IV Notes 💉

/2Cl

Loop diuretics, such as furosemide, inhibit the Na+/K+/2Cl- cotransporter in the thick ascending limb of the loop of Henle and stimulate prostaglandin E release (prostaglandins maintain renal blood flow by inducing vasodilation of the afferent arterioles). Agents that inhibit prostaglandin synthesis (NSAIDs) counteract this effect and decrease the efficacy of loop diuretics.

64y woman is brought to the ER because of a 1-week history of progressive shortness of breath, lower extremity edema. She has ischemic cardiomyopathy and rheumatoid arthritis. Her respirations are 27/min. Examination shows pitting edema of the lower extremities and crackles over both lower lung fields. Therapy is initiated with intravenous furosemide. After 2 hours, urine output is minimal. Concomitant treatment with which of the following drugs is most likely to cause treatment failure?

Nephrolithiasis typically manifests with unilateral, colicky flank pain that may radiate to the groin with associated costovertebral angle tenderness and is usually associated with microscopic hematuria and dysuria. To confirm the diagnosis, imaging is required. The gold standard is abdominopelvic CT scan to calculate size, site, and density of the stone and detect possible hydronephrosis on the affected side. However, since this patient is pregnant, the modality of choice would be ultrasound of the kidneys, ureters, and the bladder, which can also rule out other gynecological differential diagnoses. Cholecystitis is common in pregnancy due to decreased gallbladder motility and increased cholesterol content of bile. The typical presentation of cholecystitis is episodic right upper quadrant pain (with possible radiation to the back or right shoulder), especially after meals, along with nausea and vomiting. The patient described here has unilateral pain but it radiates to the groin and there is no report of symptoms being temporally related to eating. Additionally, cholecystitis would not explain her dysuria and hematuria. Ovarian torsion is a surgical emergency seen most often in nonpregnant and first-trimester women as the gravid uterus limits the mobility of the ovaries in women further along in pregnancy. Affected patients often describe acute progressive, unilateral, lower quadrant pain after exercise or other physical activity. This patient is already in the 30th week of pregnancy. Moreover, ovarian torsion could not explain the microscopic hematuria or costovertebral tenderness. Lower urinary tract infection is very common in pregnant patients since the enlarging uterus increases urinary stasis and progesterone diminishes the effectiveness of bladder mobility. Infections generally present with low-grade or no fever, dysuria, and suprapubic tenderness. Urinalysis shows hematuria, positive leukocyte esterase, and pyuria. In this patient, the absence of true pyuria (> 10 WBC) and the presence of colicky flank pain are inconsistent with the common presentation of a lower urinary tract infection. Also the typical presentation of upper urinary tract infection consists of high fevers (> 39.0° C), chills, and constant unilateral flank pain with dysuria as well as urinary frequency and urgency. Urinalysis almost always exhibits hematuria and pyuria. Although this patient has flank pain, costovertebral angle tenderness, and hematuria, she does not have fever and/or significant pyuria, which makes pyelonephritis unlikely. Appendicitis , the classic presentation consists of new-onset abdominal pain that begins diffusely in the periumbilical area and subsequently migrates to the right lower quadrant. Nausea, vomiting, fever, and reduced appetite are also often present. Although appendicitis may also manifest in a nonclassic fashion, e.g. with the kind of pain described here, it is not the most likely explanation for this patient's condition. Additionally, it would not explain her dysuria and hematuria. Acute pelvic inflammatory disease may also manifest with dysuria and nausea; however, abnormal vaginal discharge would be expected as well as severe pain of the lower abdomen instead of back pain. There is also no sexual history to indicate that this patient is at increased risk of PID. Furthermore, the risk of PID is generally lower in pregnancy since the cervical mucus plug prevents bacteria from ascending. Lastly, PID would not typically cause hematuria.

26y pregnant woman at 30 weeks' gestation comes to you because of severe right-sided back pain for the last hour. The pain is colicky and radiates to the right groin. The patient also reports nausea and dysuria. Pregnancy has been uncomplicated. Her only medication is a prenatal vitamin. Temperature is 37.0°C, pulse is 90/min, and blood pressure is 130/80 mm Hg. Examination of the back shows costovertebral angle tenderness on the right side. Urine studies show: Protein negative RBC casts negative RBC 5–7 WBC casts negative WBC 1–2

لو ركزنا مع ال Ear شوية ممكن نطلع بالأتي : - في ال otomycosis لازم أكمل ال antifungal لمدة شهر ع الأقل , قبل كدة هترجع تاني - لو فيه fruncle don't squeez it هيدخلك في perichosndritis - عيان ال common cold ميشدش نفس جامد عشان ال infection متعديش من ال ET ويخش في OM - في حالات ال acute OM ال follow up لازم يكون سريع في خلال يومين لأن ال complications بتحصل بسرعة - في الأطفال كتير هتـ misdiagnose ال Acute OM على انها GE بسبب إنها بتيجي ب vomiting & diarrhea فخد بالك - بعد علاج ال OM خد بالك إن ال discharge ممكن يستمر شهور , وده مش فارق معايا بقدر ما يفرق معايا هل فيه complications أو ال Hearing مش تمام ولا لأ , لو مفيش مشاكل كمل عادي وتابعه , لو فيه مشاكل يبقى الحل Myringotomy . - ال antihistaminic , decongestants , corticosteroids ملهمش لازمة في علاج ال AOM - Petrositis is diagnosed by gardengo triad 1- ear discharge 2- Diplopia&squent 3- facial pain - DD of pulsatile ear disharge : 1- AOM with perforation 2- Acute exacerbation of CSOM 3- Extradural abscess - Glomus tumor causes pulsatile tennitus - Hearing better in noisy areas suspecting otosclerosis - Ototoxic drugs reversible > aspirin , furosemide , quinine irreversible > aminoglycosides & cytotoxic drugs - the 2 most common causes of vertigo 1- Benign paroxysmal positional vertigo (( for secondes in shaving position )) 2- Vesitibular neuritis (( for days with nausea & vomiting )) #By_Dr_Mo

fatigue, conjunctival pallor, angular cheilitis, koilonychia, low hemoglobin, decreased MCV, and increased RDW = IDA Oral iron supplementation is the initial treatment of choice for iron deficiency anemia (IDA). This patient's high consumption of cereal puts him at risk for developing this condition because cereal is typically low in iron, and the concomitant intake of cow's milk disrupts iron absorption. Therefore, this patient should also receive counseling on how to improve dietary iron intake. Other common laboratory findings in IDA include decreased ferritin, increased transferrin, decreased transferrin saturation, and decreased mean corpuscular hemoglobin (hypochromic anemia). Regular blood transfusions are a possible treatment option in patients with major thalassemia, which are characterized by microcytic anemia, as seen here. While fatigue, low energy, and conjunctival pallor are findings typical of any type of anemia, MCV in patients with thalassemia is usually decreased more markedly (< 75 μm3) and the RDW is usually normal. Furthermore, angular cheilitis and koilonychia are not typically seen in thalassemia. Vitamin B12 supplementation is indicated in patients with vitamin B12 deficiency, which may manifest with clinical and laboratory findings of anemia (e.g., decreased hemoglobin and hematocrit, fatigue, low energy, and conjunctival pallor) and angular cheilitis. But vitamin B12 deficiency causes macrocytic anemia (↑ MCV), or more specifically, megaloblastic anemia, rather than microcytic anemia. L-thyroxine is the treatment of choice in patients with hypothyroidism. This patient has a positive family history of Hashimoto thyroiditis and presents with fatigue, which is a typical feature of hypothyroidism. However, hypothyroidism is typically associated with normocytic or macrocytic nonmegaloblastic anemia and the absence of additional features of hypothyroidism (e.g., cold intolerance, dry skin, hair loss, weight gain, constipation, myopathy) makes the diagnosis unlikely.

15y boy presented with fatigue for several weeks. The parents report that their son has low energy. The patient's academic performance has declined recently. He spends most of his time playing video games and eating milk and cereal. He reports no other symptoms and has no history of serious illness. His mother has Hashimoto thyroiditis. His vital signs are within normal limits. Examination shows conjunctival pallor, inflammation and fissuring of the corners of the mouth, and concavity of the fingernails. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 11.5 g/dL Mean corpuscular volume (MCV) 76 μm3 (N = 80-100) Red cell distribution width (RDW) 18% (N = 13%–15%) Leukocyte count 7,000/mm3 Platelet count 290,000/mm3

بالمرة نفتكر علاج ال Giardiasis Fluid replacement أهم حاجة متسيبش دماغك تسرح ناحية المضادات الحيوية وخلاص وتنسى أهم حاجة زي ما قولنا من يومين ال Dehydration ثم Metronidazole (Flagyl): 500mg oral/12h for 5 to 10 days OR Tinidazole (Protozole): 2 g oral single dose OR Albendazole (Vermizole) : 400 mg once daily oral for 5 days & Diet Low lactose/lactose free for at least 1 month, low fat

Frothy, nonbloody diarrhea with crampy abdominal pain and bloating in an afebrile individual with a history of drinking contaminated water is consistent with giardiasis. Ingesting cysts from contaminated water sources (e.g., lakes, rivers, ponds, swimming pools) can cause infection with Giardia lamblia. Giardiasis impairs absorption within the gastrointestinal tract, leading to foul-smelling, greasy, and frothy diarrhea. Abdominal pain and diarrhea after the consumption of contaminated water can be seen in shigellosis. The diarrhea typical of Shigella infection, however, is profuse inflammatory and mucoid-bloody as opposed to this patient's frothy, nonbloody diarrhea. In addition, he lacks other key features of shigellosis such as high fever and tenesmus. Finally, this patient's bloating and flatulence are not consistent with shigellosis. Campylobacteriosis typically manifests with bloody, inflammatory diarrhea, fever, and abdominal pain presenting as pseudoappendicitis or colitis, none of which is seen in this patient. Moreover, Campylobacter is transmitted by the fecal-oral route from the consumption of undercooked meat or unpasteurized milk products, and direct contact with infected animals (most commonly dogs, cats, chickens) and their waste products, which this patient has no history of. Abdominal pain and watery diarrhea are symptoms seen in salmonellosis. Infection with Salmonella also commonly manifests with fever and severe vomiting, both of which are absent in this patient. Moreover, Salmonella is transmitted by the consumption of contaminated food products (notably poultry, raw eggs, and unpasteurized dairy), as opposed to drinking contaminated water . Finally, this patient's bloating and flatulence are not consistent with salmonellosis.

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هو في أيه : عيان 25 سنة داخل عليك الطوارئ مالك ؟ : بقالي خمس أيام بمغص في بطني وإسهال كام مرة في اليوم تقريباً وشكل الاسهال ولونه ؟ : خمس ست مرات والبراز سايب كدة ومصفر وفيه رغاوي كتير في أي مشاكل تانية طيب تعباك : اه دايما فيه انتفاخات كدة ونفسي بتغم عليا أحياناً طيب كلت حاجة شربت حاجة عملت أي حاجة شاكك فيها ؟ : انا لسة راجع من الاجازة كنت في الغردقة وشربت ماية كتير من البسين بصراحة معرفش اذا كان ممكن تعمل كدة ولا ايه في أي مشاكل مزمنة عندك ؟ لأ بتاخد أي علاج لأي سبب ؟ لأ بتسخن ؟ لأ ضغط كويس نبض كويس فحص البطن فيه mild tenderness & increased bowel sound تفتكر ايه نوع ال organism ؟ ( مش سفسطة 😃 لما تعرف ال organism هتعرف تضربه بأيه بالظبط 😁)

الحمى Fever 🤒🤒.. سؤال وجواب : يعني أيه fever ؟ ال fever هي إن ال set point اللي في ال hypothalamaus رفعت درجتها فالجسم استجاب للأمر بإنه يولد طاقة حرارية عشان يوصل للدرجة المطلوبة عن طريق بعض العمليات الحيوية والإرتعاش مثلا . 🥶 على عكس ال hyperthermia اللي بيكون فيها حرارة الجسم هي اللي عالية عن مؤشر ال set point كما في ضربة الشمس وال hyperthyrodism وساعتها الجسم يحاول يعمل العكس وهو التبريد وليس التدفئة . هي ال Fever حاجة وحشة ولا حاجة حلوة ؟ 🤔 ال Fever ده رد فعل مناعي من الجسم بكامل إرادته عشان يحاول إنه يقاتل ال infection اللي دخلت عن طريق إن الحرارة دي بتزود نشاط ال neutrophils & lymphocytes ولكن طبعا مع ظهور ال specific therapies زي المضادات الحيوية أصبحنا في حاجة أقل لل fever . لابد من الأخذ في الاعتبار إن فيه مجموعة استجابتهم في رفع الحرارة أقل من غيرهم فلازم أحط اعتبار قوي لل mild fever عند الناس دي زي ال old age & immunocomprimized لو درجة الحرارة فوق ال 41.5 دي مش fever دي hyperthermia عشان ال set point غالبا متقدرش ترفع أكتر من كدة . أيه أدق طريقة لقياس الحرارة ؟ بص هو إحنا عندنا oral & axillary & tympanic بس يؤسفني أبلغك إن الوحيدة اللي تقدر تثق فيها ثقة عمياء هي ال rectal 😅 هل كل ما درجة الحرارة تعلى ده معناه إن المشكلة أكبر ؟ وهل لو قدرت أسيطر عليها بالخوافض خلاص مقلقش ؟ خالص خالص خالص , فيه مشاكل serious ودرجة حرارتها أقل من مشاكل benign , كذلك خوافض الحرارة هتقدر تسيطر بيها في الغالب على المشاكل الكبيرة والصغيرة .. حط الموضوع في قدره وتعامل مع الحرارة على إنها علامة في وسط مرض كامل . 🥵 هو أيه تاني غير ال infection ممكن يعمل fever ؟ لوكيميات أورام عامة أمراض مناعة زي ال lupus وغيرها ممكن some drugs ... يعني ايه FUO ؟ ال fever of unknown origin ده مصطلح تقدر تقوله فقط في حالة إن مريض بقاله أكتر من 3 أسابيع في fever واتفحص كويس من دكتور وموصلش لحاجة راحوا حاجزينه في مستشفى ومعرفوش يوصلوا لحاجة ساعتها نقول إننا عندنا حمى مش عارفين مصدرها وغالبا بيكون occult infection - malignancy - autoimmune disease هل ال WBCs count مؤشر على طبيعة ال fever ؟ إحتمال بس مش شرط خالص , فيه حالات bacterial infection وعندهم normal count خصوصا هؤلاء ال immunocompremised وممكن تلاقيها low والعيان بيموت من septicemia أصلاً .. وممكن يبقى ال count عالي ومش bacterial زي حالات ال dehydration . هل ال fever سبب منطقي لرزع المضاد الحيوي ؟ لأ طبعا إلا لو انت في العناية وشايف الراجل toxic أو شاكك في meningitis أو الراجل ده immunocomprimized لأي سبب من الأسباب زي أيدز أو سكر أو زارع وبياخد immunosuppressants أو old age .. يعني ممكن فيه حالات نقول ممكن تديه empiric تمام لحد ما الحقيقة تبان , الحالات اللي ضرر التأخير فيها أكبر من النفع . أيه الطريقة الأنسب لخفض الحرارة ؟ ال Fever الأساس فيها هو ال antipyritics لأنك بتتعامل مع ال set point ال hyperthermia الأساس فيها ال external cooling لأن ال set point تمام التمام ومية المية . 😁😁😁 #iv_notes #By_Dr_Mo