillaries.
. Tx -> EMERGENT FASCIOTOMY.

-> Pain
. Earlest symptom.
. ++ by passive stretch of the muscles in the affected compartment.

-> Paresthesia
. Burning or tingling sensation.
. occurs in the distribution of the affected peripheral nerve.

-> Pallor
. of the overlying skin
. result from tense swelling & compromised perfusion.

-> Pulselessness
. Late finding.
. Presence of a pulse on exam does NOT rule out compartment $.
 -> Paresis/Paralysis
. Late finding.
. resilt from nerve & muscle ischemia & necrosis.

. N.B. ESCHAR !
. Eschar is a firm necrotic tissue formed on on exposed tissue following
burn wounds.
. When eschar occurs circumferentially on an extremity,
. it restricts the outward expansion of the compartment as edema follows
burn.
. Interstitial pressure increases -> compromise vascular flow to the
limb.
. Deep pain out of proportion to injury, pulselessness, paresthesia,
cyanaosis & pallor.
. Tx -> Escharotomy.

. N.B. Compartment $ 2ry to SUPRA-CONDYLAR # of humerus:

. 2ry to fall on out-stretched hand.
. Due to ++ pressure in a limited space.
. Pain, pallor, pulselessness, paralysis & presthesia.
. Tx -> Immediate fasciotomy.

. N.B. VOLKMANN's ISCHEMIC CONTRACTURE:

. is the final sequel of compartment $ (The dead muscle is replaced by
fibrous tissue).

{4} ARTERIAL EMBOLIZATION OF THE EXTREMETIES:

______________________________________________
. H/O of Af or recent MI.
. Sudden onset painful, pale, cold, pulseless, paresthetic & paralytic
lower extremity.
. Dx -> Doppler studies to locate the obstruction.
. Tx -> Thrombolytics (if early) & Embolectomy (if later) with
fasciotomy.

. N.B. LERICHE $YNDROME = AORTO-ILIAC OCCLUSION:

_________________________________________________
. Arterial occlusion at the bifurcation of the aorta in the common iliac
arteries.
. Triad of bilateral hip, thigh & buttock claudication, impotences &
. symmetric atrophy of the bilateral lower extremeties due to chronic
ischemia.
. Absence of impotence excludes the condition.

. N.B. SPINAL CORD ISCHEMIA:

_____________________________
. Follows aortic vascular surgery due to anterior spinal artery $.
. The spinal cord derives its blood supply from the:
. anterior spinal artery & 2 posterior spinal arteries originating from
vertebral artery.
. Presents with flaccid paralysis, bowel/bladder dysfunction, sexual
dysfunction.
. Possible hypotension & loss of deep tendon reflexes.
. Spasticity & hyperreflexia develop over days to weeks.
. Vibratory & proprioceptive sensation is preserved as posterior
circulation is preserved
 . Dx -> Emergent MRI.
. Tx -> Supportive care & lumbar drains to reduce spinal pressure.

_________________________________________________________________________
_________________

. MISCELLANEOUS TOPICS:
________________________
________________________

. GASTRIC OUTLET OBSTRUCTION:

______________________________
. Can be caused by many diseases causing mechanical obstruction e.g.
. Gastric malignancy - Peptic ulcer disease - Chrons dis - Strictures e'
pyloric stenosis
. Strictures 2ry to ingestion of caustics.
. Characterized by early satiety, nausea, non-bilious vomiting & weight
loss.

. P/E -> ABDOMINAL SUCCUSSION SPLASH, elicited by placing the

stethoscope,
. over the upper abdomen & rocking the pt back & forth at the hips,
. Retained gastric material > 3 hours after a meal will generate a
splash sound,
. indicating the presence of a hollow viscus filled with both fluids &
gas.

. In a pt with a H/O of acid ingestion, pyloric stricture is the most

likely cause.
. H/O of a recent acid ingestion is a risk factor of developing pyloric
stricture.
. Acid ingestion causes fibrosis 6-12 weeks after the resolution of
acute injury.
. Dx -> Upper endoscopy.
. Tx -> Surgery.

. TOTAL BODY BURN & SYSTEMIC INFLAMMATORY RESPONSE $:

______________________________________________________
. Systemic inflammation & tissue injury.
. Burn -> Dysregulated host response,
. Massive uncontrolled release of proinflammatory substances ->
extensive tissue damage.

. This is known as systemic inflammatory response $yndrome:

-> Temperature -> > 38.5 c (101.3 F) or < 35 c (95 F) !!!!!
-> Pulse -> > 90/min.
-> Respirations -> > 20/min.
-> WBC > 12000 or < 4000 or > 10 % bands !!!!

. SIR$ can follow pancreatitis, autoimmiune dis, vasculitis & burns.

. Sepsis (SIRS e' a known infection) is considered severe when there is
end organ failure
. Oliguria - Hypotension (SBP < 90mmHg) - Thrombocytopenia (PLT <
80000).
. Metabolic acidosis - Hypoxemia.
. Hyperglycemia occur due to insulin resistance.
. Muscle wasting & protein loss & Hyperthermia.
. Sepsis with septic shock may occur in the 1st week post-burn.
 . Main causes of sepsis are pneumonia & wound infections (Staph aureus &
Pseudomonas).

. Criteria indicating sepsis -> Leukocytosis - Thrombocytopenia - Mild

hypothermia < 36.
. Tachypnea & tachycardia due to associated pneumonia.
. Worsening hyperglycemia due to worsening insulin resistance.

. Bottom line:
. In pts with severe significant total body surface areas burns,
. The major cause of morbidity & mortality is HYPOVOLEMIC SHOCK.

. In case of adequate initial fluid resuscitation,

. Bacterial infection (Bronchopneumonia or burn wound infection) ->
Sepsis & septic shock

. INTRA-PERITONEAL RUPTURE OF THE BLADDER:

___________________________________________
. Intra-abdominal pathology causing shoulder pain = Subdiaphragmatic
peritonitis.
. Among the possible blunt traumatic bladder injuries,
. Only an INTRA-PERITONEAL RUPTURE OF THE (BLADDER DOME) -> CHEMICAL
PERITONITIS.
. The dome of the bladder is the only region covered by peritoneum.
. Pain could be transferred to the ipsilateral shoulder because,
. Phrenic nerve originates from C3 to C5 spinal nerves mediating
sensation for shoulders.

. INTRA-ABDOMINAL MALIGNANCY (CANCER PANCREAS):

________________________________________________
. Day time fatigue, anorexia, significant weight loss.
. Visceral type abdominal pain interfering with sleep.
. Constant eigastric pain radiating to the back, weight loss & jaundice.
. Migratory thrombophlebitis is a classic association.

. N.B.
. A peptic duodenal ulcer causes periodic epigastric pain relieved by
meals.

. PILO-NIDAL SINUS:
____________________
. Acute pain & swelling of the midline sacro-coccygeal skin &
subcutaneous tissues.
. Due to infection of a dermal sinus tract originating over the coccyx.

. RIB #:
_________
. Pain relief is the prime objective in management of rib #.
. As it allow proper ventillation & prevent atelectasis & pneumonia.

. TETANUS PROPHYLAXIS:
_______________________
_______________________

. Un-immunized, uncertain or < 3 tetanus toxoid doses:

_______________________________________________________
. Minor clean wound -> Tetanus toxoid only.
. Severe or dirty wound -> Tetanus toxoid & tetanus immunoglobulins.

. > 3 tetanus toxoid doses:

____________________________
. Minor & clean wound -> None.
. Severe or dirty wound -> Tetanus toxoid if latest boster given > 5
years ago.

. N.B. Tetanus-diphtheria toxoid sh'd be given to individuals with

severe or dirty wounds
. who received a booster > 5ys ago
. & those with minor clean wounds who received a booster dose > 10 ys
ago.

. N.B. Tetanus immune globulin sh'd be given to any individual with

severe dirty wound
. & unclear or incomplete immunization history.

. CO CARBON MONOXIDE POISONING:

________________________________
. H/O of smoke inhalation.
. CO is a tasteless, colorless & odorless gas.
. It has affinity 200 times more than O2 for hemoglobin.
. Confusion, wheezes, headache, nausea, dyspnea, malaise, altered
mentation, dizziness.
. If severe -> Seizure, coma, syncope, heart failure & arrhythmias.
. Bright cherry lips can be seen but not specific.
. Dx -> ++ Carboxyhemoglobin level > 3 % in non-smokers & > 15 % in
smokers.
. Tx -> 100 % OXYGEN NON-BREATHER FACE MASK.

_________________________________________________________________________
_________________

. BREAST PROBLEMS:
__________________
__________________

. 1 . INTRA-DUCTAL PAPILLOMA:
______________________________
. Benign breast disease.
. Most common in peri-menopausal women.
. Intermittent BLOODY discharge from one nipple.
. Most intraductal papillomas are situated beneath the areola.
. Difficult to palpate on physical examination due to their small sizes
(< 2 mm).
. Soft in consistency.
. U/$ will be normal because it can detect masses only greater than 1 cm
in diameter.

. 2 . FIBRO-CYSTIC DISEASE:
____________________________
. Very common in pre-menopausal women.
. Bilateral breast pain.
. Associated with cystic changes of the breast.
. Benign condition.
 . Symptoms vary cyclically with the menstrual cycle.
. P/E -> Lumpiness of the breast.

. 3 . FIBRO-ADENOMA:
_____________________
. Solitary breast lesion.
. Painless, firm, mobile breast lump.
. Average size about 2 cm.
. Women ages 15 - 25 ys.
. Benign condition.
. Do NOT change with menstrual cycle.

. 4 . DUCTAL CARCINOMA IN-SITU:

________________________________
. Post-menopausal women.
. Incidental finding on mammography.
. Nipple discharge & breast mass are the most common complaints.
. It is a HISTOLOGICAL diagnosis.

. 5 . INFLAMMATORY BREAST CARCINOMA:

_____________________________________
. Brawny edematous cutaneous plaque.
. "P'eau d'orange" orange peel appearance overlying a breast mass.
. It is an aggressive tumor.
. 1/4 of the pts have metastatic disease at the time of presentation.
. Most pts present with axillary lymphadenopathy.
. Spontaneous nipple discharge is a sign of breast cancer.
. Nipple discharge in a non-lactating woman sh'd always raise suspicion
for cancer,
. spontaneous, unilateral, localized to single duct, bloody discharge in
pt > 40 ys old.
. Mass association is an imp. sign of malignancy.
. Clinicalyy, you can't differentiate it from an inflammatory process
(breast abscess).
. A BIOPSY FOR HISTOLOGY IS THE MAIN STAY OF DIAGNOSIS !

. PALPABLE BREAST MASS EVALUATION:

___________________________________

PALPABLE BREAST MASS

______________________
|
________________________________
| |
< 30 ys > 30 ys
| |
ULTRASONOGRAM ONLY MAMMOGRAM &
ULTRASONOGRAM
| |
____________________ |
| | |
SIMPLE CYST SOLID MASS SUSPICIOUS FOR
MALIGNANCY
| | |
NEEDLE ASPIRATION CORE BIOPSY CORE BIOPSY

. N.B.
. BREAST FAT NECROSIS
 . shows clinical signs & radiographic findings similar to breast cancer
!
. Syms include (Skin or nipple retraction - Calcification on
mammography).
. Biopsy of the mass -> FAT GLOBULES & FOAMY HISTIOCYTES.
. No ttt is indicated (Self limiting condition).
_________________________________________________________________________
_________________

. SPINAL CORD INJURIES:

________________________
________________________

. ANTERIOR CORD $YNDROME:

__________________________
. Burst # of the vertebra -> Occlusion of vertebral artery.
. Total loss of the motor function below the level of the lesion.
. Loss of pain & temperature on both sides below the lesion.
. NORMAL proprioception.
. NEGATIVE Straight leg raising test.
. Dx -> MRI.

. CENTRAL CORD $YNDROME:

_________________________
. Hyperextension injury in elderly pts with degenerative diseases of the
cervical spine.
. Selective damage to the central portion of the spinal cord.
. specially the corticospinal & decussating fibers of the lateral
spinothalamic tracts.
. Burning pain & paralysis in the UPPER extremeties e' relative SPARING
of lower limbs.

. POSTERIOR CORD $YNDROME:

___________________________
. Bilateral loss of vibratory & proprioceptive sensation.

. BROWN SEQUARD $YNDROME:

__________________________
. Acute hemisection of the spinal cord.
. Ipsilateral motor & proprioception loss below the level of the lesion.
. Contralateral pain loss below the level of the lesion.

. ACUTE DISK PROPLAPSE:

________________________
. Severe radicular pain.
. +ve Straight leg raising test.

. CAUDA EQUINA $YNDROME:

_________________________
. Paraplegia.
. Variable sensory loss.
. Urinary & fecal incontinence.

. SYRINGOMYELIA:
_________________
. May follow spine cord trauma.
. Whiplash is often the incinting injury.
. Symptoms develop months to years later.
. Enlargement of the central canal of the spinal cord due to CSF
retention.
 . Impaired strenght & pain/temperature sensation in upper extremeties.
. Preservation of dorsal column function (Light touch - vibration -
position sense).
. CAPE LIKE DISTRIBUTION.

_________________________________________________________________________
_________________

. # Mid-shaft humerus -> Radial nerve injury -> Wrist drop.

. # Supracondylar humerus -> Brachial artery -> pain, pallor,
pulselessness, paresthesia.
. # Humerus -> Ulnar nerve -> Claw hand.

. ROTATOR CUFF TEAR:

_____________________
. Rotator cuff is formed by tendons of:
. (supraspinatous, infraspinatous, teres minor & subscapularis muscles).
. The supraspinatous is most commonly injured,
. due to repeated bouts of ischemia near its insertion on the humerus,
. induced by its compression between the humerus & the acromion.
. Common cause of tear is fall on out-stretched hand.
. Severe shoulder pain & edema following the trauma.
. Inability to abduct the arm at 90 degrees.
. When the pt's arm is abducted passively to greater than 90 degrees,
. And the pt is asked to lower the arm slowly; the pt's arm drops
suddenly !

. N.B.
. D.D. for rotator cuff tear is "RUPTURE OF TENDON OF LONG HEAD OF
BICEPS";
. POSITIVE POPEYE SIGN (The biceps muscle belly becomes prominent in the
mid upper arm.

. PAGET'S DISEASE OF BONE = OSTEITIS DEFORMANS:

________________________________________________
. Disordered bone remodelling.
. ++ Osteoclast activity -> ++ bone resorption.
. Accelereated osteoblastic activity to rebuild the degraded bone.
. WOVEN BONE formation (Various stages of bone throughout the body).
. The woven bone is larger than normal bone & more liable to bowing & #.
. Most common presenting symptom is secondary arthritis of hip or knee.
. ++ ALKALINE PHOSPHATASE.
. NORMAL serum phosphorous & calcium levels.
. Enlargement of skull bones -> Bossing, ++ head size (Old hats no
longer fits!).
. Headaches & cranial nerve palsies.
. Hearing loss is due to damage of the cochlear nerve,
. due to enlargement of the temporal bone & entrapment at the internal
auditory meatus.

. VARICES:
___________
. NON-BLEEDING VARICES are managed with BB "Prporanolol".
. After 1st episode of bleeding -> Sclerotherapy, endoscopic band
ligation & surgery.
. If not responsive to medical or endoscopic intervention -> Porto-
systemic shunt (TIPS).
 . RESPIRATORY QUOTE (RQ):
__________________________
. RQ is the ratio bet. CO2 produced to O2 consumed.
. Used to make assessmentsof metabolism taking place in the body.
. In mechanically ventillated pt, the RQ is 1.05.
. The ratio depends upon the major fuel being oxidized for ATP
production.
. An RQ close to 1 indicates that CARBOHYDRATE is the major nutrient
being oxidized.
. The RQ for protein & lipid as sole energy sources are 0.8 & 0.7
respectively.

. Massive atelectasis could affect ABG, but once a new steady state is
achieved,
. the RQ value w'd still depend only upon the nature & proportions of
metabolics used.

. TROCHANTERIC BURSITIS:
_________________________
. Unilateral hip pain in a MIDDLE-AGED adult.
. Inflammation of the bursa around the insertion of gluteus medius
greater trochanter.
. Excessive frictional forces 2ry to overuse or trauma are common
causes.
. Hip pain when pressure is applied (When sleeping) & external rotation
or abduction.

. FEMORAL HEAD AVASCULAR NECROSIS = LEGG CALVE' PERTHES DISEASE:

_________________________________________________________________
. Boys between 4 & 10 ys with peak incidence bet. 5 & 7 us.
. Hip, groin or knee pain + Antalgic pain.
. Dx -> X-ray -> Flattened & fragmented femoral head.
. Alternating regions of lucency & density = Reflects of necrotic tissue
by new bone.
. Tx -> Conservatively with observation & bracing.
. Tx -> Surgery in cases where femoral head isn't well contained within
the acetabulum.

. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE):

____________________________________________
. Obese male child with pain during LATE CHILDHOOD or EARLY ADOLESCENCE.
. Metaphysis & femur slip relative to the epiphysis at the epiphyseal
plate.
. The capital femoral epiphysis remains structurally intact within the
acetabulum.
. Loss of abduction & internal rotation of the hip.
. Loss of external rotation of the thigh while the hip is flexed.
. Dx -> FROG-LEG LATERAL X-RAY VIEW (Diagnostic).
. Tx -> SURGICAL PINNING to avoid avascular necrosis.

. TRENDELENBURG SIGN:
______________________
. Drooping of the contralateral pelvis when the pt stands on one foot.
. Associated with TRENDELENBURG gait (Waddling) caused by the trunk
rocking,
. to compensate for the pelvic drooping !
 . Caused by weakness or paralysis of the gletues medius & minimus
muscles,
. due to superior gluteal nerve trauma or inflammation or entrappment.
. The pt presents with unilateral intermittent knee pain.
. Physical activity e.g. stair clumbing exacerbates the pain.
. Hip tenderness is common.

. SQUAMOUS CELL CARCINOMA:

___________________________
. Suspected in all non-healing wounds.
. SCC may arise within chronicallu wounded, scarred or inflammaed skin.
. SCC arising within burn wounds is known as MARJOLIN ULCER.
. SCC arise in skin overlying a focus of osteomyleitis, radiotherapy or
venous ulcers.
. SCC arising within chronic wounds exhibit aggressive behavior.
. Early diagnosis is the key to prevent metastatic spread
. A biopsy sh'd be obtained in all chronic wounds failing to heal to
rule out malignancy.

. BASAL CELL CARCINOMA:

________________________
. Presents on chronically sun-exposed skin.
. Lesions are PEARLY TELANGIECTATIC papules with a central RODENT
ulceration.

. BILATERAL LOWER LIMB EDEMA & STASIS DERMATITIS:

__________________________________________________
. Both are due to lower extremity venous valvular incompetence.
. resulting in pooling of venous blood & ++ pressure in post-capillary
venules.
. ++ pressure = VENOUS HYPERTENSION.
. ++ pressure -> Damages capillaries -> Loss of fluid, plasma ptns &
RBCs into tissue.
. Erythrocytes extravasation -> Hemosiderin deposition & bluish
discoloration.
. May be complicated by venous ulcers.
. It involves the medial leg below the knee & above the medial
malleolus.
. Xerosis is the most common early finding.
. Lipodermatosclerosis & venous ulcerations are late findings.

. RETRO-PERITONEAL HEMORRHAGE:
_______________________________
. An iatrogenic complication after cardiac catheterization.
. After cannulation of the femoral artery to access the cardiac vessels.
. A hematoma is formed at the upper thigh -> Extends into the retro-
peritoneal space.
. Significant belleding with hypotension & tachycardia.
. Ipsilateral flank/back pain.
. Dx -> CT scan of ABDOMEN & PELVIS with-OUT contrast.
. Tx -> Supportive -> Blood transfusion - IV fluids - Bed rest.
. Tx -> Immediate surgical decompression if there are neurological
deficits.

. PNEUMO-PERITONEUM:
_____________________
 . AIR UNDER DIAPHRAGM = Intra-peritoneal air.
. Best seen bet. the liver & the diaphragm.
. Caused by PERFORATED VISCUS e.g. PERFORATED PEPTIC ULCER.
. PERFORATED PEPTIC ULCER (H/O of epigastric pain & discomfort with
eating).
. Tx -> SURGICAL CONSULATATION IMMEDIATELY for EXPLORATORY LAPAROTOMY.

. CHILD ABUSE:
_______________
. Patterned scalds & burns = forceful immersion of hot object e.g.
cigarette or hot iron.
. Incoherent or impropable explanation of the injuries.
. Delay in seeking care after injury.
. #s of long bones or ribs, #s in various stages of healing.
. Suspicious bruises include those on thighs, abdomen, cheeks &
genitalia.
. Subdural hematoma & retinal hemorrhages in very young infants.
. Inaapropriate affect of the care giver.

. Physician should perform a thorough physical exam. & full radiographic

skeletal survey.
. Report the case to child protective services.
. Admit the pt to ensure their safety.

. The child should never be sent home.

. The caregiver should never be confronted.
. Physicians are mandatory reporters.

. AMPUTATION INJURY:
_____________________
. Amputated parts sh'd be wrapped in SALINE-MOISTENED GAUZE,
. SEALED IN A PLASTIC BAG,
. PLACED ON ICE,
. brought to the emergency department with the patient.

. CAUSES OF HEMOPTYSIS:
________________________
. Pulmonary -> Bronchitis - Pulmonary embolism - Bronchiectasis - Lung
cancer.
. Cardiac -> Mitral stenosis - Acute pulmonary edema.
. Infectious -> Tuberculosis - Lung abscess.
. Hematologic -> Caogulopathy.
. Vascular -> Arteriovenous malformation.
. Systemic diseases -> Wegener's granulomatosis - Goodpasture's $ - SLE
- Vasculitis.

. HEMOPTYSIS MANAGEMENT
________________________
|
. H/O & P/E to rule out other causes (Oropharynx &
GIT)

________________________________________________________
|
_______________________________
| |
 . MILD/MODERATE . MASSIVE (>600
ml/24hs)
________________
_________________________
| |
. CXR, CBC, COAGULATION STUDIES . SECURE AIRWAY, BREATHING &
CIRCULATION
. RENAL FUNCTIONS & URINALYSIS |
. RHEUMATOLOGY WORK UP . IF BLEEDING
| |
<----------------STOPS---------------------
CONTINUES
|
|
. CT SCAN + BRONCHOSCOPY
|
|
|
. treat the cause;persistent bleeding
|
treated via bronchoscopic interventions <-----------------------
--
embolization or resection.

. N.B.
. Massive hemoptysis = > 600 ml/24 hs.
. Greatest danger is asphyxiation due to airway flooding with blood.
. Establishing an adequate patent airway is the most imp. initial step.
. The pt should be placed with the bleeding lung un the dependent
lateral position,
. to avoid blood collection in the airways of the opposite lung.
. Bronchoscopy is the best to localize the bleeding site, provide
suction.
. Bronchoscopy is both diagnostic & therapeutic.

. Pt from endemic area - Night fever - weight loss - Upper lobe

involvement = T.B.
. Respiratory isolation is mandatory to prevent spread of infection.

. FAT EMBOLISM:
________________
. Common in pt with polytrauma with multiple #s of long bones.
. Severe respiratory distress, petichial rash, subconjunctival
hemorrhage.
. Tachycardia, tachypnea & fever.
. May occur after 12-72 hs after trauma.
. CNS dysfunction -> Confusion - Agitation - Stupor - Seizures - Coma.
. Dx -> Fat droplets in urine.
. Dx -> Intra-arterial fat globules on fundoscopy.
. Dx -> CXR -> Diffuse bilateral pulmonary infiltrates.
. Tx -> Respiratory support.

. NECROTIZING SURGICAL INFECTION:

__________________________________
. Intense pain in wound.
. Fever, hypotension & tachycardia.
. Decreased sensitivity at the edge of the wound.
 . Cloudy gray discharge.
. Tense edema out-side the involved skin.
. Subcutaneous gas with crepitus.
. More common in diabetics.
. Caused by mixed gram +ve & gram -ve flora.
. Tx -> Early surgical exploration & debridement of the necrotic
tissues.
. Adjunctive ttt -> Antibiotics, adequate hydration & tight glycemic
control.

. MASTITIS ASSOCIATED WITH BREAST FEEDING:

___________________________________________
. Due to transmission of bacterial organism from the infant's
nasopharynx,
. to a fissure on the mother's nipple or areola.
. Most commonly Staph. aureus.
. Tx -> Analgesics, antibiotics (Dicloxacillin-Cephalosporin) & CONTINUE
BREAST FEEDING.
. Continued nursing from the affected breast -> -- the progression of
mastitis to abscess
. Incision & drainage only if there is abscess formation !
. Mammogram is not useful in mastitis !
. Mammogram is not useful before age of 50 due to dense breast tissue.
. Suppression of breast milk is NOT recommended.

. HYPOVOLEMIC SHOCK & POSITIVE PRESSURE MECHANICAL VENTILLATION:

_________________________________________________________________
. +ve pressure mechanical ventillation -> ++ intrathoracic pressure -> -
- VR to heart.
. -- VR -> -- Ventricular preload.
. In pts with hypovolemic shock, this effect may cause circulatory
collapse !
. if the pt's intravascular volume isn't replaced before mechanical
ventillation begins.

. URETHRAL INJURY & PELVIC #:

______________________________
. POSTERIOR urethral injury is associated with pelvic #s.
. Blood at urethral meatus.
. High riding prostate.
. Scrotal hematoma.
. Inability to void despite sensing an urge to void.
. Palpable distended bladder.

. ANTERIOR urethral injury is due to blunt trauma to perineum (Straddle

injury).
. May be caused by instrumentation to urethra.
. Perineal tenderness & hematoma.
. NORMAL PROSTATE.
. Bleeding from urethra.
. NORMAL URINATION.

. DUMPING $YNDROME:
____________________
. Common post-gastrectomy complication.
 . Due to rapid emptying of gastric contents into the duodenum & small
intestine.
. Post-prandial abd. cramps - weakness - lightheadedness - diaphoresis.
. Symptoms diminish over time.
. Symptoms result from fluid shift from intravascular space to small
intestine.
. Stimulation of intestinal vasoactive peptides -> Stimulation of
autonomic reflexes.
. Dietary changes are helpful to control symptoms.
. In resistant cases, octreotide sh'd be tried.
. Reconstructive surgery is reserved for intractable cases.

. HEMATOCHEZIA:
________________
. Bright red blood in stool.
. Due to lower GI bleeding (distal to ligament of Treitz).
. May occur in very brisk upper GI bleeding.
. Most common causes of lower GI bleeding in pts >50 ys-> DIVERTICULOSIS
- ANGIODYSPLASIA
. Nasogastric tube placement with bile not blood = No active upper GI
bleeding.
. Upper endoscopy sh'd be done next not to miss duodenal bleeding.

. In cases of hematochezia due to diverticulosis,

. The initial step is COLONOSCOPY.
. If -ve -> Radio-nuclide (Technetium 99 Labelled eryhthrocyte
scintigraphy tagged RBCs).
. It is less invasive & more sensitive than angiography.
. It localizes the source of bleeding so that,
. the region can be further evaluated by colonoscopy or angiography.

. CENTRAL VENOUS CATHETERIZATION:

__________________________________
. A CXR sh'd be done to confirm proper placement & absence of
complications.
. e.g. subclavian artery injury, pneumothorax, hemothorax, thrombosis &
air embolism.
. To avoid myocardial perforation the catheter tip sh'd be located
proximal to either:
. the cardiac silhouette or the angle between the trachea & right main
stem bronchus.
. The catheter sh'd lie in the superior vena cava.

. DIABETIC FOOT ULCERS:

________________________
. Result from neuropathy, microvascular insuffeciency &
immunosuppression.
. They occur on the plantar surface of the foot under points of greatest
pressure,
. such as under the head of the 1st metatarsal bone.

. SOLITARY PULMONARY NODULE EVALUATION:

________________________________________

SOLITARY PULMONARY NODULE EVALUATION

______________________________________
 |
CHEST CT WITH CONTRAST
________________________
|
__________________________
| |
Benign features Intermediate or suspicious
for malignancy
_________________
___________________________________________
| |
SERIAL CT SCANS TO MONITOR FURTHER INVESTIGATION WITH
BIOPSY or PET scan

. VENOUS VALVULAR INCOMPETENCE:

________________________________
. is the most common cause of lower extremity edema.
. It classically worsens thoroughout the day & resolves overnight when
pt is recumbent.

. NASAL SEPTAL PERFORATION:

____________________________
. Any pt develops a whistling noise during respiration following
rhinoplasty.
. One suspect nasal septal perforation due to Septal hematoma.

. TRAUMATIC SPINAL CORD INJURIES:

__________________________________
. Should be 1st hemodynamically stabilized.
. Proper airway management.
. Urinary catheterization placement is imp. to assess for urine
retention !
. It is important to prevent bladder distension & damage.

. A retrograde urethrogram sh'd be the 1st step in management of

urethral injury,
. Foley catheterization is contraindicated as it will worsen the
condition.

. ACUTE BACTERIAL PAROTITIS:

_____________________________
. Fever, leukocytosis & parotid inflammation.
. Dehydrated post-operative pts & elderly are most prone to develop
infection.
. Painful swelling of the parotid gland aggravated by chewing.
. Tender, swollen & erythematous gland with purulent saliva expressed
from parotid duct.
. Most common infectious agent is STAPHYLOCOCCUS AUREUS.
. Tx -> Adequate fluid hydration & oral hygiene can prevent this
condition.

. N.B. Spirometry prevents post-operative respiratory complications not

parotitis.
 . DIVERTICULOSIS:
__________________
. is the most common cause of a lower gastro-intestinal hemorrhage in an
elderly.
. Bright red bleeding from the rectum is usually caused by a lower GI
hemorrhage.
. Colonic diverticula are formed due to high intra-luminal pressure,
. which causes the mucosa to herniate through the bowel wall penetrating
its vasculature.
. They don't include all layers of the bowel (False divertuculae).
. Chronic constipation is due to low fiber diet.
. Most common predisposing factor to diverticulosis.
. Diverticulae erode the bowel vasculature leading to profuse bleeding
per rectum.
. Most common site is sigmoid colon.
. Dx -> CT Abdomen.

. N.B.
. Diverticulosis -> Non-inflammed diverticula -> Painless bleeding.
. Diverticulitis -> Abdominal pain & infectious syms 2ry to obstruction
of diverticula.
. It is uncommon to see bleeding with diverticulitis !

. GASTRO-ESOPHAGEAL MURAL INJURY CHARACTERISTICS:

_________________________________________________
_________________________________________________

(A) MALLORY WEISS $YNDROME:

____________________________
. Upper gastro-intestinal MUCOSAL TEAR.
. Caused by forceful retching (++ pressure).
. Submucosal arterial or venule plexus bleeding.
. Vomiting, retching, hematemesis & epigastric pain.
. Dx -> EGD confirms diagnosis.
. Most tears heal spontaneously.
. Endoscopic therapy for continous bleeding.

(B) BOERHAAVE $YNDROME:

________________________
. Esophageal TANS-MURAL tear.
. Caused by forceful retching (++ pressure).
. ESOPHAGEAL AIR/FLUID LEAKAGE into nearby areas e.g. pleura.
. Vomiting, retching, chest & upper abdominal pain.
. Odynophagia, fever, dyspnea & septic shock may occur.
. Subcutaneous emphysema may be seen.
. Dx -> CT or CONTRAST ESOPHAGOGRAPHY e' GASTROGRAFIN (Water soluble)
confirms diagnosis.
. CXR -> Pneumo-mediastinum & pleural effusion.
. Pleural fluid analysis -> EXUDATIVE, LOW pH, VERY HIGH AMYLASE > 2500
IU.
. Tx -> Surgery for thoracic perforations.
. Conservative measures e.g. antibiotics for cervical perforation.

. IATROGENIC esophageal perforation:

. CXR -> Pleural effusion, pneumomediastinum & pneumothorax.
. Dx -> Water soluble contrast esophagogram.
. Avoid endoscopy not to worsen the condition !
 . MECHANISMS OF LOWERING INTRA-CRANIAL TENSION:
________________________________________________
. HEAD ELEVATION -> ++ venous outflow from the head.
. SEDATION -> -- metabolic demand & control of HTN.
. IV MANNITOL -> Extraction of free water out of brain tissue -> Osmotic
diuresis.
. HYPERVENTILLATION -> CO2 washout -> Cerebral VASOCONSTRICTION.

. POST-SPLENECTOMY VACCINES:
_____________________________
. Following splenectomy, pts are at ++ risk for sepsis 2ry to
encapsulated organisms
. Capsulated organisms (S. pneumoniae - N. meningitidis - H.
influenzae).
. Vaccination against these organisms sh'd be administered.
. Pneumococcal vaccine boosters are required every 5 years.

. PAROTID NEOPLASM:
____________________
. The two lobes of the parotid gland are separated by the facial nerve.
. Parotid surgery involve the deep lobe of the parotid gland -> facial
palsy.
. Facial palsy -> Facial droop.

. INJURY -> CULPRIT INJURED NERVE:

___________________________________
. HOARSENESS -> RECURRENT LARYNGEAL BRANCES OF VAGUS NERVE
(Thyroid/Parathyroid surgery).
. TIC DOULOUREUX (TRIGEMINAL NEURALGIA) -> TRIGEMINAL NERVE.
. TONGUE PALSY -> HYPOGLOSSAL NERVE (Submandibular gland surgery).
. WINGED SCAPULA -> LONG THORACIC NERVE (Axillary lymphadenectomy
surgery).

. PERIPHERAL ARTERY ANEURYSM:

______________________________
. Pulsatile mass that can compress adjacent structures (nerves - veins).
. May lead to thrombosis & ischemia.
. Most common are popliteal & femoral aneurysms.
. Associated with peripheral artery aneurysm.

. PENILE #:
____________
. Crush injury of an erect penis.
. Common during intercourse with female on top of male.
. Dx -> Emergent urethrogram to assess for urethral injury.
. Tx -> Surgical exploration to evacuate hematoma & mend the torn tunica
albuginea.

. URIC ACID STONES:

____________________
. Ureteral colic -> Vagal reaction -> ILEUS.
. Urinalysis -> Needle shaped crystals = uric acid stones.
. Dx -> CT abdomen or IV pyelography.
 . Tx -> Stones < 0.6 cm -> Pass spontaneously with hydration &
analgesia.
. Tx -> Stones > 0.6 cm -> Surgical removal.

. NASOPHARYNGEAL CARCINOMA (NPC):

__________________________________
. Undifferentiated carcinoma of squamous cell origin.
. Higher frequency in people of Mediterranean or far eastern descent.
. Most NPC are metastatic at the time of diagnosis.
. Recurrent otitis media (Due to eustachian tube obstruction by tumor).
. Recurrent epistaxis or nasal obstruction.
. Associated with positive serology for EPSTEIN BARR VIRUS (EBV).
. It is associated with smoking & chronic nitrosamine consumption
(Salted fish diet).

. PARALYTIC ILEUS:
___________________
. Abdominal pain after a traumatic injury.
. Associated with vertebral # or retro-peritoneal hemorrhage.
. Ileus is caused by an exagerrated intestinal reaction after abdominal
surgery.
. Due to disruption of normal neurologic & motor control of the
gastrointestinal tract.
. Failure to pass stool or flatus, abdominal distension, nausea &
vomiting.
. Distended abdomen with tympany.
. Decreased or absent bowel sounds.
. Abdominal x-ray -> Air-fluid levels & distended gas-filled loops of
small & large int.
. Tx -> Conservative with bowel rest & supportive care.

. LUDWIG's ANGINA:
___________________
. Infection of the submandibular & sublingual glands.
. Source of infection -> Infected tooth (2nd or 3rd mandibular molar).
. Most common cause of death -> Asphyxia.

. TORUS PALATINUS:
___________________
. CONGENITAL !
. Young individual.
. Fleshy immobile mass on the midline hard palate.
. No medical or surgical ttt is required unless the growth becomes
symptomatic.
. i.e. interfering with speech or eating.

. NEURO-ANATOMY:
_________________
_________________

. FEMORAL NERVE:
_________________
. Motor to anterior compartment of thigh (Quadriceps femoris - Sartorius
- Pectineus).
. Responsible of knee extension & hip flexion.
 . Sensory to the anterior thigh & medial leg via saphenous branch.

. TIBIAL NERVE:
________________
. Motor to posterior compartment of thigh, posterior compartment of leg
& plantar foot ms
. Responsible of knee flexion & digits & plantar flexion of foot.
. Sensory to the leg (except the medial side) & plantar foot.

. OBTURATOR NERVE:
___________________
. Motor to medial compartment of thigh.
. Responsible of thigh adduction.
. Sensory to the medial thigh.

. COMMON PERONEAL NERVE = FIBULAR NERVE:

_________________________________________
. Give rise to superficial & deep peroneal nerves.
. Motor to anterior & lateral leg.
. Sensory to antero-lateral leg & dorsum of the foot.

. GLASGOW COMA SCALE:

______________________
______________________

. EYE OPENING:
_______________
4 -> Spontaneous.
3 -> To verbal command.
2 -> To pain.
1 -> None.

. VERBAL RESPONSE:
___________________
5 -> Oriented.
4 -> Disoriented/confused.
3 -> Inappropriate words.
2 -> Incomprehensible sounds.
1 -> None.

. MOTOR RESPONSE:
__________________
6 -> Obeys.
5 -> Localizes.
4 -> Withdraws.
3 -> Flexion posturing (Decorticate).
2 -> Extension posturing (Decerebrate).
1 -> None.

Dr. Wael Tawfic Mohamed

_________________________