🟨DD of yellow nail

1_Onychomycosis
2_ Chronic paronychia
3_ Pseudonymous infection
4_ Yellow nail syndrome
5_Drugs ( Topical 5`flurouracil , tetracycline)💊

📝Restrictive/obstructive lung disaeses

🟪Restrictive_lung_disease
👉FEV1 - reduced
👉FVC - significantly reduced
👉FEV1% (FEV1/FVC) - normal or increased

◾️Main causes
*Pulmonary fibrosis
*Asbestosis
*Extrinsic hypersensitivity pneumonitis
*Sarcoidosis
*Acute respiratory distress syndrome
*Infant respiratory distress syndrome
*Kyphoscoliosis
*Neuromuscular disorders

🟪Obstructive_lung_disease
👉FEV1 - significantly reduced
👉FVC - reduced or normal
👉FEV1% (FEV1/FVC) - reduced

◾️Main causes
*Asthma
*COPD
*Bronchiectasis
*Bronchiolitis obliterans

#COPD_long_term_oxygen_therapy

✴Patients who receive LTOT should breathe supplementary oxygen for at least 15 hours
a day.

#Assess patients if any of the following:
💥very severe airflow obstruction (FEV1 < 30% predicted).
💥Assessment should be 'considered' for patients with severe airflow obstruction (FEV1 30-49% predicted)
💥cyanosis
💥polycythaemia
💥peripheral oedema
💥raised jugular venous pressure
💥oxygen saturations less than or equal to 92% on room air

#Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management.

📝Offer LTOT to patients with

1_ pO2 of < 7.3 kPa (<55 %)
2_to those with a pO2 of 7.3 - 8 kPa and one of the following:
✔secondary polycythaemia
✔nocturnal hypoxaemia
✔peripheral oedema , raised JVP
✔pulmonary hypertension

🟨Complcations of COPD

◾️2ry Polycythemia
◾️Cor-Pulmonale
◾️Recurrent infections
(Bronchiectasis)
◾️Rupture bullae
◾️Pneumothorax
◾️Type II Respiratory failure

📝Causes of pulmonary edema
🟥Cardiogenic
Acute HF

🟥Noncardiogenic
🔵 Drowning
🔵 Acute glomerulonephritis
🔵 Fluid overload
🔵 Aspiration
🔵 Inhalation injury
🔵 Opioid overdose
🔵 Salicylate toxicity
🔵 Neurogenic pulmonary edema
🔵 Allergic reaction
🔵 Adult respiratory distress syndrome

📝Pneumonia

There are 2 types of pneumonia:
👉community-acquired pneumonia 👉 hospital acquired (nosocomial) pneumonia.

Community-acquired pneumonia are either typical or atypical, and occurs in community or within the first 72 hours of hospitalization.

Typical community-acquired pneumonia presents with acute onset of shaking chills then fever, productive cough with thick purulent sputum, pleuritic chest pain, and dyspnea. Signs are tachypnea, tachycardia, and pleural friction rub (if pleural effusion). Chest X rays shows lobar or multilobar consolidation.

Atypical community-acquired pneumonia presents with insidious onset of headache, sore throat, fatigue, myalgia, fever (chills are uncommon), and dry cough (no sputum production). Signs include fever with relative bradycardia. Chest X ray shows diffuse reticulonodular infiltrates with absent or minimal consolidation.

Nosocomial pneumonia occurs during hospitalization after the first 73 hours.

The most common pathogens of typical community-acquired pneumonia are strept. pneumoniae, hemophilus influenza, klebsiella and other enterobacteriaceae, and staph. aureus.

The most common pathogens of atypical community-acquired pneumonia are mycoplasma, chlamydia, coxiella, legionella, and viral pneumonia.

The most common bacterial pathogens of nosocomial pneumonia are escherichia coli, pseudomonas, and staph. aureus.

Studies have shown that if vital signs are entirely normal, the probability of pneumonia in outpatients is less than 1%.

Atypical pneumonia refers to organisms not visible on Gram stain and not culturable on standard blood agar.

Upper respiratory infection is more likely than lower respiratory infection if nasal discharge, sore throat, or ear pain predominates.

After treatment, changes evident on CXR usually lag behind the clinical response (up to 6 weeks).

False-negative chest radiographs occur with neutropenia, dehydration, infection with pneumocystis carinii, and early disease (less than 24 hours).

Legionella pneumonia is common in organ transplant recipients, patients with renal failure, patients with chronic lung disease, and smokers; presents with GI symptoms and hyponatremia. Urinary antigen assay for legionella is very sensitive, and the antigen persists in urine for weeks even after starting the treatment.

📝Complications of Pneumonia

◽️Respiratory failure, Type 1 respiratory failure is relatively common
◽️Hypotension
◽️Atrial fibrillation
◽️Pleural effusion
◽️Empyema
◽️Lung abscess
◽️Pericarditis and Myocarditis
◽️Jaundice
◽️Septicaemia

🔴 Sleep Apnea

▪ patients often present with daytime sleepiness, nighttime snoring with apnea, nocturnal awakenings, diffculties in their jobs, and automobile accidents due to falling asleep at the wheel.

▪Specifc symptoms include paroxysmal nocturnal dyspnea, morning headaches, cardiac arrhythmias, truncal obesity, pulmonary hypertension, nocturnal enuresis, peripheral edema, hypertension, and an elevated hematocrit on laboratory examination.

▪Three patterns of sleep apnea have been described
🟨central apnea,
🟨obstructive apnea
🟨mixed apnea.

▫In central apnea👉 there is #impaired central nervous system control of respiratory effort.
▫Conversely, in obstructive apnea👉 the #upper airway becomes #transiently_obstructed, causing airfow to stop despite continuing efforts of the respiratory muscles.

▪Affected patients experience apneic periods, which can occur #between 40 and 100 times per hour.
▪During prolonged periods of apnea, the Po2 can #fall to values as low as 20 to 25 mm Hg with oxygen saturation <50%.
▪Sustained hypoxemia of this type leads to #arrhythmias, including sinus bradycardia, sinus arrest, long asystoles, frequent atrial premature beats, and ventricular arrhythmias.
▪ Pulmonary hypertension may develop with secondary right ventricular hypertrophy.

🟥An effective therapy for many patients with sleep apnea is continuous positive airway pressure (#CPAP), applied #during_sleep via mask or nasal prongs.
▪Patients treated with CPAP demonstrate #improved neuropsychiatric function and reduced daytime somnolence. Nocturnal desaturation, pulmonary hypertension, and right-sided heart failure fndings can all #improve with this technique.
▪More severe forms of sleep apnea may require
👉palatal_corrective_surgery or, in the most diffcult cases,
👉tracheostomy.

🟪Remember causes of difficult to control asthma:

1• non compliant on medications
2• poor MDI technique (always ask how you do cope with MDI).
3• CSS (remember upper and lower respiratory symptoms with mononeuritis multiplex).
4• ABPA (constitutional, hemoptysis, immunosuppressed).
5• EAA (EPisodic )
6• GERD
7• NSAIDs, drugs lower oesophageal sphincter tone
8• drugs worsen bronchoconstriction (adenosine, ticagrelor, beta blocker)
9• smoking, occupational hazards, and persistent exposure to allergens.

#Bedside_Notes
CNS / د.فاطمة النعمي

Q1_ What is the Definition of normal speech ?
👇
Pt should be understanding you and speak clear for you to understand
NO Aphysia
NO Dysartheria
NO Dysphonia

Q2_ What are the causes of dysphonia?
👇
🔸️Non neurological
1_ After prolonged speech
2_ URTI
3_ Mass compression from outside
4_ Hypothyroidism
5_ Post inhaler use
6_ Post intubation
🔸️Neurological
Recurrent laryngeal N damage

Q3_ Why you cannot use irritating substance for testing the Olfactory N ?
👇
Bc it will stimulate the 5th cranial N.

#Bedside_Notes
CNS / د.فاطمة النعمي

#Glabbelar_reflex

تبع ال 5th cranial N examination
كيف يندار ؟
تضرب ضربة خفيفة عالجبهة (بالهامر او من غيره) / ال response الطبيعي يصير Eye Blinking مرة وحدة او 2

لو استمر اكثر من هكي معناها / Exaggerated.

#Bedside_Notes
CNS /. د.الصديق عبود

🔸️How to test for congugate eye movement?
👇
تحط ايديك الزوز قدام عيون البيشنت على مسافة نص متر
بحيث وحدة تكون مفتوحة 🖐 و التانية تكون مسكرة✊

و تقول للبيشنت مرة يشوف لليد المفتوحة 🖐 ، و مرة يشوف لليد المسكرة ✊

و تراقب حركة العيون هل يتحركوا مع بعض و أمورهم تمام او لا.