Pseudotumor Cerebri (Benign Intracranial Hypertension)[/color] -Headache, worse on straining. -Visual obscurations / diplopia -Level of consciousness may be impaired. -Other deficits depend on cause of intracranial hypertension or on herniation syndrome. -Examination reveals papilledema. causes - -. Thrombosis of the transverse venous sinus as a noninfectious complication of otitis media or chronic mastoiditis, and sagittal sinus thrombosis may lead to a clinically similar picture. ---Other causes include chronic pulmonary disease, -endocrine disturbances such as hypoparathyroidism or Addison's disease, - vitamin A toxicity, and the use of tetracycline or oral contraceptives. Cases have also followed withdrawal of corticosteroids after long-term use. Symptoms and Signs headache, diplopia, and other visual disturbances due to papilledema and abducens nerve dysfunction. Examination reveals the papilledema (see funduscopy) and some enlargement of the blind spots, but patients otherwise look well. Imaging no evidence of a space-occupying lesion, and the CT scan shows small or normal ventricles. MR venography is helpful in screening for thrombosis of the intracranial venous sinuses. *Lumbar puncture confirms the presence of intracranial hypertension, but the cerebrospinal fluid is normal. studies help exclude some of the other causes mentioned earlier. RX Untreated pseudotumor cerebri leads to secondary optic atrophy and permanent visual loss[/b]. -[b]Acetazolamide reduces formation of cerebrospinal fluid and can be used to start treatment. - Oral corticosteroids may also be necessary. -Obese patients should be advised to lose weight. - Repeated lumbar puncture to lower the intracranial pressure by removal of cerebrospinal fluid is effective, but pharmacologic approaches to treatment are now more satisfactory. -Treatment is monitored by checking visual acuity and visual fields, funduscopic appearance, and pressure of the cerebrospinal fluid. -If medical treatment fails to control the intracranial pressure, surgical placement of a lumboperitoneal or other shuntor subtemporal decompression or optic nerve sheath fenestrationshould be undertaken to preserve vision. -In addition to the above measures, any specific cause of pseudotumor cerebri requires appropriate treatment. [color=darkred]Meralgia Paresthetica -The lateral femoral cutaneous nerve, (sensory nerve from the L2 and L3 roots) may be compressed or stretched in obese or diabetic patients and during pregnancy. -The nerve usually runs under the outer portion of the inguinal ligament to reach the thigh, but the ligament sometimes splits to enclose it. Hyperextension of the hip or increased lumbar lordosissuch as occurs during pregnancyleads to nerve compression by the posterior fascicle of the ligament. -Pain, paresthesia, or numbness occurs about the outer aspect of the thigh, usually unilaterally, and is sometimes relieved by sitting. -Examination shows no abnormalities except in severe cases when cutaneous sensation is impaired in the affected area. - Hydrocortisone injections medial to the anterosuperior iliac spine often relieve symptoms temporarily, nerve decompression by transposition may provide more lasting relief [color=darkred]Aneurysms of the Thoracic Aorta[/color][/b] - account for fewer than 10% of aortic aneurysms. - Medial degeneration, chronic dissection, vasculitis, and collagen-vascular disease (Marfan's syndrome or EhlersDanlos syndrome) are common causes; -syphilis is now a rare cause of thoracic aneurysm. - Traumatic aneurysms occur at the ligamentum arteriosus just beyond the left subclavian artery and result from shearing injury during rapid-deceleration automobile accidents. Thoracoabdominal aneurysms are categorized by the Crawford [b]classification: Type I extends from the left subclavian artery to the renal arteries, -type II from the left subclavian artery to the iliac bifurcation, -type III from the midthoracic to the infrarenal region, and type IV from the distal thoracic aorta to the infrarenal region. The prevalence of each type of thoracoabdominal aneurysm is roughly equal, but type IV aneurysms have the lowest operative mortality (25%) and the lowest risk of postoperative neurologic deficits (210%). Clinical Findings depend largely on the size and position of the aneurysm and its rate of growth. - -Most are asymptomatic and are discovered during a diagnostic procedure undertaken for other reasons ( x-ray). - Some patients complain of substernal, back, or abdominal pain. Others experience dyspnea, stridor, or a brassy cough from pressure on the trachea, dysphagia from pressure on the esophagus, hoarseness from pressure on the left recurrent laryngeal nerve, or neck and arm edema from external compression of the superior vena cava. - Aortic regurgitation due to distortion of the aortic valve annulus may occur with aneurysms of the ascending aorta. Imaging -An aneurysm suspected on chest radiography must be differentiated from other anterior mediastinal masses, including lung neoplasm, thymoma, cyst, and substernal goiter. -CT scan and MRI are the most sensitive and accurate means of imaging thoracic aneurysms. - Aortography may be necessary to assess involvement of the arch vessels. The coronary vessels and the aortic valve should also be studied if aortic root replacement is anticipated. RX -Control of hypertension and use of Beta-blockers may slow aneurysmal growth. -Indications for surgical treatment include the presence of symptoms, rapid expansion, or size greater than 5 cm. - The thoracotomy incision is associated with a higher risk of pulmonary complications and more challenging postoperative pain management. Proximity to the recurrent laryngeal nerve, the phrenic nerve, and the carotid and subclavian arteries makes injury to these structures possible. The great radicular artery (artery of Adamkiewicz) arises from an intercostal artery between T8 and L1 and is the dominant artery to the spinal cord

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_________________________________________________________________ ISOLATED SYSTOLIC HYPERTENTION- RX of choice=THIAZIDE DIURETICS. _________________________________________________________________ SYNCOPAL EPISODE without following disorientation(i.e., not seizure) HEARING IMPAIREMENT NORMAL PHYSICAL EXAM. FAMILY HISTORY OF SUDDEN CARDIAC DEATH DIAGNOSIS=CONJENITAL `QT`PROLONGATION SYNDROME/Jervell Lange Neilson Syndrome PATHO-PHYS=Molecular defect in ion channel.,syncope-due to development od torsade de pointes type of ventricular tachycardia. RX=SYMPTO-Beta-BLOCKER+PACEMAKER ASYMPTO-Just Beta-BLOCKER. _________________________________________________________________- TEARING CHEST PAIN radiating to back.in a patientwho is/has(pregnant,bicuspid aortic valve,co-arctation of aorta,,marfans). Has HIGH BP(hypertenstion )at presentation. Has features of ISCHEMIA on ekg (due to involement of ostia.) DIAGNOSIS=AORTIC DESSECTION NEXT STEP IN MANAGEMENT=REDUCE HYPERTENTION. BEST DIAGNOSTIC TEST=TRANS ESOPHAGEAL ECHOCARDIOGRAM(TEE) __________________________________________________________________ CHRONIC CCF patient on digoxin,frusomide,simvastatin,spironolactone Develops RECURRENT VENTRICULAR TACHYCARDIA. DIAGNOSIS-=ELECTROLYTE IMBALANCE INDUCED ARRHYTHMIA Due to hypokalemia induced by frusemide that leads to digoxin toxicity RX=stabilize pt. With AMIODARONE. NEXT STEP AFTER STABILIZING=MEASURE SERUM ELECTROLUYTE TO CONFIRM DIAGNOSIS.

CCF(dyspnea,jugular venous distrntion,pedal edema,+ve kussmals sign) CXR-CARDIOMEGALY. ECHO-SYMMETRICALY ENLARGED VENTRICULAR WALLTHICKNESS,NORMAL CAVITY AND SYSTOLIC FUNCTION.,``SPECKLED APPEARANCE``. DIAGNOSIS=RESTRICTIVE CARDIOMEGALY secondary to AMYLOIDOSIS. _____________________________________________________________ DIPYRIMADOLE AND ADENOSISNE:- -both used in myocardial perfusion scanning to show areas of decreased myocardial perfusion. -both are conary VASODILATORS ,increase flow by 3-5 times but in CAD already distal segment to obstruction is dilated ,so there is redistribution of blood occurs to nondiseased areas with decreased perfusion to deceased areas this is known as CORONARY STEAL PHENOMENON ____________________________________________________________________ a patient develops PAIN,PARAESTHESIA,,PALE,COLD LIMB 3-4 days after ANTERIOR WALL MI in lower limb. Diagnosis=EMBOLIZATION FROM THROMBUS ON ANT. WALL OF LEFT VENTRICLE. BEST DIAGNOSTIC TEST=ARTIRIOGRAM of affected limb. RX OF CHOICE/NEXT BEST STEP AFTER DIAGNOSIS=EMBOLECTOMY *CLOT in proximal arteries EMBOLECTOMY PREFFERED but if present in DISTAL ARTERIES=INTRA ARTERIAL THROMBOLYSIS IS a good alternative. __________________________________________________________________ RX OF RESTRICTIVE CARDIOMYOPATHY -among all causes (amyloidosis,hemochromatossiis,sarcoidosis,idiopathic,sclerodermal,..)of restr.cardiomypthies only case where there is improvement in prognosis is treatement of HEMOCHROMATOSIS with phlebotomy and s/c despherioxaminez __________________________________________________________________ exertional dyspnea,fever,anorhexia,malaise ,fatigue,weight loss(SYSTEMIC SYMPTOMS)+MID-DIASTOLIC MURMUR WITHOUT OPENING SNAP. ECHO=MASS in left atrium. DIAGNOSIS=ATRIAL MYXOMA. DD=MS(opening snap present and systemic symptoms unlikely unless complicated by SBENDOCARDITIS in which case blood cultures will be positive Murmur of atrial myxoma also changes with position. _________________________________________________________________ *Atrial fibrillation in hyperthyroididm is RX with PROPRANOLOL(because atrial fib in grave is due to increased sensitivity of adrenoreceptors to sympathetic stimuli *Same (beta blocker) is RX in pts with HYPERTROPHIC CARDIOMYOPATHY HAVING SYNCOPE AND CHEST PAIN here because thry improve diastoloic filling of ventricles by increasing duration of diastole by reducing heart rate.and also decreasing oxygen demand. ___________________________________________________________________ INFECTIVE ENDOCARDITIS CATEGORY ,...CAUSITIVE ORGANISM NATIVE HEART VALVE ..S.VIRIDANS(60%),ENTEROCOCCUS(20%), DAMAGED HEART VALVE S.VIRIDANS I.V. DRUG ABUSERSS.AUREUS PROSTHETIC VALVE ENDO(within first 2months).S.EPIDERMIDIS PROSTHETIC VALVE ENDO(>2 months).S.VIRIDANS ___________________________________________________________________ AR(aortic regurgitation) RX ASYMPTOMATIC=OBSERVATION AND REGULAR FOLLOWUP SYMPTOMATIC=AORTIC VALVE REPLACEMENT following stabilizing pt for CCF (digoxin,diuretic and ace inhibitors). POSTOPERATIVE patient developing sudden drop in BP following trying to sit up in blood, with DISTENDED JUGULAR VEINS,RBBB ON EKG,BRADYCARDIA Diagnosis=MASSIVE PULMONARY EMBOLISM.