Cardiomedical group

After ablation for atrial fibrillation,among patients at high risk for stroke
it's recommended to opt for:

1- anticoagulation or
2- LAA exclusion ( closure).

2-and from here was the contiuation of the medical journey(MD.int.medicine)1994-1998
from pgmi-lahore affilated to punjab university previouly&university of health sinces now.pg taining was at LGH&serveces hospitals Lahore
ومن هنا استمر المشوار في تحظير الدكتوراه في الطب الباطني
عام94-98 لاهور- باكستان

In orthostatic hypotensionthe drug of choice is fludrocortison .it helps boost blood volume&raise bp.

HTN+COPD>>
cardioselective BB
especially if associated with MI/HF

#Contraindications_of_BB_in_ACS_pts;
*prinzmetal angina
*cocain induced MI
*sever bradycardia
*cardiogenic shock
*acute heart failure
*sever hypotension
*sever bronchospasm
*Av Block
*pulmonary oedema

#FEW_PEARLS_OF_HYPOTENSION
*In orthostatic hypotensionthe drug of choice is fludrocortison .it helps boost blood volume&raise bp
.*In symptomatic hypotension advise pt with moderate increase of salt intake in diet & suffcient water drinking
* Low blood pressure that either doesn't cause signs or symptoms or causes only mild symptoms, rarely requires treatment..
*In symptomatic hypotension treatment depends on underlying cause like dehydration,RF,DM,hypothyr. rather than the low bp it self
* If hypotension is due to medications,then treatments involves adjusting the dose or stoping the drug
*If cause of symptomatic hypotension is not known raise the bp in accordance with pt's age,health status&type of hypotension
*Fluids help to increase blood volume &prevent dehydration therefore important in treating hypotension
*In orthostatic hypotensionthe drug of choice is fludrocortison .it helps boost blood volume&raise bp..
#REGARDS

post prandial abdominal pain with in10-15 min exclude mesenteric ischemia
احمد عبدالحافظ

#ST_WAVES_IN_ECG:
*The ST segment is the flat, isoelectric section of the ECG between the end of the S wave (the J point) and the beginning of the T wave.
*It represents the interval between ventricular depolarization and repolarization.
*The most important cause of ST segment abnormality (elevation or depression) is myocardial ischaemia or infarction.
#Note please: morphology of Stر elevation,St depression, T waves are quite different in different etiology...

#Osborn_Wave (#J_Wave)
is a positive deflection at the J point (negative in aVR and V1) usually most prominent in precordial leads
#Causes
Characteristically seen in hypothermia (typically T<30C), but they are not pathognomonic. May be seen in other conditions like:
*Normal variant
*hypercalcemia
*medications
*Neurological insults such as intracranial hypertension, severe head injury and subarachnoid haemorrhage
*Le syndrome d’Haïssaguerre *(idiopathic VF)

Investigations of Shurg-straus syndrome:_
cANCA positive in > 90%, pANCA positive in 25%
chest x-ray: wide variety of presentations, including cavitating lesions
renal biopsy: epithelial crescents in Bowman's capsule

Sinus bradycardia
Low voltage complexes
acute inferoposterior (now called inferolateral) OMI.

@juniors
elevated JVP, oedema, ascites, soft diffuse apex=constrictive pericarditis/restrictivr CM.

jerky pulse, double apex beat, systolic thrill at LLSE and harsh ejection systolic murmur=HOCM

muffled heart sound, elevated JVP and enlargement of cardiac dullness=pericardial effusion
.

mid-systolic click ± late systolic murmur= mitral valve prolapse

Low blood pressure (hypotension)
Ahmed Mohsen
Treatments and drugs
By Mayo Clinic Staff

1-Low blood pressure that either doesn't cause signs or symptoms or causes only mild symptoms, such as brief episodes of dizziness when standing, rarely requires treatment.

2-If you have symptoms, the most appropriate treatment depends on the underlying cause, and doctors usually try to address the primary health problem — dehydration, heart failure, diabetes or hypothyroidism, for example — rather than the low blood pressure itself.

3-When low blood pressure is caused by medications, treatment usually involves changing the dose of the medication or stopping it entirely.

4-If it's not clear what's causing low blood pressure or no effective treatment exists, the goal is to raise your blood pressure and reduce signs and symptoms. Depending on your age, health status and the type of low blood pressure you have, you can do this in several ways:

5-Use more salt. Experts usually recommend limiting the amount of salt in your diet because sodium can raise blood pressure, sometimes dramatically. For people with low blood pressure, that can be a good thing.

6-But because excess sodium can lead to heart failure, especially in older adults, it's important to check with your doctor before increasing the salt in your diet.

7-Drink more water. Although nearly everyone can benefit from drinking enough water, this is especially true if you have low blood pressure.

8-Fluids increase blood volume and help prevent dehydration, both of which are important in treating hypotension.

9-Wear compression stockings. The same elastic stockings commonly used to relieve the pain and swelling of varicose veins may help reduce the pooling of blood in your legs.

10-Medications. Several medications, either used alone or together, can be used to treat low blood pressure that occurs when you stand up (orthostatic hypotension).

For example, the drug fludrocortisone is often used to treat this form of low blood pressure. This drug helps boost your blood volume, which raises blood pressure.

Doctors often use the drug midodrine (Orvaten) to raise standing blood pressure levels in people with chronic orthostatic hypotension. It works by restricting the ability of your blood vessels to expand, which raises blood pressure.

From page prof Khaled Haj Said 👌👌👌

Management of AF during pregnancy. ⤵⤵

Management of AF in pregnancy does not differ much from the classical therapies of AF in non pregnant patients.
I will only talk about AF newly diagnosed during pregnancy

There is always a rule in pregnancy which statues that mother life is Paramount and saving baby's life is something great and challenging.

The choice between rhythm and rate control depends on the severity of the underlying valve disease, haemodynamic stability and clinical tolerance of arrhythmia.
AF management have a double impact:
- therapies with prognostic impact (anticoagulation and treatment of cardiovascular conditions) and
- therapies predominantly providing symptomatic benefit (rate control and rhythm control).

Rhythm control is considered the preferred treatment strategy during pregnancy in order to avoid potential foetal harm caused by the side effects of the antiarrhythmic and mainly rate control medication and also possible haemodynamic instability related to the tachycardia especially in patients with underlying cardiopathies.

Electrical cardioversion is recommended in patients haemodynamically unstable or if there is a considerable risk for the mother or the foetus (impending shock). Immediate electrical cardioversion is also needed for pre-excited AF with Rapid ventricular response.
When you consider a pharmacological cardioversion to avoid anaesthesia risk in stable patient , intravenous flecainide and ibutilide are the most safe AA drugs provided there is absence of structural heart diseases.
Amiodarone causes many adverse foetal outcomes and therefore should not be used during pregnancy.
Oral flecainide, propafenone, or sotalol should be considered to maintain sinus rhythm after cardioversion.
Rate control stategy is considered when the cardioversion is failed , when the patient is paucisymptomatic with an optimal hemodynamic state,the ventricular rate is not rapid and in the absence of underlying cardiopathies justifying the necessity of a sinus rythm restoration.
Oral beta-blocker (metoprolol is the most used drug) is recommended for rate controle with verapamil or digoxin as second choices when beta-blockers are not tolerated (with foetal monitoring for atrioventricular block).

Anticoagulation is recommended for patients with paroxysmal or persistent AF according to the CHA2DS2-VASc score similarly to the non pregnant patients.
In general, patients with stroke risk factors (CHA2DS2-VASc score of 1 or more for men, and 2 or more for women) are likely to benefit from oral anticoagulants.
VKAs can cross the placenta which carry a risk embryopathies in the first trimester of pregnancy.
The problem with VKAs is that they need frequent monitoring with the INR test and their level in the foetal circulation cannot be anticipated.
If a low-dose VKA ( warfarin <5 mg/day, or acenocoumarol <2 mg/day) is enough to reach the target therapeutic international normalised ratio (INR) for AF (INR between 2 and 3), then treatment with VKAs should continue in the first trimester with a low risk of teratogenicity.
Otherwise, VKAs should be interrupted during the first trimester and be replaced by unfractionated heparin (UFH) or low molecular weight heparin (LMWH). VKAs should be stopped at week 36 and should be substituted with UFH/LMWH till delivery.

NOACs are contraindicated in pregnancy.

Concerning the delivery and according to the most recent European guidelines, AF is considered a low-risk disease during delivery (vaginal delivery is allowed ).
Even though pregnant women with AF need to see a cardiologist during their pregnancy, they usually do not need a highly qualified delivery centre. As AF is usually associated with cardiac abnormalities, physicians should take into consideration the recommendations for the associated structural heart diseases.

#Erythromelalgia
#Defination:_
It is a rare vascular peripheral pain disorder in which blood vessels, usually in the lower extremities or hands, are episodically blocked (frequently on and off daily), then become hyperemic an painfull
#Causes:
*Primary erythromelalgia ...could be idiopathic or genetic
**secondary erythromelalgia include the following:
_Myeloproliferative disorders
_Medications
_Infection
_Mushroom poisoning
Most reported cases of secondary erythromelalgia are due to myeloproliferative disorders with thrombocytosis (most commonly polycythemia vera or essential thrombocytosis

Corkscrew appearance on barium esophagram shows diffuse esophageal spasm due to impaired inhibitory innervation to esophagus

Thanks to all freinds
The pictures showed:_
Dry gangrene
Libido reticularis.&
fundoscopic features of CRVO
When combined with given history, the most probable diagnosis is Antiphospholipid syndrome

antiphhospholipid sun.(APS).
#Which is an acquuired autoimmune disorder that manifests clinically by repeated venous or arterial thrombosis&repeated pregnancy morbidity&presences of specific antibodies in the blood of the pt.
#D/D *hypercoagulsbility conditions like malignancy,hormonal replacement therapy etc.
*atherosclerotic vascular disease
*systemic necrotizing vadculitis
*dic...*EI...*TTP *SLE.
#Work up includes:serum antiphospholipid Abs,,ACL, LA, cbc beta2glycoprotin,.syphlis serology,ct scan of skull,chest/abd.
#Diagnosis is done from history,clinical exam.findings&investigation results. accoording to The 2006 revised critirea for.diag. of APS,at least 1clinical critireon&1 lab.critireon should be present for a pt.to be classified as having APS.
*WARM REGARDS*****

Thanks to all freinds. The correct answer is poland syndrome.
#pictures showed*a bscence of sternal head of pectoral major muscle*ipsilatral hypoplasia of breast& nipple*same side shortening of upper extremity .* dextrocardia.
#diagnosis of poland syndrome is often made incidentally since most pts are a ssymptomatic..lab.studies includes cbc& lymph node exam.to exclude association of leukaemia& nh lymphoma.*cxr.is asked to see rib cage abn., disph.hernia&evidence of pectorlais m a bscence*ct-scan confirms abscence of muscles with normal lungs...
#D/D..*moebious synd* maclodes synd.*post mastectomy changes. #Treatments..since most pts are assymptomatic, no active managment is needed.but in some cases.surgical chest wall reconstruction may be required. ..warm greeting

#Friedreich’s #sign
occurs in the setting of constrictive pericarditis as is described as the rapid drop in central venous pressure that occurs in early diastole manifested as the rapid Y descent in the jugular venous pressure. This can also occur from severe tricuspid valve regurgitation.

#Signs_of_haemodynamic_instability_due_to #arrythmias:
1- Syncope (due to brain hypoperfusion).
2- Shock (anuria - decreased capillary refill).
3- Hypotension (systolic: <90, diastolic: <60).
4- ISCHEMIC chest pain (with or without ECG changes).
5- Heart failure (pulmonary rales)
#MANGMENT:
*vagal maneuver
*I.v adensin...........if failed
*synchronized cardioversion

Common Paraneoplastic antibodies:
1⃣Anti-Hu: SCLC
2⃣Anti-Yo: Gynecological, breast
3⃣Anti-Ri: Breast, gynecological,
SCLC
4⃣Anti-Ma proteins: Germ cell tumors of testis
5⃣Anti-VGCC: SCLC
6⃣Anti AChR: Thymoma
@Nyhar_Nayak2

Lyme disease: Mneomic
FACE
Facial nerve palsy(typically bilateral)
Arthritis
Cardiac block
Erythema migrans
treatment:doxycycline
@ USMLEmneomonic

Mnemonics for Causes of Macrocytic Anemia :
HALF MD
Hypothyroidism
Alcoholism
Liver diseases
Folic acid and B12 Deficiency
Myelodysplastic syndromes
Drugs
HIV Drugs.
Cancer drugs etc
كازل شاه

Causes of chest pain in scleroderma
GERD
Esophageal dismotility
Esophagal stricture
Pleurisy
CAD
Pericarditis
د.كازل شاه

#Causes_of_LV_hypertrophy
*Hypertension..the most common
*Aortic stenosis
*Hocom
*Arrythmias
*Excessive athletic training
*Amyloidosis

#Complications_of_LV_hypertrophy
*Heart failure.
* arrhythmias.
* ischemic heart disease.
*sudden cardiac arrest.

Patients who are positive for HBsAg for more than six months
but are HBeAg negative, HBV DNA negative and have normal ALT do not require liver biopsy nor do they require antiviral therapy, but hepatitis B serology and ALT should be monitored annually
Naser salam

#Andexanet_alfa
is a recombinant form of factor Xa which binds specifically to apixaban or rivaroxaban to reverse their anticoagulant effects.
Joshua Walinjom

#PEREPHRAL(LEG) #EDMA.
perephral(leg)edema. is defined as accumulation of the fluids in foot,ankle&leg tissues.
#D_D:
the main causes are:
* venous insufficeincy* cardiac problems like chf,cmp&h.h.dis.
*renal causes like nepg.syn,ckd
*hepatic causes like liv.cirrhosis
*pulm.htn,pregnancy,obesity*dvt* lymphedema*premenstural dysnenorrhae,drugs,hypothyroi
*malnutration,lipidemae,injury
* trauma,sitting for long time
* reflex sympathetic dystrophy
* inflamm.conditions likera,oa,gout.
#APPROACH:
*history of duratio,systemic dis,associated pain,improvement over night
*clinical exam. for signs of sys.dis. * local exam:incluing
bmi,tenderness,uni/bilatral/generalized,pitting/non pitting
*veins,skin changes.
*#investigations: cbc, urine test, lfts,rfts,s.electrolytes,s.albumin,b.sugar,thyroid function t.,s.lipids.
*ecg,cxr,ec ho* usg/ctscan abd.
*dopler exam.of leg vesseles followed by D-dimer if dvt suspected
*best regards***

#WATER_HAMMER_PULSE:
#DEFINATION:
water hammar pulse. is defined as a forcefull, bounding,rapidly increasing & suddenly collapsing pulse .
#causes:
A-physiological : like : fever&pregnancy.
B-PATHOLOGICAL:
*cardiac: aortic reg,pda,systolic htn, bradychardia,aortopulm.window&aneurism of sinus of valsalva.
*hyperdynamic states like:
anaemia,thyrotoxicosis,beri beri,av-fistula,paget disease,liver cirrhosis,copd&ch.alcholisim.
#methode of examination:
the examiner gasps the muscular part of the forarm of the pt.& raises the pt's arm vettically upward...a palpable impulse is felt by the examiner bec.of quick emptying of the artery during diastole from blood that had been pumbed by ventricle during systole. as a result of gravity effect causing a palpable pulse.
***warm regards********

Pheochromocytomas:symptoms(5H's)
HTN
Hyperglycemia
Hypermetabolism
Hyperhidrosis
Headache
@USMLE

Propylthiouracil is preferred to carbimazole in subclinical thyroiditis
احمد عبدالحافظ

#Main_Causes_of_acanthosis_nigricans
• Normal variant (Asian race)
• Obesity
• Carcinoma stomach, lung
• Lymphoma
• Cushing’s syndrome
• Acromegaly
• Insulin-resistant diabetes
• Polycystic ovary syndrome
• Androgen-secreting tumours

@Walinjom
Acute Management of Acute Coronary syndrome.
https://t.co/1nuEgnzhtu

Recommendations for initial management of Unstable Angina/NSTEMI
Manual of medicine

Ahmed Mohsen
#Tips_Tricks_STEMI

*Maximum time allowed for thrombolytic therapy in STEMI is 24 hours
(ACC STEMI guidelines 2013)

*While Maximum time allowed for Primary PCI in stable STEMI patients is 48 hours
(ESC STEMI Guidelines 2017)

Acute inferior STEMI. Due to occlusion of RCA.because STE in lead 3>2

Flaccid paraphrasing without sensory signs:
AIDP
Periodic paralysis
AIP
HSMN-1
HIV -seroconversion
Tick paralysis
Lead poisoning
Botulism
Diphtheria
Critical illness neuropathy
د.كازل شاه

❇️Hormones increase during sleep: ∞★

👉🏾Anti-diuretic hormone
👉🏾Growth hormone
👉🏾Melatonin
👉🏾Oxytocin
👉🏾Prolactin

-----------------------------------------------------------------------------
❇️Hormones decrease during sleep: ∞★

👉🏿Stress hormones (i.e. Cortisol)
👉🏿Insulin
👉🏿Thyroid stimulating hormone (TSH)
👉🏿Catecholamines
Joyraj Hossain
(FCPS, MD, Diploma)

Methaemoglobin has a bluish colour, therefore patients with significant methaemoglobinaemia appear cyanosed even when the arterial oxygen tension is normal
(FCPS, MRCP, MD, Diploma)
Rapid Revise

When pericardiocentesis may be harmful and associated with a high risk of the worsening of the underlying cause of tamponade:👇

➡️ Tamponade secondary to an aortic dissection
➡️Tamponade associated to a LV free wall rupture
Khaled Haj Said

#Erythromelalgia
#Defination:_
It is a rare vascular peripheral pain disorder in which blood vessels, usually in the lower extremities or hands, are episodically blocked (frequently on and off daily), then become hyperemic an painfull
#Causes:
*Primary erythromelalgia ...could be idiopathic or genetic
**secondary erythromelalgia include the following:
_Myeloproliferative disorders
_Medications
_Infection
_Mushroom poisoning
Most reported cases of secondary erythromelalgia are due to myeloproliferative disorders with thrombocytosis (most commonly polycythemia vera or essential thrombocytosis

Acute inferior stemi due to LCX occlusion because ste in 11=111

CULPRIT In inferior STEMI
1_RCA occlusion is suggested by:
*ST elevation in lead III > lead II
*Presence of reciprocal ST depression in lead I
*Signs of right ventricular infarction: STE in V1 and V4R
2_Circumflex occlusion is suggested by:
*ST elevation in lead II = lead III
*Absence of reciprocal ST depression in lead I
*Signs of lateral infarction: ST elevation in the lateral leads I and aVL or V5-6
(NB. Relative Q-wave depth in leads II and III is not useful in determining the culprit artery. Both RCA and LCx occlusion produce a similar pattern of Q wave changes, often with deeper Q waves seen in lead III)

#Culprit_Artry_in_inferior_STEMI
inferior STEMI can result from occlusion of all three coronary arteries:
1_The vast majority (~80%) of inferior STEMIs are due to occlusion of the dominant right coronary artery (RCA).
2-Less commonly (around 18% of the time), the culprit vessel is a dominant left circumflex artery (LCx).
3_Occasionally, inferior STEMI may result from occlusion of a “type III” or “wraparound” left anterior descending artery (LAD). This produces the unusual pattern of concomitant inferior and anterior ST elevation.
While both RCA and circumflex occlusion may cause infarction of the inferior wall, the precise area of infarction in each case is slightly different:
1_RCA occlusion is suggested by:
*ST elevation in lead III > lead II
*Presence of reciprocal ST depression in lead I
*Signs of right ventricular infarction: STE in V1 and V4R
2_Circumflex occlusion is suggested by:
*ST elevation in lead II = lead III
*Absence of reciprocal ST depression in lead I
*Signs of lateral infarction: ST elevation in the lateral leads I and aVL or V5-6
(NB. Relative Q-wave depth in leads II and III is not useful in determining the culprit artery. Both RCA and LCx occlusion produce a similar pattern of Q wave changes, often with deeper Q waves seen in lead III)

Possible causes of culture negative endocarditis:
*fungal endocarditis
*marentic endocarditis
*viral endocarditis
*HACKE organisims
*Bartonella sp .
*Chlamydia psittaci
*Coxiella burnetii

#SOME_DIABETES_RELATED_CONDITIONS:
A-diabetic dermopathy
B-acanthosis nigricans
C-prayer sign=cheiroarthropathy
D-fat atrophy due to insulin inections
E-necrosis dibeticorum
F-granuloma anularea
G-xanthoma of familial DLP

UC causes ULCCCERS:
Ulcers
Large intestine
Continuous
CRC
Crypt abscess
Extends proximally
Red diarrhea
Sclerosing cholangitis
@USMLEmnemonic

🟩Side effects of thyroxine therapy:

⚫Hyperthyroidism→ due to over treatment
⚫Reduced bone mineral density
⚫Worsening of angina
⚫Atrial fibrillation
Joyraj Hossain
(FCPS, MRCP, MD, Diploma)

Acute severe headache with ptosis(unilateral)
For D/D
1- Posterior Communicating Artery Aneurysm (Surgical 3 nerve palsy)
2-SAH
3-Cluster headache
4-Complicated migraine
5-Cavernous sinus Thrombosis (third nerve affection )
6-Temporal arteritis + third nerve palsy
7-Carotid artery Dissection with Horner syndrome
د.كازل شاه

Surgical treatment of Parkinson diaease:_
1- Total Thalamotomy
2-Pallidotomy
3-Deep brain stimulation
4-Neural Transplantation in Subthalamic nucleus and Basal Ganglia
د.كازل شاه

#Ashman_phenomena
is an abbarent wide qrs complexes beats that preceded a short R-R interval followed by a long R-R interval these beats have morphology of RBBB
.Clinically, it is often asymptomatic by itself and considered benign in nature.

#Managment_of_AF_in_STEMI pt:
For rate control of AF,iv beta B is indicated if pt.has no s/s of HF&hypotension
*iv amidrone is indicated if the pt.had ac.HF but no hypotension
*iv digoxin is indicated for rate control if there is concomittent ac.HF&hypotension
*immediate DC shock is indicated if rate control couldnt promptly achived with pharmacologic agent with ongoning ischemia
*in a pt.with doucmented denovo AF during acute STEMI,long term anticoagulant is recommended according to CHADVASC score
*early revascularization is indicated

#CLASSIFICATIONS_OF_AF:
*Recently diagnosed
*Paroxysmal
*persistant
*long standing persistant
*permenant
*Nonvalvular
*valvular

#ECG_FINDINGS_IN_HYPERKALAEMIA
*at serum potasuim level>5.5meq/l
1-peak t-waves (the earliest sign)
*serum potasuim level>6.5meq/l:
1-p waves widens and flattenes
2-pr segement lengthens
3-p waves evantually disappear
*potasuim level>7meq/l:(conduction abnormalities and bradycardia):
1-prolonged qrs intervals with bizzar qrs morphology
2-high grade a-v block
3-ventricular escape rhythem
4-sinus bradycardia or slow at.fibr,
5-devlopment of sine waves appearance(a preterminal rhythem)
*potasium level>9meq/l:cardiac arrest occur due to:
1- asystole
2-ventricular fib.

#Non invasive investigation for myocarditis ?
*Echocardiography: to exclude other causes of heart failure.

*Antimyosin scintography: to identify myocardial inflammation
*Cardiac angiography to rule out coronary ischemia.
*Gadolinium enhanced MRI to assess the extent and cellular edema.

#AGaint_pulmonary_bulla
A large hyperlucent area with no lung markings, involving the lower & mid zone of right hemithorax. The transverse fissure is displaced upwords nd there is a linear band like opacity extending from the right heart border to the right costophrenic angle..no collapsed lung border seen & no mediastinalshift=a giant pulmonary bulla+

Incidence of myocarditis is usually estimated at 1-10 cases per 100,000 persons

#Lieberman_classification_ofmyocarditis:
*fulminant myocarditis
*acute myocarditis
*chronic active myocarditis
*chronic persistant myocarditus

#Differential_Diagnoses_of_myocarditis:
*Alcoholic Cardiomyopathy
*Cardiac Tamponade
*Cardiogenic Shock
*myocardial ischemia/infraction
*Chagas Disease *(American Trypanosomiasis)
*unstable angina
*Cocaine-Related Cardiomyopathy
*Coronary Artery Atherosclerosis
*Dilated Cardiomyopathy
*Hypertrophic Cardiomyopathy
*Peripartum Cardiomyopathy
*Restrictive Cardiomyopathy

#REMEMBER_PLEASE
Endomyocardial biopsy is the standard tool for diagnosing myocarditis. However, the use of routine endomyocardial biopsy in establishing the diagnosis of myocarditis rarely is helpful clinically,

#Just_remember
Fever isn't always an indication to start antibiotic or culture of anywhere.
since there are many noninfectiuos causes of fever

Sarowar Hossain
During the first 48 hours of Acute Ischemic Stroke, BP up to 220/120 mmHg is allowed as PERMISSIVE HYPERTENSION.

Anticoagulation with sever thrombocytopenia
Khaled Haj Said
Anticoagulation is generally contraindicated when platelet count <50000
But in practice we can order anticoagulation even when it's less than 50000
If>50000: full dose anticoagulation
In between 30000 and 50000: half dose
If less than 30000: we should hold or ovoid anticoagulation
In case of acute thrombosis, full anticoagulation is often indicates with platelet transfusion to maintain the platelet count above 50000

#sarcoidosis:_
Chest X-ray pa veiw showing the 1-2-3 sign or Garland Triad or Pawnbroker's Sign, consisting of:
1-right paratracheal nodes.
2-right hilar nodes.
3-left hilar nodes.
This triad has been described in Sarcoidosis.

#ECG_changes_in_hypomagnesaemia:
*prolonged QTc.
*Atrial and ventricular ectopy,
*atrial tachyarrhythmias& *torsades de pointes are seen in the context of hypomagnesaemia,
#Whether this is a specific effect of low serum magnesium or due to concurrent hypokalaemia is *evertheless, correction of serum magnesium to >1.0 mmol/L (with concurrent correction of serum potassium to >4.0 mmol/L) is often effective in suppressing ectopy and supraventricular tachyarrhythmias, while a rapid IV bolus of magnesium 2g is a standard emergency treatment for torsades de pointes.uncertain.
*

#Caecal_embryo_sign
in caecal volvulus which describestorsion of the cecum around its mesentry that often resultsin obstruction. Multiple sir fluid levels in small bowel also seen due to obstruction caused by the volvulus.

#PLEASE_REMEMBER
Vitamin K antagonists (VKAs) are also recommended over low-molecular-weight heparin (LMWH), unless VTE is associated with malignancy, in which case LMWH is preferred over VKAs or any direct oral anticoagulants.

#The_Wells_criteria_for_pulmonary_embolism
is a risk stratification score and clinical decision rule to estimate the probability for acute pulmonary embolism (PE) in patients in which history and examination suggests acute PE is a diagnostic possibility. It provides a pre-test probability which, if deemed unlikely, can then be used in conjunction with a negative D-dimer to rule out PE avoiding imaging
#Pulmonary_Embolism_Wells_Score
*Symptoms of DVT (3 points)
*No alternative diagnosis better explains the illness (3 points)
*Tachycardia with pulse > 100 (1.5 points)
*Immobilization (>= 3 days) or surgery in the previous four weeks (1.5 points)
*Prior history of DVT or *pulmonary embolism (1.5 points)
*Presence of hemoptysis (1 point)
Presence of malignancy (1 point)
#Interpretation
Score > 6: High probability
Score >= 2 and <= 6: Moderate probability
Score < 2: Low Probability