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#DDx for hepatomegaly: Mnemonic: 2 I's, 2 B's, 2 C's - Infection (e.g. Viral hepatitis, EBV, Malaria, Hepatic abscess) - Infiltration (e.g. Sarcoid, Amyloid, Fatty liver, Haemochromatosis) - Blood-related (e.g. Lymphoma, Leukaemia, Myeloproliferative disorders, Haemolytic anaemias) - Biliary (e.g. Primary Biliary Cholangitis, Primary Sclerosing Cholangitis) - Cancer (e.g. Primary HCC, Metastatic deposits) - Congestion (e.g. RHF, Tricuspid regurgitation, Budd–Chiari syndrome) #Hepatobiliary

#DDx for hepatomegaly: Mnemonic: 2 I's, 2 B's, 2 C's - Infection (e.g. Viral hepatitis, EBV, Malaria, Hepatic abscess) - Infiltration (e.g. Sarcoid, Amyloid, Fatty liver, Haemochromatosis) - Blood-related (e.g. Lymphoma, Leukaemia, Myeloproliferative disorders, Haemolytic anaemias) - Biliary (e.g. PBC, PSC) - Cancer (e.g. Primary HCC, Metastatic deposits) - Congestion (e.g. RHF, Tricuspid regurgitation, Budd–Chiari syndrome) #Hepatobiliary

Types of Asthma: 1- Atopic asthma (= extrinsic asthma) ~ Attacks are precipitated by allergens. 2- Intrinsic asthma (=idiosyncratic or nonatopic asthma) ~ Attacks precipitated by nonimmunologic stimuli such as cold air, infections, emotional upset, ...etc. 3- Occupational asthma ~ Attacks precipitated by chemicals, irritants or allergen exposure at work. ~ Diagnose with pulmonary function tests (PFTs) before and after work. 4- Reactive airway dysfunction ~ Results from a single inhalation of large amounts of respiratory irritants like gas, smoke, vapors (e.g., chlorine gas, ammonia) ~ Suspect in a patient who develops asthma with no prior history of lung disease. 5- Exercise-induced asthma ~ SOB and wheezing only during or after exercise ~ Treat with SABA or Mast cell stabilizers before exercise 6- Nocturnal asthma ~ Symptoms only occur at night ~ Treated as other asthma types 7- Pseudoallergic reaction to Aspirin or NSAIDs ~ Treated with leukotriene receptor antagonist; If underlying condition requires use of aspirin or NSAIDs, desensitize the patient to the drugs. #Respiratory

But what if the HTN patient has comorbidities?! What drugs to give then? CAD → β-blocker or ACEi/ARB CAD + EF ≤ 40% → ACEi/ARB and β-blocker Tremor → non-selective β-blocker (e.g., propranolol) Osteoporosis → thiazide Claudication → CCB BPH → Alpha blocker (e.g., prazosin) Hyperthyroidism → β-blocker Raynaud's phenomenon → CCB Migraine → CCB or β-blocker Pregnancy → Methyldopa or clonidine Cerebrovascular disease → CCB and thiazide

First-line Antihypertensive Drugs: ACEi/ARB, CCB, Thiazide diuretics Exception: In black patients, first-line drugs are CCBs or thiazides, as they have better cardiovascular outcomes. All first-line drugs are equal unless patients has CKD or diabetic nephropathy, then choose ACEi/ARB.

What are the lifestyle modifications for HTN? 1- Exercise 2- Weight loss 3- The DASH diet 4- Potassium supplementation 5- Limiting salt and alcohol intake

Treating Hypertension - Normal BP (<120/<80): No treatment, screen annually. - Pre-hypertension: lifestyle modifications only; re-assess within a few months -Stage 1 hypertension: ~~With no other risk factors and ASCVD 10-year score <10% (low-risk patients): Lifestyle modifications ~~With ASCVD 10-year score ≥ 10%, CKD, DM, heart failure, or age ≥ 65 yrs (high-risk patients): give 1 hypertension drug + lifestyle modifications - Stage 2 hypertension: ~~Low risk patients: give 1 antihypertensive drug + lifestyle modifications ~~If high risk patient or SBP >20 or DBP >10 mmHg above BP goal: Start combination pharmcotherapy therapy with 2 drugs (usually ACEi/ARB + CCB or thiazide)

A 55- year old black male presents with multiple readings of >150/90 mmHg. He has no hx of NSAID use or alcohol abuse.

White Coat Hypertension vs. Masked Hypertension White coat hypertension refers to elevated blood pressure readings in the clinic or hospital with normal readings at home. Treatment: reassurance Masked Hypertension refers to hypertension at home with normal BP readings in the clinic. Treatment: as essential hypertension.

Hypercoagulability work-up following a DVT: This should be considered in patients without a clear risk factor for DVT (unprovoked cases), young patients with weak provoking factors or strong family history, patients with recurrent DVT, or DVT in an unusual anatomical location. However, it should not be done during an acute attack as anticoagulation therapy can affect the results. Points to consider: - Protein C, S, anti-cardiolipin antibodies, prothrombin G20210A, and Factor V Leiden can be sent when patients are taking heparin. Note that Proteins C and S are vitamin K dependent factors and will be lowered by warfarin therapy. - AT III, Protein C, and Protein S may be transiently depressed during the acute event, and levels should generally not be assessed during this period. - Wait to send entire panel until two weeks after warfarin stopped, at least two days after DOAC stopped, and at least 24 hours after heparin stopped. #Vascular

If anticoagulation is contraindicated (active bleeding, bleeding disorder, hx of intracranial hemorrhage), an IVC filter should be placed. #Vascular

But of course, don't forget about HIT.

Duration of therapy is typically 3 months for provoked DVT. Longer periods of anticoagulation can be considered in patients with unprovoked DVTs or significant risk of another VTE. #Vascular

Treating DVTs Enoxaparin (1 mg/kg SQ q12h) + warfarin (5 mg PO qnight). ~ Continue enoxaparin until patient has received a minimum of five days of enoxaparin and has two consecutive INR >2 separated by 24 hours. Check PT/INR daily and adjust warfarin dose based on the results of these checks until a stable warfarin dose is achieved. OR consider initiation of a DOAC: - Dabigatran: 150mg PO BID after 5 days of heparin. Note: Heparin precedes dabigatran and is not a bridge. - Rivaroxaban: 15mg PO BID for 21 days, followed by 20mg daily. - Apixiban: 10mg BID for 7 days, then 5mg BID for 6 months. Note: Factor Xa inhibitors (Rivaroxaban, Apixiban) don't need a heparin bridge. #Vascular

Ultrasound findings in DVT include lack of compressibility of a vein and abnormal Doppler flow. #Vascular

DVT Workup 1- Calculate Well's Score 2- If low probability → perform D-Dimer 2.a D-Dimer negative → DVT excluded 2.b D-Dimer elevated → Duplex Ultrasound 3. Intermediate or high probability → Duplex ultrasound 3.a Ultrasound positive → DVT confirmed 3.b Ultrasound negative → Repeat in one week #Vascular

DVT complications: ~ Pulmonary embolism ~ Chronic venous insufficiency ~ Recurrence ~ Venous gangrene ~ Post-phlebitis syndrome #Vascular

#DDx of DVT: 1. Ruptured Baker's Cyst 2. Cellulitis 3. Compartment syndrome 4. Superficial thrombophlebitis 5. Calf muscle hematoma 6. Ruptures plantaris tendon 7. Lymphedema #Vascular

DVT most often affects the left leg due to left iliac v. compression by the right iliac a. #Vascular