تفريغ محاضرة HTN🔥

Cardiology

Kidney

تفريغ محاضرة
Abnormal ECG & Arrhythmia
للدكتورة أمة الرحيم

ملف دورة ECG بصورة واضحة ل الذي لم يتضح له في الملخص

تفريغ لكلام الدكتوره بس ما ادري ان كان كافي او لا 🤷🤷

تفريغ محاضرة الدكتورة أمه الرحيم القهالي

nephritic syndrome.doc'

mechanical valves VS  bioprosthetic valves

محاضرة الدكتورة امة الرحيم congenital heart disease👆👆

من قناة الدفعه 2 البكالوريوس

كل الشكر للزميل عادل القيسي

الملف الذي كتب الدكتور نشوان الحالات منه في الاختبارات السابقة 👆

_____بوست 3️⃣____
Unusual features in SLE & Associated conditions
-----------------------------------------------------------------------------

دليلك الكامل لكل ما هو صعب وغير نمطى فى مريض
الذئبه

#Nonspecific cutaneous SLE
~~||~|~~~

✅Nonspecific cutaneous SLE refers to features relating to underlying illness rather than an autoimmune attack.

🌀These features may occur in other connective tissue and autoimmune diseases.

1) Nail fold capillary telangiectasia

2) Raynaud phenomenon (white fingers and toes on exposure to the cold)

3) Vasculopathy of tips of digits (occlusion of small blood vessels by thrombus)

4- Diffuse hair thinning without brittle hair

5- Urticaria, which may be neutrophilic on biopsy
Angioedema also can occur

6- Cutaneous vasculitis: palpable purpura or
urticarial vasculitis

7- Livedo reticularis (a network pattern of blood vessels) in 20–30% patients with SLE

N.B : patient with SLE can present by Angioedema

🔷Uncommon GIT symptoms
•••••••••••••••••••••••••••••••••••••••

✏️Anorexia , nausea and vomting

✏️Abdominal pain due to peritoneal inflammation ( peritonitis as one of polyserositis)

✏️mesentric vasculitis , bowel infarction , perforation & peritonitis

✏️Liver affection
Associated elevated liver enzymes

✏️SLE can be associated with Autoimmune hepatitis at the same time

🔷Uncommon chest Features
••••••••••••••••••••••••••••••••••••••

✏️Acute pneumonitis :
Presents é fever , cough , dyspnea and pleurisy along with late inspiratory crackles on the chest
🫁CT chest : ground glass apperance

✏️Alveolar hemorrhage ; acute onset of dyspnea , fever , hemoptysis + low O2 saturation
🫁CT chest : bilateral alveolar shadows with airbronchograms

✏️interstitial lung fibrosis related to SLE as any connective tissue disease ( gradual dyspnea , dry cough along with inspiratory crackles on the chest

✏️Pulmonary Hypertension ( high JVP, pitting LL edema , accentuated P2 ± left parasternal pulsations/heave

✏️Shrinking Lung Syndrome
It is a a rare complication characterized by dyspnea , episodic pleuritic chest pain , and progressive reduction in lung volume in abscence of interstitial fibrosis
🫁CT chest : unexplained lobar collapses


✏️Pulomnary embolism can occur due to Anti-phospholipid syndrome secondary to SLE مهمه جداااا

Unusual Cardiac manifestations of SLE
=================================

✏️Valvular lesions called Libman-Sacks endocarditis that develop in 6 - 10 % of all SLE patients
#there are non-bacterial verrucous lesions near the edge of mitral , aortic and tricuspid valves { mostly affecting the mitral valve leading to Mitral Regurge

Some of cases are Asymptomatic while
the others are Symptomatic ,
Some cases lead to systemic emboli
Also Non-bacterial endicarditis may occur

N.B : Mitral Valve proplapse is frequently seen in SLE patients

✏️Myocarditis : is an uncommon comolication of SLE

C/P
resting tachycardia out of proportion to temperature with non specific ECG changes + Cardiomegaly
-> Global hypokinesia is seen on ECHO

✏️Coronary heart disease can occur because of autoimmune coronary vasculitis + accelerated atherosclerosis

✏️Associated Anti-phospholipid Syndrome may lead to Myocardial infarction

✏️Pediatric complications
In mothers of SLE with positive Anti-Ro and/or Anti-La , there is 3% risk of developing NEONATAL LUPUS with Congenital Heart Block

Unusual neuropsychiatric features in SLE
••••••••••••••••••••••••••••••••••••••••••••••••••••••

Rule 1 : the range of neuropsychiatric symptoms of SLE is broad , it ranges from mild symptoms such as poor concentration and emotional disturbances to SEVERE SYMPTOMS such as Seizures, stroke and psychosis



Rule 2 :
التصنيف من الاكثر حدوثا فالاقل و هكذا

From the most to the least common, symptoms range from DEPRESSION, COGNITIVE DISTURBANCES , HEADACHE , MOOD DISORDERS , STROKE/TIA, SEIZURES , POLYNEUROPATHY , ANXIETY and PSYCHOSIS

Rule 3 : any neuro-psychiatric features should be assessed carefully ( there are many causes of each symptoms
لابد من استبعاد اى سبب اخر لاى عرض عصبى او نفسى ،، وفى حالة استبعاد الاسباب الاخرى تصنف الاعراض العصبيه او النفسيه بانها عرض للذئبه الحمراء

الكليه الامريكيه للروماتيزم صنفت كل الاعراض العصبيه
⤵️ للذئبه الحمراء كالاتى

Central ( brain & Spinal cord affection )

- Psychosis
- Mood disorder نفسى
- Cognitive dysfunction
مشاكل فى الذاكره والتركيز
- Anxiety disorder
اضطراب القلق
- Acute Confusional state
خلل حاد فى مستوى الوعى مع اضطراب الكلام والتصرفات

- Seizure تشنجات
- Stroke جلطة بالمخ
- Headache الصداع النصفى والعصبى
- Myelopathy
التهاب حاد فى الحبل الشوكى وغالبا ما يسبب شلل الاطراف وفقدان الاحساس تحت مستوى ال lesion مع عدم التحكم فى البول

- Movement disorders {Chorea & Ataxia}

- Demyelinating diseases

- Aseptic meningitis

Peripheral
••••••••••••••
- Guillain Barré Syndrome ( Association )
- Autonomic Neuropathy
- Mononeuropathy
- Polyneuropathy
- Plexopathy
- Cranial Neuropathy
- Myasthenia Gravis ( Association)

Uncommon manifestations include ⤵️

🚩Tranverse Myelitis
Triad ( Paraplegia + sensory level + Sphincteric features )
ودى حاله طارئه

🚩 CNS vasculitis
Rare manifestion in SLE ( fever, severe headache , confusion , progressing rapidly to seizures , psychosis then coma

🚩Reversible posterior leucoencephalopathy syndrome ( clinically , Seizure , disturbed conscious level , visual changes , and headache
MRI brain in PRES 🧠 --> vasogenic cerebral edema in posterior cerebral hemispheres

🚩Movement disorders ( chorea & Ataxia )

🚩Cranial neuropathies ( 5th, 7th and bulbar )

🚩Aseptic Meningitis

Unusual hematological features of SLE
===================================

#Evans Syndrome

Prescence of Autoimmune hemolytic anemia ( Coomb's positive ) + Thrombocytopenia concurrently at the same time

#TTP ( Thrombotic Thrombocytopenic Purpura )

Hemolytic anemia + thrombocytopenia

بس بشروط وهى ⤵️⤵️⤵️⤵️

1) evidence of intravascular hemolysis ( high retics , high LDH , low haptoglobin , positive hemosiderin ± hemoglobin in urine

2) Coomb's test must be negative to exclude autoimmune type of hemolytic anemia

3) blood film must have evidence of Fragmented RBC's ( Schistocytes)

4) associated Renal impairement
ممكن اه وممكن لا

5) Neurological features at the same time of this hemotological problem
فى صورة خلل فى الوعى او ضعف مؤقت فى جزء من الجسم وليس جلطه مكتمله بالمخ وده بردو ممكن اه او لا

6)associated fever at the same time of hematological problem

والنوع ده من ال ----------⤵️⤵️⤵️
TTP is secondary to SLE

#Pancytopenia

#Macrophage Activating Syndrome ( MAS)
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••

It is a rare condition that occurs secondary to SLE

It is a form of HLH ( hemophagocytic lymphohisteocytosis or hemophagocytic syndrome )

ودى اعراضها كالاتى ⤵️

- Bi or pancytopenia
- high PT , PTT
- marked elevated FERRITIN بالالاف
- high Triglycerides

Cause : low or abscent Natural killer cell activity --> ↑ soluble CD25 ( IL2 receptors)

Clinical features
••••••••••••••••••••••

Fever , weight loss , arthritis and rash

فى مثل هذه الحالات لابد ايضا من عمل بذل نخاع لاثبات التشخيص
BM examination will reveal hemophagocytosis ( infiltration of the BM by phagoctyes or histeocytes )

This condition responds well to
immunosuppression

🪩 Eyes Signs & symptoms in SLE
````````````````````````````````````````````````

المفروض مريضة الذئبه مش بتشتكى من عنيها ،، طب لو اشتكت ايه الاحتمالات الممكنه اللى ممكن تصيب العين ؟

1) Keratoconjunctivitis sicca

ودى هتخلى المريضه تشتكى من جفاف بالعين محتاج قطره واحمرار متكرر واحساس بوجود جسم غريب بالعين يسبب الحكه gritty sensation

Keratoconjunctivitis Sicca ? Why ??
⤵️
Associated Sjogren's syndrome

ملحوظه :
Sjogren's syndrome might come as a primary condition ,or secondary to other collagen diseases like SLE and Rheumatoid Arthritis
RA > SLE

2) Anterior Uveitis , keratitis and episcleritis
ودول بيحمروا العين ودكتور الرمد بيميزهم

3)retinal vasculopathy

General features of SLE
••••••••••••••••••••••••••••••••

As SLE is a systemic autoimune inflammatory disease , so Active inflammation with Active immune system will lead to the following 🔰

#weight loss

#Generalized Lymphadenopathy

#Organomegaly particularly,Splenomegaly!!

Very important item
°°°°°°°°°°°°°°°°°°°°°°°°°
#Conditions which might come in Association with SLE

🚩مهم جدااا جدااااا🚩

1️⃣ Anti-phospholipid Syndrome ( APS)

SLE & APS = high Association

2️⃣ Sjogren's syndrome
⤵️⤵️⤵️⤵️
Dry mouth & Dry eyes + red eyes

3️⃣ Rheumatoid Arthritis

SLE + RA at the same time

Rheumatoid + Lupus is called ”RUPUS”
ودى تسمية خبراء الروماتيزم الاجانب

4️⃣Polymyositis + Systemic sclerosis ( scleroderma) + SLE in the same patient
”Mixed connective tissue disease ”

Specific autoantibody
Anti-U1 RNP

5️⃣If the 3 diseases affect the same persons with coexisting Sjogren's ± RA , it is called Overlap syndrome.

6️⃣Fibromyalgia

طبعا هتلاقى المريضه بتشتكى من الم فى عضلاتها

NB ; diffuse muscle pain can't be explained by SLE

7️⃣other autoimmune non rheumatological conditions e g Thyroid disease , AIH , Myasthenia and etc !!

____بوست 2️⃣ 💻______
How to take focused history ?
To do focused examination 🩺 ‼️
To order suitable workup in a case 🧪
Of SLE and diagnostic criteria
🎯 والمعايير التشخيصية العالميه 🎯
🔷 لمرض الذئبه الحمراء 🔷 _________

👥Focused history/Focused Examination in SLE 🩺
====================================

🕵️Ask about the following 🔰

1️⃣ joint pain ( using SOCRATES rule )

✓Comment on distribution & Morning stiffness

✓Examine for affected jounts ( hands, UL & LL)

🩺 Look , feel , move protocol , give a particular attention to prescence of ACTIVE SYNOVITIS and DEFORMITIES { JACCOUD'S ARTHROPATHY}

2️⃣Skin features
~~

✅Assess the prescence of acute , subacute and chronic cutaneous lupus lesions

✔️Look for such lesions and describe them

3️⃣Hair/scalp lesions
~~~~~~

✔️Ask about hair loss , Alopecia , rash on the scalp

✅Look fo such rashes and describe them

4️⃣Mucosal affection
~~~~~

✔️Ask about Oral & nasopharyngeal ulcers

✔️Look for ulcers

5️⃣Serosal affection
~~~

✔️Ask about
Pleurisy ( pleuritic chest pain )

✔️Pleural effusion ( dyspnea )
Confirm your diagnosis by auscultation & percussion

✔️Pericarditis ( ask about pleuritic chest pain that ↓ with leaning forwards

✔️Confirm your Dx by auscultation of Pericardial Rub

✔️pericardial effusion
Screen for Beck's Triad ( high JVP , hypotension and distant heart sounds)

5️⃣Blood Affection
~~

✔️Ask about pallor & fatigue ( anemia )

✔️Ask about jaundice ( hemolytic anemia )
Confirm by exam

✔️Ask about bleeding tendency bleeding spots( purpuric eruption and bleeding orifices )

6️⃣Kidney Affection
~~~~

✔️Ask about Frothy urine , red urine and reduced urine output

✔️Ask about periorbital edema ( especially at the morning )

✔️Check BP for high BP

7️⃣CNS /PNS affection
~~~~~

✔️Ask about confusion , delerium , seizures and psychotic features

✔️Ask about foot drop and hand drop ( confirm by exam )

🕵️Lab abnormality 🧪
~~~~~

✔️Ask about any previous labs like
Anemia
Or
✔️Autoimmune hemolytic Anemia ( AIHA)
Or
✔️Thrombocytopenia
Or
✔️Leucpenia
Or
✔️Pancytopenia

#Any labs that prove high ESR

#Any lab test that proves Positive ANA and Anti-ds DNA

✏️Workup✏️
°°°°°°°°°°°°°

Basic Labs
~~~~~~~

✓CBC
✓LFTs
✓RFTs
✓Coagulation profile
✓Random blood glucose

Specific Labs
----------------------

*ANA ( titre must be ≥ 1/80)

*Anti-ds DNA ± Anti Smith Ab

* Lupus Anticoagulant , Anti-cardiolipin Ab and Anti-glycoprotein Ab

* C3 & C4

* ESR

🔷Screen for organ affection ⤵️

🟤Kidney ;
✔️Urine analysis & microscopy , ACR
✔️Biospy should be done if the proteinuria is significant or RPGN is suspected

🟤Blood ; Coomb's test , Retics

🟤Polyserositis ( CXR & ECHO if clinically indicated ) Diagnostic aspiration is indicated also

Important Quiz ‼️❓

Does ANA negative SLE occur ?

The answer
==========

If you suspect SLE but ANA is negative , please don't rule out SLE untill doing HEp-2 assay !!

American College of Rheumatology ACR recently recommend the new specific technique for detecting ANA which is called HEp-2 assay

The HEp-2 cell, a native protein array with hundreds of antigens, provides an ideal substrate for the detection of ANA1.

The detection of ANA in human serum is an important screening tool for connective tissue diseases, and IIF ( indirect immunofluorescne )is the reference method for ANA testing

. Recently, IIF on HEp-2 cells has been replaced in some laboratories with antigen-specific immunoassays and multiplex methods.

Due to concerns over false negative results and the lack of transparency to clinicians,

the American College of Rheumatology formed a Task Force that concluded that IIF using HEp-2 cells should be the “gold standard” for ANA screening.

🔷Diagnostic criteria 🔷 المعايير التشخيصية
``````|``````|``````|

``|``

|

ACR 1982 criteria ( updated in 1997 ) for the diagnosis of SLE

🟢 11 criteria 🕵️


✏️Mnemonics for simplification
اختار اى واحد يعجبك ويسهل الحفظ

💻SOAP BRAIN MD

S: Serositis ( pleurisy or pericarditis )

O: Oral/nasal ulcers

A: Arthralgia/arthritis ( non erosive)

P: Photosensitivity

B: Blood disorder : hemolytic anemia , Leucopenia , lymphopenia or thrombocytopenia

R: Renal involvement : persistent proteinuria or cellular casts ( dysmorphic RBC's)

A: Anti-nuclear Antibody (ANA)

I: immunologic marker ( positive Antids DNA , Anti-smith Ab , and/or Anti-phospholipid Ab

N: Neurological disorder ( seizures or psychosis)

M: Malar Rash

D: Discoid Rash

-------------------------------
Another Mnemonic !!

💻I'M DAMN SHARP
~~~~~

I: immunoglobulins : antidsDNA , AntiSm Ab , Anti-phospholipid

M: Malar Rash

D: Discoid Rash

A: Anti-nuclear Antibody (ANA)

M: Mucositis ( Oropharyngeal ulcers)

N: Neurological disorders

S: Serositis { pleurisy & pericarditis }

H: Hematologic ( Cytopenias)

A: Arthritis

R: Renal disease(Nephritis)

P: Photosensitivity
----------------------------------------------
Another Mnemonic!!

💻RASH ON MAIDS ( young woman with rash) ⤵️

R: Renal ; proteinuria , active urine sediments)

A: Arthritis

S: Serositis

H: hematologic

O : Oral or Nasopharyngeal ulcers

N: Neurologic

M: Malar Rash

A: ANA positive

I: Immunologic like AntidsDNA

D: Discoid lupus

S : Sun sensitive rash

To diagnose SLE , the patient must fulfill at least 4/11 criteria ( ≥ 4/11)

📈 SLICC criteria for the diagnosis of SLE ( 2012)

🅰️] CLINICAL CRITERIA :
---------------------------------------
1️⃣) Acute cutaneous lupus ( malar rash & maculopapular rash & photosensitive rash )

#Subacute cutaneous lupus : ( non indurated psoriasiform lesions and/or annular polycyclic lesions that resolve without scarring

2️⃣) Chronic cutaneous lupus ( Discoid rash above the neck )

3️⃣) oral ulcers ( oral, palate nasal)

4️⃣) Non-Scarring alpoecia : diffuse thinning or hair fragility with visible broken hair

5️⃣) Synovitis involving 2 or more joints characterized by swelling or effusion or tenderness on two or more joints and 30 minutes or more morning stiffness

6️⃣) serositis
( pericarditis or pericardial effusion)
(Pleurisy or pleural effusion )

7️⃣) Renal affection
( proteinuria > 0.5 gm and or RBC's casts

8️⃣) Neurologic ( seizures , psychosis , mononeurutis multiplex )

9️⃣) hemolytic anemia
1️⃣0️⃣) leucopenia ( < 4000)
1️⃣1️⃣) thrombocytopenia ( < 100,000)

🅱️] Immunological Criteria
-----------------------------------------
1️⃣) ANA above lab reference range
2️⃣) anti-ds DNA above lab ref. range
3️⃣) Anti-Sm Ab
4️⃣) Antiphospholipid Abs ( lupus anticoagulant , Anticardiolipin Ab)
5️⃣) Low Complement
6️⃣) Direct coomb's test

💻To diagnose SLE , the patient must fulfill
≥ 4/ 18 with at least one clinical and one lab criteria

N .B
SLICC : systemic lupus international collaborative clinic

Diagnosis needs at least 4/18 , (at least one clinical and one lab)

__________
New ACR/EULAR 2019 classification Criteria for systemic lupus erythromatosis (SLE) diagnosis
___________

❇ Entry Criterion 👇👇

ANA positive( titre ≥ 1/80)

➡ if abscent don't classify as SLE

➡If present , Apply ⬇⬇⬇

Additive Criteria 👇👇👇

▶ Constitutional
Fever -----> 2️⃣

▶Hematologic
Leucopenia ---> 3️⃣
Thrombocytopenia --> 4️⃣
Autoimmune hemolysis ---> 4️⃣

▶ Neuropsychiatric
Psychosis ---> 3️⃣
Delirium ---> 2️⃣
Seizures ----> 5️⃣

▶Mucocutaneous
Non-scarring alopecia ---> 2️⃣
Oral ulcers --->2️⃣
Subacute cutaneous lupus or discoid lupus ---> 4️⃣
Acute cutaneous lupus ---> 6️⃣

▶ Serosal
Pleural effusion /Pericardial effusion ->5️⃣
Pericarditis --> 6️⃣

▶ Musculoskeletal
Joint involvement ---> 6️⃣

▶Renal
Proteinuria > 0.5 gm --> 4️⃣
Biopsy class II or V lupus nephritis -> 8️⃣
Biopsy class III or IV lupus nephritis
-> 1️⃣0️⃣