When you see a patient with murmur and they have fever or general malaise, you should always consider infective endocarditis (IE) even tho it's not the most common dx, and other infections can be the culprit (this is especially important in the elderly because their symptoms are not very specific).

Btw, the classic signs and symptoms of IE (like Janeway lesions, Osler nodes, and splinter hemorrhage) are not usually present, so don't rely on them.

Levodopa (for Parkinson's treatment) is usually used in combination with a selective dopa decarboxylase inhibitor which does not cross the blood–brain barrier and reduces peripheral adverse effects. The commonest side-effects are nausea, vomiting, dizziness, postural hypotension and neuropsychiatric problems.

Some notes about Parkinson's treatment (and selegiline)

When you see an old patient with CV disease presenting with severe abdominal pain, you should consider bowel ischemia among other diagnoses.

Here's a curious case:

Four months ago a 47-year-old patient was admitted to hospital with acute chest pain.
A subendocardial inferior myocardial infarction was diagnosed and he was treated with thrombolytics and aspirin. After discharge he complained of angina, and coronary angiography was performed. This showed severe triple-vessel disease not suitable for stenting, and coronary artery bypass grafting was performed. He is attending a cardiac rehabilitation clinic and he has had no further angina since his surgery. He has a strong family history of ischaemic heart disease, with his father and two paternal uncles having died of myocardial infarctions in their 50s; his 50-year-old brother has angina. He is married with two children. He smokes 25 cigarettes per day and drinks at least 40 units of alcohol per week. He is taking atenolol and aspirin.

On examination he is slightly overweight (85 kg; body mass index = 28). He has tar-stained nails. He has bilateral corneal arcus, xanthelasmata around his eyes and xanthomata on his Achilles tendons. He has a well-healed midline sternotomy scar. His pulse is 64/min regular, blood pressure 150/84 mmHg. He has no palpable pedal pulses. His respiratory, gastrointestinal and neurological systems are normal.

The patient suffers from Familial Hypercholesterolemia (FH) which causes significant CV morbidity and mortality by causing coronary artery disease and peripheral artery disease (as evidenced by absence of pedal pulses).

FH is a single-gene autosomal dominant disease that reduces the numbers of high-affinity cell-surface LDL receptors (especially in the liver). This leads to high levels of serum LDL, and subsequent increase in foam cell formation and promotion of atherosclerosis.

المهم، هالمرض (بالإضافة لأمراض أُخرى) يعتبر من الأسباب المهمة والشائعة نسبيًا لزيادة الكوليسترول ويزيد إحتمالية الإصابة بأمراض القلب والأوعية الدموية بعمر مبكر (قبل الـ 50) ولهذا لازم الواحد ينتبه لعلاماته المميزة والـ clinical picture

His lab results

Xanthomata around the knee

الـ xanthomata تظهر عند المريض بسبب الـ hypercholesterolemia وبالعادة تكون حول المفاصل أو الأوتار، مثلًا بحالة الكيس الفوك جانت حول الـ Achilles tendon

يكلك نسبة المرض عند المسيحيين اللبنانيين توصل 1:170 which is fairly high

There's another disease called polygenic hypercholesterolemia (PGH) in which patients have a similar lipid profile to familial hypercholesterolemia but they do not develop xanthomata.

Also, PGH is caused by multiple genetic mutations, while FH is caused by a single gene.

Yet another disease is called familial combined hyperlipidemia (FCH) in which both triglycerides and cholesterol are raised.

In contrast to FCH, patients with FH or PGH have either normal or slightly elevated triglycerides.

يكلك أكو مضاد حيوي إسمه Demeclocycline من عائلة الـ tetracycline يسبب عارض جانبي زبالة كلش هو nephrogenic diabetes insipidus (يقلل تأثير الـ vasopressin على الكِلية بشكل كبير). هالأيام محد يستخدمه بصفته مضاد حيوي لأن صارت تجاهه مقاومة من البكتيريا وفقد فعاليته بشكل كبير، بس بحالات الـ SIADH¹ يستغلون عارضه الجانبي هذا ويستخدموه لعلاج المتلازمة، خاصة إذا ما متوفرة الـ vasopressin antagonists.

مصائب قومٍ عند قوم فوائد

الفكرة هي أنّ الـ SIADH والـ Diabetes insipidus (DI) هنّ حالات متعاكسة:
الأول يمثل إفراز الـ vasopressin بشكل جبير كلش، والثاني يمثل إفرازه بشكل قليل كلش.

فالأدوية اللي تسبب الثاني (DI)، ممكن نستخدمها لعلاج الأول (SIADH): سابقًا جنة نستخدم الليثيوم لأن همين يسبب DI، بس أعراضه الجانبية مزعجة فاستبدلناه بالـ demeclocycline. وبعدين حتى هذا استبدلناه بالـ vasopressin-receptor antagonists مثل الـ Tolvaptan

ليهسة أتذكر طالبة المرحلة الخامسة مدري السادسة بالفاينل، عود داساعدها، حليت الها السؤال: SIADH واني جنت اقصد DI... يمكن ليهسة بعدها تغلط علية...