AAS Medical Notes

اكو نقاط مهمة لازم تراعيها و انت تسمع الهستري مال المريض. الشي الي ما مخليه ع بالك، مستحيل تنتبهله بالفحص، ممكن طالب كلية يشوفه و ينتبهله، و انت يفوتك لأن ما مفكر بيه The eyes can't see what the brain can't see. هاي البيشنت 7 months hx of recurrent syncopal attacks. و مراجعة نيورو و كارديو و مسويه EEG و ECG و هولتر و ايكو اكثر من كذا مرة. من غير الـ routine lab tests. من تسمع للهستري و تاخذ general look المفروض دماغك مباشرة يربط. there is obvious hyperpigmentation It is a case of Primary Adrenal insufficiency. C.P: Weakness, fatigue, and orthostatic hypotension are early symptoms and signs of Addison disease. Hyperpigmentation is characterized by diffuse darkening of exposed and, to a lesser extent, unexposed portions of the body, especially on pressure points (bony prominences), skin folds, scars, and extensor surfaces. Black freckles are common on the forehead, face, neck, and shoulders. Bluish black discolorations of the areolae and mucous membranes of the lips, mouth, rectum, and vagina occur.

Rx of Sjogren syndrome

Pulmonary involvement is common in SLE, with most patients presenting with pleuritis (45%-60%). Pleural effusions occur in approximately half of these patients and are typically exudative; fluid analysis may reveal lymphocytic pleocytosis and mildly depressed glucose levels. Parenchymal lung involvement occurs in less than 10% of patients with SLE. A nonspecific interstitial pneumonia pattern is most common, and evaluation centers on assessing SLE activity and excluding other causes of diffuse parenchymal lung disease. Two rare but potentially life-threatening complications of SLE lung disease are acute lupus pneumonitis (presenting as fever, cough, dyspnea, hypoxemia, pleuritic chest pain, and infiltrates) and diffuse alveolar hemorrhage (presenting with dyspnea, hypoxemia, diffuse alveolar infiltrates, a dropping hematocrit, and a high DLCO). Both carry a high mortality rate (>50%). Early recognition, rapid evaluation (CT and/or bronchoscopy with bronchoalveolar lavage or biopsy), and aggressive respiratory support combined with high-dose glucocorticoids and immunosuppression are required. With new pulmonary infiltrates, differentiation between these disorders and infection can be difficult, and antibiotics and immunosuppressive therapy are often administered simultaneously until the diagnosis is clear. Shrinking lung syndrome is a rare but characteristic syndrome consisting of pleuritic chest pain and dyspnea, with progressive decrease in lung volumes. The cause is uncertain, but pleuropulmonary disease and/or diaphragmatic dysfunction may contribute. Immunosuppression may reverse the process in some patients.

Reactive arthritis #rheumatology

Polymyalgia rheumatica PMR #rheumatology

سبحان الله، بنفس اليوم، بالنايت كوول هم اجونا كيسين الاول كان serum Na 164 و الثاني serum Na 106

من الكيسات الحلوة او الاصح الكيسات المتناقضة: عدنا كيسين اليوم الأول كان hypercalcemic emergency و الثاني كان hypocalcemic emergency و كل واحد طلع من الطوارىء "و طينته بخده" 😎😎

Alternative diagnoses of treatable conditions that may provoke or be associated with fibromyalgia include hypothyroidism, polymyalgia rheumatica, and depression. Multiple rheumatologic conditions (Sjögren syndrome, systemic lupus erythematosus, rheumatoid arthritis) are also associated with a higher risk for coexistent fibromyalgia than seen in the general population. In patients with autoimmune disease and comorbid fibromyalgia, it is crucial to recognize when comorbid fibromyalgia is the primary driver of musculoskeletal symptoms in order to avoid overtreatment with immunosuppressive agents.

Nice algorithmic approach for inflammatory joint pain.

Before initiation of anti-TNF therapy, all patients should be tested for latent tuberculosis (TB) and for hepatitis B, and treated appropriately if either is found. Contraindications to TNF inhibitors include active infection or high risk of infection; multiple sclerosis; and history of hematologic malignancy, SLE, or related autoimmunity. Pregnancy and breast-feeding are no longer considered contraindications if appropriate precautions are taken. Certolizumab pegol’s label includes minimal transplacental or breast milk transfer. However, infants exposed to anti-TNF in utero should not be given live vaccines before age 6 months.

Clinical picture of Behcet disease: The most common symptoms are associated with mucocutaneous tissues. Oral ulcers are seen in virtually all patients and are commonly the first manifestation. Commonly, like ordinary cancer sores, they are usually multiple. They last around 10 days but recur unless treated. Only the uncommon, major ulcers tend to scar. Beneficial effects of dental and periodontal therapies suggest that decreased oral health is associated with disease severity. Genital ulcers are the most specific lesions, most commonly occurring on the scrotum or labia. They are larger and deeper and take longer to heal than oral ulcers and tend to form scars. Acne-like or papulopustular lesions are indistinguishable from acne vulgaris in appearance and pathology. They are seen both at the usual acne sites as well as at uncommon sites such as lower extremities. Other skin findings are the nodular lesions, which are of two types: erythema nodosum lesions due to panniculitis and superficial vein thromboses. Superficial thrombophlebitis often occurs in men and is associated with deep-vein thrombosis; it should trigger workup for other vascular involvement, including pulmonary artery aneurysms. Pathergy reaction is a nonspecific hyperreactivity of the skin to trauma. Typically, a papule or pustule forms in 24–48 h after a needle prick. It is rather unique for Behçet syndrome and is part of the ISG diagnostic criteria. Arthralgia or arthritis is seen in about half of patients; it is usually a mono- or oligoarthritis in the lower extremities and does not usually cause deformity or erosions. Eye involvement is seen in half of all patients and in ~70% of males. It is most commonly a bilateral panuveitis. A hypopyon, seen in ~10% of patients with eye disease, is an intense inflammation in the anterior chamber and is quite specific for Behçet syndrome. Male gender, posterior involvement, frequent attacks (>3 per year), strong vitreous opacity, and macular edema are poor prognostic factors. Vascular disease is seen in up to 40% of patients. It is associated with intensive thrombosis and runs a relapsing course. Several well-defined venous vascular associations are seen, and superficial and deep-vein thrombosis, Budd-Chiari syndrome, inferior vena cava syndrome, pulmonary artery involvement, intracardiac thrombosis, and cerebral venous sinus thrombosis frequently cluster in various combinations. Pulmonary artery aneurysms carry a 5-year mortality rate of 20–25%. Prevalence of neurologic involvement is ~5%, with about threequarters of patients presenting with parenchymal involvement, while the remaining cases present with cerebral venous sinus thrombosis.

Unlike other autoimmune diseases, however, Behçet syndrome is not typically associated with autoantibodies, Raynaud’s phenomenon, Sjögren’s syndrome, thrombocytopenia, hemolytic anemia, sun hypersensitivity, serosal involvement, or an increased risk for other autoimmune diseases.

Nutrition in critically ill patients: Patients with critical illness should receive early oral feeding when possible and should be considered at risk for malnutrition when they have not received nutrition for more than 48 hours. If oral nutrition is not feasible, early enteral nutrition is indicated to minimize infectious complications associated with delayed enteral nutrition. New guidelines suggest that, in malnourished patients, caloric and protein needs should be increased gradually to their goal over the course of 3 to 7 days to avoid risks associated with early refeeding syndrome. When patients are chronically malnourished or endure prolonged starvation, the body shifts from metabolizing carbohydrates to metabolizing protein and fat as the main source of ATP production. In the process, intracellular depletion of key electrolytes such as potassium, phosphorous, and magnesium begins to occur. When carbohydrates or other simple sugars are reintroduced to the diet or given intravenously, production of insulin causes rapid intracellular uptake and a rapid drop in extracellular concentrations of electrolytes. These shifts have potentially life-threatening consequences, including diaphragmatic weakness and respiratory impairment, tissue hypoxia, fatal arrhythmias, and cardiomyopathies (refeeding syndrome). Guidelines suggest that enteral intake should be increased slowly over a period of 3 to 7 days. Should electrolyte levels markedly decrease from their baseline, suggesting refeeding syndrome, these abnormalities should be corrected and the number of calories the patient is receiving should be either reduced or held steady.

Macrolides in COPD: Macrolide antibiotics have anti-inflammatory and antimicrobial effects. Long-term macrolide therapy may reduce the frequency of exacerbations when prescribed to patients with severe COPD and a history of frequent exacerbations but do not result in slowing the decline in lung function or reduce the risk of death. Indication for macrolide use is in patients with COPD treated with combination long-acting β2-agonist, long-acting muscarinic antagonist, and inhaled glucocorticoid who continue to have exacerbations, especially in those who are not current smokers. Dose: azithromycin 250 mg daily or 500 mg three times per week.

The U.S. Preventive Services Task Force recommends annual lung cancer screening with low-dose CT for those who are aged 50 to 80 years and have at least a 20-pack-year smoking history, including those who have quit smoking within the past 15 years; in contrast, the American Cancer Society recommends screening all former smokers who meet the criteria regardless of when they last smoked.

Oxygen therapy: 👉 Evidence now suggests that supplementing oxygen for patients whose oxygen saturation is already 96% or higher actually increases mortality. 👉 Recommendations include both that an SpO2 of 96% or lower should be maintained in patients receiving oxygen therapy and that oxygen therapy should not be started for patients with acute myocardial infarction or stroke and an SpO2 of 93% or higher. 👉 These guidelines do not apply to all acute medical conditions. For example, higher SaO2 values are beneficial for patients with carbon monoxide poisoning (a specific case in which SpO2 may be unreliable and SaO2 should be used instead), cluster headache, sickle cell crisis, and pneumothorax.

قبل ٣ سنوات تقريباً نشرت ملاحظة بأنه Ringer lactate is the best fluid in septic shock and should be used over normal saline و كان بذاك الوقت هذا الموضوع دراسات، و نقلت الدراسة لكن الكثير ما كان مقتنع الموضوع و منذ فترة ليست بقصيرة صار مثبت ضمن الـ guideline و كنقطة لا خلاف عليها. و ايضاً نشرت ب ٢٠٢٢ بأنه RL is the fluid of choice in DKA و ان شاء الله هالشي راح ينزل و يثبت بالـ guideline خلال السنين القادمة

Steroids in septic shock: The use of glucocorticoids in the setting of sepsis has been suggested to achieve hemodynamic stability in patients with an ongoing vasopressor requirement. A 2018 meta-analysis of 42 trials concluded that although there was no evidence that glucocorticoids improve mortality, patients with septic shock who receive glucocorticoids are more likely to have reversal of shock within 7 days. Guidelines published by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine in 2017 recommend consideration of glucocorticoids for patients with refractory septic shock at a maximum dose of 400 mg hydrocortisone daily or the equivalent using another glucocorticoid. The 2022 Surviving Sepsis Campaign guidelines recommend hydrocortisone in doses up to 200 mg daily for refractory shock either as 50 mg/q6h or continuous infusion. Also recommend to consider steroids only if the patient remain hypoperfused after 30 ml/kg of RL and adequate vasopressor dose.

Oxygen therapy: Providing supplemental oxygen for patients with an SpO2 higher than 96% increased mortality by approximately 1%. Based on these results, an international expert panel provided two strong recommendations: (1) an SpO2 of 96% or lower should be maintained in patients receiving oxygen therapy, and (2) oxygen therapy should not be started for patients with acute myocardial infarction or stroke and an SpO2 of 93% or higher. These guidelines do not apply to all acute medical conditions. For example, higher SaO2 values of nearly 100% are likely beneficial for patients with carbon monoxide poisoning, cluster headache, sickle cell crisis, or pneumothorax.

This 15 yr old girl, with history of failure to thrive, diagnosed later on as a case of CKD. Just imagine this angelic face has end stage renal disease and she will start dialysis today. "The most painful smiles are the ones given by those who deserve to cry the most."