Study Group

10/08/2024

01/12/2022

US diagnostic criteria for failure of pregnancy

Discriminatory values for absence of cardiac activity at a certain CRL, absence of an embryo at a certain MSD, and time-based non-visualization of a live embryo were initially established in the 1980s, when endovaginal US was first deployed.

With the goal of absolute certainty of pregnancy failure before initiation of irrevocable medical or surgical management, the Society of Radiologists in Ultrasound 2012 consensus panel revisited the traditional discriminatory values to establish more conservative criteria for definitive pregnancy failure and suspicion of pregnancy failure.

Previously, a CRL of 5 mm without cardiac activity fulfilled the criterion for pregnancy failure; however, in one series, this resulted in a false-positive rate of 8.3%. There have also been reports of embryos with a CRL of 6 mm and no cardiac activity resulting in viable pregnancies. Because of interobserver variability in endovaginal US measurements of CRL, a 7-mm CRL is necessary to yield a specificity and positive predictive value of 100%, thereby decreasing the likelihood of a false-positive diagnosis associated with a 5-mm CRL cutoff.

The same reasoning applies to using an MSD cutoff of 25 mm without an embryo as a criterion for pregnancy failure rather than the previously recommended MSD of 16 mm; and an MSD range of 16–24 mm without an embryo as an indica- tor of suspicion of pregnancy failure. Using an MSD of 16 mm as a cutoff to diagnose pregnancy failure resulted in a false-positive rate of 4.4% in one series.

Gestational sacs with mean diameters between 17 and 21 mm and no visible embryo have resulted in viable pregnancies. Because of interobserver variability in endovaginal US measurements, an MSD cut- off of 25 mm increases the specificity to 100%.

Not all failed or potentially nonviable intrauterine pregnancies demonstrate a 7-mm CRL without cardiac activity or a 25-mm MSD with no embryo, necessitating additional criteria based on nonvisualization of a live embryo by a certain time interval.

22/09/2022

Tricyclic antidepressants most common)
*Type Ia antiarrhythmics (quinidine, procainamide)
*Type Ic antiarrhythmics (flecainide, encainide)
*Local anaesthetics (bupivacaine, ropivacaine)
*Antimalarials (chloroquine, hydroxychloroquine)
*Dextropropoxyphene
*Propranolol
*Carbamazepine
*Quinine


In overdose, the tricyclics produce rapid onset (within 1-2 hours) of:
Sedation and coma
Seizures
Hypotension
Tachycardia
Broad complex dysrhythmias
Anticholinergic syndrome
Tricyclics mediate their cardiotoxic effects via blockade of myocardial fast sodium channels (QRS prolongation, tall R wave in aVR), inhibition of potassium channels (QTc prolongation) and direct myocardial depression.
Other toxic effects are produced by blockade at muscarinic (M1), histamine (H1) and α1-adenergic receptors. The degree of QRS broadening on the ECG is correlated with adverse events:
QRS > 100 ms is predictive of seizures
QRS > 160 ms is predictive of ventricular arrhythmias (e.g. VT)
:
*Interventricular conduction delay — QRS > 100 ms in lead II
*Right axis deviation of the terminal QRS:
*Terminal R wave > 3 mm in aVR
*R/S ratio > 0.7 in aVR
Patients with tricyclic overdose will also usually demonstrate *sinus tachycardia secondary to muscarinic (M1) receptor
Overdose >10mg/kg with Signs of cardiotoxicity (ECG changes)
Patients need to be managed in a monitored area equipped for airway management and resuscitation.
Secure IV access, administer high flow oxygen and attach monitoring equipment.
Administer IV sodium bicarbonate 100 mEq (1-2 mEq / kg); repeat every few minutes until BP improves and QRS complexes begin to narrow.
Intubate as soon as possible.
Hyperventilate to maintain a pH of 7.50 – 7.55.
Once the airway is secure, place a nasogastric tube and give 50g (1g/kg) of activated charcoal.
Treat seizures with IV benzodiazepines (e.g. diazepam 5-10mg).
Treat hypotension with a crystalloid bolus (10-20 mL/kg). If this is unsuccessful in restoring BP then consider starting vasopressors (e.g. noradrenaline infusion).
If arrhythmias occur, the first step is to give more sodium bicarbonate. Lidocaine (1.5mg/kg) IV is a third-line agent (after bicarbonate and hyperventilation) once pH is > 7.5.
Avoid Ia (procainamide) and Ic (flecainide) antiarrhythmics, beta-blockers and amiodarone as they may worsen hypotension and conduction abnormalities.
Admit the patient to the intensive care unit for ongoing management.blockade.

Internal medicine

21/02/2022

H2 blocker Renitidine (NDMA component) is carcinogenic.
It's already off the USA market.

03/04/2021

of Dyspnea with clear chest:
*Most common
*Anxiety
*Anaemia
*Hypotension
*Hypoglycemia
*Sever Fatiguebility
*DKA acidotic breathing
*Neuromuscular diseases
*Brain stroke
*Morbid Obesity
*Pregnancy
*Polmonary embolism
*Sarcoidosis

24/03/2021

23/03/2021

's
This maneuver is achieved by having the patient elevate both arms until they touch the sides of the face. A positive Pemberton's sign is marked by the presence of facial congestion and cyanosis, as well as respiratory distress after approximately one minute... the sign is used to evaluate SVC obstruction due to various causes like
​ are :-
*Bronchogenic Carcinoma.
*Lymphoma.
*Retrosternal Goiter.
*Mediastinal mass.

23/03/2021

An 85-year-old woman suffered a fall, as a result of which she fractured her left neck of femur and was admitted to the orthopaedic ward. She underwent a successful opera- tion. Since her medical history included hypertension and chronic renal impairment, her team were aware that low-molecular-weight heparin (LMWH, e.g. enoxaparin) should be avoided; hence heparin was used postoperatively to prevent thrombus formation. Four days later the patient is complaining of a nosebleed that does not seem to be stopping.

Blood count at admission: Normal range
White cells 9.9 109/L
Haemoglobin g/dL
Platelets 350 × 109/L
Repeat count after the nosebleed: Normal range
White cells 10.000/cumm Haemoglobin 11.8 gr/dl Platelets 90. 000 /109
Questions
• Why might the patient’s platelet count be falling?
• Should you stop the heparin?

Internal medicine

19/03/2021

*Is an approach of treating hypertension in acute ischemic stroke , in which antihypertensive treatment is warranted in patients with systolic blood pressure greater than 220 mm Hg,or diastolic blood presure greater than 120mmhg in the pts receiving thrombolytic therapy, or with concomitant medical issues
The goal would be to lower blood pressure by 15% during the first 24 hours after onset of stroke
,* it is recommended that the blood pressure be reduced and maintained below 185 mm Hg systolic for the first 24 hours. The first-line drugs for lowering of blood pressure remain labetalol, nicardipine, and sodium nitroprusside.

Internal medicine

19/03/2021

• A sickle cell chest crisis should be suspected in a patients with a known sickle cell disease
who develops hypoxia.
• A chest crisis can be fatal, so a patient should be reviewed early for antibiotics,
intravenous fluids, oxygen and possibly a blood transfusion to try to improve the hypoxic tissue dammage

Internal medicine

18/03/2021

Case no 11-:

A 28-year-old pregnant woman who is at 34 weeks’ gestation presents to the emergency department complaining of a headache. She feels nauseous and has noticed some ankle swelling over recent days. This is her first pregnancy and she has been well up until this point.

This woman’s heart rate is 70/min but her blood pressure is 160/90 mmHg on three
differ- ent readings, taken 10 minutes apart. Her heart sounds are normal and her chest sounds clear. A full neurological examination is significant for 6 beats of clonus at both ankles. The symphysis–fundal height is 34 cm (normal for the gestation) and the presentation is cephalic. The fetal heart rate is 130/min. Her urine has been dipped and shows the pres- ence of protein.

• What condition could this pregnant woman be suffering from?
• How would you manage the patient?

17/03/2021

:
*microcytic anaemia with low s.ferritin& high TIBC=iron defeciency anaemia
*microcytic anaemia with high s.ferritin&low TIBC=anaemia of chronic diseases
*microcytic anaemia with high s.iron= sidroblastic anaemia
*microcytic anaemia with NORMAL iron studies=thalacemia