⚠️ دورات مجانية لتعلم اللغة الإنجليزية
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#Febrile_Seizure

#Risk_factors_for_recurrence :

#MAJOR_criteria
📍Age <1 yr
📍Duration of fever <24 hr
📍Fever 38-39'C(100.4-102.2F)

#MINOR_criteria
💉Family history of febrile seizures
💉Family history of epilepsy
💉Complex febrile seizure
💉Daycare
💉Male gender
💉Lower serum sodium at time of presentation

🌷🌷🌷🌷

#Risk_factor_for_subsequent_epilepsy
📌 simple febrile seizure 1%
📌recurrent febrile seizures 4%
📌complex febrile seizures (more than 15 min duration or recurrent within 24 hr) 6%
📌 fever<1 hr before febrile seizure 11%
📌family history of epilepsy 18%
📌complex febrile seizures (focal) 29%
📌Neurodevelopmental abnormalities 33%

#M_kh☺️
https://hottg.com/Medical_Channel_222

#Candidates for surgery — All patients with PHPT are "candidates" for surgery, which offers the only established option for long-term cure of the disease .
#For asymptomatic individuals who meet the Fifth International Workshop on Asymptomatic Primary Hyperparathyroidism guidelines☝ (table 1), we suggest surgical intervention as opposed to observation .
Patients need to meet only one of the following criteria for surgery:
●Serum calcium concentration of >1 mg/dL (0.25 mmol/L) above the upper limit of normal.
●Skeletal indications:
•Bone density at the hip, lumbar spine, or distal radius that is at least 2.5 standard deviations below peak bone mass (T-score ≤-2.5).
•Previous asymptomatic vertebral fracture (by radiograph, computed tomography [CT], magnetic resonance imaging [MRI], or vertebral fracture assessment).
●Kidney indications:
•Estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2.
•Twenty-four-hour urinary calcium >250 mg/day (6.25 mmol/day) in women and >300 mg/day (7.5 mmol/day) in men.
•Nephrolithiasis or nephrocalcinosis by radiograph, ultrasound, or CT.
●Age less than 50 years.

( Important items in GIT passmedicine 2 )

# Appropriate tool to screen for malnutrition ?
MUST ( malnutrition universal screen tool )

# Villous adenoma = persistent diarrhea + hypokalemia

# Malabsorption of bile salts is common cause of opening diarrhea following ileal resection in Crohn's with normal CRP, normal fecal calprotectin, normal small bowel biopsy which exclude active Crohn's.
-Beneficial intervention is oral cholestyramine and therefore immunmodulator drugs are not appropriate.

# SeHCAT test is the investigation of choice for bile acid malabsorption



# Charcot's triad (right upper quadrant pain, fever and jaundice) = ascending cholangitis
-First line investigation of ascending cholangitis ?
Ultrasound scan

# Appropriate management of asymptomatic gall stones ?
asymptomatic gall stones which are located in the gallbladder are common and don't require treatment ( just observation )



# Wilson disease is caused by defect in gene located on chromosome 13
While hemochromatosis is caused by mutation of HFE gene located on chromosome 6

)) Wilson disease = Combination of neuropsychiatric symptoms ( tremors, changes in behaviour ) + liver cirrhosis with abnormal liver enzymes, jaundiced sclera + in a young adult

@ Kayser-Fleischer ring ( dark circular marks around iris due to copper accumulation in descemet membrane ) is the single most important diagnostic sign in Wilson's disease; it is found in 95% of patients. Virtually all patients with Kayser-Fleischer rings have neurological manifestations

)) Wilson's disease is autosomal recessive disorder characterised by excessive copper deposition in the tissues. Most copper is deposited in the brain in basal ganglia.

@ Diagnosis of wilson disease ?
- reduced serum ceruloplasmin ( most suggestive test )
- increased 24hr urinary copper excretion
- Slit lamp examination for Kayser Fleischer ring

)) most appropriate therapy of wilson ?
Penicillamine ( copper chelating agent )



# Haemochromatosis is autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6

)) Features of hemochromatosis ? Bronzed diabetes
-increased skin pigmentation ( bronze skin, tanned, slate gray appearance of skin )
-new onset diabetes ( polyurea, polydipsia )
-dilated cardiomyopathy & heart failure ( raised JVP, pitting edema )
-fatigue and arthralgia : Joint pain, with evidence of chondrocalcinosis, Osteophytes of osteoarthritis
-deranged liver function tests
-Testicular atrophy, erectile dysfunction
-Psychoses

@ In hemochromatosis, cardiomyopathy and skin pigmentation are reversible with treatment

# Screening for haemochromatosis ?
-In general population: Initial investigation strategy include transferrin saturation + ferritin which are used to monitor response to treatment ( venesection is first line treatment )
-positive family members history: HFE genetic testing



# Causes of pruritis ( itching ), jaundice and high alkaline phosphatase in middle aged females ?
Primary biliary cirrhosis PBC & primary sclerosing cholangitis PSC
@ How to differentiate?
1- antimitochondrial antibody is positive in 95% of cases of PBC while negative in PSC
2- By MRCP/ERCP ...
PBC, loss of intrahepatic bile ducts+ intact extrahepatic bile ducts
PSC, loss of intrahepatic bile ducts + loss of extrahepatic bile ducts
3- primary biliary cirrhosis PBC is most strongly associated with Sjogren syndrome while Primary sclerosing cholangitis is most associated with Ulcerative colitis

)) HLA DR 7 and 8, HLA DRB1 antigens contributed to the susceptibility of PBC

)) Primary biliary cirrhosis increased risk of hepatocellular carcinoma ( 20 fold increased risk )

)) First line treatment of primary biliary cirrhosis ? Ursodeoxycolic acid.



# side effect of Clindamycin ?
It is associated with high risk of clostridium difficile infection manifested by sever watery diarrhea.

# Drugs cause gram positive anerobic clostridium difficile infection ( pseudomembranous colitis ) ?
-Clindamycin ( the commonest drug )
-Cephalosporins ( ex .. ceftriaxone )
-Quinolones ( ex .. ciprofloxacin )
-Other than antibiotics, proton pump inhibitors

** Note that .. Piperacillin-tazobactam is the least associated drug with pseudomembranous colitis

# Sigmoidoscopy of pseudomembranous colitis shows multiple white plaques adherent to gastrointestinal mucosa

# treatment of clostridium difficile infection ?
-Oral metronidazole for 10 days is the first line treatment
-If no response to oral metronidazole, then oral vancomycin for 14 days,
-If no improvement, third line therapy is oral vancomycin and IV metronidazole should be tried.



# Obesity - NICE indications of bariatric surgery ..
-With risk factors ( hypertension, type 2 DM ) .. BMI more than 35
-No risk factors .. BMI more than 40

# Spontaneous bacterial peritonitis ..
-diagnosid by Paracentesis shows neutrophil count more than 250 cells in ascitic fluid
-Most common organism found on ascitic fluid culture ? E. Coli
-The most appropriate treatment ? IV cefotaxime
-Patients with ascites and protein concentration less than 15 g/ L should be given oral ciprofloxacin as prophylaxis concerning risk of Spontaneous bacterial peritonitis


# Features of mesenteric ischemia = ischemic colitis ?
-Old age
-history of Atrial fibrillation, hypertension, dyslipidemia
-Sudden onset Abdominal pain
-Bloody diarrhea
-Fever
-Elevated white blood cell count
-Low bicarbonate & metabolic acidosis
-X ray abdomen shows air in the wall of colon ( pneumatosis coli )
-Splenic flexure is the most commonly affected site in ischemic colitis.

# Definitive management of Liver abscess ?
Drainge and antibiotics ( amoxicillin + ciprofloxacin + metronidazole )

# Brush border enzymes ...
-Amylase enzyme breaks starch down into sugars
-Lactase enzyme cleaves disaccharide lactose results in formation of glucose + galactose



# Percent of patients with positive Fecal occult blood test Will have colorectal cancer ? 5-15%

# Carcinoembyonic antigen may be used to monitor patients with colorectal cancer.

# Most common type of inherited colorectal cancer ?
heriditary non polyposis Colorectal carcinoma HNPCC ( autosomal dominant )
-It is due to defect in MSH2 gene ( 60% of cases )
-function of MSH2 gene ? DNA mismatch repair


# Non inherited colon cancer often involves mutation of adenomatous polyposis coli gene ( APC gene )

# familial adenomatous polyposis coli ...
-Mode of inheritance ? Autosomal dominant
-It is due to mutation in tumour suppressor gene called APC located on chromosome 5



# Management of hepatic encephalopathy ?
-Lactulose first line, with addition of rifuxamin for secondary prophylaxis of hepatic encephalopathy.

)) Precipitating factors of hepatic encephalopathy ?
1-high protein diet, Constipation, TIPS
2-Hypokalemia and metabolic alkalosis
3-Infections, fever
4-Excessive diuretics, excessive Paracentesis

# Transjugular Intrahepatic portosystemic shunt TIPS commonly causes exacerbation of hepatic encephalopathy manifested by :-
-Patient is not oriented to persons, place, time
-Difficulty to arouse
-More agitated
-Evidence of asterixis ( hand tremors )


# Hepatorenal syndrome = patient with chronic liver disease then develop renal failure
)) Pathophysiology of hepatorenal syndrome ?
Vasoactive mediators such as nitric oxide cause splanchnic vasodilation
)) Types of Hepatorenal syndrome ?
-Type 1 is rapid onset doubling of serum creatinie less than 2 weeks following acute event such as upper GIT bleeding.
-Type 2 is gradual onset decline in renal functions generally associated with refractory ascites.
)) Management of hepatorenal syndrome ?
Terlipressin ( vasopressin analogue ) + albumin to correct hypovolemia

# Autoimmune hepatitis = combination of deranged liver functions ( jaundice and elevated liver enzymes ) & secondary Amenorrhea, fatigue, joint pains in young female
-The condition is linked with other autoimmune conditions including :- pernicious anemia and type 1 diabetes mellitus
-Investigations ? Positive anti liver/ kidney microsomal antibody, positive anti smooth muscle antibody, elevated IgG levels -- the most appropriate next investigation ? Liver function tests
-Management ?
Steroids - immunosuppressives such as azathioprine - liver transplant



# non alcoholic fatty liver disease NAFLD = abnormal liver function tests + obese individuals + who doesn't have history of excessive alcohol consumption + history of prediabetes or type 2 DM is a risk factor

)) The single most important step to prevent progression of NAFLD is .. weight loss



# Most common cause of hepatocellular carcinoma in United Kingdom ?
Liver cirrhosis secondary to chronic Hepatitis C

# Risk factors of hepatocellular carcinoma ?
-Hepatitis C, hepatitis B
-Alcohol
-Hemochromatosis
-Primary biliary cirrhosis
-Aflatoxin
(Wilson disease is not risk factor of hepatocellular carcinoma)


# Any patient more than 55 years with unexplained microcytic anemia should do upper GIT endoscopy and colonoscopy to exclude stomach cancer & colorectal cancer

)) Macrocytic anemia + history of hypothyroidism = pernicious Anemia
-Investigation of choice ? Intrinsic factor antibodies

# Butter contains the most energy calories per unit weight



# Crohn's ( nonbloody diarrhea ) is characterized by ...
-non-caseating granulomas
-inflammation occurs in all layers down to the serosa ( mucosa, submucosa, musclosa and serosa ). This predisposes to strictures ( kantor string sign ), fistulas, adhesions and skip lesions
-oedema of mucosa and submucosa, combined with deep fissured ulcers ('rose-thorn') leads to a'cobblestone' pattern

)) Crypt abscess is characteristic of ulcerative colitis ( not Crohn's )

# The most important etiological factor for Crohn's is : genetic predisposition

)) Colonoscopy is the gold standard for the evaluation of patients with Crohn's disease

)) The most important intervention to reduce chance of further episodes of Crohn's ?
Stop smoking

)) Treatment of exacerbation of Crohn's ?
Prednisolone then mesalazine then azathioprine

)) Thiopurine methyltransferase activity should be assessed before commencing azathioprine therapy in Crohn's disease.




# Ulcerative colitis ( bloody diarrhea ) is characterized by :-
-Crypt abscess
-inflammation confined to mucosa and submucosa
-Inflammatory cell infiltrate in lamina propria
-Depletion of goblet cells & pseudopolyps
-Loss of haustration

)) non-caseating granulomas is characteristic of Crohn's ( not ulcerative colitis )

# Rectum is the most common site affected in ulcerative colitis

# Smoking cessation may trigger flare of ulcerative colitis

)) Treatment of mild / moderate flare of ulcerative colitis ?
-Oral aminosalicylate ( oral mesalazine ) should be added to rectal aminosalicylate ( rectal mesalazine )
-If mild / moderate flare of ulcerative colitis doesn't respond to topical rectal mesalazine or oral mesalazine, then add oral prednisolone


# Criteria of Sever flare of ulcerative colitis ...
(1) opening bowels more than 6 times per day with blood
(2) tachycardia ( HR more than 90 )
(3) fever ( temperature more than 37.5 )
(4) anemia ( hemoglobin less than 10.5 )
(5) raised CRP more than 30

# Most suitable initial Treatment of Sever flare of ulcerative colitis ?
Hospital admission + IV hydrocortisone

)) Factors increase risk of colorectal cancer in patients with ulcerative colitis ?
1-Chronic inflammation
2-Disease duration more than 10 years
3-Onset before 15 years old
4-Unremitting disease
5-Poor compliance to treatment
6-Patients with pancolitis not confined to rectum


# Side effects of mesalazine ?
Headache, acute pancreatitis, Interstitial nephritis, Agranulocytosis
( Infertility is not adverse effect of mesalazine )

# Side effects of sulphasalazine ?
Skin rash, oligospermia & male infertility, diarrhea, Agranulocytosis
( Visual disturbance is not adverse effect of sulphasalazine )




# following start of nasogastric feeding, Refeeding syndrome is caused by rapid refeeding after a period of malnutrition, characterised by hypophosphataemia, hypokalemia and hypomagnesemia.

-Hypophosphatemia is characteristic biochemical sign in patients at risk of refeeding syndrome .. ex .. anorexia nervosa

-Hypophosphatemia cause shortness of breath, muscle weakness followed by confusion, coma and death

-Sever hypokalemia and hypomagnesemia can lead to development of Torsades de pointes ( a variant of polymorphic VT with prolonged QT interval )

-How to avoid refeeding syndrome in starved patients ( more than 5 days ) ?
Provide 50% of Normal energy and protein requirements for the first 2 days.



# Dubin Johnson syndrome is characterized by ...
-Conjugated ( direct ) hyperbilirubinemia
-Cause defective hepatic bilirubin excretion
-Autosomal recessive disorder
-Due to defect in canalicular multispecific organic anion transporter
-Runs a benign course

# Notes on bacterial exotoxins ...
- They are mainly produced by Gram positive bacteria
- Staphylococcus aureus exotoxins lead to acute gastroenteritis
- Systemic distribution of diphteria toxin necrosis may produce necrosis of myocardial, neural and renal tissue
- cholera toxin causes activation of adenylate cyclase leading to increases in cAMP levels
- Lock jaw is caused by Clostridium tetani neurotoxin (tetanospasmin) which blocks the release of GABA and glycine



)) Investigation of choice for cystic fibrosis ?
Sweat chloride test more than 60

# Enumerate autosomal recessive disorders ?
alpha-1 antitrypsin deficiency
Cystic fibrosis
Dubin Johnson syndrome
gilbert syndrome
hemochromatosis
Wilson

# Mode of inheritance of acute intermittent porphyria ?
Autosomal dominant


)) Most common cause of obstructive jaundice ( elevated bilirubin + raised alkaline phosphatase + normal liver enzymes ) in patients with HIV is ... Sclerosing cholangitis

)) The single most appropriate initial investigation to assess presence of free fluid in abdomen and chest in case of trauma is FAST scan

)) Transient elastography ( = Fibroscan ) is now the investigation of choice to detect liver cirrhosis

# المهتمين_MRCP
#notes_passmedicine ☝️☝️☝️

بشرى سارة

يعلن مستشفى الشفاء الحديث
عن انضمام
الدكتوره / سلوى عبده احمد
#استشارية الجراحه العامه

الدكتوره / إيمان سحلول
#استشارية جراحة نساء وولادة

وبمناسبة العام الجديد 2024 م
نعلن للجمهور الكريم با اجراء عمليات مجانيه كاالاتي:
عمليات #البواسير والنواسير والشقوق.
عمليات اصلاح #الهزر - الفتق -
عمليات استئصال اورام #الثدي.

ونسبة تخفيض #30بالميه من جميع العمليات الجراحه العامه الاخرى لمدة شهر. والذي ستجريها:
#الدكتوره سلوى عبده احمد

موعد حجز العمليات المجانية
________
بداية من السبت الموافق
30/12/2023
ولمدة ثلاثة ايام حتى يوم الأثنين
الموافق 4 /1 /2024
.
_________
ونسبة تخفيض #50بالميه من جميع العمليات النساء ولولاده.
مع الاضافة #المعاينه مجانا.
الذي ستجريها:
#الدكتوره ايمان سحلول

بداية من السبت الموافق 30/12/2023
حتى 30/1/2024
----------------------------------

Antinuclear Antibodies (ANA)
ANA or Anti-NucIear Antibody refers to antibodies against antigens in the nucleus → like dsDNA, centromeres, ribonucleoprotein.
The immunofluorescence assay (IFA) is the main technique used to detect ANAs. Using fluorescence microscopy and serial dilution, a pattern and titer is reported.
Positive ANA ≠ Autoimmune Disease!
• +ANA can be seen in up to 33% of healthy adults, and should be interpreted in the context of other symptoms and physical exam findings
• Titer: The higher the ANA titer, the more likely it will be clinically significant
• Pattern: The ANA patterns are associated with different rheumatic diseases, but often not specific
ANA Patterns and Associated Rheumatic Diseases:
• Homogeneous: Systemic lupus erythematosus (SLE), Mixed connective tissue disease (MCTD), Drug-induced Lupus, Juvenile Idiopathic Arthritis (JIA)
• Speckled: Systemic lupus erythematosus (SLE), Sjogren's Syndrome (SS), Polymyositis/Dermatomyositis (PM/DM), Systemic sclerosis or scleroderma (SSc)
• Nucleolar: Diffuse systemic sclerosis/scleroderma, Polymyositis
• Centromere: Limited systemic sclerosis/scleroderma
• Peripheral: Systemic lupus erythematosus (SLE), Systemic sclerosis/scleroderma
What diseases are associated with a +ANA?
• Rheumatic Diseases: Lupus (SLE), Systemic Sclerosis (scleroderma), Rheumatoid Arthritis, Sjögren Syndrome, Myositis, Mixed Connective Tissue Disease (MCTD), Juvenile Idiopathic Arthritis, Drug-Induced Lupus
• Non-Rheumatic Diseases: Malignancy, Lymphoproliferative Disorders, Infection, Autoimmune Thyroid, Autoimmune Hepatitis, Primary Biliary Cirrhosis, Drug-Induced, Inflammatory Bowel Disease, Interstitial Pulmonary Fibrosis, Multiple Sclerosis