Dr.

Rami Abazid

1

MAGDY ABBAS


BRAIN MAP

FOR

PACES


PREPARED BY:
DR. RAMI ABAZID

Dr. Rami Abazid

2


TO: THE SOUL OF MY PARENTS



TO: Jailan, Diaa,
Mariam and Reham




Dr. Rami Abazid

3

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

4


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
Dr. Rami Abazid

5


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

6

THE PACES EXAMINATION:





Cardiology
10 mins.


Communication
Skill
20 mins.
Brief Clinical
Consultation
10 mins.





Brief Clinical
Consultation
10 mins.
(5) (4)
(3)
(1) (2)
Neurology
10 mins.

History taking
20 mins.

Chest
10 mins.

Abdomen
10 mins.

Dr. Rami Abazid

7


STATION I

MAP FOR

ABDOMEN

&

CHEST


Dr. Rami Abazid

8

ABDOMEN CASES

With stigmata of without stigmata of
CLD 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)
Dr. Rami Abazid

9

C L D

Signs Decompensated D-D Investigation
Signs General
* CBC
Spider Clubbing Ascites * electrolyte complications
Naevi Arms leuconychia
Fistula Hands Palmer erythma Assess
Dupuytrens Jaundice Liver & FP
Contracture Function
Hepatic Encephalopathy -S. Bil. U/S
Flap -S. Alb
. -PT
-ALT Search
-AST for the
Parotid cause
Swelling
Jaundice
Wasting Face
Pallor Spider
Anthelasma Naevi
Chest reduced axillary hair hepatitis H.chr. Wilson
Gynaecomastia C. B.
Alcohol PBC Virdogy
Shrunken Drugs Study
Liver
Hepatomegaly AIH Alpha 1,AT Auto Immune Iron
Splenomegaly Abdomen Study Study
Ascites
venous
Hum ---L.L. oedema Metabolic Wilson
Alpha1 AT

Caput Medusa -Testicular Atrophy







Dr. Rami Abazid

10

COMPLICATION
OF
CIRRHOSIS



Portal hypertension Hepato Cellular Dysfunction


Varices Ascites hepato Encephalopathy Hepato
Renal cellular
Syndrome carcinoma

Coagulopathy
Bleeding Spontaneous
Bacterial
Peritonitis





Dr. Rami Abazid

11

POOR PROGNOSTIC FACTORS
IN
LIVER CIRRHOSIS


Encephalopathy Na Albumin PT
< 120 25g/L


FACTORS PRECIPITATE HEPATIC ENCEPHALOPATHY



Infection Diuretics Electrolyte Sedative Surgery
Diarrhea Imbalance
Vomiting Paracentesis
GI Bleeding


Dr. Rami Abazid

12

TREATMENT OF ASCITES
IN
C L D

Salt restriction Furosemide Serial
to <29/day up to Paracentesis
Rest (Dietician) 120mg/day
Fluid
Spirino Lactone Restriction
Na excretion >78 If Na is < 125mmol/L
mmol/day
up to 400mg/day


TIPS
Transjugular
Intra hepatic
Portal systemic
Shunt

(Aim: one KG weight loss/day)
Dr. Rami Abazid

13


PRIMARY PREVENTION OF VARICEAL BLEEDING
DIAGNOSIS OF CIRRHOSIS
O G D

No varices Grade I Varices Grade 2 or 3 varices

Repeat OGD repeat OGD one year Propranolol
3-4 years 80-160mg/day

HR60
Band ligation if
Propranolol intolerant
or Verapamil
Diltiazem
MANAGEMENT OF VARICEAL BLEEDING
IN CIRRHOSIS

TIPS
Blood transfusion Octreotide Endoscopic Endoscopic Balloon
Sclerotherapy ligation Tamponade
Dr. Rami Abazid

14



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

Dr. Rami Abazid

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SPLENOMEGALLY


Mild Moderate Massive
<4 cm (4-8 cm)
INFECTIONS -Infections
EBU -Myeloproliferative Kala Azar
Infective Endocarditis -Lymph proliferative Malaria
Hepatitis -Hemolytic anaemia Bulhorzia
AUTO IMMUNE - Infiltration -Myeloproliferative
Rh. Arthritis Gauchers CML
Infiltration Amyloidosis Myelofibrosis
Sarcoid






Dr. Rami Abazid

16


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 MAGs SYNDROME
CLD CHC CRF MALIGNANCY T.B. INFECTION




Dr. Rami Abazid

17



RENAL ANGLE MASS

Polycystic Renal Cell Hydronephrosis
Carcinoma Adrenal mass

Retroperitoneal
Mass





WHY RENAL MASS


Can get Minimal Resonant to
Above it Ballottable No movement with Percussion
Notch inspiration







Dr. Rami Abazid

18


SURGICAL INTERVENTION IN
POLYCYSTIC KIDNEY




Massive Recurrent Transplant Recurrent Possible
Cysts Pain work up Infected Malignancy
Cysts


ASSOCIATED INHERITED CONDITION
WITH RENAL CYSTIC DISEASE



Autosomal
Tuberous Von-Hippel Autosomal recessive
Sclerosis Lindou disease dominant polycystic Polycystic
Kidney Kidney













Dr. Rami Abazid

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Dr. Rami Abazid

20

INTERSTITIAL LUNG DISEASE


Dry S.O.B. Fine Endispiratory
Cough Crackles


C A U S E S


TIP
Rheumatological
- Rh. Arthritis Vasculitis
- S.L.E. - PAN
- Systemic Sclerosis -Wegners Pneumocomosis
- Polymyositis -Churg-Strauss -Asbestosis Drugs
- Dermatomyositis -Good Pastures Silicosis Amiodarone
- Ankylosing Spondilitis -Beryliosis Nitrofurnatone
- MCTD Busulphan
- Sjogrens Syndrome Bleomycine
Allergic Gold
Radiation Methotraxte
OTHERS
Extrinsic Gauchers
Allergic Lymphangiomyelomatosis
Alveolitis Niemann Pick
NF
Tuberous Sclerosis




Dr. Rami Abazid

21



IDIOPATHIC INTERSTITIAL PNEUMONIA
TIP


N D A R U C Linda

Usual lymphoid
Interstitial Interstitial
Pneumonia Pneumonia
(UIP) (LIP)
Non Specific
Interstitial Desefuamative Respiratory Cryptogenic
Pneumonia Interstitial Bronchiolitis organizing
(HSIP) Pneumonia Interstitial Pneumonia
(DIP) Lung disease (COP)
(RB-ILD)


Acute Interstitial
Pneumonia
(AIP)



Dr. Rami Abazid

22

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 B A L
-Precipitins
-Serum ACE
-ABG Honey combing neutrophils lymphocytes

Not responded
To cortisone
Good response
To corticosteroid
Bad prognosis Good prognosis


Respond to
Corticosteroid









Dr. Rami Abazid

23








MANAGEMENT OF ILD


Non Pharmacological Lung Transportation



Smoke Avoid exposure long term corticosteroids Young Patent
Cessation to toxic oxygen + rapidly
Substance Azathoprine progressive
Disease




If not tolerate
Corticosteroids if not tolerate
Azathoprine alone Azathoprine
Cyclophosphamide
Discontinuation
Of toxic medication









Dr. Rami Abazid

24





UNILATERAL LUNG FIBROSIS
EXAMINATION



Flattening of
The affected side
Heterogenous Breath sounds trachea is
percussion of reduced shifted to
the affected + the affected
side coarse crackles side
not changed with
cough
+
VR
on the affected side
Reduced movement
Of the affected side











Dr. Rami Abazid

25





CAUSES OF APICAL FIBROSIS


Histoplasmosis
Old T.B. Radiation Ankylosing
Spondolitis Sarcoidosis


Extrinsic allergic
Alveolitis



CAUSES OF BASAL FIBROSIS


ILD


Aspiration Asbestosis Drugs Connective
Tissue disease







Dr. Rami Abazid

26



PLEURAL EFFUSION



Chest expansion breath sounds
On the affected side bronchial breathing
Above the effusion


Stony dullness on
Percussion

PLEURAL EFFUSION




Exudates Pl. Protein between Transudates
PL. protein>35g/L (25-35) g/L Pl. protein
<25g/L


Lights criteria
For exudates







Dr. Rami Abazid

27


PLEURAL EFFUSION

Exudates Transudates


Protein >35g/L between Protein <25g/L
25g/L 25g/L
Lights criteria for
Exudates
Megs
Syndrome
Cardiac
Failure CLD
Infiltration
(neoplasm) CRD




infections 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


Dr. Rami Abazid

28



PNEUMONECTOMY


Chest wall

Chest expansion Trachea
Scar Flattering of the
Affected side
Absent on Grossly deviated
The affected side to the affected side


Breath sounds
absent on
the affected side

LOBECTOMY

Scar

Chest wall Chest expansion Trachea Breath sounds



localized reduced on the deviated to the reduced on the
Deformity affected lobe affected lobe affected lobe
On upp.lobectomy

Dr. Rami Abazid

29

LUNG CONSOLIDATION



Chest wall Chest expansion Trachea Percussion


normal
Reduced not shifted dullness
Except if associated
Collapse

Breath
Sounds

C A U S E S
Bronchial
breathing


crepitations

Infection Vasculitis malignancy Cysts
Vocal
Infarction resonance


Granuloma





Dr. Rami Abazid

30



BRONCHIECTASIS

Irreversible dilatation, destruction and Inflammation
of the Bronchial wall
Examination



Excessive
Productive finger clubbing Coarse Inspiratory
Cough Crepitations which
Alter with coughing



C A U S E S


T.B. Malignancy
CONGENITAL CHILDHOOD INFECTION
- Immotile -measles
- Cilliary syndrome -Pertussis Foreign
- Kartagners syndrome Body
- Young syndrome
C.F. -Post Pneumonia Immune deficiency
(Staph., Klibsella) - hypogan maglobulnoia
-Allergic Aspergillosis

-



Dr. Rami Abazid

31








BRONCHIECTASIS
Investigations


Lab Radiology Special


-Sputum CLS
-Sputum AFB
-Sputum gram stain CXR HRCT Bronchoscopy
-Immunoglobulins for malignancy
-Rheumatology profile
-Na Sweat Test
-Genetic Screening for C.F. Tranlines shadows Signet ring sign
Ring shadows Thickened dilated
Bronchi Larger than
Vascular bundle













Dr. Rami Abazid

32













BRONCHIECTASIS MANAGEMENT



Non Pharmacological Medical


-Stop smoking
-Pulmonary Rehabilitation Vaccination Surgery
-Multi-disciplinary -annual Influenza for localized
Management -H. influenza -Antibiotic disease
-Pneumococcal for exacerbation
-long term antibiotic
-bronchodilators
-Inhaled corticosteroid












Dr. Rami Abazid

33








OBSTRUCTIVE AIRWAY DISEASES


Chronic Asthma Chronic
Obstructive
airway disease
COAD




Reversible Cause Chronic Emphysema
Bronchitis




Diurnal
Variation Smoking


Irreversible No Cause
Diunal
variation Pollution





Dr. Rami Abazid

34







INVESTIGATIONS OF OBSTRUCTIVE
LUNG DISEASE



Lab.
Others

-FBC Radiology E.C.G.
-urea Electrolytes
-LFT -CXR -Rt. ventricles
Hypertrophy
-Inflammatory markers -HRCT -P. Pulmonale
-S. & antitypsis for emphysemia
-ABG -Echo

-Sputum -RFT
CLS (Spirometry)
gram
Stain








Dr. Rami Abazid

35









MANAGEMENT OF OBSTRUCTIVE
AIR WAY DISEASE


Non pharmacological Vaccination Pharmacological



-Stop smoking
-Pul. Rehabilitation
Annual H. Influenza Pneumococcal
Influenza Pneumonia
Vaccine



Bronchial Asthma


C O A D



B2 against or LABA LABA
Anticholinegic + +
SABA inhaled inhaled
Or SAMA corticostriods +
Theophylline
Dr. Rami Abazid

36










BRITISH THORACIC SOCIETY GUIDELINES


STEP STEP STEP =step 4
Add beclomethasone +
100-400 ug/12h -oral Prednisolone

Occasional
Short acting
Inhaled B2 against STEP STEP
+
-LABA -Beclomethasone to 1000 ug/12h
- dose of oral Theophylline
Beclomethasone oral leukotrene antagonist
To 400ug/12h
If > than once daily oral B2 against
Or night Time symptoms oral leukotrene receptor
oral Theophylline

STEP









1
2
3

4

5

2
Dr. Rami Abazid

37






STATION 3


MAP FOR

CARDIOLOGY

NEUROLOGY


Dr. Rami Abazid

38



CARDIOLOGY EXAMINATION


Non Auscultatory Auscultatory
Rt. A.S.


Carotid
Thrill
Pulse

Lf. P.S.
Both
Radial

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


Collapsing
Water V Wave w/
Hammer Carotid TR
Or not




Dr. Rami Abazid

39








AUSCULTATORY

APEX
Axilla 2
nd
Rt. Intercostal 3
rd
left intercostals space
Soft Pansystolic space while patient leans forward
Murmur -1
st
H.S. after expiration early
MR ejection systolic diastolic murmur
Murmur A.S.
H.S. Murmurs
Lower left A.R.
Sternal edge 2
nd
left
TR ( Insp.) intercostal

4
th
H.S. Left sternal Carotid
Near the 1
st
H.S. edge R A.S.
V.S.D. L P.S.
2
nd
H.S. opening A.S.D. 2
nd H.S.

snap near it

fixed splitting
2
nd
H.S.
HOCM
valsalvis
1
st
H.S.
P. HTN

normal M.R. A.S.
P.S.

M.S.





Dr. Rami Abazid

40


AORTIC STENOSIS
A.S.


Symptoms Non Auscultatory Auscultatory
Findings


Ejection systolic
Murmur with
Expiration radiate to
neck
Dyspnoea Syncope -small pulse
Volume Apex
heaving
-Slow Rising
Chest pain 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 Systolic Soft 2
nd
4
th
H.S. Long
Apex Thrill heart sound murmurs
A2

Dr. Rami Abazid

41











Bicuspid Congenital Rheumatic Degenerative





Indications for Aortic
Valve replacement












Dr. Rami Abazid

42


AORTIC REGURGITATION A.R.

SYMPTOMS NON AUSCULTATORY AUSCULTATORY
FINDINGS FINDINGS






SIGNS OF SEVERITY

Long duration of
The murmur Austin Flint murmur P.HTN

Wide Pulse 3
rd
H.S.
Pressure






Dr. Rami Abazid

43







A.R.


CAUSES INDICATION FOR SURGERY























Dr. Rami Abazid

44







MITRAL STENOSIS

SYMPTOMS NON AUSCULTATORY AUSCULTATORY
















Dr. Rami Abazid

45


M.S.

COMPLICATION DD SIGNS OF SEVERITY

Left Atrial myxoma Clinical Echo
Austin-flint murmur

INDICATION OF SURGERY




Pul. Pul. Recurrent
Congestion HTN thromboembolic
Events despite
Anticoagulation

Haemoptysis





Dr. Rami Abazid

46

MITRAL REGURGITATION



Symptoms Non Auscultatory Auscultatory


1
st
H.S. S3

Pan-systolic murmur
soft and radiating
to axilla

===========================================================================

CAUSES INDICATIONS FOR SURGERY


Acute Chronic Symptomatic Asymptomatic
Despite optimum
Prolapse Medical therapy LVEF LVES D
Rupture MI NYAH III-IV 60% 45mm
Rheumatic Functional EF~35-50%


3 act. Endocarditis

Connective tissue
Disease



Dr. Rami Abazid

47




SOME CONGENITAL ANOMALY

A.S.D. V.S.D. HOCM PDA



On Pulmonary at the lower
area sternal edge
Coarctation Thrill left
of Aorta Inter-space
Thrill fixed splitting
2
nd
H.S. thrill at machinery
Lower sterna murmurs
Ejection systolic Edge loudest below
Murmur left clavicle
Ejection systolic
Murmur valsalvi
Systolic Pansystolic
thrill murmur

no radiation


Fallots
continuous
V.S.D. Rt. vent. Pul. Stenosis radiofemoral murmur radiating
Hypertrophy delay to back



Dr. Rami Abazid

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Dr. Rami Abazid

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