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Dr.

Rami Abazid

MAGDY ABBAS

BRAIN MAP
FOR
PACES
PREPARED BY:
DR. RAMI ABAZID

Dr. Rami Abazid

TO: THE SOUL OF MY PARENTS

TO: Jailan, Diaa,


Mariam and Reham

Dr. Rami Abazid

PREFACE
This edition of the brain map for
PACES is basically designed for the
busy dynamic young doctors who
intended to go through the exam.

I hope this will help candidates to


pass with case.

Dr. Rami Abazid

ACKNOWLEDGEMENTS

I would like to express my sincere feelings and


thanks to the following people.

Dr. Abdulfatah Arafaa-Medical Consultant in the


Farouk Charity Hospital-Cairo

Dr. Abdulla Hamed Abo Jabal-Consultant in Tropical


Medicine, Embaba Fever Hospital-Cairo

Dr. Mohamed Samer-Senior Cardiologist in Mubarak


Hospital-Kuwait

Dr. Samy Zaki-Professor of Gastroenterology-Al


Azhar University-Cairo
4

Dr. Rami Abazid

ABOUT THE AUTHOR

DR. MAGDY ABBAS

Graduate from Cairo University worked as a


Registrar in Kasr El Aini Hospital (Cairo)
Senior Registrar In Adan University (Kuwait)
Consultant in Embaba Fever Hospital (Cairo)

Participated in many Teaching programmed in


Egypt

Dr. Rami Abazid

THE PACES EXAMINATION:

Brief Clinical
Consultation
Communication

10 mins.

Skill

Brief Clinical
Consultation

20 mins.

Cardiology
10 mins.

10 mins.
(5)

(4)
(3)

(1)

(2)
Neurology

Chest

History taking

10 mins.

20 mins.

Abdomen
10 mins.
6

10 mins.

Dr. Rami Abazid

STATION I
MAP FOR

ABDOMEN
&

CHEST

Dr. Rami Abazid

ABDOMEN CASES
With stigmata of
CLD

without stigmata of
CLD

Cirrhosis

Hepatomegally

hepatosplenomegally

Splenomegaly

Ascites

Abdominal masses

I would like to complete my examination


1- Per rectal examination
2- External genitalia
3- Hernia orifices
4- Lymph nodes
5- Urine dipstick
6- BP T (temperature)
8

Dr. Rami Abazid

CLD
Signs

Decompensated
Signs

Spider
Naevi Arms
Fistula
Hands

Parotid
Swelling
Jaundice
Wasting
Pallor
Anthelasma

Ascites

Jaundice

Investigation

General
* CBC
* electrolyte
Assess
Liver
Function
-S. Bil.
-S. Alb
-PT
-ALT
-AST

complications

& FP
U/S

Search
for the
cause

Face

Chest

Shrunken
Liver
Hepatomegaly
Splenomegaly
Ascites

Clubbing
leuconychia
Palmer erythma
Dupuytrens
Contracture
Hepatic
Encephalopathy
Flap
.

D-D

Spider
Naevi
reduced axillary hair
Gynaecomastia

hepatitis
H.chr. Wilson
C. B.
Alcohol PBC
Virdogy
Drugs
Study
AIH

Abdomen
venous
Hum ---L.L. oedema

Alpha 1,AT

Auto Immune
Iron
Study
Study

Metabolic

Caput Medusa -Testicular Atrophy

Wilson
Alpha1 AT

Dr. Rami Abazid

COMPLICATION
OF
CIRRHOSIS

Portal hypertension

Varices

Ascites

Hepato Cellular Dysfunction

hepato
Renal
Syndrome

Encephalopathy

Coagulopathy
Bleeding

Spontaneous
Bacterial
Peritonitis

10

Hepato
cellular
carcinoma

Dr. Rami Abazid

POOR PROGNOSTIC FACTORS


IN
LIVER CIRRHOSIS

Encephalopathy

Na

PT

Albumin
25g/L

< 120

FACTORS PRECIPITATE HEPATIC ENCEPHALOPATHY

Infection

Diuretics

Electrolyte

Diarrhea

Imbalance

Vomiting

Sedative

Surgery

Paracentesis

GI Bleeding

11

Dr. Rami Abazid

TREATMENT OF ASCITES
IN

CLD

Rest

Salt restriction
to <29/day
(Dietician)

Furosemide
up to
120mg/day

Serial
Paracentesis
Fluid
Restriction
If Na is < 125mmol/L

Spirino Lactone
Na excretion >78
mmol/day
up to 400mg/day

TIPS
Transjugular
Intra hepatic
Portal systemic
Shunt

(Aim: one KG weight loss/day)


12

Dr. Rami Abazid

PRIMARY PREVENTION OF VARICEAL BLEEDING


DIAGNOSIS OF CIRRHOSIS

OGD
No varices

Repeat OGD

Grade I Varices

repeat OGD one year

3-4 years

Grade 2 or 3 varices

Propranolol
80-160mg/day
HR60
Band ligation if
Propranolol intolerant
or Verapamil
Diltiazem

MANAGEMENT OF VARICEAL BLEEDING


IN CIRRHOSIS

Blood transfusion Octreotide

Endoscopic
Sclerotherapy
13

Endoscopic
ligation

TIPS
Balloon
Tamponade

Dr. Rami Abazid

HEPATOMEGALY

3 C

3 I

1-Cirrhosis

1-Infection

2-Cardiac CCF

-HBU

3-Cancer

-HCU
-T.B.
-Brucella
2-Infiltrative
-Amyloid
-Sarcoid
-Myeloproliferative
3-Immune
-AIH
-PBC

14

Dr. Rami Abazid

SPLENOMEGALLY

Mild

Moderate

<4 cm

(4-8 cm)

INFECTIONS

Massive

-Infections

EBU

-Myeloproliferative

Kala Azar

Infective Endocarditis

-Lymph proliferative

Malaria

Hepatitis

-Hemolytic anaemia

Bulhorzia

AUTO IMMUNE

- Infiltration

-Myeloproliferative

Rh. Arthritis

Gauchers

CML

Infiltration
Sarcoid

Amyloidosis

Myelofibrosis

15

Dr. Rami Abazid

MOST COMMON CAUSES OF ASCITES

Pancreatitis
Cirrhosis

Malignancy

Heart Failure Tuberculosis

TRANSUDATIVE OR EXUDATIVE
S-A ALBUMIN GRADIENT

11 g/L

11 g/L

Transudative

Exudative

MYXAEDEMA
CLD

CHC

MAGs SYNDROME

CRF

MALIGNANCY T.B.

16

INFECTION

Dr. Rami Abazid

RENAL ANGLE MASS

Polycystic

Renal Cell
Carcinoma

Hydronephrosis
Adrenal mass
Retroperitoneal
Mass

WHY RENAL MASS

Can get
Above it

Ballottable

Minimal
movement with
inspiration

No
Notch

17

Resonant to
Percussion

Dr. Rami Abazid

SURGICAL INTERVENTION IN
POLYCYSTIC KIDNEY

Massive
Cysts

Recurrent
Pain

Transplant
work up

Recurrent
Infected
Cysts

Possible
Malignancy

ASSOCIATED INHERITED CONDITION


WITH RENAL CYSTIC DISEASE

Tuberous
Sclerosis

Von-Hippel
Lindou disease

Autosomal
dominant polycystic
Kidney

18

Autosomal
recessive
Polycystic
Kidney

Dr. Rami Abazid

CHEST CASES

19

Dr. Rami Abazid

INTERSTITIAL LUNG DISEASE


Dry
Cough

S.O.B.

Fine Endispiratory
Crackles

CAUSES

TIP
Rheumatological
- Rh. Arthritis
Vasculitis
- S.L.E.
- PAN
- Systemic Sclerosis
-Wegners
- Polymyositis
-Churg-Strauss
- Dermatomyositis
-Good Pastures
- Ankylosing Spondilitis
- MCTD
- Sjogrens Syndrome
Allergic

Pneumocomosis
-Asbestosis
Silicosis
-Beryliosis

Extrinsic
Allergic
Alveolitis

20

Drugs
Amiodarone
Nitrofurnatone
Busulphan
Bleomycine
Gold
Radiation
Methotraxte
OTHERS
Gauchers
Lymphangiomyelomatosis
Niemann Pick
NF
Tuberous Sclerosis

Dr. Rami Abazid

IDIOPATHIC INTERSTITIAL PNEUMONIA


TIP

Linda

Usual
Interstitial
Pneumonia
(UIP)
Non Specific
Interstitial
Desefuamative
Pneumonia Interstitial
(HSIP)
Pneumonia
(DIP)

Respiratory
Bronchiolitis
Interstitial
Lung disease
(RB-ILD)

Acute Interstitial
Pneumonia
(AIP)

21

lymphoid
Interstitial
Pneumonia
(LIP)
Cryptogenic
organizing
Pneumonia
(COP)

Dr. Rami Abazid

INVESTIGATIONS OF ILD

Lab.
Radiology
Respiratory
-FBC
better for
-Inflammatory markers
upper lobe
-immunoglobulin
-autoimmune profile
CXR HRCT
MRI
ANA
Pul. Function
lung
ENA
Test
biopsy
ANCA
restrictive
Anti G-BM
pattern
Reticular
Coarse
Ground
Shadowing reticular
glass
BAL
-Precipitins
-Serum ACE
-ABG
Honey combing
neutrophils
lymphocytes
Not responded
To cortisone
Good response
To corticosteroid
Bad prognosis Good prognosis

Respond to
Corticosteroid

22

Dr. Rami Abazid

MANAGEMENT OF ILD

Non Pharmacological

Smoke
Cessation

Avoid exposure
to toxic
Substance

Lung Transportation

long term
oxygen

corticosteroids
+
Azathoprine

If not tolerate
Corticosteroids
Azathoprine alone
Discontinuation
Of toxic medication

23

Young Patent
rapidly
progressive
Disease

if not tolerate
Azathoprine
Cyclophosphamide

Dr. Rami Abazid

UNILATERAL LUNG FIBROSIS


EXAMINATION

Flattening of
The affected side
Heterogenous
percussion of
the affected
side

Breath sounds
trachea is
reduced
shifted to
+
the affected
coarse crackles side
not changed with
cough
+
VR
on the affected side

Reduced movement
Of the affected side

24

Dr. Rami Abazid

CAUSES OF APICAL FIBROSIS

Histoplasmosis
Old T.B.

Radiation

Ankylosing
Spondolitis

Sarcoidosis

Extrinsic allergic
Alveolitis

CAUSES OF BASAL FIBROSIS

ILD

Aspiration

Asbestosis

Drugs

25

Connective
Tissue disease

Dr. Rami Abazid

PLEURAL EFFUSION

Chest expansion
On the affected side

breath sounds
bronchial breathing
Above the effusion

Stony dullness on
Percussion

PLEURAL EFFUSION

Exudates
PL. protein>35g/L

Pl. Protein between


(25-35) g/L

Lights criteria
For exudates

26

Transudates
Pl. protein
<25g/L

Dr. Rami Abazid

PLEURAL EFFUSION
Exudates

Transudates

Protein >35g/L

between
25g/L 25g/L
Lights criteria for
Exudates

Protein <25g/L

Megs
Syndrome
Cardiac
Failure
Infiltration
(neoplasm)

infections

CLD

CRD

Inflammation
Rh. arthritis

SLE
Infarction P.E.

Pl. Fluid LDH 2/3 of


serum LDH
Protein/Serum Protein >0.5
Pl. Fluid LDH

DRUGS
Serum LDH >0.6

Amiodorone

Phenytoin

Methotrexate

27

Dr. Rami Abazid

PNEUMONECTOMY

Chest wall
Chest expansion
Scar

Trachea

Flattering of the
Affected side
Absent on
The affected side

Grossly deviated
to the affected side

Breath sounds
absent on
the affected side

LOBECTOMY
Scar

Chest wall

localized
Deformity

Chest expansion

Trachea

reduced on the
affected lobe

deviated to the
affected lobe
On upp.lobectomy

28

Breath sounds

reduced on the
affected lobe

Dr. Rami Abazid

LUNG CONSOLIDATION

Chest wall

Chest expansion

Trachea

Percussion

Reduced

not shifted
Except if associated
Collapse

normal
dullness

Breath
Sounds

CAUSES
Bronchial
breathing

crepitations
Infection

Vasculitis

malignancy

Cysts
Vocal
resonance

Infarction

Granuloma

29

Dr. Rami Abazid

BRONCHIECTASIS
Irreversible dilatation, destruction and Inflammation
of the Bronchial wall

Examination

Excessive
Productive
Cough

finger clubbing

Coarse Inspiratory
Crepitations which
Alter with coughing

CAUSES

T.B.
CONGENITAL
-

Immotile
Cilliary syndrome
Kartagners syndrome
Young syndrome
C.F.

Malignancy

CHILDHOOD INFECTION
-measles
-Pertussis

Foreign
Body

-Post Pneumonia
(Staph., Klibsella)

30

Immune deficiency
- hypogan maglobulnoia
-Allergic Aspergillosis

Dr. Rami Abazid

BRONCHIECTASIS
Investigations

Lab

-Sputum CLS
-Sputum AFB
-Sputum gram stain
-Immunoglobulins
-Rheumatology profile
-Na Sweat Test
-Genetic Screening for C.F.

Radiology

CXR

HRCT

Special

Bronchoscopy
for malignancy

Tranlines shadows
Ring shadows

31

Signet ring sign


Thickened dilated
Bronchi Larger than
Vascular bundle

Dr. Rami Abazid

BRONCHIECTASIS MANAGEMENT

Non Pharmacological
-Stop smoking
-Pulmonary Rehabilitation
-Multi-disciplinary
Management

Medical

Vaccination
Surgery
-annual Influenza
for localized
-H. influenza
-Antibiotic
disease
-Pneumococcal
for exacerbation
-long term antibiotic
-bronchodilators
-Inhaled corticosteroid

32

Dr. Rami Abazid

OBSTRUCTIVE AIRWAY DISEASES

Chronic Asthma

Reversible

Chronic
Obstructive
airway disease
COAD

Cause

Chronic
Bronchitis

Diurnal
Variation

Emphysema

Smoking

Irreversible

33

No
Cause
Diunal
variation Pollution

Dr. Rami Abazid

INVESTIGATIONS OF OBSTRUCTIVE
LUNG DISEASE

Lab.
Others
-FBC

Radiology

E.C.G.

-urea Electrolytes
-LFT

-CXR

-Rt. ventricles
Hypertrophy
-P. Pulmonale

-Inflammatory markers
-S. & antitypsis
-ABG

-HRCT
for emphysemia

-Echo

-Sputum

-RFT

CLS
gram
Stain

(Spirometry)

34

Dr. Rami Abazid

MANAGEMENT OF OBSTRUCTIVE
AIR WAY DISEASE

Non pharmacological

Vaccination

Pharmacological

-Stop smoking
-Pul. Rehabilitation
Annual
Influenza
Vaccine

H. Influenza

Pneumococcal
Pneumonia

Bronchial Asthma

COAD

B2 against or
Anticholinegic
SABA
Or SAMA
35

LABA
+
inhaled
corticostriods

LABA
+
inhaled
+
Theophylline

Dr. Rami Abazid

BRITISH THORACIC SOCIETY GUIDELINES

STEP 1

STEP

STEP 5 =step 4

Add beclomethasone
100-400 ug/12h

Occasional
Short acting
Inhaled B2 against

If > than once daily


Or night Time symptoms

+
-oral Prednisolone

STEP
+ 3

STEP 4

-LABA
-Beclomethasone to 1000 ug/12h
- dose of
oral Theophylline
Beclomethasone
oral leukotrene antagonist
To 400ug/12h
oral B2 against
oral leukotrene receptor
oral Theophylline

STEP 2

36

Dr. Rami Abazid

STATION 3
MAP FOR
CARDIOLOGY
NEUROLOGY

37

Dr. Rami Abazid

CARDIOLOGY EXAMINATION

Non Auscultatory

Auscultatory
Rt. A.S.

Carotid
Thrill
Pulse
Lf. P.S.
Both
Radial

JVP

AF
or not
-small pulse
Or
-Big pulse volume
-Average

Collapsing
Water
Hammer
Or not

V Wave w/
Carotid TR

38

Dr. Rami Abazid

AUSCULTATORY
APEX
Axilla
Soft Pansystolic
Murmur
MR

H.S.

2nd Rt. Intercostal


space
-1st H.S.
ejection systolic
Murmur A.S.

3rd left intercostals space


while patient leans forward
after expiration early
diastolic murmur

Murmurs
Lower left
Sternal edge
TR ( Insp.)
4th H.S.
Near the 1st H.S.
2nd H.S. opening
snap near it

A.R.
nd

2 left
intercostal
Left sternal Carotid
edge
R A.S.
V.S.D.
L
P.S.
A.S.D.
fixed splitting
2nd H.S.
HOCM
valsalvis

2nd H.S.

1st H.S.
P. HTN
normal

M.R.

A.S.
P.S.

M.S.

39

Dr. Rami Abazid

AORTIC STENOSIS
A.S.

Symptoms

Non Auscultatory
Findings

Auscultatory

Ejection systolic
Murmur with
Expiration radiate to
neck
Dyspnoea

Syncope

Chest pain

-small pulse
Volume

Apex
heaving

-Slow Rising
Pulse
-Narrow Pulse
Pressure

Systolic thrill in
Aortic area

SIGNS OF SEVERITY
Pul. HTN

Pul.
congestion
Slow-rising pulse
Small Pulse volume
Narrow Pulse Pressure

Heaving
Apex

Systolic
Thrill

40

Soft 2nd
heart sound
A2

4th H.S. Long


murmurs

Dr. Rami Abazid

Bicuspid

Congenital

Indications for Aortic


Valve replacement

41

Rheumatic

Degenerative

Dr. Rami Abazid

AORTIC REGURGITATION A.R.

SYMPTOMS

NON AUSCULTATORY
FINDINGS

AUSCULTATORY
FINDINGS

SIGNS OF SEVERITY
Long duration of
The murmur

Wide Pulse
Pressure

Austin Flint murmur

3rd H.S.

42

P.HTN

Dr. Rami Abazid

A.R.

CAUSES

INDICATION FOR SURGERY

43

Dr. Rami Abazid

MITRAL STENOSIS
SYMPTOMS

NON AUSCULTATORY

AUSCULTATORY

44

Dr. Rami Abazid

M.S.

COMPLICATION

DD

SIGNS OF SEVERITY

Left Atrial myxoma

Clinical

Austin-flint murmur

INDICATION OF SURGERY

Pul.
Congestion

Pul.
HTN

Recurrent
thromboembolic
Events despite
Anticoagulation

Haemoptysis

45

Echo

Dr. Rami Abazid

MITRAL REGURGITATION

Symptoms

Non Auscultatory

Auscultatory

1st H.S.

S3

Pan-systolic murmur
soft and radiating
to axilla
===========================================================================
CAUSES

Acute

INDICATIONS FOR SURGERY

Chronic
Prolapse

Rupture MI
Rheumatic

Functional

Symptomatic
Despite optimum
Medical therapy

LVEF

NYAH III-IV

60%

EF~35-50%

3 act. Endocarditis
Connective tissue
Disease

46

Asymptomatic
LVES D
45mm

Dr. Rami Abazid

SOME CONGENITAL ANOMALY


A.S.D.

V.S.D.

On Pulmonary
area

HOCM

PDA

at the lower
sternal edge
Coarctation
of Aorta

Thrill

fixed splitting
2nd H.S.

thrill at
Lower sterna
Edge

Ejection systolic
Murmur

Thrill left
Inter-space
machinery
murmurs
loudest below
left clavicle

Ejection systolic
Murmur valsalvi
Systolic
thrill

Pansystolic
murmur
no radiation

Fallots
V.S.D.

Rt. vent. Pul. Stenosis


Hypertrophy

radiofemoral
delay

47

continuous
murmur radiating
to back

Dr. Rami Abazid

48

Dr. Rami Abazid

49