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👽 Massive splenomegaly:
Def: enlarged beyond 8 cm below the left costal margin or weighs more than 1000g
Most common causes:
- CML
- Myelofibrosis
- Chronic Malaria
- Visceral Leishmaniasis (Kala-Azar)
- Lymphoma (NHL)
💡 Dont be tricked:
target hemoglobin level is set lower in patients with high HbS compared to those with low HbS due to the risk of hyperviscosity syndrome
70F with type 2 DM on metformin 1 g BID is having difficulty in naming and calling things lately. She has no memory impairment or personality changes, diagnosis?
🦠 Chronic Hep B:
chronic HBV infection cannot be cured, the goals of treatment are:
- to suppress viral replication
- to halt progression of liver disease
- to prevent HCC.
When to treat chronic HBV with anti-virals?
- immune active phase: (ALT >2x, sAg high, eAg positive and DNA >20K)
- HBeAg negative chronic hep B: (ALT >2x, sAg intermediate, eAg negative, DNA >2K)
- cirrhosis with HBV DNA ≥2K
- decompensated cirrhosis due to hep B
- acute liver failure due to acute hep B
- pregnant (3rd trimester with HBV DNA ≥200k)
- inactive carriers started on immunosuppression
- HCC
- HCV co-infection
Duration of treatment:
- In immune active: if seroconversion or after 1 year if ALT normalized and DNA suppressed or until sAg cleared
- in cirrhosis and HBeAg negative chronic hep B: indefinite
Medication:
- Entecavir
- Tenofovir (preferred if patient has history of Lamivudine resistance)
patient with asymptomatic chronic hepatitis B and the following LFT results:
AST 80, ALT 90, with slightly elevated bilirubin, what is the most appropriate management?
📊 Test your self:
Patient presents with pic of hemolytic anemia after taking sulfonamide, G6PD level 1 day later was normal.
Q: does normal level of G6PD rule out G6PD deficiency 🤥?
Indian male with RUQ pain with on and off fever for the last 3w
He has raised LFT, high WBC (neutrophils 70%).
US: homogenous hypochoic mass in the liver. diagnosis?
patient presents with ascites and jaundice. Serum albumin is 30, ascitic albumin is 14, and ascitic protein is 10.
What is the likely diagnosis?
70M presented with a diastolic murmur best heard at the left sternal edge with the apex displaced outwards. A sound resembling a pistol shot was heard over femoral a. What is the likely condition?
🩸 Causes of macrocytic hyperchromic anemia:
- vitamin B12 deficiency
- folate deficiency
- MDS
- liver disease
- hypothyroidism
- alcoholism
- drugs ex: hydroxyurea
Which vitamin deficiency is associated with iron overload ?
🩸Alpha thalassemia:
Criteria to initiate regular transfusion (Transfusion-dependent thalassemia “TDT”):
1- confirmed diagnosis
2- Hb <7 on two occasions >2week apart and/or
- symptomatic anemia
- failure to thrive
- 2ry sexual development failure
- pathological fracture or facial changes (due to excessive intra-medullary hematopoiesis)
Transfusion every 2-5 weeks
- pre transfusion target is:
• 9-10.5
• 11-12 if there is cardiac complications
- post transfusion target <14-15
Chelating agent should started (in TDT):
- after 1st 10-20 transfusion
- ferritin >1000
📚 Nitrofurantoin SE:
- Pulmonary Toxicity:
• hypersensitivity pneumonitis: in short-term therapy.
• pulmonary fibrosis: prolonged use >6 months.
- Hepatotoxicity
- Peripheral Neuropathy: prolonged use >6 months.
- Hemolytic Anemia: in patient with G6PD deficiency
diabetic woman presents to the ED with dysuria. Her lab results show WBC 14, creatinine 230 umol/L and urine culture positive for > 100,000 cfu/ml E. coli. Which of the following is contraindication?
شفت كثير مجاوبين على السؤال هذا بـ increase furosemide
وللاسف في انتيرن اعتذر منه سبق وقالي عالسؤال وجاوبت نفس الشي. عموما الاجابه الصحيحه therapeutic paracentesis
And here is my justification 🤓:
Management of ascites due to cirrhosis in general:
First line is: Na restriction plus spironolactone & furosamide combination (ratio of 5:2) dose can be increase up to 400-160 but maintaining ratio is important (increase both diuretics together)
- paracentesis, reasonable to initiate in patient presented with grade3 (large ascites)
- TIPS
A: wrong, IV diuretics should be avoided in such patient ( high risk for AKI)
B: correct, as per EASL guidelines, they recommend paracentesis in large ascites as 1st line
C: wrong, 5:2 ratio should be maintained, exceptions to this rule is: patient older than 90s or with risk to hyperkalemia (known CKD patients) spironolactone can be maintained in lower dose
D: wrong, it use in patients with very frequent requirement of large-volume paracentesis, or in those in whom paracentesis is ineffective
- Check references in the comments
- هذا والله اعلم
patient presents to the ED with large ascites. The patient is currently on spironolactone 50 mg/day and furosemide 40 mg/day. Laboratory results show low Na & normal K, How would you manage?
