Chadi's Blog

Tachycardia Approach and Management

noreply@blogger.com (M Chadi Alraies) — Thu, 10 Sep 2009 04:16:00 +0000

Palpitations and tachycardia are common problems in all age groups, young and old populations. The patient usually presents with shortness of breath and palpitations or sometimes can be settled and the only presentation is fatigue or generalized weakness.

In this lecture I am going to go with you over the type of tachycardia and how to differentiate between each type and what is the appropriate management at the bedside and by the expert.

It is going to be helpful for all people in the medical fields, nurses, paramedics, physician assistants, and doctors in training or in practice.

Please feel free to let me know if you have any comments or additions.

Thank you

Tachycardia Approach and Management

β-Blockers and Cardiac Events in Noncardiac Surgery

noreply@blogger.com (M Chadi Alraies) — Mon, 31 Aug 2009 05:16:00 +0000

Betablockers are known for their cardioprotective properties when used in noncardiac surgeries. This was one of the main principles in the perioperative medicine. However, lately this concepts being questions and this cardio protective properties have almost fallen of the AHA/ACC guidelines giving the risk of increased mortality for patient using this medication around the surgery time.

POISE trial in 2008 was a landmark in the beta blockers literature. It showed that beta blockers are not always safe and the use of this dug should me customized for each patient. Mid 2009, Poldermans et al, showed that beta blockers is an effective medication if it is used in correct way and titrated gradually over time to make the real effect take place overtime.

In this slide show you I am reviewing the old and new literature and present the 2007 ACC/AHA perioperative guidelines and the level of evidence for this drug.

This topic is an interesting and hot topic and I hope this slide show will help you make the correct decision in you daily perioperative practice.

Let me know what you think.

β-Blockers and Cardiac Events in Noncardiac Surgery

Tip of The Day

noreply@blogger.com (M Chadi Alraies) — Sat, 29 Aug 2009 17:38:00 +0000

Serum Lipid Abnormalities

noreply@blogger.com (M Chadi Alraies) — Thu, 13 Aug 2009 22:48:00 +0000

Hyperlipidemia is a common problem in the medical clinics. I am trying in these slides to introduce these abnormalities. At the end of this slide show you will be able to:

Know the different types of lipid abnormalities.
Diagnose Hyperlipidemia.
Screen for Hyperlipidemia.
Manage abnormal lipid panels.

I hope you'll find these slides helpful. Let me know if you have any questions.

Serum Lipid Abnormalities

Fundamentals of Electrocardiogram (ECG)

noreply@blogger.com (M Chadi Alraies) — Mon, 03 Aug 2009 04:40:00 +0000

Electrocardiogram is one of the fundamental skills in medicine. The most important hint I can give you is "practice". However, there is few point you should be aware of and master as a beginner before enjoying reading ECG by your own.

In this slide presentation I will go through the basics of electrocardiogram and I guarantee for you that you will find EKG is the most interesting tool in diagnostic medicine.

Let me know if you have any questions or comment by clicking on the "post a comment" botton below.

Fundamentals of Electrocardiogram (ECG)

Valvuar Heart Disease

noreply@blogger.com (M Chadi Alraies) — Tue, 07 Jul 2009 01:27:00 +0000

A brief description of the valvual heart disease. It includes; congential and acquired disease of the heart valves. Starting from types, pathophysiology, clinical presentation and finally, management.

Valvular Heart Disease

Valvular heart disease M Chadi Alraies, MD Chief Medical Resident Sunday, February 10, 2008 Valvular heart disease         Mitral regurgitation. Mitral stenosis. Aortic stenosis. Aortic regurgitation. Tricuspid regurgitation. Tricuspid stenosis. Pulmonary stenosis Pulmonary regurgitation. M Chadi Alraies 2 Jones criteria Major manifestations      Carditis Polyarthritis Chorea Erythema marginatum Subcutaneous nodules M Chadi Alraies 4 Minor manifestations  Clinical findings   Arthralgia Fever Elevated acute phase reactants (erythrocyte sedimentation rate, C-reactive protein) Prolonged PR interval  Laboratory findings    Evidence of preceding streptococcal infection:   Positive throat culture for group A betahemolytic streptococci or positive rapid streptococcal antigen test. antistreptolysin O M Chadi Alraies 5 MITRAL STENOSIS Prevalence     43% of all VHD in 1960 9% of all VHD in 1985 Rheumatic heart disease still affecting 21 out of 1,000 school-age children in Asia. 2/3 of all patient with rheumatic MS are women. M Chadi Alraies 7 Causes          Rheumatic fever. Congenital chordal fusion. Congenital papillary muscle malposition. Mitral annular calcification (e.g. ESRD, elderly) Mitral valve repair. Surgical valve replacement. Obstruction by large vegetation. Rheumatoid arthritis. Carcinoid syndrome. M Chadi Alraies 8 Pathophysiology  Orifice area <2 cm2: Diastolic filling of the LV is impaired.  Increased LA pressures.   Orifice area <1 cm2: LA pressure is > 25 mmHg.  Symptoms of HF  Tachycardia   LV diastolic pressure is usually normal in isolated MS. M Chadi Alraies 9 Signs and symptoms         Dyspnea Orthopnea PND LL edema Pulmonary edema Mitral facies. Hemoptysis Embolic events: MI, stroke, renal emboli. M Chadi Alraies 10 Signs and symptoms   Mild MS is asymptomatic at rest and mild exertion. Symptoms triggered by factors that increase blood flow across the mitral valve or shortening of the diastolic period…      Stress Exercise Infection Pregnancy Atrial fibrillation with RVR M Chadi Alraies 11 Physical exam the murmur       "Tapping" sensation over area of expected PMI. Accentuated S1 Opening snap. Mid-diastolic murmur (rumble) low in pitch. S2-OS interval of 70 msec is seen in severe MS. Best heard after exercise, left lateral recumbency. M Chadi Alraies 12 ECG   Low sensitivity P mitrale:   Lead II broad and bifid > 0.12 sec Lead V1 broad and deep negative component of biphasic P wave, longer than 0.04 sec and 1 mm in depth.    If pulmonary hypertension is present, tall peaked P waves, right axis deviation, or right ventricular hypertrophy appears. Atrial fib. Atrial flutter. M Chadi Alraies 13 CXR M Chadi Alraies 15 CXR M Chadi Alraies 16 CXR       Straight left heart border. Large left atrium. Sharply indenting esophagus. Elevation of left mainstem bronchus. Large right ventricle and pulmonary artery if pulmonary hypertension is present. Calcification occasionally seen in mitral valve. M Chadi Alraies 17 2D echocardiogram    Estimates the severity of MS Measure the pressure gradient between LA to LV. Define the etiology. M Chadi Alraies 18 Treatment   BB and CCB for rate control Anticoagulation with warfarin if… Chronic A.fib  Prior embolic events.  Severe MS with LA >5.5 cm on echocardiogram.   A.fib recurrence is 20-30% after the first episode. M Chadi Alraies 19 Surgery  Indications for intervention focus on: Episode of pulmonary edema,  Decline in exercise capacity,  Evidence for pulmonary hypertension.  M Chadi Alraies 20 Surgery  Percutaneous mitral balloon valvotomy:  Mitral valve area <1.5 cm2  MVR:  Mitral valve area <1.0 cm2 M Chadi Alraies 21 Questions? Mitral regurgitation Etiology         Myxomatous degeneration: MVR, Marfan’s Mitral annular calcification. Rheumatic heart disease. Congenital malformation. Ruptured papillary muscles and cordae tindinea. Infective endocarditis. Tumors. Functional:  Ischemia, DCM,Minfiltrative CMP and Chadi Alraies 24 Prevalence  20% of post Mi patients. M Chadi Alraies 25 Sign and symptoms      Symptoms typical for the underlying cause. Exercise intolerance. DOE Pulmonary edema and CHF. Triggers for symptoms…  Atrial fibrillation, pregnancy and infection. M Chadi Alraies 26 Physical exam     Forceful, brisk PMI; systolic thrill over PMI. Pansystolic: begins with M1 and ends at or after A2. Loudest over PMI; transmitted to left axilla, left infrascapular area. After exercise; diaphragm chest piece. M Chadi Alraies 27 Tests ECG     Left axis deviation. Left ventricular hypertrophy. P waves broad, tall, or notched in standard leads. Broad negative phase of diphasic P in V1. M Chadi Alraies 29 CXR M Chadi Alraies 30 M Chadi Alraies 31 2D echocardiogram    Thickened mitral valve in rheumatic disease. Enlarged left ventricle with abovenormal, normal, or decreased function. Regurgitant flow mapped into left atrium. M Chadi Alraies 32 Management  Acute MR: Emergency surgery.  Stabilization with vasodilators (nitroprusside)  Intra-aortic balloon counterpulsation.   Chronic MR: Afterload reduction: ACEI  Anticoagulation in case of atrial fibrillation. M Chadi Alraies  33 When to refer for surgery? 1. 2. 3. 4. 5. 6. Acute symptomatic MR Severe MR, NYHA II-IV with EF >60%. Severe MR, EF 50-60%, ESD 45-50 mm. Severe MR, EF 30-50%, ESD 50-55 mm. Severe MR, A. Fib with NL EF Severe MR, severe pulmonary HTN, M Chadi Alraies 34 Questions? Aortic stenosis Etiology      Bicuspid valve. Degenerative Congenital Rheumatic Infective endocarditis. M Chadi Alraies 37 Prevalence    25% of patients over age 65 years and 35% of those over age 70 years The most common surgical valve lesion in developed countries, and many patients are elderly. M Chadi Alraies 38 Risk factors    Hypertension, Hypercholesterolemia, and Smoking M Chadi Alraies 39 M Chadi Alraies 40 Signs and symptoms  Cardiac output is maintained until the stenosis is severe (with a valve area < 0.8 cm2). LV failure,  Angina pectoris.  Syncope exertional and a late finding.   all occur with exertion. M Chadi Alraies 41 Physical exam     Powerful, heaving PMI to left and slightly below MCL. Small and slowly rising carotid pulse. A2 normal, soft, or absent. Paradoxic splitting of S2 if A2 is audible. M Chadi Alraies 42 Physical exam     Prominent S4. Midsystolic: begins after M1, ends before A2, reaches maximum intensity in mid systole. Right second ICS parasternally or at apex, heard in carotids and occasionally in upper interscapular area. Patient resting, leaning forward, breath held in full expiration. M Chadi Alraies 43 Tests ECG     Left axis deviation. Left ventricular hypertrophy. LBBB Repolarization changes. M Chadi Alraies 45 CXR    Concentric left ventricular hypertrophy. Prominent ascending aorta, small knob. Calcified valve. M Chadi Alraies 46 2D echocardiogram     Poststenotic dilation of the aorta, Restricted opening of the aortic leaflets, Bicuspid aortic valve in about 30%. Increased transvalvular flow velocity M Chadi Alraies 47 Management  Medical management… No vasodilators.  Indicated in asymptomatic patients only with preserved LV function.  M Chadi Alraies 48 Surgery, when?  Symptomatic: Improve survival in preserved and depressed LVF  Depressed LV function.   Prophylactic AVR: Patients going for CABG with severe AS  Patients going for other valvular surgery with moderate AS.  M Chadi Alraies 49 Questions? Aortic regurgitation Etiology 1. 2. 3. 4. 5. 6. 7. 8. Bicuspid aortic valve. HTN Rheumatic Congenital Aneurysm of the sinus of Valsalva. Infective endocarditis. Post aortic stenosis repair. Osteogenesis imperfecta. M Chadi Alraies 52 Pathophysiology     Increased preload and afterload to the LV. The response to these effects is to hypertrophy by laying sarcomeres end to end. Increasing the LV chamber size greater than the wall thickness (eccentric hypertrophy). The amount of hypertrophy is substantial and greater than that M Chadi Alraies 53 Signs and symptoms    LV failure is a late event and may be sudden in onset. Exertional dyspnea and fatigue are the most frequent symptoms. Angina pectoris. M Chadi Alraies 54 Physical exam      wide arterial pulse pressure. water-hammer pulse or Corrigan's pulse. Quincke's pulses (subungual capillary pulsations) Duroziez's sign (to and fro murmur over a partially compressed peripheral artery, commonly the femoral) Musset's sign (head bob with each M Chadi Alraies 55  The apical impulse is… prominent,  laterally displaced,  usually hyperdynamic, and  may be sustained.  M Chadi Alraies 56 The murmur…    Aortic diastolic murmur is usually high-pitched and decrescendo. A mid or late diastolic low-pitched mitral murmur (Austin Flint murmur) may be heard. Patient leaning forward, breath held in expiration. M Chadi Alraies 57 Tests ECG   Left axis deviation. Left ventricular hypertrophy. M Chadi Alraies 59 Management  Acute aortic regurgitation… Treatment of the underlying infection.  Surgical management.   Chronic regurgitation… vasodilators, such as hydralazine, nifedipine, and ACE inhibitors, can reduce the severity of regurgitation.  prescribe ACE inhibitors whenever the LV diastolic size is increased > 5.0 cm.  M Chadi Alraies 60 Surgery, when?    LV dysfunction EF is < 55% or if the LV end-systolic dimension is > 5.0 cm. aortic root diameters of > 5.0 cm in Marfan or > 5.5 cm in non-Marfan patients. surgical risk is higher than in aortic stenosis patients with a similar EF. M Chadi Alraies 61 Questions? Tricuspid regurgitation Etiology 1. RV geometry abnormality:       Pulmonary hypertension Severe pulmonic regurgitation. LVF RV infarction. Cor pulmonale. Mitral stenosis. Infective endocarditis. Ebstein's anomaly Marfan’s syndrome Carcinoid syndrome TV prolapse. M Chadi Alraies 64 2. Anatomic issues with the valve itself: 1. 2. 3. 4. 5. Signs and symptoms  RV failure hepatomegaly,  edema, and  ascites  M Chadi Alraies 65 Physical exam      Cyanosis may be present. Occasionally systolic thrill at lower left sternal edge. Systolic pulsation of liver. Blowing, coarse, or musical murmur. Murmur usually becomes louder during inspiration. M Chadi Alraies 66 Management    Elimination of the cause of the tricuspid regurgitation. Intravenous diuretics should initially be used. Torsemide is better absorbed. M Chadi Alraies 67 Surgery, when?     Symptoms and annular dilatation. Endocarditis. Ebstein’s anomaly. Bioprosthetic valve, and not a mechanical valve, is used. M Chadi Alraies 68 DD of systolic murmur Intervention Valsalva HOCM Aortic Stenosis or Standing Handgrip or squatting Supine position with legs elevated Exercise Amyl nitrite Increase d Increase d Decreas ed Decreas ed Decreas Decreas Inc or ed ed or dec same Increase Decreas Increase d ed d Decreas Increase Decreas ed d ed Increase No Decreas d change ed Mitral Regurgitatio n Mitral Prolapse IsoProterenol Increase Increase Decreas Increase d d ed d Markedly Increase Decreas Increase increase d ed d d Markedly Increase Decreas Increase increase d ed d 70 M Chadi Alraies References   CMDT 2007 ACC/AHA 2006 Guidelines for the management of patient with valvular heart disease. THANK YOU M Chadi Alraies 71

Radiology lecture part II

noreply@blogger.com (M Chadi Alraies) — Wed, 01 Jul 2009 04:26:00 +0000

Radiology lecture part II

Chest Radiography Interpretation Part III M Chadi Alraies, MD Chief Medical Resident St. Vincent Charity Hospital Case Western Reserve University www.chadialraies.blogspot.com 1 Wilhelm Conrad Röntgen November 8, 1895 www.chadialraies.blogspot.com 2 www.chadialraies.blogspot.com 3 Patient 1 www.chadialraies.blogspot.com 4 www.chadialraies.blogspot.com 5 www.chadialraies.blogspot.com 6 Normal CXR with good inspiration www.chadialraies.blogspot.com 7 RUL (Right Upper Lung) www.chadialraies.blogspot.com 8 RML (Right Middle Lung) www.chadialraies.blogspot.com 9 RLL (Right Lower Lung) www.chadialraies.blogspot.com 10 www.chadialraies.blogspot.com 11 Patient 2 www.chadialraies.blogspot.com 12 www.chadialraies.blogspot.com 13 www.chadialraies.blogspot.com 14 Normal CXR with poor inspiration in an obese patient. www.chadialraies.blogspot.com 15 www.chadialraies.blogspot.com 16 Patient 3 www.chadialraies.blogspot.com 17 www.chadialraies.blogspot.com 18 What is your next step? www.chadialraies.blogspot.com 19 www.chadialraies.blogspot.com 20 www.chadialraies.blogspot.com 21 www.chadialraies.blogspot.com 22 www.chadialraies.blogspot.com 23 www.chadialraies.blogspot.com 24 www.chadialraies.blogspot.com 25 www.chadialraies.blogspot.com 26 www.chadialraies.blogspot.com 27 www.chadialraies.blogspot.com 28 www.chadialraies.blogspot.com 29 Right upper lobe infiltrate “cotton lobe pneumonia” www.chadialraies.blogspot.com 30 www.chadialraies.blogspot.com 31 Patient 4 www.chadialraies.blogspot.com 32 www.chadialraies.blogspot.com 33 www.chadialraies.blogspot.com 34 IPF (idiopathic Pulmonary Fibrosis)    Right tracheal deviation Interstitial infiltrate Thickening of the alveolar septum www.chadialraies.blogspot.com 35 Patient 5 www.chadialraies.blogspot.com 36 www.chadialraies.blogspot.com 37 www.chadialraies.blogspot.com 38   Nodular infiltrate in RLL Reticular component in peripheral lung fields bilaterally www.chadialraies.blogspot.com 39 www.chadialraies.blogspot.com 40 Patient 6 www.chadialraies.blogspot.com 41 www.chadialraies.blogspot.com 42 ARDS      Cardiomegaly Bilateral interstitial infiltrate. Edema in bronchial wall. Kerlly B lines Pleural effusion. www.chadialraies.blogspot.com 43 Patient 7 www.chadialraies.blogspot.com 44 www.chadialraies.blogspot.com 45 www.chadialraies.blogspot.com 46 www.chadialraies.blogspot.com 47 Patient 8 www.chadialraies.blogspot.com 48 www.chadialraies.blogspot.com 49 www.chadialraies.blogspot.com 50 Bilateral pleural effusion www.chadialraies.blogspot.com 51 Patient 9 www.chadialraies.blogspot.com 52 www.chadialraies.blogspot.com 53 Next step? www.chadialraies.blogspot.com 54 Right middle lobe solid mass with airbronchogram www.chadialraies.blogspot.com 55 Patient 10 www.chadialraies.blogspot.com 56 www.chadialraies.blogspot.com 57 www.chadialraies.blogspot.com 58 Bilateral pleural effusion www.chadialraies.blogspot.com 59 www.chadialraies.blogspot.com 60 Patient 11 www.chadialraies.blogspot.com 61 www.chadialraies.blogspot.com 62 www.chadialraies.blogspot.com 63  Pleural-based disease. Loculations  Mass  Empyema  Mesothelioma  www.chadialraies.blogspot.com 64 Patient 12 www.chadialraies.blogspot.com 65 www.chadialraies.blogspot.com 66 Two right lung masses (coin lesions) www.chadialraies.blogspot.com 67 www.chadialraies.blogspot.com 68 www.chadialraies.blogspot.com 69 www.chadialraies.blogspot.com 70 www.chadialraies.blogspot.com 71 www.chadialraies.blogspot.com 72 www.chadialraies.blogspot.com 73 Patient 13 www.chadialraies.blogspot.com 74 www.chadialraies.blogspot.com 75 www.chadialraies.blogspot.com 76 www.chadialraies.blogspot.com 77 Patient 14 www.chadialraies.blogspot.com 78 www.chadialraies.blogspot.com 79 www.chadialraies.blogspot.com 80 Patient 15 www.chadialraies.blogspot.com 81 www.chadialraies.blogspot.com 82     Alveolar infiltrate with hematuria Patient responded to steroids therapy Diagnosis… GPS www.chadialraies.blogspot.com 83 www.chadialraies.blogspot Thank you www.chadialraies.blogspot.com 84

In the Literature The Latest Research You Need to Know :: Article in The Hospitalist News Letter

noreply@blogger.com (M Chadi Alraies) — Thu, 11 Jun 2009 14:19:00 +0000

Readers want to know timely, concise updates of medical literature relevant to hospital medicine. Additionally, they want the take home message without reading the article with the shortest time. The goal of this column is to alert readers to the important research that is being published. I had the chance to review few studies in the latest edition of The Hospitalist. Please click on the link below.

In the Literature The Latest Research You Need to Know :: Article

Hope you are going to find it useful for you in you daily practice.

Diastolic Dysfunction Heart Failure

noreply@blogger.com (M Chadi Alraies) — Sun, 07 Jun 2009 03:24:00 +0000

Diastolic Dysfunction Heart Failure

Diastolic Heart Failure A Disorder of the Elderly Patient M Chadi Alraies, MD Chief Medical Resident St. Vincent Charity Hospital/Case Western Reserve University Diastolic Heart Failure Defined1:  Clinical presentation and symptoms of heart failure with preserved LV systolic function Stiff ventricle equals decreased compliance and impaired relaxation leading to ↑ LVEDP  M Chadi Alraies 2 Background:  Prevalence: as of 2004, 4.8 million Americans are affected by diastolic heart failure (HF)1,2,3 Diastolic HF prevalence increases with age4,5,6,7: <> 70 years old: 50% M Chadi Alraies 3  Background (cont.)  Incidence: about 500,000 new cases diagnosed per year1,2,3,4 HF is the leading cause of hospitalization in persons over the age of 654,8  M Chadi Alraies 4 Background (cont.)   More than 50% of patients with HF have preserved LV function4,9 Mortality rates for patients with diastolic HF: Advanced disease: 30-40% mortality in 5-10 years4,10  Mortality rates are comparable to those seen in systolic HF4,9  M Chadi Alraies 5   A 68-year-old woman is hospitalized with palpitations and shortness of breath. She has a history of hypertension and chronic atrial fibrillation, and her medications include furosemide, candesartan, and warfarin. On physical examination, the heart rate is 120/min with an irregularly irregular rhythm, and blood pressure is 130/80 mm Hg; she has an elevated jugular venous pulse, crackles in both lungs, and marked lower extremity edema. Echocardiography shows left ventricular hypertrophy, an ejection fraction of 70%, and no significant valvular disease. She is treated with intravenous diuretics, with improvement in her symptoms and resolution of peripheral edema and of crackles on lung examination. Her heart rate is now 99/min and her blood pressure is 120/75 mm Hg. Which of the following would be the most appropriate medication to add?  A Lisinopril M Chadi Alraies 6 Risk Factors for Diastolic 4,11 HF :    Elderly Female Hypertensive M Chadi Alraies 7 Etiology4:  Long-standing HTN with LVH12:  A hypertensive hypertrophic cardiomyopathy with LVEF >75% in the elderly6    Aortic Stenosis with normal LVEF13 Severe aortic or mitral regurgitation Ischemic Heart Disease  Regional wall motion abnormalities  Restrictive Cardiomyopathy – Idiopathic vs. Infiltrative  Sarcoidosis, Amyloidosis, Hemochromatosis 6. 7. HOCM Hypothyroidism M Chadi Alraies 8 Asymptomatic Diastolic HF:   More common than symptomatic diastolic HF Mayo Clinic study of 2,042 subjects > age 45: Prevalence of symptomatic HF: 2.2%  Of those, 44% had diastolic HF  In subjects without symptoms of HF, 28% had diastolic HF by echo criteria4,15.  M Chadi Alraies 9 Pathyphysiology Diastolic Function 4,16 : Myocardial Relaxation Elasticity - An active process - Requires energy energy - A passive process - Requires no M Chadi Alraies 10 Pathophysiology (cont.)17:    Normally, LV relaxation during diastole creates a negative LA to LV pressure gradient, thereby augmenting diastolic filling Decrease in LV relaxation and distensibility causes increased LA, LV, PV, and PCW pressures Increase in LV filling during late diastole, increase in dependence on atrial contraction M Chadi Alraies 11 Cardiac Cycle Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment. Am Fam Physician 2004;69:2609-16. M Chadi Alraies 12 Pathophysiology (cont.)17 Why do patients with diastolic dysfunction have poor exercise tolerance? During normal exercise, increase in HR associated with increase in SV → ( CO = HR x SV ) Increased HR leads to compensatory increase in relaxation rate, maintaining normal LVEDP & PCWP Increased LVEDV normally leads to increased SV due to Frank-Starling mechanism Normal LV distensibility allows normal LVEDP to be maintained at increased LVEDV  M Chadi Alraies 13      Increased PCWP During Exercise in Pts. With Diastolic HF  Data from Kitzman, DW, Higginbotham, MB, Cobb, FR, et al, J Am Coll Cardiol 1991; M Chadi Alraies 14 Pathophysiology (cont.)   Why is diastolic dysfunction more common in elderly persons? Age-related changes18,19: Increased collagen cross-linking  Increased smooth muscle content  Loss of elastic fibers  M Chadi Alraies 15 Clinical Manifestations : 4      Similar to systolic HF AF poorly tolerated due to loss of atrial kick Tachycardia poorly tolerated due to shortening of late diastolic filling time Elevated systemic blood pressure increases LV wall stress and further impairs relaxation Acute-on-chronic diastolic dysfunction caused by ischemia M Chadi Alraies 16 Diagnosis : 4    Controversy: does clinical HF + normal LVEF = diagnosis of diastolic HF? Most patients with overt clinical HF and normal LV systolic function have some element of diastolic dysfunction A study of 63 HF patients with LVH and normal systolic function by echo found that 100% of patients had at least one index of diastolic M Chadi Alraies 17 Diagnosis (cont.)1  Gold standard for diagnosis is cardiac catheterization: Direct measurement of LVEDP  Risk outweighs benefit for routine use in diagnosing diastolic dysfunction   Doppler Echocardiography: the primary diagnostic modality for diagnosis M Chadi Alraies 18 Doppler Echocardiography1   Tau = time constant of LV pressure decay during isovolumetric relaxation that correlates with LV stiffness Diastolic trans-mitral valve blood flow:  Measurement of peak velocities during early diastolic filling: 1) E wave = Early diastolic filling 2) A wave = Atrial Alraies M Chadi contraction 19 Spectrum of Diastolic Dysfunction1  Normal:   E wave > A wave Ratio 1.5:1.0 M Chadi Alraies 20 Spectrum of Diastolic Dysfunction1 1. Early Diastolic Dysfunction: Abnormal Relaxation    E-to-A ratio reverses to <> 2.0 → poor prognosis M Chadi Alraies 23 Normal Trans-Mitral-Valve Spectral Doppler Flow Pattern Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment. Am Fam Physician 2004;69:2609-16. Alraies M Chadi 24 Abnormal Relaxation Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment. Am Fam Physician 2004;69:2609-16. M Chadi Alraies 25 Severe (Restrictive) Diastolic Dysfunction  Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment. Am Fam Physician 2004;69:2609-16. M Chadi Alraies 26 Doppler Echocardiography (cont.)  Adapted from: Zile MR. Clinical manifestations and diagnosis of diastolic heart failure. http://www.utdol.com/diastolic heart failure/clinical manifestations and diagnosis of diastolic heart failure. 3/2/07 M Chadi Alraies 27  BNP elevated in patients with both systolic and diastolic HF, but cannot be used to differentiate between the two21-24 A study of 357 patients referred for echocardiography based on clinical suspicion for heart failure revealed the following mean BNP levels25: Diastolic Dysfunction = 373 (+/- 335)  Systolic Dysfunction = 550 (+/- 602)  Combined Dysfunction = 919 (+/- 604) M Chadi Alraies  Brain Natriuretic Peptide (BNP)4  28 BNP (cont.)  4 A study of 400 randomly selected patients referred for echo to evaluate LV function21: With normal LV function – mean BNP was 30  BNP of 75: sensitivity of 85% and specificity of 97% in detecting ventricular dysfunction  In the patients with normal LV systolic function, BNP of 57 detected 28 patients M Chadi Alraies with isolated diastolic dysfunction with 29  BNP (cont.)  4 A study of 294 patients with echocardiographically normal LV systolic function23:  Mean BNP: All diastolic dysfunction = 286; normals = 33  Impaired relaxation = 202  Pseudonormal = 294  Restrictive = 402   For diagnosis of diastolic dysfunction, BNP of 62: sensitivity 85%; specificity 83% M Chadi Alraies 30 BNP (cont.)   ACE-Is, ARBs, Spironolactone, and Diuretics: ↓ BNP levels26 Thus, monitoring of BNP levels may be a useful method of assessing response to treatment M Chadi Alraies 31 Treatment : 27   Trial data limited compared with systolic HF Aim of therapy is to prevent or control hemodynamic stressors. M Chadi Alraies 32 Treatment (cont.)  27,28 2) 3) 4) 5) 2005 ACC/AHA Task Force Guidelines on Management of Chronic Diastolic HF: Control of systolic and diastolic HTN Control of VR in patients with AF Control of pulmonary edema and peripheral congestion with diuretics Coronary revascularization in CAD patients if ischemia thought to be contributing to diastolic dysfunction M Chadi Alraies 33 Pharmacologic Therapy 27  Patients with small, stiff LV chamber are sensitive to excessive preload reduction Diuretics, Nitrates, Dihydropyridine CCBs, ACE-Is – use with caution due to potential to cause LV underfilling Frank-Starling curve has a steeper slope Monitor for symptoms of weakness, lightheadedness, syncope M Chadi Alraies 34    Digoxin27   No survival benefit29 DIG ancillary trial: role of digoxin in patients with HF and EF >45%  At 37-month follow-up, no effect on all-cause or CV hospitalization with digoxin   A study examining the effect of IV digoxin on echocardiographic diastolic parameters demonstrated a significant decrease of trans-mitral peak E and E-to-A ratio, and a significant lengthening of deceleration time30 However, consensus is that digoxin should be avoided in diastolic HF M Chadi Alraies 35 27 β -blockers β -blockers  Can cause regression of LVH and improvement of diastolic function Can ↓ HR, ↑ diastolic filling time, ↓ oxygen consumption, ↓ BP1 Carvedilol has been shown to improve Eto-A ratio31   M Chadi Alraies 36 Calcium channel blockers27    Non-dihydropyridine CCBs (diltiazem, verapamil) - more potent negative inotropes CCBs - can cause regression of LVH and improvement of diastolic function Verapamil   May have a “lusitropic” (relaxation-enhancing) effect27 A study on 20 patients with diastolic HF taking verapamil:   ↓ signs and symptoms of HF ↑ LV diastolic filling rate and treadmill exercise time32  Amlodipine - a study of 59 patients with 37 M Chadi Alraies ACE-Inhibitors27  Afterload reduction not as important as with systolic HF, but some evidence of benefit ACE-Is – can cause regression of LVH and improvement of diastolic function ACE-Is – improve NYHA functional class, QOL, and may prevent myocardial fibrosis associated with LVH M Chadi Alraies 38   Angiotensin II Receptor Blockers27   ARBs - can cause regression of LVH and improvement of diastolic function CHARM-Preserved trial34:    3023 patients with symptomatic HF and LVEF > 40% Randomly assigned to receive candesartan or placebo x mean 37 months Small but almost significant reduction in incidence of primary endpoints of CV death and hospitalization for HF in the candesartan group M Chadi Alraies 39 Antihypertensives and LVH27    Regression of LVH may improve diastolic function35 2003 meta-analysis examining the efficacy of various antihypertensives in reversal of LVH36 Relative reductions in LV mass index:      ARBs – 13% CCBs – 11% ACE-Is – 10% Diuretics – 8% β-blockers – 6% M Chadi Alraies 40 Regression of LVH M Chadi Alraies 41 Reproduced from: Zile MR. Treatment and prognosis of diastolic heart failure. www.utdol.com. 3/2/07 www.utdol.com. Prognosis  27   Varies with symptomatic vs. asymptomatic HF Framingham Heart Study and V-HeFT trials showed better prognosis with diastolic HF than with systolic HF, but worse than controls 37-39 A study of 522 patients showed similar 5-year mortality for diastolic vs. systolic HF (25% vs. 42%)40 M Chadi Alraies 42 Survival Reproduced from: Zile MR. Treatment and prognosis of diastolic heart failure. www.utdol.com. 3/2/0743 www.utdol.com. M Chadi Alraies References: 1. Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment. Am Fam Physician 2004;69:2609-16. 2. Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol 1993;22(4 suppl A):6A-13A. 3. Berry C, Murdoch DR, McMurray JJ. The economics of chronic heart failure. Eur J Heart Fail 2001; 3:283-91. 4. Zile MR. Clinical manifestations and diagnosis of diastolic heart failure. www.utdol.com. 3/2/2007 www.utdol.com. 5. Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure: Part I: diagnosis, prognosis, and measurements of diastolic function. Circulation 2002; 105:1387. 6. Topol EJ; Traill TA; Fortuin NJ. Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med 1985 Jan 31;312(5):277-83. 7. Gottdiener JS; McClelland RL; Marshall R; Shemanski L; Furberg CD; Kitzman DW; Cushman M; Polak J; Gardin JM; Gersh BJ; Aurigemma GP; Manolio TA. Outcome of congestive heart failure in elderly persons: influence of left ventricular systolic function. TheCardiovascular Health Study. Ann Intern Med 2002 Oct 15;137(8):631-9. 8. O’Connell JB, Bristow MR. Economic impact of heart failure in the United States: time for a different approach. J Heart Lung Transplant 1994;13:S107-12. 9. Bursi F, Weston SA, Redfield MM, Jacobsen SJ, Pakhomov S, Nkomo VT, Meverden RA, Roger VL. Systolic and diastolic heart failure in the community. JAMA. 2006 Nov 8;296(18):2209-16. JAMA. 10. Massie BM, Shah NB. Evolving trends in the epidemiologic factors of heart failure: rationale for preventive strategies and comprehensive disease management. Am Heart J 1997;133:703-12. 11. Yancy CW; Lopatin M; Stevenson LW; De Marco T; Fonarow Clinical presentation, management, and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National Registry (ADHERE) Database. J Am Coll Cardiol. 2006 Jan 3;47(1):76-84. Epub 2005 Dec 15. Cardiol. 12. Vasan RS; Levy D. The role of hypertension in the pathogenesis of heart failure. A clinical mechanistic overview. Arch Intern Med 1996 Sep 9;156(16):1789-96. 13. Fifer MA; Bourdillon PD; Lorell BH. Altered left ventricular diastolic properties during pacing-induced angina in patients with aortic stenosis. Circulation 1986 Oct;74(4):675-83. 14. Chiladakis JA, Koutsogiannis N, Kalogeropoulos A, Alexopoulos D. Acute effects of VVI pacing on ventricular diastolic performance in elderly patients with normal left ventricular systolic function. Int J Cardiol. 2006 Oct 16; [Epub ahead of print] Cardiol. 15. Redfield MM; Jacobsen SJ; Burnett JC Jr; Mahoney DW; Bailey KR; Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 2003 Jan 8;289(2):194-202. 16. Aurigemma GP, Gaasch WH. Clinical Practice. Diastolic Heart Failure. N Engl J Med 2004; 351:1387. 17. Zile MR, Eberli FR, Wexler L. Pathophysiology of diastolic heart failure. www.utdol.com 3/2/2007. 18. Wei JY. Age and the cardiovascular system. N Engl J Med 1992;327:1735-9. 19. Gaasch WH. Diagnosis and treatment of heart failure based on left ventricular systolic or diastolic dysfunction. JAMA 1994;271:1276-1280. 20. Zile MR; Gaasch WH; Carroll JD; Feldman MD; Aurigemma GP; Schaer GL; Ghali JK; Liebson PR. Heart failure with a normal ejection fraction: is measurement of diastolic function necessary to make the diagnosis of diastolic heart failure? Circulation 2001 Aug 14;104(7):779-82. 21. Maisel AS, Koon J, Krishnaswamy P, et al. Utility of B-natriuretic peptide as a rapid, point-of-care test for screening patients undergoing echocardiography to determine left ventricular dysfunction. Am Heart J 2001; 141:367. 22. Krishnaswamy, P, Lubien, E, Clopton, P, Koon, J. Utility of B-natriuretic peptide levels in identifying patients with left ventricular systolic or diastolic dysfunction. Am J Med 2001; 111:274. 23. Lubien, E, DeMaria, A, Krishnaswamy, P, et al. Utility of B-natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. Circulation 2002; 105:595. 24. Tschope, C, Kasner, M, Westermann, D, et al. The role of NT-proBNP inAlraies M Chadi the diagnostics of isolated diastolic dysfunction: correlation with 44 echocardiographic and invasive measurements. Eur Heart J 2005; 26:2277. References (cont.) 26. Doust J, Lehman R, Glasziou P. The role of BNP testing in heart failure. Am Fam Physician 2006 Dec 1;74(11):1893-8. 27. Zile MR. Treatment and prognosis of diastolic heart failure. www.utdol.com. 3/2/2007. www.utdol.com. 28. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005; 112:e154. 29. Ahmed A, Rich MW, Fleg JL, et al. Effects of digoxin on morbidity and mortality in diastolic heart failure: the ancillary digitalis investigation group trial. Circulation 2006; 114:397. 30. Giunta A, Maione S, Arnese MR, Giacummo A, Liucci GA, Palma M, de Campora P, Cangianiello S, Condorelli M. Effects of intravenous digoxin on pulmonary venous and transmitral flows in patients with chronic heart failure of different degrees. Clin Cardiol 1995 Jan;18(1):27-33. 31. Bergstrom A, Andersson B, Edner M, et al. Effect of carvedilol on diastolic function in patients with diastolic heart failure and preserved systolic function. Results of the Swedish Doppler-echocardiographic study (SWEDIC). Eur J Heart Fail 2004; 6:453. 32. Setaro JF, Zaret BL, Schulman DS, et al. Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diastolic filling and normal left ventricular systolic performance. Am J Cardiol 1990; 66:981. 33. Zaliunas R, Bradzionyte J, Zabiela V, Jurkevicius R. Effects of amlodipine and lacidipine on heart rate variability in hypertensive patients with stable angina pectoris and isolated left ventricular diastolic dysfunction. Int J Cardiol 2005 Jun 8;101(3):347-53. 34. Yusuf S, Pfeffer MA, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and preserved leftventricular ejection fraction: the CHARM-Preserved trial. Lancet 2003; 362:777. 35. Watchtell K, Bella JN, Rokkedal J, et al. Change in diastolic left ventricular filling after one year of antihypertensive treatment: The Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) Study. Circulation 2002; 105:1071. 36. Klingbeil AU, Schneider M, Martus P, Messerli FH. A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension. Am J Med 2003; 115:41. 37. Vasan, RS, Larson, MG, Benjamin, EJ, et al. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: Prevalence and mortality in a population-based cohort. J Am Coll Cardiol 1999; 33:1948. 38. Cohn, JN, Johnson, G, and Veterans Administration Cooperative Study Group. Heart failure with normal ejection fraction. The V-HeFT Study. Circulation 1990; 81:III48. 39. Gottdiener, JS, McClelland, RL, Marshall, R, et al. Outcome of congestive heart failure in elderly persons: influence of left ventricular systolic function. The Cardiovascular Health Study. Ann Intern Med 2002; 137:631. 40. MacCarthy PA, Kearney MT, Nolan J, et al. Prognosis in heart failure with preserved left ventricular systolic function: prospective cohort study. BMJ 2003; 327:78. M Chadi Alraies 45 Thank you

ارتفاع ضغط الدم الشرياني

noreply@blogger.com (M Chadi Alraies) — Thu, 19 Mar 2009 13:49:00 +0000

ارتفاع ضغط الدم الشرياني

Hypertension

ما هو ضغط الدم المرتفع؟

يشير مقياس ضغط الدم إلى مقدار الضغط الذى يبذله الدم على جدران الشرايين التى تقوم بنقله من القلب إلى سائر أجزاء الجسم. وفى بعض الحالات، لايستطيع الدم أن يمر يسهولة من خلال الشرايين نتيجة ضيقها وإصابتها بالتصلب، وفى هذه الحالات سيرتفع الضغط حتى يضمن إستمرارية مرور الدم من خلال هذه الشرايين المصابة. هذا هو ما يسمى بمرض "ضغط الدم المرتفع"

حقائق علمية عن مرض "ضغط الدم المرتفع"

1. ضغط الدم المرتفع مرض شائع ولكنه فى نفس الوقت مرض خطير للغاية - يطلق عليه إسم "القاتل الصامت" لأن معظم المصابين به لايشعرون بأية أعراض، بينما إذا لم يعالج هذا المرض وظل ضغط الدم مرتفعا فسيؤدى هذا إلى الإصابة بالأزمات القلبية والصدمات الدماغية وأمراض الكلى وغيرها من الأمراض الناتجة عن إتلاف الشرايين بالجسم.

2. لهذا يعتبر علاج ضغط الدم المرتفع وإبقاء ضغط الدم مستقرا على معدلاته الطبيعية أمرا هاما وحيويا لمنع حدوث هذه المضاعفات الخطيرة.

3. ضغط الدم المرتفع ليس له سبب معروف فى أغلبية المرضى (حوالى 90 % من المرضى).

4. تلعب العوامل الوراثية وأسلوب الحياة مثل زيادة الملح فى الطعام دورا هاما فى حدوث ضغط الدم المرتفع.

5. يعتبر ضغط الدم المرتفع أحد عوامل الخطورة الهامة التى تزيد من نسبة الإصابة بأمراض الشرايين التاجية المغذية لعضلة القلب وكثيرا ما يكون ضغط الدم المرتفع مصاحبا بقصور الشرايين التاجية سواء كان ظاهرا أم خفيا- وفى الحالة الأخيرة كثيرا ما يكون أول صورة لمعاناة هذا المريض هى الإصابة بإحتشاء عضلة القلب أو حدوث السكتة القلبية.

6. من أجل ضمان نجاح علاج ضغط الدم المرتفع، يجب أيضا علاج أى أمراض مصاحبة له و السالف ذكرها فمرض السكر وإرتفاع نسبة الكوليسترول فى الدم، كل منهما يساعد على إرتفاع ضغط الدم.

7. أكثر من 99 % من حالات إرتفاع ضغط الدم لايمكن شفاؤها ولكن يمكن بالعلاج المستمر السيطرة على إرتفاع ضغط الدم، بمعنى إعادته لصورته الطبيعية.

8. فى أغلب الأحيان، يستمر ضغط الدم المرتفع مدى الحياة، ولايوجد شفاء كامل من هذا المرض فالسيطرة على ضغط الدم بالعلاج لاتعنى الشفاء الكامل منه- لذا يحتاج المريض دائما إلى متابعة علاجية مستمرة.

9. إن ارتفاع ضغط الدم ليس نتيجة للعصبية أو التوتر ولذلك فإنه يستدعى العلاج بأدوية خاصة وليس مجرد المهدئات.

10. ضغط الدم المرتفع ليس له أعراض فى معظم الحالات، فالصداع، إحمرار الوجه، الدوار، الدوخة، وطنين الأذن والإغماء كلها أعراض تحدث بنسبة متقاربة فى مرضى ضغط الدم المرتفع وغير المرضى على حد سواء ولذلك يجب ألايعتمد الشخص على هذه الأعراض أو مايشعر به لكى يعرف مستوى ضغط دمه- والطريقة الوحيدة لمعرفة ضغط الدم هى قياسه بواسطة الجهاز المعد لذلك. وفى حالة الحاجة لقياس الضغط بصفة متكررة، يمكن قياسه بجهاز القياس المتواصل لضغط الدم لمدة 24 ساعة.

ماذا يحدث إذا ترك ضغط الدم المرتفع بدون علاج؟

إن إرتفاع ضغط الدم يقوم بإتلاف شرايينك أو شعورك بهذا. وكلما طالت مدة إرتفاع ضغط الدم، كلما زادت نسبة إصابة الشرايين بهذا التلف ويتسبب هذا فى إتلاف القلب والكلى والمخ والأوعية الدموية وكلها مضاعفات خطيرة للغاية. والجدير بالذكر أن الشخص الذى يعانى من ضغط الدم المرتفع يكون أكثر عرضة للإصابة بالأزمات القلبية خمسة أضعاف الشخص الطبيعى. لذا فإن علاج ضغط الدم المرتفع يمنع حدوث المضاعفات ويقلل من إحتمالات الوفاة المبكرة.

تعديل أسلوب الحياة و علاج إرتفاع ضغط الدم:

الحد من تناول الملح فى الطعام

إنقاص الوزن الزائد

ممارسة الرياضة بإنتظام

الإقلاع عن التدخين والعادات الصحية السيئة فى الأكل

الإمتناع عن الكحوليات

هى جزء هام فى علاج ضغط الدم المرتفع، وقد تؤدى فى بعض الأحيان إلى الإقلال من جرعات الدواء التى يحتاجها المريض للسيطرة على إرتفاع ضغط الدم.

نصائح وإرشادات هامة يجب على المريض إتباعها:

1. يجب ألا يزيد ضغطك عن 89 / 139 مم زئبق فى أى حال من الأحوال. أما إذا كنت تعانى من مرض السكر فيجب ألا يزيد ضغطك عن 84 / 129 مم زئبق وفى حالات وجود زلال فى البول بكميات كبيرة نتيجة مضاعفات مرض السكر يجب ألا يزيد ضغطك عن 74 / 124 مم زئبق.

2. لاتأخذ نصيحة من شخص غير مؤهل أو ليس مختصا.

3. علاقتك مع طبيبك:

- يجب أن تشارك طبيبك وتساعده على العناية بك وعلاجك.

- فى بداية الأمر سيكون الأمر صعبا بعض الشىء عندما تغير من عاداتك اليومية لإدخال البرنامج العلاجى.

- سيقوم الطبيب بالإستفادة من زيارتك لكى يتابع تطور حالتك وللتأكد من أن قلبك يعمل بطريقة فعالة.

نظام الغذاء

1- الإقلال من ملح الصوديوم فى نظامك الغذائى. لذا يجب عليك مراعاة الأتى:

الإقلال من إستخدام ملح الطعام.

الإقلال من إستخدام الأغذية المحفوظة (لإحتوائها على نسب عالية من الصوديوم كمادة حافظة ).

الإبتعاد عن الوجبات الخفيفة كثيرة الملح مثل الشيبس والبسكويت المملح والمكسرات المملحة والبسطرمة

تجنب تناول الوجبات السريعة "Fast Foods" لأن كثيرا منها يحتوى على نسبة عالية من الصوديوم

تجنب أية مصادر للملح مثل الجبن الرومى والزيتون والمخلل والأسماك المحفوظة.قراءة الورقة الملصوقة بالأطعمة المختلفة الموجودة بالأسواق للتأكد من نسبة الصوديوم فيها

الإقلال من السكر والحلويات لأن ذلك يؤدى إلى زيادة الوزن.

2. الإمتناع عن الأطعمة الغنية بالكوليسترول مثل: اللحم الأحمر - اللحوم السمينة مثل الضأن، والمخ والكبدة والكلاوى والسجق والهامبرجر - صفار البيض - البط والإوز والحمام وجلد الطيور - المكرونة المجهزة بالبيض أو اللبن أو المواد الدسمة الأخرى كالباشمل والسمن والقشدة والألبان الدسمة والآيس كريم والجبن الدسم الجمبرى والاستاكوزا والأسماك عالية الدهون.

3. الإكثار من تناول زيوت الأسماك متعددة التشبع "Fish Oil" أو التعود على تناول عدد ثلاث وجبات أو أكثر من الأسماك بإنتظام كل أسبوع. إستخدام زيت الذرة أو زيت عباد الشمس أو زيت الزيتون فى الطعام والإمتناع عن المسبكات والدهون والأكلات الدسمة.

3- الإكثار من تناول الأطعمة الغنية بالألياف مثل الخضراوات والفاكهة الطازجة.

4- الإمتناع عن المشروبات الغازية والمشروبات ذات السكر العالى.

5- الإقلال من الشاى والكاكاو والقهوة والنسكافيه - ويمكن تناول النوعيات الخالية من الكافيين.

6- الإمتناع عن المشروبات الكحولية بمختلف أنواعها فالكحول يساعد على إرتفاع ضغط الدم.

7-ليس من الضرورى الحد من تناول السوائل طالما كان تدفق البول طبيعيا.

التدخين

يجب الإمتناع عن التدخين بمختلف أنواعه

إذا كنت مدخنا فيجب أن تقلع فورا عن التدخين.

التدخين مرتبط إرتباط مباشر بحدوث أزمات القلب والصدمات الدماغية.

التدخين يحد من كمية الأ**يجين فى الدم ويتسبب أيضا فى تقلص الأوعية الدموية مما يقلل من كمية الدم التى تصل إلى عضلة القلب.

التدخين يضر بالرئتين.

زيادة الوزن - السمنة (Obesity)

السمنة تساعد على إرتفاع ضغط الدم كما أنها تجعل القلب يعمل بصورة أشد

السمنة تساعد على إرتفاع نسبة الكوليسترول فى الدم.السمنة تساعد على حدوث مرض السكر

يجب الإنقاص من وزن الجسم الى الوزن الطبيعى اذا ماكان المريض بدينا، وذلك بإتباع النظام الغذائى الخاص بالسمنة مع مراعاة إحتياجات الجسم اليومية من العناصر الغذائية الهامة

قلل من نسبة الدهون فى نظام غذائك

أكثر من الخضراوات والفواكه الطازجة

قم بممارسة التمرينات الرياضية حسب إرشادات الطبيب

قم بمتابعة وزنك بإستمرار.

ممارسة التمرينات الرياضية

إن القلب عبارة عن عضلة فهى تحتاج إلى تمرينات منتظمة لتجعلها قوية وتعمل بكفاءة. تؤثر التمرينات الرياضية بصورة إيجابية على معدلات الكوليسترول بالدم. تساعد التمرينات الرياضية على إقلال الوزن و علاج السمنة.إن التمرينات الرياضية تساعد على خفض ضغط الدم ولكن لن تكون هذه التمرينات مجدية إلا إذا كانت تمارس بصورة منتظمة. مارس التمرينات الرياضية حوالى نصف ساعة أو أكثر فى اليوم لمدة ثلاثة أيام على الأقل أسبوعيا حتى تساعد على خفض ضغط الدم ومعدلات الكوليسترول فى الدم. إن أفضل رياضة للقلب هى المشى بانتظام يوميا لمدة ساعة على الأقل فى جو مناسب. يجب تجنب الرياضات العنيفة خاصة رفع الأثقال. إستشر طبيبك عن نوعية وحجم التمرينات الصحية لك.

تذكر الآتى

إن ضغط الدم المرتفع يعتبر مشكلة فقط إذا ترك بدون علاج فلا تنزعج من إصابتك بهذا المرض فهو يمكن علاجه وهو لا يعوقك أو يؤثر فى طبيعة حياتك اليومية أو نوع العمل الذى تؤديه

يجب أن يصبح العلاج جزء من روتين يومك

حتى إذا كنت تشعر إنك معافى، يجب عليك:مراجعة طبيبك بصفة دورية.إتباع تعليمات طبيبك المعالج.الإلتزام بالنظام الغذائى وبرنامج التمرينات الرياضبة الموصوفين لك

الإقلاع عن التدخين

أخذ الدواء الموصوف لك حسب إرشادات طبيبك المعالج

لايسمح باستخدام الملح على مائدة الطعام أو أثناء الطهى أو عند إعداد الخبز، ويمكن استخدام عصير الليمون أو الخل لجعل الطعام مستساغا أو مقبولا.

شادي الريس

Carotid Intima-Media Thickness Can IT Be a New Predictor of Cardiac Risk

noreply@blogger.com (M Chadi Alraies) — Sun, 08 Mar 2009 17:36:00 +0000

I was reading the latest issue of Mayo Clinic Proceedings and I came across two interesting studies talking about new approach to predict the risk of cardiovascular disease. Both studies were proposing that the carotid intima-media thickness has the tendency to predict the cardiac risk even in patients with low Framingham Risk Score (FRS). I will leave you with the abstract and please follow the links at the end of the abstract for the full text.

A Cross-sectional Study of Intima-Media Thickness, Ethnicity, Metabolic Syndrome, and Cardiovascular Risk in 2268 Study Participants.

Allen Adolphe, MD, PhD, Linda S. Cook, PhD and Xun Huang, MS

Abstract:

OBJECTIVE: To describe the association between intima-media thickness (IMT) and metabolic syndrome (MetS) and to examine if the addition of IMT to a traditional MetS definition adds value to the assessment of predicted cardiovascular disease (CVD) risk in a large multiethnic population.
PARTICIPANTS AND METHODS: In this cross-sectional study, carotid IMT was measured in 2268 men and women as part of a wellness physical examination between August 1, 2000, and October 1, 2001. The wellness examination included a fasting lipid panel, physical examination, and medical history. Mean IMT was described by sex, ethnicity, and the MetS. Predicted risk for CVD was determined with IMT as a component of the diagnostic criteria for MetS.

RESULTS: Intima-media thickness increased with each additional component of the MetS, increasing from 0.516 mm for 0 components to 0.688 mm for 4 or more components (P<.001). In each ethnic group (non-Hispanic whites, blacks, Hispanics, and Asians), those with the MetS had higher mean IMT (increased by 0.084 mm to 0.134 mm) than those without MetS. The addition of IMT as a “new” component in the diagnosis of MetS allowed us to identify 78 (3.4%) participants who were not previously diagnosed as having MetS but who had a high 10-year estimated risk of MetS as measured by the Framingham risk score (11.67%).

CONCLUSION: The addition of IMT to the traditional criteria for the diagnosis of the MetS may help identify individuals who otherwise would not have been identified to be at high risk of CVD.

Full article: Click here

________________________________________________________

Carotid Intima-Media Thickness and Coronary Artery Calcium Score as Indications of Subclinical Atherosclerosis

Steven J. Lester, MD, FRCPC, Mackram F. Eleid, MD, Bijoy K. Khandheria, MD and R. Todd Hurst, MD

Abstract:

OBJECTIVE: To determine the ability of carotid intima-media thickness (CIMT) and coronary artery calcium score (CACS) to detect subclinical atherosclerosis in a young to middle-aged, low-risk, primary-prevention population.

PATIENTS AND METHODS: Patients aged 36 to 59 years who underwent determination of CIMT and CACS at our institution between May 1, 2004, and April 1, 2008, were included in the study. Those with diabetes mellitus or a history of coronary, peripheral, or cerebral vascular disease were excluded. Other information, such as Framingham risk score (FRS), was obtained by a review of clinical and laboratory data.

RESULTS: Of 118 patients, 89 (75%) had a CACS of zero and 94 (80%) were men; mean ± SD age was 48.9±5.7 years. The mean FRS of this group was 4.0; 86 patients (97%) were considered at low risk (<1% class="blsp-spelling-error" id="SPELLING_ERROR_56">CIMT above the 75th percentile was found in 12 (13%) of age-, sex-, and race-matched control patients. Of the 40 patients with low-risk CIMT (below the 50th percentile), 4 (10%) had a CACS at or above the 50th percentile.

CONCLUSION: Subclinical vascular disease can be detected by CIMT evaluation in young to middle-aged patients with a low FRS and a CACS of zero. These findings have important implications for vascular disease screening and the implementation of primary-prevention strategies.

Full article: click here

TNF Blockers in RA and Risk Of Serious Infections

noreply@blogger.com (M Chadi Alraies) — Wed, 21 Jan 2009 13:17:00 +0000

Because tumor necrosis factor-alpha (TNF-alpha) is an important component of the immune system's response to a variety of infections, TNF inhibitors can cause serious infections. These include bacterial infections (particularly pneumonia), tuberculosis, and opportunistic infections. Because of the increased risk of tuberculosis, a chest radiograph and purified protein derivative (PPD) test should be performed before the initiation of TNF inhibitor therapy. Till now there is no clear correlation between these medications and infections. Data from individual randomized clinical trials failed to demonstrate a consistent increase in treatment-related infections.

Recently (in January of 2009) C. Salliot and colleagues published in Annals of Rheumatic Disease Journal a meta-analyses of randomised placebo-controlled trials addressing the infection risks during rituximab, abatacept and anakinra treatments for rheumatoid arthritis. In summary, these meta-analyses did not reveal a significant increase in the risk of serious infections during rituximab or abatacept treatments in patients with rheumatoid arthritis; however, high doses of anakinra may increase this risk, especially when patients have comorbidity factors. Large studies must be performed to confirm this safety profile in daily practice.

To go to the ARD journal please click here

How To Read Chest X-Rays

noreply@blogger.com (M Chadi Alraies) — Sat, 22 Nov 2008 17:56:00 +0000

During my internal medicine training and especially during the internship, I was trying to master few things beside history taking and physical examination. One of these goals was how to read and interpret plain chest x-rays?

I tried different ways to achieve this goal, reading books, attending our noon teaching activity or asking my teaching attending. What I found most useful is to go to the radiology lab or PACS and pull out the films and see it myself or with my senior resident. After that if there is a final radiologist report I used to compare my findings with the official report and fill my lacking reading. Another useful way is to read the CXR while the teaching attending with me and that will give you the advantage of direct feedback on my reading skills.

I kept doing this for the rest of my residency training and during my chief resident year I put together powerpoint sildes (see below) summarizing what I have collected and presented it to my residents and got nice comments a feedback.

I published this work on Scribd website and it has been viewed more than 11,000 times (>1,000 views every month).

How to read chest x-rays

Publish at Scribd or explore others: Short Stories Health & Medicine read chest

ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use

noreply@blogger.com (M Chadi Alraies) — Wed, 12 Nov 2008 19:00:00 +0000

A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Please remeber the following point about this expert consensus document. Click here for more.

100% Internal Medicine Board Passing Rate

noreply@blogger.com (M Chadi Alraies) — Fri, 07 Nov 2008 17:23:00 +0000

Early October was a great moments for all St. Vincent Charity Hospital / Case Western reserve University 2008 class graduates. All class passed the ABIM (American Board of Internal Medicine) exam. This is the second year in a row St. Vincent has been achieving this passing rate.

I served as a third year and chief resident at the same time for 2007-2008 academic year. We (all residents) played like champions to achieve this honor. Early 2008 was the start for this plan. Please click here to log in to the ABIM planner that you might find helpful for passing the boards.

Good Luck

Blood management summit 2008 - CCF

noreply@blogger.com (M Chadi Alraies) — Mon, 03 Nov 2008 20:58:00 +0000

I learned the following points that I would like to share with you. I recommend this summit for everybody in the medical field especially hospital medicine (in-patient medicine). Please click here to get to the related page.

Dementia More Prevalent in Women Than Men After Age 90

noreply@blogger.com (M Chadi Alraies) — Thu, 09 Oct 2008 12:17:00 +0000

After age 90, dementia becomes more common with age in women but stabilizes in men, a study in Neurology suggests. Among some 900 mostly white, upper-middle-class subjects who were 90 or older, about 41% of women and 28% of men had dementia. Moreover, the odds of dementia in women approximately doubled from ages 90–94 to ages 95 and up, but remained stable in men. Higher education levels correlated with lower dementia rates in women, but not in men. The authors speculate that the discrepancy between men and women might be due to differences in dementia risk factors or in education levels, to a healthy-survivor effect in men, or to a longer duration of survival after dementia diagnosis in women than in men.

Neurology article.

ABIM 2008 Study Group

noreply@blogger.com (M Chadi Alraies) — Sun, 23 Mar 2008 04:00:00 +0000

As third year internal medicine residents we prepared for the 2008 ABIM (American Board of Internal Medicine) exam as one group. I initiated this project as a personal planner to prepare for the board. Later on, I introduced this plan to my colleagues who found it helpful. I am blogging this since we have 100% passing rate that year and to share the plan with other board takers.

When did we start? We started in April since majority of my class have finished call rotations and can comply more with the plan agenda.

Reading materials: This is was hard choice since many board review books and series are available in the marker and few residents started preparing from different sources. However, I was looking for something concise, focused and brief. I sent questionnaires to former graduates of our program who passed the boards asking for their recommendations. I came to conclusion that MedStudy published by MedStudy Corporation has the best reviews among our residents and across the US medical residents.

Questions materials: Again having the same issue finding the right one, but we concluded that MKSAP 14 multiple choice questions published by the American College of Physician (ACP) was one of the best and covers majority of the ABIM topics and has the similar style as well. Other source that I personally used as well were: MedStudy MCQ’s book and Medscape board review self assessment questions from acponline.org. Click here to download.

Schedule: We planned to finish reading and discussing the 5 books of MedStudy within 2 months period (before graduation) by assigning 15-20 pages per week. We finished as planned.

Follow-up: weekly meeting (Thursday morning) for 1 hour discussing the pages we read and doing an average of 10-20 questions from MKSAP bank. These meeting kept us on the same reading pace. Questions and unclear points were discussed and shared with our faculty attendings.

Result: 100% ABIM passing rate.

My Resume

noreply@blogger.com (M Chadi Alraies) — Tue, 26 Jun 2007 18:07:00 +0000

Few facts about me and what I have done. Please Click Here.

The ECG book

noreply@blogger.com (M Chadi Alraies) — Fri, 22 Sep 2006 03:23:00 +0000

A total of 66 electrocardiograms were collected during my first year and beginning of my internal medicine training. Each ECG is presented with short clinical scenario followed by the patient's ECG. On the next page you'll find the right answer with detailed explanation. My next step is upload those electrocardiograms to this website. If you you want to see the cover, please click here

Medical Presentations

noreply@blogger.com (M Chadi Alraies) — Wed, 21 Dec 2005 00:16:00 +0000

Please choose one of the following slide presentations. If you need help or have a question, please leave me a comment.

Diastolic Heart Failure
Coronary Heart Disease
Valvular Heart Disease
Rapid Response Team
Lipid Abnormalities (Right click then "save target as" to get the slides)
Parynchymal Kidney Disease (Right click then "save target as" to get the slides)
Vasculitis (Right click then "save target as" to get the slides)
Comatose patient with core temperature of 28.1C
Chest Radiography Interpretation Part I
Chest Radiography Interpretation Part II
Chest Radiography Interpretation Part III
Chest Radiography Interpretation Part IV
Perioperative Medicine Cases

ECG book cover

noreply@blogger.com (M Chadi Alraies) — Tue, 22 Mar 2005 03:31:00 +0000

ABIM 2008 group study

noreply@blogger.com (M Chadi Alraies) — Wed, 16 Mar 2005 17:22:00 +0000

Were are done guys. Thank you for sharing with me your ideas and thoughts and congratulations for passing the boards. In summary, I found the following materials very useful:

MKSAP 14
MedStudy 3rd volume
ACP / MedScape ABIM-based MCQ's (more than 500 MCQ, Click Here to download)

And I prepared for the boards using MedStudy 12th edition books.

CLICK HERE to find all the TIPS and Key points that will help your preparation for the ABIM.

Please help improve this forum by sharing your ideas and thoughts. All you have to do is click on "post a comment" at the end of this page and start writing. When you are done, fill in your name (if you want) and click on publish your comment. If you have any new ideas or books, please share it with us. We appreciate any input.

Thank you

Perioperative Notes

noreply@blogger.com (M Chadi Alraies) — Thu, 18 Nov 2004 19:51:00 +0000

Soon I will have here my personal review the perioperative medicine literature. Please stay tuned!

Medical tips board

noreply@blogger.com (M Chadi Alraies) — Thu, 12 Aug 2004 14:23:00 +0000

288-Cards: AICD reduces the risk of sudden cardiac death in survivors of cardiac arrest due to hypertrophic cardiomyopathy and ventricular tachycardia/fibrillation.

287-Neu: Young patients with no underlying medical problems who presents with acute dense unilateral neurological deficits with negative non-contrast CT imaging of the brain requires MRI & MRA of the brain and neck to role out vertebral artery dissection as a cause of stroke.

286-Neu: Neurological deficits in patients with underlying malignancy requires carefull assessment and evlauation of the entire spine. The imaging modality of choice is always MRI of the whole spine.

285-Neu : Obstructive hydrocephalus medical management aims to either reduce CSF production or increase CSF absorption.

CSF production can be reduced through the use of high-dose acetazolamide (25 mg/kg/d divided into 3 doses, with a maximum daily dose of 2 g) and
Furosemide (1 mg/kg/d divided into 3 doses).
Isosorbide nitrate may be given to increase CSF absorption, although its effectiveness remains questionable.
Patients with brain metastases with acute worsening of mentation should be given corticosteroids to decrease cerebral edema. Dexamethasone is the preferred medication, as it has limited mineralocorticoid action and thereby reduces the potential for fluid retention. Typically, dexamethasone is given as a loading dose of 10 mg, followed by 4 mg every 6 hours.
Patients who present with elevated intracranial pressure can also be treated with mannitol to reduce cerebral edema, with a starting dose of 0.5-1.0 mg/kg. This can be repeated every 4-6 hours.
Patients with rapidly declining mental status can also be intubated and hyperventilated to elicit a transient drop in intracranial pressure.
Patients may also present with seizures; in these cases, anticonvulsant medications should be given, although the role of prophylactic anticonvulsants remains controversial.

284- Neu: Obstructive hydrocephalus occurs when there is ventricular enlargement under tension as a result of an obstruction of the flow of CSF anywhere in the above-described pathway. The criteria for diagnosing acute hydrocephalus by diagnostic imaging are as follows: the ratio between the largest width of the frontal horns and the internal diameter, from inner-table to inner-table at this level, should be greater than 0.5; the ratio of the largest width of the frontal horns to the maximum biparietal diameter should be greater than 0.3; the temporal horns are enlarged (this is helpful in distinguishing hydrocephalus from atrophy, wherein the temporal horns are typically normal in size); the sulci and interhemispheric and sylvian fissures are narrowed (in atrophy, these are widened); transependymal absorption of CSF is seen as periventricular low density; on sagittal images, upward bowing of the corpus callosum and decreased distance between the pons and the mammillary bodies are seen. Common imaging findings for chronic hydrocephalus include less prominent temporal horn dilation, third ventricle herniation, erosion of the sella turcica, macrocrania, and an atrophied corpus callosum.

283- Neu: CSF cycle: Normally, CSF is produced in the choroid plexus, and it flows through the CNS by the following route: from the choroid plexus, the CSF flows (1) to the lateral ventricle, (2) through the interventricular foramen of Monro, (3) into the third ventricle, (4) through the cerebral aqueduct of Sylvius, (5) into the fourth ventricle, (6) through the 2 lateral foramina of Luschka and the single medial foramen of Magendie, and finally, (7) into the subarachnoid space. In the subarachnoid space, the CSF is absorbed by the arachnoid granulations into the dural sinus and drains into the venous system.

282- Misc:

Decrease the dose of OHA when giving aspirin or NASAID's in general.
RA treatment is a setp-down appraoch rather than step-up.
Methotrexate causes: Stomatitis and bone marrow suppression. Monitor the CBC twice a year.

281- Neu: Polymyositis is characterized by proximal muscle weakness, elevated creatine kinase levels, and needle electromyography showing diffuse fibrillations and myopathic motor unit potentials. Results of creatine kinase measurement and needle electromyography are invariably normal in steroid myopathy but abnormal in inflammatory myopathy.

280- Neu: Patients with the locked-in syndrome are quadriplegic, have paralysis of horizontal eye movements and bulbar muscles, and can communicate only by moving their eyes vertically or blinking. The locked-in state is due to a lesion of the base of the pons, usually from pontine infarction due to basilar artery occlusion.

279- Neu: Multiple system atrophy is characterized by orthostatic hypotension, neurogenic bladder, constipation, and impotence, with gait-predominant parkinsonism and corticospinal tract signs.

278- Neu: Amantadine is the first-line pharmacologic agent for treatment of multiple sclerosis-related fatigue.

277- Neu: Mild cognitive impairment consists of isolated mild amnesia with no impairment of interpersonal, occupational, or daily living activities. The conversion rate from mild cognitive impairment to mild dementia is 10% to 15% per year. There are several reasons to perform neuropsychological testing. First, depression is often difficult to diagnose, especially in an articulate, well-compensated person. Second, testing is indicated because of the patient's position of responsibility. The evaluation will provide a basis for deciding whether or not to increase his level of supervision or reduce his level of responsibility. Third, neuropsychological examination will also provide an objective baseline. Follow-up evaluation in 1 year is appropriate, as many affected patients may have predemential Alzheimer's disease. The conversion rate from mild cognitive impairment to mild dementia is 10% to 15% per year.

Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56:1133-42. [PMID: 11342677] [PubMed]

276- GI: A Dieulafoy lesion is an unusually large aberrant submucosal artery that can cause significant gastrointestinal bleeding. A Dieulafoy lesion may be missed on upper endoscopy unless active bleeding is occurring at the time of the endoscopic examination.

275- GI: Wilson's disease should be considered in a young patient with abnormal liver chemistry studies, cognitive changes, and hemolysis. A low serum ceruloplasmin value (<20>

274- GI: The great majority of recurrent colorectal cancers develop within 2 years postoperatively. A patient who has undergone resection for colorectal cancer requires surveillance colonoscopy 3 years postoperatively to detect the possible presence of metachronous lesions.

273- GI: The serum–ascites albumin gradient (SAAG) of ≥1.1 g/dL (≥11 g/L) (serum albumin of 3.5 minus ascitic fluid albumin of 1.6 = 1.9) is consistent with portal hypertension. Portal hypertension due to cirrhosis is associated with an ascitic fluid protein <2.5>2.5 g/dL (>25 g/L).

272- GI: The initial test in a patient with possible gastric outlet obstruction is upper endoscopy.

271- GI: Dyssenergic defecation (pelvic floor dysfunction) refers to impaired defecation caused by inappropriate contraction or impaired relaxation of the puborectalis and external anal sphincter muscles. Anorectal manometry is the most appropriate study for diagnosing dyssenergic defecation.

270- GI: CT enterography is the most appropriate study for a patient with possible Crohn's disease but with a normal colonoscopic examination.

269- GI: Chronic intestinal pseudo-obstruction is a disorder of gastrointestinal motility that involves abnormal small bowel pacemaker cells (interstitial cells of Cajal). Pseudo-obstruction may be a neuropathic disorder (paraneoplastic syndrome) or a myopathic condition secondary to smooth muscle disease (e.g., amyloidosis or systemic sclerosis).

268- GI: Nonulcer dyspepsia is the most common cause of epigastric pain in a young, otherwise healthy patient. A trial of a proton pump inhibitor is warranted in a young patient with a first episode of nonulcer dyspepsia and a negative serologic test for Helicobacter pylori.

267- GI: Patients who have had two or more episodes of diverticulitis are more likely to develop complications such as abscesses, strictures, and perforation. Patients who have had two or more episodes of diverticulitis should undergo surgical resection of the affected intestine. The risk of recurrent diverticulitis is 10% to 20% after a first attack but increases to 30% to 50% after a second attack. In addition, complications such as abscesses, fistulas, and perforation are more likely to occur after each new episode.

266- GI: Liver biopsy should be considered for selected patients with suspected nonalcoholic fatty liver disease. Rosiglitazone or pioglitazone may be indicated for patients with nonalcoholic steatohepatitis and features of the metabolic syndrome in order to prevent progression of the liver disease. Although a liver biopsy is not required for all patients with NAFLD, biopsy should be considered for those who are older than 45 years of age, are obese, have diabetes mellitus, or have a serum aspartate aminotransferase to serum alanine aminotransferase ratio (AST:ALT) >1, as these may be predictors of fibrosis.

265- ID: Corticosteroids have been shown to significantly alleviate acute pain in patients with herpes zoster (shingles). Corticosteroids are contraindicated in patients with poorly controlled plasma glucose levels, osteoporosis, or hypertension.

264- ID: (fever, headache, rash, myalgias, and general malaise) and laboratory data are typical of Rocky Mountain spotted fever. Several cases have now been described in the southwestern deserts of the United States. Presumptive treatment is almost always advisable when Rocky Mountain spotted fever is suspected because untreated patients have a significant mortality rate, the diagnosis usually takes many days to confirm by laboratory studies or biopsy, and the treatment (doxycycline) is very effective and has relatively few complications.

263- ID: Trimethoprim–sulfamethoxazole is the preferred antimicrobial therapy for a patient with a brain abscess caused by Nocardia species.

262- ID: Angiostrongylus cantonensis (the rat lungworm) is the most common cause of eosinophilic meningitis worldwide. It is endemic in many tropical areas throughout the world and can infect humans when poorly cooked or uncooked intermediate hosts such as snails are ingested or vegetables contaminated with the larvae are consumed. The meningitis is self-limited, and the diagnosis is established by serologic studies demonstrating antibodies to the parasite.

261- ID: Patients with osteomyelitis and an epidural abscess who do not have focal neurologic deficits can usually be treated with antimicrobial therapy alone, but must be monitored carefully. However, emergency surgical decompression should be performed for any patient with increasing neurologic deficits, persistent severe pain, increasing fever, or a persistently elevated leukocyte count.

260- ID: A maculopapular rash, especially on the palms and soles, is characteristic of disseminated (secondary) syphilis. A patient with possible neurosyphilis should receive intravenous aqueous crystal penicillin G for 14 days.

259- ID: Oral valganciclovir is as effective as intravenous ganciclovir for treating patients with cytomegalovirus retinitis.

258- ID: West Nile virus can be transmitted by blood transfusions. West Nile virus can be
transmitted to transplant recipients from organ donors.

257- ID: West Nile virus encephalitis is most likely to occur in patients 65 years of age and older.Findings in patients with West Nile virus encephalitis include fever, severe headache, marked muscle weakness involving the lower motor neurons, mental status changes, and possibly seizures.

256- ID: The development of focal lymphadenitis in a patient with HIV infection is most commonly caused by mycobacteria, Streptococcus species, or Staphylococcus species.

255- ID: In contrast to patients with sporadic, genetic, or iatrogenic Creutzfeldt–Jakob disease, patients with the variant form of the disorder tend to be younger and have psychiatric symptoms rather than dementia early in the disease, more prominent sensory findings, and MRI abnormalities in pulvinar area of the thalamus rather than in the basal ganglia and putamen.

254- ID: Acute retinal necrosis occurs most often in patients with HIV infection or AIDS.
Intravenous acyclovir is the preferred treatment for acute retinal necrosis. It is most likely caused by varicella-zoster virus or possibly by herpes simplex virus. The preferred treatment for either of these viruses is intravenous acyclovir.

253- ID: Polyomavirus BK is associated with nephropathy and deteriorating renal function in renal transplant recipients. The presence of intranuclear inclusions in tubular epithelial cells or transitional cells is highly indicative of polyomavirus BK.

252- ID: In patients with a contiguous foot ulcer and possible osteomyelitis, bone biopsy with cultures and histopathologic examination should be performed before initiating antimicrobial therapy.

251- ID: African tick bite fever is the most common rickettsial infection in humans. Symptoms of African tick bite fever are relatively mild and are characterized by a vesicular rash with an inoculation eschar.

250- ID: The most appropriate empiric therapy for Streptococcus pneumoniae meningitis is vancomycin plus ceftriaxone and dexamethasone.

249- ID: Gastrointestinal cytomegalovirus infection is a potentially fatal complication because an ulcer may perforate and cause peritonitis, or the patient may bleed to death because of sudden and massive hemorrhage. Administration of ganciclovir or valganciclovir has greatly reduced, but not eliminated, the occurrence of cytomegalovirus infections in transplant recipients.

248- ID: The epidemiology and clinical presentation (fever, myalgias, arthralgias, severe headache, leukopenia, and thrombocytopenia) are classic for dengue fever, which is spread by mosquitoes in endemic areas in the Caribbean and Central and South America. The diagnosis cannot be confirmed early in the course of illness, when other more serious diseases need to be ruled out. The usual diagnostic method is finding a rise in dengue virus antibodies in convalescent sera, although viral culture or polymerase chain reaction is available in some institutions. Treatment is supportive.

247- ID: Antiretroviral therapy should be initiated for a treatment-naïve patient with HIV infection and a CD4 cell count less than 200/µL (0.2 × 109/L), even if the patient is asymptomatic. A regimen containing lamivudine, efavirenz, and tenofovir is appropriate for a treatment-naïve patient with HIV infection who also has chronic hepatitis B.

246- ID: West Nile virus can be transmitted in blood products. Most patients with West Nile virus infection have a subclinical infection.

245- ID: Progressive multifocal leukoencephalopathy is a demyelinating disease with a high mortality rate that occurs primarily in immunosuppressed patients. It is associated with reactivation of polyomavirus JC and occurs most often in immunosuppressed patients. There is no treatment. However, if the disease is detected early, it can possibly be arrested by decreasing or stopping a patient's immunosuppressive agents. Therefore, if this patient's central nervous system damage is not too severe, he and his family should be told about the possibility of stopping immunosuppression and sacrificing the renal transplant to preserve remaining nervous system function.

244- ID: Oseltamivir and zanamivir are both active against influenza A and B.
Because zanamivir may induce bronchospasm, it is contraindicated in patients with asthma.

243- Neph: Black patients with lupus nephritis have a much poorer prognosis compared with white patients despite treatment with corticosteroids and intravenous cyclophosphamide. Therefore, maintenance therapy is indicated. Recent studies have suggested that maintenance therapy with mycophenolate mofetil or azathioprine is beneficial in lupus nephritis. In addition, a recent randomized trial compared the induction of therapy with intravenous cyclophosphamide followed by maintenance therapy with intravenous cyclophosphamide, azathioprine, or mycophenolate mofetil (Contreras). Both mycophenolate mofetil and azathioprine were shown to be less toxic and more efficacious than maintenance intravenous cyclophosphamide.

242- Neph: Nonsteroidal anti-inflammatory drug use is a common cause of resistance to antihypertensive therapy.

241- Neph: Hematuria is a common finding that occurs in 1% to 3% of all patients and in as many as 10% of all men. One of the most important initial steps in the evaluation of microscopic hematuria is microscopic analysis of urine sediment to assess erythrocyte morphology to distinguish between glomerular hematuria and nonglomerular hematuria of the urinary tract. Monomorphic or intact erythrocytes characterize nonglomerular hematuria, whereas dysmorphic erythrocytes are associated with glomerular hematuria. In men >50 years of age with persistent hematuria, genitourinary tract malignancy must be excluded by cystoscopy, especially in the setting of associated risk factors such as cigarette smoking, analgesic abuse, benzene exposure, or a history of voiding abnormalities.

240- Neph: Refeeding Syndorm:The phosphate is sequestered in the intracellular compartment, whereas intracellular depletion of phosphate is critical. Once this patient is supplied with calories (particularly carbohydrates), oxidative phosphorylation and generation of adenosine triphosphate quickly deplete the intracellular phosphate, which leads to rhabdomyolysis. The best method of preventing this complication from occurring is recognizing patients at risk for this disorder. Phosphate levels should be monitored closely in patients in this setting to prevent the development of this complication.

239- Neph: The liver helps to metabolize circulating steroid hormones. Elevated levels of progestins in end-stage liver disease lead to stimulation of the respiratory drive, which causes a primary respiratory alkalosis.

238- Neph: IgA glomerulonephritis, Goodpasture's syndrome, and antineutrophil cytoplasmic antibody glomerulonephritis are not associated with low complement levels. IgA glomerulonephritis would develop at the same time as pharyngitis, not 3 weeks later.

237- Neph: Postinfectious glomerulonephritis is the most likely diagnosis in a young woman who develops glomerular disease 3 weeks after the onset of respiratory tract infection. In addition, the presence of low serum C3 levels and normal C4 levels strongly suggests this diagnosis and raises suspicion for the significant volume expansion that accompanies this condition.

236-Neph: Obesity-related glomerulopathy typically manifests with nephrotic range proteinuria but lacks other manifestations of the nephrotic syndrome seen in focal segmental glomerulosclerosis, minimal change disease, or membranous nephropathy. Compared with these conditions, obesity-related glomerulopathy is associated with a lower incidence of the nephrotic syndrome, a more benign course, and slower progression to renal failure.

235- Pul: The propofol infusion syndrome in adults occurs primarily in patients with acute neurologic or acute inflammatory diseases complicated by severe infection or sepsis, and receiving catecholamines and/or corticosteroids in addition to propofol. The main features of the propofol infusion syndrome are cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure associated with hyperkalemia.

234- Pul: Hereditary hemorrhagic telangiectasia (HHT) is diagnosed clinically by the presence of three of the following four criteria: (1) recurrent epistaxis; (2) telangiectasias in the lips, oral cavity, fingers, or nose; (3) visceral lesions such as gastrointestinal telangiectasias, or arteriovenous malformations in the lung, liver, or brain; and (4) first-degree relatives with the syndrome.

233- Pul: Epoprostenol is first-line therapy for patients with severe pulmonary hypertension, and may be life-saving for patients in cor pulmonale. Bosentan causes pulmonary artery vasodilation and is associated with a reduction in mortality in patients with pulmonary artery hypertension

232- Pul: No drug is FDA-approved for the treatment of delirium, but clinical practice guidelines recommend antipsychotic agents, such as haloperidol. All antipsychotics, and especially “typical” agents, pose a risk of torsades de pointes and extrapyramidal side-effects as well as the more rare neuroleptic malignant syndrome.

231- Pul: Crytogenic organizing pneumonia is an idiopathic interstitial pneumonia that clinically resembles a flulike syndrome, and is characterized by crackles and patchy persistent infiltrates on chest radiograph, and restrictive lung defect with decrease in carbon monoxide diffusing capacity.

230- Pul: The most common form of delirium in the ICU is hypoactive or “quiet” delirium.
Delirium is a form of acute brain dysfunction that occurs in 50% to 80% of ventilated patients in the intensive care unit; it is associated with higher mortality rates, longer hospital and ICU stay, higher costs, and chronic cognitive deficits. The cardinal features of delirium are 1) acute onset or fluctuations in mental status over a 24 hour period, 2) inattention, 3) disorganization of thinking, and 4) an altered level of consciousness at the time of the evaluation. http://www.icudelirium.org/delirium/

229- Pul: Vocal cord dysfunction mimics asthma, but unlike asthma, it begins and ends abruptly, does not respond to β-agonists, and airflow limitation is mainly during inspiration.

228- Pul: In patients with acute lung injury/ARDS on mechanical ventilation with a lung protective strategy, PEEP should be increased in 2- to 3-cm H2O increments to lower FiO2 to 60%, if possible, and to maintain an arterial oxygen saturation of ≥88% and ≤ 95%

227- Pul: For ventilator-associated pneumonia manifesting clinical resolution of symptoms and signs of infection, radiologic improvement, and requirement for less ventilatory support with improving oxygenation, courses of no more than 8 days of antibiotic therapy are associated with as good outcomes as longer courses.

226- Pul: The triglyceride concentration in a chylothorax is >110 mg/dL and occurs in association with a low pleural fluid cholesterol concentration. If the triglyceride level is <50> 200 mg/dL) and cholesterol crystals on microscopy signifies the presence of pseudochylous effusion. These pseudochylous effusions, also called chyliform effusions may have a triglyceride level >110 mg/dL, but the cholesterol level will usually be >200 mg/dL. Cholesterol crystals will be seen on microscopy. A major proportion of the lipids in these effusions comprise lecithin-globulin complexes.

225- Pul: The reactive airway dysfunction syndrome follows a single, accidental inhalation of high levels of a nonspecific respiratory irritant in patients who typically do not have a history of asthma. The diagnosis of the reactive airways dysfunction syndrome is based on history and confirmed by positive methacholine challenge

224- Pul: Diffuse alveolar hemorrhage is characterized by dyspnea and diffuse alveolar infiltrates; it can be the initial manifestation of primary or secondary pulmonary vasculitis, drug reactions, coagulation disorders, and infection. The diagnosis of diffuse alveolar hemorrhage is made with bronchoalveolar lavage, with serial samplings showing a persistently bloody fluid.

223- Hem: Marginal-zone B-cell lymphoma has been associated with hepatitis C virus in some patients; treatment of the underlying infection may result in remission of the lymphoma.

222- Hem: Gonadotropin-releasing hormone agonists, such as leuprolide, lead to decreased serum testosterone levels. These reduced levels of testosterone result in less conversion of testosterone to estradiol, which is needed to protect and strengthen bones, and the absence of which causes bone loss in the lumbar spine ranging from 2% to 8% per year of androgen-deprivation therapy use. Although not supported by clinical evidence, many clinicians manage men who receive long-term androgen ablation therapy with the same approach used in postmenopausal woman with bone loss. This management strategy consists of yearly bone-density scans, prophylactic vitamin D and calcium supplementation, and bisphosphonates.

Diamond TH, Higano CS, Smith MR, Guise TA, Singer FR. Osteoporosis in men with prostate carcinoma receiving androgen-deprivation therapy: recommendations for diagnosis and therapies. Cancer. 2004;100(5):892-9

221- Hem: Patients with BRCA1/2 mutations have a higher risk for breast and ovarian cancer compared with the general population. Patients with a family history suggestive of germline-susceptibility cancer should be referred for genetic counseling.

220- Hem: Imatinib mesylate can cause a mild, maculopapular rash that is most prominent over the extremities and trunk, and typically resolves within a week of interruption of therapy. For most patients who experience an imatinib-induced rash, the drug can be re-instituted after the rash resolves, without recurrence.

219- Hem: Patients with vitamin B12 deficiency have elevated serum lactate dehydrogenase and unconjugated bilirubin and may have increased forgetfulness. Supplemental vitamin B12 does not always reverse the neurologic findings of B12 deficiency but may prevent further deterioration of mental status.

218- Hem: Several randomized trials have shown a disease-free and overall survival advantage for patients receiving high-dose chemotherapy and autologous stem cell transplantation during the first complete or partial remission or plateau phase of the disease. Therefore, patients who have no contraindications for high-dose chemotherapy and autologous stem cell transplantation should be offered this treatment after initial therapy for multiple myeloma therapy.

217- Hem: Fatigue, weight loss, massive splenomegaly, and teardrop-shaped erythrocytes on peripheral blood are consistent with myelofibrosis. Chronic transfusion therapy is an appropriate management option for some patients with myelofibrosis.

216- Hem: Fondaparinux administered for 28 days results in a low frequency of venous thromboembolism after hip-fracture repair and is FDA approved for extended thromboprophylaxis following this procedure.

215- Hem: Factor VIII inhibitors characteristically develop in association with certain malignancies, particularly lymphomas; in patients with autoimmune disorders; and in the postpartum setting. Diagnosis of the presence of an inhibitor occurs by first performing a mixing study, or inhibitor screen, in which patient and normal plasma is mixed in a 1:1 ratio, and the abnormal test is repeated. If the coagulation abnormality results from a factor deficiency, the test result on the mixed plasmas will normalize. However, if an inhibitor is present, the added factor from the control plasma will also be neutralized, and the abnormal study will not be corrected. Therefore, if this patient has developed a factor VIII inhibitor, the mixing study will not correct the abnormality, and a confirmatory measurement of factor VIII activity should then be performed. If factor VIII activity level is low, additional studies to measure the inhibitor titer (in Bethesda units) would be indicated.

214- Hem: Primary (AL) amyloidosis should be suspected in patients with nephrotic-range proteinuria in the presence of monoclonal gammaglobulin in serum or urine. A diagnosis of primary (AL) amyloidosis can be established by kidney biopsy.

213- Hem: Erythropoietin failure in patients receiving dialysis can be caused by iron deficiency, folate deficiency, ongoing blood loss, or iron overload. Supplemental vitamin C can improve the response to erythropoietin in patients receiving dialysis.

212- Hem: Incidental thrombocytopenia of pregnancy requires careful follow-up monitoring of the platelet count. Patients with incidental thrombocytopenia of pregnancy require further diagnostic evaluation when platelet values decrease to lower than 70,000/μL (70× 109/L).

211- Hem: warm antibody autoimmune hemolytic anemia (AIHA); the first step in treatment is corticosteroid therapy. The peripheral blood smear shows polychromatic red blood cells and spherocytes. Polychromasia in AIHA usually results from reticulocytosis. Reticulocytes contain nucleic acids that stain blue. Warm antibody AIHA occurs when IgG antibodies bind to red blood cell antigens (usually of Rh-type) at body temperature. These cells are eventually cleared by splenic macrophages. Spherocytes are detected in patients with AIHA because of membrane removal by macrophages in the spleen. Although warm antibody AIHA is initially treated with corticosteroid therapy, intravenous immune globulin and splenectomy are also treatment options. However, intravenous immunoglobulin has not been shown to be as effective as corticosteroid therapy in these patients. Red blood cells are microcytic in iron deficiency. Therefore, iron and erythropoietin are not useful in the treatment of AIHA.

210- Hem: Thrombotic thrombocytopenia purpura (TTP) is characterized by fever, neurologic abnormalities, thrombocytopenia, microangiopathic hemolytic anemia, and renal insufficiency.
The treatment of choice for TTP is emergent plasma exchange, followed by plasma infusion when the former is not immediately available.

209- Hem: Complete hematologic remission rates for patients with CML who received imatinib mesylate compared with interferon and low-dose cytarabine were 95% and 56%, respectively.

208- Hem: Immunosuppressive therapy with antithymocyte globulin and cyclosporine is effective in reducing transfusion requirements in >70% of patients with aplastic anemia.

207- Hem: Acute chest syndrome (ACS) is characterized by fever, chest pain, shortness of breath, hypoxia, and a chest infiltrate in a patient with a sickling disorder. Patients with ACS require erythrocyte transfusion to achieve a target hemoglobin of 10 g/dL (100 g/L).

206- Hem: Patients with delayed-onset heparin-induced thrombocytopenia (HIT) can present with typical manifestations of HIT as late as 3 to 4 weeks after heparin exposure. Patients with delayed-onset HIT require anticoagulation therapy with a direct thrombin inhibitor and no further exposure to heparin.

205- Hem: Signs suggestive of disease transformation from myelodysplastic syndrome to acute myeloid leukemia (AML) include severe pancytopenia and circulating myeloid blasts on peripheral blood smear. Patients with transformed versus de novo AML have poorer response rates and disease-free survival, despite receiving the same chemotherapeutic regimen.

204- Hem: Major diagnostic criteria of polycythemia vera include an elevated red blood cell mass, a normal blood oxygen saturation, and the presence of splenomegaly. Low-dose aspirin reduces the risk of thrombotic complications in polycythemia vera.

203- Hem: (TRALI) Transfusion-related acute lung injury is an inflammatory infusion reaction in the pulmonary vasculature manifested primarily by hypoxemia. Antileukocyte antibodies in donor plasma react with antigens on the surface of patients' leukocytes, chiefly neutrophils, leading to neutrophil aggregation and leukostasis in the pulmonary vasculature. This produces inflammatory reactions that cause alveolitis, and often, acute respiratory distress syndrome. Hypoxemia is the primary manifestation of transfusion-related acute lung injury. This condition is managed with supportive care of the respiratory failure, because the injured lung tissue recovers as the inflammation subsides, usually in 1 to 2 days. Diuretics have been reported to worsen this condition, and the role of corticosteroids in this setting is unproved.

202- Hem: Hematologic findings in iron-deficiency anemia consist of microcytic, hypochromic red blood cells; abnormalities in erythrocyte size and shape; and occasional bizarre-shaped red blood cells. Iron-deficiency anemia is treated with iron therapy.

201- Hem: Patients with acute venous thromboembolism and metastatic cancer are at higher risk for recurrent venous thrombosis than those without malignancy. Chronic low-molecular-weight heparin at therapeutic doses reduces the risk for thrombotic recurrence compared with standard-intensity warfarin in patients with venous thromboembolism and cancer.

200- Cardio: According to the ACC/AHA guidelines, the administration of nitroglycerin is contraindicated in patients who have used the phosphodiesterase-5 inhibitors sildenafil or vardenafil within the past 24 hours and tadalafil within the past 48 hours because of the risks of potentiating hypotension.
Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004;110:588-636.

199- Hem: APS is recognized as being a prethrombotic condition, with the development of venous thrombi predominating over that of arterial thrombi. Recent studies have shown that the optimal level of oral anticoagulation has a target INR of 2 to 3. (Previously higher INRs were used, but these have not been shown to be more effective.) Recent studies have shown that these patients frequently have a recurrence of their VTE even after 3 to 6 months of therapeutic oral anticoagulation. Currently, the optimal duration of oral anticoagulation remains uncertain but some physicians recommend longer-term treatment, which could last for years.
Lim W, Crowther MA, Eikelboom JW. Management of antiphospholipid antibody syndrome. A systematic review. JAMA. 2006;295:1050-1057.

198- Cardio: All of the following scenarios meet ACC/AHA criteria for management by coronary artery bypass grafting:

Patients with asymptomatic or mild angina who have significant left main coronary stenosis.
Patients with asymptomatic or mild angina who have a left main equivalent, defined as a =70% obstruction in the proximal left anterior and proximal circumflex arteries.
Patients with stable angina, EF <50%>.
Patients of age <75>

197- Cardio: The Treating to New Targets (TNT) trial was a large CV outcomes trial of 10 001 patients with stable CAD and LDL-C <130 n =" 5006)" n =" 4995)" size="-2">
LaRosa JC, Grundy SM, Waters DD, et al. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med. 2005;352:1425-1435.

196- Cardio: The Bezold-Jarisch reflex (bradycardia, hypotension, and apnea) can occur after
reperfusion therapy for an inferior MI, but is typically transient.
Thompson P, McKeown B. Complications after myocardial infarction. In: Yusuf S, Cairnes JA, Camm JA, Fallen EL, Gersh BJ, eds. Evidence Based Cardiology. 2nd ed. London, UK: British Medical Journal Books; 2003.

195- Cardio: PCI after reperfusion with fibrinolytics is efficacious only when patients have persistent symptoms or ST elevations after thrombolysis or when patients go on to develop cardiogenic shock. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with STelevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol. 2004;44:E1-E211.

194- Cardio: In ACS the optimal time to reestablishing perfusion with fibrinolysis is <1 size="-2">Libby P. Current concepts of the pathogenesis of the acute coronary syndromes. Circulation. 2001;104:365-372.

193- Hem: The relative risk of factor V Leiden inducing a DVT is fairly low and only 5% to 10% of individuals who have a factor V Leiden deficiency will develop a DVT by ages 50 to 60 years. For this reason, most physicians do not routinely screen for factor V Leiden, but if it is found in an individual who will have elective surgery in the future, most physicians would use prophylactic strategies such as LMWH prophylaxis. Crowther MA, Kelton JG. Congenital thrombophilic states associated with venous thrombosis: a qualitative overview and proposed classification system. Ann Intern Med. 2003;138:128-134.

192- Cardio: Dyssynchronous ventricular contraction is characterized on electrocardiogram by a QRS duration that exceeds 120 ms. CRT combined with conventional HF pharmacologic regimens (ACE inhibitors, beta-blockade, diuretics, etc) improves the mechanical properties of myocardium. CRT is associated with improvements in HF class, exercise capacity, LVEF, mitral regurgitation, HF hospitalization, and mortality. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005;112:e154-e235.

191- Cardio: There is a paucity of clinical data regarding the use of warfarin in the setting of ACS in the era of long-term dual antiplatelet therapy. These patients are exposed to the increased bleeding risk associated with the combination of aspirin, clopidogrel, and warfarin. Clear indications for this combination include atrial fibrillation and mechanical prosthetic valves. The ACC/AHA guidelines also recommend warfarin for patients with evidence of LV thrombus and those who have an aspirin allergy (class I indication). The use of warfarin to prevent embolic complications among patients with reduced systolic function is considered a class IIb recommendation. An anterior MI in and of itself is not an indication for warfarin therapy. In fact, according to a recent analysis of a large registry of patients presenting with STEMI who were treated with fibrinolytic therapy, strokes were more common among patients presenting with inferior MIs. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST–elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol. 2004;44:E1-E211.

190- Gen: Recommended prophylaxis for elective total knee replacement before the patient is ambulating consists of high-dose low-molecular-weight heparin, fondaparinux, adjusted-dose warfarin with a target INR of 2.5, or use of a continuous SCD. Low-dose low-molecular-weight heparin (subcutaneous enoxaparin, 40 mg daily) and low- or high-dose unfractionated heparin (5000 U subcutaneously twice or three times daily) are effective prophylaxis for patients undergoing general surgery but are not adequate for those undergoing knee-replacement surgery. Ref: Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:338S-400S. [PMID: 15383478] [PubMed]

189- Gen: Short-term studies have shown that black cohosh is effective in reducing hot flushes.

188- Gen: A score of less than 23 (of 30) on the Mini-Mental State Examination is considered to be a positive screening result for dementia.

187- Gen: In patients with nonspecific dyspepsia and no alarm symptoms, a “test-and-treat” approach with urea breath testing followed by Helicobacter pylori eradication in patients with positive results is the most cost-effective strategy for curing symptoms.

186- Gen: Cancers that most commonly spread to bone include prostate, breast, lung, thyroid, and renal cell carcinomas.

185- Gen: Nasal corticosteroids are more effective than either leukotriene inhibitors or oral antihistamines—both sedating and non-sedating—in treating patients with allergic rhinitis.

184- Gen: All the selective serotonin reuptake inhibitors and the serotonin norepinephrine reuptake inhibitors are effective for depression and generalized anxiety disorder and have Food and Drug Administration approval for these indications. Depressive symptoms often respond more quickly to treatment than do anxiety symptoms, and it is not uncommon for anxiety to be “unmasked” during the first few weeks of antidepressant treatment.

183- Gen: Imaging studies are appropriate in patients with suspected chronic sinusitis who have not responded to medical treatment.

182- Gen: Topical ketoconazole cream is an effective therapy for patients with tinea versicolor.

181- Gen: Alopecia areata is common in thyroid disease, vitiligo, diabetes, atopy, and Down's syndrome. The affected skin in alopecia areata generally has no signs of inflammation, desquamation, or scarring

180- Gen: The inactivated influenza vaccine is recommended for patients with chronic medical conditions, including heart failure, kidney disease, lung disease, diabetes, asthma, HIV/AIDS, cancer, and chronic corticosteroid therapy.

179- Gen: Osteomalacia and osteoporosis are common in celiac disease and can occur even in patients who have no gastrointestinal symptoms. Bone loss is related to secondary hyperparathyroidism due to prolonged vitamin D deficiency not normalized with a gluten-free diet. Most patients are asymptomatic; very few have bone pain. The incidence of osteoporosis is 27% to 36% in patients with celiac disease; men are more severely affected than women. Routine screening for osteoporosis with a dual X-ray absorptiometry (DXA) scan for bone density is important in this high-risk population.

178- Gen: The criteria for acute bacterial rhinosinusitis are duration of symptoms longer than 1 week and worsening symptoms after initial improvement, maxillary tenderness, purulent drainage, and poor response to decongestants. Antibiotics should be reserved for patients who meet the criteria for acute bacterial rhinosinusitis.

177- Gen: Wearing below-knee elastic compression stockings during the day for 2 years or longer reduces the risk for postphlebitic syndrome by approximately 50% in patients with symptomatic proximal deep venous thrombosis. 176- Gen: Severe cases of poison ivy, including those with extensive involvement and associated edema, can be treated with oral prednisone

176- Gen: Severe cases of poison ivy, including those with extensive involvement and associated edema, can be treated with oral prednisone.

175- Gen: Lipodermatosclerosis can occur in patients with advanced chronic venous insufficiency and involves circumferential areas of fibrosis extending proximally from above the ankles, with pitting edema above the area of fibrosis and over the feet.

174- Gen: β-Blockers, oral nitrates, and most antihypertensive drugs should be continued the morning of surgery and reinstituted when patients begin eating. The anti-inflammatory and pleotrophic plaque-stabilizing effects of statins appear to reduce the risk for postoperative cardiac complications in observational studies and should be continued the morning of surgery and reinstituted when patients begin eating. Ref: Mercado DL, Petty BG. Perioperative medication management. Med Clin North Am. 2003;87:41-57. [PMID: 12575883] [PubMed]

173- Gen: Acute shoulder pain and weakness after falling on an outstretched arm is characteristic of a rotator cuff tear. The inability to smoothly lower the affected arm from full abduction (positive drop-arm test) is a highly specific finding for a rotator cuff tear.

172- Gen: Graded exercise therapy and cognitive behavioral therapy are the nonpharmacologic therapies of choice in patients with fibromyalgia syndrome (FMS). Patient education, acupuncture, hypnosis, biofeedback, and mineral baths may improve FMS symptoms.

171- Gen: Obesity is associated with an increased risk for total mortality and chronic conditions, including coronary artery disease, stroke, type 2 diabetes, heart failure, dyslipidemia, and hypertension. Weight loss of approximately 5% at 1 year decreased progression to type 2 diabetes and improved control of lipid levels and hypertension. Ref: Snow V, Barry P, Fitterman N, Qaseem A, Weiss K. Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2005;142:525-31. [PMID: 15809464] [PubMed]

170- Gen: Selective serotonin reuptake inhibitors may increase the risk for surgical bleeding complications. Estrogen and selective estrogen receptor modulators increase the risk for thromboembolism and should be discontinued perioperatively.

169- Gen: Minor depression consists of the presence of either depressed mood or anhedonia (or both) with other symptoms that total more than two but less than the five total symptoms required to establish a diagnosis of major depression. Although minor depression decreases functional status, several treatment trials of pharmacotherapy and psychotherapy have reported that treatment outcomes for these modalities are no better than those associated with placebo.

168- Gen: Fatigue, hypotension, bradycardia, and exacerbations of reactive airway disease and heart failure are recognized side effects of timolol eye drops.

167- Gen: Revised Cardiac Risk Index assigns one point each for the following six variables: high-risk surgery, history of ischemic heart disease, history of heart failure, history of cerebrovascular disease, diabetes mellitus treated with insulin, and serum creatinine level >2.0 mg/dL (176.84 µmol/L). According to their score, patients fall into one of four risk strata: 0, 1, 2, or ≥3 points.

166- Gen: “Alarm” symptoms in patients with abdominal pain include hematochezia, weight loss >4.5 kg (10 lb), family history of colon cancer, recurring fever, anemia, or chronic severe diarrhea.

165- Gen: First-line therapy for panic disorder consists of selective serotonin reuptake inhibitors, such as paroxetine.

164- Gen: Causes of unexplained weight loss in the elderly include depression, cancer, benign gastrointestinal conditions, medication toxicities, and socioeconomic concerns.
The most common malignancies characterized by weight loss in the elderly are lung and gastrointestinal malignancies.

163- Gen: Among patients with chronic noncardiac chest pain, randomized, placebo-controlled studies have demonstrated that tricyclic antidepressants, β-blockers, ACE inhibitors, L-arginine, statins, and exercise may relieve symptoms.

162- Gen: In patients with a history of deep venous thrombosis (DVT), the levonorgestrel intrauterine device will not increase the risk for developing embolic disease and also sufficiently decreases the likelihood of pregnancy. Both oral and topical hormonal contraception are contraindicated in patients with a history of DVT.

161- Gen: Urticaria that does not respond to usual treatment should prompt a workup for urticarial vasculitis, including erythrocyte sedimentation rate, complete blood count, and skin biopsy from the edge of the wheal.

160- Gen: The live varicella vaccine causes some viral shedding in the 4 weeks after injection

159- Gen: Headaches that are acute in onset, occur after age 50 years, and are associated with a history of malignancy are “red flags” prompting immediate neuroradiologic evaluation.

158- Gen: Cauda equina syndrome is characterized by urinary retention, saddle anesthesia, and radiculopathy. Cauda equina syndrome is an indication for urgent evaluation and requires definitive imaging to visualize the spinal cord and epidural space.

157- Gen: Arrhythmia should be strongly suspected in patients with syncope and coronary artery disease and bifascicular block. Long-term (≥30 days) event monitoring with external or implantable continuous-loop recorders is recommended when suspicion of arrhythmia remains after inpatient telemetry and ambulatory electrocardiographic monitoring are nondiagnostic.

156- Gen: Blood counts should be monitored in men receiving testosterone-replacement therapy, initially within 1 to 2 months of initiating therapy, then every 3 to 6 months for the first year, and then annually. Higher testosterone levels stimulate erythropoiesis, and injections are more potent stimulants than transdermal preparations.

155- Gen: The best treatment for brown recluse spider bites is ice application, wound elevation, and avoidance of strenuous exercise in the muscles surrounding the bite.

154- Gen: The evidence-based standard is selective preoperative testing based on medical history, physical examination, and risk for surgery-specific blood loss. Multiple studies have shown that indiscriminant preoperative testing rarely identifies clinically important abnormalities, delays surgery, or predicts complications.

Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am. 2003;87:7-40. [PMID: 12575882] [PubMed]
Macpherson DS, Snow R, Lofgren RP. Preoperative screening: value of previous tests. Ann Intern Med. 1990;113:969-73. [PMID: 2240920] [PubMed]

153- GenE: ffective therapies for reducing the severity of nasal congestion in patients with viral upper respiratory infections include pseudoephedrine, ipratropium nasal inhaler, cromolyn sodium nasal inhaler, and humidified air. Pseudoephedrine is safe in patients with well-controlled hypertension.

152- Gen: Based on the Ottawa ankle rules, radiography of the ankle is not indicated in patients with ankle injury who can bear weight and have no bony tenderness over the lateral malleolus or fifth metatarsal bone. Patients with moderate ankle sprains usually are not treated with cast immobilization, which can delay return to normal activities compared with functional therapy.

151- Gen: Criteria for hospitalization of patients with anorexia nervosa include severe malnutrition or dehydration, electrolyte disturbances, cardiac arrhythmias, physiologic instability, failure of outpatient treatment, acute food refusal, uncontrollable bingeing and purging, acute medical complication of malnutrition, suicidal ideation, and the presence of comorbid problems interfering with treatment.

150- Gen: Age-related macular degeneration is the leading cause of legal blindness among people aged 65 years or older in the United States.
Patients with this disorder typically have unilateral symptoms of gradual or sudden central vision loss.

149- Gen: Situational syncope is associated with a particular situation and includes syncope associated with vagal stimulation, such as straining at micturition, defecation, cough, and, occasionally, swallowing, especially very cold liquids.

148-Gen: widespread superficial tenderness, pain on axial loading of the skull, and inconsistent straight-leg-raising tests (should be positive both when the patient is sitting and supine), suggest a nonorganic component to his back pain. These findings (Waddell's signs) are considered nonorganic because they do not correspond to anatomic distributions or make physiologic sense.

147- Gen: A common reason for social isolation in the elderly is functional decrease in vision and/or hearing.

146- Gen: Dry eyes, commonly caused by keratoconjunctivitis sicca (KCS), can often become recalcitrant to standard treatment with ocular moisture therapy. Cevimeline is a useful secretagogue therapy for the treatment of dry eyes unresponsive to moisture-replacement therapy.

145- Gen: Plantar fasciitis is the most common cause of heel pain; the gradual onset of symptoms, morning pain, and inferior heel tenderness are characteristic findings. Conservative treatment for plantar fasciitis includes rest, ice application, exercises, NSAIDs, orthotics, and cushioned soles.

144- Gen: Patients with uncontrolled asthma or the presence of wheezes have an increased risk
for postoperative pulmonary complications.

143- Gen: Persistent rhinitis symptoms in the setting of nasal decongestant spray overuse suggests rhinitis medicamentosa.

142- Gen: Potential causes of postoperative delirium include hyponatremia, severe hyperglycemia, marked decline in hemoglobin, hypoxemia, infection, unstable coronary syndrome, pneumonia, and opiate medications. Once the initial evaluation is completed, haloperidol or newer antipsychotics can be prescribed for sedation, and empiric antibiotics and CT or MRI of the head can be performed if indicated.

141- Gen: Surgical intervention of patients with low back pain should be considered only if symptoms persist for more than 6 weeks or if progressive neurologic deficits develop.
Controlled trials demonstrate that NSAIDs provide effective short-term symptom relief for patients with acute low back pain with or without sciatica.

140- Gen: A careful clinical breast examination should take approximately 3 minutes per breast. Duration of the examination correlates significantly with lump detection and accuracy.

139- Gen: Carpal tunnel syndrome is best diagnosed by compatible Katz hand diagram results and diminished pain sensitivity in the distribution of the median nerve. Tinel's sign and the flick and Phalen's maneuver have limited diagnostic discrimination in carpal tunnel syndrome.

138- Gen: Hyponatremia is a common and dangerous cause of delirium in hospitalized patients. Undernourished elderly patients are at particularly high risk for this condition and should always be checked when they may be susceptible to hyponatremia and exhibit changes in their mental status.

137- Gen: Brief interventions are associated with a significant increase in the number of patients who quit and abstain from smoking at 1 year. Advising a patient to stop smoking through a clear personalized message is an important component of a brief intervention.

136- Gen: In patients with heart failure, reduce the loading dose of lidocaine by half.

135- Gen: Ginkgo biloba may impair hemostasis and cause perioperative bleeding complications. Kava may potentiate central nervous system depressants, echinacea has the potential to interfere with immunosuppressants, and St. John's wort alters metabolism of many drugs (warfarin, digoxin, cyclosporin, antiretrovirals), but none of these supplements predispose to bleeding or are known to interact with anesthetics.

134- Gen: Systematic reviews use explicit methods to limit bias and help improve the reliability and validity of the conclusions. Single randomized studies rarely provide definitive answers to clinical questions.

133- Endo: The humoral mediator of hypercalcemia of malignancy in most cases, especially in lung cancer, is parathyroid hormone–related peptide (PTHrp), which is secreted by the tumor.

132- Endo: The somatostatin analogue, octreotide, reduces growth hormone production and shrinks tumor in patients with acromegaly and is first-line therapy for patients not cured by surgery alone or surgery combined with radiation.

131- Endo: The two causes of central hyperthyroidism are a TSH-producing adenoma and the resistance to thyroid hormone syndrome. The two causes of central hyperthyroidism, TSH-producing adenoma and the resistance to thyroid hormone syndrome, can be distinguished by measuring TSH α subunit.

130- Endo: The major storage form of vitamin D in the body is 25-dihydroxyvitamin D, and therefore this is the best test to assess for vitamin D deficiency.

129- Endo: Prediabetes glycemic states consist of impaired glucose tolerance, defined as a 2-hour glucose level of 140-199 mg/dL (7.77-11.04 mmol/L) during an oral glucose tolerance test, and impaired fasting glucose, defined as a fasting glucose level of 100-125 mg/dL (5.55-6.94 mmol/L). Ref. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2005;28 Suppl 1:S37-42. [PMID: 15618111] [PubMed]

128- Endo: Testosterone therapy does not cause prostate cancer but can stimulate the growth of occult tumors. In patients beginning testosterone therapy, a rectal examination of the prostate gland before the first dose and the serum prostate-specific antigen should be measured at 3, 6, and 12 months after the start of therapy.

127- Endo: In patients with concomitant autoimmune adrenal and thyroid failure (Schmidt's syndrome), adrenal failure is often unrecognized initially; as thyroxine deficiency is corrected, the patient develops clinical adrenal insufficiency, requiring glucocorticoid supplementation.

126- Endo: Evaluation of Adrenal nodule should start with:

A history and physical examination, directed towards detection of adrenal hormone excess.
Subclinical Cushing's syndrome should be excluded with an overnight dexamethasone (1 mg) test. An early morning cortisol concentration <1.8>
Fractionated plasma metanephrines should be assessed to rule out pheochromocytoma.
Hypertensive patients should be screened with plasma aldosterone/plasma renin activity ratios; ratios >20 with aldosterone concentrations >15 ng/dL suggest autonomous mineralocorticoid secretion.
Adrenal androgens should only be assessed if the female patient is masculinized.

125- Endo: Most adrenal nodules are hormonally silent and have no malignant potential.
Patients with an incidentally detected adrenal mass should be screened for pheochromocytoma, Cushing's syndrome, and primary aldosteronism.

124- Endo: Celiac disease and autoimmune thyroid disease occur together at a higher frequency than that expected from observation of incidence in the general population.

123- Endo: Teriparatide (recombinant human parathyroid hormone [1-34]) stimulates osteoblastic bone formation; it significantly increases bone mass in patients with osteoporosis and can decrease the incidence of both vertebral and nonvertebral fractures.

122- Endo: Pericardial effusion is a consequence of moderate to severe hypothyroidism and is indicated by diminished heart sounds, low voltage on electrocardiography, and an enlarged cardiac silhouette. The “hypothyroid heart” refers to decreased contractility and pulse rate—both contributing to a decreased cardiac output at a time when peripheral vascular resistance is increased.

121- Endo: Latent autoimmune diabetes of adulthood (LADA) occurs in lean patients with initially apparent type 2 diabetes who become insulin-dependent later in life and exhibit the labile glycemic tendencies and many of the autoimmune markers of patients with type 1 diabetes. Latent autoimmune diabetes of adulthood (LADA) is characterized by slowly progressive loss of beta-cell function, leading to severe insulin deficiency and labile glycemic control. Patients with latent autoimmune diabetes of adulthood (LADA) become refractory to oral agents and as insulin-dependent and ketosis-prone as patients with type 1 diabetes.

120- Endo: The classic presentation of thyroid lymphoma is an elderly woman with autoimmune thyroiditis and a rapidly expanding thyroid mass.

119- Endo: The treatment of choice for a nonfunctioning pituitary adenoma is transsphenoidal tumor resection. Indications for surgery include presence of hormonal deficiency and mass effects, including visual deficits, cranial nerve palsies, and headaches.

118- Endo: Breast enlargement in a young man occurs most commonly with drugs or substances or alterations in the androgen/estrogen ratio—either androgen deficiency or estrogen excess
High concentrations of hCG in a man suggest the diagnosis of choriocarcinoma, an aggressive germ cell tumor.

117- Endo: In patients with macroprolactinoma and normal visual fields, dopamine agonist therapy effectively reduces prolactin secretion and tumor size.

116- Endo: Silent thyroiditis is an autoimmune disorder characterized by high levels of antithyroid peroxidase antibodies, painless enlargement of the thyroid gland, and a triphasic course with early thyrotoxicosis followed by hypothyroidism and then a return to euthyroidism in most patients. Most patients with interferon alfa–associated thyroid dysfunction recover after the drug is discontinued.

115- Endo: Hypercalcemia associated with thyrotoxicosis usually resolves when the patient becomes euthyroid.

114- Endo: Orthostatic hypotension is a common manifestation of diabetic autonomic neuropathy, reflecting loss of normal vasoconstrictor tone, with deranged compensation to upright posture. Fludrocortisone therapy expands the plasma volume, thereby raising blood pressure and improving symptoms in diabetic autonomic neuropathy.

113- Endo: Obese, insulin-resistant men generally have a reduced serum total testosterone concentration, primarily as a result of a low sex-hormone binding globulin concentration.

112- Endo: In hypercalcemia secondary to production of parathyroid hormone-related peptide by a carcinoid, the serum parathyroid hormone level is suppressed.

111- Endo: The diagnosis of gestational diabetes mellitus requires any two of the following four values in a 3-h, 100-g oral glucose tolerance test: fasting ≥95 mg/dL (5.27 mmol/L); 1-h ≥180 mg/dL (9.99 mmol/L); 2-h ≥155 mg/dL (3.05 mmol/L); 3-h ≥140 mg/dL (7.77 mmol/L).

110- Endo: During a normal pregnancy, thyroid hormone production must be increased to provide thyroid hormone to the developing fetus; most women who are taking thyroid hormone replacement require a 30% to 50% increase in their thyroid hormone dose during their pregnancy.

109- Endo: Screening for primary aldosteronism is best accomplished by obtaining a morning plasma aldosterone and plasma renin activity – known as an aldosterone/renin ratio or ARR. An ARR ratio > 20, with a plasma aldosterone >15 ng/dL (416.1 pmol/L) strongly suggests primary aldosteronism, but does not confirm the diagnosis. The only antihypertensive agent which influences the ARR ratio is spironolactone, which must be discontinued for 6 weeks.

108- Endo: Potential complications of Paget's disease of the bone include osteogenic sarcoma in affected bone, hypercalcemia, high-output congestive heart failure, deafness, and excessive bleeding during surgery as a result of hypervascular bone.

107- Endo: Potential complications of Paget's disease of the bone include osteogenic sarcoma in affected bone, hypercalcemia, high-output congestive heart failure, deafness, and excessive bleeding during surgery as a result of hypervascular bone.

106- Endo: Features of the euthyroid sick syndrome include a precipitous drop in serum total and free T3 levels, and a concomitant increase in reverse T3. Euthyroid sick syndrome can occur during a host of nonthyroidal illnesses such as caloric deprivation, major surgery, and sepsis

105- Endo: Indications for measurement of bone mass include:

Women ≥65 years of age (regardless of risk factors),
Postmenopausal women <65>.
Postmenopausal women who present with fractures,
Women who are considering therapy for osteoporosis and for whom bone mineral densitometry tests results would influence this decision,
Women who have been receiving hormone replacement therapy for a prolonged period,
Radiographic findings suggestive of osteoporosis or vertebral deformity,
Corticosteroid therapy for more than 3 months,
Primary hyperparathyroidism, and
Treatment for osteoporosis (to monitor therapeutic response).

104- Endo: Risk factors for osteoporosis in men include a BMI <18,>

103- Endo: The classic triad of symptoms for pheochromocytoma consists of headaches, palpitation and diaphoresis. The sensitivity of fractionated plasma metanephrines for catecholamine-producing tumors is nearly 97%; however, the specificity is 85%.

102- Endo: Postmenopausal women with subclinical hyperthyroidism and an undetectable TSH have an increased risk of developing osteoporosis.

101- Endo: The presence of three or more pituitary hormone deficiencies has a positive predictive value for growth hormone deficiency of 95%. Replacement of growth hormone in hormone-deficient adults has been shown to improve body composition, lipid parameters, and bone mineral density.

100- Endo: The classic symptoms of renal osteodystrophy are vague bone pain localized to the lower back, hips, or legs; muscle weakness often occurs with normal muscle enzymes and nonspecific electromyography changes. The main radiographic feature of renal osteodystrophy is increased bone resorption, most commonly in the subperiosteal surfaces of the hands, neck of femur, and clavicle.

99- Endo: Computed tomography of the abdomen with thin sections through the adrenals is the preferred initial localizing study for pheochromocytoma.

98- Endo: Secondary diabetes mellitus may be the direct result of such underlying disease states as other endocrinopathies, islet cell neoplasms, and disorders of the exocrine pancreas such as pancreatitis, pancreatic malignancies, and cystic fibrosis.

97- Endo: Serum prolactin levels greater than 200 ng/mL (200 mg/L) in a nonpregnant woman usually suggest a tumor instead of another cause of hyperprolactinemia.

96- Endo: Osteoporosis is diagnosed by the presence of fragility fractures or by a bone mineral density value <−2.5 in patients who have not experienced a fragility fracture.

95- Endo: In euthyroid patients, amiodarone therapy results in high free and total T4, low-normal T3, and high-normal TSH.

94- Endo: Inferior petrosal sinus sampling is a confirmatory test for Cushing's syndrome in patients with ambiguous results in screening tests; the technique is very sensitive and specific, but extremely costly, technically difficult, and somewhat hazardous.

93: Endo: Hyperprolactinemia can cause hypogonadism because prolactin directly suppresses gonadotropin-releasing hormone secretion and thus luteinizing hormone and testosterone production. The initial treatment for prolactin-producing macroadenomas is a dopamine agonist, such as bromocriptine or cabergoline, which decreases prolactin level, shrinks the tumor, and improves visual fields and pituitary function in most patients.

92- Endo: The average patient with type 1 diabetes mellitus, who does not have coexisting insulin resistance, requires a total daily dose (TDD) of about 0.4 to 0.5 units of insulin per kg of body weight. Most patients take 40% to 50% of their total daily dose as basal insulin (glargine) and 50% to 60% as meal boluses (lispro or aspart).

91- Endo: Primary hypothyroidism is a common secondary cause of hyperprolactinemia, likely caused by increased stimulation of the pituitary gland by thyrotropin-releasing hormone.

90- Endo: Benign adrenal adenomas generally have smooth borders, attenuation values <10>6 cm are carcinomas.

89- Endo: The ADA recommended goals for management of adults with diabetes are hemoglobin A1C <7.0%,>40 mg/dL (1.03 mmol/L), and LDL cholesterol <100>. Reference: Standards of medical care in diabetes. Diabetes Care. 2005;28 Suppl 1:S4-S36. [PMID: 15618112]

88- Endo: Pendred's syndrome is an autosomal-recessive disorder of iodine organification characterized by congenital sensorineural hearing loss combined with goiter.

87- Endo: Non–parathyroid hormone–mediated hypercalcemia is characterized by suppressed parathyroid hormone levels (<20>

86- Endo: Patients with gestational diabetes mellitus have a 50% risk of developing type 2 diabetes mellitus in the 5 to 10 years after the diagnosis of gestational diabetes.

85- Endo: The serum TSH cannot be used to monitor thyroid hormone replacement therapy in patients with central hypothyroidism. On patients with central hypothyroidism, the goal of thyroid hormone replacement is to titrate the dose to normalize the free T4 (or total T4 and free thyroxine index) not to normalize the TSH.

84- Endo: Pseudo-Cushing's syndrome consists of hypercortisolism in patients with such disorders as depression and alcohol use that alter hypothalamic - pituitary - adrenal function enough to perturb screening tests for Cushing's syndrome. If standard screening tests are equivocal in a patient with a strong pretest probability for Cushing's syndrome, the combined dexamethasone - CRH stimulation test may distinguish Cushing's syndrome from pseudo-cushing's syndrome.

83-Pulmonary: In Acute lung injury (ALI)/ARDS cases, National Institutes of Health ARDS Network conducted the Fluid and Catheter Treatment Trial (FACTT). Fluid management was guided by either a central venous catheter or a pulmonary artery catheter. Patients were also randomized to a fluid-restrictive strategy (a target central venous pressure [CVP] of ≤4 mm Hg or pulmonary artery occlusion pressure of ≤8 mm Hg) or a more liberal approach (CVP of 10 to 14 mm Hg or pulmonary artery occlusion pressure of 14 to 18 mm Hg). The fluid-restrictive strategy resulted in more days free of mechanical ventilation, lower indices of lung injury, and fewer days in intensive care. It did not result in an increase in the occurrence of either hypotension or the need for renal replacement therapy. By contrast, regardless of the fluid strategy employed, the use of pulmonary artery catheters did not reduce ventilator-free or intensive care unit days, but it did increase the number of catheter-related complications (mostly dysrhythmias). Reference: National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wheeler AP, Bernard GR, Thompson BT, et al. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006;354(21):2213-24.

82-Pulmonary: In patients with acute lung injury/acute respiratory distress syndrome, a fluid-conservative strategy has been shown to improve lung function and shorten duration of mechanical ventilation and intensive care unit stay without increasing nonpulmonary organ failure. Reference: National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wheeler AP, Bernard GR, Thompson BT, et al. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006;354(21):2213-24.

81
WHAT IS THE INDICATION FOR ORAL ANTIBIOTICS IN HEPATIC ENCEPHALOPATHY?

Although neomycin has been used for many years to treat hepatic encephalopathy, no controlled studies have found it to be effective compared with standard treatment alone. a more recent randomized trial reported no difference in outcomes between placebo and Neomycin. In addition, neomycin is associated with ototoxicity and nephrotoxicity, limiting long-term use.

Other antibiotics, such as metronidazole, vancomycin, and rifaximin, have been found effective in limited clinical trials and are better tolerated than neomycin.

Nevertheless, strong evidence of effectiveness is lacking, and all antibiotics can cause alterations in gut flora that may contribute to bacterial overgrowth syndromes. Thus, their use is typically limited to patients who cannot tolerate or are resistant to disaccharides.

Reference: Up-To-Date 14.3

80
What are the major causes of acute renal failure developing during hospital stay?

ATN 45 percent
Prerenal 21 percent
Acute on chronic renal failure 13 percent (mostly due to ATN and prerenal disease)
Urinary tract obstruction 10 percent
Glomerulonephritis or vasculitis 4 percent
Acute interstitial nephritis 2 percent
Atheroemboli 1 percent

Reference: up to date 14.3

79
What are the casues of thrombocytopenia in the ICU patient?

Infection, sepsis, septic shock
heparin
DIC
Massive blood transfusion
Post-transfusion purpura
CPR
Cardiopulmonary bypass
ARDS
PE
IV catheters
Solid organ allograft rejection
Drugs (eg, antibiotics, chemotherapy, antiplatelet agents such as abciximab)

78
What is "OGILVIE'S SYNDROME"?

Acute colonic pseudo-obstruction AKA (Ogilvie's syndrome) is a disorder characterized by gross dilatation of the cecum and right hemicolon (although occasionally extending to the rectum), in the absence of an anatomic lesion that obstructs the flow of intestinal contents.
Reference: up-to-date 14.3

77
How does pneumonia present in elderly compared to young patients?

In the nonelderly population, cough in the absence of fever, tachycardia, and tachypnea generally suggests bronchitis rather than pneumonia. The presence of normal vital signs and the absence of rales and egophony on chest examination suggest that pneumonia is so unlikely that further diagnostic testing is usually unnecessary. An exception, however, is cough in elderly patients; pneumonia in elderly patients is often characterized by an absence of distinctive signs and symptoms. Among patients 75 years of age and older who had community-acquired pneumonia, only 30% had a temperature above 38 C, and only 37% had a
heart rate of more than 100 beats per minute.
Reference: ACUTE BRONCHITIS, N Engl J Med 2006; 355:2125-2130, Nov 16, 2006.

76
What are three important atypical bacteria that commonly cause acute bronchitis?

While the role of bacteria in acute bronchitis or its attendant symptoms remains unclear, atypical bacteria are important causes, including Bordetella pertussis, Chlamydophila (Chlamydia) pneumoniae, and Mycoplasma pneumoniae. Some data have suggested that B. pertussis may underlie 12 to 32% of cases of cough lasting 6 days or longer, although in a recent prospective study, B. pertussis comprised only 1% of cases of acute bronchitis. For antimicrobial treatment of atypical bacterial infections, macrolides such as azithromycin are recommended.
Reference: ACUTE BRONCHITIS, N Engl J Med 2006; 355:2125-2130, Nov 16, 2006.

75
What is the recommended Hemoglobin level in CRD patients?

The recent recommendations of the National Kidney Foundation Disease Outcomes Quality Initiative (K/DOQI) panel on anemia suggest that the target hemoglobin level should be 11.0 g per deciliter or greater with caution urged if a hemoglobin value of more than 13.0 g per deciliter is intentionally maintained. However, as thE two new studies by Dr eke et al. and Singh et al. demonstrate, while the degree of anemia is a strong indicator of poor prognosis, complete correction of anemia does not improve outcomes and appears to be associated with increased risk of adverse events in this patient population.

Reference: Normalization of Hemoglobin Level in Patients with Chronic Kidney Disease and Anemia, N Engl J Med 2006; 355:2071-2084, Nov 16, 2006.

74
What is the average duration of cough in acute bronchitis?

Cough after acute bronchitis typically persists for 10 to 20 days but occasionally may last for 4 or more weeks. In a recent report (Ward et al., NEJM, 2005) the median duration of cough from acute bronchitis due to all causes was 18 days (mean, 24). Approximately 50% of patients with acute bronchitis report the production of purulent sputum, an indication of sloughed tracheobronchial epithelium and inflammatory cells (in otherwise healthy patients). Purulent sputum has a low positive predictive value for the presence of alveolar disease, approximately 10%.

REFERENCE: NACUTE BRONCHITIS, Engl J Med 2006; 355:2125-2130, Nov 16, 2006.

73
Acute Bronchitis: Are Antimicrobials Effective?

Antimicrobial agents are not recommended in most cases of acute bronchitis. Systematic analyses of clinical trials have suggested that antibiotics may reduce the duration of symptoms, but modestly at best. One meta-analysis (Evans et al., Am J Med, 1999) of eight trials involving patients with acute bronchitis suggested that symptoms were reduced by only a small fraction with the use of erythromycin, doxycycline, or trimethoprim-sulfamethoxazole. The results were statistically significant but clinically trivial.

Reference: NEJM 11/2006

72
What is the clinical presentation for stroke involving the Corpus Callosum?

Tactile anomia (Inability to name objects by touch but by sight only)

Reference: Up-to-Date

71
What is the most common worldwide parasitic CNS infection?
Neurocyticercosis (tinea solium - tapeworm)

History of illness:
cysts in the brain, break down of the cyst wall, cerebral edema, seizure as a first
presentation.

Diagnosis:
CT of the brain usually shows multiple 1 cm cysts.

Treatment:
Niclosamide for GI treatment Albendazole or Praziquantel with corticosteroids.

REFERENCE: UP-TO-DATE, MEDSTUDY

70
What is the differential diagnosis for change in mental status in an AIDS patient?

AIDS encephalopathy
Progressive multifocal leukoencephalopathy (PML)
Lymphoma
Toxoplasmosis

References: Up-to-date 14.3, Medstudy

69
What is Status epilepticus?

Definition:
seizure that last more than 30 minutes or series of 2 or more seizures without regaining
consciousness.

Causes:
Stroke
Alcohol or drugs withdrawal
Tumors
Trauma
Metabolic causes (e.g. hypoglycemia)
Stopping or changing in seizure medication
Hypoxia
CNS infections

Treatment:
Lorazepam 0.1 mg/kg IV
Diazepam 0.2 mg/kg IV
Phenytoin load IV

REFERENCE: MEDSTUDY, UPTODATE 14.3

68
What are the risk factors for seizure recurrence?

1. Abnormal EEG on first presentation
2. Abnormal MRI too
3. Positive family history
4. History of previous neurologic injury
5. First seizure as a partial complex.

Reference: Uptodate, Medstudy

68
What is Meniere s disease?

Clinically: Hearing loss, Tinnitus and Episodic vertigo with nausea and vomiting

Unilateral most of the time with 20-30% bilateral

Etiology:
increased endolymphatic fluid pressure

Treatment:
no definite treatment but decreased salt intake and diuretics. In refractory
situations, shunting procedures might help.

REFERENCE: MEDSTUDY 2006

66
What are the rates of ECG abnormalities and arrhythmia following STROKE?

Evaluated 100 patients with stroke and no prior history of heart disease.

Prolonged QT......................28
U waves/tall U waves..............9
ST depression/changes............25
T wave inversion/changes.........34
Tachycardia/sinus tachycardia....15
Left ventricular hypertrophy......4
Q waves..........................9
Atrial fibrillation..............0
Premature ventricular contractions...0
Decreased heart rate/sinus bradycardia 11
Right bundle branch block....... NR
First degree heart block........2
Premature atrial contractures....NR
Left atrial enlargement/hypertrophy..2
ST elevation.............NR
Left bundle branch block.......NR

Reference: Up-To-Date version 14.3

65
ON EKG, WHAT IS PROMINENT "U" WAVE?

U waves has two types, positive and negative.

Positive U waves are deflections that are generally seen in leads V4-6 just after T waves.

Positive U waves may be seen in

Hypokalemia

Hypercalcemia

Digitalis

Class 1A and 3 antiarrhythmic drugs

Thyrotoxicosis

Intracranial hemorrhage

Exercise

Congenital long QT syndrome

Negative U waves are seen in the presence of :

Myocardial ischemia

Left ventricular volume overload

Significant stenosis of the left main (LM) or left anterior descending coronary artery LAD

Reference: Up-To-Date version 14.3 Philip J Podrid, MD

64
What are the agents used for pharmacologic cardioversion in Atrial Fibrillation?

IBUTILIDE
DOFETILIDE
FLECAINIDE
PROCAINAMIDE
SOTALOL
AMIODARONE

REFERENCE:: NEJM 2001;344:1067

63
What is the rule of thumb for ACE inhibitors in CHF treatment?

It is as simple as this.... Once you start the ACE inhibitors for CHF treatment

NEVER STOP
unless side effects showed up.

reference: CONSENSUS, NEJM 1987,316:1429

62
WHAT ARE THE RED FLAGS OF DYSPEPSIA?

DYSPHAGIA
+ FECAL HEMOCCULT BLOOD
ANEMIA
PERSISTENT ANOREXIA AND VOMITING
WEIGHT LOSS
PALPABLE MASS OR ADENOPATHY
AGE >45 YEARS

THESE RED FLAGS WARRANT AN EGD AND GI CONSULT FOR FURTHER WORK UP.

REFERENCE: BMJ 2003;326:433

61
What are the risk factors for STROKE in patients with ATRIAL FIBRILLATION?

CHADS2 score

Congestive heart failure (any history)1 point
Hypertension (prior history)1 point
Age (> 75 years)1 point
Diabetes mellitus
Secondary prevention in patients with a prior ischemic stroke or TIA and patient with a
systemic embolic event. 2 ponts

Low risk 0 point
moderate risk 1-2 points
High risk >3 points

Reference: Validation of Clinical Classification Schemes for Predicting Stroke, Results From the National Registry of Atrial Fibrillation, JAMA. 2001;285:2864-2870.

60
What are the risk factors for idiopathic PULMONARY HTN?

Familial: 5-10% BMPR2 abnormalities

Female gender

Portal hypertension 2-10%

Sickle cell disease

connective tissue diseases,
-CREST syndrome 50% (calcinosis cutis, Raynaud phenomenon, esophageal motility
disorder, sclerodactyly, and telangiectasia) Scleroderma,
-Systemic lupus erythematosus, and
-Mixed connective tissue disease

anorexigens
Fenfluramine,
Dexfenfluramine,
Diethylpropion
Amphetamines

Alpha-adrenergic stimulants (eg, cocaine, amphetamines)

HIV seropositivity

Human herpesvirus-8

References:
· 1) Rubin, LJ, Barst, RJ, Kaiser, LR, et al. Primary pulmonary hypertension.
ACCP Consensus Report. Chest 1993; 104:236.
· 2) Obesity, dexfenfluramine, and pulmonary hypertension. A lesson not
learned, Am J Respir Crit Care Med 1997 Mar;155(3):786-8.

Tip 32
WE FACE LOW HDL LEVELS ALOT DURING OUR COMPUTER ROUNDS AND ALL WHAT WE CARE ABOUT IS CORRECTING THE HIGH LDL AND DON'T GIVE ENOUGH ATTENTION TO THE LOW HDL THAT IS ASSOCIATED WITH HIGH RISK FOR ACS IN PATIENT WITH CAD. SO........

WHAT IS THE FIRST LINE TREATMENT FOR LOW HDL IN PATIENTS WITH CAD AND HIGH RISK FOR CAD (e.g. METABOLIC SYMDOME)?

1. lifestyle modifications:
a. Exercise, weight loss (in overweight subjects),
b. Smoking cessation,
c. Substitution of monounsaturated for saturated fatty acids.
d. medications that lower HDL-cholesterol (beta blockers, benzodiazepines, and
e. androgens) should be discontinued, if possible

2. Medications:

I. High LDL levels with low HDL, statins are the treatment of choice.
II. Low HDL with high Triglyceride, Fenofibrate (TriCor) is the treatment of choice.
III. Nicotinic acid is the most effective therapy for high risk patients who have low HDL
IV. Levels without any other lipid abnormality.

Note: Patients who cannot tolerate nicotinic acid should be treated with a fibrate or, if necessary, a statin. Simvastatin at a dose of 40 or 80 mg/day may be more effective for raising HDL than atorvastatin. However, rosuvastatin may be even more effective, raising HDL-C by up to 10 percent.

Tip 31
WHAT ARE THE RECOMMENDATIONS FOR STARTING TZDS (e.g., PIOGLITAZONE, ROSIGLITAZONE) IN PATIENTS WITH CHF?

Risk Factors for Heart Failure in Patients Treated With TZDs:

1. History of heart failure (either systolic or diastolic)
2. History of prior myocardial infarction or symptomatic coronary artery disease
3. Hypertension
4. Left ventricular hypertrophy
5. Significant aortic or mitral valve heart disease
6. Advanced age (>70 years)
7. Long-standing diabetes (>10 years)
8. Preexisting edema or current treatment with loop diuretics
9. Development of edema or weight gain on TZD therapy
10. Insulin coadministration
11. Chronic renal failure (creatinine >2.0 mg/dL)

In 2003, the American Heart Association and the American Diabetes Association published a consensus statement on thiazolidinedione use, fluid retention, and HF. The following were the major recommendations:

* Thiazolidinediones should not be given to patients with New York Heart Association (NYHA)
class III or IV HF.

* The initial dose should be low (e.g., 2 to 4 mg rosiglitazone daily or 15 mg pioglitazone daily) in patients with one or more risk factors for HF, asymptomatic left ventricular dysfunction, or NYHA class I or II HF. Patients should be observed for weight gain or edema. Dose escalation should be performed gradually while reassessing the patient for signs of HF.

* If weight gain and edema develop in a patient taking a thiazolidinedione, a careful
assessment for evidence of HF should be made.

Ref: Thiazolidinedione use, fluid retention, and congestive heart failure: a consensus statement from the American Heart Association and American Diabetes Association. Circulation 2003; 108:2941.

up-to-date version 14.1

Tip 30
59 Y/O AAM KNOWN CASE PF HTN AND DM ON METFORMIN, ADMITTED TO THE ICU WITH SEPTIC SHOCK. METFORMIN WAS DISCONTINUED ON ADMISSION ORDERS AND STARTED ON INSULIN INSTEAD. WHAT IS THE RATIONALE BEHIND THAT?

METFORMIN PROVEN TO INCREASE LACTIC ACIDOSIS IN PATIENTS WITH SOCK.

REFERENCE: MANAGEMENT OF TYPE II DIABETES, NEJM 347,17, OCT24 2002

Tip 29
DURING THE MORNING REPORT WITH DR.TAHIR (FRI, 08/04/06) THE FOLLOWING QUESTION WAS RAISED.

THE CASUES FOR LOW FeNa OTHER THAN PRERENAL ETIOLOGY?

THE ANSWER ALREADY MENTIONED IN TIP DATED (07/07/06), HOWEVER, HERE IS THE ANSWER:

HYPOPERFUSION
GLOMERULONEPHRITIS
CONTRAST INDUCED NEPHROPATHY
MYOGLOBINURIA
HEMOGLOBINURIA
EARLY ATN (ACUTE TUBULAR NECROSIS)

Tip 28
67 year old AAM, know case of ESRD, HTN, DM and foot ulcer, came with fever, high WBC's and turn to be his foot ulcer that is infected again. Culture from the ulcer and sensitivity report showed Staph Aureus (MRSA) and gram Negative bacilli. Moreover, the patient is allergic to Penicillin that cause sever rash in the past.

What is your SINGLE one antibiotic of choice to cover this spectrum of germs?

Tigecycline (Tygacil)

The answer for this question is not easy, and you can pick couple of antibiotics that canwork in this situation. But this antibiotics showed and WIDE-Spectrum and covers, Gram positive, Gram Negative, MRSA and even VRE bacteria. The only uncovered bug is Pseudomonas Aeruginosa. It is a nice and effective drug and it is useful especially in patients allergic to Penicillin’s.

Thanks to : Indrani Chutcky.

Tip 27
WHAT IS THE MAXIMUM DOSE OF VERSED (MIDAZOLAM) FOR SEDATION PURPOSES?

Answer is: NO maximum dose!

Versed infusion dose is 2-5 mg/hour and this doses was studied and showed good sedation response in most of the patient, but we should keep in mind that there is no maximum dose for Versed (Midazolam) and adjustment of the IV drip rate is dependent on the awareness of the patient that can be assessed by either:

RAMSAY SEDATION SCALE, or BIS (Bispectral Index): which provides depth of consciousness and sedation monitoring for use in the OR, ICU, and other clinical settings.

Addendum: Benzodiazepines bind to specific receptors in the gamma aminobutyric acid (GABA) receptor complex, leading to enhanced binding of this inhibitory neurotransmitter. Tolerance (defined by increasing dosage requirements with continued administration) is a problem with all benzodiazepines, and may reflect changes in volume of distribution of the drug, or alterations in benzodiazepine receptor density, binding affinity, and occupancy.

Tip 26
How can we estimate the blood sugar level for the last 4-6 month depending on the HgA1C?

LET'S SAY YOU HAVE A PATIENT WITH HgAIC OF 10 (ABNORMAL) AND AS YOU KNOW THIS REFLECTS THE BLOOD SUGARS FOR THE LAST 3-4 MONTHS, AND YOU WANT TO KNOW WHAT THE EXACT BLOOD SUGAR FOR THAT PERIOD OF TIME! HERE IS THE FORMULA:

30 (HgA1C - 6) + 110

TO APPLY THIS TO MY PATIENT:
30 (10 - 6) + 110 = 230

To make more sense, normal HgA1c is 6, that's why we are taking it from the measured HgA1c. The number we have is multiplied by 30 because every increase in HgA1c by 1% equals elevation of blood sugars by 30. Finally, we are adding 110 which is the normal blood sugar level.

Many thanks to Dr.Pai

Tip 25
The Food and Drug Administration (FDA) has a system to rate drugs in terms of their safety during pregnancy, do you know what is it?

Category A drugs that have been tested for safety during pregnancy and have been found to be safe. e.g. folic acid, vitamin B6

Category B drugs that have been used a lot during pregnancy and do not appear to cause major birth defects or other problems. e.g. antibiotics, acetaminophen, insulin and Pepcid.

Category C drugs that are more likely to cause problems for the mother or fetus. Also includes drugs for which safety studies have not been finished. The majority of these drugs do not have safety studies in progress. These drugs often come with a warning that they should be used only if the benefits of taking them outweigh the risks. prochlorperzaine (Compazine), Sudafed, fluconazole (Diflucan), and ciprofloxacin (Cipro).

Category D drugs that have clear health risks for the fetus and include alcohol, lithium phenytoin, and most chemotherapy.

Category X drugs that have been shown to cause birth defects and should never be taken during pregnancy. This includes drugs to treat skin conditions like cystic acne (Accutane) and psoriasis (Tegison or Soriatane); a sedative (thalidomide); and (diethylstilbestrol or DES).

Tip 24
WHEN YOU WRITE FOR NITRATES (NITROGLYCERIN, IMDUR) AS AN ORDER OR A SCRIPT, YOUR ORDER SHOULD INCLUDE TO BE TAKEN AFTER MEALS, WHY?

NITRATE (PO) CAN INDUCE GE REFLUX AND CAN PRODUCE DISCOMFORT OR HEARTBURN IF TAKEN ON EMPTY STOMACH. THIS SIDE EFFECT CAN BE PREVENTED BY TAKING NITRATE WITH/AFTER MEAL. THIS EXCLUDE NITRO SKIN PATCHES AND PASTES.

REFERENCE: Manual of Cardiovascular Medicine, 2004 by Brian P Griffin, Eric J Topol, A. Thomas McRae, Adrian W Messerli, Matthew A Hook

23
WHAT ARE THE CAUSES OF ELEVATED TROPONINS OTHER THAN MYOCARDIAL INJURY/NECROSIS?

1) No clear precipitating event 47%
2) Tachycardia 28 %
3) Pericarditis 10 %
4) Strenuous exercise 10%
5) Coronary vasospasm 10%
6) Heart failure 05%
7) clinical settings (5-10%):
8) sepsis,
9) septic shock,
10) SIRS
11) hypotension or hypovolemia
12) Hypothyroidism 1-3%
13) Left ventricular hypertrophy (5%)
14) Acute stroke (27% of acute stroke patients)
15) Pulmonary embolism (20-50% of PE patients)
16) Pulmonary hypertension (15% of chronic PHTN)
17) MISC: HEPARIN, AMYLOIDOSIS

Other cardiac causes:
1) Pacing, AICD
2) Cardiac surgery
3) keep in mind that Heart failure can elevate troponins in 5% of the cases. (it is
4) confusing in this case, cause no clear culprit in this case!)

22
WHAT ARE THE PRICIPITATING FACTORS OF CHF EXACERBATIONS?

1) PERICARDITIS
2) PERICARDIAL EFFUSIONS
3) ISCHEMIC HEART DISEASES (STEMI, NSTEMI AND UA)
4) CARDIOMYOPATHY (DILIATED, HYPERTROPHIC AND RESTRICTIVE, ETC...)
5) ARRHYTHMIAS (ESPECIALLY A.FIB, V.TACH, ETC...)
6) VALVUALR AND CONGENITAL HEART DISEASE (MR, AS, VSD, ASD, PDA AND COARCTATION OF THE AORTA
7) HYPERTENSION (HYPERTENSIVE URGENCY AND MALIGNANCY AND EVEN UNCONTROLLED HTN)
8) SYSTEMIC CAUSES (HYPERDYNAMIC STATE):
· ANEMIA
· INFECTION
· HYPER AND HYPOTHYROIDISM
· VITAMIN DEFICIENCY (WET BERI BERI)
9) PREGNANCY

21
WHY IT IS RECOMMENED TO GIVE CARVEDILOL WITH MEALS?

Carvidelol should be ingested with meals, because administration with food minimizes risks of orthostatic hypotension.

20
How frequent should LFT's be monitored in patient newly started on STATINS?
Monitoring of hepatic aminotransferase levels is recommended for those taking HMG CoA reductase inhibitors. Levels should be measured 6 weeks and 3 months after initiation of therapy and every 6 moths thereafter.
Because of the excellent safety profiles of Pravastatin and Simvastatin the U.S FDA recommend discontinuing hepatic enzyme monitoring after 6 months of continuous same-dose therapy for Simvastatin and 3 months for Pravastatin. However, therapy with Statins should be discontinued when more than tree fold elevation in aminotransferase occurs and initiation with lower dose or different agent can be started.

19
WHAT PRECAUTIONS YOU SHOULD CONSIDER WHEN PRESCRIBING ALPHA BLOCKERS?

ALPHA BLOCKERS ARE WELL-KNOWN TO CAUSE WHAT IS CALLED: FIRST DOSE EFFECT, WHICH IS DIZZINESS, HYPOTENSION, BLURRED VISION AND EVEN SYNCOPE WHEN TAKING THE FIRST DOSE. THAT'S WHY, IT IS RECOMMENDED TO ADVICE THE PATIENT TO TAKE THE FIRST 2-3 DOSES AT BED TIME, AND EVEN WHILE THEY ARE IN BED JUST BEFORE GOING TO SLEEP. AND THEN IF THEY CAN HAVE IT WHENEVER DURING THE DAY.

I BELIEVE THIS PRECAUTION IS ALREADY KNOWN,BUT THIS MATTER WAS RASIED DURING MY ROTATION WITH DR.BALLESTEROS AND IT IS GOOD TO REFRESH YOUR KNOWLEDGE.

REFERENCE: UP-TO-DATE

18
NOW, MY TIP FOR THE WEEKEND IS AN INTERESTING BOOK:

---= WHO MOVED MY CHEESE =---

This is a brief tale of two mice and two humans who live in a maze and one day are faced with change: someone moves their cheese. Reactions vary from quick adjustment to waiting for the situation to change by itself to suit their needs. This story is about adjusting attitudes toward change in life, especially at work. Change occurs whether a person is ready or not, but the author (Spencer Johnson, MD) affirms that it can be positive. His principles are to anticipate change, let go of the old, and do what you would do if you were not afraid.

17
What is the role of Vit C, E, and beta carotene in prevention of Coronary Artery Disease?

Supplementation with beta carotene, vitamin C and vitamin E, either alone or in combination with each other or other antioxidant vitamins does not appear to be efficacious either in the primary or secondary prevention of CHD.

Reference: Vivekananthan DP; Penn MS; Sapp SK; Hsu A; Topol EJ. Use of antioxidant vitamins for the prevention of cardiovascular disease: meta-analysis of randomized trials. Lancet 2003 Jun 14;361(9374):2017-23.

16
What is "SYNDROME X"?

This Syndrome carry two meaning, I mean it is used in two different medical conditions:

Metabolic Syndrome
Angina pectoris with normal coronary arteries

If you want more details, please scroll down or print and read at home.

1. Metabolic Syndrome: According to The International Diabetes Federation (IDF) metabolic syndrome or Syndrome X defined as:

I. Increased waist circumference defined as a waist circumference in men >102 cm (40
in) and in women >88 cm (35 in)

PLUS any two of the following:

II. Triglycerides >150 mg/dL (1.7 mol/L) or treatment for elevated triglycerides

III. HDL cholesterol <40>130, diastolic blood pressure >85, or treatment for hypertension

V. Fasting plasma glucose >100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetes.

Reference: The metabolic syndrome--a new worldwide definition. Lancet 2005 Sep 24-30;366(9491):1059-62.

2. Angina pectoris with normal coronary arteries: It has three characteristic features, each of which can be seen in other disorders:

I. Angina or angina-like chest pain with exertion.
II. ST segment depression on treadmill exercise testing.
III. Normal coronary arteriography, with no spontaneous or inducible epicardial coronary artery spasm on ergonovine or acetylcholine provocation.

Reference: Engl J Med 2002 Jun 20;346(25):1948-53. Abnormal subendocardial perfusion in cardiac syndrome X detected by cardiovascular magnetic resonance imaging.

15
What are the drugs approved by the United States FDA for treatment of androgenetic alopecia in men?

FENASTERIDE (Propecia) 1 mg every day AND/OR MINOXIDIL 5 percent (Rogaine) applied twice a day.

There is insufficient evidence for the use of both medications in the treatment of lopecia. Only minoxidil is approved in women.

FENASTERIDE MECHANISM OF ACTION: is a competitive inhibitor of both tissue and hpatic 5-alpha reductase. This results in inhibition of the conversion of testosterone to dhydrotestosterone and markedly suppresses serum dihydrotestosterone levels which plays a ajor role in androgenic alopecia.

references: -Price, VH. Treatment of hair loss. N Engl J Med 1999; 341:964. -Price, VH, Menefee, E, Sanchez, M, et al. Changes in hair weight and hair count in men with androgenetic alopecia after treatment with finasteride, 1 mg, daily. J Am Acad
Dermatol 2002; 46:517.

14
For what type of bone fractures does raloxifene reduce risk: Vertebral or hip?

While raloxifene has been found to increase bone density in the spine and femoral neck, it only significantly reduces the risk of vertebral, not hip, fractures. Raloxifene reduced the risk of clinical vertebral fractures (relative risk reduction, 35 percent) but not of nonvertebral fractures.

Reference: New England Journal of Medicine, Vol. 355, No. 2, July 13, 2006

13
What is the best answer during case manager rounds to justify the patient hospital stay?

You should struggle little bit with them but telling that the patient is on one of the
following is more than enough to justify his stay in the hospital:

IV Lasix for CHF exacerbation.
IV steroids for COPD exacerbation
IV fluids for dehydration or renal failure
IV Antibiotics for pneumonia, UTI or soft tissue infection.

In general, any IV medication or therapy, is more than enough. But you should be ready to pecify the duration the patient should be on this treatment.

12
WHAT IS THE DIFFERENTIAL DIAGNOSIS OF PROMINENT R WAVE IN LEAD V1 ON EKG?

Before answering the question, the normal R wave height increases from V1-5. The normal R wave height in V5 is always taller than that in V6, because of the attenuating effect of the lungs.

A common problem in electrocardiography is the presence of tall R waves in the right precordial leads, usually V1 and sometimes V2, or an R/S ratio > 1 in lead V1. Causes include the following:
1. RVH (the most common cause): here is an R/S ratio > 1 or an R wave height > 7 mm tall in lead V1.
2. Posterior MI: here is an R wave > 6 mm in lead V1 or > 15 mm in lead V2.
3. Right bundle branch block: he QRS duration is prolonged as well in this situation.
4. The WPW pattern: left-sided accessory pathway locations produce prominent R waves with an R/S ratio > 1 in V1.

11
WHAT IS THE PROPER WAY TO MEASURE THE BLOOD PRESSURE?

MEASURING BP IN OFFICE SETTINGS

-Patients should be seated quietly for at least 5 minutes in a chair rather than on an
examination table, with feet on the floor and arm supported at heart level.

-Measurement of BP in the standing position is indicated periodically, especially in those
at risk for postural hypotension.

-An appropriate-sized cuff (CUFF BLADDER encircling at least 80% of the arm) should be used
to ensure accuracy.

-An artery mark on the exterior surface of the cuff indicated the middle of the bladder and should be over the Brachial artery.

-An arrow on the exterior surface of the cuff should point within the range scale on the interior surface of the cuff. Being before or after the range --> change the cuff to smaller or bigger size for more accurate reading.

-Auscultation should be on bared skin without any cloths between the stethoscope and the
skin.

-Lower edge of the cuff should be at least 2-3 cm above Anticubital fossa and the cuff NEVER covers the stethoscope.

-At least 2 measurements should be made.

-Systolic BP is the point at which the first of 2 or more sounds is heard (phase 1) and diastolic BP is the point before the disappearance of sounds (phase 5).

-Physicians should provide to patients, verbally and in writing, their specific BP numbers and BP goals.

REFERENCE: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, JAMA. 2003;289:(doi:10.1001/jama.289.19.2560).

10
IN PATIENTS WITH HIV POSITIVE TEST, DO THEY HAVE TO USE SEPARATE AND ISOLATED HEMODIALYSIS MACHINES, OR IT IS OK TO SHARE NON-HIV ESRD PATIENTS?

THE ANSWER IS ...... NO. IT IS OK TO SHARE NON-HIV PATIENTS, BUT THERE IS SOME KIND OF PREPARATION AND CLEANING OF THE HD UNIT FILTERS THAT PROTECT INFECTING NON-HIV PATIENTS.

9
What are the conditions associated with elevate serum LIPASE?

In DESCENDING order of incidence:

Acute and chronic Pancreatitis
Acute cholecystitis
Bowel obstruction or infarction
Duodenal ulceration
Pancreatic calculus
Pancreatic tumors
Diabetic ketoacidosis (24 percent of patients with diabetic ketoacidosis)
HIV disease (60% of HIV patients)
Macrolipasemia
Post ERCP/Trauma
Celiac disease
Idiopathic
Drugs (e.g. Furosemide, Thiazide diuretics, idomethacin and methylprednisolone)

References:

Up-to-Date (14.2)
Washington Manual of Medical Therapeutics, 31st Edition

8
62 year old African American male known case of HTN, DM, Dyslipidemia, CAD s/p PTCA, on
Metoprolol, ASA, Lisinopril, Viagra and insulin, admitted to ED with chest pain for 20 min. ED staff wants to role out MI and after retrieving full history from the patient regarding the pain he wants to start him on MONA cocktail. What do you think he should ask the patient before starting this treatment?

MONA = Morphine, Oxygen, NTG and Aspirin.

Answer:

When was the last time you took your VIAGRA?

I believe a lot of question can be asked in this case. But what I am trying to point hereis to make sure that the patient didn't take any Sildenafil in the last 24 hours, because of the risk of developing HYPOTESION when giving Nitroglycerin. And in this case NTG is contraindicated.

Tomorrow's question:

What are the other conditions that elevate lipase beside Pancreatitis?

7
What are the causes for LOW FeNa (fractional excretion of Na), other than Pre-renal Acute
renal failure?

HYPOPERFUSION
GLOMERULONEPHRITIS
CONTRAST INDUCED NEPHROPATHY
MYOGLOBINURIA
HEMOGLOBINURIA
EARLY ATN (ACUTE TUBULAR NECROSIS)

Low FeNa: <1 mona =" Morphine,">