I . HIV infection : HIV: high risk patient, oral manifestation, investigation, complication ? *mode of transmission: 1.

sexual : homosexual and heterosexual. 2. parental : transmission in recipients of blood or blood product and injection of drug user 3. vertical : from mother to baby * risk factor (patient): 1. sexual transmitted infection, especially genital ulcer 2. injection drug use transmission : sharing needle, frequency of use, prostitutes, intravenous use. 3. occupational transmission ( nurse, doctor, lab worker ) deep injury, visible blood on device 4. vertical transmission : ( peripartum and breast feeding ) * natural history : 1. primary infection/ seroconversion : -Is symptomatic and occurs 2-4 weeks after exposure (incubation period ) -clinical feature : Fever erythematous fatigue mucosal ulceration headache Opportunistic infections such as oropharyngeal candidiasis. -recovery occurs in 1-2 weeks but may take up to 10 weeks 2. asymptomatic infection / clinical latency : -no evidence of disease -persistent of generalized lymphoadenopathy -the virus continues to replicate -the median time is 10 yrs from infection to development the AIDS. 3. mildly symptomatic disease: - chronic weight loss, fever, diarrhea, oral or vaginal candidiasis, oral hairy leukoplakia, recurrent herpes zoster, sever pelvic inflammatory disease, cervical dysplasia & ITP 4. AIDS : - development of specified opportunistic infections and tumors. - progresses the viral load rises - CD4 count falls -kaposi's sarcoma, Cryptococcus, histoplasmosis * clinical syndrome : -mucocutaneous manifestation - gastrointestinal effect - hematological complication - respiratory complication - neurological disease *oral manifestation: - oropharyngeal candidiasis - oral candidiasis - aphthous ulcer

- eye disease - renal complication - cardiac complication

- mucosal ulceration in the mouth - oral hairy leukoplakia - SSC

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- kaposi' sarcoma - lymphoma *complication: - kaposi's sarcoma - histoplasmosis

- fungal infection

- Cryptococcus - molluscum contagiousm - non-hodgkin's lymphoma

*investigation : -HIV antibody : confirmation of HIV by ELISA antibody testing - PCR for HIV RNA - viral load ( HIV RNA ): by PCR or bDNA or NASBA method - absolute CD4 count * management : Antiretroviral drugs : - Nucleoside reverse transcriptase inhibitors - Non-Nucleoside reverse transcriptase inhibitors - Protease inhibitors

II . Asthma & COPD: 1. COPD : causes, sign, symptoms, investigation, complication ? *Definition: airflow limitation that is not fully reversible due to chronic bronchitis or emphysema. The airflow limitation is progressive and associated with abnormal inflammatory response of the lungs to noxious particles or gases. *Causes: 1- cigarette smoking is the primary cause. 2-Air pollution, airway infection, allergy and familial disorder. 3-Alpha 1- antitrypsin deficiency. *Risk factors: Host factors: - genes (alpha 1- antitrypsin deficiency). - hyper responsiveness. - lung growth. Exposure: - tobacco smoke. - Occupational dust and chemicals. - Infections. - Socioeconomic status. *Signs: Inspection: - dyspnea - accessory muscles of respiration are used (sternomastoid, scalene). - pursing of lips. - reduction in the length of trachea above the sterna notch.

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- tracheal tug. - jugular venous distention during expiration. - chest becomes barrel-shaped. - central cyanosis. Palpation: -percussion note is hyper-resonant. - loss of normal area of cardiac & liver dullness. Auscultation: -breath sounds are decreased. - prolonged expiration. - coarse crepitations. - rhonchi at expiration. *Symptoms: Cough: tightness in the chest. Expectoration: sputum. Dyspnea: on heavy exertion. *Investigations: -Chest x-ray - ABGs. - pulmonary function test. - sputum culture & sensitivity. - ECG: tall P wave. - alpha 1- antitrypsin deficiency. - echocardiography: to assess pulmonary artery pressure. *Complications: -type 1 & type 2 respiratory failure. - secondary polycythemia. - spontaneous pneumothorax. - acute bronchitis, pneumonia. - pulmonary hypertension and right ventricular failure (corpulmonale). Hypoxia pulmonary arteriolar vasoconstriction pulmonary hypertension RT heart failure (cor pulmonale). 2. bronchial asthma : definition, type, precipitating factor? sign and symptom of acute exacerbation? * Definition : the narrowing of bronchial airway is due to muscle spasm, mucosal swelling and viscid bronchial secretion (paroxysmal narrowing) chronic inflammation leads to increase airway hyperresponsiveness with recurrent episodes of wheezing, coughing and shortness of breath. * Types : -early onset asthma (episodic, atopic or extrinsic asthma) -late onset asthma (chronic or non-atopic or intrinsic asthma) * Etiology : - atopy and allergy - airway hyperactivity

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* Pathogenesis : -inflammation and asthma -immediate response -late phase response (or reaction) *Precipitating factor : - abrupt changes in weather - dust, tobacco smoke, atmospheric pollution - respirator viral infection - drugs and other NSAID, beta-blockers *Investigation : - chest x-ray - arterial blood gases *Complication : - dehydration - pneumothorax

-cold air -exercise -emotional stress

- peak expiratory flow rate

- airway infections - respiratory failure

- exhaustion - Cor pulmonale

*Management : - prevention : - Avoid : - causative allergens, - beta-blockers - ACE-inhibitor drugs - early ttt - stop smoking, - pneumococcal vaccination, - hyposensitization (vaccination). - treatment : - long term control medication Inhaled steroid, long acting beta2 agonist, antileukotrienes, methylxanthines, systemic steroid - quick-relief medication Short acting beta2 agonist, anticholinergics, systemic steroids Acute sever asthma : *sign: - sever shortness of breath - cannot speak - central cynosis - cannot lie down - unable to speak - relative bradycardia - unrecordable PEF - O2 saturation <1% - exhaustion, confusion, reduced conscious level *Symptoms: - feeling of tightness in the chest - unproductive cough which aggravates the dyspenea

- episode of dyspnea - wheeze

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III . Infective endocarditis : What are the clinical feature of infective endocarditis ? Sign, symptom, complication of infective endocarditis ? * Clinical features (signs & symptoms): - General sestems: malaise , clubbing, anorexia, weight loss, night sweats, fatigue. - Cardiac features: murmurs, cardiac failure. - Arthralgia, back pain. - Pyrexia - Features of immune vasculitis (Skin lesions): osler's nodes, splinter hemorrhage, janeway lesions, petechiae. - Eyes: roth spots, conjunctival, splinter hemorrhages. - Splenomegaly. - Neurological: cerebral emboli, mycotic aneurysm. - Renal: haematuria. - Features of embolism: stroke, sever limb pain, pulmonary or myocardial infarction. * Complications: 1- Cardiac complications: - CHF. - valvular damage. - valvular stenosis. - abscess extending to myocardium (conduction disturbances) and pericardium (purulent pericarditis). - coronary embolism. - prosthetic dehiscence. 2- extracardiac complications: - Embolism (cerebral - renal - splenic). - stroke - blindness - gangrenous extremities - unusual pain syndromes - paralysis - Abscesses. - Pulmonary abscess or infarction. - Immune complex (arthritis glomerulonephritis).

Done by: Turki Alkhallagi Shaymaa Mudhaffer Sumayah Halabi 4th year 2009 2010

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