Infective endocarditis

              Patient usually come recurrent history of fever, tired, night sweat, athralgia, weight loss. May or may not have history of  rheumatic history. Sign: splinter heamorrhage, janeway lesion, osler node, roth spot (heamorrhage, pale at the centre), splenomegally.

duke's criteria: ( 2 majors, 1 mojar and 3 minors or 5 minors)

Major Criteria:

a) positive blood culture (3/4 consequtive blood culture, typical organism

b) positive echo finding (new murmur, vegetation

Minor Criteria:

1) risk factor: IVDU, prosthetic valve, rhematic fever.

2) fever 38'C

3) evidence of vasculitis lesion: (splinter heamorage, optic??,JL)

4) blood culture that not meet criteria

5) echo finding that not meet criteria 

Investigation:

FBC, renal function, blood culture, ESR, urine (microscopic heamaturia), echo, ECG, TB workup (if suspected), 

complication:

a) emboli

b) CF, heart block.

management:

abx (4-6w)

strep : penicillin G and iv gentamicin. staphy (cloxacillin or vancomycin), culture negative of native valve: (penicillin G and Iv gentamiccin)

ENLARGE KIDNEY

Differentials:

• hydronephrosis
• acute pylonephrosis
• polycystic kidney disease
• renal cell carcinoma
• renal abcess (usually unilateral)

Describtion:

There is a mass on left/right lumbar region. 

it is firm and non tender

it is ovule in shape, well-define margine and smooth surface. measure is...

can get above and below it. belotable.non pursatile.

it descends inferiorly during inspiration.

resonance on purcussion and no bruit.

Chronic liver disease

Cause of chronic liver disease:(AAudiO)

• Infective: hepatitis
• drug: methydopa and methotraxate
• autoimmune - autoimmune hepatitis
• alchohol
• other: primary biliary cirhosis, wilson's disease.

complication: HEPATIK

• hepatic encephalopathy
• Portal hypertension + varices 
• Ascites
• Tumour (hepatoma)
• Infection (spontanous bacterial peritonitis)
• Kidney (hepatorenal syndrome)

Examination: 

general inspection:

• confuse, drowsienss(hepatic encephalopathy), hyperpigmentation (heamotocromatosis)

hand :

• leukonychia, duputyren's contracture, flapping tremor, palmar erythema, fingger clubbing (5)

forearm: 

• scratch mark, tatoo, bruising, injection mark. (IVDU)

face

• scleral icterus, xanthelasma, parotid swelling

neck

• lymphadenopathy

chest 

• spider neavi, gyneacomastia, loss of axilary hair, 

abdomen

• caput medusa, dilated vein,  hepatomegally, ascites, loss of pubic hair, splenomegally

leg

• oedema

end examination:

other: testicular atrophy

ask history about alcohol, drug abuse.

Investigation: (aaudio)

• liver function test : gamma GT, liver damage, bilirubin 
• Full blood count : anemia(bleeding, folate def, alcohol), thrombocytopenia and leukopenoa (TL - hypersplensim)
• coagulation profile - lbleeding tendency
• hepatitis serology
• antimicrobial antibody (PCB)
• sm antibody, antinuclear antibody, anti-microsomal antibody - autoimmune hepatitis
• ascites fluid analysis
• ultrasound
• liver biopsy

  

Splenomegally

Describtion.

There is mass on left upper quandrat or left hypocondrium.

It is firm and non tender.

It ovule in shape, well define edge and smooth surface. there is a notch felt on the medial border of the mass. The size is 10 cm.

The mass decends inferiomedially with respiration.

i cannot get above it but can get below it. Not bellotable, non pursatile.

dull on percussion,trob space is dull and no bruit.

so my inference is spellenomegally.

Causes of splenomegally: (CHINA)

• Congestion- portal hypertension, congestive heart failure
• Hemolytic anaemia - thalessemia and hereditary spherocytosis
• Infection :- bacteria (thypoid, typhus, infective endocarditis), Viral (CMV, Infective mononucleosis), paracitic (malaria), fungal
• Neoplasia (myelo/lymphoproliferative disorder)
• Autoimmune - Connective tissue disease.

Causes of splenomegally

• cirhhosis with portal hypertenion
• infection: infective mononucleosis, acute viral hepatitis
• hematological disorder : lymp/myeloproliferative disease
• connective tissue disease :SLE

Hepatomegally

Normal liver span: women 6-10cm man 8-12cm.

Describtion:

there is a mass on the RIGHT UPPER Quadrant:

- shape, size, edge, surface, consistency

- tender, pursatile, move up and down with respiration.

- ausculatation: bruit

eg: there is a mass on right upper quadrant which move with inspiration.

It is has irregular shape, smooth surface, well define age and firm consistency, liver span is 15 cm.

Cant get above it but can get below it.

it tender on palpation, non pursatile, dull on purcusssion and no bruit. 

so my differential diagnosis will be acute hepatitis, acute biliary obstruction, acute cholangitis and acute congestion of liver secondary to cardiac failure.

we should also consider other c auses of hepatomegally: (DIA MIC)

• Drug/toxic: alcohol
• Infection: hepatitis, abcess (amebic, pyogenic),thypoid
• Autoimmune : lupus hepatitis.
• metabolic: Wilson's disease
• Infiltative: benign (fatty liver), malignancy (lymp/myeloproliferative), hepatoma, metastasis.
• Congestion: Congestive heart failure

Tender liver:

• acute hepatitis
• acute cholangitis
• liver abcess
• acute bilirary obstruction
• acute congestion of liver due to congestive heart failure

Irregular and firm liver

• hepatoma, cirrosis, metastases and cystic liver.

Tuberculosis quiz

what is the side effects, interection and contraindication of the TB medication. remember  (IRP SE)

1. Isoniazide

• SE:
• I:
• CI

2.  Rifampicin

• SE:
• I:
• CI:

3. Pyrazinamide

• SE:
• I:
• CI:

4. Streptomycin

• SE:
• I:
• CI:

5. Ethambutol

• SE:
• I:
• CI:

(complete within 5 min)

pneumonia quiz

1. How do u classify pnemonia?

2. What pathogens responsible?

3. CURB-65?and it interpretation?

4. What antibiotic that u gonna use?