Petra Emtiaz Lecture Notes Of Medicine Dr. Hassan Abd Al-Majeed Alkhatatbah Assisted by Dr. Mohammad Abdel jalil Amrosisoxqyg 0986) ‘stsmaayypuorg, Sweety SD ce 8 em eh RO eee rem oO OP ET IY annesad fan een Patan ne praia fe E eo P AMOR eee FRE BHT IMF eeP RPAH F eC en TNS f raE me Se aD gD it? Se ee Peer LEY ome cp evemetet poses ywowmoud- foot aff SP eA ey 20 rE en FRAC os Asovesrdson rane, Cop CETS-LS66-846 NOSE Axyedokoxps09 pop: topos toc “wopmgessic 3 Be sop uowez 1y Sepep er Mey soseostp yoy se]0aye europe Aaeuounn, Megymmery Pooley pay WSs 0 Sa)ON BMD] eM ENA ‘squpsesopue annoys i vwonuanodgy i ane eae j pray i sesronp not 6003 i £07 Wray RT oe i s } Ie MEF: TSOEPES 979600 — Aer? ? GIZISES9TIGOD = “spiiattoD JoaEL Te ' 3 ey eA HP SIFY Moy - os PS iP Sa1{PSMedicine Pulmonary embolism Sarcoidosis Obstructive sleep apnea Respiratory failure Pulmonary edema Occupational lang diseases Fosinophilic lang diseases SVC syndrome Homer syndrome Chapter Hematology Anemia Hemostasis Bleeding disorders pic Polyeythemia ‘Thrombocytopenia Functional platelet disorder Thrombocytosis Pancytopenia Multiple myeloma “Myeloproliferative disorders, Leukemia Lymphoma ‘Nephritie syndrome Nephrotic syndrome Electrolyte Chapter 5 Infections diseases Jomune system Antibioties Herpes zoster Infectious mononcleasus ‘Typhoid fever Brucellosis Diarrhea Meningitis HIV/AIDS Syphilis Cat soratch diseaso ‘Toxic shock syndrome Pericarditissaree, Anamyeusssody, awospuss foun; pede mnsopon Burp, Sorqgnye LON, ‘sorospuss uaitofs, wouswouand preukey ain wspecwosge Aeedos woneaudse pany e1A0uss ‘SpE RODISO syunpre andag snmp eneBau0r0s vunopoizyos wofiopnasd stupa prwamony Stoqovemnon gadeqg, poe revery wa ‘punys proxcyy, nproutpesediod ty upper i L Naw ssourm supoopus anwar avis: snpicsinsreqecr odes ‘ewouope Krenn Somme sus0puy. cade Aauayoyfop wrest, soxpeneg sovostp 20780 vondiosqereyy sisoyeutonouapy se9sIp uosttay pusdXanue | wydly rms Kreutag mig Aroursa, suedoy auneeurosny speday 1, NUH Hog soya, soseosip joo Kioprunse ap reapsamonsey 9 sander 9091Medicine ———___ Chapter 9 Neurology Stroke Subarachnoid hemorrhage Headache M sclerosis ops Myasthenia gravis Lambert Eaton syndrome Parkinson Aphasia UMN Meiosismyerasis Press Wemicke encephalopathy Cranial nerves tr is abnormal heart rythm Sinus rythm, Is the normal heart rhythm jnormaly heart rate is 60-100 beat/minute ,every p wave is followed by QRS and every QRS followed by T wave. With regular interval .p wave representsatrial depolarization(contraction). QRS represents lar depolarization, T wave represents ventricular repolarization(relaxation), Atrial repolarization wave(relaxation) is not seen on ECG(nasked by QRS). sinus tachyeardia(HR more than 100 but normal rhythm) . causes of sinus tachycardia (Pain ,fever,anemia, fear,Exercise, hyperttryroidism,drugs like atropine and adrenaline) Sinus bradycardia(HR Jess than 60 but normal rhythm). (Hypothyroidism, athletes,B-blocker _Drug,increased intracranial pressure) are causes of bradycardia Bradycardia if asymptomatic necd no treatment,but if symptomatic treated by atropineayn pre Jo somereadde yoo) KS eS TE uoneqy [eH se wousSeueUE ouemodde yjoopmes sMoys DOQIONNEL THY < ads }xeaT Jo WoNDa«LI09 21094 SHOP 9-f 105 nonemndeoarae st yuameon os porsouion s} OReTIAHT [eEe Jy Wsqoqueoquionp srmays4s Jo SLL v St SIU PUR SI9qI qwey ox 9pISM ONE snquIONA Jo Ys v oTeoLOUL, say gp < 21N0IM TT -worsz9aoqpaes poauayqe;sun JE mq ‘91ge18 AteouEuouoy st quaned om JE (arxoByp aotsysoq puneys uMpED § 19yD01 g)TOREI;pauT Kaparees], Sa SF WEED SSE INTE ITT ON eGY [LE Jo woMyEALy, (ress yay epsdaun ane d ow) von youre sMoNs NOT lorena aseosip weayy peruaBu0D < ToHooTy < Asa8ms oeiprey ¢ spipmeoniog < vruoumoug < (stsoorxoyox4qn) wxsipronspradsy] ompedompy < (HD esvasiq uwoH ormeqps| < WONTTEGKE Teeny Jo sasne emo ‘Aw ONC AV < Qu [EUW EN parelposse Ayfensn acwospuss MA GA‘ aawAL HPP SMOYS DOT (Md AA) etHoapuds oA WosUMpAEE J1OA5 DA sod opuypusn uouuos jsou-nonveytiqy avpaosy00, (CaeinBoa 3p SHO PLA) NOTE EIpavodyor} remouHEA “O8T Up as0W YH'SAD MosreU ‘seInaa oaeMm gE OU OOFC(LAS)EIpIEDAYDE? svnoLMAEIdNg sounrwadde Wroo}-aues sMoYS OOHsINMLY PIT avpnieunt GAM gow OTe (re V)uONEELGY |EETY Asouy pmnoys nox ermmzAqaae TouNLO:> oumipen‘Medicine —— > Supra-ventriculer tachycardia (SVT) ° No P wave, regular, narrow QRS,HR>180 ECG showing SVT Treatment Learotid massage. first done to increase Vagal tone & decreaseHR,done unilateral because bilateral carotid massage simultaneously can cause sever bradycardia. 2-valsalva maneuver increase intrathoracic pressure and stimulate vagus nerve which decrease HR. 3-Oceular massage 4-Adenosin LV 6/12/12mg regimen(the drug of choiceif the above methods failed). Adenosine can cause bronchospasm and hypotentionso it is contraindicated in asthma or hypotention(systolic BP<90). Inasthma patient with SVT give Diltiazem(calcium channel blocker). 5-DC shock(cardioversion). If hypotensive (systolic BP<90) or if not responding to medication. Medic Remember that: > Adenosin Contraindicated in pt. With systolic BP less ‘than 90 & in asthma pt. Instead you should give Catt channel blocker ( verapamil, deltiazem ). > Dmug of choice in SVT is adenosin > Adenosin side efect * Bronchospasm. © Hypotension > Ventricular tachycardia : Regular, wide QRS,no ?’ or T wave ECG showing ventrienlar tachycardia(Goqoey ys MORTGY TELE WIA pareioosse sty JL Iq yUaUHEDN soy pavapisuos pue CVD %seunm wonuaodApy Josye uorsuousdAy pou ou spewoydurdse pue vonEGY ee ou Jr ouRLaL, Burjomg (sourmjasea wp sons Doe ayosm St THING FHT St TCLTFOMB BION “10H pastaxsap pue'poroys9fONP'D. LTT paseosouy(suorenusou0s TCT = umes Aqqeoypoads)—_eruxajozmssojoqoradyy SHOP RUSE HES sd 2avad CHIP(MAM) OMLOAPUKS aA WOSUPLTE FOAL ‘yenqU fenduyqns 10 ysa4 Kq POAotry wowiaxa Aq pawania3y © orgy sera 4098 HO “yp0U Jo Japinogs Yo ue YeT Oo} eFIDEY = (ssounyap) ss aH STOINEN & (jenuao) eurasoney © suped ysoyp aid. 7 Ne eee ee t (qpoys Qq)uorssaAo%pzes spoou' yA asod wruNpAYae ov smojduidg I waned Nog seep oUNEIMBaM MOPELAGY e|NDENHEA aseasip Fay SROIRpSsoIMPY 10 (CI) aseasiC Hea] OrMIOYDSy p3| (vorstoatpae)yo0ys 1A % Ydd € a1eIsE) UuoReporUae 20 oMESOPHL NT € AIGA 4+ Bo'=yDOIq q 10)oo_OND Jo Bnp oy st TorEpormEUDY re gE EE eee eee t Sec EEEREEEEErEoeMedicine ‘Hyperglycemia (due to DM or other) Type A Behavioral pattems (Nervous serious personality) Lack of exercise Anemia ‘Consumption of alcohol Stress Diet rich in saturated fats Saturated fat (animal fats) >barmfl ‘Unsaturated fat 1) useful Obesity Men over 60; women over 65 Male (M>F) Aartic stenosis icrease the risk of CAD Hypermocystinuria (Increase homoeystein increase the risk of CAD) .Treatment folic acid decrease h CAD includesAngina(stable or unstable) and myocardial infaretion(STEMLor NON STEMI). Coronary artery syndromeincludes unstable angina, STEMI,non STEMI(but not stable angina). Medicine Pathophysiology: cholesterol plaques deposit in the coronary vessels ,these plaques release chemicals that attract platelet which result in narrowing of blood vessels.Left anterior descending(LAD)coronary artery is most common site for atherosclerosis, most common cause of acute coronary syndrome is rupture of plaque. Angina Anginadoesn’t cause myocardial muscle necrosis (unlike MI which cause necrosis) so angina doesn’t cause elevation of cardiac enzymes, 1-Stable angina Precipitated by some activity (running, walking, etc.) with non- existent symptoms at rest.Present with chest pain that start after yual ity,Last 5-15 minutes and relieved by rest or su nitrate. Occur with stable frequency. ECG and cardiac enzymes are normal Diagnosis treadmill stress test, cardiac catheterization ‘Treatment “Modify risk factors (treat DM,HTN,and Hyperlipidemia)(s&ep oT )readdestp auo ysvy pue'wadde uo isei HAT sAep €-7 UY [eMrIOM OF WAN9a pur szy ZTE UE ASU FAHD sKup 1, Ut Jemurom 0} winjox pue ay ZI-¢ UE asIT “(4594 a1ujse se oyads pus oanrsaas ysout)ysaq om: J-uruodos Gf asvazour uo suonoafay awMosaURENUT 10 sIsKjowosputs Kreuox09 93n9y ered (SOW Jo mounvan 998) wwouRRaN yus8m s10Ur Poot pue vuidue ages ueIy snoraZuep arour st eure oyqeisim- sourdza ovipres asearout ueo‘ynpe Sunok uy woos auour (sjsoquromp rom)sjassas £reuCH09 30 wsedsoswa‘(oul3ue queyea) vmguy jeauzUUY (suroydunés pue Souanbayy paseaioul) opusasai e YGIM smI9Q ayy up emiue sty sor yw SIN000) eq) eurSue sopnpour emisue apqESU (SOV ewoxputs Kreuoz0o aynoe Jo wed) eusuy ayqnsup-z (oc> YT] asearog 0} woreotpout pi ney Su pure AneyOU aseanac~-(ysv)uEIdsy “06> ae OHorss Jt 40°sIy pz ISB] OUP UT VOBI(eIBELA TYE JE usa you" wonua}odéy (0°) aypuproy‘apnyout woe opis “Keyour GQ —aseaisap —_,usa0p reat nq ured amp 2ptojor pur peozard aseaxsap yoIya uoReeIIp ‘SOTeHIN smiouaa sasmea osje' Srey Areuo19 yep Poy] FO PuEWEP ZO PUL YH esea:99p"""--4a9PO|ET pom ¥ oumy ¢ salnunwgg-Q¢ktprder Supra) Kasse pworskyd kre ouypayyMedicine Combination of troponin I and CK-MB are the most sensitive 2ECG STEMI shows ST elevation Whi Mi(affect whole thickness of cardiac wall).non STEMI transmural shows ST depression and other ECG changes but not ST clevation.(non STEMI is not transmural). ‘Treatment: IMER.......GIVE MONA-B and anticoagulate with heparin and then emergency reperfusion _therapy(cardiac catheterization (PCIand stenting(best) or fibrinolytic ‘therapy(urokinase or streptokinase) M: morphine (as MI pain doesn’t respond to nitroglycerine ) : oxygen (02) N: nitroglycerine (nitrates) angina respond but MI less or no A: Aspirin (crushed) 325 mg B: B Blocker PCI (percutaneous coronary intervention) is the best reperfusion therapy in ACS ,and best done in the first 90 minutes. Wibrinolytic therapy: includes streptokinase and urokinase. ccilg i j | ‘Medicine $$$ Streptokinase is derived from bacterial protein(streptococcus protein.its antigenic which produce antibody that decrease its, efficacy with repeated use. Urokinase isn’t antigenic ,doesa’t produce antibody and doesn’t loss efficacy with repeated use(more expensive than streptokinase). mechanism of action : activate plasminogen into plasmin which dissolve the fibrin around the thrombus. Indications: STEMI(not used in non STEMD),If no PCI available or the nearest PCI need >90 minutes.if no contraindications. Bestto use it in 1 4 hrs of STEMI (but not used after 12 hours of STEMI symptoms: Contraindications: Previous hemorrhagic stroke ,suspected aortic disscction,beeding disorder,active bleeding.brain tumor, HIN >180/110.pregnancy ,recent major trauma or surgery in the last 2-4 weeks.Aspirinand clopidogrel should be continued for 1 year post PCI and coronary stenting to prevent stent thrombosis,then topped and patient continue on idogrel aspirin39014 AV pus vipaodpLIa-y asrasip weap] onwuatps] sf amnypey yway| Jo asawd uoUNHOD ySOWYT, usps Areaomnd aynoe pue aanyes semoUjUAA YOL-E ypoys o1uaBoypse>-z TW 3sed ma90 Jey BUUEPAYLE ow ay SI WORETEAGY AemMoENUEA “LAL Sod ALSTOM OF MPEIP Jo DOW wyuNBALAE reMIEIAA-T Tyo suopeandwoy TW eidasoxomay -s TAL arty EATA SPRL UY OAC A SMOS HOgT*payejos! ATuoUMTOD ssojuonOMyUT Jerre] JO rONAyU ue Jo 1%: 9 ay uy Buu Tens SIA 10ays0q-¢ (Ca 20122106) pA-T4 SPA HE HORIEARIS LS SMOUS DOT ca ay PArop1e Smpusssep Aoy19}Ue Yo] Jo VOISNIOI0 01 anp*pA-TA spEa| UI GONRAgIA 1S SDA sopay-7 IN soHAFMTAE PUE TTT SPH MY HONEAD!D JS 8804S DOT (ren aay3 }.op)uonUa}odAy- pue uonoUNyskp sFINOE UDA THERE Jo YSU pavdjso1q AV o2 anp eIpauedpesg Jo ¥SUAAE UE TUL TL Speay uy uoNEAaa ps‘uONON 90K Jousje wey) sisougosd ojgemoaRy azour (yoy)AIeUE Axenos03 y3nyo uolsnjoso Woy Ajsour TA4OHA;UT-T TAGES 30 SoS sainMedicine (more with inferior MI due to increase risk of AV block) AV block with inferior MI usually transient and no need for pacemaker but AV block in anterior MI aeeds pacemaker (AV block here from ischemia not vagal stimulation) S-Ventricular aneurysm develop 3-7 days post MI (persistent ST elevation is indication for that) 6-ventricular rupture usually occur 1 week post MI. 7-Papillary muscle rupture and mitral regurgitation(more ferior MD). 8-VSD in case of anteroseptal MI occur 3-7 days post MI. 9-Acute cardiac tamponade. 10-right ventricular dysfunction (more with inferior M1) ‘Note: avoid nitrate in inferior MI with right ventricular dysfunction,and give I:V fluid and dobutamine. 11-pericarditis(ressler syndrome) occur 2 weeks post MI 12-intramural thrombus due to blood stasis with risk of systemic embolization(stroke bowel ischemia lower limb ischemia) | | | Medien Notes ECG in pericarditis show diffuse ST clevationMI doesn't cause diffuse elevation, ‘Ml usually present with epigastric pain not chest pain and occur more in iabetio, ‘New left bundle branch block(but not right) on ECG can indicates transmural ML ECG sequence in STEMI 1" is peaked T wave followed by ST clovation followed by T wave inversion and finaly Q wave ‘Q wave persst(doesn’tdisappeat) and when you find it on ECG means old M1) STEMIalso called Q yrve Mii tranemural necrosisynon STEMI(non Q wave) is superficial necrosis co venticular rupture and aneyrysm occur with ‘STEMI not non STEMI Indications for coronary artery bypass grafting(CABG) 1-3 vessels diseases 2- occlusion of the proximal left main coronary artery 3-significant atherosclerosis in left proximal anterior descending coronary artery with ejection fraction less than 50% 4-chronic disabeling angina, Vesselsused in CABG. are great saphenous vein (7O%patency after 10 years) or intemal thoracic (mammary)artery (the best 90% patency after 10 years)or [—aneoais animOA ETE pea poreioosse —ar0ur 40 upqUIOA 10 vasneu sso] “TOA TORTT AG POTTY ION WEDOAFORTE Aq PSAry sonutar gz < somntna S1-E Seu INALS tou x woHEAdp-[ | oytods-uou 10 [RULONE- DOU SOHN SWOIN ON suuikzns GEIB CF) Cyamikas SepIED wan Ta SES DYV ‘wONSTepay [eIpAEsON Dy way TTS 1D SIO woy uonqosge TW 9 tuisuy upera -gsprore Ayey Yo vouIO-p Aqureur pid quoaard ompmmzaysajoq5-¢ stssfosuopges pu yyedo Kur st 199379 OPIS pawenay &sourtsd st OJ ww posh saymsqU-Z st AmOpqeyp Uy esvasour Yorys(sfd0) [aaa] aseuryoydsoyd sutPaI9 amseout parodsns 1) st jokmopqes pur kpedosm st aye 1S Qsoq)pareaaye Aprewud st TPL st pasn Apso, BEECH PEGE ee ere Geet eee poppet 81 aseyonpar V Oo DWH TAM VOW (apesvams 30)smyes-T eID] ody Jo ywaunyan ut posn sBnagl 1922)89]04), (OL) apyeosiL aseasnop sf yaya (esvazomy J) myosn— (uppoadody Aysuop-¥3N) “TO adi prdiy ymyzeq ssour axp-(mpayoadod ajourpessdyp 40 wrareynqop 2x11 1591 ssoays ywoySojooemseyd op am (eseasip senosea jesoyduod axas 10 syLRoaSO azaaos)uuajqoud yeuonoumy. 0} onp asjoxox9 op youues.voHed JF “sppavso4ur 40 sprpavouiod JOAIS'NLLH Faas 40 aanyyey java saaas‘Aqedodurorpaes amdonradky = 20 sysomays_ anor —_sa4ast(skep OT UREN) TAL Wwase.'eurSue ajqrysun : suoneorpmIEsyHO “%OL< SISOUDIS JL 0915 pw UOHEZEAIaED perpies £q pamoyjoy 2q pmous ys sons samsog. (om p< wowssandop 1g" OHM SL asousierp 0 pasr, (se: warpeon) 189} ssouys aspu9xgMedicine HeareFaitureainy Decrease myocardial ability to pump blood to other organsIs Ejection fraction < 40% (By echocardiogram). Ejection fraction(EF)=strokevolume/end diastolic volume. Normaly EF=50-75% Classification I-Systolic Vs Diastolic heart failure In systolic HF EF <40% due to left ventricular dysfunction in Diastolic HF ...mormalWF but decrease filling of the heart during relaxation (diastole) 2-Left Vs Right HF or Biventricular HF(congestive HF) Causes of Li side HF Ischemic heard disease (MD)isThe mast cor ‘cause(in.c.c),cardiomyopathy, HTN,valvular heart disease, myocarditis arrhythmia other causes like sever anemia. Causes of Rt side HP L-Lt side HF is the m.c.c(long standing It side HF will cause eventually Rt side HF) 2-Core pulmonale is Rt side HF not caused by Lt side (isolated Rt side HF,causcs of core pulmonale include Medicine a chronic respiratory diseases like COPD Bronchiectasis,lung fibrosis primary pulmonary HTN. Signs & Symptoms = Left-sided failure © Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND) = Pulmonary edema, laterally displaced apex beat, gallop rhythm (Si, $2, $3) = Right-side failure Peripheral edema, ascites, hepatomegaly,increase jugular venous pressure(JVP) Increased jugular venous pressare(JVP)> distended neck veins Diagnosis «= Echocardiography (EF-><40%) History and physical exam....signs of HF = CXR look for pulmonary edema and cardiomegaly differentiate wy edema if it caused by left side ‘* Atrial natriuretic peptide(ANP) Pp HF(cardiogenic)or non cardiogenic,ANP increase in 21‘saSueyo o1fjonsoj pus wonespAyap'sérup anssarddnsounummr‘ujo Awomp 19‘auorepormre'sonaaIp 2970019 { 29yD0[q PUUEYDH FD OY sBup yam jeaestaBe PIO Aarorxo} waxodyp aseas904 7eIp S40)9H -(qpeop jo o-3-w Ow St PHUNpANLIE)qVEIP pUe poreyp*emray nj .9dky orampAtaseeyprEApeg Jo vIpreodysey: ‘oye ‘SunIaiOA ‘easneu uNKOSIG Jo A'S uonpezuoo oerpreo —pasenoure+Ze) Posoorouy GEM OMY FON WEY VOW 1x0) ApaEy pur 4 Hou aseadap 3,us90p Tormpramo “oxdosig ‘jojoxdeyour Ayyeuow aseaso9p SIND ET “P31 paseausar gg (epuojoure ‘suoroyueULY ‘ouo;efouords) anaanIp Suneds 43 4ZED paswasap ‘Hy pasvaioap ag apiurasoany #TED pasvasouy ‘sy paseai99p F's OPPAENL, (meri0w asvassap yemp sonoanip Aqwo am) st auoyaHonosy )yyeprous aszaisap 2.uop nq(emapa) smoydurds yeas} 0) sOMOAMIG « w Aqye row asean9p uenesyeA, UNWSO[E(TAV) 494904 40;do991 MISUO}OSUY = (009 asne> Y.US90P FAVIEUV OF YUMsean0d Kp J] Gm pasearoul) mpmapejadéyy “( janoy usupyspeuq asvasour wo Yysnos) (%0T) yanor Ampe(as}2N2 apis uonaunyssp zemonueA Yor TIM swayed ur Aen sonpor oy umoys act pue 271] Jo Anqenb pur pwataans ososdunr (judo “udowsry “qudodes ‘qudeyeus) stomqrymy = gow Moprqyat (ADV) auLdzn9 Sups9sd09-uisHO,OIBAE ET qwomoseuepy, sar ye swordurks p S825) Ayanoe Ayrep Jo woneyaT 12A98 ¢ sseIE) aanyrey }189q Jo UoRwaYssePD [PUOHSUN -omaforprea ow ang wuap9 Areuowynd —omaZoypse3 SUPIPOTMedicine ——————____— Treatment of toxicity Stop digoxin,02,LV fluid,clectrotyte correction Antidote is digoxine immune Fab Lidocaine is the drug of choice for digoxin induced arrhythmia, Note that ACE. Inhibitor,ARB,spironolactone,B. Blockers _(metaprolol,bisoprolol, decrease the mortalityimprove survival) But thiazide, furosemide, digoxin don’t decrease mortality (only decrease symptoms). 24 Meee “Hypertension HIN or high blood pressure Normal blood pressure at rest 100-140 mmkig systolic and 60- 90 mmHg diastolic Classified as primary (essential) hypertension with no underlying cause or secondary hypertension due to secondary cause About 90-95% of cases are “primary hypertension” 5-10% are secondary hypertension Signs & Symptoms = Usually asymptomatic = Usually Diagnosed accidentally by screening Classification PreHTN systolic BP(120-139) and diastolic HTN (80-89) Stage L HTN Systolic BP (140-159) and diastolic (90-99) Stage 2 HTN systolic 160-179 diastolic 100-109 Stage 3 HTN(emergency HTN) systolic >~180 or >=110 Note thatdiastolic HTN is more dangerous Than systolic HIN 25SuOIOISopTe asvarouTsouONbY] © (eysdurjoo-o1d) KouenBorg « worsuapi9d Ay A1epuossg x9910-F NIL onoiseyp sasnes cussiproskModay NAH O0s4s sosnus EC urstproaypoddyy © AteBomos9y © wistprordyperedsodkyy « uuossuayiadAy sasteo sp joo0ons Jo woyaroas aaissooxo uv amoupudg s,Sumysn urapa asnud },ussop‘Jorg] IUD MO|'SISOTEATE oqoqusur = ‘erunenoddyenmspeyodkYN IIT = SPS. wonaroxa +3] aseazour pov wongiosqe OCH pue +e eseanoUt ‘suOraISOp[E aseaxouy (ewosputg s,un03) wsstuoraysopyexad EE (e1ursoS{iedéy‘z0man so7f2d'sso] ya"eprEakypEySuNAAMS gag “WOHIUNSUODOSEA sojowoud yonya oumydamds ue autzydourdazou JO wora99s aatssooxa Aq pasmeagemop4oomosysoaqE © S1opzosIp ompD0pte 0} Krepuos9s worsuay sod Cyy-¢ ———awprpanu spuydauojuswo[y mye feuar oro) © S19pzosip Jeuas 19430 0} Lreptodas woysuapxody]-7 uonestejnoseaas Teordans popes IT veisefdsp sejnosmenozgyy uy 1ynsaz xopoq “Bunuais pue AysejdorSue snoauemnarad s} uoMEOAY, AqdestiorSue ysaq :stsoudery ‘stsouats Stone [ouas soHe 9 us poreoypurENUOD St ONqINRE ADV BON Tera}0TIq 40 fesoyOTFUN aq pInos sisoURyS Aroyre yeUEY, stsozaposozampe Uw sisougoud sor19q sey pur (sapeuray unog wy waas) vise[dshpaejnosnurosqyy “Kapp ul uss (stsouopasozoype) sisousys Aioyre Jouor si esnes WoUIWIOD 150} NILH Atupuoaas jo satauoysuayi0ddy se]nosea-ousy-[ worsuapiad yy Azpuooag yo ssn onestpew NLA Bue aso 10 Z pom NIH Z93HS uopesrpau ayiuis £q poyjonuos NILA T Beg ‘uoweoq pour of43s 251] uo woNyeorp>it 10g p99u OM NTH 34d (ae run ueoe m azo. saynquques get 11038 ey fsamssoid yaya wD, 2UR1BWMediing * Liddle syndrome activation mutation in aldosterone le receptors, s8s syndrome but in low(unlike conn) syndrome aldosterone level + Drugs->cortisone, oral ine, MAOI,NSAID, adrenergic contraceptive Fever and pain can increase BP White coat syndrome due to anxiety of patient during doctor clinic visit. 5- coarctation of aorta Narrowing of aorta distal to the origin of left subclavian artery(post ductal) ‘M>F 2:1 more in Turner syndrome (45 XO) S&Sincrease BP in upper extremities but decrease it in lower extremities,intermittent claudication and pain in lower limbs, lower limb atrophy,radiofemoral — delay,systolic murmer,CXR rib notching from collaterals ‘Treatment surgery | | | | Medieine Hypertensive Crises (malignant or —_ accelerated hypertension) Severely elevated blood pressure ( or = 180 (systolic) or 110 (@iastolic)) High risk of Diagnosed when there is direct damage to one or more organs as a result of severely elevated blood pressure Complications «Hypertensive encephalopathy Altered si ¢ of consciousness (confusion or drowsiness) Retinal papilledema and/or fundal hemorthages Chest pain Left ventricular failure Pulmonary edema © Emergency HIN BP >180/110 & one or more organ damage don’t rapidly reduce BP(cisk of brain ischemia) so diuretics should not be used in HTN emergency 29‘(Amor da asvaxsop) sarsuaixoma sarsuayiodsy uy pasn AUG © (Aisnowaxenut waais) siren ao XeppI 0} SOLU Jo 9fosNU TOUS 31p UO KDINp SII (prom ‘comzeyeapsyy ‘opissnadoaya umgpos) sioreuposea © (quedesoa swazengp ‘oudipoia ‘omdiporare) sxoysog jouueyD UMEIL « sroydaoar tisuajo18ue Jo UORRATOR at OIG FAV o (noo snes 3,uop) aeyestea ‘roeso1¢ (ery) ssuOeyUE r0}dod9z TT UISUD}OSUY (sisouays A1oyre poms y81990) 4 uaped ‘Uy pas Jy aanyfey [euas aynse osneD weo}-stsoua}S Avoure yous (esapeyg pur Kouvasosd uy pareorpuyenuo; emopaosSnet exmapeyrodiq'ysnos 1p gs, TL ysuajo1due oy | uIsuapOrSUR JO wolsreauoo am soy aqqisuodser gIVE(HOW) auikzua SunieAuootnsuaorsuy Jo ALANoR amp AIyUL (tadeyena Suudeyde>) sionqequy IV eiseydiodAy oneysoud uStuag wi ys9q €(uisomyly “wsozexocy “uisojnsuey) sxoyporg-eydry © 2013p or (Souwudoad | WETIEGeT) sIPOIG PE F eMIIV POXTA © (jojouexdoxd ‘joqoxdoyour opouare) saayPOI-LIPA © pad} 3 aseaxouy-(epuojeure umyoueLn auoyoejouostds) sonoamep guueds + y(4ieQpueLy — esvousop)apruresomny(++89 asealour puny y esvaxoop)aprmatp st Sup ,1esoparm sSUOnESTpaAL sso] 347048 poe ‘osrox0xe yeoisdyd “(tes aseoxsap)soBueys LIKI « ssuOBEOgIpOU 943595] qwanseney fqyedomdan sxisuoyedéy] « Aqyedounes aassuanadkyy NIH s} asneo mourmos ysoug-aSeqsiowaqrmEoenuy « ayonsquapiooe mjroseaosqais) ue Sipedoyeydaous oatsuausdy uonareyuy perpeso.4yy_ pure ‘Ayredourospaeo aaisuayodsyy — “Aydomsadky—eynomnuon YT = uoysuopiodéyy Jo suomnMedicine —— Choice of Initial Medication ° ° ° ° NoteBblocker and cat+ channel blocker are wrong, com © Thiazide diuretics are effective >best fi * ‘Thiazide causes Hypercalcemia, Hypokalemia © Diabetes>ACE inhibitors and angiotensin receptor the renal and retinal complications of TheACE inhibitors decrease Nephropathy & decreased retinopathy in DM(Decrease proteinurea) Heart Failure ACE inhibitor (decrease mor Benign prostatic hyperplasia(BPH)>can be improved with the use of an alpha blocker Kidney stones improved with thiazide-type diuretics Increased absorption of Ca2+ so decrease risk of stone formation Pregnancy->alpha-methyldopa (Best), labetalol Post-MI >B-Blocker ‘Also ACE Inhibitor and ARB are wrong combination. 2 Medicine Most common bacteria is streptococcus viridans Inflammation of the inner tissue of the heart (valves) ‘Most common bacteria in [V drug abusers is staphylococcus aureus Signs & Symptoms Fever (97%), Heart murmur or changing murmur, Weight joss, ing Finger etal Vascular phenomena(Septic embolism->cause thromboembolic problems (stroke in parietal lobe of brain or gangrene of fingers) Janeway lesions-> painless hemorrhagic cutaneous lesions on palms or soles, Intracranial hemorrhage Conjunctival hemorrhage, Splinter hemorrhage,Renal infarcts Splenic infarcts Splenomegaly, Stroke,abscess (Brain, lung, kidney) Osler’s nodes>painful subcutaneous lesions in the distal fingers Roth's spots on the retina Causes * Bacteremia would be cleared quickly->no adverse ‘consequences 33‘eneo WoUWOD ySOL_D'e'H NOLO oUL-o-U (eusioeg aanysod aseinSe09 payie> oste)snaume snsooa0isqdeys st stosnqe Sap ATW eLsIeq aut vaaea pudsnay sf sxaenqe Sap AT My ang aATEA pesHUE St poysasUT aayEA orm “soaqea jouniouqe pus jeauioN eye uxo snozMe snoooaopiqdeas iq aayna jeutiouge suo yoayse suepusta sars0s0ydonns, snoooa0[ydeis aaneou asepnieos pores osje'sanqea snompsord yooyuy wfanseq'>'w) sypymaapeda snaza20 Kydes, ‘th0¢{ 204 anpnsod st aarayro poota Jf Adoasouojoa op os sa9uN9 wopo> uss pawTDOssE sf stAoG suap000}da.9s —S910N, 999A 9-Z 40J ponunuos are sopoIqAIY sonorgnee osop (BIT = suomyeaay, sapou 5.29150) ‘snuydeuopmismoys — :surajqoxd—yeotoyounumury aun ve aSeqniowoy fearjoumn{uod “suorsay Sesoury ‘syouEjUL Arenournd “yoqass yepiorre swisyoqury Jo ooUOPLAT 2 svaxBap gE < 30403 wonsofit Srup yeuonwarso2 ‘uoisoy sep uNOUy —sOFRY Busodsyparg opnpuy vay AON (uone}Ba 7p) uresBoypresoyso oantsog -« (eanisod scesre 30a Jasmyyno poojq aatnsog « apnppuy vray soley = stsouseig (suioydarfs pidex a1ou)sname snas020.Xyders 51 UOUIMIOS ysOULg. (TY) SHIPIeIOpUD PELL}EQ 9NIy (smorduxds penpes8)suepysta snoaos0ydaays st wou asoue (as) opus jeHO}Ieq smMIEqNS = MOH EOMISSELD suasnqe Brup Aj ‘sampoooud jeep Aq pases emumaoeg « poystiqzise aq wes uonoajut uv PUB SOAjeswON YORHE oF BLaIEq et I0F aoejd e sapiaoid anqea atp ‘paeurep st anjea weay eI] eT TTY‘Meaehae $$$. An inflammatory disease thet occurs following a streptococcus pyogenes infection(group A b hemolytic streptococcus) Caused by antibody cross-resetivity that can involve the heart, Joints, skis appears in children between the ages of 6-15 and brain, Acute rheumatic fever commonly Diagnosis = Major Criteria (John’s Criteria) © Polparth) Carditis, Erythema marginatum, Sydenahm’s chorea, Subcutaneous nodules » Minor Criteria © Fever, Arthralgia, Raised erythrocyte sedimentation rate (increased ESR) or C reactive protein, Leukocytosis (increased WBC),ECG prolonged PR interval Diagnosis needs Evidence (Anti-streptolysin O antibody ASO titer) & 2 major criteria OR Evidence (ASO titer) & 1 major & 2 minor OR Evidence (ASO titer) &chorea alone ‘Treatment * High dose antibiotic (Penicillin) andNSAID (Aspirin) © Lipid Lowering Agents © Statins (HIMG COA reductase inhibitors) simvast © Fibrates (Gemfibrozil) © Bile acid bindings (Cholestyramine)>GI side effect © Nicotinic acid © Fish oil (Omega 3) d “5 Syncope Is temporary impairment of consciousness non cardiac cuases of syncope include, seizure, hypoglycemia,hepatic encephalopathy,electrolyte changes, encephalitis. Cardiac Syncope Causes include -Arrhythmia Aortic stenosis, -Hypertroph Cardiac Syncope is sudden,without warning symptoms, usually occur after exercise,Lasts for 1-2 minutes,with Completes recaveryafter that.6¢ “@onoyserp)dvus Suyuodo‘mmane aHOsMIP MOY MOL “IS pmo| “YSN ETE LE.SUaIS wong [ELIE 29 WsToquIDOqMION] ‘earn peaSuzey uangs0x ssaaduoo wnuye af paBrejua) 9940s asIKO}y -(owopo Areuownd woy)ssidouaR No Axeucuynd puzeweps Kmuowng (quomedsequa petiye yay) amssard rye yoy paseaxouy, surodenks >9 sug 44949) sp euanonpy St 9sne0 woUTUIOD ISO sysonDg [EAL seovosrq eo arms) ~ ae erxodéy sans jt woneyAuan foOrNEyAP (omssoud sre oanisod snonupuos) qVd-O oumysydounny aumuoyy = popoou str yeadou (Sur 98-0P) AL 9pIwIOSOIN Zw 9409 WEEK uonisod Suns ur waned qwounrasy, Seppo sou-g a9 CGpzeyng) Aopegs [ENA = (ax) Kerx © sappery © umphys dope « suaig stsouek wiprakyoey, = SoZ04M vaudssq = surosdurtg stsoUD)s JENA, « uoneymdar peng « IW « (oro'm)asneo Hourttos som e-2.n]1Es IE POPIS YO'T “europe Axeuommynd yo sosne sempse 4 wwopa Gemma adMedina $$ Treatment warfarin is indicated if MS associated with atrial fifrilation. Surgery if pulmonary pressure>50 mmbg, Mitral regurgitation ‘Most cominon cause is rheumatic fever Other causes include(papillary muscle rupture in ML infective ventricular dilatation,mitral valve prolapse) S&SLeft atrial enlargement, pulmonary edema,atrial fibrillation is common in MR and MS Signs>pan-systolicor holosystolic murmur ,S3 in sever MR ‘Treatment medical ACE inhibitor and diuretics. If sever surgery Mitral Valve Prolapse © Mc valve proplem....may be normal variant. ° PM © Associated with Marfan Syndrome & Hyperthyroi © Signs>mid- Late systolic elick(increase with standing and decrease in supine position) 40 9M hi $$ Tricuspid Regurgitation M.c.c is Right ventricular dilatation Causes pan-systolic or holosystolic murmur that increase with inspiration increase JVP,ascites lower limb edema(as Rt side HF symptoms carcinoid tumor),Pulsatile liver. Tricuspid stenosis, Causes include rheumatic _fever,endoc: carcinoid tumor,congenital S&SDiastolic murmur increase with inspiration enlarged right atrium, increase JVP,lower limb edema and ascites. Notes ‘Tricuspid valve disease murmur increase with inspiration while mitral valve murmurs increase with expiratic twicuspid valve diseases causes lowe Iimb edema and ascites while mitral valve diseases causes pulmonary edema, Carcinoid tumors’ are asso ith tricuspid valve diseases but not mitral valve diseases. Aortic Stenosis, ‘Most common cause * In old age->caleification(degenerative valve disease) "In children>Bicuspid aortic valve 41‘urxollp ou nq ywsuNNAN UE posn FaxDO]G JoUTTEGD +429 s0'DHOOIG (anurana yours nq, stsousjs oqo se oures)ypeap appns ‘odoauKgeursunyeandsscy suiodunkgry suBts soiayte 3unoX uy yvop wappns Jo osteo oUTUIOD ISON, (queurmop yewosome) jerome (WOOHDAMedosmorpaey oanonnsgo smydonsodéyy-z ‘sjueeSeoonue pue orunpdumenue sopnyour jounvedy, wsyoquisoquronn, JO.4SH ose" (qpeap Jo oowerunp Kye 7p oan peay 9sNeD eD uonsesu09 200d 7p 2f>UTUEA YO] Pore Aqyedodmorpaes payenq-L oyorserp snus oporss = amssaud asing asvarouy agtnd yim pray jo Zu1gqoq: 19 PRA = run MO ySty St yOIY. (ANWant juyG-uNsMY) INULIN syOIsEI (amnpoaasind a8uep)osind Aupunoq so(sommepZ s2y0m) asmnd Susdepoy « Suptpan oo —- (eunssaid oyoyserp aseazoap pur amsseud o1joyss aswor9uE oyanp aanssaad asqnd apzay) azmssaud asind uf asvosouy sudig ‘emopa Suemouynd asneo we ‘wonoassip syesotedap' sonay oneulnot opnjour sasneo -wonenianday a0 Saumur og J AIBA = quouyeary, (Gnu onjersss uonoafa) anuumen syo3s4s Ape (aq yoiserp pur ‘oxforshs wsanyaq 2ousrayyip)amssaud asind ur aseas03p = ++-(snpey snsind) asind Bayst1-moig, ypeop uoppng Aqdonsodéy seynounusa Yor] ompry ura « (esyor0xo ups) adoousg VD 20) Ys13 10 pue eB suroydundg 7g suas, upon.Medicine —~ 3-Restrictive Cardiomyopathy Most common cause is Amyloid Rigid ventricles 4-Constrictive Pericarditis Most coramon cause is idiopathic Other causes> TB, sarcoidosis S&S-Right side heart failure (lower limbs edema, ascites, Hepatomegaly, increased JVP) Signs>Kussmual sign(Increased JVP with inspiration) , Palsus paradoxus(decrease of systolic blood pressure of more than 10 somhg with inspiration ADDITIONAL NOTES: ‘+ Normal Stroke volume =70 CC ‘+ End-diastolic volume (EDV) is the largest yolume in the leftt ventricle just at the end of ventricular relaxation. jection Fraction (EN) = Stroke volume / EDV (© Normal level EF > 55-70% © Heart failure if EF <40% * Congestive heart failuro-Pright & left side heart failure 44 | ‘Medicine + Most common cause of right side heart failure is left side heart failure + Core pulmonale->right side heart failure;Not caused by left side heart failure Causes-> COPD, Pulmonary HTN, chronic respiratory diseases + ACE inhibitor (captopril, enlepril) © Rest for heart falure,and DM(decrease proteinuria) © Side effects = Dry coughPswitch to ARB if cough occur(ARB don’t cause cough) + Hyperkalemia = Angio edema © Contraindication © Prognaney + Renal failure + Bilateral renal artery stenosis ‘© Drugs that decrease mortality in Heart failure are * ACE inhibitor ARB + B-Blocker (Carvedilol, Metaprolol, Bisoprolol) Spironolactone © Drugs that don’t decrease mortality in HF->Furosemide, ‘Thiazide, Digoxin 45ly “eyuaAysTEOY Squom E(mmepp ‘yawdeA) mpUAdompsyp-LON © AEH eKuworg (meepopN expoqeNy) mpuAdompsiga © seppore fom HD+ (weprespe, “ueuesoT) Gav © ‘stsouas Are [ual INET ermapepsi sung ea = kounarg = opeopumnu0y © umeaosd parearoap ‘Aqnodomqdow anaquip 500120 WCL = AuyeuOU pase1sop EINE MEOH; = 21 NUHL305 010N930 Brug. © wuspeoey + si poreorouy at09 ig» svopoapis 0 (qudepeug Tudoxée9) sonQIE BOY (Had Wes id or aarsuopedAquue seq)Hag Mt post ¢sey20Iq-eydTY + IMSYOS qu JOMOT STUOIID ‘seaeip snynasea peioydog requoy © 491A stmoyduss exuons(Bodse WEL + erupts wouounyskp TemKag upresdped raeyaapis © spo ‘wanoumyy, ‘spuosouie ouorseouords si pesraioul = sonomp Suunds +x 0 -¥28D poseainop “Hy pasvarnepE-opmurasomy o +28 pasearouy 4H paseaINPE ApH, © sonamq (2anypey our eynoe aene9 wea}srsous Auqse [our [BAW wl paepUIERUES S| sONAIIUY IOV o¥lonsenp £2 + en OHSKs E/T = amMssarg LOY USA = Dla (81 -10< (Om) NEUEN, 601-001 641-091 | 66-06 “6s t-0F1 ove rrpMedicine ——— # ‘Systolic Murmir | “Diastolle Murmur Aortic Pulmonary —_| Stenosis ‘Regurgitation Mitral Tricuspid | Regurgitation Stenosis Pan Sy regurgitation and Ventricular Septal Defect (VSD) Murmur seen in mitral regurgitation,tricuspid Pulsus paradoxus sever asthma,tamponade,pericardial effusion o constrictive pericarditis. Pulsus alternans seen in sover left side HE. ‘© Pulsus tardus seen in aortic stenosis(slow rising pulse) ‘© Pulsus bisferiens seen in Aortic Regurgitation,and Hypertrophic bstructive cardiomyopathy. + Wide fixed splitting of $2 een in atrial septal defect(ASD) * Continuous machinery murmur scon in patent ductus arteriosus(PDA) + Normal Beart sounds is St(closure of mitral and tricuspid valves) and $2(closure of aortic and pulmonary valves) + $3. seen in children(uormabpregnancysLeft side heart failure sever aortic regurgitation sever mitral regurgitation) Collapsing or bounding — pulse seen_— in (ARPDA, fever,pregnancy,aneminhepatic failure,CO2 retention,hyperthyroidism),which means large pulse volume. = Aortic Regurgitation causes wide pulse pressure while Aortic Stenosis causes narrow pulse pressure 48 Medic L-Typical vs Atypical 2-Community acquired vs hospital acquired vs ICU acquired pneumonia “Typical pneumonia are caused by bacteria and charachterised by high feverproductive cough(sputum with cough)and patient look —_unwell(toxic), CXR shows consolidation(lobar pneumonia) -M.cc is streptococcus pneumonia(pneumococcus)(also caused by Hb, staphylococcus, pseudomonas,E-coli,klet -Atypical pneumonia milder symptoms than typical pneumonia with no or low grade fever,dry cough(no sputum),patient looking well,usually caused by viral.fungalor atypical _bacteria(legionelia,mycoplasma,chlamydia),CXR shows diffuse patchy infiltration unilateral or bilateral 49SESH re tere ee PEE EEE SPE “suojounboronyy 20 aprroxsent 4q quanedino se paiwan oq ues astwuatpo “sonoiqnue wee] -€{ snyd apyosseur 30 auojourboxong q paren pue uonnmppe pocu vitownoud x9A0s Jo suis axour 30 z sexy uoned TH)Ayranas emoumaud 0; Supiosse ssnoignue qwoped ino 10 ywapeduy VO Jo wounvary, suorouey parq ut o’orur (sisooemsdomsd expydop Aue - suoned (Ory siseyza4qouosq’st y ousko ur euoumoud = yo. 9" setomopnosg- waned oogooye ur o'o'ur BIPOSaTN- moray SMUT uanggny SMOqTOY Ayjensh equOUIMoUd snaame suov000] Guoned sary wy eyommoud Jo 9-9-1) emomnaad apg st afdwexoQuaned pastwordwooounumy uur Aquo sooo) dun rus pM quyed ff IN00 AIADN- eycounond yesuny ‘equouinoud AW O Jo HOUT ay St (TvE)eeasy sepoaateoyouorg uo sorpog worsmouy $$ -saorpony (uorermeydsuen sod sypom g-p)uoneuejdsuen ysod quoned posruosdmooounuty uu anavo—_psourremmommnaud(Awo)snataopesouonsg- sivas ¢> suaspyyp ur euoumaud Jo ‘asnea uouTod ysour 1p si(ASU) SHIA PERISUAS Lroyesidsoy- AWOASY ‘StuAouape vzuaNU eT eyuoumoud pea4A, SypOM ¢ 0y aUgaoAXOp 10 aplorEM JuoMEALL, ‘UTPAUTE;YD soy WET stsoulieg §—~ emya'sse PIO. eIpSuTETYS-E apHoem yusunesdy, ApeBowoustds asneo ueo'(A3])Is9) HOR EUBNIaTe plo aanisod pus emsuE sBAjomoy YM payETD% euisedookurz apyosseu juomyeasy, 389} waByUE ouLIN sIsoUsEIC, areydsoyd pur u 1S paswausep smoys squyvoumelp pur emuounoud ya qwoRed UL jouoroy Jo YUNP)eoAEP TA poreroosse"(souruns ur oxou)mayshs Zumomipuos are wo paxinboe- eplauorsay-1 eHoyeq endiry oupewMedicine ‘Hospital acquired pneumonia(AP) “Pneumonia that develop 2 days after hospitalization for another cause. Staphylococcus aureus( m.c) and pseudomonas are the most ‘common bacteria in HAP If patient was on ventilator and developed pneumonia tis called ventilator acquired pneumonia(VAP) ‘Treatment vancomycin and 2 antipseudomonas antibiotics like imepinem and gentamycine. Aspiration pneumonia -Due to aspiration of GI contents in semicomatosed ppatient(intubation, vomiting of semicomatosed patient) -Most common bacteria is anaerobic(bacteroid,fusobacterium) -CXR finding usually ocor after 6 hrs of aspiration,and moast ‘common infilstration site is Right lower lobe. ‘Treatmentshould include antil that cover anaero (clindamycin) Complications of pneumonia -Sepsis,DIC,arrhythmia(atrial lure,tespiratory failure,lung _abscess,empyema(exudate pleural effusion),and death. Medicine slung abeess i ly treated by antibiotics(not drainage).if not respond to antibiotics then needs drainage(percutaneous or surgerical) Additional notes: CMV pneumonis diagnosed by BAL (inclusion bodies) andtreated by gancyclovir, -pneumocysts carini peumonta(PCP) is fungel,m.c.e of pueumonia in AIDS pati bilateral infiltrate and treated by (cotrimaxazole) sur when CD4 const <200,in CXR shows diffuse imethoprime/ sulfamethaxazole mycobacterium avium complex occur in AIDS patient when CD4 count <100,and treated by el count>100 ithromycin(macrolide)and increase CD4 “sputum culture is indicated when pneumonia doesn’t respond to antibiaties(not always positive) -stain for AFB(TB) should be done in upper lobe pneumonia and ‘pneumonia not responding to antibiotics. Methicillin resistant staphylococcus aureus (MRSA) antibiotic of choice vancomycin or linezolid. Sapooroso pray amtoon- a og (OUOMAH ASKAL | 9pIs pax Jo sturordAs eonpoud Qian Kourusiqeyy | sHEpseazid — 9AKo4NySUOD- a (owospus cuorsnya yeanayd | w'stsoqun>'feuaa)emyreyue8iQ ferous uy 99°m0 au SI TH go< 90> (aaiord yBuarepmxa pur (mayoxd mo[) ayepnsmesy sopnyoUy (qd py)xeromoydys‘(poog J1)xex0youIIT(49yeAK SI Ping J)xesomospy pareo‘aords yemayd ui voRBTRUsA0 woysnie TeaNafal aE, Jo ated ax] soo] 19900(-) wIEIE sup sqequseyes eyexesoyy | 09 Vou pue sieysnjo ur 1o903( uss, stpyauiapids snso020/{qdeag. GpReTEOS pue sioysmyo uy yooos (+ ume snaane snas0s0[qders, i ‘snaD8s0%Mip Gi JURE ‘suasosoumTITU ‘anes teas wEapEq urejoeqoze}-urroesodid- (eiaexo gong] you nq sarsexoordts)souajounbomy-g jouodegreos SUNprZEy20-¢ punidyao-¢ vruoumoud s9aas Jo suits, saBueyp stays [eoueg dOD YO AH MH SAHIGeUIOe-Z nue senoMTopRasnUy VETOES ZO 5 OISTOES opto cpaimandanayy 6a aHOsKs-9 ogenes StLQUHey | 3K 9¢<030-] —Medicine. Diagnosis 1-CXR loss of costophrenic angle 2-Aspiration of the fluid and test for protein, LDH, bacteria to determine if exudte or transudate CXR SHOWS Right PLEURALEFFUSION ‘Treatment according to the cause -HF —diuretics,empyema needs drainage(chest tube and anti iotics) -Pleurodysis in case of reccurent pleural effusion which means introducing tetracycline or bleomycine in pleural space to obliterate it Surgery for multilocular empyema either by thoracoscop or thoracotomy 56 ce Medicine Notes = ‘chylothorax has white color (rich in'TG),2nd With exudate features, with TE>110, pulmonary embolism can cause both exudate and sransudate pleural effusion Airborn transmition(from respiratory droplet) primarly affect Jung(puimonary TB) Caused by mycobacterium TB(Aerobi spore forming,has high lipid contents stain weekly (+)in gram stain Mycobacterium TB also called acid fact bacilli(AFB). ‘TB usually affect upper lobe causing upper lobe cavitation. 15-20% have extrapulmonary TB which is more in immunocompromised patient and childrens,and genitourinary ‘TB(kidneyand ureter) is the m.c.c of extrapulmonary TB. primary sites for TB inchide(ung,genitourinary,bone(m.c in vertebra and is called potts disease)Gi(m.c. in ileocecal region),brain and meninges,pleura,tonsils)‘srompo at, sdnos ystx Moy ur mag [<— “up aus ‘URIP sso] yng auospr09 wo UTEd‘smAk FouoUPHNS'sIosnge Sua [Al pute ssojWoy(ioyoauos Mau) gdd eanesau snoraasdssy0M ames wyeoy oyy| dnosd ys apeypowLiopuy mE uTTEQT<— (qquow | wemp amet sop Aup/BarcT oaponpord aes smrojdusAs par sais ‘Funy amp Jo Aponseye ayy soonpar osye yf “Burpeasq Suunp (Gurjows Jo Axoys1y Zuoy Aypousn)o-o-u ayy st Bupfous SpIXoIp uogies pu uaSKKo Jo aBUEYDXD yp ZOE Iq) ad -ouiy s9A0 asi0m Afoayssaxoad sja8 Ayqensn pue EIqeLEA var soupins oy soonpar STEM souds Ie Jo VoRONZISeP eHL- you)ojqissasa4ay St wonEuN] sm “wapse or iseNUOS UT stres x0 Jo UOHINAySaP WEA ‘saomauosg yEUpULL, oy OF [eISIP (eoudsxp) yrvasq Jo ssouyz0ys Buysneo ‘sétm aif WOH pus 0} aTe Jo MOY ax JO BONEN & OF SPEOT SHHL- sooeds aye axp Jo ywouSsejua se pouysp st euascyding- pamonie owooaq sxvaute euroskqdg-Z aun YON UE sBum] amp Jo sosvosyp Fupsrxa-09 AyuouROS ‘umjnds ypu ynoo v Baysneo put sete Jo med v ‘euiasdura 30 spryoucig a¢toayo Jo SouSKMII0 SU (G45) 2869514 Kiewowmng sanonnsag o01H) unin snonua x0 st 9224) YNsorv Sy “Ava ox Jo spuETS ‘snoana pur s][20 191908 aip. go (AydomiadAy) 2215 paseaxour pur (eseydiodq) raquinu pasvaun pasvassap 220 AM PUP OTL: saeak aannoasuos omy J0f ‘avaX & Jo suMOUT E JO} B08 UL poUYsp st SHUG [NON « E stsorqyy Suny asneo uro rey Kdezaqouroup st molow dose 02, not 100% 02 Note: nergies are better than B2 agonists in COPD 'B2 agonist is better than Anticholinergics in asthma Signs of Hypercapnia (increased CO2) which can be seen in exacerbations: Headache, decreased conscious increase intracranial pressure,papilledema, coma, vasodilation, warm extremities ‘Tremor (asterixis), large volume pulse (collapsing pulse). 68 i | Medtetme Asthma Is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms(unlike COPD which irreversible and not variable) reversible airflow obstru airway obstruction in asthma is usually reversible airway byper-responsiveness and bronchospasm increased mucus produc mn (increase mucus and gob) cells) airways edema and smooth muscle hypertrophy increase inflammatory cells in airways (esepi 2 types Atopic" children. Increased IgE Non-atopic>> or = to 40 years/ normal IgE ‘Causes and Risk factors It is thought to be caused by 2 combination of genetic and environmental factors o{HUGH Ee BONE Pa {Yoys pur UOSRUOD [E10 30 Sep a9 wos payequ as0p WAI | 94o9>| Sep somry | no _ytom, senas yequoke za Simae pwo voys pur) 9608 trosquoe paequt asop wot] -09| —>eomyim<| Ap | _arapous SI 2500 | Ta moe ows” pue Appaniou| — Syop ou | suaisod Lwostuo9 paTeyUt aSOp NOT | %608-<| Inq _GWOUNe<| mq ame PIAL DBT su jsmote ze Sumae noys | 94o9< sponge | yommat puoweany | Tact fowatay | Gunas woneamnsseL) Guoned vunpse ‘ut ewusOU)-sasme9 sOYJO [01 0 Ng SISOUBKIP 10} YoU AX, “TAAL aseaz09p pu qdoned vurgse wr wisedsoyou0rq sonpur — (atiautjoya)outfooeyeurastazexa'ye poo so} auayqeyo asinaxo"S9] 9Bu9| eyo Ou!Joo afusqeyo sm ploa apnyou(pasn Sfows)sys91 INI sstuode 7 Supae yo Ys yim ungan Bumopoy (LAKD MOY yead Jo yuouonoscuy 9471 0} = 40 TATA ANeuonds « sysouteig (suoreqiooexa yo 29° 2) sf wondaguy) wuNpse ussioM Ue WEN AroVeNdsar voddn aq jo. suonoaywy jenaieq pue sama qog » i sypeHe ome Jo sme WoUNHOD B ame sauMyrag “suaauaTe uted “Burjous Jsnp apnyout woreZIeK> 0} pea| UeD IBM siOIoeF OWO]] wogeqnorxy © Joa} Kat] pu umazoa se yas aswastp o1dore Jo A10NSIY we st wunpse Buydopaap oy sovey ys ysoBU0Ns oy, te pfoo 20 asioioxa 0} astiodsar uy 10 (sfaAey auospi00 Mot) SawsouL Ajteo ou U1 Jo ABM ye asroM YO axe sug « ‘SunyBnoo pue ssauysiy ayo “Ipw9.q Jo ssouDoYS Buyzooym apnjour eunpse jo suoydurXs wounMOD « smojdwidg pue sudig {snyongouoaq) POOUPHMS Uy MoNIaFUNSAYD raAastKysaqo)sIO}2F SLT IaKyO- ‘wungpse Jo su asvarour Sanjouis peared 10 Soueutfasd Surin Supjous- ‘wUNyse 10) YsHaTe (ADT asva1ou), acy are ty 2900} Aer sostadt | OFM EUIOZe STUY O°BIO]TE (AOE ys ysoBuons)ABioye pur sasvasip oidoe ur a0w irMedicine Asthma exacebations Acute attack of ashma could be precipitated by Infection(m.c.c),smoking,dust,old furniture, pets,pollens,strong odorlike perfiumes,cold _air,cxercise. Drugs(NSAID,aspirin,B blocker) Signs of sever life threatening asthma ‘amental status change -hypotention<90mmhg peak flow <33% cyanosis -arythmia -silent chest (no wheezes) -normal or high C02 -PO2 <60 or saturation <92% -RR>25 - inability to complete sentence in one breath —use of breath accessory muscles of neck -Note thet asthma usually has low CO2 level (hyperventilation ‘wash out CO2),but in sever life threatening, asthma because of sever bronchospasm CO2 not eliminated wich result in normal and then increase CO2 -also no wheezes(silent chest) in sever ashma due to sever bronchospasm Medicine Asthma medications Quick relief medications | Controller medications Used in acute asthma attack to | Not used in acute attack but used to abort it decrease frequency of ashma attacks L-short acting ——B2 | L-long acting B2 agonist(salbutamol.albuterol) | medication(salmetrol,formetrol) 2-short acting | 2-long acting anticholenergicsGpratropium | anticholenergics(tiotropium) bromide) 3-methylxanthine 3esystemic cortisone ecg bees Scrafiricukast,montelukast,zeliuton 6-sodium cromoglycate Status asthmaticus is sever life threatening asthma not responding to routin short acting B2 agonist ‘Treatment OXYGEN, Corticosteroids (IV), Adrenaline (IV),Intubation Prognosis of ashma -The prognosis for asthma is generally good especially for children with mild disease -54% of children with asthma no longer have the disease after 10 years,(euajaeq 2m aq st senomopnasd)uonsazut say wamooar st sismsorjouorq ut uorRoydutos ow (jsaq)ue9s 9 voRnjosar YN sJsoudeI Oye SEE IDVATP 3,51 SupjoUs- shuyye plowumors wr azows- oyoeg su St ABATE ‘swoxpuds souSeaey paw wISsUPYsKp AaeIID'sISOIQY, onsfo'siomm §—-&q_—oOMSqo‘gL —_uoraaTu)saseastp somo 0} Aepuoses 30 peUaduod aq pros — sesnuy (@Bungqnyp pew asnes 1,uop GaOD pur emrse)BuIqqnp> Tru'sezzaqasis60 means CF ‘Treatment Antibiotic prophylaxis, mucolytics.physiotherapy.vitamin KEDA supplements,pancreatic enzymes supplement....... symptomatic treatment APE is a blockage of the main artery of the lung or one of ° its branches © PE most commonly results from deep vein thrombosis(DVT)(but can occur without DVT) © Mesite for DVT. ileofemoral vein6 (sxopaostp stsKjounngy /ooounnseyd pue vruourgscoowoyiodsy ‘KouaDgapHY wquompnne ‘dousyysp § marr * Aousfayap 2 ur}oxd (uomsEEOD WoRMPPT A We) LYNdoqwoN onoWDD « (gat &q paysai0s you E14 aseas2uy Pav'suemosnex —oapray‘eqadoyAsoqmosp‘uoysoqe quaanas0xGd\ LAC waimaoau)owoxpuxs _Speqnue —_pidyoydsoydnuy = ‘praarposjod pue ronenuscuosouny woneapsyacl asnedouaur‘uondaoexuoa evowoy SarmTeWwos-ussoNsT « (Quemnieos-o1d o5y2) spoura ‘(quejnSe0o-o1d ose) Aysaqo. “{jue{neoo-o1d ose) Aouenaxd “ami Aasfms saye) uonez ounay sHoEM ISAT Oo (AAC poseaiout) aanssaud snouas anjnnt posteyy (23) spunos s3e0q puosas pro quososd seumauuos s] uorstyye [eana|q “woudiyor; woy(ZQQ MOpsIsopEHTE Lroyexdsoyy ———ourpapy 8 ‘Heap wappns pur sisoundo se yons stBis sonpur ue sasea azaAas axoyy, sishidouay poe ySnos <(Surqeaq 4q pouesiom) amyou ontmoyd Jo ured ysayp ‘(@umpreasq prdex) vaudéyor ‘roydeads yur-(qea1q Jo ssauproys) voudsfp yasuo ueppng ra Jo smoydurks 2p sud1g suesquiour jo aumydnu pue Araarfap sayy wsyoqura sjoramy (anwap)axnjovsy 40g BU0[ WSO sama90 mIsHOqUD 18, (aopsosuy amy esyua> Zapmp Meap vappns jo y>m)uoMsH; om JeENUID TeIAP[OqNS yy (CON) esvasicl wostey €-sI201, ° ° ° uy sana90 wisyoquia arty * “peey iyonsn ping onoruume ey ‘ap Jo uonezqoquis amp 01 anp axe sasea Jo uoriod tjews “ay 10) aan st §0 a9[ddog pur'ga Jo S14 HBt Ww 9m LACK TeMNEXOSd aI sisouSerp SF 40F aamisuas you st sr sayddoq pue'gd asnes oF Apoyypon ase (ie> MOF9q) LAC [ISIC ° °-For PE pulmonary angiogram is the gold standard but not routine(invasive) ~CT pulmonary angiography (Best initial)( contraindicated in renal failure). -ventilation/ perfusion sean in case of renal failure and allergy to contrast. -for DVT do Doppler us (best initial test) if not seen do venography (best,definitive test for DVT) -Norma! D-dimer is enough to exclude or rule out the of thrombotic PE(sensitive),but positive d-dimer don’t rule in the disease as d-Dimer increased in many conditions also(aot specific) -BCG:sinus tachyeat the mec.finding on ECG. ~The classic signs for PE on ECG are a large $ wave in lead I, @ Jarge Q wave in lead Ill, and an inverted T wave in lead II (S1Q3T3) 80 —— el ‘Mesieine = ‘Treatment -Anticoagulation(heparin and warfarin) >d thrombus but prevents its progression.—Target INR is2-3, dissolve ~ length of treatment is 3-6 month in provoked (occur with risk factor) DVT Or PE,6-12 mont mut risk — factors)), if Unprovoked(occur in patient wit fe long in case of thrombophilia ‘Thrombolysis: (Streptokinase, urokinase, Tissue Plasminogen activators-Dissolves thrombs = used onl inBlemodynamic instability->low blood pressure <90 pressure. -IVC filter used to prevent PE in patient with DVT and has contraindication for anticoagulation(internal bleeding) -IVC filter not used for treatment of PE(only prophylactic to prevent PE) -IVC actually increase risk of DVT -thrombectomy in case of PE with contraindication for anticoagulation,eae SPE eq pue ued mol ‘mmsopou ewoypls) smoupuks war8jory ‘Ayedouspeydug — eruoue's ‘snumpre'yinos Arp ‘onggey ‘onsea om suzoxdwAs uounuo3- uvir0 Kuo paye ure pur asvasip Aropeurureyur axurapshs & st sisoproores- oruosyp 20 (quowwan 103 paar out) opwusoydunse 99 Key: smoydunkg 79 suBtg Aysnoaueyuods dn sxe9[9 40 saacadurr non-caseating granuloma -Bronchoalveolar lavage(BAL) _ imerease lymphocyte with cparcps>4 **(hypersensitivity pneumaonia increase also lymphocyte on BAL but CD4/CD8<1) Chest X-Ray changes are divided into four stages © Stage 1: bihilar lymphadenopathy ‘= Stage 2: bihilar lymphadenopathy and reticulonodular infiltrates ‘© Stage 3: bilateral pulmonary infiltrates © Stage 4: fibrocystic sarcoidosis typically with fibrosis > ground-glass appearance -inerease serum ACE level which used to monitor response to treatment. ‘Treatmentif asymptomatic no need for treatment. Corticosteroids, prednisolone, have been the standard treatment 84 ‘Medicine Prognosis ‘The disease can remit spontaneously or become chronic Increased risk for cancer (lung cancer) and malignant lymphomas Good prognosis Bad prognosis young old Fee Stage 1 ee Stage 4 or organ involvement | white Black Erythema nodosum or Lofgren | Lupus perinio syndrome _ | Obstructive Stedp ‘Apnea (OSA) ~Most important cause is obesity -Can cause episodes of apnea during sleep -Symptoms * Snoring * Day-time sleeping (Because of poor sleep) * Sleep apnea due to airway obstruction ° Complication Pulmonary HTN Right side heart failure (Core pulmonele) 85-dund worreg oMoveNuy pur auUEMNGOP aAtF yOYs oruaBorpI UL O 128 J uonelnueA jworEExDeUT 70 oHEMUIA amssaid oanisod © aurydiom- (appurasoing)sonemp 0 saiap sp uomisod qysisdn o squounray], pee SEE EEE spoys aqua8orpsto- mypaeapeag 19005- oa pumyycuae a fsouomnd- §— apmEpe YaE woe BanSox asgea an10%- uonendse- sqy pur sisdas- woeyBingos ppeopno pryy- opsaysunn | PUP SISOMDYS o4peA EAU oojg, apd anys qeuas-) (o-w) ant opS rT ‘BUIapo Peet Arwuouynd aqusforpres uo] varspe Amuownd oxzaBoxpse-y (ANY op>tHoSorpa¥s uoM JOCANV)pAded onemine [EY OOT<)>NWeHoIp.Es epnjouy- Sun] aup jo jHNS!AWH: UL PENI meme ai 98 TE vuigjse Suuayeanp ap] J9A9s"uMIBATOKD ee snyoad)sonmemonge 14) creuousnd’sigreanpseeunnse ssoyo'woneypucaodse'sonoamu'sHs4o03q paar) SHHOHID | ayy uon‘eruoumsnd‘emrasiqdur | some, some aimed pag | aay amaxod hy pares oy (woudeanedkzo9 {op Moy 30 youaIOT | SSBOIOUL YIM ZOd 95891997 TPL SyEUMIQG>ZOqaseaz99¢] TwowauaA aredunr ywip Aaruu0yop soy 10 oHaNASGO 0930 jyenjouorq soA0s 30 uoneinusacdéy | ysemscemme uayed ApoANTwaI 1 anp soqpl2 200 12 0 USE ON. ‘pls uoneyauonsady, op Rroweaydsan 7 2K, anges Goyeandvaa Today | © Gapemney Aayeandsoy Comssarg Kesanry aanisog snonmmuod) avd [oyoore “Bunjouss proxy (queqrodunr ysour) ss0] 3319.4 qususBeuyy © doas Jo moy | ut woud $0 soposids Q]< (AydexBourossjod) peas daoqg sso o upayMedicine -Lung diseases that occur due to long exposure to certain substances in certain occupations, which can cause lung fibrosis. latency period 20-30yr. -Include:silicosis(m.c),asbestosis,beryllium,and berylliosis.coal worker pneumoconiosis(black lung) -all of the above mentioned diseases affect upper lobe except asbestosis which affect lower lobe. silicosis asbestosis Coal worker pneumoconiosis Lobe Upperlabe | Lower lobe (mainly | Upper lobe pleura causing bilateral ickening) CXR gg shell | Bilateral pleural | Less fibrotic ‘calcification | thickening and pleural | than silicosis in upper lobe _| effusion(m.c) ‘Associated | Increase TB | Strongest risk factor risk risk 30 times. | for pleural ceancer(mesothelioma) More than smoking occur after 40 years of ‘exposure Medicine Rare diseases that charachterised by increase eosinophil count in airway and hung parenchyma Causes, 1-ascaris infection(loeffler syndrome) and other helminthic infection. 2-allergic bronchopulmonary aspergillosis 3-churg-strauss syndrome 4-eosinophilic pneumonia S-drugs and toxins: like inhaled cocaine, phenytoin, tryptophan,some antibiotics) Diagnsis “Rare diseases so should be suspected in any patient with respiratoty problems with increase eosinophil in CRCor BAL or lung biobsy -Remember that sarcoidosis and hypersensitivity pneumonia increase lymphocyte but not cosinophil on BAL so are not Eosinophilic lung diseases.mye e9y 10A98 J) smn mopoTOBSAS asind Sumpunog » eipmakyoes, « (waxprryp wr woydwaAs‘oM) JOE = anes eq Jo swoxduAs pue ‘s8aj oy Jo uonRorpnE|S WONT] = ‘wurde ‘suonended 6 (eaudéyoez) uorsaxa wo vaudskq so0d “2 “ssounpog smordunss 79 wig © produ 0} speoy wumauy “sonssy, oq) 0} sBuny sy Woy UsBkxo sox AjpeuuON MgO[oWI]] o poor om tH (GH)MIoPBourDY 30 sOgY Jo 1oquNU ay UT aseaI2aq_O ——— suqerpydous-f apis parooe amp re Supeams ou)sisoxpAque [e (geind yyemns)stsoroun pexayerisdi-z_stsord pezore swmordunds pure suBtg ~ (zoum) ystooued pajfes)soumng Suny yeatde £q worssardusos 2 amp uonounyskp onayredwAs yeorazo9 Aq pase Siaiipelliiion j “asmvo Sutspopun oyp ean = WOMBEDAL sosseur jounserpau (ou puosasyemogdardy ‘ (%549'9"ts)sasuE9 Buny:sasne]- oypepeaif(q 1) amnssaud erumioeur asvaxsur‘euiopo une jerpey'susA SONPANPSU PAUP GAL —aseo19Ur ssunojduids pure suis DAS JO Hononnsqg- pias OAS)¥AE euad zoniodns oupaIWMedicine: ° ° specific signs Koilonychias(spoon nails),angular stomatitis, glossitis, (een in iron deficiency anemia Jaundice (seen in hemolytic anemia) Bone deformities (sees Jassemnia major Leg ulcers (seen in sickle cell disease) Anemia workup: CBC (look at Hb level,mean cell volume(MCV),other cells( WBC. platelet to see if the are pencytopenia or not) 4 parameters (RBC count, hemoglobin concentration, MCV(mean cell volume) and BDW) Reticulocyte count{immature RBC) is the measure of the bone marrow’s activity (increase reticulocyte if bone marrow is active) iron,ferritin,total iron binding capacity(TIBS)vitamin B12 or folic acid Blood film Medicine: According to MCV (normal 76-96)anemia is classified as Mierocytie(MCV=7 6 Normocytie(aormat me) “Macrocytic(mev>96 Lilron deficiency anemia IDAGm.c anemia) -scute blood loss of chronic 3-pemitious anemia 2-thalasemia ‘A-liver diseases(cithosis) 3-sideroblastic iseasescithosis) snemia S-alcoho! Alead toxicity 6-hypothyroidism 5- anemia of chronic | S-hypothyroidism | 7 iseases(in 25%) drugs(methotrexate;phem alproic acid cotrimexezele) IDA is the mec.anemia -megaloblastic anemia is macrocytie anemia that result from vitamin B12 or folic acid defici -methotrexate,phenytoin,valproic acid,cotrimaxazole, all can decrease folic acid resulting in megaloplastic anemia, -Pernitious anemia(autoimmune atrophic gastritis): ~ is autoimmune discase ,antibody against gastric parictal cell (normaly produce HCL and intrinsic factor(IF) H be no IF( which normaly complex with VitaminB12 to aid in its, so there absorbtion in terminal ileum)...cesult in vitamin B12 defeceincy and megaloblastic anemia. 9355 —- eee vorrenussu09 upopisouray Monenr auog | sodasar uLysUEN 9]qnjos oxdooqnonar Oe won umey AW] MC uuysmEn saseazoap soseo1ou Var 1 sqe7 doasopua sadn pu Adoosouojos op os Buypaajq JO a1uoKyS JO AONB Plnoys nod‘ VT] MIA qosard 14 OG< Juaned Kuve OON, qwounzan vor, Teo 0} qweISisar YET Sasne9 (aseasIp oe1J90) HONquOsqRIEU-p wou! yo pueursp posvororg Aourusorg-¢ (UONMNUFEAI)ROIP UF UON jo ETT 109 Buypasyg eunsaimonseD ‘siagin ondod ‘spowod Aavay)orou sop poojq s1oxy3-1 asme Weg: erie so adi woumst09 yoy RG Husysg dol -asvaxoap aLXo0mnapar 0s aseosD9p Hoponpoid Mose auoq wnuaM onsuqo|eBeu 10 Yq, uF suompata 6 “sisoroopnonos wt SunIMsat os ayesuadU0D O1 EY ‘as0ur sonpoad 01 Mozreur awog ayeanse AteSoumousyds 10 wrunote onkjowoy uf se woponnssp Dey eseaxour'SuIpso|q anov- ange JOU st ANOLIEU 90g TEIN SoPRO]pUT ayooqHOTF aseaIDep- ‘anoe st MOTEUr ‘au0q wy sowoIpUY (sISokooMONe)oLMooTMoNe: asvasoUt- 9%C> St pooyg Wt arKoo]nionE4 Jo [aad PeUIOU- -YNRL tp Sutaourar Aq Oe mye opuy (snojonu you nq YN Sey HOM Dey ame) ayfooqnone Jo WoIsIOAUOD st uOHSNposd Jey ur days yeuy sraoyds q paronnsop cjeunou rep sae pue Aep oz st weds eT DER “YNQT OU pur snojont ou sex Ser (AaupHy ur paonposd unarodosm sve Aq pareymums)woueur 2u0q ur paonposd st DER mmonanpoad Dnt “(3 sonmuow osyereuDyeyody st spuoned erwoue sonrmuad ut 71q waa Supams oye weydord ayspono9]9 ous Suo] apy pur (jes0 jou)uopsafuy 71g unUTETA JuOMNTTAZL aaoutea auxyseS Jo st osvaxoU erutoue sonnruod- 0p96)-Decreased RBC count and hemoglobin levels -Reticulocyte count is decreased -Macrocytes (larger than normal RBCs) are present -Hyper-segmented neutrophils on blood film (Neutrophil 6- 10 lobe, normal level 3-5).paamnbow SA 9H8uaH ~T wouLoyisse|y ‘SISAJOUIDY 20 389) OALISUAS SOUT are FYCTT pure wigo|Zordey- mageata Azuun jo souasqe pue uaSouriqoi Arent aseaouy (waoydod BRAT] WOH eorpanel apnyoxo omuonouny saAqy [eUON = sso] St ADC eIMASSETRILL, Wlaoxe [eUNION S! AO. (s1s01400jnonoa) ano aKoojnonax pasvexouy ‘wqnayEg 1omIpUr paseaxoUy (eseuaSompdyop averse) HAT waru9s paseasouy ungoydordey wansas pasvasoaqy sqrt © ry Ste oy ‘suoHPDH UID uLIo}-Fuoy epNoN red Jo ystE oy) sosvaxour pur aorpunel 07 spra] sf]99 par Jo stskjowoy ayy- (eruaue UO UL uaasjaoomonas pasearoME <-sisoLkoo[nonoy- paumboe 10 paycioyur se sor posse) (weds ayn Dena aseazsap) siséjomay or anp enuauy supp “pre HOY Waals aq pmmoys stsSfouray so ym waned fue os- uaAt you Jt Aoutaoayap UL yynsox wea pue paseorOUE st plow o1foy 20F puBUIDp os'snp, Jo} eqesuaduroo 0} eatioe si MouEUr auOg ERMINE sNAoUIOT CI veuadoyXoued asneo 1.U0p VC ‘08 pue voyonpoad Sey 10F juedun st uo ynq‘eruadoréoued asnea tea Aouraaayap aA3s os (siojere|d Se ‘OeW)sTIO2 Poor 8 Jo sisampuAs soy ueuoduat ore prow ojos pue 21-1 UUM! A- -Kouotayop ploe 91}OF Jou INg AauaKaFOp ZIG URMENA WM asearoM CyPApIe omMOjor Apa ‘aYONS pure (LY JOF YSH St YI [Pao MISKoowOK, aseauoay AousIoaJap TI WUMYA puvsousteayap plow ovoy- wandompawEN opraTON pe aioidpea‘usoxsuaydoxexonornong non qzosqeruruonsasor snap (ps4qous2q stmomoquyuueWard)paewep asvoxsuy 'sqp[eUE]OYOOPE'uOREAUPEYA, ‘oe Aan ;oajep Zr wNUREHA go sosmeg | (YSWE>ASUDIDIQ}Op prow oMOp Jo sosRED torreGenetic or hereditary acquired I- Membrane abnormalities | -autoimmune hemolytic anemia Tike HS. HE -microangiopathic hemolytic 2 Enzyme defect like | anemia(DIC,TTP,LUS) GOPD.pyruvate kinase } pyr defecei | ee -infection Tike malaria 3+ Hemoglopinopathies Hike : SCA, thalassernia -prosthetic heart valve also can , cause hemolysis. “SLE 2- Intravascular (RBC destroyed inside blood vessel)VS extravascular (RBC destroyed in spleen)hemolysis Intravascular hemolysis Extravascular hemolysis -prosthetic valve autoimmune hemolytic, -GorD -heridatary “PND spherocytosis(HS),0r eli ssis(HE) Microangiopathie(DIC,TTP,us) | UP Acute hemolytic reaction in incompatible blood transfusion 100 Presi =eeeeeee eereeECeeeeeeeeeereereeeeeeseeeerees eet ‘Aereditary spherocytosis (HS)Heréditary elliptocytosis(A) -autosomal dominant -defect in RBC membrane called spectrin so RBC shape become spherical -RBC in HS do its function in carrying O2 normaly but when recognized by: spleen are destroyed (extravascular hemolysis) -Complications Kemicterus in neonate,GB stones,folic acid deficiency. -DiagnosisTest osmotic fragility(hemolysis in hypoosmolar solution) -Treatment if mild observation if sever splenectomy at 5-7 years. -pneumococcus,meningiococcus, Hib vaccine should be given at least 2 weeks before splenectomy -any chronic hemolysis patient should be given folic acid(vitamin BO),sc ur Sunmse: wo ue oy MOY pool raiser ue sonEmdes JORNSq s[[99 OPIS -(woydarks su)s|sHO aAIsNIIIQ-0seA- swords asi ay St SHIP pue seBug uy Soyoms pur ured)sqyAEp TUM (UG Ie JouIAIG Ye s~pLOU! g-p Te pus suo\dWAE- surojduidg pur sudig lo steak (95-cp) €Aourroadxa ayt| aBeso0y- (11 suosomony) mgofoury go ueYD MgO aH WY uONEIME yuOg- (edeys appors “pedy) Seu podeys sqeunouqe pneumococcus, meningococcus, Haemophilus influenza(due to autosplenectomy) Aplastic crises Triggered by parvovirus B19 which suppress bone marrow(ususlly active in hemolytic anemia to compensate),result in sever drop in Hb,and reticulocyte count Complications i-Overwhel post-auto-splenectomy infection (OPSI) © For encapsulated bacteria "Streptococcus pneumonia * Hemophilus influenza (Hib) * Meningococcus oie ieledbhaassee tae 2-Stroke 3-Cholel sis (pigmented gallstones) and cholecystitis 4-Pulmonary hypertension 5-Priapism (erection for > or = 6 hours) and infarction of the penis 6-Leg ulcers lary necrosis in the kidneys and Chronic renal 8-Avascular necrosis of head of femur 9-Osteomyclitis (bacterial bone infection)>cause sal Diagnosis Hb electrophoresis (best) 1Lif show increase Jevel of HbS>70% HbF<30%(in sickle ceil anemia) 2-sickle cell trait if HbS 40-50% and HbA 50-60% 3-HbSC if 50%EbS 50%EbC 411bS60% increase HbA2 HF <30% this HbS -B thalassemia Notes -Hb electrophoresis shouldn't be done if patient took blood transfusion (wait 1 month after blood transfusion) 105£0. “sysSyouroy ut yon yomyaa(oraryosu zqst o1'(ergnqos) VALI cra ome 3ye {uous p mood exmoue yoo appus poe BIMASSEE- jo suds o5- ‘sqjuous $-z y8 1n900 [WAFL O1 TEAS PUE AqHIAOS SeH ste YoULION M65 EeaAHT CoS'L6<09 PIOUS HORM) TVAH 5: GE AIMpe feuLoN :s0}0N wosasaER, | mosnem ouoq ou0tU sof [:iaag “Suonmnur wuDssom oxy ssjaiTe Mog JE | eTMOSSETEUT, ‘expounsiuT ‘sunroy ours pure 1ofewr uo2Mu3q ayetpomssquE uorpUOD y | eruDesEleLL, CASLE) TY EIgDFBOMATT WE BSEEISP Bus « pur (o66'¢<) cv mMgorRowa}asearouruauTeAN Joy | psou ovonewoxduxse iq xo} ADW “HuAUE 160.0" 29 AYNS TEM ToNPIAIpU vonBMUT wgOFs-A eyo suo | rMassEIER, wondnaseq aN sofem erurasseye B39q TALS TAPIA ‘SulOs Joy aanemn oq ue syMe[dsuER MouEr uO © USIP sor (omen) sour oraosseyerp pu ‘expoxuoyot equssepeyy ‘sofeu wiusseyein :sumuoy eM Sout (erq018-4) 11 atosoworyo wo owed suOREINAL * ugorfouay Jo sumeyo w2q om Jo sIsoUUAS qWUOSqe 0 paonpsy ermasseley ]-e)>g, (11 suosomonp)emasserep mag pu(g] auosowosys) eydyy summoy toler Z ‘uorfay uveuezoupayy UI a70u!- (Mo} ADIN) 2nK0010- anissooas fowosoyny- So entasserea Te (eaneins opt ONY pv snoqmapo ane Sout, ig say $THONS aIp ant 130 | ue oVp as0qp pur ‘syoref sdoupdyorom wy aR MEAL | Toler Rae ao] swoydushs roatg “(euregp J s1zamex}a1) 11 WGO(BourEyL poe -seeosip HY uIgo|BOuDy] poles st UONIpUOD aU, ¢ quorodonpks jaunow Auwse ywaned ust wae omen) wrunasseyeureqdye poffeo s] worpuOD STL Sopa weps spe ModMATe emo ued 01 xfnous qdre amy, ayo youoRANE sas 1 eee ‘papaye | comnossojern nude jo wondupsoq| sofaitv fore souod wgo} erp