Wolf-Parkinson-White (WPW) OR Pre-excitation syndrome:

Wolf-Parkinson-White (WPW)

                                  Notice short PR interval and gradual upstroke of QRS complex

It's the premature excitation of the ventricular muscle before the normal conduction pathway delivers the normal electrical impulse due to the presence of an accessory bundle between Atria and Ventricle.

ECG would show:

1- Short PR interval

2- Wide QRS complex with an initial slow upstroke (called DELTA wave) before QRS complex

Management:

1- If the patient is clinically stable: use Procainamide, the use of B blockers or calcium channel blockers are absolutely contraindicated, because they may lead to over-riding of the bundle of Kent which may predispose to SVTs and VTs.

2- If the patient is Unstable: Electric cardio-version.

3- Ablation of the accessory bundle is the Definitive treatment.

Uric acid stones

- Uric acid renal stones develop in patients with chronic gout due to hyperuricosuria,
 

- Uric acid stones present with loin pain radiating to the flanks, hematuria, and history of previous attacks of gouty arthritis or hyperuricemia.

- Uric acid stones are RADIOLUCENT and don't appear on X-ray, so for diagnosis CT scan (without contrast) is required.

- Management:

It's mandatory to start with adequate hydration, analgesics and pain killers.

Also you have to add either Potassium Citrate or alkalization of urine using Potassium bicarbonate; you have in general to avoid alkalization of urine with sodium bicarbonate in order to prevent formation of calcium stones.

Renal stones less than 2 cm are treated with Extra-Corporeal shock wave lithotripsy (ECSWL), multiple or stones greater than 2 cm in size should undergo per-cutaneous extraction.

Chondrocalcinosis

Pseudogout:

-Due to the deposition of calcium pyrophosphate crystals into the joints, clinically it presents identical to the acute gouty arthritis, most commonly occurring in the knee, ankle, shoulder and Wrist joints.

-Most commonly occurs in joints with a previous damage; in elderly with no history of joint lesion always think about metabolic causes like hyperparathyroidism, hemochromatosis, hypophosphatemia and hypomagnesaemia.

Diagnosis is established through aspiration of the synovial fluid showing characteristic rectangular, rhomboid shaped POSITIVE BIREFRINGENCE crystals.

X-ray will show characteristic chondrocalcinosis. (IMPORTANT)

Management is identical to acute gouty arthritis, with NSAIDs, or steroids in elderly patients with renal impairments whom cannot tolerate NSAIDs or colchicine which is rarely used in general.

Management of GERD

Diagnosis of GERD is mainly CLINICAL, and once it's clinically suspected it's treated directly, no need for investigations unless the diagnosis is equivocal,

 

The most specific test for GERD is 24 hours esophageal pH manometry test, which is rarely performed.

Endoscopy may be associated with esophageal inflammation, or may be normal; a normal endoscopy DOESN'T exclude GERD.

Endoscopy is ONLY performed in the following conditions:

1- Loss of weight

2- Anemia/Heme positive stools

3- Dysphagia

4- Persistence of symptoms for more than 5 years to exclude anatomical abnormalities as Barett's esophagus.

INTERMITTENT Reflux is treated by Antacids and H2 blockers.

PERSISTENT Reflux is treated through Proton Pump Inhibitors.

If GERD symptoms didn't improve upon with medical treatment, surgical intervention may be scheduled:

1- Nissen Fundoplication: wrapping the stomach around the LES

2- Endoninch: suturing around the LES guided by endoscopy

3- Heat/Laser irradiation to induce scar.

Alzheimer's disease:

DSM IV criteria in diagnosis of Alzheimer's disease include:

Progressive loss of Memory in addition to any of the following criteria:

1- Impaired language functions

2- Inability to execute motor activities in absence of suggestive pathological motor weakness, confirmed by normal physical examination.

3- Impaired executive functions

4- Disturbances of visual processing (Hallucinations, delusions, illusions and Paranoid/aggressive behavior).

Diagnosis is confirmed by conduction of Mini-mental status examinations MMSE which will show impaired mental status regarding memory cognitive and executable functions.

Radiological investigations are not necessary at all, as diagnosis of Alzheimer's disease is essentially clinical.

CT scan will show diffuse cortical atrophy with no cerebral masses

Don't be confused with any lab abnormalities or any associated anemia, unless you are suspecting other causes of dementia or delirium like hepatic or renal encephalopathy.

Management:

 Is targeting to slow down progression of the disease as the disease is an Irreversible debilitating condition .

Donepezil, Rivastagmin, Galantamine are Anticholinesterases

Memantine are NMDA receptors ANTAGONIST.