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Cardiology + Gastroenterology

Verapamil is used in the prophylaxis of prox. AF.

PFO: cause of stroke in a young patient. Dx by bubble test echocardiography.

Pacemaker syndrome in VVI (Heart block like): Retrograde atrial activation from ventricular
signal.

Co-arctation of aorta murmur: late systolic, loudest over thoracic spine.

Early PVE (up to 8 weeks) due to Staph epidermidis (commonest), Late PVE same as native valve
Staph viridans.

In-stent thrombosis occurs 2 days post PCI, treated with abciximab + ASA and Heparin,
and transfer to coronary angiography unit.

Confirmation of burgadas syndrome: IV ajmaline (unmasks burgada) and EPS.

First line in chemical cardioversion of WPW: Flecanide, BBs may be used.

Cardiac arrest with ventricular arrhythmia at low core temperature: DC and chemical
cardioversion is ineffective, so CPR must be carried.

Indication of FAB fragments in digoxin toxicity: 1. Severe arrhythmia 2. Hyperkalemia 3.


Hemodynamic instability 4. Serum level >13 mg/dl.

After initial management of pulmonary edema with oxygen, furosemide, and morphine, GTN: 1.
BP>100 mmHg give Nitroglycerin infusion, 2. BP 100-70 mmHg: with symptoms of shock give
dopamine, without give dobutamine, 3. BP <70 mmHg give norepinephrine.

Indication of AVR in AR: 1. EF <55% 2. Severe LVEDV >80ml even if the patient
asymptomatic 3. Symptomatic.

HOPE study suggested ACEIs decrease morbidity and mortality for patient with high risk
cardiovascular events with normal LVEF.

Fall of BP or BP>250mmHg: is a termination cause of stress test. Diastolic pressure usually


doesnt change or drop a little bit.

Tocolysis and steroid used in pregnancy can cause pulmonary edema.

WPW sundrome: Type A: delta wave best seen in aVF and V4, and dominant R wave in lead
V1. Type B a negative delta wave in V1.

Septic shock, first managed by fluids if not responding inotropes.

Second provoked DVT is treated by 6 month warfarin.

First line for drug induced long QT syndrome: stopping the offending drug, correction of
electrolytes, and starting IV Mg2+.

Patients with idiopathic pericarditis: NSAIDs is tried first, then colchicine, steroids, and
pericardiotomy.

Type A Aortic Dissection (involves ascending aorta): Treated surgically, while Type B that
doesnt involve ascending aorta is treated medically with BBs unless there is complication.

Development of cardiogenic shock with VSD complicated MI: must be surgically treated.

Ventricular free wall rupture is more common than VSD following MI.

Contraindication of balloon mitral valvulotomy and indication of MVR: 1. Heavily calcific valve.
2. Moderate to severe MR. 3. CAD that needs to be corrected. 4. Left atrial thrombus.

Dysbetalipoproteinemia: cc by palmar xanthoma, High TAGs, High Cholesterol, normal HDL


and low LDL.

Myocarditis associated with cardiogenic shock management: 1. High flow oxygen 2.


Hemodynamic suppot (PCWP>15 give inotropic (preferably IABP)+/-diuretics. If PCWP < 15 mmHg
give cautious IV fluid). 3. Morphine (vasodilator and reduce anxiety).

Ebsteins anomaly may be associated with WPW.

One of indication of temporary pacemaker: Junctional rhythm with QRS>160 ms.

Complete heart block as a reperfusion arrhythmia carries the worst prognosis.

Intermediate risk of CAD: Stress Nuclear Imaging is recommended.

INR > 8 with no/minor bleedingStop warfarin and restart when INR<5, INR>8 with high
risk bleeding should be given Vitamin K 500ug IV (recommended over 500mg oral). Severe
bleeding---FFP.

TTP can happen rarely with Clopidogrel and Ticlopidine.

Serial BNP helps to differentiate between HF and COPD exacerbation.

Flash pulmonary edema occurs in (from common to less): Myocardial ischemia, RAS, and AR.

BBs are the first line in idiopathic asymptomatic long QT syndrome.

Calcium channel blocker is the first line in treatment of idiopathic pulmonary hypertension.

Starting BBs in DCM can worsen symptoms of congestion initially, but it should be continued and
increase the diuretics dose.

Pyoderma Gangrenosum can occur around stoma in patients with surgical corrected Crohns
disease.

HF symptoms associated with HOCM is treated with BBs, if failed or outflow pressure >50mmHg
myomectomy.

Cardio-inhibitory CSH treated with: Dual chamber PM.

Risk of in-stent restenosis of non-coated PCI in DM is 40-50%, decrease by 80% if drug


illutant and dual antiplatelet is used.

Lutembachers syndrome: ASD+MS (Congenital).

NASH is a silent liver disease discovered accidently.

Celiac Ds is associated with disturbed liver enzymes.

Bacterial overgrowth is marked with increased folate.

UTI symptoms in a Diverticulitis patient due it peri-ureteric inflammation.

Chronic mesenteric occlusion: can cause malabsorption syndrome.

Hepatic Hydrothorax (peritoneal fluid is sucked through diaphragmatic openings usually on the
right) is treated conservatively with low salt diet and diuretics if failed, liver transplantation
should be tried, if no facility TIPS can be done.

Antibiotic is started in traveller diarrhea only if >3 days.

Purines is preferred to 5-ASA compounds in maintain remission of crohns disease.

Cholestasis of pregnancy: can be associated with increased PT.

Intermediate colitis (shares picture of UC and crohns disease)

HNPCC family: is screened for colorectal cancer every 2 year starting from early twenties.

Fasting transferrin level>55% is diagnostic for hemochromatosis.

Acute Liver rejection occurs 2 weeks post transplantation; first sign is increased ALP and
bilirubin. First line: IV methyl prednisolone.

Cardiac and liver symptoms of hemochromatosis improve with treatment.

Antibodies associated with autoimmune hepatitis type I: ANA and Antismooth antibody, Type
II (in children): AntiLKM, Type III: soluble liver kidney antigen.

IgA is raised in Alcoholic and chronic active hepatitis.

Terilpressin is contraindicated in IHD; instead octerotide is used in esophageal bleeing varcies.

Coeliac Disease: is associated with T-cell lymphoma.

Radiation enteritis (chronic ischemia of intestine): occurs up to 1.5 years after radiation
treatment of pelvic malignancy. Treatment rectal sucralfate, metronidazole and local antiinflammatory.

Ascending cholangitis occurs in HIV is usually due to viral or fungal causes. First step MRCP.

Serum Albumin Ascetic fluid index: >1.1 portal hypertension (HF-high protein, Cirrhosis-- low
protein, Budd chaiari-- high protein), <1.1 no portal hypertension (T.B, Nephrotic, Malignancy).

VT associated Digoxin toxicity is best treated by IV lidocaine.

Hepatitis C infection leads to chronicity in 70-80% and 20-30% cirrhosis.

MRCP is superior to CT scan in the diagnosis of Gall stones.

Causes of GI fistula: Crohns, colorectal cancer and Diverticulosis.

Cirrhosis: associated with increased CA-125.

Cryotherapy is most useful in non-surgical treatment of Barretts esophagus.

Meckels scan is useful between the attacks of bleeding.

Octreotide scan is used for detecting neuroendocrine tumors.

Waist-Hip ratio is useful in dx of central obesity.

Mid-arm ms circumflex & skin fold thickness is useful tool in detecting nutritional status.

Tx of MALT lymphoma is Anti H.Pylori if failed Chemotherapy.

False ve in C breath test is -

Coccoid of HP dont produce urease


-

Antibiotic

H2 blocker

PPIs.

SBP is diagnosed by PNLs > 250 cells.

Pancreatic Pseudocyst is best diagnosed with CT scan.

Barretts oesopeghgus can lead to Adenocarcinoma in asymptomatic patients.

In Paracetamol overdose taken days ago, serum level could be normal or undetected.

Peripartum Cardiomyopathy can happen up to 5 month after delivery.

Esophageal manometery confirms the dx of Achalasia, which consists of absent peristalsis in


the body of esophagus and increased tone of LES.

Lupus anticoagulant (increased PTT with normal PT) can cause Budd Chaiari syndrome.

Fundaparniux is anticoagulant used in patient with renal failure, because it is easily removed with
dialysis.

RF for Long QT syndrome: 1.Female 2.hypokalemia 3.hypomagnesmia 4.CHF 5.Digitalis


toxicity 6.bradycardia 7.severe alkalosis.

Spironolactone decrease mortality when used in combination in patients with CHF.

Best antiplatelet after CVA (TIA or stroke) is Clopidogrel according the recent guidelines.

Procethic valve thrombosis management: Unstable patientsFibrinolysis, Stable patients---Left sided valves surgery, right sided valves Fibrinolysis.

Dobutamine stress Echo in patients with low EF differentiate between true AS requiring AVR and
patients with pseudo AS due to low EF----in patients with true AS the trans aortic gradient
increase and the aortic area remain the same, while in patients with pseudo AS the aortic area
increases.

Treatment of peripartum cardiomyopathy: Low Na, Diuretics, afterload lowering agent typically
hydralazine, heparin (due increase incidence of clotting) and digoxin.

Patients with high risk CVD (DM, PVD, CAD): should keep their LDL level below 2 mmol/l.

Osler Weber Rendu Syndrome (A.D): Also known as, Hereditary hemorrhagic telangiectasia
cc by multiple telangiectasia on the skin and the mucus membrane with tendency to bleed and
causing anemia, AV malformations.

Cirrhosis Types: 1. Macronodular: Chronic viral Hepatitis, 2. Micronodular: chronic alcoholism,


However any type can be formed with both diseases.

Radiation enteritis: causes selective B12 deficiency, due to stricture and bacterial overgrowth.

PBC: Can be associated other autoimmune Ds like, Sjogren, CREST, and SLE.

Withdrwal of HRT is necessary in Hepatocellular adenoma, and Budd chaiari syndrome.

Acute fatty liver of pregnancy: causes low albumin level.

Fulminant Wilsons Ds: increased serum copper and hemolysis.

Most common causes of Chronic Pancreatitis: Alcohol, CF, Idiopathic.

Marker of the Neuroendocrine tumors: Serum Chromogranin A except insulinoma.

Varigate Porphyria: N, V, abdominal pain, increased porphyria in urine, stool, and plasma.

Porphyria

Acute intermittent

Variegate porphyria

porphyria
Clinical pic

N, V, Abd pain,
photosensitivity,
neuropsychiatric

Hereditary
coproporphyria

Same

Same

symptoms
Urine Porphyria

Elevated

Elevated

Elevated

Fecal Porphyria

Normal

Elevated

Elevated

Plasma Porphyria

Normal

Marked Elevated

Normal

FMF: cc by paroxysm of Fever and serosal inflammation (peritoneal and plueral). Constipation with
fever and becomes diarrhea with resolution, amyloidosis.
Disease

Achalasia

Scleroderma

Nutcracker

LES Manometery

Increased Tone

Decreased

Normal

Body peristalsis

Absent

Absent

Increased

Increased gastrin and increased Basal acid in stomach: ZES and H.Pylori infection
(Can be diff by secretin test, which inhibits gastrin in H. pylori infection)

Increased gastrin and Decreased Basal acid: PPIs, Gastric cancer and pernicious anemia.
Whipples Dsiease: Attacks intestine (malabsorption), Heart (pericarditis), Joints (Arthritis and
arthralgia), CNS (Ocular and Cerebellar) and cause Hyperpigmentation.
Left Petrous Temporal region lesion: Affects all branches of trigeminal nerve and abducent.
Hamartomatus Polyps in: Puetz Jeghers Ds, Codwens syndrome, Familial juvenile polyposis, NF1,
and MEN type IIb.
Iron Deficiency anemia without obvious cause investigations: Upper and Lower endoscopy, urine
analysis and celiac Ds markers.
Proven benefit treatment in acute pancreatitis: Oxygen, IV fluids and enteral feeding.
Chest pain + Troponin> 0.03 suggests MI: Do Coronary Angiography.
Autoimmune Hepatitis: CC by increased Liver enzymes and Increased ALP.
Obese + HTN + Signs of CHF: Start ACEIs or ARBs.
Q waves in the Anterolateral and inferior leads in: HCM.
Treatment of VSD caused by MI: Medications: Inotropes, Surgical: Intra-aortic balloon, formal
surgery and percutaneous closure .
Treatment of High altitude pulmonary Odema: Oxygen, if not available calcium channel blockers.
BBs is the 1st choice in prophylaxis against paroxysmal AF.

BP goal in HTN+DM and HTN+RF is 130/80 mmHg.


JLS1 and 2: Long QT+ Deafness
LQT1: Attack during or after exercise
LQT2: Attack during exercise or auditory stimuli
LQT3: Attack at night during sleep.
LQT4: paroxysmal AF.
Pancreatic Psuedocyst: Complicate Acute pancreatitis after few weeks cause: Abdominal Pain,
Tender mass, persistent elevated enzymes, low grade fever.
Prophoryia can be precipitated by Alcohol or drugs like OCP.
Hemochromatosis: Confirmed by Genetic testing or liver biopsy.
Thumb printing: Sign of Ischemic Colitis.
Hepatic Steatosis: Is caused by 1. Alcohol 2. Obesity 3. DM.
Pellagra Ds Triad: Dermatitis, Diarrhea and Dementia.
Zieves Ds: Alcoholsim+Hemolysis+Hyperlipidemia+Abdominal pain+increased Bilirubin.
In UC endoscopic rectal biopsy: if associated with dysplasia, it means there is carcinoma elsewhere
in the body.
Secretin Test in Chronic Pancreatitis: Volume>2ml, and HCO3 <80mEq.
Secretin Test in Pancreatic Duct Obstruction: Volume<2ml, and HCO3 >80mEq.
Treatment of Stable Angina: Mainly pharmacological if asymptomatic at rest.
Treatment of SVT in asthmatic people: IV verapamil or IV flecanide.
Treatment of accelerated HTN (HTN+Retinopathy): Oral nifidipine or oral atenolol.
Patients under 75 yo with MVP+AF and low LVEF: Should undergo TOE as evaluation for surgical
correction.

Respiratory:

Drugs cause pulmonary fibrosis: Busulphan, methotrexate, Amiodarone, cyclophosphamide,


methysergide, Ethambutol, penicillamine and minocycline.

ABPA: Causes increase in the IgE level during the attack.

Healthy adults with spontaneous pneumothorax:

High dose combination (Fluticasone+Long acting B2 agonist) used in severe COPD leads to
slow deterioration in FEV1.

Aspergillus (stained with H&E) causes 5 lung diseases: 1. Asthma (type I HS), 2. ABPA
(type III HS) 3. Aspergilloma 4. Invasive Aspergillosis 5. Externsic allergic alveolitis.

INH causes Optic neuritis.

Deviation of the trachea is seen with tension pneumothorax, but not spontaneous
pneumothorax.

Pulmonary hemorrhage caused by wegner granulomatosis is associated by increased DLCO.

Lymphangitis carcinomatosis: gives Restrictive pattern.

Pulmonary alveolar proteiniosis: Causes lung infiltration (crazy paving) with PAS +ve granules
made from surfactant protein.

Prednisolone is added to the tx regimen of PCP if the oxygen <9.3.

TRALI (common in multiparous women): caused by anti HLA or Anti neutrophil due to
blood transfusion, with a picture similar to pulmonary edema. Treatment supportive.

Bronchoscopy is the tool of choice in large lung mass, because using other tool will risk
causing pneumothorax.

Mild OSA: Weight loss and/or intraoral device. Moderate to severe OSA with day time
sleeplessness: CPAP.

Classification of COPD according to FEV1: mild>80% predicted, moderate 80-50%, severe


50-30% and very severe <30%.

HRCT is confirmatory for Sarcoidosis.

The initial investigation in partial upper airway obstruction is Flow Volume loop.

D-dimer: is increased in PE, pregnancy, inflammatory conditions, and malignancy.

Low probability in the V/Q=highly unlikely for PE.

Hyper-eosinophillic syndrome: Increased eosinophil, toxemia, and heart affection


(restrictive picture). Treated with steroids and/or immunosuppessors.

Mycoplasma pnuemonie: Associated with SIADH occasionally.

COHb prognostic level: <30% headache and dizziness, 30-60% tachycardia, tachypnea,
fits,>60% Cardiorespiratory failure and death.

CO poisoning: Patient is conscious fitting mask with 100% oxygen, Comatose intubate and
ventilate.

X-ray in patients with CF: Sinus XR Shows panopacification of the sinuses, CXR shows
hyperinflation and peribronchial thickening (Bronchiectasis).

Acute Fat embolism: Treated with IV fluid to maintain RV pressure.

Respiratory failure type II in COPD patients: Conscious: BiPAP, or Doxapram


(#Hypertension), Unconscious: Intubate and ventilate.

RF for Staphylococcal pneumonia: Post influenza and IV drug user.

Chrug Strauss triad: Asthma, Eosinophilia, and Systemic vasculitis.

Idiopathic PF: 1. Common in middle age male smokers 2. Linked to Wood and Metal dust 3.
Associated with positive ANA and RF in 50%.

Mixed obstructive/restrictive pattern + Polyurea and Polydepsia: Histocytosis X

PCP and Methotrexate induced pneumonitis: Causes Fever, SOB and Desaturation during
exercise.

Respiratory intervention in patients with GBS is done when the FVC around 1 liter.

In patients with high risk perioperative mortality for lung cancer: Combined chemo and
radiotherapy increase the chance of survival.

Treatment of ABPA: Oral steroids +/- Antifungal.

In the reversible obstruction COPD patients: Use of steroid inhaler + B2 agonist decrease
COPD exacerbation.

Rusty colored sputum in Strept pneumonia.

Chemoprophylaxis of HIV patients exposed to TB: INH + Pyridoxine twice weekly for 9
months or Rifampin for 4 months.

Hepatopulmonary syndrome: A-V shunting, Pleural effusion, Hx of liver disease, Hypoxia and
Platyapnea (relief on lying flat), Tx: liver transplation.

FVC is the most important investigation to monitor GBS.

Contraindication of pneumonectomy in lung cancer is: FEV1<2 L post bronchodilator, MI


within 6 weeks.

Hypoxic IPF: increase survival with long term oxygen.

Pulmonary rehab. : increase exercise tolerance in COPD.

Poor response to broad spectrum antibiotic in the treatment of pneumonia: is due to either
Atypical or fungal pneumonia.

Treatment of choice in chlamydial pneumonia is Tetracycline.

Acute sarcoidosis is self-limiting and the treatment is only supportive.

Life threatening Asthma either presents by: 1.PO2 <8 2.PEFR <33% (200L) 3.Spo2 92%
4.PCO2 normal (4.6-6) or increased 5.silent chest 6.cyanosis 7.poor respiratory effort
8.arrhythmia 9.poor conscious.

Treatment of Angioedema is: IM epi and IV hydrocortisone.

Investigation of choice in Mesothelioma is Thoracoscopy with biopsy.

Large (>2cm) 2ry pneumothorax: Proceed to formal chest tube.

Treatment of ARDS patients: intubate and ventilate.

Eaton Lambert: Antibodies against calcium channels the NMJ (Anti calcium channel
antibody).

Management of PE: Heparization, if the BP is boarder line with signs of right sided HF give
volume expanders. Use thrombolytic if the patient is collapsed or failure of increase of BP
after 30 mins from giving the volume expanders.

Best treatment of hypersensitivity pneumonitis is avoidance of the allergen.

Alveolar microlithiasis (AR): CC by calcified microlithes deposition in the alveoli, PFTs


restrictive, CXR lungs shows microcalcifications, Fatal eventually from respiratory failure.

Factors increase perioperative mortality in COPD: 1. Increased PCO2 on oxygen 2. FEV1 <0.8
3.Obesity 4.poor performance and cardiac status.

TB pleural effusion: +ve for acid fast bacillus in 10-20% only.

Amiodarone can cause pleural effusion.

Klebsiella pneumonia is common in Alcoholics.

Features raise the possibility of malignancy of lung nodule: 1.Old age 2. Smoking history
3.enhanced contrast on CT 4. Speckled mass with distortion of the near vessels.

Nuclear pleomorphisim with absent mitosis in lung mass: Diagnose carcinoid tumor.

Management of bronchial carcinoid: if solitary lung mass, surgical removal, if not Ocreotide
should be tried.

Indication of LTOT: 1.PO2 <7.3 2.Corpulmonale 3.HB>15mg

MRI is the investigation of choice in metastatic spinal lesions.

EAA causes fibrosis in the upper lung zone.

High IgG and Eosinophil: Chronic eosinophilic pneumonia.

Endocrine:

The most common cause of Addisons in UK is Autoimmune, which may be accompanied


with other autoimmune diseases.

Pheochromocytoma is associated with Von Hipple lindu.

Candidal UTI is seen commonly in uncontrolled DM.

Episodes of sweating in: Pheochromocytoma, Hypoglycemia, and Carcinoid. Constant


sweating in: Thyrotoxicosis.

Treatment of Charcot joint as a DM complication is: Contact plaster.

Treatment of subacute thyroiditis (De Querivan): NSAIDs or Steroid in severe


cases.

Fever + Bilateral adrenal enlargement: Lymphoma, T.B and Histoplasmosis.

Adrenal enlargement due Histoplasmosis: Dx by Biopsy or FNA of adrenal and use of


croccott stain.

Mixtard insulin peaks after 6 hrs.

Most common cause of Hyperprolactinemia is pregnancy.

Basedow Paraplegia (thyrotoxicosis myopathy): Weakness and paralysis of the


proximal L.L muscles.

Sudden stoppage of antiparkinsons causes neuroleptic malignant like syndrome.

Initial tests for polydipsia and polyuria are UA, Serum Ca and Serum Glucose.

Gravis Eye Disease can occur with normal TFTs.

Wolmans Ds: Hypoadernalsism, HSM, steatorrhea.

Wolframs Ds: DM, DI, Optic atrophy and deafness.

PGSI: Key Mucocutneous candidiasis. PGS II (commonest type): key DM.

Prolactin level > 3000 is diagnostic for microprolactinoma, and > 6000 for
macroprolactinoma.

Euthyroid sick syndrome: Low T3, T4 and normal TSH.

Osteomalacia: Increased ALP, decreased PO4, Decreased Ca2.

Familial Heterogeneous Hypercholesterolemia: CC by Cholesterol >7.5, Achilles


tendon xanthomas, increased risk of CAD.

GH deficiency is diagnosed with insulin tolerance test (GH <10mU/L) or GnRH


combined with arginine + ve test if former is contraindicated.

Partial DI: CC by urine osmolarity of 300-800 and failure to rise >800 after
DAAVP injection.

Pseudohypoparathyroidism: short stature, squint, low ca (due to PTH resistance), high


po4, associated hypothyroidism (resistance to TSH).

Initial medication for treatment of gestational diabetes after failing life style
modification is Metformin then insulin if failed.

Initial Tx of Thyrotoxicosis is Carbimazole.

Weight loss in PCOS leads to: decrease insulin resistance, and increase SHBG
which decrease free Androgens.

Glucgnoma: DM + NME skin rash.

Liddles syndrome: Low renin+ Hypokalemia+ Hypertensive+ metabolic alkalosis. Tx:


Amiloride.

Carcinoid syndrome: can produce GnRH in addition to serotonin.

Bratters and Gitelmans syndrome: Elevated renin and Aldosterone+ Hypokalemia+


Normotensive.

Indication of surgery in Hyperparathyroidism: Calcium> 3mmol, increased RFTs,


Hypercalciurea, marked increase bone reabsorption, nephrocalcinosis and increased
bone stones.

Tumor produces phosphaturic substances: Prostatic carcinoma, CLL, and MM.

Necrobiosis lipoidica diabeticorum: Assoicated with uncontrolled DM, Erythematous


Plaques on shins and wrists. Tx: Steroids (Topical and injectable steroids).

Throtoxicosis during pregnancy Tx: Initially start with PTU, if no improvement


increase the dose, then change the drug, and if failed surgery.

Initial Test for Pagets Ds is: Skeletal Survey. Tx: Bisphosphanate.

Hypertriglyceridemia: CC by eruptive xanthomas.

Pregnancy and old age can decrease TSH.

RF for Thyroid malignancy: 1. Female Sex 2. Endemic goiter 3. Hashimotos 4. FAP 5.


Radioactive Iodine 6. Hx of thyroid adenoma 7. Radiotherapy.

Metformin and Sulfonylurea is contraindicated in moderate RF.

DM causes increased TGs and Decrease HDL.

Klinfilters and Mumps orchitis after puberty can cause 1ry testicular failure.

Supraseller Calcified cyst= Craniopharyngeoma.

Amiodarone induced hyperthyroditis AIH: 1. Type I (Iodine content, Increase blood


flow with Doppler, Normal RAI uptake, normal IL6, Tx: Antithyroid+potassium
Percholorate) 2. Type II (Destructive thyroiditis, decreased BF with Doppler,
decreased RAI uptake, increased IL6 Tx: Antithyroid+steroids).

Postpartum thyroiditis (3-7 months after labor): the same clinical data as hashimotos
Ds. Treatment: Low dose thyroxin, withdrawn after 6 month to measure the
success of treatment.

In insulinoma fasting test: the cutoff value after 15 hrs fasting of glucose 2.5 mmol
and 5 mu/l insulin.

In patients with combined hypothyroidism and hypoadernalisim, dont give thyroxin


before treating hypoadernalisim because it might precipitate addisonian crisis.

Renal Artery Stenosis: Causes increased Renin and Aldosterone.

High dose Metformin causes Bile acid malabsorption and diarrhea.

Phenoxybenzamine is used 3 days before pheochromocytoma surgery to ensure alpha


block.

Suppressed TSH and increased Free T4 is normally seen in pregnancy.

LMW Heparin is used in the management of DKA to prevent venous thrombosis.

Treatment of thyrotoxic adenoma: Radioiodine or Subtotal thyroidectomy. In


pregnancy: PTU.

Pentagastrin stimulation test: Used for Medullary thyroid carcinoma.

Metformin is the initial step in treatment of GDM.

DM associated with chronic pancreatitis is treated with insulin.

Essential Thrombocytosis is associated with pseudo-hyperkalemia when the sample


auto hemolyse.

Treatment of osteoporosis associated Klinfelters is Testosterone.

Peroglide and Cabergoline is associated with pericarditis.

Alfacalcidiol is used in tx of 2ry hyperparathyroidism.

Cinacalcet is used in patient with hyperparathyroidism and ESRD.

P. Neuropathy is treated with Doxletine, Amitryipaline or carbamazepine.

Absent olfactory pulp in Kallmans syndrome.

Nonfunctioning pituitary adenoma: Treated surgically.

Lung cancers and Adrenals: Paraneoplastic=Ectopic ACTH=Cushing, Adrenal


Metastasis=Hypoadrenalisim.

DM who wishes to exercise heavily are advised to use basal insulin bolus instead of
mixed insulin.

Management of postural hypotension of DM neuropathy: 1. Stop Antihypertensive


(VDs and Diuretics) 2. Elastic stocking 3. Fludrocortisone.

Prolactinoma: PL should be >5000.

Diabetic Amylotrophy (usu. involves sacral plexuses): Require control with insulin.

In Synthacyn test: Cortisone should rise>550 after 30mins.

Initial treatment in MODY3 is: SUs.

Conns Ds: Due to Aldosterone secreting adenoma (low renin).

Treatment of myxedema coma: IV hydrocortisone (first if there hypoadernalism or


status unkown, Slow rewarming and Thyroxin.

Treatment of gravis ophthalmology: 1. Steroids (tried first) 2. Surgical


decompression 3. Orbital radiotherapy.

McCune Albright syndrome: Increased risk of osteosarcoma.

Nephrology:

Commonest renal pathology occurs with RT is Mesangioproliferative GN.

PCKD causes RF with increased Hb level (increased erythropoietin secretion).

Cholesterol emboli: Low C3, eosinophilia, Increased ESR and Urine protein.

Oral Iron in not well absorbed in patients with CRF, thus should be given in IV form.

Tight control of glucose in DM reduces microvascular complication: 1. Neuropathy


60% 2. 50% Retinopathy 3. Nephropathy and proteinuria by 30-40%.

Pulmonary hemorrhage seen in Wegner Granulomatosis and Goodpasture.

Sinus affection + Renal affection= WG.

Psuedohyponatremia in Nephrotic syndrome due to high serum lipid.

CKD patients should have k < 5.5 mg/dl if undergoing surgery.

Chaurg strauss: Can cause renal affection and nephritic syndrome.

Calciphylaxis (deposition of calcium in arteries leads to necrosis): A life threating


seen in ESRD on dialysis
Types of grafts: 1. Autograft: from, to same person 2. Isograft: from identical
genetic person. 3. Allograft: from similar genetic person 4. Xenograft: from different
species.

Othrotopic: Graft in same anatomical place. Heterotopic: Different anatomical place.

Triad of renal cell carcinoma: Costovertebral pain, Hematuria, and Mass.

Types of kidney stones: 1. Ca oxalate (Most common): Radio opaque from


hypercalcemia. 2. Cystiene stone: Radio opaque from cystinuria. 3. Urate stone: Radiolucent
from hyperuracemia. 4. Oxalate stone: Radio opaque from IBDs and ethyl glycol ingestion. 5.
Struvite stone: Radio opaque from infection especially protues, pseudomonas and kelibsiela.

Aluminum causes osteopenia and osteomalacia.

Bratter syndrome: CC by Low Na, K, and Cl.

In central DI: Urine osmolality must rise by 50%.

Gitelmans: Assocaited with Hypomagnesaemia and Hypocalciuria.

Scleroderma renal crisis: HTN+Microangiopathic Hemolysis, Treated with ACEIs or


ARBs.

ATN treatment supportive.

Flash Pulmonary odema: Seen in RAS, and Fibromuscular dysplasia.

ADPCKD: its recommended to screen patients after 20 yrs. old in high risk group.

Normal urine: Can contain red cells, granular and hyaline casts.

IgA Nephropathy: IgA is only elevated in 50%.

Dapsone: Causes hemolytic anemia.

Xanthgranulomatous Pyelonephritis: Occurs in DM, Difficult to distinguish from RCC


(Weight loss, fever, loin pain), treatment is nephrectomy.

Fibromuscular Dysplasia can become symptomatic with HTN in pregnancy.

Calciphylaxis: Occurs in patients with CKD, Ulcers with calcified blood vessels.

Anemia with CKD: if ferritin<100 and/or transferrin<20% treat with IV iron first.

Porphyria: Urine turns dark on standing as for Alkapinuria.

Renal affection in FMF (polyserositis): AA amyloidosis and/or Analgesic nephropathy,


confirmed by renal biopsy.

Post cranial surgery DI: Treated initially with proper fluid replacement.

Beer Potomania: Hyponatremia due to EToh ingestion, self correction if ETOh


stopped.

Sickle cell Ds: is associated with Distal RTA.

In DM I: Microalbuminuria must be confirmed twice with 3-6 ms difference, before


commencing ACIs or ARBs.
Analgesic nephropathy (salt loosing): Can cause obstructive picture, when the renal
papillae sloughs and fell into the ureter.
Malignant HTN: is treated with oral antihypertensive over 1-2 days (gradual
reduction).

ANCA is rarely positive in PAN.

EPO induced epilepsy: A rare complication within 90 days after initiation of


therapy.
Co-trimoxazole increases concentration of indinavir causes crystal nephropathy.
Tx: IV fluids.
Anemic CRF patients: Should keep their Hb between 10-12 md/dl by EPO (not more
than 12 to avoid hypertensive crisis).

Alphacalcidiol: Activated vit. D for 2ry hyperparathyroidism associated with CRF.

Cinacalcet: PTH antagonist for 3ry Hyperparathyroidism.

Goods Pasture: Anti GBM. Charug Strauss: ANCA-P.

Treatment of SBP from long term peritoneal dialysis: IP gentamycin and vancomycin.

Iron deficiency anemia should be corrected before starting CRF patients on EPO.

Primary Hyperparathyroidism can present with normal PTH level.

A non-progressive initial 20-30% increase in serum creatinin is acceptable after


starting ACEIs.
To reduce the risk of contrast nephropathy: 1. Hydration 2. Stop nephrotoxic and
dehydration medications.

Incision of flexor retinaculae in carpal tunnel syndrome to relief compression.

Corticosteroids and other immunosuppressive is NOT needed in treatment of CIN.

Treatment of HIV associated Nephropathy: HAARVT+ ACEIs.

Diabetic Nephropathy: Chance of 45% renal function worsening during pregnancy.

Membranous Nephropathy Treatment: Control of BP and edema by diuretics and


Clexan.
Thyroid Function Test: Should always be checked in elderly presenting with
behavioral changes.

Serum osmolarity: 2(Na+K)+ Urea+ Glucose.

Hematology
Acanthocytosis: cc by spur bodies in peripheral blood, hemolytic anemia, fat mal-absorption
symptoms, movement and CNS problems esp. orolingual.
Phases of the clinical trial: Phase 0 (pharmacodynamics and pharmacokinetics), Phase I
(safety of the drug often done with phase II), Phase II (efficacy and safety), Phase III
(comparison with another drug), Phase IV (post marketing).
In patients with lab finding of DIC without obvious symptoms: Treatment is directed only
for the cause (no blood product is given).
CML treatment in young: if there is no matched sibling for stem cell transfusion, used
Imatinib.

Rapid reversal of warfarin is ideally done by prothrombin concentrate.

INR > 8 without symptoms: Give Oral or IV vitamin K.


Hydroxyurea decrease the incidence of acute chest syndromes with HbSS
Cold Agglutinins (IgM): P. blood shows agglutination in cold temp., Coombs is +ve, usually not
paroxysmal.
Paroxysmal cold hemoglobinuria (Antibody attaches to RBCs in cold temp.): Causes severe
hemolysis, back pain and rigors. Coombs is negative.
Warfarin induced Skin necrosis: Due to fast decline in vitamin K dependent protein C (1-2
days).
Heparin induced skin necrosis: Antibody mediated (10-14 days).
Alpha Thalassemia minor: Silent will have normal hemoglobin electrophoresis.

Delayed transfusion reactions (5-10 days): picture of autoimmune hemolytic anemia.

Myelofibrosis: Causes increased WBCs and +/- increased Platelets.


Leucoerthyroblastic changes in blood (increase band cells, promyelocytes and myelocytes)
in BM infiltration and severe hemolysis.
Only treat CLL when patient is symptomatic with B symptoms.
Antiphospholipid syndrome: CC by venous and arterial thromboembolism, miscarriage in 1st
trimester, levidoreticularis, and libmansac endocarditis. Tx: Warfarin
Leukemia prognosis depends on cytogenetic.
Acquired haemophillia: Antifactor VIII. Tx: Steroids and/or immunosuppressors.
Treatment of ITP: High dose steroids.
Prothrombin Complex: Contain vitamin K dependent factors, used in severe bleeding due to
warfarin overdose.
Cryoprecipitate: Contain factor 8 and fibrinogen.
FFP: Contain low doses of coagulation factors.
HIT: Type I: in 1st few days after starting heparin, plts mild decrease. Type II: after
week to 2 weeks, plts < 50000, venous thromboembolism.
Irradiated blood: is needed in patients with cellular immunodeficiency (Post stem cell
transplant, cong. Immunodeficiency).
Fludarabine: can be complicated with PCP infection, thus co-trimoxazole prophylaxis is
recommended.
Acquired Hemophilia: Common in elderly and pregnancy (Associated with autoimmune
disease due to antibodies towards factor 8). Treatment activated factor 8.
Isotope white cells scan: used in Fe deficiency anemia when inflammatory disorder is
suspected.
FFP: Is rich in fibrinogen like cryoprecipitate.
Myelofibrosis: Old age, pancytopenia, splenomegaly, increased BM cellularity.
Commonest organism to infect neutropenic patient is: gram +ve (stap epidermidis).

Wiskott Aldrich: Reduced Igs, eczema, and thrombocytopenia.

Stains in hematology: 1. TARP +ve: Hairy cell leukemia. 2. Sudan Black and myeloperoxidase
+ve: AML 3. TDT +ve: ALL 4. LAP High: PRV, and Myelofibrosis, Low LAP: CML.

Difference between Alpha thalassemia minor and Beta thalassemia minor is HbA2
(decreased in A TM, Increased in B TM).

Spleen is considered LN group in staging lymphoma.

Veno-oclusive disease of liver usually occurs 2 weeks after BMT.

Waldenstroms causes: Lymphoplasmacytoid lymphoma, LN enlargement and BM infiltration.

Rheumatology
In shrimer test for Sjogren syndrome: The wetting of the filter paper should be at least 4
mm after 5 mins.
First line in treatment of 1ry Osteoporosis is Bisphosphonates.

The risk of osteosarcoma in Pagets disease is < 1%.

Proteus infection is linked to development of RA.

Difference in vertebral affection between AS and Psoriatic arthritis is symmetry and nonsymmetry, respectively.

First sign of SLE reactivation activity is C4 level falling.

Relapsing polychondoritis: Recurrent Fever, Weight loss, Cartilage inflammation (picture


according to site), Tx: Symptomatic + Steroids.

Treatment of felty syndrome: pulsed steroids or cyclophosphamide, if failed splenectomy.

Poor response with HBV vaccine and Tetanus in IgA deficiency.

Factor V leiden increase the risk of venous thromboembolism only if patient uses OCP.

There is increased risk of hemolytic anemia with RA.

Treatment of Pagets disease: Bisphosphonate or Colchicine.

ANA +ve in 60-90% of SS, while other antibodies specific for SS is +ve in 50% only.

ANA +ve in 20% of Stills disease.

Nail fold capillarscopy differentiate between 1ry and 2ry Raynauds.

Joints symptoms + Purpuric rash + positive RF= Cryogolubinemia or Sjogrens.

Drug that can be used for RA during pregnancy: Sulfadiazine, Azathioprine (not in breast
feeding)

Charcot Joint (increase osteoclastic activity): Severe joint destruction with minimal
symptoms. (DM, Syphilis, Leprosy, syringomyelia). DDx: indium radiolabelled WBCs.
Treatment: Immobilization+/-Bisphosphonate.

Neuropsychiatric Lupus: Lupus manifestation + Neurological and Psychiatric symptoms.

Polymyocyitis can cause bulbar muscle weakness.

Lead poisoning: causes aldosterone resistance (RTA type 4).

Thyroxin need in pregnancy is increased by 25%.

Adult onset Stills Disease: Fever, Weight loss, Arthralgia/Arthritis, Anemia, HSM+ve and
Lymphadenopathy.

Anti TNF must be stopped 2-4 wks before major surgery (Because it interfere with wound
healing).

C1 estrase inhibitor deficiency: recurrent angioedema due to trauma, causes abdominal


pain and swelling without rash or fever. Treatment C1 inhibitor.

T- score of -1.5 is a cutoff value to start osteoporosis treatment in steroid user patients.

P-ANCA: can be positive with MM.

Feltys syndrome: Occurs in longstanding RF seropositive patients cc by: 1. RF signs. 2.


Splenomegaly 3. Leucopenia 4. Lymphadenopathy 5. Skin ulcers. 5. ANA +Ve in 90%.

Pseudogout: NOT associated with Bakers Cyst.

Electromyography and nerve conduction: Used for confirmation of Carpal Tunnel Syndrome
before surgery.

Drug induced Lupus: ANA +ve, RF +ve, Antihistone +ve, and Normal Comp. level.

Osteomalacia can cause muscle pain and weakness.

Discoid Lupus: Form of lupus with scarring photosensitive skin manifestations is the main
symptoms.

Lupus pnerio: Dusky skin lesion on nose in sarciodosis.

The most common Lung manifestation in Lupus is Pleural effusion and pleuritis.

Simvastatin and Captopril can cause drug induced Lupus.

Anti dsDNA is confirmatory for Lupus and correlate for disease activity.

Treatment of methotrexate overdose: Ca folinate, Hydration and Alkalanization of urine.

Proprionibactirum Acne: Common gram +ve organism found in hip prosthesis during time of
revision (Asymptomatic).

Rubricase: Used in the treatment and prevention of gout associated with tumor-lysis
syndrome.

Neurology, Psychiatry and ophthalmology:

There is a variant in Huntington chorea that expressed in youth (Early), with associated
Parkinsons symptoms.

Steroids are proven to favor outcome of facial palsy.


MND (LMNL+UMLN+bulbar affection): can affect old age.
Basilar artery territory lesion causes: cerebellar, ocular and speech dysfunction.

IIH is a diagnosis of exclusion (cerebral venous thrombosis must be excluded).

New variant CJD: affects young age and EEG is variable unlike sporadic CJD.

IV IGs and plasmapharesis can reverse the symptoms of MG quickly.

CIDP: increased protein in CSF, lymphocytic pleocytosis, MRI enhancement.

Normal pressure hydrocephalus triad: starts with gait disturbance, cognitive deterioration
then urinary incontinence.

Lumbar puncture and nerve conduction studies can be normal early in GBS.

Mononeuritis multiplex: improves over 6 month period with occupational therapy and
physiotherapy.

Holmes Aides eye: dilated sluggish reactive pupil, with decreased reflexes of body.

Friedreich ataxia: cerebellar symptoms, pes cavus, heart hypertrophy, areflexia and spastic
paralysis.

Botulism can cause false +ve tensilon test.

Refsums disease (accumulation of phytanic acid): peripheral neuropathy, deafness,


anosmia, cerebellar symptoms, blindness and pes cavus.
Difference between paroxysmal hemicrania (treatment: Indomethacin) and cluster
headache: PH in female vs. male in CH, up to 50 attacks vs. 1-4, shorter duration 20 mins vs.
hour. They share the same autonomic and unilateral criteria.

Sudden deterioration of MG (myasthenic crisis), due to illness or spontaneous occuring,


Treatment: Elective ventilation, stoppage of anticholinergic, Plasmapharesis or IV Igs.

Giant cell arteritis: Associated with anterior chamber ischemic optic neuropathy (painless
loss of vision).

Anticoagulant is given in vertebral artery dissection (use MRA to confirm) to prevent distal
thromboembolism.
Thyrotoxicosis is associated with periodic paralysis (Hypokalemia).
Pituitary Apoplexy (hemorrhage inside the gland): causes bitemporal hemianopia,
hypopituitarism.
Occulomastactory Myorrhythmia: in whipples (Nystagmus, upward gaze palsy and jaw
claudication).
Rubeosis iridis: complication of diabetes and HTN, can lead to blindness. Treatment pan
retina photocoagulation (prognosis is poor).

Radiation Plexopathy: occurs after radiotherapy >6000 cGy, usually in upper brachial plexus,
painless and associated with lymphodema.
Deja vu, epigastric sensation, followed by loss of consciousness and oral automatisms:
Temporal lobe epilepsy (complex partial seizure, Hx of febrile seizures).
Locked in syndrome: occlusion of basilar artery, quardripelgia, only blinking and upward
gaze is present.

Sub-acute sclerosing pan-encephalitis: chronic measles infection (measles early in life


followed by 6-8 years of no symptoms, then mental and motor deterioration).

EEG in herpetic encephalitis shows front-temporal wave slowing, with intermittent sharp
wave complexes.
Annual Fundoscopy is offered to people with DM1 and DM2 with normal retina.
Causes of isolated 6th nerve palsy: MG, Sarcoidosis, Thyrotoxicosis, MS, and GCA (old Age).
MS: Worsening of symptoms a hot bath.
Temporal lobe lesion causes: Contralateral superior homonymous quardrantanopia, while
Parietal lobe causes contralateral inferior homonymous quardrantanopia.

Wilson Disease: Causes extrapyramidal signs, emotional liability, personality changes and
depression.

Causes of Acute confusional state (Fluctuating course, worse at night): Systemic


infections, drugs, metabolic, hypoxia, hypercapnia, vascular, and trauma.

Carotid artery dissection: cause lower cranial nerve palsies (VII, Hypoglossal).

Organism associated with GBS: Campylobacter, Chlamydia, Hep B, EBV, HIV, HZV, CMV
and Mycoplasma.

First line of Idiopathic Parkinsons disease treatment: <75 year old--Dopamine agonist
(parmipexole, ropinirole), > 75 yrs old--Levedopa.

Toxoplasma Chorioretinitis : Unilateral, mild ocular pain, blurred vision (hazy), White yellow
lesions in fundoscopy.

REM sleep behavior disorder: Early sign of Parkinsons disease.

Serotonin syndrome (caused by SSRIs or MAOs): Hyperthermia, Muscle rigidity,


circulatory instability and agitation.

Feredirech Ataxia: Upper and lower MN lesions, Sensory affection, Atrophy of small muscles
of hand, Ataxia, and nystagmus.

GBS causes Nerve demyelination (Slow conduction and Blocked at several intervals).

Ependyoma: Tumor arises near filum terminal in spinal cord causes chronic back pain +/Saiatica and increased T2 signal on MRI.

Pontine lesions are associated with convergent squint (due to lateral rectus palsy).

Lymphoctosis+Low CSF glucose+Hight Protein= T.B meningitis.

Clopidogrel is used in 2ry prevention of TIA according to the current guidelines.

PSP: Parkinsonian + Dementia + Ophthalmopelgia.

Miller Fisher (Variant of GBS): Ophthalmoplegia + Areflexia + Ataxia + muscle weakness.

Metabolic causes of convulsion: Hypo/Hyperglycemia, Hypo/hypernatremia, Hypocalcaemia,


Hypomagnesaemia, uremia and hypoxia.

Cerebral venous sinus thrombosis: Headache, Focal motor and sensory sign, Papilledema. RF:
Increased coagulopathy. DDx: MRV. Tx: Heparin followed by warfarin.

Corticobasal Degenration: (Parkinsons plus syndrome) Parkinsons feature + Aphasia +


Alien limb phenomena +/- dystonia, myoclonus.

Glomus Jagulare Tumor (vascular tumor) arises near jugular foramen (compress VII, IX, X,
XI and causes conductive hearing loss.

Tropical spastic paresis (HLTV-1 associated myelopathy): UMNL in legs that is contagious.

Inclusion Body myositis (most common acquired myopathy): Affects quadriceps and long
flexors. CPK increased but not much.

Huntington Disease: CC by behavioral disturbance with suicide ideation and abnormal eye
movement (slow saccades).

Brachial neuritis (Neuroalgic Amylotrophy): Tender, pain with movement, weakness in


shoulder griddle muscle following surgery or infection, with sensory loss over deltoid muscle.

Narcolepsy: is characterized by tetradExcessive daytime sleeping, Cataplexy, sleep


paralysis, sleep hallucinations. DDx by sleep latency test Tx: Modafinil.

Vertebral artery dissection: can be associated with Lateral or Medial medullary syndrome.

Subacute combined degeneration: can occur in folate deficiency!

Subthalamic nucleus damage due stroke or inflammation: causes contralateral


hemibalithmus. Treated with dopamine antagonist (helps with movement disorder).

The rash of dermatomyositis is photosensitive.

Bickerstaff's encephalitis: Ataxia, Opthalmoplegia and hyperreflexia (vs Miller Fisher,


Ataxia, opthalmoplegia and areflexia). DDx: Anti JQb1 is often positive as MFS.

Sarcoidosis can cause basal meningitis with lower cranial nerve palsies as a complication.

Limbic encephalitis (Antibodies to potassium channel): Memory impairment, disturbed


conscious +/- seizures and psychiatric disturbances.

L4: (Knee Reflex), Sensation--Anteromedial of calf region, Knee Extension.

L5: Sensation--Anterolateral, Knee Flexion.

S1: (Ankle reflex), Sensation--Sole of foot, Foot eversion.

Kearn Sayre Syndrome (mitochondrial disorder): Loves eye (Opthalmoplegia (upward gaze),
Ptosis, Retinitis pigmentosa. Cardiac symptoms. Cerebellar symptoms.

Carotid angiography: is the gold standard in diagnosis of Carotid Dissection, although non
invasive technique can be used e.g. Carotid duplex.

PSP: Upward and Downward gaze can be affected before horizontal one.

You can drive the car after 6 month in unprovoked seizure (after being assessed), 3 years
in seizure during sleep and night.

Phenytoin toxicity: Cerebellar symptoms.

Carotid artery dissection: Posterior Neck pain may be the only presenting symptom, Cranial
nerve palsies, and stroke. Treatment: Anticoagulant.

Vertebral artery dissection: Severe neck and occipital pain, symptom of cerebellar
affection.

Antidyslipidemic should be used in the 2ry prevention of CVA, even if the cholesterol
normal.

Painful 3rd nerve palsy: Due to vascular lesion (posterior communicating artery aneurysm,
DM (ischemia), and coarticoaortic fistula.

Cerebello-pontine angle space occupying lesions: Affect cranial nerve 5, 6, 7, and 8.

Benign Coital Headache (variant of migraine): Acute severe headache happens with or after
orgasm (due to autonomic dysregulation). DD. Subarachnoid hemorrhage.

Propranalol can exacerbate MG.

Interferon B is used in MS to reduce relapses. Steroids are used during acute attacks.

Neurological affection in Lyme disease: Mono-neuritis multiplex, cranial nerves 4, 5, 6,


7, and 8.

Sciatic nerve palsy (L4:S3): Supply all muscles of the lower leg.

Multifocal neuropathy (Autoimmune Disease): LMNL affecting particular limb+ No sensory


affection, multiple conduction block in NCS.

Wernicke Encephalopathy Triad: Ataxia, opthalmoplegia and delirium, also there may be
hypoglycemia, Hyothermia and hypotension. Can occur in any malnorshiment (e.g.
Hyperemesis gravidarum).

Carotid Artery Dissection: Intracranial type headache + Stroke, Extra-cranial type: Neck
swelling + 9, 10, 11 cranial palsies + Horners.

Vertebral Artery Dissection: Occipital pain and affection of posterior circulation


(cerebellum) or Affection of anterior spinal artery.

Intra-cecal Lymphoma: Associated with increased oligoconal bands and decreased glucose
in CSF.

Binswanger Disease: (small vessel arteriopathy) caused by hypertension and leads to


encephalopathy.

Chronic Headache syndrome (overuse of pain killers): starts with tension or migrane
headache. Treatment: Discontinue pain killers, amitrypitaline.

CADASIL: (small vessel arteriopathy) subcortical infarcts and leucoenchephalopathy. BP is


normal.

Anterior inferior cerebellar artery (lateral lower pontine infarction): Affection of cranial
nerve 8, 7, conjugate eye movement and Horner syndrome.

Juvenile Myoclonic epilepsy: Hx of convulsions at morning + absent seizures, 4-6 Hz spikes


in EEG. Treatment: Valproate (carbamazepine and phenobarbitone should be avoided
(worsen seizures)).

Burning limbs after exercise, hot weather or febrile illness in Fabrys Disease.

Stiff person syndrome (Autoimmune, paraneoplastic): Recurrent stiffness in proximal lower


limb muscles and paraspinal muscles (absent during sleep).

Critical illness myopathy: Proximal myopathy in critically ill persons receiving muscle
relaxants and steroids.

Delusional Depression is best treated by ECT.

Lock in syndrome: infarction of proximal and middle basilar artery segments (Brain stem),
bulbar and UMNLs. Distal lesions are CC by deterioration in consciousness.

Contraindication to thrombolysis in stroke: recent head trauma, BP>180mmHg, active


bleeding.

Inpatients suffers from stroke, should be transferred to stroke unit for better result.

Lewy body dementia (visual hallucinations and Parkinsonism with fluctuating dementia):
treated by Anticholinesterase.

Indications of carotid endarterectomy: the more the risk factors, the more is the benefit.

MG: Anti acetylcholine receptor positive in 90%, while the remaining 10% can be diagnosed
with anti specific muscle kinase.

Weber syndrome--Eye (Midbrain lesion in cerebral peduncle): 3rd nerve palsy, contralateral
hemiplegia (flaccid paralysis + up going planter reflex).

Gretsmanns syndrome (dominant parietal lobe lesion): Finger agnosia, left to right
disorientation, dysgraphia and achalcula.

Marchiafava Bignami (corpous collusom degeneration): chronic Alcohol use.

MG: is exacerbated with pregnancy, and usually associated with other autoimmune
diseases.

Brain tumors: is generally not chemosensitive. Whole brain radiation is used for multiple
brain metastasis, while sterotactic radiotherapy is more localized for specific lesions.

Juvenile myoclonic epilepsy (early onset): Myoclonic jerks (worse in the morning) +
Generalized tonic clonic + absence seizures. First line: Valproate.

ASA is used for 1ry prevention of stroke, while it is switched to clopidogrel in 2ry
prevention.

CADASIL: (Mutation NOTCH-3 gene) Autosomal dominant, migraine followed by subcortical


infarcts and then dementia.

Vision constriction is seen in patients using vigabatrin.

Electromyography: can be used to confirm myotonic dystrophy (waxing and waning potential
Dive bomber), instead of biopsy.

Alcoholic Neuropathy: Early numbness, then paresthesia (especially at night), progressing to


severe pain. Also have features of motor loss.

Infectious Disease and GUM


Endometritis: Fever, foul vaginal discharge, abdominal pain, Treat: Clindamycin +
gentamycin.
Loaisis: Angioedema + Parathesia + leukocytosis + Eosinophilia.

PML: Presents with Visual, cognitive, behavioral, motor, and masses on Head CT in
immunocomporomized.
Herpes Zoster Opthalmicus: Can lead to serious eye complications if not treated.
Acute Histoplasma infection: can presents with glandular fever and erythema nodsum.
The most common organism causes meningitis after shunt operation for hydrocephalus is
staph epidermides.
Salmon Colored rash in: Typhoid Fever.
Tick Typhus (R.Conori): Causes black eschar + Lymphyadenopathy. Tx: Doxycycline.

HIV can be associated with TTP and should be excluded on clinical suspicion.

Tropical Sprue: Diarrhea with partial villous atrophy.


Patient with meningitis from placed shunt is investigated with MRI.
Dengue Fever: Associated with fever > 40 C and hemorrhagic symptoms.
Esinophilic folliculitis: Most common papular purpuric skin lesion in HIV (usu CD4<300).

CMV adrenalitis: causes Addisons disease in HIV.

CT scan abdomen: is the best to demonstrate hydatit cyst.


Traveller Diarrhea (Ecoli the commonest): Self limiting only supportive.
Treatment of Scabies: Application of premethrin lotion all over body below the neck.
Wipple disease is treated with co-trimoxazole.
Vincents Angina: Ulcerative Pharyngitis.
Yersenia enterocolitica: Causes polyarthritis, Uveitis, apthus ulcer, GN, Appendicitis,
Lymphadenitis and erythema nodosum.
Leshmania Tropica Minor: Causes Cutaenous leshmaniasis (Scaly skin ulceration).
Aciclovir if started early within 72 hours of HZV infection, can lead to shortening and less
complicated disease.
Chronic Brucellosis: Loves liver, bone, CNS and BM. Treated: Doxycycline with streptomycin
or rifampicin.
Bradycardia in Typhoid and Brucellosis.
Acute HIV causes: Leucopenia with relative lymphocytosis and thrombocytopenia.

Meningitis associated with fracture skull base: IV linezolid should be given (covers staph
aureus and epidermidis)
Alopecia and Apthous ulcer is a common association with 2ry syphilis.
Difference between oral hairy leukoplakia and oral candidiasis is that patches are dislodged
easily in candidiasis.
Parvovirus causes anemia in HIV persons Treated with IV Igs.
When PO2 <9.3 (70mmHg), start IV steroids in PCP.
Exudative pharyngitis + Swollen neck (bulls neck)= Dipthiteria.
HSV >6 attacks per month, Aciclovir given for 3 months.
Typhoid Fever: FAHM, diarrhea or constipation, Cough, Salmon colored rash. (D.D. Malaria).
Treated with Ceftriaxone (or Amoxicillin, Ciprofloxacin (high resistance)).
Slapped Cheek Disease (Caused by Parvovirus): Causes Fetal Anemia and Hydrops fetalis.
Treatment IV IGs.
Dengue Fever is either a hemorrhagic fever, rash, FAHM, early lymphocytosis, later
lymphopenia, thrombocytopenia and anemia. Or a simple (remitting) fever, sweating,
lymphadenopathy, maculopapular rash. Treatment: Supportive.
Allow 48 hrs after giving antimalarial to see an effect on parasitaemia (>10% exchange
transfusion).
Chancriod (H.ducrei) is treated by macrolides or quinolones.
Ciprofloxacin+ Loperamide: reduce the severity of traveler diarrhea.
Malaria prophylaxis should be continued 7 days after return using Atovaquone/proguanil or 4
weeks using mefloquine alone.
Drugs used in the prophylaxis of meningitis: Rifampicin, Ciprofloxacin (First line, Single
dose), and ceftriaxone (Single dose).
Yaws (trepenoma): HyperKeratotic skin lesion looks like wart (TPHA is positive), Treatment:
Penicillin.
Strongyoides (Far East area): Anemia, Pulmonary infiltration(can be chronic),, GI
symptoms (can be chronic), eosinophilia, rash (may be linear) Treatment: Ivermectin or
Albendazole.
Zidovudine: Associated with fat distribution and Hyperglycemia.
Nucleoside reverse TI: Associated with cardiomyopathy.
Pinta (trepenoma): Hyper-pigmented skin lesions.

Cryptosporidum: Diarrhea in immunocompromised. Tx: Nitzoxanide.


VZV Igs: given within 3-7 days post exposure.
Nucleic acid amplification testing (NAAT): is used to detect gonococcus and chlamydia.
Histoplasmosis (common with exposure to bats and birds): Treated with Ampho B followed by
Itraconazole.
Filariasis: Treated with Albendazole (single), Ivermectin, and DEC.
Chagas Disease: Treated by nifurtimox or benzidazole.
Churg Strauss: can cause CNS vasculitis.
Vaccines can be used in pregnancy: TT, Diptheria, and Hep B.

Dermatology:

Acanthosis nigrigans: Associated with hypothyroidism.

CCBs: Associated with intermittent facial flushing.

Necrobiosis Lioidica (in DM): Lesions on front of shins (shiny, Atrophic, brown-red or
slightly yellow and margins could be erythematous or violet).

Phototoxic reaction: erythema and blisters in a patient using drug (e.g. ciprofloxacin) after
exposure to sunlight.

Morphoea (Localized scleroderma): Thickening in the skin following by hyper or


hypopigmentation. Treated with topical steroids.

Vitamin D analogue is used as a second line after topical steroids in psoriasis.

Granuloma annulare (immunocompromised): Dermal nodules fused together to form rough


ring shape. Treated with intra-lesion steroids.

T.B salpingitis: Can occur without pulmonary signs.

Drug Hypersensitivity syndrome (3-6 weeks after starting the drug): Fever, Facial edema,
popular and pastular rash and lymphadenopathy.

Ulcers in Behcet Disease are Apthsus type.

Lupus Vulgaris: Scarring skin lesions due to T.B infection. Treated with Anti T.B.

Cutaneous leshmaniasis: Flu like illness then Skin lesions.

Treatment for tenia capitis is given for at least 3 months.

Lichen Planus: Heals with hypopigmentation in dark skinned persons.

Pyoderma Gangernosum: Can occur at the site of surgery.

Herpetic Whitlow (HSV affecting fingers): cause herpetic rash, cellulitis, lymphadenitis
and lymphedema.

Stevens-Johnson syndrome: Erythematous papules and blisters affecting body and mouth,
conjunctive and genitalia.

Seborrhoeic Keratoses (senile warts): in old age, stuck on appearance, usually on the back.

People showing dermatitis herptiforms rash for coeliac disease may be asymptomatic.

Tenia cruris: Sharply demarcated rash (symmetrical or Asymmetrical) that spares the
scrotum if it involves genitalia (D.D. candida: involves scrotum).

HPV (kissing warts): Skin colored nodules.

Oral leukoplakia: White lesions at the side of the mouth that cant be dislodged caused by
smoking and alcohol.

Dermatitis Artifacta: Self inflected linear or geographical lesions that appear overnight.

Toxic Epidermal Necrolysis is a Cytotoxic T cells and apoptosis.

Rosacea (photosensitive): erythema with telangiectasia, papules and pastules mimicking acne
but no comedones, swelling and distortion of nose. Treatment antibiotics.

Retention Keratosis (complication from varicose veins): Treatment surgical debridment.

Oral acyclovir is useful only if given in the 1st 48hrs after HZV infection.

Yellow nail syndrome: in bronchiectasis, COPD, pleural effusion, nephrotic syndrome and
penicillamine use.

Erythema Multiforme: occurs in mycoplasma, HSV, sulphonamides and penicillins.

Lichen Planus: occurs at the site of a previous scar.

Erythema gyratum repens: Wood grain rash appearance, associated with malignancy.

Isotretinoin side effects: Teratogenic, depression, impairment of night vision, alopecia,


and worsening of acne.

Mohs surgery is done in BCC for cosmetic consideration.

Erythroderma (90% of the body affected): in Eczema, and psoriasis.

Clinical Pharmacology and toxicology:

Phenytoin (can cause increased liver enzyme) and Carbamazpine: causes cerebellar
toxicity.

Indication of liver transplantation in Paracetamol toxicity: 1. PH <7.3 or arterial


lactate > 3 mmol after fluid resuscitation. 2. Three of the following Cr >300, PT>100
(INR>6.5) and GIII or IV Encephalopathy.

PTU is recommended early in pregnancy, while carbimazole is recommended later.

The rash of psoriasis is increased by BBs, lithium, NSAIDs and Antimalarial.

Long term antiepileptics are not required in treatment of acute alcohol withdrawal,
instead IV lorazepam can be used for prophylaxis.

Parlidoxime: Antidote for organophosphate poisoning (muscarinic and nicotinic


symptoms).

SSRIs and SNRIs: Enhance the effect of anticoagulant.

Zivudine: cause red cell aplasia and megalobastosis.

Activated charcoal can be given up to 12 hours after salicylates toxication.

Treatment of digoxin related VT: 1st line IV phenytoin, 2nd line lidocaine.

Antidote of cyanide: Dicobalt edetate, sodium nitrate or sodium thiosulphate.

Senna and Dantron Laxative: cause melanosis coli.

HIT type I: Platelet count is observed without stopping LMWH.

Calcium Folinate (leucoverin): used in the overdose of methotrexate.

Treatment of Non functioning adrenal adenocarcinoma: Mitotane.

Oral Diazepam reducing dose: used initially in treatment of BDZs withdrawal.

Dystonic reaction caused by Metoclopramide, stemetil, is treated by procyclidine.

Treatment of neuroleptic malignant syndrome: Bromocriptine.

Pyridoxine: can cause non-iron microcytic anemia.

Penicillamine: cause MG.

Antidote for barbiturates: Sodium bicarbonate.

Safe antibiotic to be used in G6PD deficiency: Augmentin.

Arsenic poisoning (glass industry/rodenticide): Diarrhea, Horizontal nail lines


(mees), and abdominal pain.

Indinavir: Renal stones and hyperbilirubinemia.

Clozapine: Associated with 7 fold increase in risk of DM and weight gain.

Fibrates: Leads to formation of gallstones.

St. Johns wart: Enzyme inducer.

Clozapine: causes neutropenia (CBC monitoring required).

Alkalinzation of urine in treatment of salicylates overdose is done by IV NaHCO3


(NOT WITH forced alkalnization of urine).

Mefenamic Acid (Ponstan) overdose presents with seizures.

Adminstration of NAC in treatment of paracetamol overdose: can cause anaphlactoid


reaction initially (Tx: stop the infusion temporarily, if there is severe respiratory
reaction: give adrenaline).

Multiple dose charcoal can be given with overdose of: Carbamazipine, Digioxin,
Dapsone, Theophylline, phenobarbital, salicylates and Qunine.

Paracetamol overdose is asymptomatic in the first hours after ingestion.

Hydroxyurea: decreases pain and hospital admission of SSHb.

Drug induced psuedolymphoma (skin): T-cell infiltration due to usage of


antiepileptic, antihistaminic, antiarrhythmic, and some antibiotics.

VT associated with TCA toxicity: is treated with NAHCO3 if failed Lidocaine.

Treatment of ATN associated with paracetamol toxicity is hemodialysis.

Treatment of Parkinsons related Depression: Fluoxetine, Psychosis: Resipridone.

Calcium Alginate: used in the dressing of bed sore with necrotic tissue.

Ketoconazole and Fluconazole are enzyme inhibitors.

Promethazine: is used as a first line in nausea with pregnancy.

Antimalarial exacerbates psoriasis.

Ethylene Glycol toxicity: Multiorgan failure.

Using antibiotic once daily is safer than using multiple doses in nephrotoxic
antibiotics.

Alpha methyldopa and Labetalol is safe antihypertensive during pregnancy.

Early toxicity of Aspirin overdose is Respiratory Alkalosis, and then late it is


metabolic acidosis.

Latent T.B (+ve blood test without symptoms and signs of T.B): Rifampicin + INH
for 3 months.

Sodium Nitroprossiude: degrades into cyanide when exposed to sunlight.

Atenolol causes IUGR in pregnant, while labetalol and nifidipine are safe.

Vancomycin is associated with dizziness and tinnitus.

Adrenaline IM dose in anaphylaxis: 0.3-0.5 ml of 1:1000

Amantadine is alternative for (interferon + Ribavirin) in treatment of hepatitis C


in patients suffer from adverse effects.

Early cyanide poisoning cause HTN+bradycardia, vomiting, abdominal pain, later


hypotension and coma.

Augmentin and ciprofloxacin: Associated with pic of obstructive jaundice.


Erythromycin increases liver enzymes only.

Antibiotic safe in pregnancy: Amoxicillin, Ampicillin,Clindamycin,Erythromycin, Penicillin.

In salicylates poisoning: if the patient is hypokalemic, correction of hypokalemia is done


first, before giving NaHCO3 (at PH<7.1).

Donepezil side effects (CNS stimulant): Irritability, hallucinations, insomnia and seizures.

Drugs following zero order kinetics (Peas and WHEATS): Phenytoin, warfarin, heparin,
ethanol, aspirin, theophylline, salicylates.

Cranberry Juice (enzyme inhibitor) interacts with warfarin (Increase INR).

Grapefruit juice (enzyme inhibitor) interacts with simvastatin and ciclosporin.

Sodium Valproate (can cause PCOS like syndrome): 1st line in absence seizure

Cyclizine or Domperidone is preferred over metoclopramide or prochlorperazine as


antiemetic in young people for risk of dystonic reactions.

Indication of antivenom: systemic affection (Hypotension, tachycardia, high WBCs,


severe limb swelling.

Contraindications of infliximab: 1. Active infections 2.MS 3.Pregnancy 4. Breast feeding


5. HF 6.Active T.B

Volatile substance abuse is associated with type 1 distal RTA.

Fullers earth is given post paraquat ingestion, if not found and within 4 hrs of ingestion
activated charcoal may be given.

Contraindications of sodium nitroprossiude: Vitamin B12 deficiency, Lebers optic atrophy


and severe liver disease.

Porphyria is made worse by carbamazepine.

Colchicine: causes myoneuropathy.

Posterior leucoencephalopathy (looks like hypertensive encephalopathy): caused by


immunosuppressive drugs like cyclosporine, Tacrolimus, cyclophosphamide, and
methotrexate.

Isoniazid overdose: causes renal failure and metabolic acidosis.

Lead poisoning: Associated with proximal RTA.

Hyperkeratosis of skin of palm and soles, with transverse line on nails: Arsenic poisoning.

Theophylline toxicity: Agitation, polyuria, Hypotension, GI upset, metabolic acidosis and


hypokalemia.

Dot sign in sylvian fissure: sign of brain infarction (MCA). Treatment thrombolysis.

Oncology and palliative medicine:

Hypercalcemia of malignancy: Treated with IV fluids and bisphosphonate.

Cord compression: Dx. best with MRI. Treatment: IV steroids +/-surgery or radiation.

Liver transplantation can be done in liver tumors up to 3 masses < 3cm.

Carcinoid syndrome can cause pellagra due to consumption of tryptophan.

1st line in SVC syndrome (obstruction with lung tumor): IV steroids.

Tumor marker of seminoma: B-HCG.

Bony metastases: associated with hot spots in bone scan (may be osteogenic or osteolytic).

Corrected calcium= serum calcium + (40-serum Albumin) X0.027.

Patient with pretreatment of myeloprolifirative disorders high LDH, is at risk of tumor lysis
syndrome.

Dermatomyocytosis is associated with esophageal cancer.

Poor prognosis of Ewings sarcoma in: male, >12 years old, anemia, increased LDH, poor
response to chemotherapy.

There is an association of papillary carcinoma of thyroid and FAB.

Contraindication of surgical removal of lung cancer: 1. SVC affection 2. Near main


bronchus 3. Malignant pleural effusion 4. FEV < 2 L.

Mesothelioma: increased risk with radiation exposure.

Prognosis of breast cancer depends a lot on nodal affection.

Most common solitary nodule in non-smokers is 2ry from RCC.

Usage of somatostatin analogue shrink tumor before surgery of pituitary.

Small cell carcinoma is almost always disseminated by the time of diagnosis. Treatment
chemotherapy+ Radiotherapy.

VHL: Hemangioblastoma affecting retina, cerebellum, brain and abdomen.

Hairy cell leukemia causes monocytopenia.

Pupil of Horner syndrome caused by pancosts syndrome doesnt dilate with atropine.

Successful treatment of non-Hodgkin lymphoma increase risk of leukemia.

Upper and middle esophageal cancer needs bronchoscopy to exclude tracheal involvement.

Pheochromocytoma is associated with 2ry polycythaemia.

Hodgkin Lymphoma occurs in relatively young age, while non-Hodgkin occurs in old age.

Paraneoplastic syndrome of RCC secretes: EPO, PTrP, and ADH.

Testicular choriocarcinoma: can be small size and not detected with clinical exam,
associated with markedly high bHCG, normal AFP and CEA, and early metastasis to lung.

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