-Anterior STEMI Vs RV infraction:

How to differentiate between Anterior STEMI and isolated RV infarction (as both can shows ST elevation from V1-V3)?
-In patients with anterior left ventricular infarction, ST segment elevation is the lowest in lead V1, increasing in amplitude toward lead V5.
On the other hand, patients with an occluded RCA and RV infarction display the greatest amplitude of ST segment elevation in lead V1, which progressively decreases toward lead V5.

#Cardiology

-Relations of ECG to area of myocardium & C.vessele affected in CAD.

#Cardiology

-IgA Nephropathy (Berger’s disease):

-It is the most common type of Primary GN in developed countries.

-When IgA affect the kidney only this is called IgA nephropathy, while HSP is systemic IgA disorder, in which the skin, kidney and other organs will be affected.

#Nephrology

-Nephrotic syndrome is the combination of nephrotic-range proteinuria with a low serum albumin level and edema.

-Nephrotic-range proteinuria is the loss of 3 grams or more per day of protein into the urine or, on a single spot urine collection, the presence of 2 g of protein per gram of urine creatinine.

#Nephrology

-The first sign of nephrotic syndrome in children is usually swelling of the face; this is followed by swelling of the entire body.

-Adults can present with dependent edema. Fatigue and loss of appetite are common symptoms.

#Nephrology

•Urinary protein measurement

-Urinary protein is measured by a timed collection or a single spot collection.

-A timed collection is typically done over a 24-hour period, starting at 7 am and finishing the next day at the same time. In healthy individuals, less than 150 mg of total protein is present in a 24-hour urine collection.

-A single spot urine collection is much easier to obtain. When the ratio of urine protein to urine creatinine is greater than 2 g/g, this corresponds to 3 g of urinary protein per day or more.

#Nephrology

•Indications of Admission in Malaria:

1-ARDS
2-Shock
3-Anemia, Hb <5mg /dl
4-Hyperparasitaemia >10٪
5-Pregnancy
6-Renal failure
7-Hypoglycemia(<2mmol)
8-CNS affection
9-Bleeding tendency, DIC
10- Jaundice,(Bilirubin >5mg/dl).

#Infections

-Causes of Bilateral Ptosis :

• MG
• Dystrophia myotonica
• Tabes dorsalis
• Congenital
• Bilateral Horner's.

#Neurology

•In linitis plastica:
-The mucosa is often spared malignant infiltration, making endoscopic diagnosis extremely difficult.
-Therfore,multiple endoscopic biopsies are recquired.

#Stomach

-In gastric linitis plastica
Most of the patients presenting with symptoms have an advanced form of the disease.

#Stomach

•Main features of graves disaese include :

-Diffuse goiter
-Thyroid eye disease
-Pretibial myxoedema
-Thyroid acropathy.

#Thyroid
#Endocrine

•Parameters indicate severe diabetic ketoacidosis:

-pH < 7
-Blood ketone > 6 mmol/L
-Bicarbonate < 5 mmol/L
-Anion gap >16 mmol/l
-Potassium < 3.5 mmol/L on admission
-Tachycardia or bradycardia
-Systolic blood pressure <90 mmHg
-Oxygen saturation <92% on air
-GCS < 12.

#Diabetes

•Indications of DC cardioversion in AF are:

1-Blood pressure less than 90 mmHg
2-Chest pain
3-Heart failure
4-Impaired consciousness.
5-HR > 200 bpm.

#Cardiology

-The tendency of breast cancer to metastasize to the spine is explained by the free communication of posterior intercostal veins with vertebral venous plexus.

#Breast

-Cancer Antigen 15-3 (CA 15-3 )is the tumor marker for breast cancer .

-It is elevated in large or disseminated tumors.

-It is not useful for diagnosis but it is used to monitor response to breast cancer treatment and disease recurrence .

#Breast

Arm edema after breast cancer treatment

◼️Axillary lymph node dissection combined with radical radiotherapy causes destruction of the lymphatic drainage of the upper limb with consequence lymphatic edema.

◼️The condition is now uncommon because radical radiotherapy and axillary lymph node dissection are rarely combined together, but it still can occasionally occur even if either modalities are used alone.

◼️It may take months or years to develop, but when it develops it is very essential to exclude recurrence of cancer which infilerate the axilla and cause both lymphatic and venous occlusion.

◼️Axillary infilteration by tumor cells can be so painful, because of brachial plexus nerve involvement.

◼️Treatment is by arm elevation, elastic arm stockings and pneumatic compression devices, it can prove difficult to treat.

◼️The above is a patient who is suffering from left arm lymph edema following radical axillary dissection.

#Breast

Skin manifestations of breast cancer

◼️Dimpling = the tumor pulls the skin into a pit by fibrosis acted upon via cooper's ligament (conical ligaments connecting skin to pectoralis
fascia).

◼️Puckering = multiple dimplings.

◼️Tethering = Tumor is connected to cooper's ligaments but did not cause a dimpling, however when the patient lifts up the arms and breast skin is stretched, a pit appear.

◼️Malignant ulcer = tumor has broken through the skin.

◼️Fungating tumor = see image above.

◼️Peau d orange = cutaneous lymphedema due to malignant lymphatic obstruction (see before).

◼️Cancer en cuirasse = the skin is infilterated by malignant cells forming a shield like coat. Word 'cuirasse' is french for armour or shield worn as a breast plate.

#Breast

Ductal carcinoma in situ (DCIS)

◼️This is a pre-invasive stage of breast cancer in which malignant cells had not breached the basement membrane of mammary ducts.

◼️In the early stages, the proliferating cells grows into a papillary projections (see figure above) which is simply known as the papillary type, here it may be difficult to differentiate DCIS from simple hyperplasia seen commonly in women with fibrocystic breasts.

◼️Later on these papilla grows even more with spaces inbetween the clumps of malignant cells, this is called the Cribriform type, eventually these cells obliterate the lumen of the duct completely, and this is called the Solid type.

◼️When the cells overgrow their blood supply, necrotic areas appear which undergo microcalcifications seen on mammography, this is called the Comedo type which is considered to have a high risk of progression to invasive cancer.

◼️N.B Lobular carcinoma in situ is a marker of risk and not a direct anatomic precursor to malignancy.

#Breast

Role of axillary surgery in breast cancer

◼️It is accepted that, presence of metastatic deposits in axillary lymph nodes is still the single best marker of prognosis, despite this removal of axillary lymph nodes do not improve survival because it is not a reservoir of disease but merely a reflection of the metastatic potential of the disease, this means that presence of lymph node metastasis likely means presence of distant micrometastases that cannot be detected, therefore axillary surgery is justified for staging not for improving survival, and when positive systemic chemotherapy is justified.

◼️Above fig shows the groups of axillary lymph nodes:

1) Interpectoral group (Rotter nodes).
2) Anterior Group along the free edge of pectoralis major.
3) Posterior group on subscapularis muscle.
4) Lateral group along axillary vein.
5) Central group embedded in the centre of axilla.
6) Apical Group, which is continuous with lateral group but above the pectoralis minor muscle.

#Breast