Resources:

-American College of Clinical Pharmacy "ACCP"
-American College of Chest Physicians.
-BMJ "British medical journal"
-British medical association
-Rosen&Barkin’s Emergency Medicine Consult
-Oxford handbook of clinical medicine
-American Board of Emergency Medicine
-Dr. Ahmed AAS medical notes
-Medscape.

Remember:

•Pleural fluid normally present: 5 to 15 mL.
•At least 500 mL of fluid is necessary to detect clinically.
•At least 300 mL of fluid is necessary to detect radiologically in PA view.
•At least 100 mL of fluid is necessary to detect radiologically in lateral decubitus position.
•Less than 100 mL or small amount of fluid is detected by ultrasonography (even 20 to 25 mL fluid can be detected).

#Respiratory

•Approach to the diagnosis of Pleural effusions.

#Respiratory

Remember:


-Pleural fluid cholesterol level < 60 mg dl indicates transudate.

-In all malignant effusion, pleural fluid cholesterol > 60 mg/dL. So, this test is useful to separate these two types of effusion.

-High pleural fluid ADA indicates tubercular pleural effusion.

#Respiratory

هذا تحليل للـ Pleural fluid لمريض معه pleural effusion.

-Total white blood cell count is elevated and notice.
Lymphocyte-rich fluid (>50% lymphocytes) may suggest malignancy or tuberculosis (TB).

Also protein is elevated.

Adenosine deaminase (ADA) level in pleural fluid:


When is considered elevated?!
-It's (>40 U/L) in TB

Test

Requested if tuberculosis (TB) effusion is suspected. 

Factors such as a positive skin test for TB, a positive interferon gamma release assay (IGRA), incarceration, travel to an endemic area, immunocompromise (including HIV infection), and apical cavities on chest x-ray increase suspicion.

-Pleural fluid ADA >40 U/L has a sensitivity of 90% to 100% and a specificity of 85% to 95% for tuberculous pleurisy.

-BMJ


So the patient has T.B. Pleural effusion.

Hemothorax in patient with trauma "fall" .
Also the patient has a flail chest.

Flail chest:
-Three or more ribs fractured in 2 or more places.
-Bilateral costochondral separation will result in flail sternum.

Patient comes to you with osteoarthritis and you do Knee X-ray, which shows second stage osteoarthritis.

What is the prescription?

1)Etoheal or Acroxia 120 mg tab "Etoricoxib"
1×1×30
Or Mobic 15mg tab "Meloxicam"
1×2×15

2)Mydocalm tab or myoheal tab or myofen tab "muscle relaxant"
1×2×10

3)Vudron gel "
1×2 ×10 "Diclofenac sodium"

4)Ortholink tab
1×1 ×30

Myofen.
Muscle relaxant.
Used twice daily.

You can use Myoheal, myonal, myorelax, myorar.. etc

.The ACR/AF, AAOS, and OARSI guidelines strongly recommend use of oral NSAIDs in the management of knee OA.

-Currently, the ACR/AF guidelines provide conditional support, whereas use of acetaminophen/ paracetamol 👉🏼was not recommended in the 2019 OARSI guideline for any OA phenotype or comorbidity subgroup.

-Acetaminophen is often an early choice for mild-to-moderate pain associated with knee OA 👉🏼 given its👉🏼relatively safe gastrointestinal toxicity profile.

-Guideline recommendations for medical management of knee osteoarthritis.

Management of Bacterial meningitis in pediatrics:

ملاحظات كيف نتعامل مع الـ meningitis في الواقع العملي. 👇🏽

أول شيء أيش أسباب الـ Bacterial meningitis؟

ضروري نعرف الأسباب، لأجل نعطي appropriate antibiotics.

على حسب العمر، لكن في ثلاث Bacteria تعتبر common لكل الأعمار.
S. pneumoniae
H. influenzae
N. meningitidis.

-لهذا عنجيب مضادات تشتغل على الكل كـ empirical treatment.
-الـ Ceftriaxone يشتغل على N. meningitidis وكذلك الـ Penicillin sensitive S.pneumoniae وكذلك الـ H. influenzae.

-ليش نجيب الـ Vancomycin ومافي عندنا MRSA؟
لأن الـ S.pneumoniae هنا تكون أو نعتبرها resistant وماعاد ينفع معها الـ Ceftriaxone لذلك دائماً يضيفوا الـ Vancomycin حسب CDC guidelines.

-In neonates E. coli and GBS are the common.

في ثانيات على حسب الـ risk factor.
مثلاً:

-Staphylococcal meningitis primarily occurs after neurosurgery or penetrating head trauma. Also in patients with shunts.

-Listeria monocytogenes is common in immunocompromised patients and extremities of age, also in pregnancy.

-If patient has AIDS,so cryptococcosis is common and we should give antifungal "amphotericin".

-If patient has leukemia and undergoing chemotherapy, with meningitis ,he'll have neutropenia so pseudomonas will also be implicated.

-ليش يحصل photophobia مع مريض الـ meningitis؟

•لأن الـ optic nerve العصب الوحيد من الـ cranial nerves اللي متغطي بـ meninges لذلك حين يحصل التهاب يتضمن الـ optic nerve وتحصل photophobia.