AAS Medical Notes

For prediabetes: The American Diabetes Association recommends a program for intensive lifestyle behavioral changes that includes at least a 7% weight loss over 6 months and at least 150 minutes per week of moderate-intensity exercise. These intervention can prevent development of DM by 58%. Patients with prediabetes should be retested yearly to monitor for the development of type 2 diabetes.

حسب رأيي، المفروض قرار اعطاء التداخلات المنقذة للحياة لا يتم مناقشتها مع المريض او مرافقه، المفروض الطبيب يتخذ الاجرات المطلوبة الطارئة و بما يراه مناسبا. اليوم مريض 47 سنة اجه بـ sudden onset palptation ECG: VT ما استجاب على 2 loading doses of amiodarone, and he started to develop chest pain and dyspnea. فكان القرار هو syn DC. مرافق المريض عمره 20 سنة، طفل، كلشي ما يفتهم، يكول لا ما اوافق. يعني تخيل، تسلم حياة شخص ب ايد شخص آخر جاهل، كلشي ميعرف. "كلمة جاهل، يعني فاقد المعرفة ب شيء معين، و ليس بشتيمة" احد القصص الي تضوجك و تعكر يومك.

الإحبة الكرام، الأصدقاء الأفاضل: أحب أبشركم بأن كتابي Ahmed for common ICU and ward cases صار جاهز للحجز المسبق. الكتاب، اغلبيتكم اذا مو كلكم، صار عدكم علم عن محتواه، و طريقة طرح المعلومه فيه. لكن للتذكير: أنا برأيي مهما كان مستواك العلمي، فهو راح يضيفلك الكثير. المواضيع الي مشروحه بيه ما راح تحتاج تقراها بمكان آخر. الكتاب هو خلاصة لـ guidelines مختلفة، يتطلب من عندك وقت هواي يلا تقراها. حسب تجربتي البسيطة، هذا الكتاب راح يغطيلك اكثر من 80% من جميع الحالات الي نواجها سواء بالطوارىء او الـ ICU، او ال ward. مو مدحا، بس انا اوعدك انه من تاخذ الكتاب وياك (سواء طوارى او انعاش او ردهة)، راح تشوف اي كيس يواجهك هو مذكور و مشروح بطريقة مفصلة و عميقة. يعني راح تلكه الكيس مشروح، و الـ ddx مذكورة، و العلاج و مراقبة العلاج و السايد ايفكت كلها مذكورة و بطريقة عميقة. موجود في مكتبة مشروع مثقف، اي استفسار تواصلوا وي المكتبة، و هاي حساباتهم: https://www.instagram.com/educated_project?igsh=MTM3OHl0dzV6YXJz صفحة إنستگرام https://www.facebook.com/educatedproject?mibextid=wwXIfr&mibextid=wwXIfr صفحة الفيسبوك

Graves’ ophthalmopathy (thyroid eye disease, TED) can occur even in patients without overt thyroid dysfunction (euthyroid or subclinical hyperthyroidism). The treatment focuses on reducing inflammation, relieving symptoms, and preventing complications. 1. Conservative Measures (Mild Disease) • Lifestyle modifications: • Smoking cessation (a major risk factor for worsening TED) • Selenium supplementation (200 mcg/day) may benefit mild, active disease • Sunglasses for photophobia and irritation • Lubricating eye drops (artificial tears) and ointments for dry eyes • Sleeping with the head elevated to reduce periorbital swelling 2. Medical Therapy (Moderate to Severe Active Disease) A. Corticosteroids: • First-line for active, moderate-to-severe TED • IV methylprednisolone (weekly pulses) is more effective and safer than oral prednisone B. Teprotumumab (a monoclonal IGF-1R inhibitor): • FDA-approved for moderate-to-severe TED • Reduces proptosis and inflammation C. Other immunosuppressants (if steroids are ineffective or not tolerated): • Mycophenolate mofetil or azathioprine • Tocilizumab (IL-6 inhibitor) may be useful in refractory cases 3. Radiation Therapy • Low-dose orbital radiation can be considered in moderate disease, especially if corticosteroids are ineffective or contraindicated. 4. Surgical Management (Inactive or Severe Disease) • Orbital decompression surgery: For vision-threatening proptosis or optic neuropathy • Strabismus surgery: If diplopia persists after inflammation subsides • Eyelid surgery: For severe eyelid retraction or exposure keratopathy Summary: • Mild cases: Supportive care + selenium • Moderate-to-severe active disease: IV steroids, teprotumumab, or immunosuppressants • Severe or vision-threatening cases: Orbital decompression surgery

احلى شي ب مكساب انه يحل الخصام بمواضيع معقدة بأسطر قليلة واضحة سهلة التطبيق DKA and HHS from MKSAP

Hyperthyroidism in pregnancy: 1. Physiology and reference range: A. Placental human chorionic gonadotropin stimulates thyroid hormone secretion, and TSH may decrease as a result. B. In the late first trimester (weeks 7-12), the lower limit of the TSH reference range decreases by 0.4 μU/mL (0.4 mU/L) and the upper limit by 0.5 μU/mL (0.5 mU/L). TSH gradually returns to the nonpregnant reference range in the second and third trimester. C. Total T4 concentrations increase linearly during pregnancy. After week 16, the upper limit of the total T4 reference range can be estimated by multiplying the nonpregnant upper limit by 1.5. Free T4 measured by indirect analogue immunoassays are inaccurate in pregnancy unless method- and trimester-specific reference ranges are applied. 2. Endocrinology consultation is indicated for thyrotoxicosis management during pregnancy. 3. Gestational thyrotoxicosis from high human chorionic gonadotropin levels is the most common cause of transient TSH suppression. If serum total or free T4 remains within the trimester-specific reference range, treatment is unnecessary. 4. Patients with moderate to severe hyperthyroidism in early pregnancy should be treated with PTU because it is less teratogenic than methimazole. After the first trimester, patients can be transitioned to methimazole. 5. Monitoring: Thyroid function during treatment with thionamides should be followed closely, keeping the serum total or free T4 at or just above the trimester-specific reference range to avoid fetal hypothyroidism.

Hypothyroidism in pregnancy 1. Hypothyroidism increases the risk of miscarriage, premature birth, and low birth weight; additionally, it is associated with decreased infant neurocognitive function. 2. Levothyroxine is the recommended treatment. For patients with preexisting hypothyroidism. A. levothyroxine dosing can be empirically increased by 30% when pregnancy is confirmed. B. In treatment-naïve pregnant individuals with positive TPO antibodies, levothyroxine is started if the TSH level is 2.5 μU/mL (2.5 mU/L) or higher.

3. Treatment is indicated for pregnant individuals who are A. TPO-negative with TSH above the pregnancy-specific reference range. B. TPO-positive with TSH 2.5 or higher. 4. Follow up: TSH should be measured every 4 weeks for the first half of pregnancy and around 30 weeks in all hypothyroid patients and in those at risk for hypothyroidism (antibody positive or history of hemithyroidectomy or 131I therapy). 5. Target: A TSH level less than 2.5 μU/mL (2.5 mU/L) should be targeted in treated patients with hypothyroidism before conception and during pregnancy.

الاكزامنيشن شگد ما هو بسيط و سهل، شكد ما هو ينطيك تشخيص و فكرة، في بعض الاحيان اكثر من الهستري (خاصة هستري الريلتف الي جوابهم جبناه لأن تخربط). اجى مريض بالغ من العمر 73 سنة، بسبب acute confusion state أستلمت الكيس، الي قبلي حرفيا كلشي مسويله، ما مقصرين ابد CT brain CBC RFT LFT S electrolytes ABG septic workup All back normal و كلشي طالع نگتف، و باقي سبب ال confusion ما محدد. فأجيت بفحص سريع (بسبب اللود) NO lymphadenopathy no neck stiffness no sign of fluid overload symmetrical reactive pupil clear chest normal S1/S2 skin: no sign of cellulitis abd exam: Sub umbilical mass !!! sent for pelvic US: showed urine retention with hugely distended bladder after Foley insertion, about 1300 ml of urine was passed. about 4 hrs later, the patient return completely to normal consciousness اصلا اجيت الصبح اسلّم الكيس، لگيتهم موقعين و طالعين ع مسؤوليتهم. شكد شي بسيط و سهل، بس بنفس الوقت مستهلك المقيمين الي شافوه بحيث دازيه كلشي، و ما واصلين لنتيجة. مرات واحد ينسى بسبب اللود، عادي جدا. بس عود نفسك ع الفحص السريع، ما راح تخسر شي، و بنفس الوقت راح تشخص هواي اشياء انت اصلا ما مفكر بيه. دائما افحص و دائما اخذ ال drug hx

A nice case for teaching purpose

Hepatitis B virus Treatment of hepatitis B virus (HBV) infection is advised for patients with: 1. acute liver failure 2. chronic infection in the immune-active phase or reactivation phase 3. cirrhosis 4. selected immunosuppressed patients. 5. beginning of the third trimester in pregnant patients with viral load greater than 200,000 U/mL. 6. Prophylactic oral antiviral therapy should be given to patients who are HBsAg-positive or isolated core antibody–positive and are receiving B-cell–depleting therapy (e.g., rituximab or ofatumumab), prednisone (≥10 mg/d for at least 4 weeks), or anthracycline derivatives. Patients receiving tumor necrosis factor-α or tyrosine kinase inhibitors should also be considered for prophylaxis. 7. Extra-hepatic manifestations like membranous nephropathy or polyarteritis nodosa Note: Immune-active chronic HBV infection is defined by presence of hepatitis B core antibody, elevated ALT level, and HBV viral load greater than 2000 U/mL in patients negative for HBeAg OR greater than 20,000 U/mL in patients positive for HBeAg. Treatment: First-line treatment is entecavir or tenofovir. Pegylated interferon can be used for 48 weeks in patients without cirrhosis who have high ALT levels and low HBV DNA levels. Lamivudine, adefovir, and telbivudine are less commonly used because of resistance. Target or goal of antiviral treatment: A. Treatment goals for patients in the HBeAg-positive immune-active phase are HBeAg loss with anti-HBe seroconversion, which should then be followed by an additional 12 months of treatment. B. Goals of treatment in the HBeAg-negative immune-active phase are HBV DNA suppression and ALT normalization; oral antiviral agents are generally continued indefinitely in this setting. C. Patients with cirrhosis should continue oral antiviral medications indefinitely. Note: HBsAg seroconversion rarely occurs with oral antiviral treatment and therefore is not a treatment goal.

ليش نگول الفحص مهم و مطلوب و عوّد نفسك ان تفحص و لو الاشياء الكمن ع السريع، ما ياخذ منك 3 دقائق A 47 yr old F, hx of liver cirrhosis due to primary biliary cirrhosis PBC. Referred from out patient clinic as a case of acute on chronic liver cirrhosis. By hx: the patient reported hx of fever with chills. no dysuria, abd pain, dyspnea, headache, rhinorrhea, or any focus of infection. Temp 39.9 C PR 101 soft abd, no organomegaly no skin infection -ve meningeal sign no stigmata of endocarditis no dental infection left bronchial breathing with wheeze ?? so sent for CXR, which showed mild infiltration. look to the CT chest?? severe left side consolidation Treated as a case of CAP.

Euglycemic DKA from Ahmed for common Ward and ICU Cases

السلام عليكم بظل لوود الطوارىء و كثرة كيسات الفلو و ألم المعدة و تساقط الشعر و الشعور بالخمول لأكثر من شهرين، راح تضيع الكيسات ال serious و الي الطوارىء موجودة علمودها. 57 yr old lady with hx of DM and hypertension >20 yrs. presented with shortness of breath SOB. This SOB preceded by 7 days hx of retrosternal chest pain, worsened by lying flat. الأكزام كان: dyspneic lady distended JVP markedly muffled heart sounds absent air entry on lung bases shocked patients و كلكم تتذكرون البوست البسيط الي نشرناه قبل فترة how to JVP guide you for diagnosis of shocked patient. هسه هذا البيشنت shock + distended jvp + muffled heart sounds + central trachea الـ ECG جدا واضح low voltage ECG This is a case of cardiac tamonade. Emergent pericardiocentesis was done (1000 ml), and the patient dramatically improved shortly after that. فيا زملائي الأعزاء: مو كل شووك، لازم تنطي فلود، و لا كل شووك لازم تستعمل نورادرينالين. هذا الفحص كله ما يطول منك 3 دقائق، و راح يكون منقذ للحياة.

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Methylene blue is used in vasoplegic shock when high-dose norepinephrine, vasopressin, and steroids fail to maintain MAP ≥ 65 mmHg. It works by inhibiting nitric oxide (NO)-mediated vasodilation, helping restore vascular tone. Indications for Methylene Blue in Septic Shock * Refractory Septic Shock (MAP < 65 mmHg despite high-dose vasopressors). * Vasoplegia (Distributive Shock) with High Cardiac Output, Low SVR. * Septic Shock with Profound Acidosis (Lactate > 4 mmol/L, pH < 7.2). * Post-cardiopulmonary bypass vasoplegia (if refractory to catecholamines). For the Infusion Protocol 1. Loading Dose (Slow IV Bolus Over 15-30 Minutes): • 1–2 mg/kg IV over 15–30 minutes • Dilution: Mix 50 mg (5 mL) of 1% methylene blue in 100 mL Normal Saline (NS) or D5W. • Infusion rate: Administer at 200–300 mL/hour to avoid hypotension. 2. Continuous Infusion (If Needed): • 0.25–0.5 mg/kg/hour IV infusion for 6–12 hours. • Dilution: Prepare 50 mg in 500 mL NS or D5W and run at 2–5 mL/hour (titrate based on response). For Monitoring & Precautions * Monitor BP every 5 minutes during bolus → Rapid infusion may cause paradoxical hypotension. * Check methemoglobin levels if prolonged infusion (>6 hrs). * Watch for rebound hypotension after stopping infusion. * Monitor renal & hepatic function (risk of toxicity in dysfunction).

محتويات الكتاب للي سألوا عن الفهرست، هذا هو و اذا اكو مواضيع تنضاف ببالكم، حتى اضيفها ع الطبعة الجاية بأذن الله

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