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👉 IMPORTANT 686 👈 Some info about Stress echocardiography 1.Performed before and immediately after exercise. 2.Exercise-induced ischemia is evidenced by wall motion abnormalities (e.g., akinesis or hypokinesis) not present at rest. This study is less reliable in patients with existing wall motion abnormalities or lowered EF. 3.Favored by many cardiologists over stress ECG. It is more sensitive in detecting ischemia, can assess LV size and function, can diagnose valvular disease, and can be used to identify CAD in the presence of pre-existing ECG abnormalities. Ideally patients with a positive test result should undergo cardiac catheterization. paceUrMRCP.

👉 IMPORTANT 685 👈 Few etiologies of dyspnoea by timing of onset Acute Foreign body Pneumothorax Pulmonary embolus Acute pulmonary oedema Subacute Asthma Parenchymal disease,eg alveolitis pneumonia, Effusion Chronic COPD and chronic parenchymal diseases Non-respiratory causes, eg cardiac failure, anaemia paceUrMRCP.

👉 IMPORTANT 684 👈 MRC Dyspnoea Scale 1.Not troubled by breathlessness except on strenuous exercise. 2.Short of breath when hurrying or walking up a slight hill 3.Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace 4.Stops for breath after walking about 100m or after a few minutes on level ground 5.Too breathless to leave house or breathless when dressing paceUrMRCP.

ANNOUNCEMENT FOR ONLINE COURSE NO 42 ( 22 July 24—09 Aug 24 ) Hello and salam everyone. We are pleased to announce admissions for our July-Aug 2024 online course ( 15 days ) for PACES MRCP (UK) and CLINICAL EXAM MRCPI . We will start from 22th of July 24 and finish on 09th of Aug 24. Active slots available on first come--first served basis. Listener slot available too. At least 90 Important exam cases ( including recent diets cases ) will be practiced and discussed as we do in our weekly Sunday sessions. After the performance detailed feedback will be given to elaborate on the weak skills. It is equally beneficial for those who are beginners or have exams in coming diet. Interested candidates may send a personal message for details. WhatsApp No: +923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

👉 IMPORTANT 683 👈 Few DVT Risk Factors: Hematological • Thrombophilia: e.g. Activated protein C resistance, protein C and S deficiency • Polycythemia • Paroxysmal nocturnal hemoglobinuria • Hyperviscosity syndrome Autoimmune • Antiphospholipid syndrome • Behcet's Drugs • Combined oral contraceptive pill • Antipsychotics (especially olanzapine) have recently been shown to be a risk factor Other conditions • Homocystinuria paceUrMRCP.

👉 IMPORTANT 682 👈 Some risk factors for Ischemic heart disease a. Diabetes mellitus (DM)—worst risk factor b. Hyperlipidemia —elevated low-density lipoprotein (LDL) c. Hypertension (HTN)—most common risk factor d. Cigarette smoking e. Age (men >45 years; women >55 years) f. Family history of premature coronary artery disease (CAD) or myocardial infarction (MI) in first-degree relative: Men <55 years; women <65 years g. Low levels of high-density lipoprotein(HDL) h.end-stage renal disease (ESRD) on hemodialysis, i.human immunodeficiency virus (HIV) infection, j.history of mediastinal radiation. And never miss to ask about obesity,sedentary lifestyle (lack of physical activity), stress, excess alcohol use. paceUrMRCP.

👉 IMPORTANT 681 👈 Some info about Dyspnoea Subjective sensation of shortness of breath, often exacerbated by exertion. • Lung—airway and interstitial disease. May be hard to separate from cardiac causes; asthma may wake patient, and cause early morning dyspnoea & wheeze. • Cardiac—eg ischaemic heart disease or left ventricular failure (LVF), mitral stenosis, of any cause. LVF is associated with orthopnoea (dyspnoea worse on lying; ‘How many pillows do you use while sleeping?’) and paroxysmal nocturnal dyspnoea (PND;dyspnoea waking one up). Other features include ankle oedema, lung crepitations, and raised JVP. • Anatomical—eg diseases of the chest wall, muscles, pleura. Ascites can cause breathlessness by splinting the diaphragm, restricting its movement. • Others Any shocked patient may also be dyspnoeic—dyspnoea may be shock’s presenting feature. Also anaemia or metabolic acidosis causing respiratory compensation, eg ketoacidosis, aspirin poisoning. Look for other clues—dyspnoea at rest unassociated with exertion, may be psychogenic: prolonged hyperventilation causes respiratory alkalosis. This causes a fall in ionized calcium leading to apparent hypocalcaemia. Features include peripheral and perioral paraesthesiae ± carpopedal spasm. Speed of onset helps diagnosis. paceUrMRCP.

✌️✌️ HEARTIEST CONGRATULATIONS ✌️✌️ To Dr Sneha Thomas For passing PACES MRCP ( UK ) from India. We wish her the best for her future.

👉 IMPORTANT 680 👈 Some info about NOACS The table below summaries the three direct oral anticoagulants (DOACs): dabigatran, rivaroxaban and apixaban. Dabigatran(Pradaxa) Rivaroxaban(Xarelto) Apixaban(Eliquis) DABIGATRIN: ExcretionMajority renal RIVAROXABAN: Majority liver. APIXABAN Majority faecal. NICE indications. Prevention of VTE following hip/knee surgery Treatment of DVT and PE Prevention of stroke in non-valvular AF . Dabigatrin reversal:Idarucizumab RIVORAXABAN and APIXABAN Reversal:Andexanet. NICE stipulate that certain other risk factors should be present. These are complicated and differ between the DOACs but generally require one of the following to be present: prior stroke or transient ischaemic attack age 75 years or older hypertension diabetes mellitus heart failure paceUrMRCP.

👉 IMPORTANT 679 👈 Few more signs of Aortic regurgitation for academic interest* Gerhardt Sign ..... Systolic Pulsation of Spleen RosenBach Sign ..... Systolic Pulsation of liver Becker Sign .......systolic foundation of Retinal vessels. paceUrMRCP.

👉 IMPORTANT 678 👈 Some signs of Aortic Regurgitation de Musset’s sign —head nodding . Müller’s sign —systolic pulsations of the uvula. Corrigan’s sign —visible carotid pulsations. Quincke’s sign —capillary nailbed pulsation in the fingers. Traube’s sign —‘pistol shot’ femorals, a booming sound heard over the femorals. Duroziez’s sign —to and fro diastolic murmur heard when compressing the femorals proximally with the stethoscope. paceUrMRCP.

ANNOUNCEMENT FOR ONLINE COURSE NO 42 ( 22 July 24—09 Aug 24 ) Hello and salam everyone. We are pleased to announce admissions for our July-Aug 2024 online course ( 15 days ) for PACES MRCP (UK) and CLINICAL EXAM MRCPI . We will start from 22th of July 24 and finish on 09th of Aug 24. Active slots available on first come--first served basis. Listener slot available too. At least 90 Important exam cases ( including recent diets cases ) will be practiced and discussed as we do in our weekly Sunday sessions. After the performance detailed feedback will be given to elaborate on the weak skills. It is equally beneficial for those who are beginners or have exams in coming diet. Interested candidates may send a personal message for details. WhatsApp No: +923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

👉 IMPORTANT 677 👈 Some prognostic indicators of Coronary artery Disease 1. Left ventricular function (ejection fraction [EF]) Normal >50% If <50%, associated with increased mortality 2.. Vessel(s) involved (severity/extent of ischemia) Left main coronary artery—poor prognosis because it supplies approximately two-thirds of the heart Two- or three-vessel CAD—worse prognosis paceUrMRCP.

👉 IMPORTANT 676 👈 Some info about heart sounds 4th heart sound (S4) occurs just before S1. Always abnormal. It represents atrial contraction against a ventricle made stiff by any cause, eg aortic stenosis or hypertensive heart disease. paceUrMRCP.

👉 IMPORTANT 675 👈 Some info about heart rhythms Triple and gallop rhythms A 3rd or 4th heart sound occurring with a sinus tachycardia may give the impression of galloping hooves. When S3 and S4 occur in a tachycardia, eg with pulmonary embolism, they may summate and appear as a single sound, a summation gallop. paceUrMRCP.

👉 IMPORTANT 674 👈 Some info about heart sounds 3rd heart sound (S3) may occur just after S2. It is low pitched and best heard with the bell of the stethoscope. S3 is pathological over the age of 30yrs. A loud S3 occurs in a dilated left ventricle with rapid ventricular filling (mitral regurgitation, VSD) or poor LV function (post MI, dilated cardiomyopathy). In constrictive pericarditis or restrictive cardiomyopathy it occurs early and is more high pitched (‘pericardial knock’). paceUrMRCP.

👉 IMPORTANT 673 👈 Some info about heart sounds The 2nd heart sound ( S2) Represents aortic ( A2 )and pulmonary valve ( P2) closure. The most important abnormality of A2 is softening in aortic stenosis. • A2 is said to be loud in tachycardia, hypertension, and transposition, but this is probably not a useful clinical entity. • P2 is loud in pulmonary hypertension and soft in pulmonary stenosis. • Splitting of S2 in inspiration is normal and is mainly due to the variation of right heart venous return with respiration, delaying the pulmonary component. • Wide splitting occurs in right bundle branch block (BBB), pulmonary stenosis, deep inspiration, mitral regurgitation, and VSD. • Wide fixed splitting occurs in atrial septal defect (ASD). • Reversed splitting (ie A2 following P2, with splitting increasing on expiration) occurs in left bundle branch block, aortic stenosis, PDA (patent ductus arteriosus), and right ventricular pacing. • A single S2 occurs in Fallot’s tetralogy, severe aortic or pulmonary stenosis, pulmonary atresia, Eisenmenger’s syndrome, large VSD, or hypertension. NB: splitting and P2 are heard best in the pulmonary area. paceUrMRCP.

👉 IMPORTANT 672 👈 Please note that Elderly patients with BPH might be taking alpha 1 blockers which may cause postural (orthostatic) hypotension, a common case of dizziness in elderly patients in exams. examples (tamsulosin, prazocin) paceUrMRCP.

ANNOUNCEMENT FOR ONLINE COURSE NO 42 ( 22 July 24—09 Aug 24 ) Hello and salam everyone. We are pleased to announce admissions for our July-Aug 2024 online course ( 15 days ) for PACES MRCP (UK) and CLINICAL EXAM MRCPI . We will start from 22th of July 24 and finish on 09th of Aug 24. Active slots available on first come--first served basis. Listener slot available too. At least 90 Important exam cases ( including recent diets cases ) will be practiced and discussed as we do in our weekly Sunday sessions. After the performance detailed feedback will be given to elaborate on the weak skills. It is equally beneficial for those who are beginners or have exams in coming diet. Interested candidates may send a personal message for details. WhatsApp No: +923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

Dear colleagues I regret to inform you that our session for tomorrow is cancelled due to some inevitable travelling. I am sorry for any inconvenience.