Note

💪🏻 (Injuries of the upper limb) ⁉️Fracture of the clavicle: this bone is easily fractured in children, and almost united rapidly on conservative treatment, without complication. In adults, it is caused by fall on out stretched hand. The outer fragment pulled downward by the weight of the arm,  while the inner fragment is displaced superiorly and posteriorly by the pull of sternomastoid muscle. 🩺Clinical feature: the patient presented with pain and deformity. Careful examination is needed to exclude neurovascular injury. 💡X ray: usually standard AP view is enough; but sometimes, CT scan is needed to assess the displacement, shortening, comminution, and non-union. 💊Treatment:     NON-OPERATIVE TREATMENT: is by arm sling immobilization for 2-4 weeks followed by gentle range of movement and exercises. This non-operative treatment is indicated for: • Non displaced- mild displaced fractures • Stable fractures. • Pediatric age group. OPERATIVE TREATMENT:  it is done by Open Reduction with Internal Fixation (ORIF), eg. by plate and screws. This treatment is indicated for: • Unstable fracture • Displaced fracture with shortening more than 2 cm. • Open fractures • Displaced fracture with skin tenting by sharp fragment • Vascular injury (subclavian artery or vein) • Floating shoulder (clavicle fracture with scapular neck fracture) • Symptomatic non-union of clavicle fracture Complications:        Early : (rare) injury to vital structure like brachial plexus, subclavian vessels, or pneumothorax.       Late: non-union, mal-union, stiff shoulder. #ortho

⚠️Notes about Bed wetting: 💢Bed wetting is normal below 5 years of age, mastery of nighttime continence can take months to years and boys generally achieve this milestone later than girls. 💢Chronic constipation can reduce bladder capacity and contribute to urinary incontinence and stool burden can be assessed by abdominal x ray but it is unnecessary in the setting of soft regular bowel movements.. #pediatrics #اطفال

⚠️DKA⚠️ It’s one of the most common presentations in the ER and it is metabolic disorders due to acute insulin insufficiency. ✅PATHOGENESIS: Diabetic patients exposure to a stressful event leads to ⁃ Insulin insufficiency ➡️ hyperglycemia ➡️ diuresis ➡️ dehydration ⁃ ⬆️Free fatty acid metabolism ➡️ketones ➡️ aceton breathing + metabolic acidosis which causes abdominal pain, diarrhea and vomiting ➡️ further dehydration. ✅CLINICAL PRESENTATION: EARLY: polyurea, abdominal pain and vomiting. THEN: dehydration and kussmaul breathing. LATE: impaired consciousness. ✅DIAGNOSIS: ⁃ diabetic ➡️ RBS: >300mg/dl + glucosuria ⁃ Keto ➡️ serum ketones >3m.mol/l + ketonuria ⁃ Acidosis ➡️ PH=<7.25 , HCO3 <15 meq/l ⁃ Others may include electrolytes like Na + K , CBC and ECG for hypo or hyperkalemia. ✅MANAGEMENT: 2 I.V lines one for fluid and the other for insulin. 🔴1- fluids resuscitation: ringer or saline given as bolus 20mg/kg in the first hour then ( 85mg/kg + maintenance - bolus) / 23 hour Note: - should be corrected slowly to prevent brain edema. ⁃ Acidosis almost always corrected by fluids &insulin infusion so, Sodium bicarbonate is not usually indicated. It is given only in severe intractable acidosis unresponsive to other therapy (pH < 7.1). ⁃ When blood glucose reaches 250 mgldl add glucose 5% to saline as 14 mmoVL. 🔴2- Insulin: ⁃ use regular insulin which must be given as slow IV infusion 0.1 unit / kg. ⁃ Decrease insulin infusion rate when the patient become conscious and blood glucose drop below 300 mg/dl to avoid hypoglycemia. ⁃ Shift to subcutaneous insulin (0.2- 0.4 ulkg every 6-8 hr) when: pH> 7.30, HC0 3 > 16 meq/L, Sodium is stable between 135-145 mEq/L, No vomiting. 🔴3- Flow sheet: For electrolytes, blood glucose, pH ,and fluid balance every 1-4 hours. 🔴4-Treat precipitating factors e.g. Antibiotics for infections. Hazards during treatment: * Hypokalemia. * Hypoglycemia. * Brain edema #pediatric #اطفال

⁉️Adhesive Capsulitis (Frozen Shoulder) • Common disease , define as pain and loss of motion in shoulder with no other cause.   🔎Patho-anatomy • soft tissue scarring and contracture, with fibroblastic proliferation of capsular tissue seen on biopsy 🔀Associated conditions associated with : *diabetes (both types) *thyroid disorders (autoimmune etiology) *previous surgery (lung and breast) *prolonged immobilization   🩺Presentation • Symptoms : it is characterized by pain and stiffness   The condition progress in three stages: 1.Painful stage: there is gradual diffuse of pain (6 weeks to 9 months). 2.Stiffness stage: the pain is decreased but there is decrease in rage of motion(4 to 9 months) 3.Thawing stage: there is gradual return of motion (5 to 6 months) لذلك المرض هذا يطول سنة تقريباً بكل مراحلة السابقة • Physical exam: there is painful arc of motion , with decreased ROM (especially external rotation) ✅The diagnosis of frozen shoulder is clinical, resting on two characteristic features: (1) painful restriction of movement in the presence of normal xrays; and (2) a natural progression through three successive phases. 💡Imaging  • Radiographs : recommended views  •AP in neutral rotation • AP in internal rotation • AP in external rotation • scapular-Y • axillary lateral ➡️To see any associated problems •MR arthrogram ➡️loss of axillary recess indicates contracture of joint capsule   💊Treatment • Nonoperative : NSAIDs, physical therapy, and intra-articular steroid injections. The physical therapy is by program of gentle, pain-free stretching and moist heat, which should be supervised and last for 3-6 months.   تمارين زيادة الحركة تدريجياً تحت اشراف الاخصائيين • Operative: • it is by manipulation under anesthesia (MUA). نحرك المفصل تحت التخدير العام It is indicated for cases failed to improve with therapy and NSAIDs. • Or by arthroscopic surgical release. #ortho

⁉️Subacromial impingement It is the first stage of rotator cuff disease which is a continuum of disease from   o impingement and bursitis, may lead to ↩️ o partial to full-thickness tear↩️ o massive rotator cuff tears↩️ o rotator cuff tear arthropathy   ✅sub-acromial impingement is the most common cause of shoulder pain اكثر سبب لالآم الكتف 🔎Pathophysiology 1.extrinsic compression of the rotator cuff between the humeral head and  •anterior acromion   •coraco-acromial ligaments •acromioclavicular joint   مثلا سوفان بالمفصل 2.intrinsic degeneration of supraspinatus 3.inflammatory process :inflammation of the subacromial bursa 🩺Presentation  • Symptoms   o pain : the pain is insidious in onset , exacerbated by overhead activities • and many times there is night pain من يرفع ايده يزداد الالم ومن ينام يزداد الالم • Physical exam o muscle strength usually normal قوة العضلات تكون طبيعية o impingement tests: •positive Neer impingement sign (positive if passive forward flexion >90° causes pain)  •positive Neer impingement test (if a subacromial injection relieves pain associated with passive forward flexion >90°)  •positive Hawkins test (positive if internal rotation and passive forward flexion to 90° causes pain)  •Jobe test (pain with resisted pronation and forward flexion to 90° indicates supraspinatus pathology)  •internal impingement test (positive if pain is elicited with abduction and external rotation of the shoulder)  طريقة الفحص بالفديوات موضحة👇🏻 https://youtu.be/NXYN9bnu0C0 https://youtu.be/oMxUGcHpg-Q https://youtu.be/g92VbV56AAY https://youtu.be/X9YiuvQJVJc 💡Imaging  1.Radiographs  : recommended views •true AP of the shoulder ➡️useful in evaluating the acromiohumeral interval (normal distance is 7-14 mm ) in this disease it will decrease •supraspinatus outlet view ➡️useful in defining acromial morphology findings: common radiographic findings associated with impingement مهمات جداً •proximal migration of the humerus as seen in rotator cuff tear arthropathy  يكون الhumerus صاعد للاعلى •traction osteophytes  •calcification of the coracoacromial ligament   •cystic changes within the greater tuberosity •Type III-hooked acromion  •os acromiale (best seen on axillary lateral; is a developmental defect which results from the lack of an osseous union between the ossification centers of the acromion, leading to the fibrocartilaginous tissue connection) صورة الاشعة بالاسفل👇🏻 2.MRI▶️useful in evaluating the degree of rotator cuff pathology 3. Ultrasound ▶️can also accurately image the rotator cuff tendons and muscle bellies to see any inflammation, tear and muscles fibrosis. 💊Treatment • Non-operative   o physical therapy, oral anti-inflammatory medication, subacromial injections⬇️ •first line and mainstay of treatment of subacromial impingement alone without rotator cuff tear   • Operative o subacromial decompression / acromioplasty ⬇️ subacromial impingement syndrome that has failed a minimum of 4-6 months of nonoperative treatment . #ortho

سلام عليكم 🌸 ان شاء الله تكونون بخير وعافية 🙏 والف مبروك لكل الناجحين وكل التوفيق بحياتكم ان شاء الله🙏💙 الحمدلله اني تخرجت واخيرا 😍 صح درجتي ما تناسب تعبي بس الف الحمد لله والشكر ع كل شيء 🙏 والانجاز الحقيقي الحققته وفرحت بي هو القناة 💚 ما تتخيلون شكد افرح من احد يراسلني ويكلي اني استفاديت منها لان كلش اتعب وابحث بالمصادر حتى تكون المعلومة دقيقة 😍 جدا جدا اشكركم 🌸💜 حتى نستمر بالنشر اريد 2 آدمن وياي (ستاجيرية ) واحد منهم كون من الكوفة (لان النظام يختلف ) الي يحب يساعد ويكون كد الامانة يراسلني ع معرفي موجود بالبايو 💚 وكل التوفيق يارب 🙏💚

These days will create my future. I hope that you will mention me in your prayers 🙏

📌Causes of diarrhea in DM - diarrhea follow constipation (stagnation so bacterial overgrowth ) so in constipation give motility and in diarrhea give metanidazole - celiac disease - medication (metformin, acarbose) 📌Phenomena - down phenomena ( morning hyperglycemia ) —> Rx by increase dose of evening insulin - somogi phenomena ( over the night “3:00 am” hypoglycemia flowed by morning hyperglycemia —> this occur because effect of soluble and lnete arise at the same time ) —> Rx by seperation of evening dose by giving soluble insulin before meal and lente before sleeping 📌Surgery & DM ** management 🌱pre-op - HbA1c must be within target level = 8-9%, and delay elective surgery until the patient reach the target Level - BP, ECG 🌱Peri-op - fasting for 8 hrs - omit morning dose of hypoglycemic agent - be the first on the list of surgery - during surgery start IV fluid + insulin with follow each 2hr for RBS 🌱Post-op - after surgery patient continue on insulin + dextrose (0.45% NS + 5% dextrose + 0.15% kcl ) until he start oral feeding - adequate k replacement - when he start oral feeding start oral hypoglycemic agent and stop insulin after 1hr (delay action of oral hypoglycemic agent) - maintain blood glucose within target 108 - 180 - Patients normally controlled on tablets may require temporary subcutaneous insulin treatment until the increased ‘stress’ of surgery, wound healing or infection has resolved.

📌 7- Insulin ✔️Types of insulin : 1- Rapid acting (Lispro, Aspart) -onset : 10-15 min -duration : 2-4 hr 2- Short acting (Regular, soluble, صافي) -onset : 30 min -duration : 3-6 hr 3- Intermediate acting (Isophan "NPH", Lente خابط) -onset : 2-4 hr -duration : 12-18 hr 4- Long acting "Basal" (Glargine, Degludec, Detemir) -onset : peakless -duration : 24 hr 5- Premixed "Mixtard" (L\R = Lente/rapid 70\30 or 50\50 المخلوط) ✔️Indications of insulin therapy : -Type 1 DM -Type 2 DM with acute stressful condition (like severe infection, burn, ...) -Type 2 DM which failed to respond to oral agents ✔️ Routes of administration : -subcut -IV -IM -Inhaler ✔️ Standard insulin regimens : 1-Once daily regimen -used for type 2 DM which failed to respond to oral agents -one dose of basal or intermediate insulin -given before breakfast or at bed time -can be used in combination with OH 2-Twice daily regimen -used for type 1 DM -2 doses of premixed insulin -given before breakfast & before dinner -2\3 of total dose given before breakfast & 1\3 of total dose given before dinner -short-acting : intermediated-acting = 1:2 3-Basal-bolus insulin regimen -used for strict glycemic control -need high compliance, education, regular meal, lifestyle changes -carries higher risk of hypoglycemia -single dose of basal insulin (50% of total) at bed time + 2-3 doses of short acting (prandial) insulin before meal to control post-prandial hyperglycemia 4-Continuous subcut infusion using insulin pump -software problems -expensive -change the needle weekly ✔️Side effects of insulin therapy : -hypoglycemia -weight gain -peripheral edema (causes salt and water retention in the short term) -insulin antibodies -local allergy (rare) -lipodystrophy at injection sites 📌At present, islet transplantation is usually suitable only for patients with unstable glycemic control characterized by recurrent severe hypoglycemia that cannot be corrected by standard conventional and intensive insulin therapies **cardiovascular benefit from anti-DM (also weight reduction) : - liraglutide (sc) - canagliflozin (oral)

🔴 Antidiabetic Agents : 📌 1- Insulin Secretagogues ✔️ A- Sulphonylureas -Action : block potassium-ATP channel in the B-cell of pancreas -> decreasing K efflux -> AP & Ca influx -> triggers insulin secretion -Examples : Glibenclamide (Daonil), Glimepride (Amaryl), Gliclazide, ... -S\E : hypoglycemia, weight gain ✔️ B- Meglitinides -Action : direct stimulation of B-cells in the pancreas to secrete insulin -Examples : Repaglinide (Novonorm), Nateglinide -S\E : hypoglycemia & weight gain -safe in renal failure (due to its hepatic metabolism) 📌 2- Insulin Sensitizers ✔️ A- Biguanides (Metformin "generic name is Glucophage") -Action : increase insulin sensitivity *its main effects are on fasting glucose & are insulin-independent *it also reduces hepatic glucose production *decrease gluconeogenesis -S\E : GI upset (diarrhea, abd cramps, bloating, nausea), metallic taste, lactic acidosis (rare) -not a\w weight gain, cheap, effective, not a\w hypoglycemia - It should be omitted temporarily during any acute illness where acute kidney injury is possible, as this greatly increases the risk of lactic acidosis-> insulin treatment may be required while metformin is withheld. -it is contraindicated in AKI, hepatic failure, excessive alcohol drinking -in pt with renal impairment (eGFR 30-45) --> half the dose -can be given with insulin in obese pt with type 1 DM ✔️ B- Thiazolidindiones (also called TZD, glitazones, PPARy agonists) -Action : increase insulin sensitivity -Example : Pioglitazons (Actos) -S\E : edema, HF, bone #, weight gain, bladder CA -not a\w hypoglycemia -can be used with insulin (but with caution due to due to increased risk of fluid retention & HF) 📌 3- Incretin-Based Therapy ✔️ A- Dipeptidyl peptidase 4 (DPP-4) inhibitors -Action : inhibits GLP-1 degradation -Examples : Sitagliptin (Januvia), Vildagliptin (Galvus) -S\E : GI upset, low risk of hypoglycemia, pancreatitis -not a\w weight gain ✔️ B- Glucagon-like peptide (GLP-1) receptor agonists -Examples : Liraglutide (Victosa) -given by subcut. injection -S\E : GI upset, low risk of hypoglycemia, pancreatitis -induce significant weight loss -a\w improved cardiovascular outcomes 📌 4- Sodium-Glucose Linked Transporter (SGLT2) Inhibitors -Action : block renal glucose reabsorption -Examples : Canagliflozin (Invokana) -S\E : mycotic genital infections, UTI, euglycemic DKA (rare) -induce weight loss -a\w improved cardiovascular outcomes 📌 5- Amylin agents -Action : slows gastric emptying, supresses glucagon, regulate appetite -Examples : Pramlintide (Symlin) -S\E : GI upset, hypoglycemia 📌 6- Alpha Glucosidase Inhibitors -Action : inhibits glucosidase enzyme in GIT -Examples : Acarbose (Precose) -S\E : diarrhea, abd distention

اعتذر لتوقف النشر لعدم تفرغي للدراسة في هذه الفترة بسبب الحالة الصحية لعائلتي 💔 اسألكم الدعاء 🙏

Very Very useful 😍😍👇

✔ Single-lumen cuffed endotracheal tube: This will required in a general anaesthetic, so a definitive airway is required. The endotracheal tube passes via the mouth into the trachea and allows for temporary mechanical ventilation of the patient. The cuffed end (a balloon) creates a seal to prevent aspiration of stomach contents. ✔Double-lumen cuffed endotracheal tube: has been developed for lung and other intra-thoracic surgery. It allows for one lung to be ventilated while the other is collapsed to make surgery easier. ✔Single-lumen uncuffed endotracheal tube : uncuffed endotracheal tube is preferred in children, as the trachea is not as strong as in adults, and the use of a cuff increases the risk of tracheal damage with resulting stenosis. The risk of developing stenosis outweighs that of aspiration.