Act as Internalist 👨🏻‍⚕️🫀🩺

🔴Pneumothorax ▪︎Air Accumulation in Pleural Space (Between Visceral & Parietal Pleura) 🔹Causes Of Pneumothorax 📍1. Primary Sponetousnus : ▪︎Due To Apical Subpleural Blebs Rupture ▪︎No Hx Of Lung Disease ▪︎Mostly Occurs in Persons With : 🔻I. Cigarette & Cannabis Smokers 🔻II. Tall/Slim/Young Age Males (20-40 Years) 🔻III. Marfan Syndrome & Homocystinuria 📍2. Secondary Sponetousnus : ▪︎Hx Of Lung Disease Present ▪︎High Mortality Rate ▪︎Mostly Due To : 🔻I. COPD (Asthma Or Bullae Rupture in Emphysema) 🔻II. TB Infection & Lung Abscess 🔻III. Pulmonary Infarction 🔻IV. Lung Cancer 🔻V. Lung Fibrosis 🔻VI. Cystic Fibrosis 📍3. Traumatic ➡️ After Blunt Or Penetrating Or Iatrogenic Chest Trauma 📍4. Catamenial Pneumothorax ➡️ Pneumothorax Occurs At Time Of Menstruation In Women (Due To Endometriosis involving The Pleura) 🔹Types Of Sponetousnus Pneumothorax 📍1. Closed : ▪︎Air Accumulates Inside The Pleura Then The Leakage Stops ▪︎Spontaneous Air Absorption & Lung Re-Expansion in Days To Weeks 📍2. Open : ▪︎Air Moves Freely in & Out The Pleura ▪︎Seen in Emphysematous Bullae Rupture/TB Cavity/Lung Abscess ▪︎Risk Of Infection 📍3. Tension Pneumothorax (Most Dangerous) : ▪︎The Leakage Point Acts As One Way Valve Allow Air To Enter But Not Escape ▪︎Causing Large Amount Of Air Accumulation & Mediastinal Shift & Cardiovascular Compromise 🔹Clinical Features 📍1. Sudden Onset Unilateral Pleuritic Chest Pain & Dyspnea 📍2. Unilateral Decrease Or Absent Breath Sounds 📍3. Unilateral HyperResonant To Percussion 📍4. Unilateral Reduce Chest Expansion 📍5. Marked Tachycardia/Hypotension/Cyanosis/Tracheal Deviation Away (In Tension Pneumothorax) 🔹Dx Of Pneumothorax (By Chest Xray) 📍1. Visible Pleural Line 📍2. Absent Lung Markings At Periphery 📍3. Deep Sulcus Sign (Depression Of CostoPhrenic Angle) *For Tiny Pneumothorax ➡️ Use Lateral Chest Xray 🔹Mx Of Pneumothorax 📍1. Give High flow Oxygen To All Patients 📍2. Mild Primary Sponetousnus (Lung Edge <2cm) ➡️ Resolve Spontaneously 📍3. Moderate To Large Primary Sponetousnus ➡️ Percutaneous Needle Aspiration Of Air 📍4. Secondary Sponetousnus (Chronic Lung Disease & Respiratory Distress Present) ➡️ InterCostal Tube Drainage & inpatient Observation 📍5. Tension Pneumothorax : ▪︎Immediate Insertion Of Blunt Cannula into The 2nd InterCostal Space Mid Clavicular Line ▪︎Then Chest Drain inserted into The 4th-5th-6th InterCostal Space Mid Axillary Line

❇️ Nail Changes 🛑Koilonychia ▪︎Spoon-shaped depression of nail plate ▪︎Iron deiciency anaemia ▪︎lichen planus ▪︎repeated exposure to detergents 🛑Splinter haemorrhages ▪︎Small red streaks lie longitudinally in the nail plate ▪︎Trauma ▪︎infective endocarditis 🛑Leukonychia (white nails) ▪︎hypoalbuminaemia ▪︎protein calorie malnutrition (kwashiorkor) ▪︎malabsorption due to protein-losing enteropathy, e.g. coeliac disease ▪︎heavy and prolonged proteinuria (nephrotic syndrome)

❇️Grading Of Murmurs

❇️Timing Of Heart Murmurs

🔸D. ARDS (Adult Or Acute Respiratory Distress Syndrome)

▪︎Is Acute Respiratory Failure Due To Diffuse Neutrophilic Alveolitis (Neutrophils Infiltrate The Alveoli) ▪︎Occurs Mostly After Sepsis (Systemic Infection)

🔹Risk Factors For ARDS

📍1. Direct Lung Injury :

▪︎Acid Aspiration & Toxin inhalation & O² Toxicity ▪︎Pneumonia & Radiation Pneumonitis ▪︎Chest Trauma & Drowning ▪︎Pulmonary Embolism

📍2. Indirect Lung Injury :

▪︎Sepsis (Systemic Infection) ▪︎Severe Body Trauma Or Severe Head Injury & Massive Blood Transfusion ▪︎Acute Pancreatitis ▪︎Anaphylaxis & DIC & Shock ▪︎Narcotic Drugs Overdose ▪︎Prolonged Cardiopulmonary Bypass Surgery

🔹Pathological Features Of ARDS

📍1. Hyaline Membrane Formation (Exudation Accumulates Inside The Alveoli) 📍2. Loss Of Surfactant

🔹Clinical Features & Dx Of ARDS

📍1. Onset Within 1w Of Clinical Insult (Or New Or Worsening Respiratory Symptoms) 📍2. Bilateral Lung Opacities At The Periphery (Seen By Xray) 📍3. Respiratory Failure & Impaired Oxygenation (Hypoxemia/HyperCapnia) 📍4. Acute Dyspnea (SOB)/Tachycardia/Tachypnea/Cyanosis 📍5. Fever/Cough/Chest Pain 📍6. Diffuse Crackles

🔹Mx Of ARDS

📍1. Prone Position نايم على بطنه 📍2. Oxygen (Keep Saturation >90%) 📍3. Fluids 📍4. Mechanical Support : ▪︎Mechanical Ventilation ▪︎ECMO (Extra Corporial Membrane Oxygenation) 📍5. Drugs : ▪︎Diuretics ▪︎Neuromuscular Blockers (Muscle Relaxants) ▪︎Steroids ▪︎Surfactant ▪︎Nitric Oxide ▪︎Epoprostenol ▪︎Antibiotics ▪︎Bronchodilators

🔹Complications Of ARDS

📍1. Permanent Lung Injury 📍2. Renal Failure Or Multi-Organ Failure 📍4. Stress Ulcer 📍5. Mechanical Ventilation Complications (BartoTrauma/Pneumonia) 📍6. Infections (Catheter & NG Tube Infections/UTI)

⭕️Indication of pericardiocentesis: 1-Cardiac tamponade (emergency). 2-Sever pericardial effusion. 3-Suspected purulent pericarditis. 4-Suspected tuberculous pericarditis.

أخانا ورفيقَ الخُطى الدكتور عبدالكريم: ​في رحلتنا الشاقة بين أروقةِ الطب وميادين التعب، في زحمةِ الصبرِ وشَرَفِ الرسالة، تعلمنَا أن النُّبلَ لا يُكتسب، بل هو خُلُقٌ فِطريّ، وأن العقولَ الكبيرةَ هي التي تُميّزُ قَدرَ القراراتِ ومَصيريّتها. ​واليوم، ونحن نراك تخطو بكاملِ الوعي والنُّضجِ نحو هذا الميثاقِ الغليظ ، نزفَّ لك أصدقَ نبضاتِ قلوبنا ومشاعِرِنا الوديّة ؛ لأننا ندركُ أنك لا تفتحُ باباً مجرداً لخطوبة، بل تُؤسسُ لكيانٍ مَهيب، وتختارُ بعقلِ الحكيمِ وروحِ النبيلِ مَن تُشارِكُك ثِقلَ المسيرةِ وسُموَّ الغاية فالزواج مرفأُ الأرواحِ التي تعرفُ كيف تبني وتصون، وإنك أليقُ الناسِ بأن تفتحَ بابَ هذا الفضل، وأهلٌ لأن تُشيّد بيتاً على أركانٍ وثيقةٍ من الوعي، والمودة.. ​نسألُ اللهَ العليّ القديرَ أن يبارك لكما وعليكما، وأن يجمع بينكما في خير، وأن يجعلَ هذا الرباطَ بدايةً لعمرٍ مِلؤهُ السكينةُ والرفعة، وزاداً لك على طريقِ التميز والجهاد مقدمة من رفاق الدرب.. دفعة سيف القدس – كلية الطب البشري

charcot foot - DM pt

💢When to Use The Bell of Stethoscope The bell of the stethoscope is more effective at detecting low-frequency sounds, like: ▪︎the mid-diastolic murmur of mitral stenosis.

💢Valve locations ▪︎Mitral valve: 5th intercostal space in the midclavicular line. ▪︎Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge. ▪︎Pulmonary valve: 2nd intercostal space at the left sternal edge. ▪︎Aortic valve: 2nd intercostal space at the right sternal edge.

💢Collapsing pulse (water hammer pulse) is a forceful pulse that rapidly increases and subsequently collapses. 🔹To assess for a collapsing pulse: ▪︎Palpate the radial pulse with your right hand wrapped around the patient’s wrist. ▪︎Palpate the brachial pulse (medial to the biceps brachii tendon) with your left hand. ▪︎Raise the patient’s arm above their head. ▪︎As blood rapidly empties from the arm in diastole, you should be able to feel a tapping impulse through the muscle bulk of the arm. This is caused by the sudden retraction of the column of blood within the arm during diastole. 🔹Causes of a collapsing pulse ▪︎Normal physiological states (e.g. fever, pregnancy) ▪︎Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus) ▪︎High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)

💢Radio-radial delay is a loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times. 🔹To assess for radio-radial delay: ▪︎Palpate both radial pulses simultaneously. ▪︎In healthy individuals, the pulses should occur at the same time. ▪︎If the radial pulses are out of sync, this would be described as radio-radial delay. 🔹Causes of radio-radial delay include: ▪︎Subclavian artery stenosis (e.g. compression by a cervical rib) ▪︎Aortic dissection ▪︎Aortic coarctation

💢Types of pulse character ▪︎Normal ▪︎Slow-rising •Aortic stenosis ▪︎Bounding •Aortic regurgitation •CO2 retention ▪︎Thready •intravascular hypovolaemia in conditions such as sepsis 🔹Pulsus paradoxus:  ▪︎pulse wave volume decreases significantly during the inspiratory phase. ▪︎Indicate •late sign of cardiac tamponade •severe acute asthma •severe exacerbations of COPD

❇️DDX in Respiratory Examination 🔹Fine Crackles ▪︎Interstitial Lung Disease (Fibrosis). ▪︎Pulmonary Edema. ▪︎Early Phase of Pneumonia. ▪︎Atypical Pneumonia 🔹Coarse Crackles ▪︎Bronchiectesis. ▪︎Chronic Bronchitis. ▪︎Late Phase of Pneumonia. (Resolution) ▪︎Tb Abcess ▪︎Advanced Pulmonary Oedema *Crackels Heard during inspiration *Coarse Crackles Disappeared by Cough. 🔹Wheeze ▪︎Unilateral ➡️ Local Obstruction Of major airway (By Tumor/Foreign Body/Mucus Plug) ▪︎Bilateral ➡️ Asthma & COPD/Bronchiolitis/Cardiac Asthma (Pulmonary Edema Due To HF) *Wheeze Heard in Expiration 🔹Bronchial Breathing ▪︎Consolidation of Pneumonia 🔹Pleural Rub ▪︎pleuritis (Inflammation of Pleural Tissue) 🔹Stridor ▪︎obstruction or narrowing in the upper airway 🔹Bilateral Decrease in air entry ▪︎Asthma. ▪︎COPD. ▪︎Bronchiectesis. ▪︎Interstitial Lung Disease. 🔹Unilateral Decrease in air entry ▪︎Pleural Effusion. ▪︎Pneumothorax. ▪︎Lung Collapse. ▪︎Pneumonectomy or Lobectomy. 🔹Bilateral Decrease Chest Movement ▪︎Asthma. ▪︎COPD. ▪︎Bronchiectesis. ▪︎Interstitial Lung Disease (ILD). ▪︎Broncho-Pneumonia. 🔹Unilateral Decrease Chest Movement ▪︎Pleural Effusion (Lower Zone). ▪︎Pneumothorax (Upper Zone). ▪︎Lung Collapse. ▪︎Lobar-Pneumonia. ▪︎Pneumonectomy or Lobectomy 🔹Increase Tactile Vocal Fremitus & Vocal Resonant ▪︎Consolidation in Pneumonia 🔹Decrease Tactile Vocal Fremitus & Vocal Resonant ▪︎Asthma. ▪︎COPD. ▪︎Lung Fibrosis. ▪︎Pleural Effusion. ▪︎Pneumothorax. 🔹Hyper-Resonant ▪︎Pneumothorax ▪︎COPD (Asthma, Broncheictesis). 🔹Dull ➡️ Consolidation (Pneumonia)/Collapse/Cavity 🔹Stony Dull ➡️ Pleural Effusion.

🔴Respiratory Failure (RF) ▪︎When The Pulmonary System Fails To Maintain Normal Level Of Arterial Oxygen & CO² ▪︎Normal PaO² ➡️ 80-100 mmHg ▪︎Normal PaCo² ➡️ 35-45 mmHg 🔰Types Of RF 🔸A. Hypoxic (Type I RF/Only Low Oxygen) ▪︎Results From Diseases Affect Specific Part Of The Lung (Impaired Oxygenation in Specific Part Of The Lung) ▪︎Results In Mixture Of Under Ventilated & Normally Ventilated Parts Of lung ▪︎The Normal Parts Of The Lung Will Compensate & Prevent The Development Of Hypercapnia فيه اجزاء كبيرة من الرئة تشتغل طبيعي بالتالي تقدر تعوض وتصحح الارتفاع الحاصل بنسبة الكاربون ، بالتالي نسبة الكاربون بالدم راح تبقى طبيعية (او ممكن تقل) ، اما نسبة الأوكسجين تنخفض بسبب ان الهيموجلوبين صاير فيه تشبع وما يقدر يعوض النقص 🔹Main Features Of Type I RF 📍1. Hypoxemia (PaO² <60 mmHg) 📍2. Normal Or Low PaCo² (≤45 mmHg) 📍3. Cyanosis & Dyspnea (SOB) 📍4. Tachycardia/Tachypnea/Confusion 🔹Causes Of Type I RF 1. Pneumonia 2. Lobar Collapse (Atelectasis) 3. Local Lung Injury 4. ARDS (Acute Respiratory Distress Syndrome) 5. Pneumothorax 6. Pulmonary Embolism (PE) 7. Pulmonary Edema 🔹Mx Of Type I RF 📍1. High Flow Oxygen Concentration (40-60% By Mask) 📍2. Mechanical Ventilation in Severe Conditions (Severe Multilobar Pneumonia) 🔸B. Hypercapnic (Type II RF/Low Oxygen & High CO²) ▪︎Results From Diseases Affect The Entire Work Of The Respiratory System (Generalised Severe Ventilation Perfusion Mismatch) ▪︎No Sufficient Normal Parts Of The Lung Can Compensate الاجزاء المتبقية من الرئة ما تكفي ان تعوض وتصحح المشاكل الحاصلة ، بالتالي نسبة الكاربون بالدم راح ترتفع ونسبة الأوكسجين تقل 🔹Main Features Of Type II RF 📍1. Hypoxemia (PaO² <60 mmHg) 📍2. Hypercapnia (PaCo² >45 mmHg) 📍3. Warm Limbs With Flapping Tremor (Astrexis) 📍4. Headache & Somnolence (منعس) 📍5. Respiratory Acidosis (High Co²/Low PH) 🔹Causes Of Type II RF 1. COPD & Asthma 2. CNS & Respiratory Centres Depression 3. Neuromuscular Disorders 4. KyphoScoliosis & Ankylosing Spondylitis 5. Electrolytes Imbalance 6. Sleep Apnea 7. Upper Airway Obstruction (By Foreign Body Or Trauma Or Edema) 🔹Mx Of Type II RF (According To Cause) 📍1. Inspiratory Stridor Present (Acute Upper Airway Obstruction) : ▪︎Heimlich Maneuver ▪︎Immediate Intubation ▪︎Emergent Tracheostomy 📍2. COPD/Asthma/ARDS/Pneumothorax : ▪︎Oxygen (Low Concentration 24-28% For COPD/High Concentration 60% For Others) ▪︎Chest Drain For Pneumothorax ▪︎Bronchodilators (Salbutamol 2.5mg) For COPD & Asthma 📍3. Mechanical Ventilation If : ▪︎No Response To Mx ▪︎Decrease Conscious Level ▪︎Worsening Respiratory Acidosis (Ph<7.3) ▪︎Continue Raising Co² (>50 mmHg) 🔸C. Acute On Chronic Type II RF ▪︎Acute Exacerbations Of Longstanding Chronic Respiratory Failure ▪︎Mostly Due To COPD Exacerbations By Infection ▪︎Acute Exacerbations Causing Loss Chemosensitivity To Chronic High Levels Of Co² بالحالة الطبيعية المريض المزمن يكون متعود على المستويات العالية من الكاربون بالدم، لذلك ما ترتفع عنده حامضية الدم ، اما من تحصل مشكلة سريعة مثل التهاب، هنا تتخربط الاوضاع ويفقد القدرة على تحمل مستويات الكاربون العالية، بالتالي يدخل بحامضية الدم (Acidosis) 🔹Main Features Of Acute On Chronic RF 📍1. Acute Acidosis 📍2. Respiratory Distress 📍3. Drowsiness & Coma 📍4. Severe Hypoxemia & Hypercapnia 📍5. Delirium 📍6. Flapping Tremor 📍7. Bounding Pulse نبض قوي 📍8. Patients Not Appears Distressed (Due To Chronic Tolerance To High Co² Levels) 🔹Mx Of Acute On Chronic RF 📍1. Nebulised Bronchodilators 📍2. Low Concentration Oxygen (24%) 📍3. Antibiotics (If Infection Present) 📍4. Diuretics (If Fluid Overload Present) 📍5. Mechanical Ventilation (If PaCo² Continue Raise Or PaO² Still Low)

Palmer erythema هذه الذي نعرفها