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MKSAP notes:

- Hard to draw conclusion in observational studies


- MDRD is more accurate than cockcroft gault equation to calculate GFR in patients who
are obese or older patients.
- Cross sectional and case series designs are limited because there is no control group
- Meta-analysis is statistical analysis of studies taken from systematic review, the studies
should meet predefined criteria.
- Two types of error, random and systematic, the former can be decreased by increasing
measurement precision and sample size, the latter is caused by Bias and can only be
solved by solving the bias (control are sampled, analysed and measured same way)
- Rosacea mainly involves the convex surfaces of the face and spares the perioral
regions, lesions include telangiectasia, papules, pustules, nodules or ocular disease, but
no comedones. Some triggers can cause flushing lasting>10 min
- Evolocumab is monoclonal AB that target serine protease PCSK9 (proprotein
convertase subtilisin/kexin type 9) and inhibits the degradation of LDL receptors. Result
in significant reduction in LDL levels and all cause mortality compared to placebo or
ezetimibe. It is mainly used in patients with clinical atherosclerolitic CVD and
unacceptably high LDL while on the highest tolerated statin dose. And it can be given in
certain cases of familial hypercholesterolemia. The drawback is 13000 $ annual cost
and twice SC injection/mo
- Note that FDA cancel its approval for niacin or fenofibrate combination with statin. Note
that those 2 drugs can affect HDL and triglyceride levels, but they don’t change mortality
- Hematogenous osteomyelitis of vertebrae can sometimes be seen on XR, when it is it
manifest with diminished intervertebral space, erosions/osteopenia of contiguous
vertebral bodies
- SJS and TEN are two variants with similar manifestation. TEN >30% body surface, SJS
<10%. While TEN-SJS is in between. They involve > 2 mucosal surfaces involved in
80% of cases (eyes, nasopharynx, mouth, genitalia Systemic inflammation can be seen
and manifest with hepatitis, nephritis, pneumonia, myocarditis and arthralgia .
Common drugs to cause it: Antiepileptics (carbamazepine, lamotrigine, phenytoin),
other less common causes: antibiotics (B lactam, sulfa, fluoroquinolones, minocycline),
NSAID, Allopurinol, sertraline, pantoprazole, Tramadol. The reaction usually occur
within 8 weeks of drug initiation. Note that TEN is mainly by drugs and it is rare but
SJS can also be a reaction from infections and vaccines. Tx is stop offending agent and
supportive Mx.
The reaction is painful, in contrast to drug exanthem which is pruritic.
- Tai Chi showed beneficial effect for OA as physical Therapy. Modified insoles and
cooling therapy (fluoromethane spray) or US therapy has no added documented benefit
- IBM (inclusion body myositis) usually present in Men >50, includes proximal and distal
muscles weakness and can be asymmetrical in 15%. Rarely has fever, rash or
pulmonary involvement. Skin is spared. Muscle enzymes is moderately elevated
<1000 U/L or it can be normal. Three characteristic on EMG: slow low amplitude
polyphasic potential, fibrillation potential at rest, and bizarre high frequency repetitive
discharges.
- Statin induced myopathy usually within 6 months and no EMG findings/weakness
- If you suspect diverticulitis, do abdominal imaging, avoid colonoscopy
- In hypertensive hemorrhagic stroke with intracerebral extension and cerebral edema
guidelines instruct to lower BP <140 in Patients with SBP 150-220. Nicardipine first
choice.
Hematoma evacuation is indicated if hematoma in cerebellum (diameter >3 cm)
Intraventricular catheter with subsequent measurement of CSF pressure and diverting
CSF is indicated if altered mentation (especially if GCS<8) and hydrocephalus
- Patients who received kidney transplant from HLA incompatible donor showed improved
survival compared to those who did not receive transplants or remained on waiting list
for transplant from deceased donors.
- Old treatment regimen for CLL 1- Rituximab, fludarabine, cyclophosphamide and
prednisone. 2- Bendamustine plus rituximab 3- single agent with chlorambucil or
Fludarabine.
- The first choice of tx for CLL is Tyrosine kinase inhibitor (Ibrutinib). Indications for
treating CLL are: significant weight loss, bulky Lymphadenopathy and disabling night
sweats.
- Steroids by itself as a single agent is not used in Tx of CLL, it can be used as single
agent in CLL if it is used to treat warm AB autoimmune hemolytic anemia
- Ibrutinib can cause an initial rise in lymphocytes count, no intervention needed
- LABA plus fluticasone (IG) vs Fluticasone alone in asthma showed same risk for serious
asthma related events (Hospitalisation/intubation/death). While the former showed less
exacerbation.
- Dupuytren contracture occur in patient with jobs involving repetitive motion/vibration,
alcohol, DM, smoking or complex regional pain syndrome.
- ABPA cause is a chronic hypersensitivity reaction, occur when aspergillus colonize the
lower airways. Usually seen in patients with asthma or CF. present with severe asthma
resistant to usual treatment. It can cause bronchiectasis (centrilobular), destruction of
pulmonary parenchyma and impaired mucus clearance. Patient may present with low
grade fever, productive cough. CXR may show normal findings, or recurrent infiltrates
and evidence of centrilobular bronchiectasis.
Diagnosis: immediate skin test reactivity to aspergillus Ag (first test). serum antibodies
titers. Along with evidence of eosinophilia > 1000 and high IgE >1000
- Eosinophilic granulomatosis with polyangiitis (formerly churg strauss) present with
asthma like sx, along with skin purpura hands/legs, sensory/motor neuropathy
- Hypersensitivity pneumonitis present after inhaling inciting agent. It can be acute,
intermittent or chronic, present with fatigue/SOB/Cough. NO eosinophilia or high IgE
- Polymyalgia Rheumatica is seen mainly in women >50. Present with symmetrical
stiffness and pain in shoulder, neck and hip. It can be associated with mild synovitis in
hands/wrists. Negative muscle enzymes and negative RF/Anti-citrulline Ab. No need for
EMG (used in myositis). In patient with significant elevation of ESR on presentation
(>40) or peripheral arthritis, they are at higher risk of relapse. Also patient with
comorbidities like DM-II or osteoporosis, at higher risk of steroid SE. Early institution of
methotrexate in these patients is helpful to decrease steroid cumulative dose and
duration of steroid therapy along with decreasing risk of relapse.
- P mitrale: long P wave >110 ms (about 2.5 small square), distance between two peaks
around 40 ms. Mainly look at left atrial leads (I, II, aVL).
V1 shows Biphasic P wave with terminal negative portion >40 ms length, >1 mm deep
- P pulmonale: >2.5 mm in inferior leads, and >1.5 mm in V1,V2
- LVH: one voltage criteria plus one non voltage criteria
Voltage criteria: S wave in V1 or V2 plus R wave in V5 or V6 >35 mm
Non voltage criteria: strain pattern in left lateral leads (ST depression along with T
inversion) or increase R wave peak time >50 ms in leads V5,V6
- Ruptured baker cyst is a finding commonly seen in osteoarthritis and RA (it is posterior
herniation of knee effusion), it can mimic DVT -causing calf pain- and can present with
crescent sign (ecchymosis below the medial malleolus)
- In patient with adrenal insufficiency, diagnosed with low morning serum cortisol (<3
microgram/dl) and sx: N/V, fatigue and unintentional weight loss. Start with treatment
before further testing, give glucocorticoid (hydrocortisone) and mineralocorticoids
(fludrocortisone). No need for further testing if levels <3. If 4-12, then do cosyntropin
stimulation test, if levels go up above 20 then it is normal.
- D lactic acidosis present with confusion, ataxia, slurred speech. On labs: AG metabolic
acidosis. Lactate levels is normal because we usually test for L lactate. This type of
metabolic acidosis usually occur in patients with jejunoileal bypass or small bowel
resection higher levels of D-lactate reach the colon in these cases.
- The appropriate wound dressing for pressure ulcer is by using hydrocolloid or foam
dressing, it help absorb the exudate, accelerate wound healing.
- Note that pressure ulcer need other measures like: keep moving the pressure zones,
keep area dry, maintain adequate nutrition, electrical stimulation (high voltage pulsed
stimulation)
- Maggot therapy can be used to clean and debride non healing wounds with necrotic
tissue
Wet to dry dressing used in deeper wounds with necrotic tissue
Vacuum assisted closure device used for deep wounds
- Test all patients with newly diagnosed colon cancer for mismatch repair gene mutation
to diagnose possible Lynch syndrome.
- Lynch syndrome accounts for 5 % of colon cancer, and it is in right ascending colon in
70% of cases. Criteria for Lynch syndrome: 1- one first degree relative or two second
degree relatives diagnosed with colon cancer at age <50. 2- synchronous or
metachronous cancer of colon, stomach, pancreas, small intestine, endometrium,
ovarian, ureter, sebaceous.
- Testing for Lynch syndrome has prognostic implications. Screening for confirmed lynch
is the following: colonoscopy every 1-2 years. Upper endoscopy with bx of antrum every
2-3 years starting at the age of 30-35, genitourinary US yearly and women should have
TV US with endometrial bx annually. Urinalysis recommended starting at age 30-35
because of increased risk of pelvic/bladder TCC.
- Ethanol glycol and methanol poisoning are associated with AG metabolic acidosis.
HCO3 <10 and plasma osmolal gap >10 mosm.
- Propylene glycol is a vehicle used to deliver many IV medications. Toxicity will cause AG
metabolic acidosis along with increased osmolal gap, and it is principally due to L-lactate
and D-lactate (breakdown products of propylene glycol)
- Pyroglutamic acidosis typically happens in patients receiving chronic doses of
acetaminophen who are critically ill, liver and kidney disease, poor nutrition or on
vegetarian diet. They present with AG MA and confusion. Measure urine pyroglutamic
acid levels for dx.
- Cryoprecipitate contain factor I, VIII, XIII and VWF. some of its uses are in patients with
fibrinogen disorders, liver disease, uremia where desmopressin was ineffective, DIC. It
can also be used in pregnancy where there is inherited fibrinogen disorder. It can be
rarely used in factor VIII, XIII, VWF deficiency when pure factors are not available
- Idarucizumab is a monoclonal AB approved in treating dabigatran overdose who
concomitantly present with life significant bleeding. Its effect is immediate. If significant
bleeding persist or bleeding tests (aPTT, PT, TT) keep rising, consider giving another
dose
- In addition to the above, give antifibrinolytic agents like tranexamic acid or aminocaproic
acid. Charcoal if within 2 hours of ingestion, hemodialysis is also an option.
- Andexanet alfa is being developed as an antagonist for factor X inhibitors like apixaban,
rivaroxaban.
- Note that the aforementioned anticoagulants, FFP or cryoprecipitate are not reliable in
reversing their potential life threatening bleeding side effect
- SCD: spindle/crescent shaped RBC, howell jolly bodies, target cells.
- Esophageal chest pain is usually prolonged, nonexertional, associated with esophageal
sx like dysphagia, odynophagia or reflux. You need to R/O cardiac cause especially if it
meets criteria of atypical chest pain (2 out of 3 of the followings: substernal chest pain,
exacerbated by emotions/exertion, relieved by rest/nitroglycerin). Do exercise stress
testing. The most common cause of noncardiac chest pain involve GERD followed by
motility disorders.
- Give elemental iron at a dose of 40-80 mg daily for IDA, higher doses has been
associated with increased hepcidin with ultimately decreased iron absorption and
utilization. So once daily dose is recommended, alternate day dosing is still not fully
validated.
- Lifting of nail off nail bed (onycholysis) which manifest as white areas on the edge of the
nail is typically seen in psoriasis. Oil drop sign (yellowish color) is also seen.
- Dermatophytes is the most common fungi affecting the skin, tinea manuum affects one
hand (and two feet) and in advanced disease it will involve the nails.
- Fundoscopic findings of nonproliferative diabetic retinopathy include hard exudates,
microaneurysm and minor hemorrhage. Usually no change in vision acuity but it is a
marker that things can progress and lead to vision loss in future.
- Erosive changes and lysis of terminal phalanges along with periostitis. Can all affect a
joint at the same time and give the appearance of pencil in a cup
- If high suspicion of spondyloarthropathy and plain X ray is negative→ Do MRI spine (it is
the most sensitive to detect inflammation in the spine and sacroiliac joints.
- Note that HLA-b27 could be negative! That does not rule out Spondyloarthropathy!
- Ultrasound could be helpful in detecting enthesitis and peripheral arthritis.
- Women who take methotrexate should stop taking it 3 months before attempting
pregnancy!
- Continue hydroxychloroquine during pregnancy, not enough evidence about adverse
effect on the baby or Mom, try to avoid steroid if possible before 14 weeks because of
increased risk of cleft palate. Steroid also increase risk of gestational DM and HTN, but
continue to give it if benefit outweigh the risk (like in controlling RA)
- Physicians should keep their social and professional online presence separate and
conduct themselves professionally on both spheres.
- USPSTF: no enough evidence to screen for skin cancer in adults with low risk of skin
cancer. Exceptions: sun exposure and burns as a child- hx of tanning bed use, family
hx malignant lesions, personal hx of malignant or premalignant lesions.
- Risks on the previously high risk patients is increased, assess them with ABCDE rule
- Treat severe neuropathic pain due to DM with SNRI like duloxetine. Note that pregabalin
and gabapentin are also first line
- Transdermal lidocaine can be used in disease affecting single dermatomes like shingles.
- TACO occur in 0.3-8% of patients who receive blood transfusion, it occur within 6 hours
of transfusion and have at least 3 of the following: ARDS, elevated CVP, evidence of left
heart failure, evidence of pulmonary edema on Chest imaging, elevated BNP, evidence
of +ve fluid balance. RF for TACO include age>60, CKD, CHF, number of units and rate
of transfusion. To avoid TACO, give a rate of 1 ml/kg/hr along with diuresis to maintain
euvolemia.
- To develop TRALI, you follow 2 hit hypothesis. Neutrophils primed in recipient and donor
blood product contains anti HLA. implications of diagnosing TRALI is imp, inform blood
bank with “possible TRALI” or confirmed one. Donors implicated in TRALI should be
deferred from future platelets apheresis, plasmapheresis, and possibly also whole blood
donation.
- Differences between TRALI and TACO includes the following: TACO has evidence of
volume overload manifested by JVD, PAOP (pulmonary a. Occlusion pressure) >18
mmHg, S3 along with rales, decreased CO, BNP >1200, good response to diuretics,
transudate lung effusion, no fever or hypotension. While in TRALI no evidence of volume
of overload. BNP< 250, PAOP <18 mmHg, variable response to diuretics, rales on
auscultation, normal CO. exudative lung effusion. Fever and hypotension may be
present.
- TRALI criteria: Hypoxia, evidence of b/l lung infiltrates on CXR, no volume overload or
evidence of increased left atrial pressure, within 6 hours of transfusion, no existing ALI/
ARDS. confirmed TRALI if no RF for ARDS, possible TRALI if RF for ARDS present!
- Topical steroid potency ranges from category I-VII. VII being the least potent
(hydrocortisone 1% or 2.5%, hydrocortisone valerate, fumarate). Sensitive areas like
skin folds or face→ use low potency or you risk having lightening of the skin, atrophy
and telangiectasia. REVISE STEROID POTENCY FROM AAFP. In general, from
highest to low potency: clobetasol, betamethasone, halobetasol, fluocinonide,
fluticasone, triamcinolone, hydrocortisone butyrate and probutate, mometasone and
finally the 4 mentioned above.
- Demyelination plaques appear as hyperintense signals on T2 and hypointense if
apparent at all in T1. usually in periventricular regions, corpus callosum, subcortical and
sometimes in basal ganglia and deep white matter. Ovoid and at right angle from
ventricles.
- Patient with sx of hypothyroidism and have low normal TSH→ test for free thyroxine
levels. TSH is sensitive test to assess thyroid function in patients with intact HPA axis. If
suspected central hypothyroidism (e.g patient had cranial radiation→ measure serum
free thyroxine levels.
- Lyme arthritis is a late manifestation of illness, occur after months. Initial evaluation
include EIA, very sensitive test. If +ve proceed with western blot, if +ve only for IgM then
consider +ve lyme if sx less than one months, but if more than month IgG should also be
+ve. Detection of borrelia in synovial fluid is only indicated in patients previously
seropositive and develop new arthritis. Note that tx is 28 days of doxycycline or
amoxicillin, ceftriaxone used if no clinical response to tx.
- Low dose ASA is indicated in patients with newly diagnosed GCA (giant cell arteritis).
These patients at higher risk of CAD, CVA and PVD especially in first year after
diagnosis. It is explained by imbalance in LDL/HDL and vascular inflammation.
- In patient who are at increased risk of steroids or has comorbidities like DM,
osteoporosis or cataract, early addition of methotrexate help in tx if GCA.
- Patients with GCA are at risk of thoracic aortic aneurysm and should get baseline
chest radiograph and then yearly for 10 years.
- Toxic megacolon occur mainly in IBD, but it can occur in volvulus, diverticulitis,
obstructive colon CA, usually the transverse and ascending colon are involved with
diameter of more than 6 cm and disturbed haustra. Descending and sigmoid usually not
involved. Toxic megacolon distinguished from colonic distention by presence of fever,
tachycardia and leukocytosis.
- Switch ACEI with ARNI (angiotensin receptor blocker neprilysin inhibitor) in patients with
chronic HF with reduced EF and mild-moderate sx - NYHA II/III (and patient tolerating
ACEI/ARB). ARNI is valsartan-sacubitril. It is associated with decreased risk of HF
mortality and hospitalization compared to enalapril alone. Don’t give if hx of angioedema
and don’t give within 36 hours of last ACEI done→ risk of angioedema. ARNI increases
neprilysin which inhibit the neurohormonal activation seen in HF (vasoconstriction and
Na retention
- For patients with HFrEF with EF<35% and NYHA II-IV, and HR >70 while on optimum
therapy for HF would benefit from taking ivabradine. Before initiating this drug the patient
should be on optimum dose of BB. if HR still>70 → initiate Ivabradine
- ARB is associated with decreased risk of cough and angioedema, but risk of
angioedema is still present. Don’t add ACEI with ARB→ hyperkalemia/RF
- Patients with CKD could have normal BP in clinic but abnormal 24 hours BP monitoring,
this put them at higher risk of CV target organ damage, decrease GFR and proteinuria
- This condition is called masked HTN and can be assessed using 24 hrs BP monitor
(ABPM)- ambulatory BP monitor. About 28% of CKD pt have masked HTN
- In cases of masked HTN use ACEI plus diuretics (loop or thiazide)
- Guidelines recommend PMRT (postmastectomy radiotherapy) post mastectomy in
patient with cancers T1-T2 with involvement of 1-3 LN. previous guidelines talked about
postmastectomy and 4 or more LN. surveillance is only an option if the patient refuse
radiotherapy, very old or can’t tolerate radiotherapy.
- Hypertensive emergencies general principles: In case of stroke don’t lower BP unless it
is >220/120 or >185/110 in patients who are candidate for reperfusion therapy. In case
of ICH there are different goals for tx. And in case of acute aortic dissection lower the BP
to 100-120 SBP within 20 minutes.
- In patients with ACS in whom the culprit artery has been treated with PCI or
thrombolysis , treatment of the non culprit artery is indicated if:
Cardiogenic shock persisting even after treating culprit artery, Those with spontaneously
or easily provoked sx of myocardial ischemia, asymptomatic patients with sx of ischemia
on noninvasive testing, asymptomatic patients with an intermediate stenosis (50%-70%)
and FFR of 0.8 or less.
FFR (fractional flow ratio): ratio of blood flow distal to stenosis compared to proximal on
maximal blood flow, it can be measured during cath and using adenosine to achieve
maximal flow.
CABG indications: Left main coronary artery stenosis >50%, three major vessel
stenosis >70%, Proximal LAD disease plus one other major vessel, or previous cardiac
arrest caused by ischemia mediated Vtach caused by significant stenosis (>70%) in
major coronary artery. Myocardial viability study is used to assess LV function, heart
failure sx and the natural hx after revascularization.
- Study of gallbladder could be indeterminate if GB is not visualized (could happen if non
fasting patient)
- Diverticula are 5-10 mm in size, occur due to vasa recta penetration of bowel wall,
decrease fibers intake or motility issues (simultaneous or excessive haustral
contractions)
Diverticulitis can present with micro or macro perforation.
- Mutation in G protein coupled calcium sensing receptors (CASR). These receptors are in
the kidneys and parathyroid gland, there will be upward shift in the calcium sensing
resulting in mildly elevated Ca (<11) along with high normal or mildly elevated PTH
- Granulomatous disease has increased hydroxylase activity by macrophage→ so
increase metabolically active 1,25 OH cholecalciferol
- Thiazide may elevate blood Calcium slightly because of activation of Na-Ca co
transporter in DCT.
- Stem cell transplant or BMT can be done on patients with SCID.
- Selective IgA deficiency is the most common inherited immunodeficiency. It could be
sporadic or AR or AD. IgA levels < 7 mg/dl. Could be asymptomatic or repeated
sinopulmonary infections. Either way treatment is not necessary except with AB when
the patient has infections. Uncommon sx is anaphylaxis to blood product. Patient are at
increased risk of Autoimmune diseases like SLE, RA, hemolytic anemias, ITP. additional
manifestation include urticaria, asthma, atopic eczema.
- IV immunoglobulin given to patients like agammaglobulinemia or CVID. IgA deficiency
patients has normal other Ig levels. And giving IV IgA won’t achieve adequate levels in
the mucosal surface→ so not indicated.
- Prosthetic valve is associated with increased risk of bleeding, thrombosis, teratogenicity
and fetal loss. Tx options include warfarin, LMWH or unfractionated heparin. Warfarin is
the best studied to lower the risk of thrombosis. Dose around 4 mg has low risk of
teratogenicity. Unfractionated heparin can be used and therapeutic dose is tailored
with measured aPTT. LMWH can be used as well but it should be tailored
according to anti factor X activity not according to weight during pregnancy.
- Isotretinoin should be discontinued if liver transaminase X3 of normal, significantly high
Triglyceridemia (>800) that could cause pancreatitis, or other marked labs abnormalities.
- Recommended lab tests for patients on isotretinoin is done 4 weeks and 8 weeks after
initiation of the drug. If things are stable→ no more testing. Usually no significant
changes in the labs between week 8 and 20 of treatment.
- colloids has no advantage over crystalloid except is septic shock unresponsive to
crystalloid.
- In case of incidental thyroid nodule→ test for TSH. if TSH is normal or elevated→ do not
do radionuclide scan as initial imaging choice. Do the scan as 1st choice if TSH
subnormal
- Do not test routinely for thyroglobulin levels. No recommendation weather to test
calcitonin
- US for neck LN should be performed before thyroid surgery in suspected or confirmed
thyroid cancer. Suspicious node with short axis diameter of more than 8-10 mm should
be biopsied. Thyroid cancer is associated with LN mets in anterior and lateral neck in
50% of cases. And can be diagnosed with US in 30% of cases. Diagnosing LN mets
will require total or subtotal thyroidectomy along with compartmental dissection instead
of just lumpectomy.
- PDG PET/CT scan not usually used in thyroid evaluation.
- Measuring serum thyroglobulin and antithyroglobulin levels is used post thyroid surgery
not before and can be used as evidence of persistent/recurrent disease if there
elevated thyroglobulin in the absence of antithyroglobulin.
- I123 radioactive iodine scan is usually performed after surgery for thyroid cancer in
patients with suspected or at high risk of mets or with suspected remnant disease
- Evaluation of thyroid nodules and FNA result:
https://www.uptodate.com/contents/image?topicKey=7890&imageKey=ENDO%2F90862
&source=outline_link&search=solitary%20thyroid%20nodule
https://www.uptodate.com/contents/image?topicKey=7890&imageKey=ENDO%2F90863
&source=outline_link&search=solitary%20thyroid%20nodule
- Treatment for constrictive pericarditis is similar to acute pericarditis, basically NSAID,
steroids can be tried. NSAID dose is high→ ibuprofen 800 TID, indomethacin 50 TID or
aspirin 650 TID. if no response in 2-3 months then definitive management of heart failure
in constrictive pericarditis is pericardiectomy.
- Tx of acne depends on severity:
1- comedonal acne
2- mild papulopustular acne and mixed (papulo pustular and comedonal)
3- moderate papulopustular acne and mixed
3- severe papulopustular acne and mixed
- Tx for (1) topical retinoid or salicylic acid or azelaic acid
(2) topical antimicrobial (benzoyl peroxide (BP) +/- topical antibiotics) and retinoid or
topical BP and topical AB
(3) topical BP and oral antibiotic and topical retinoid
(4) like 3 or isotretinoin monotherapy
- Unexplained chronic cough tx recommendations: gabapentin 300 mg then escalated to
900 mg BID for a duration of 6 months. PPI is not recommended for treating chronic
cough unless active GERD sx is there. Inhaled steroids used if evidence of reactive
airway disease. Use of morphine can help with chronic cough but not recommended
giving the side effects of morphine
- Different Ticks transmit different diseases
A- Deer tick (Ixodes tick): Transmit lyme, babesiosis, Anaplasma
B- Dog tick: Transmit Rocky mountain spotted fever
C- Lone star tick: Transmit Ehrlichia
Note that Ehrlichia cause Human monocytic Ehrlichiosis while anaplasma cause human
granulocytic anaplasmosis
- Recommendations regarding Zika virus in pregnant women:
1- If sx of zika virus with possible zika exposure→ test for Zika
2- If no sx of zika and there is ongoing exposure to zika→ test for Zika in 1st and 2nd
trimester of pregnancy
3- If no sx of zika and there is past exposure (not ongoing) → no need to test
- Overall advise against travel of pregnant women to areas of local mosquito-borne
transmission of Zika virus, However if still need to go, insect repellent, long sleeve
clothes, along with control mosquitos in and around the house by following appropriate
measures
- Risk of birth defect from Zika happens throughout pregnancy not just 1st trimester,
appropriate measures should be taken throughout pregnancy including avoiding
mosquitos bites and having unprotected sex with partners at risk of exposure
- Note that Aedes Aegyptii is the main responsible vector, active day and night
- Primary CNS lymphoma can be missed in 10% of CT scans, best imaging modality is
MRI with contrast, 50-70% of lesions occur as solitary in immunocompetent individual.
60% occur as a periventricular lesion, the rest in brain lobes. Well circumcised lesion
- Subclinical hypothyroidism is associated with increased risk of hip fractures especially if
TSH levels <0.1, It is unclear weather treating this condition will improve that risk

- In patients at high risk of surgery (STS of 8-15%), anatomical limitation for surgery, or
friability. TAVI is preferred option. Note that early (<1 mo) and midterm (<1 yr) all cause
mortality is less with TAVI than SAVR (transcutaneous aortic valve intervention vs
surgical aortic valve replacement). Risk of bleeding, AKI and early MI is less with TAVI,
while TAVI has more risk of pacemaker insertion, vascular complications and
paravalvular leak.
- Percutaneous aortic balloon dilatation is mainly used in children, in adults it can be a
bridging measure in severe symptomatic AS awaiting for definitive tx. There is high risk
of restenosis and regurgitation within 6-12 months.
- SAVR is the procedure of choice in patients <70 with severe symptomatic AS and low
risk for surgery. Mortality rates is 1-3 %
- Aortic valve repair is restricted to limited patients with aortic regurgitation and favorable
anatomy of the aortic valve and the root
- Note that aortic balloon dilatation can be considered in three cases
1- bridging to definitive tx
2- To differentiate dyspnea sx in high risk patients with significant comorbidities like
COPD
3- tx of calcific aortic stenosis with hemodynamic instability or decompensation.
Note that aortic regurgitation is a contraindication for balloon dilatation
- TAVR could be also considered for patients with moderate risk for surgery. In general
anyone with score of >4 in STS system should be considered. Not enough data
regarding bicuspid aortic valve. Note also that severe calcification favors surgery
- Torsades de pointes usually happen in underlying QT prolongation
- Colonoscopy surveillance guidelines:
- Two of the medications which can be used in idiopathic pulmonary HTN include
ambrisentan (endothelin receptor antagonist) and tadalafil (PDE5 inhibitor)
- Pressure values of the heart: pulmonary pressure→ systolic is 20-30, diastolic 8-12,
mean is 25. Pulmonary vascular resistance 37-250 dynes/sec/cm. PCWP 4-12. RV
pressure→ diastolic 0-5, systolic is 20-30. CO is 4-8 L/min, Cardiac index→ CO/BSA is
2.5-4
- Selexipag which is prostacyclin receptor agonist was found to decrease composite
endpoint death and complication in patients with idiopathic pulmonary HTN (PAH),
weather they are on tx or not. It is an oral agents. Don’t use with prostacyclin analogue
which is considered the DOC in severe cases of PAH and require continuous
administration via a central line.
Current guidelines recommend treating patients with PAH to decrease annual mortality
rate to <5%. If the patient NYHA grade III-IV, his/her annual risk is 5-10%. Further Tx is
needed in that case
- 6 minute walk test: used to assess patients with chronic lung disease like COPD, PAH
and pulmonary fibrosis, it can assess function and improvement on tx. Normal range is
400-700 m, improvement of 30 m in distance considered significant. We monitor HR
recovery time, total distance walked and magnitude of desaturation
- Blatchford score is designed to assess upper GI bleeding; components include BUN,
Hb levels and gender, SBP, and other variables including presence of melena, syncope
at presentation, HR>100, presence of HF and underlying liver disease.
- AIMS65 is best to predict mortality in patient presenting with GI bleeding: Albumin <3,
INR>1.5, altered mental status (GCS<14), SBP<90, age >65
A score of > 2 is best to predict mortality.
- Glasgow blatchford score is best in assessing the need for inpatient admission-and
inpatient interventions. Score of <1 indicate spontaneous resolution is expected and the
patient can be sent for outpatient GI referral. A score of > 7 indicate the need for
endoscopy. Note that the scoring system does not apply to inpatient.
- For patients with prehypertension, tx is lifestyle modification and recheck BP in one
year. The modifications include exercise program along with DASH diet. The diet include
vegetables and fruits, legumes, low fat dairy products, and limiting sweets, saturated/
total fat and red meat.
- Note that prehypertension is defined as BP (120-139/80-89) without pre existing
evidence of end organ damage (CKD, DM, CVD).
Ambulatory BP monitoring is indicated in white coat syndrome, masked HTN (evidence
of end organ damage with normal BP reading), or assess resistant HTN or evaluate
response to HTN medications.
- Glioblastoma multiforme: post successful surgical resection, combined therapy with
radiation and temozolomide chemotherapy is indicated, and according to recent studies
recommended in both less and over 65. There is no such thing as clear margins in GBM
- Note that chemo alone is not superior to radiotherapy. But each is superior to no tx. And
CT “combined therapy” is superior to all.
- Higher sodium urine excretion (24 hours urine Na) increases the risk of CVD in CKD
patients. Note that the value is 24 hr- urine Na >4500 mg, which is twice the RDI of Na in
normal individual (2300 mg) and trice the RDI in CKD (1500 mg)
- In patients with moderate to severe osteoarthritis; TKR followed by nonsurgical tx
(exercise, pain medications, weight loss, insoles) is better than nonsurgical tx alone
- Arthroscopic procedure is not performed in osteoarthritis, no clinical trials showed
efficacy even if there is internal derangements.
- Autologous chondrocyte implantation is beneficial if there is small localised cartilage
defect; especially if caused by trauma.
- Liraglutide is glucagon like peptide 1 analogue “incretin” which work by increasing insulin
secretion and decreasing glucagon, it has been shown to decrease risk for CVD events
and death in patients with hx of CAD and DM.
Sitagliptin is a Dipeptidyl peptidase inhibitor, works by inhibiting breakdown of incretin, It
can’t be given if GFR<50
- BP guidelines (JNC 8): If no DM or CKD→ if age <60 then goal is <140/90, if age >60
then goal <150/90.
If DM with no CKD then goal is <140/90 in all age groups, if CKD with or without DM
then goal is <140/90 in all age groups and races.
- Subclinical hypothyroidism is defined as normal thyroid hormones along with elevated
TSH. Patient with this condition could be symptomatic, they are at increased risk of
CVD
- Recommendations:
1- If TSH >10 then treat with thyroid hormones
2- If TSH 7-9.9 then tx with thyroid hormones if age <65-70, you also tx in this range if
>65-70 and sx of hypothyroidism
3- No tx needed if TSH between upper limit and 7 and age >65-70, if age <65-70 and sx
of hypothyroidism (or titers of TPO Antibodies) then treat!
- Indications for tx in CLL:
1- evidence of marrow suppression which can manifest with anemia or
thrombocytopenia
2- splenomegaly (>6 cm below rib line)
3- lymphadenopathy which is progressive/painful, or single large>10 cm LN
4- progressive lymphocytosis with >50% increase in numbers over 2 months,
5- constitutional signs like fever for more than 2 weeks, night sweats for 1 month, wt loss
>10%, significant fatigue
6- advanced stage CLL
- Staging of CLL (Rai staging)
Stage 0 Lymphocytosis with no enlargement of spleen or liver or LN
Stage 1 lymphocytosis with enlarged LN, no enlargement of liver or spleen
Stage 2 Lymphocytosis with enlargement of spleen (with/without liver involvement)
Stage 3 Lymphocytosis with anemia, regardless or LN, spleen or liver
Stage 4 Lymphocytosis with thrombocytopenia regardless of LN, spleen or liver
Note that stage 2-4 could be with or without LN involvement
Note that no anemia or thrombocytopenia in stage 0-2
- Routine maintenance fluids rules: Normal daily fluid and electrolyte requirements: 25–30
ml/kg/d water; 1 mmol/kg/day sodium, potassium, chloride 50–100 g/day glucose (e.g.
glucose 5% contains 5 g/100ml).
- Thrombolysis in PE (pulmonary embolism):
There are two scenarios:
1- Hemodynamically unstable patients: if SBP <90 or BP drop <40 mmHg from baseline
in the setting of acute PE or recurrent PE while on anticoagulation (And the patient is not
at increased risk of bleeding); the recommendation is to administer alteplase through
peripherally inserted venous catheter.
If there is increased risk of bleeding or the patient failed systemic thrombolytic, the
recommendation is catheter guided thrombectomy with/without thrombolysis.

2- Hemodynamically stable patients: It is recommended against thrombolysis. If PE


along with RV strain, then judge on case by case basis, catheter based or surgical
based thrombectomy per expert opinions (but optimum method is unknown).
Note that there are 4 conditions in which there is a contemplation over thrombolysis in
hemodynamically stable patients:
1- severe or worsening right ventricular dysfunction
2- severe/extensive clot burden seen on CT or V/Q scan
3- cardiac arrest as a complication of PE (eg SBP >90 after resuscitation)
4- free floating right atrial or ventricular clot
It is recommended to look at PESI (PE severity index) alongside LV dysfunction,
abnormal BNP and troponin. Low intermediate risk = abnormal PESI plus either RV
dysfunction or elevated troponin or BNP , while high intermediate risk = abnormal
PESI and both RV dysfunction and elevated BNP or troponin
- Amiodarone use in Afib:
1- Oral: start by loading the patient, goal to achieve 10 g, give 600-800 mg daily. Then
switch to maintenance dose of 200 mg daily, you can consider maintenance dose of 100
mg in elderly with low weight.
2- IV: load the patient with 150 mg/min over 10 min, then 1 mg/min for 6 hours, then 0.5
mg/min for 18 hours. Then the patient can be placed on maintenance (200 mg oral daily)
- Amiodarone use in pulseless Vtach of Vfib: 300 mg IV bolus, if Vfib or Vtach persist
after subsequent defibrillation attempt or if it recurred, then give 150 mg IV
- Amiodarone use to prevent serious life threatening arrhythmia: 800-1600 mg for 1-
3 weeks, then 600-800 mg for a month, then maintenance of 400 mg/day
- Amiodarone use in stable Vtach: IV 150 mg given over 10 min … same as Afib dose
- Digoxin in Afib: Load with IV digoxin 8-12 mcg/kg, give 50% over 10 min, then give 25%
over 4-8 hours interval. Another approach is to give multiple doses of 0.25 mg over 24
hours period and not to exceed 1.5 mg
Switch to oral maintenance after that (0.125 or 0.25 mg). Note that maintenance can be
as low as 0.125 mg QOD in elderly with low body weight.
- Concomitant use of amiodarone and digoxin is discouraged. Amiodarone can increase
the levels of digoxin up to 100%, if you use digoxin, decrease the dose up to 30-50%
- SBP: if low suspicion, take paracentesis with measuring PMN and a culture, if PMN>
250 then send for blood, urine and sputum culture. Start ceftazidime 2 g Q 8 hours. Give
albumin 1.5 g/kg as a first dose, then 1 g/kg on day 3.
*Albumin is given if Cr>1, BUN >30 or total bilirubin >4
If high suspicion of SBP, get culture of ascites fluid, blood, urine and sputum culture.
Start Antibiotics like above with albumin
- Most important sx patients with SBP have are fever, abdominal pain, altered mental
status, abdominal tenderness, diarrhea, ileus, hypotension and hypothermia
- Acid base bullet points:
1- in cases of respiratory acidosis, for each 10 units increase in Pco2, HCO3 increase
by 1 unit, but if it is a chronic process, then it increase by 3-4.
* whenever you have HCO3>30→ think of either chronic respiratory acidosis or
concurrent metabolic alkalosis.
* Renal compensation takes 4 days and it is never complete (pH never normalise)
* Diseases associated with respiratory acidosis: CNS depression (drugs, disease,
hypoventilation synd), lung diseases (COPD, ARDS), pleural disease, MSS dis
2- respiratory alkalosis: ex include ICH, interstitial lung dis, drugs (progesterone,
salicylate), 3rd trimester- pregnancy, anxiety, cirrhosis and sepsis.
* These processes should not be a consequence of hypoxemia!
* compensation: if CO2 drop acutely, for each 10→ HCO3 drop by 2, but if it is a chronic
process then HCO3 drop by 5. Renal compensation can be complete (pH normalise)
* Whenever you have > 2-4 drop in HCO3, suspect either concomitant metabolic
acidosis, salicylate, chronic resp alkalosis, or sepsis.
3- Metabolic alkalosis: causes include→ contracture alkalosis (happen with volume
loss through GI, resp, Kidneys, skin, third spacing or bleeding), or hypokalemia. It can
also occur with excessive mineralocorticoids or glucocorticoids, also happens with
excess alkali ingestion (milk alkali)
Two major types: * Chloride responsive like in (vomiting, NG tube, diarrhea, villous
adenoma, diuretics), Tx with NS. urine Cl is less than 10
* chloride resistance: distal exchange site stimulation by aldosterone, resulting in H and
K excretion and Na reabsorption as NaHCO3.
Compensation is unpredictable, but in general in chronic metabolic alkalosis for each 10
elevation in HCO3 there is 5 increase in PCO2.

4- Metabolic acidosis

- Before extubation, do SBT (spontaneous breathing trials), and reassess using RSBI
(rapid shallow breathing index): RR/TV “in liters”
If it is <105 then it is good. Also assess for other variables like minute ventilation, if <15
L/min→ good sign, means not high metabolic demand. if NIF is around -30 also a good
sign.
- Things to check before extubation:
1- mechanics of breathing: checking SBT and if they have good ABG
2- mental status: assess whether they have good mental status
3- secretions: if they have excessive secretions then they might not be able to breath on
their own
4- Air leak: when we deflate, we will get air leak after providing positive pressure (good
sign), but if we did not hear any air leak→ it means tracheal swelling around the cuff
- In pleural effusion and the patient on diuretics, pleural protein levels could be elevated
giving a false +ve exudative criteria, two methods that can be used are : measuring
pleural NT proBNP (levels >1500 points toward HF), if it is not available then do serum
pleural protein gradient (serum- pleural), if it is >3.1 then it is transudative
- Mixture of helium with oxygen instead of nitrogen and oxygen may help with airflow
given that helium has less density→ hence less resistance.
In inhalation injury you will see edema involving pharynx extending toward the larynx.
Monophonic wheeze can be heard. Proceed with intubation.

- Alcohol withdrawal, manifestations and treatment:

- Alcohol withdrawal occur within 6-24 hours after stopping drinking or significantly
decreasing amount. Sx include agitation, anxiety, insomnia, palpitation, sweating,
alcohol craving, nausea/vomiting/loss of appetite.
Alcoholic hallucinosis (usually happen due to genetic factor or poor absorption of
thiamin) occur within 12-24 hours and resolve within 1-2 days.
Alcohol withdrawal seizure occur within 6-48 hours period.
Delirium tremens occur in day 3-5
- Note that alcohol hallucinosis is not associated with altered cognition like DT
- US ID society recommend empiric antibiotic covering MRSA for tx post drainage of
abscess if: systemic sx/findings, abscess size >5 cm, immunocompromised.
New studies showed that this approach could also apply to smaller abscesses and
showed to decrease the rate of further surgical drainages, spread of infection and skin
infection at new sites
- New studies showed significant higher cure rates by using of bactrim post abscess
drainage vs drainage alone
- In cases of isolated elevation of ALP, test for GGT to confirm that its biliary source
- Causes for ALP elevation (non biliary):
Primary Bone malignancy, osteomalacia, paget's disease of bone, bone mets, CKD,
pregnancy, DM, increasing age (especially women), childhood growth, peritonitis,
extrahepatic malignancy, lymphoma, hyperthyroidism, hyperparathyroidism, gastric
ulcer, blood type B and O, elevation of ALP after fatty meal, medications include
nitrofurantoin, phenytoin, erythromycin, disulfiram.
- Use of Fluorouracil proven by randomized trials to be DOC in cases of extensive actinic
keratosis (>10-15 lesions) and it provides chemopreventive effects. (reduce the number
of new AK lesions over the following 6-24 months) hence reduce the need for targeted
therapy like liquid nitrogen -Cryo.
- Electrodesiccation and curettage can be used in early small lesions which are superficial
(some BCC and SCC). Rheumatoid arthritis, alcohol drinking (3 or more units)
- Compensation in respiratory acidosis: Acute→ for each 10 rise in CO2, 1 rise in HCO3,
and 0.08 drop in pH. While in chronic (4 days), for 10 rise in CO2, 3-4 rise in HCO3 and
0.03 drop in pH
- Compensation in respiratory alkalosis: Acute→ for each 10 drop in CO2, 2 drop in
HCO3, and 0.08 increase in pH, chronic→ for each 10 drop in CO2, 4 drop in HCO3,
and 0.03 increase in pH
- Indications for antibiotics use in COPD exacerbation: (any of the following)
1- presence of the three cardinal sx: increase sputum volume, increase sputuum
purulence, increased dyspnea
2- two of the cardinal sx as long as one of them is increased purulence of sputum
3- patients who require mechanical ventilation

CARDIOLOGY:

- TTE is indicated in case of symptomatic murmur, systolic murmur grade 3/6 or above,
diastolic murmur, holosystolic or late murmur, continuous murmur
- Chest CT maybe helpful in further evaluation of aortic valve pathology (ex would be
evaluation of bicuspid valve or looking for concomitant aortopathy)
- Stroke prevention after catheter ablation of atrial fibrillation should depend on risk
stratification (CHADSVASC score) not on rhythm status.
- Addition of ASA in patients already on warfarin should only be used if the patient has a
history of/or active CAD or acute coronary syndrome
- Note that patients with hx of CNS event has an annual risk of stroke greater than 5%
- Dual antiplatelets therapy is inferior to warfarin in preventing stroke, and no significant
bleeding risk difference between the two
- Catheter ablation for atrial fibrillation usually a useful strategy in symptomatic patients
who failed antiarrhythmic medications. It is best reserved for patients without multiple
comorbidities or evidence of LA enlargement. (procedure: catheter Ablation and
pulmonary vein isolation)
70-90% of patients with paroxysmal Afib are sx free at 1 year s/p ablation
- Complications of ablation include tamponade (immediate or delayed), vascular
complications, 0.5-1 % risk of stroke.
Patients who develop dyspnea months-years after ablation procedure may have
developed pulmonary vein stenosis
- Anticoagulation is a must for first 2-3 months post ablation, and after that based on risk
- If the patient is scheduled for open heart surgery he can benefit from maze procedure if
he/she has refractory Afib
- Note that certain patients with symptomatic tachycardia not responsive to antiarrhythmic
would benefit from pacemaker insertion and AV nodal ablation→ still need AC based on
risk.
- Dynamic left ventricular outflow tract obstruction (LVOT) affects 70% of patients with
HCM.
- HCM is exacerbated by anything decreasing preload (diuretics) or afterload (vasodilator,
forced expiration), treatment focused in avoiding these agents and BB, CCB (decreasing
heart rate) and disopyramide.
Surgical treatment with surgical myectomy (septal reduction therapy) or alcohol septal
ablation can be considered in severe symptoms refractory to medical therapy
Note that decreasing PVR will increase murmur intensity because higher blood
velocity leads MV anterior leaflet will move more toward the IVS and cause more
obstruction
- Type B aortic injury (as long as they are not in cardiogenic shock) is best treated
medically with IV BB to achieve HR <60 followed by (as needed to control BP) peripheral
arterial vasodilator (sodium nitroprusside)
- Focal PAU (peripheral atherosclerotic ulcer) occur usually in descending aorta, in
elderly, and indicate excessive atherosclerosis burden
- Elevated D dimer is frequently seen in acute aortic syndromes
- Malperfusion syndromes rarely seen in PAU, and sometimes seen with occult dissection,
if patient has limb or visceral malperfusion→ endovascular repair/stent +/- fenestration
- Vasodilator includes rapidly titratable agents (hydralazine, nitroprusside, labetalol,
nicardipine, enalaprilat)
- Emergency surgery is recommended for all cases of type A aortic dissection and type A
intramural hematoma; surgery include reconstruction, coronaries reimplantation, aortic
valve repair etc (depends on anatomy)
- Indications for surgery in type B aortic injury are: rapidly expanding aneurysm,
rupture, refractory hypertension or pain, or malperfusion syndromes
- Effusive constrictive pericarditis is an entity where patients contine to have sx and
hemodynamic derangement even after pericardiocentesis.
- Effusive constrictive pericarditis is subentity of constrictive pericarditis, both have
systemic congestion, decreased cardiac output, and increased venous jugular pulse
pressure. While in the effusive entity; pericardial knock is absent and y descent is less
prominent. pulsus paradoxus can be heard occasionally.
- Thickening of the visceral pericardium (the pathology in constrictive pericarditis) can be
difficult to see on CT or noninvasive imaging.
- Constrictive pericarditis involve inflammation, fibrosis and calcification. Could be
idiopathic, secondary causes include: post radiation, heart surgery, trauma, post MI or
systemic processes involving the heart (malignancy, CTD, TB and other infections)
- Effusive constrictive pericarditis can happen in any of the above etiologies but mainly
seen in TB, suspect the diagnosis when clinical condition does not improve after
pericardiocentesis.
- diagnosis of constrictive pericarditis is by doppler echo and cardiac cath, the basic
hemodynamic finding is based on interventricular dependence (where the LV and RV
acts on the expense of each others/independently), and there is equalization of diastolic
pressure in the four chambers. The inelastic pericardium prevent the transmission
of thoracic to intracardiac pressure. That means that early diastolic filling between the
two ventricles are different during the respiratory cycle, during inspiration left
ventricular filling is less and more venous return from the IVC while in expiration
more LV filling and less RV filling, that finding is possible because the IV septum
is not affected and it can bulge to accommodate this difference in ventricular
pressure during the respiratory cycle (a finding that is not seen in restrictive
cardiomyopathy)
- During inspiration, there will be a drop in pressure of intrathoracic cavity,
pulmonary venous pressure but not intracardiac pressure, hence the filling
gradient is lost.
Candidates for high-intensity statin therapy include:

● Patients with known atherosclerotic disease (clinical CHD, cerebrovascular


disease, or peripheral arterial disease)
● Patients with an LDL cholesterol level 190 mg/dL (4.92 mmol/L) or greater
● Patients with diabetes mellitus, an LDL cholesterol level below 190 mg/dL (4.92
mmol/L), and calculated 10-year CHD risk of 7.5% or higher
● Some patients without diabetes with an LDL cholesterol level below 190 mg/dL
(4.92 mmol/L) and calculated 10-year CHD risk of 7.5% or higher
Moderate-intensity statin therapy can be considered for:
● Patients with diabetes who are not receiving high-intensity therapy
● Most patients without diabetes with an LDL cholesterol level below 190 mg/dL
(4.92 mmol/L) and calculated 10-year CHD risk of 7.5% or higher
● Some patients without diabetes with an LDL cholesterol level below 190 mg/dL
(4.92 mmol/L) and calculated 10-year CHD risk of 5% or higher but lower than
7.5%
- Fluvastatin conversion is half of pravastatin intensity, lovastatin= pravastatin intensity
- FDA advise against using simvastatin 80 mg when high intensity statin is required given
higher risk of myopathy, and recommend toward switching to other agent

- Risk of stroke is 2-6 folds increased in diabetic patients, risk of heart disease is 2-4 folds
increased. Overall ⅔ of diabetic die of heart disease, diabetes increase cardiac disease
mainly in women
- Two most common causes of cough in heart failure patients are volume overload and
ACEI side effect (which can occur even 9 months after initiation of therapy; switch to
ARB and observe for few weeks
- Repeating cardiac echo in patients diagnosed with heart failure indications:
1- every 2-3 years to assess for LV dilatation and assessing EF
2- In case of functional decline to reassess the LV/valvular function
3- after uptitrating therapy to reevaluate the function
- BNP can be used in acute dyspnea setting, higher numbers associated with higher
mortality, not used to guide therapy-diuretics
- When atrial septal aneurysm (redundant tissue on the septum associated with PFO) is
identified on echo, no further management or treatment necessary. Anti platelets are
given if co existent cryptogenic stroke in the setting of isolated atrial septal
aneurysm.
- First line agent for antianginal medication are Beta blockers and nitrates, use diltiazem if
patient can’t tolerate BB or not controlled on BB and nitrate combination
- Exercise stress test:
1- low risk 6+
2- moderate -10 - 4+ (mortality 1-3 %)
3- high risk stress testing < - 10 (mortality > 3%)
- Antianginal agents reduce sx severity and prolong the time needed to reproduce the sx
on exercises.
- Coronary angiography is reserved for patients with lifestyle limiting sx despite optimal
medical therapy or high risk findings on stress testing; these include ST depression on
low workload, hypotension, or ST elevation
- Two categories of nitrates used in angina: emergent (sublingual and spray); daily use
(oral or topical), note that daily use should have period off nitrates (usually at night) to
prevent tolerance
- Ranolazine is an antianginal agent used after the 3 other agents used (expensive)
- Calcium channel blocker is contraindicated in LV dysfunction, advanced AV
block
- Bicuspid aortic valve is the 2nd most common cause of aortic stenosis after calcified
valve, and the 2nd most common cause of aortic regurgitation after aortic root dilatation
- Patient with bicuspid aortic valve can present with systolic murmur as the disease
progress, it could also present with aortic regurgitation (valve incompetence)
- Bicuspid aortic valve is associated with coarctation of the aorta, interrupted aortic arch,
and turner syndrome
- 70% of the patients will require surgery at some point during their life for AS/AR
- Note that these patients are at risk of aortopathy, aneurysm and dissection, and
premature valve calcification
- Coarctation of the aorta come with systolic murmur in the left subclavicular region,
discrepancies in the BP between the extremities, weak femoral pulse
- Mitral stenosis murmur is diastolic decrescendo, as it gets worse it will be early diastolic
(as pressure build up in LA with increase stenosis, leads to early opening of the mitral
valve)
- Main finding of ASD is systolic flow murmur and fixed s2
- Flu vaccine decrease the risk of cardiovascular events (up to 36% less risk of cardiac
events compared with non immunized patients) “secondary prevention”
- Folic acid and vitamin E was not found to decrease risk of Cardiovascular events
- Colchicine was associated with decreased risk of CVD events in patient treated with this
medication (gout, familial mediterranean fever), but not proven for secondary prevention
- QTc >500→ patient at risk of torsades de pointes, medications that can prolong QT
interval include antibiotics (macrolides, fluoroquinolones), antipsychotics,
antidepressant, some antiarrhythmic agents.
- QTc= QT/ square root of R-R interval
- Cardioprotective medications
1- Aspirin: indicated in all cases of established CAD (reduce MI, stroke and cardiac
mortality), if aspirin allergic use clopidogrel, new agents like prasugrel and ticagrelor not
yet studied enough.
2- BB: indicated as first line in all stable angina, titrate to achieve HR 55-60, side effect
include depression, decrease exercise capacity, fatigue, erectile dysfunction.
Contraindicated if high degree AV block, symptomatic bradycardia, severe reactive
airways disease or acute decompensated HF
- Nondiabetic proteinuric CKD require use of ACEI or ARB (I think with HTN)
- ACEI is indicated to use in tx of stable angina, reduce cardiac and all cause mortality. Its
effect is more profound in patients with concomitant LV dysfunction or Diabetes
- Patient with ASCVD and age >75→ moderate intensity statins
- Two step testing is used in patients who already had TB infection in the past.
Test with PPD, if positive after 2-3 days then infected, if negative repeat testing in 1-3
weeks after first PPD, if positive then means remote infection, if negative then negative
- In patients with HFpEF main target therapy is diuretics (they are volume sensitive and
patients should monitor their weight), if patient come with exacerbation and not on
diuretics then start it, if on diuretics it is reasonable to at least give him his dose
equivalent (or more) as intravenous.
- Although spironolactone was associated with less hospitalization for patients with
HFpEF, no change in mortality was found, along with increased rates of elevated serum
creatinine and potassium.
- Note that aggressive tx of BP in HFpEF (SBP <130) is the target
- Low pressure cardiac tamponade occur if patient is dehydrated.
Signs of cardiac tamponade:
Diastolic inversion of right sided chambers
Respiratory variation in mitral inflow pattern
IVC plethora and ventricular septal deviation could occur
- Tx in case of low pressure cardiac tamponade is IVF along with pericardiocentesis
- Note that the typical elevated JVP and pulsus paradoxus may not be present in patient
with low pressure tamponade, conditions associated with the previous include TB,
malignancy and severe chronic illnesses that lead to dehydration and pericardial
effusion
- Surgical options include pericardial window or open pericardiectomy, there are indicated
if pericardiocentesis did not solve the tamponade (no response), done using VATS or
open heart surgery
- Pericardiocentesis should be avoided if the cause of tamponade is aortic dissection,
because abrupt increase in EF can worsen the dissection
- Note that open pericardiectomy can be beneficial when tissue sample is needed
- Pericardiocentesis usually is enough for tx, but surgical options are needed when the
fluid is viscous or lobulated, or if blood has been for a while and clotted, or it is in the
posterior surface of the heart
- Sometimes during pericardiocentesis the tense pericardium might discharge fluid into
pleural space, in that case no further attempt to drain is needed
- 9 modifiable risk factors contribute to 90% of risk factors for MI, they are in
descending order: Dyslipidemia, smoking, psychosocial stressors, DM, HTN, obesity,
no alcohol consumption, inadequate physical activity and diet low in fruit and vegetables
- According to new guidelines by AHA/ACC; HTN is defined as:
Stage I HTN: BP 130-139/80-89
Stage II HTN: BP > 140/90
Note that SBP 120-129 and DBP <80 is considered pre HTN
- When trying to slow the progression of nondiabetic CKD, protein excretion above 500 to
1000 mg/day identifies patients who are most likely to benefit from antihypertensive
therapy with RAS inhibitors. By contrast, there appears to be no preferential benefit of
RAS inhibitors in patients excreting less than 500 mg/day (BP target <130/80)
- Non pharmacological measures is recommended to control BP only if pre HTN and 10
years risk of CVD <10% (and no hx of CVD)
- Otherwise use medications to achieve BP target <130/80
- Remember that HFpEF, HFrEF, diabetes, IHD are all reasons to achieve the above BP
goal (<130/80)
- Note that if stage II HTN and BP goal is > (20/10) above the goal, then use combination
therapy of first line agents
- Evidence is lacking regarding using anti HTN in TIA/ischemic stroke with BP <140/90,
but if patient has hx of ICH/hemorrhagic stroke then BP target is <130/80
- Black population are more resistant to BP medications and often require combination
therapy, CCB or thiazide diuretics are preferred, ACEI/ARB can also be used especially
in combination
- Remember that non dihydropyridines decrease proteinuria in CKD, but not
dihydropyridine
- 1st line for HTN include thiazide (e.g HCTZ, chlorthalidone), CCB, ACEI/ARB, potassium
sparing diuretics - monitor electrolytes especially if used with ACEI/ARB-(eplerenone,
spironolactone, amiloride)
- There is increased risk of myopathy when using CCB with statins, specifically
simvastatin 10 mg or lovastatin 20 mg with diltiazem/verapamil or simvastatin 20
mg with amlodipine
- While the AAFP and ACP recommended SBP <150 is patients >60, tighter BP
control to SBP <140 if patient has a hx of TIA/stroke or high CVD risk
- Metabolic syndrome defined as > 3 of the following:
Elevated blood sugar, HTN, central obesity, high TG, low HDL
- Pulmonary regurgitation is the most common structural abnormality seen after TOF
repair, findings are mainly those of right heart volume overload, on exam parasternal
lift, soft systolic flow murmur can be heard, the diastolic murmur on the left 2nd
intercostal and it is worse during inspiration-caused by pulmonic regurgitation
- aortic regurgitation is a late complication after TOF repair and it is caused by
progressive aortic root dilatation, is less prominent during inspiration and
parasternal lift won’t be seen- no RV prominence).
- Note that there is single S2 s/p TOF repair because the valve function is sacrificed
- VSD will have systolic murmur at left sternal border, obliterates S1, S2
- Few complications that can arise after TOF repair include: pulmonary valve
regurgitation, VSD, aortic regurgitation (from aortic root dilatation), tricuspid regurgitation
(as a result from chronic right sided prominence)
- Use of hsCRP is helpful in risk stratification of patients with intermediate risk of coronary
artery disease according to pool cohort equation (5-7.5% 10 year risk) (or framingham
10-20%). With as many as 30% of patients reclassified to low or high risk
- hsCRP has a strong linear association with stroke and vascular mortality.
Measure levels, if <1 low risk, if >1 then repeat in 2 weeks to check for persistent
elevation. If levels >3 then high risk.
- Make sure to rule out possible inflammatory or infectious causes when elevated CRP
- Coronary calcium scoring is not part of routine evaluation, and note that its absence
does not rule out the presence of soft plaques
- TEE is indicated for
A- systolic murmur grade 3/6, late systolic or pansystolic murmur
B- Diastolic or continuous murmur
C- murmurs with symptoms
* pansystolic murmur seen with MR, TR and VSD, HCOM, while late systolic murmur
seen with MVP
- Chet CT can be used to screen for bicuspid aortic valve or look for concomitant
aortopathy in patients with bicuspid aortic valve (not 1st step)
- Note that if symptoms are equivocal→ BNP and/or stress echo to measure exercise
tolerance and pulmonary pressure, if images quality is bad→ TEE, if still can’t evaluate
then go for CT/MRI to assess aorta and ventricles
- In afib whether to anticoagulate or not in CHADSVASC score of 1 is debatable, but
clinical judgement play a role and being female or with vascular risk are generally lower
risk than HTN, DM or age 65-74
CABG vs PCI:
● Before deciding which to choose, patients should be counseled about risk of stroke,
death and need for revascularization
● Significantly Diseased vessel is defined as > 70% stenosis (> 50 in left main)
● In patients with single vessel disease PCI with DES
● In patients with 2- vessel disease (not proximal LAD) proceed with DES
● In patients with LAD disease plus either RCA or LCX proceed with CABG if patient is
diabetic or large area of myocardium is supplied by the disease vessels
● Triple vessel disease CABG. If patient has low syntax and not diabetic PCI is
reasonable
● If patient has 2-3 vessel disease and complete revascularization can’t be achieved with
PCI CABG
● If all the above was not enough to make a decision, use SYNTAX tool (although not yet
proven benefit)
● FREEDOM trial showed the primary composite endpoint of death, MI and stroke was
significantly lower in CABG group (compared to PCI), primary because of lower death
and MI rate, but stroke is higher in CABG group
● Myocardial viability testing (perfusion testing- radionuclide uptake by viable
myocardium), STICH trial showed that there is no relationship between viability
testing findings and success/ results of bypass. Use viability testing in high risk
patients for bypass to help guide Management

● Stepwise approach to diagnose adrenal insufficiency:


1. Morning cortisol levels: if levels >15 unlikely diagnosis
2. if levels <3 AI is likely
3. ACTH stimulation test done in everyone, appropriate response (levels >18-20 after 30-
60 min of administration rule out AI)
4. use high dose test (250 mcg) unless new onset AI (1-2 weeks) is suspected (like
recent pituitary surgery) in that case use low dose (1 mcg)
5. Diagram
6.
7.
● Patient with asymptomatic severe aortic aneurysm should have scheduled Echo every
6-12 months, no intervention needed unless LV dysfunction (EF< 50) or the patient is
having open heart surgery for (CABG, surgery on the aorta or other valves)
● Note that patient should be warned about the sx (dyspnea, exertional chest pain,
syncope, lightheadedness and reduced exercise tolerance) in that case schedule earlier
appointment
● TAVR should not be performed in patients with low- intermediate risk for surgery
● Balloon valvuloplasty is only used in pediatrics (not used in adults because of high risk of
complications and low efficacy of the procedure)
Severe aortic stenosis could be either high gradient (in 50% of cases) or low gradient
A- High gradient: diagnoses is made when transvalvular velocity is >4 m/s, and when mean
transvalvular pressure is > 40 mmHg, typically AVA (aortic valve area) is <1 cm2
(indexed to BSA to <0.6 cm2/m2
B- Low gradient and/or low flow AS
-
●Low flow severe AS is identified by the presence of severe AS (AVA ≤1 cm2 with AVA
indexed to body surface area ≤0.6 cm2/m2) associated with a low flow defined as a
stroke volume indexed to body surface area ≤35 mL/m2 (or cardiac index <3 L/min/m2).
Since the transvalvular gradient depends on the flow per beat rather than the flow per
minute, the stroke volume index is the most frequently used parameter to identify low
flow [4].
•Many patients with low flow AS also have a low transvalvular gradient (ie, low flow, low
gradient [LFLG] AS), as described below.
•Some patients with very severe AS and low flow have a high transvalvular gradient (mean
gradient >40 mmHg) and are thus more easily identified as having true AS.
●Low gradient severe AS is identified by the presence of severe AS (AVA ≤1 cm2 with
AVA indexed to body surface area ≤0.6 cm2/m2) associated with a transvalvular mean
pressure gradient ≤40 mmHg (table 1).
•Many patients with low gradient AS also have low flow (ie, LFLG AS), as described below.
•Some patients with low gradient AS have normal flow (stroke volume index >35 mL/m2), ie,
normal flow, low gradient (NFLG) AS.
●LFLG severe AS is identified by the presence of severe AS (AVA ≤1 cm2 with AVA
indexed to body surface area ≤0.6 cm2/m2) with both of the above conditions, that is,
stroke volume indexed to surface area ≤35 mL/m2 and mean pressure gradient ≤40
mmHg.
● Takatsubo cardiomyopathy criteria:
● 1- ST segment elevation
● 2- absent significant obstructive coronary artery disease
● 3- absence of temporary cause of LV dysfunction (e.g myocarditis)
● 4- transient wall motion abnormalities on imaging
● If patient does not have cardiogenic shock, tx is metoprolol and ACEI. Recovery usually
expected within 7 days

● Differential cyanosis causes



● A- PDA and pulmonary HTN
● B- PDA and preductal (infantile) coarcitation
● Both A and B will cause cyanosis in lower extremitites
● C- PDA and transposition of great arteries, pulmonary artery will have the saturated
blood which will be send to upper extremities through PDA

● Patient who has cardiogenic shock with sings/sx of hypotension and decreased organ
perfusion (AKI, elevated transaminases, cool extremities) should be treated with
vasoactive agents; those include dobutamine or milrinone, the latter can cause
vasodilation and worsen hypotension and can’t be given in renal failure because it is
metabolized by the kidneys

● Note that mechanical support (aortic balloon, VADs) can be used if medical
therapy and diuresis did not work within 12-24 hours

● VSD can cause pulmonary HTN if persistent beyond the age of 2, cyanosis and clubbing
can be seen if Eisenmenger develop

● In aortic dissection type A mortality rate is 1% per hour, so early surgical intervention is
imperative

● HTN is important risk factor for aortic dissection, however only a small fraction of
hypertensive patients will have dissection.

● Syncope occurs in around 10% of aortic dissection cases. Enlarged aortic contour is an
important sign on imaging (note that it is not seen in 15% of aortic dissection cases)

● 10 years survival rate of aortic dissection range between 30%- 60%

● Indications of antibiotics prophylaxis to prevent endocarditis include after dental


procedure (which involve manipulation of gingival tissue or periapical region of the tooth
or perforation of the oral mucosa). Also in case of procedures involving incision or biopsy
of the respiratory tract

● If the patient has any of the following:

● 1- previous endocarditis
● 2- post cardiac transplant and valvulopathy
● 3-prosthetic valve
● 4- prosthetic material used to repair the valve (include annuloplasty rings and chords)
● 5- congenital heart disease including

● a- cyanotic congenital heart disease
● b- completely repaired heart defect with prosthetic material/devise during the 1st 6
months
● c- repaired congenital heart disease with residual defect

● Note that antibiotic ppx is not indicated post GI (including endoscopy/colonoscopy/hernia


repair) , UG procedures, or TEE in the setting of no active infection

● Ppx should be given 30-60 min before the procedure, and if missed then should be given
up to 2 hours after the procedure

● Choice of antibiotics includes amoxicillin 2 g (oral) or ampicillin 2 g (IV). If the patient is


allergic to penicillin then choice include azithromycin 500 mg, clindamycin 600 mg,
cefazolin or ceftriaxone 1 g IV

● The new guidelines focus on giving ppx to patients who are expected to get worse
outcomes if they get endocarditis (not the one who has higher lifetime risk of
endocarditis)

● No need for antibiotics ppx in patients with MVP with regurgitation, native valve, bicuspid
aortic valve, or rheumatic heart disease

● Indications for cardioversion in patients with atrial fibrillation:

a- new onset symptomatic atrial fibrillation:


if asymptomatic; age >80 or have multiple comorbidities then risk outweigh the benefit,
otherwise specially if symptomatic it deserves the shot
b- Afib with RVR that present with hypotension, ischemia or heart failure
c- symptomatic persistent Afib
d- patient that will be placed on long term antiarrhythmic or going to undergo ablation
then he should be sent for cardioversion before doing the above

● In cases of Afib with preexcitation syndrome tx of choice is procainamide (Avoid BB/


CCB)

● If pharmacologic cardioversion is chosen, class IC (propafenone, flecainide), or class III


● (Ibutilide). These agents can be used if no structural heart disease

● Note that if new onset Afib (<48 hours), there is two approaches
● a- AC for 4 weeks before cardioversion especially in patient with heart failure, DM or
prior hx of thromboembolism.
● b- before or immediately after cardioversion along with TEE and continue for 4 weeks
(then if depending on CHADSVASC choose whether they need AC)

● if duration of Afib is unknown or >2 days, then anticoagulated for 4 weeks before
cardioversion, then AC for 4 weeks
● Note that if urgent cardioversion is needed then the AC prior/during cardioversion then
for 4 weeks along with TEE before the procedure is an acceptable alternative

● To diagnose PVD, we do ankle brachial index, that would be BP in dorsalis pedis and
posterior tibial artery on both sides (the higher pressure would be the ankle pressure)
divided by brachial pressure (regardless which side-whichever is higher)

● Note that values of 0.91-0.99 is borderline and at risk of adverse cardiac events , 0.41-
0.89 then it is mild to moderate, if it is < 0.4 then it is severe PVD

● ABI 1-1.39 is normal, while ABI > 1.4 is associated with medial calcinosis, DM or ESRD
the results considered uninterpretable

● Exercise treadmill with ABI has more sensitivity, it is recommended for patients with
normal or borderline ABI along with lower extremities sx with exercise not attributable to
MSS. Ankle pressure will drop if PAD is present and it takes time to return to normal
consistent with mild PAD, if the drop is >20% then it is consistent with severe PAD.
● treadmill protocol is walking at speed of 2 miles/hr for 5 min or until in 12% incline

● Duplex US, CTA and MRA are modalities to delineate the pathology, CTA is easier
option and it can better visualize the adjacent soft tissue and stent grafts, ability to detect
calcifications, along with higher special resolution

● Antiplatelet therapy in patients with NSTEMI:

A- all patients should receive ASA sooner than later, 165-325 mg, patient should be
discharged on ASA 75-100 mg, if ticagrelor was chosen as P2Y12 blocker then ASA
dose should not exceed 100 mg on discharge

B- it is recommended to give DAPT in all patients, choice of P2Y12 depends on the tx


approach

● invasive approach
- give P2Y12 blocker as early as possible, could be held if high chance of open heart
surgery is anticipated.
- inpatient who will receive P2Y12 before PCI, recommendation is to give ticagreloras
opposed to clopidogrel, it is not recommended to give prasugrel
- if P2Y12 is withheld for after angiography then use prasugrel or ticagrelor rather than
clopidogrel is recommended
* loading dose ticagrelor 180 mg, prasugrel 60 mg, clopidogrel 300-600 mg
- it is not recommended to add factor IIB/IIIA inhibitor unless the following:
* patient at risk of PCI complications specially those who show extensive thrombotic
burden evident on angiography
* evidence of ongoing ischemia despite DAPT
- if factor IIB/IIIA blocker is indicated, it is recommended to use tirofiban or eptifibatide
rather than abciximab if before angiography, any of the three is acceptable choice if after
angiography

● In patient s/p stent and if he/she developed Afib then they should continue to get DAPT
along with anticoagulation (if warfarin is chosen then target INR 2-2.5
● Risk of stroke in nonvalvular Afib is 4%/ year, up 15-20 times based on comorbidities
● Note that HTN is important risk factor for Afib and stroke, so aggressive BP control is
recommended
● In patients with Afib if any of the following present regardless of CHADSVASC score
then AC is recommended:
● mitral stenosis, rheumatic heart disease, prior embolization, left atrial appendage
thrombus, hypertrophic cardiomyopathy, prosthetic heart valve
● According to UpToDate
● if CHADSVASC score is 1, then some recommend AC others don’t, note that age 65-74
is a stronger risk factor than the others in CHADSVASC (applies also to HTN, DM)
● if CHADSVASC is 0 or 1 in females then AC is not recommended
● Valvular Afib: Afib in the setting of mitral stenosis or artificial heart valve (and valve
repair- only in North America definition-). Those patients should be treated with Warfarin

Medicati Reversibilit Frequenc Type of AF Cautions


on y y

Warfarin Yes Dosing Valvular or Avoid in pregnancy. Caution with


(vitamin K adjusted to nonvalvular idiopathic thrombocytopenic
antagonist) INR purpura, HIT, hepatic disease,
protein C or S deficiency. Many
drug interactions.
Dabigatran Yesa Twice daily Nonvalvular Decrease dose if CrCl 15-30.
(direct Caution with P-glycoprotein
thrombin inhibition.
inhibitor)

Rivaroxaban No b Once daily Nonvalvular Avoid with CrCl <30, moderate


(factor Xa hepatic disease. Caution with mild
inhibitor) hepatic disease.

Apixaban No b Twice daily Nonvalvular Avoid with severe hepatic disease,


(factor Xa strong dual inhibitors or inducers of
inhibitor) CYP3A4 and P-glycoprotein.
Caution with moderate hepatic
disease.
1. Idarucizumab is a monoclonal antibody that is a reversal agent for dabigatran
2. Early data shows that PCC can be used as reversing agent for 3 and 4
● The three NOAC has less risk of ICH, dabigatran and apixaban are superior to warfarin
in preventing stroke, rivaroxaban is equivalent. All three NOAC have higher risk of GI
bleeding
● * all NOAC are cleared by the kidneys, yearly KFT is recommended, they are
contraindicated in ESRD
● Patients with stable CAD and Afib can have single agent (anticoagulation) to
prevent both stroke and ACS
● if patient had ACS or revascularization within the last 12 months then he would
benefit from ASA (low dose) plus AC – they are at increased risk of bleeding-
● if patient had PMS he needs triple agents for at least a month, if DES then triple
agents for 6-12 months

STRESS TESTING:

- Beneficial in moderate risk patients to stratify them into high or low risk, could also be
used in patient with hx of ACS/CAD who is having recurrent sx to further stratify them
- Routine testing for diabetic patients is not recommended if they are asymptomatic
- Cardiac ischemia can be detected depending on modalities used to test, nuclear testing
and cardiac MRI can early detect CAD (detect perfusion defects), while Echo can detect
later more advanced CAD (which cause diastolic then systolic dysfunction), ECG is the
latest to detect CAD (usually when there is significant disease
- Testing for CAD categorized into:
Testing for functionality

GASTROENTEROLOGY
Hepatitis C infection

- Most common bloodborne infection in united states is Hep C (4 million infected)


- Screening for Hep C is recommended for those born between 1945-1965
- 60-85% will transition to chronic Hep C infection, over a course of 25-30 years, 30% will
develop cirrhosis, those are at risk of HCC/liver failure
- In contrast to Hep B, Hep C rarely cause HCC in the absence of cirrhosis
- Sx: cute infection rarely comes with sx, while chronic infection sometimes manifest with
chronic fatigue and vague RUQ pain. On the long run those who develop cirrhosis
manifest with portal HTN sx. Extrahepatic manifestation include cryoglobulinemic
vasculitis, porphyria cutanea tarda, membranoproliferative GN
- HCV RNA levels does not correlates with disease activity, monitored mainly during HCV
treatment. HCV genotype should be determined upon diagnosis
- Liver findings include portal inflammation along with lymphoid aggregates , steatosis
along with variable fibrosis, liver biopsy is less frequently needed with advent of new
technologies
- SVR (sustained virological response) is the goal of therapy→ undetectable HCV RNA at
6 months, it is achieved in 90% of cases overall, note that patient with cirrhosis are more
difficult to achieve that goal.
Test for HBV before initiating therapy because there is a risk of reactivation when
starting direct antiviral agents. And in those who are positive, monitor LFT during
therapy
- Treatment for HCV genotype 1 (most common genotype in US) include direct antiviral
agent (sofosbuvir and ledipasvir) which come as a combination pill→ they achieve
SVR in 95%
- Another option approved for tx of type 1 HCV is direct antiviral ombitasvir and
paritaprevir which is combined with protease inhibitor ritonavir in one pill, these
coadministered with the direct antiviral agent dasabuvir. Ribavirin can be administered
(optional)
- 3rd and last option (not approved by FDA) is giving sofosbuvir along with protease
inhibitor simeprevir, with or without ribavirin
- Genotype 2 treated with sofosbuvir and ribavirin for 12 weeks, while genotype 3
treated for 24 weeks.
Sofosbuvir and ledipasvir along with ribavirin may have a role in treating genotype 3
who does not achieve SVR with other regimens
- Genotype 4 currently treated with sofosbuvir and ribavirin along with pegylated
interferon
- In 2016 FDA accepted expedit approval for elbasvir and grazoprevir for the tx of HCV
genotype 1 in patient with ESRD on hemodialysis and also for tx of HCV genotype 4
-

Pulmonary and critical care


- In patients with significant inhalational injury, along with evidence of airway swelling/
inflammation and strider, first step in to secure the upper airways.
Note that steroids does not have a role in treating inhalation injury or upper airway
edema.
Heliox (mix of o2 with helium instead of nitrogen) will produce less dense air and could
help when there is increased airway resistance
- Inhalational injury cause damage by 3 mechanism: direct thermal damage (Rarely
extends beyond larynx), irritant induced tracheobronchial injury, and cyanide or CO
poisoning)
- Intubate if thermal injury or stridor, otherwise fiberoptic laryngoscopy can identify
edematous larynx→ prophylactic intubation.
Extubate after ensuring edema is resolving, deflating cuff and looking for leak is one
way, in ambiguous cases go for scope
Note that URT edema can be worsened with IVF (supportive tx of burns)
- Lower resp injury manifest with wheezes, dyspnea and cough 12-36 hours post injury
Bronchodilator and supportive, note that bronchoscopy sometimes help clearing clots
and secretions
- Early mobilization and physical activity along with management of pain and delirium is
essential in rapid recovery after ICU/hospital stay
- Things that put a patient with SLN at higher risk of lung cancer include age, current/
former smoking, female sex, hx of cancer or family hx of cancer, asbestos exposure,
emphysema, solid/partial solid structure.
- Malignancy risk can be done by clinical judgement or by some formulas, in general they
divide patients to low risk <5%, intermediate risk 5-65%, and high risk >65%
- General approach to solitary solid lung nodule:
- if patient lung nodule has fat (likely hamartoma), or calcifications (granuloma or
hamartoma), then likely benign.
- if none of the above, then look at previous records, if stable over 24 months then no
further investigations, if growing then bx or resection- likely malignant. If equivocal or
unknown then next step
- if nodule is <6 mm, then if low risk pt then no further w/u, if moderate/high risk you
can repeat CT in one year
- if nodule 6-8 mm, then repeat in 6-12 months, if resolved then NTD, if growth then bx/
resection, if stable then if pt low risk then NTD, if moderate/high risk then repeat CT in
18-24 months and only intervene if growing, otherwise ignore
- if nodule >8mm, if moderate/high risk then bx/resection, otherwise repeat in 3 months,
if stable repeat in 9 months then in 18 months respectively if remained stable, otherwise
ignore if resolving or intervene if growing.
- Note that PET is usually negative even if malignant lesion in cases of subcentimeter
lung nodules
- Each visit for COPD patient assess for worsening sx of exercise capacity, evaluate the
medication side effects, adherence, proper technique.
- It is worthwhile to do spirometry annually to identify patients with rapid lung function
deterioration, but that is specially required for worsening symptoms of COPD.
- It is not necessary to repeat complete PFT unless the patient is considered for lung
transplant or lung volume reduction surgery (LVRS)