🗯 Part 2 :-

■ Meningitis :

○ انا بعمل CT أو MRI عشان بس to exclude SAH
و يعتبر 1st investigation
○ lumbar puncture Is the single most
important investigation and it is the cornerstone of the diagnosis

○Once suspected meningitis should start ttt immedialty even before culture results

○ given Cs before antibiotics in cases of children , TB , streptoccal meningitis

■ cr nr 2 ( ON ) :-

○ parital lobe tumors affect upper fibers of optic radiation
بيعمل  lower  quadrantic contralateral homonymus  hemianopia
○ Temporal lobe tumors affect lower fibers of optic radiation
بيعمل upper quadrantic contralateral homonymus hemianopia

○ Lesion in occiptal lobe :
بيعمل contralateral homonymus hemianopia with preservation of macular vision

■ Cr V nr :
○ central lesion : 
بيحصل lost pain & temperature مع preservation of touch & deep sensations
○ peripheral lesion :
خلي بالك بيحصل sparing the angle of mandible ف sensation

● in trigeminal nr  lesion ( the jaw deviated to the affected side )

● facial nr lesion in UMNL  ( the mouth deviated to the healthy side )

● in hypoglosaal nr lesion ( the tongue deviated to the same side of lesion )

🗯 Part 3 :- 

■ thrombophilia workup is indiacted with unexplained stroke with young < 50yr , hx of thrombosis or clinical suspicion of hypercogulable state

■ CSF analysis :-

● SAH : groosly blood , high ptn , normal
( sugar & CL) , RBCs cells

● meningitis : turbid , high ptn , low
( glucose , CL ) , predominate lymphocyte

● Encephalitis : normal or modest amount of lymphocyte , neutrophil , high Ptn , low
( glucose , CL )

● خلي بالك CRP & ESR عاليين ف meningitis ما عدا ف حالة viral meningitis
● glucose & Cl are low in meningitis except normal with viral

● WBCs > 300/ mm3 except with bacterial meningitis

● thrombolysis with rt-PA should be given with 3-4.5 h & age 18 or older & symptoms suggest ischemic stroke

● rt-PA is CI if BP > ( 185/110mmHg) , within 3 months of brain surgery,  large infarction , INR (> 1.7)

● intra-arterial menchanical thrombectomy is indicated in case of large artery occulsion  in AC circulation

🗯 Focal neurological deficits :

■ NOTES :

● Part 1 :
https://t.me/med_Notes2/923

● Part 2 :
https://t.me/med_Notes2/925

● Part 3 :
https://t.me/med_Notes2/928

● Part 4 :
https://t.me/med_Notes2/930

● Part 5 :
https://t.me/med_Notes2/931

●Part 6 :
https://t.me/med_Notes2/934


■ MCQ :
https://t.me/med_Notes2/910

■ الجدول دا مهم ازاي تفرق بينهم و ممكن يجيب case عليهم ف mcq

■ شرحه سريعاً :-

● cerebral thrombosis :
بيجي ف old age و أشهر سبب بيعمله atherosclerosis ف العمر دا و العيان بيجي ب rapid onset من الأعراض و العيان ضغطه عالي بسبب atheroslerosis , زي ما بيحصل thrombosis ف brain ، بيحصل thrombsis ف ال coronary artery لانه atherosclrosis مسؤول عن 99 % من CAD

● Embolism :

أشهر حاجة و commonly أنها تيجي من heart و غالباً العيان عنده AF or valvular lesion و هتلاقي العيان بيجي sudden onset من الأعراض لأنها جلطة متكونة و جاهزة و أكثر حاجة بتحصل مع female

● cerebral hge :

أكثر حاجة و أشهر سبب بيعمله HTN و عشان كدا هتلاقي العيان ضغطه عالي و أكثر ناس بيحصلهم دا old age فالأعراض تبدأ عنده كارثية فيدخل ف vomiting & fever & DCL up to coma
و سبب دا hge as space occuping lesion بيزود ICT or brain edema فيبدأ يدمر BBB و يعمل irritative lesion على Vomiting center & heat regulating centers و يضغط على RC فنلاقي العيان عنده cheyne stokes breathing و خلي بالك بسبب chronic HTN اللي عنده بيعمل pressure overload on Lt ventricle فتلاقي عنده LV hypertrophy و لو سحبنا من CSF هنلاقي فيه blood & increased tension

🗯 صباح الخير يا شباب

● كل أنواع ال shock ال BP بيقل يعني في hypotension و كلهم بكون فيه Increase in respiratory rate

● طيب بالنسبة لل HR كلهم بيحصل فيهم tachycardia ما عدا neurogenic shock
ال HR بكون فيه bradycardia ؟

بتحصل ليه عشان قلل
sympathetic tone lead to unopposed parasympathtic response
lead to decrease vascular tone & HR

🗯 دكتور الشافعي بقول :-

● أنه العيان اللي جاي ب Hemorrhage أول حاجة بنعملها هي resuscitation  و دايماً تدي للعيان saline لحد م يجيلك   fresh blood  ما عدا Hemoptysis
لانه ال 1st line of ttt is intubation

● أنت عشان تدخل ف hemorrhagic shock محتاج تفقد ع الأقل 2 لتر من blood على الأقل و ال trachea تتسد ب 200 ml of blood  عشان لو دخلت ال trachea هدخل العيان ف asphyxia & death  عشان كده أهم حاجة ال intubation

■ توضيح بسيط ف imaging in case of focal neurological deficits :-

● Non contrast CT of the brain is the most commonly used

● في حالة ischemic stroke ( infarction) :

♤ Infarction مش هتظهر غير ما بعد من 24 to 48 hours ، even small infarction

♤ عشان كدا لازم اعمل follow up بعد 48 hs عشان اتأكد من ischemic stroke

● hemorraghic stroke :

♤ bleeding appears immediatley even very small lesion

♤ عشان كدا CT scan help to rule out of a hge stroke

■ MRI أحسن في حالة و أفضل في حالة infarction
لأنه infarction مش ببان ب CT غير بعد 48 ساعة

■ MRI is more sensitive في حالة acute ischemic infarction

🗯 تجميعات توكسو في المنهج :-

■ dilated fixed pupil with ( atropine , TCA , nutmeg , botulism )

■ bradycardia with ( OPs on M receptor , rabbit fish)

■ opsithotonus position ( high arched back ) with tetanus , Acute dystonic reactions , strchynine

■ hyperthermia with only herbicides , rabbit fish , NMS

■ HTN with tachycardia :
NMS , L.S.D , acute dystonic reactions , scorpion , strchynine

■ Gait : unsteady gait ( in atropine ) , shuffling gait ( in parkinsonism )

🗯 TTT of AF :-

■ if the patient is hemodynamic stable :

● Rate control
( slow Ventricular rate ) : BCD
♤ BBs , CCBs as verapamil & diltiazem , digoxin

● Rhythm control : (restore sinus rhythm)

◇ methods :-

1- chemical cardioversion ( oral class IC & class III , IAa agent , IV ibutilide )

2-electrical cardioversion ( DC)

♤ precautions :-

• DOACs is indicated if ( previous embolization , before DC , valvular disease as MS )

1- if AF < 48 h : immediately without DOACs

2- if AF > 48h : DOACs 3wk before & 4 wk after DC

■ if the patient is hemodynamic unstable ( hypotensive , angina , uncontrolled HF ) :
▪︎DC cardioversion

🗯 ttt of PSVT :-

■ If the patient is hemodynamic stable :-

1- vagal stimulation by carotid sinus massage or valsalva

2- slow ventricular rate ( rate control ) : IV ABCD : adenosine , BBs as propranolol , CCBs as verapamil , digitalis

■ if the pateint is hemodynamic unstable : ( hypotension , HF ) :
• DC cardioversion

■ prevention of PSVT : by evaluation by Electrophysiology for RFCA ( Radiofrequency Catheter Ablation)

🗯🗯 توقعات آخر امتحان نظري medical emergency :-

● التوكسو :-

○ C/P & ttt of organophosphorus

○ give a short note about antitode of snake venom

● الأطفال :

○ Define Respiratory faliure , its type , give in a short brief about investigation & clinical features

● الباطنة :

○ ttt of AF or ttt of VT

○ Enumerate 3 parental antihypertensive drugs used in ttt of HTN emergency with their indication & S.E

□ give a short note about HTN urgency

□ Define cardiac or CNS symptoms & examination & investigation for diagnosis of HTN emergency

■ سؤال AF اتكرر قبل كدا كثير و دايماً بجي ttt و أقل بيجي causes & presentation

■ سؤال VT جه كثير و اتكرر قبل كداا خاصة ttt & causes
دول بالمناسبة أكثر حاجة مشهورة و common