Theories of Hepatic encephalopathy.

1- Toxic metabolitis (amonia, free fatty acid, mercaptan, methionin and tryptophan,
tyramine, octopamine, manganes).
2- Increased sensitivity of inhibitory neurotransmitter (GABA)
3- Increased circulating level of endogenous benzodiazepines.
4- Astryocyte dysfunction (amonia and manganes are neurotoxic to astryocytes
leading to BBB failure).
5- Increased amonia production in the GIT (bacteria degrade amines, amino acid,
purine and urea to amonia).
.........................
Causes of Proptosis:
Bilat. Proptosis:
- Familial
- Grave's ophthalmopathy
- Lymphoma, leukemia and metastasis
- Cavernous Sinus thrombosis and fistula
- Sarcoidosis
Unilat. Proptosis:
- Traumatic
- Orbital cellulitis and abscess
- Retrobulbar hematoma and tumor
- Sarcoidosis
- Tolosa Hunt syndrome
.........................
Indications of steroids for R.A:
- Treatment of acute flares
- Bridging treatment between initiation of and response to DMARDs.
- Extra-articular involvement (Eye, Lung)
- Low-dose steroids for resistant cases.
- Pt. is the breadwinner of the family
.........................
Optic Neuritis Causes:
Demyelinating Disorders: MS, NMO
Rheumatological disorders: SLE, Behcet disease
Metabolic: Sarcoidosis, Vit. B12 Deficiency
Infection: Syphilis, Lyme disease
Toxins & Drugs: Methanol, Ethambutol
.........................
Uveitis Causes:
1- autoimmune:
- Behcet disease
- Ankylosing spondylitis,
- SLE
- R.A
2- Graneolomatous inflammatory:
- Sarcoidosis
- IBD
- Lymphoma
3- Infective:
- Herpes zoster
- Syphilis
- Toxoplasmosis
- Tuberculosis
4- Medication S.E
- Cidovovir
- Cobalt
- Diethylcarbamazepine
5- Eye injury or surgery
.........................
Internuclear ophthalmoplegia causes:
- Multiple sclerosis
- Brainstem infarction
- Head trauma,
- Brainstem and fourth ventricular tumors,
- Arnold-Chiari malformation,
- Infection,
- Hydrocephalus,
- SLE
.........................
Avascular necrosis causes (PLASTIC RAGS):
P- Pancreatitis, Pregnancy
L- Lupus (SLE)
A- Alcohol excess (chronic)
S- Steroids
T- Trauma
I- Idiopathic, infection
C- Caisson disease, Collagen vascular disease
R- Radiation, Rheumatoid arthritis
A- Amyloid arthropathy
G- Gaucher disease
S- Sickle cell disease
.........................
* Daily caloric requirement:
Men= 2500 kcal/day
Women= 2000 kcal/day
* Eenergy equivalents of food staff:
One gram of carbs = 4 cal.
One gram of protein = 4 cal.
One gram of fat = 9 cal.
* Balanced diet:
45-65% carbs,
10-35% protein,
20-35% fat.
* Weight reduction diet:
10-30% carbos,
40-50% protein,
30-40% fat.
.........................
Causes of hypercalcemia (CHIMPANZEES):
C- Calcium supplementation
H- Hydrochlorothiazide, Hyperthyroidism
I- Iatrogenic, Immobilization
M- Multiple myeloma, Milk-alkali syndrome, Medications (e.g Lithium)
P- Parathyroid hyperplasia or adenoma
A- Alcohol
N- Neoplasm (e.g breast cancer, lung cancer)
Z- Zollinger Ellison syndrome
E- Excessive vitamin D
E- Excessive vitamin A
S- Sarcoidosis
.........................
HIV test Window Periods:
- Nucleic Acid Test (NAT): 10 to 33 days.
- Antigen/antibody test (Venous Blood): 18 to 45 days.
- Antigen/antibody tests (Finger Stick): 18 to 90 days.
- Antibody tests: 23 to 90 days
.........................
Chemotherapy agents:
1- DNA alkylating agents:
cyclophosphamide,
chlorambucil,
dacarbazine,
platinum agents (carboplatin, cisplatin, and oxaliplatin).
2- Antitumor antibiotics:
bleomycin,
etoposide,
topotecan,
irinotecan,
doxorubicin,
daunorubicin,
mitoxantrone.
3- Antimetabolite agent:
methotrexate,
azathioprine,
5-fluorouracil,
cytosine arabinoside,
gemcitabine,
fludarabine,
asparaginase,
pemetrexed
4- antimitotic agents: 
vincristine,
vinblastine,
vinorelbine,
paclitaxel,
docetaxel
5- tyrosine kinase inhibitors:
imatinib,
gefitinib,
erlotinib,
sorafenib,
sunitinib.
5- molecularly targeted agents:
All-trans retinoic acid
histone deacetylase inhibitors
mTOR (mammalian target of rapamycin) inhibitors
.........................
Red flags of headache (S2NO2P5):
- S: systemic symptoms  (fever, weight loss)
- S: secondary risk factors (immunosuppression, cancer)
- N: neurologic deficits or altered consciousness
- O: onset is sudden, abrupt or thunderclap headache
- O: older, age >50 for new-onset headache (giant cell arteritis)
- P: pattern: change 
- P: pregnancy
- P: positional or postural
- P: papilledema
- P: precipitation with Valsalva maneuver or exertion
.........................
M.V:
1- Minute ventilation=Vt*F (should be increased in case of hypercapnia)
Driving pressure=platue pressure - PEEP(should be <15)
Platue pressure=intrapulm. pressure
PEEP=airway pressure.
Peak inspiratory pressure = pressure to overcome resistance in the  ETT & airways +
elastance o f the lung parenchyma, pleural space & chest wall.(increase in airway
obstruction and thoracic or pulmonary problems)
Inspiratory plateau pressure= pressure to overcome elastance of the lung
parenchyma, pleural space & chest wall (not increase in airway obstruction).
.........................
General Communication Skills:
1- Introduction yourself to patient
2- Setting
3- Concise summery
4- Idea & Knowledge of patient
5- Concerns
6- Procedures, Drugs, Alternatives
7- Expectations
8- Organize for another visit or senior opinion & Offer help and contact number
.........................
Communication with angery patient:
1- Show empathy and care
2- Ask about the cause of annoying
3- Explain the cause of problem
4- Give a solution
5- Deal with future concerns
.........................
Dealing with a difficult patient:
1- Set boundries
2- Calm patient
3- Show empathy
4- Do not argue
5- Do not take it personally
6- Never accept abuse
7- Ask for help if needed
8- Take brief history
9- Know underlying causes of angery (Idea, Concerns, Expectation)
10- Give solutions and negotiate with patient about importance of treatment
11- Arrange for senior consultation
12- Arrange for another session
12- Offer help for patient if possible
13- Give contact number
.........................
Dupuytren's contracture:
- Alcoholism
- Diabetic cheroarthropathy
- Hand trauma
- Cigarette smoking
- HIV
- previous M.I
.........................
Na+ Stibogluconate is adminisered with allopurinol,  ketoconazole,  pentoxiphyline
.........................
CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts &
leukoencephalopathy):
- Recurrent strokes
- Migraine with aura
- Cognitive impairment
- Psychiatric disturbances
.........................
Tropical Hypersplenomegaly syndrome :
Major criteria:
- Gross splenomegaly: 10 cm or more in adult for which no other cause can be found.
- High serum IgM: 2 standard deviations or more above the local mean.
- Clinical and immunologic responses to antimalarial therapy.
- Regression of splenomegaly by 40% by 6 months after start of therapy.
- High antibody levels of Plasmodium species (= or >1:800).
Minor criteria:
- Sinusoidal lymphocytosis & hyperplasia on liver biopsy.
- Lymphocytic proliferation on splenic aspirate.
- Hypersplenism.
- Normal cellular and humoral responses to antigenic challenge excluding
plasmodium.
- Familial occurrence.
.........................
Obstructive Sleep Apnea (STOP BANG) = or > 3 points:
Snoring
Tiredness during daytime
Observed apnea
Pressure: elevated
BMI>35
Age>50 years
Neck circum.>40cm
Gender: male
.........................
Upper Lobe Lung Fibrosis (SHARCoT):
S: Silicosis, sarcoidosis
H: Hypersensitivity pneumonitits, Histiocytosis (Langerhans cell histiocytosis) and
histoplasmosis
A: Allergic bronchopulmonary aspergillosis, ankylosing spondylitis
R: Radiation (typically in mid zone)
Co: Coal worker’s pneumoconiosis
T: TB
.........................
Lower Lobe Lung Fibrosis (HACID):
H: Hypereosinophilic syndrome
A: Asbestosis
C: Connective tissue disease
I: Idiopathic pulmonary fibrosis
D: Drugs (bleomycin, busulphan, nitrofurantoin, methotrexate and amiodarone)
.........................
Weights of organs:
Kidney: male: 150g & female: 130g
Spleen: 150-250g
Heart: 300-500g
Liver: 1000-1300g
Brain: 1000-1300g
.........................
Causes of elevated Troponin (ABCD-ESR):
Amyloidosis
Burn
Cardioversion, Carditis
Dissection of aorta
Embolism
Sepsis, Stroke
Renal failure
.........................
Pneumonia + Diagnostic Hints
Pneumonia + hemolysis = mycoplasma.
Pneumonia + erythema multiforme = mycoplasma
Pneumonia + hyponatremia = legionella.
Pneumonia + herpes libialis = strept pneumoniea.
Pneumonia + rusty sputum = strept pneumoniea.
Pneumonia + elderly / diabetic / alcoholic = klesiella.
Pneumonia + perceding influenza = staph. aureus.
Pneumonia + mutilple abscesses = staph. aureus.
Pneumonia + parrots = chalymdia Psittacosis
Pneumonia + smoker = hemoph. influenze.
Pneumonia + neutropenia/chemotherapy= pseudomonas auregenosa.
Pneumonia + unconsiouness/anasthesia = anaerobes.
.........................
Neurological Examination of Limbs: (LFT - CRP - CSF)
Look for lateralization, fasciculation
Feel temperature and muscle bulk
Tone
Clonus if hypertonia
Reflexes and Plantar reflex
Power
Coordination
Sensation (Superficial & Deep)
Foot walking and gait
.........................
Cranial Nerves Deviation (17 & 17):
- To opposite side (7+10=17)
- To same side (5+12=17)
.........................
Examination of ptosis:
1- Inspection (unilat. vs bilat. and incision at neck)
2- Ocular movement (INO)
3- Pupillary reflex ( normal, miosis, mydriasis)
4- Sensation and anhidrosis (Horner)
5- Facial expression (M.S)
6- Power of U.L (Weber syndrome)
7- Coordination of U. L (Calude & Bendict syndrome)
.........................
Bilateral Facial Palsy (A Bull DOG LIMPS):
- A = AIDS
- Bull = Basilar skull fracture, Botulism, Brainstem encephalitis.
- D = Diabetes Mellitus
- O = Osteopetrosis
- G = Guillain-Barre syndrome
- L = Leukemia, Leprosy, Lyme disease
- I = Isoniazid and Infectious mononucleosis
- M= Myasthenia gravis, Myotonic dystrophy.
- P = Polio, Polyarteritis nodosa, Acute Intermittent Porphyria.
- S= Sarcoidosis, Syphilis
.........................
Myotomes of Limbs:

Hip flexion ---------->L1, L2 (iliopsoas)

Hip extension ---------->L5, S1,S2 (glutus maximus)

Hip adduction---------->L2, L3, L4 (adductor longus, magnus and brevis)

Hip abduction ---------->L4, L5, S1 (gluteus medius and minimus)

Knee flexion ---------->L5, S1, S2 (hamstrings)

 
Knee extension ---------->L3, L4 (quadriceps femoris)

Plantar flexion of ankle ---------->S1, S2 (gastrocnemius and plantaris)

Dorsiflexion of ankle ----------> L4, L5 (tibialis anterior)

Inversion of foot ---------->L5, S1 (tibialis posterior)

Eversion of foot ---------->L5, S1 (peroneus longus and brevis)

Extension of great toe ---------->L5 (extensor hallucis longus)

Abduction of shoulder---------->C5, C6 (supraspinatus and deltoid)

Adduction of shoulder ---------->C6, C7, C8 (pectoralis major and latissimus dorsi)

Flexion of elbow ---------->C5, C6 (biceps and brachialis)

Extension of elbow ---------->C7, C8 (triceps brachii)

Flexion of wrist ---------->C6, C7 (flexor carpi ulnaris and radialis)

Extension of wrist ---------->C7, C8 (extensor carpi radialis longus & brevis and
ulnaris)

Extension of fingers ---------->C7, C8 (extensor digitorum communis)

Flexion of fingers ---------->C7, C8 (flexor digitorum profundus)

Abduction of fingers ---------->C8, T1 (dorsal interossei)

Adduction of fingers ---------->C8, T1 (volar interossei)

Thumb opposition ---------->T1 (opponens pollicis)

Thumb abduction ---------->C8,T1 (abductor pollicis brevis)

Thumb flextion ---------->T1 (flexor pollicis brevis)

Thumb extension ---------->C8 (extensor pollicis brevis)
.........................
Examination of hand:
1- motor function:
- Radial nerve: extension of fingers.
- Median nerve: abduction of thumb
- Ulnar nerve: abduction of fingers.
2- Sensory Function:
- Radial nerve: dorsal aspect of hand between 1st and 2nd metacarpals.
- Median nerve: palmar aspect of lateral three and half fingers.
- Ulnar nerve: palmar aspect of medial one and half fingers.
.........................
Renal Papillary Necrosis (POST CARD):
- Pyelonephritis
- Obstructive nephropathy
- SCA
- T.B
- Cirrhosis
- Analgesics
- Radiation & Rejection of transplant
- D.M
.........................
Facial nerve syndromes (Facial Synkinesis):
Crocodile tears syndrome (Bogorad syndrome): tearing on eating due to
misinnervation bt. nerve to lacrimal gland and nerve to salivary gland.
Marin Amat syndrome: involuntary closure of eye while opening mouth due to
misinnervation bt. facial nerve and trigeminal nerve.
.........................
Shelf-life of blood products:
1- PRBC or whole blood= 35 days
2- Platelets= 5 days
3- FFP (thawed)= 1 day
4- Half-life of human albumine= 21 days
.........................
Dexrazoxane is a EDTA chelator used as a cardioprotective agent to doxorubicin
cardiotoxicity
.........................
Metastatic disease that can be surgically resected: 
1- Osteosarcoma with metastasis to the lung.
which can be cured by resection of the lung lesion.
2- Non–small cell lung cancer with a solitary brain metastasis at the time of
diagnosis.
3- Colon cancer with liver metastases fewer than five lesions in a single hepatic
lobe.
.........................
Signs of TB reactivation:
- Constitutional symptoms
- Hemoptysis
- Apical crepitation
- Cystic lesion on CXR
- AFB smear positive of sputum
.........................
Signs of prosthetic valve failure:
- loss of metalic click
- Muffled heart sounds
- Regurgitation murmur
- Heart failure
- Cardiogenic shock
.........................
Abdominal Auscultation:
- Venous hum: over epigastric area for portal hypertension.
- Friction rub: over spleen for infarction
- Hepatic Bruit: over liver for alcoholic hepatitis, hemangioma, hepatoma.
- Renal bruit or suffle: 2 cm lateral and above umbilicus for renal artery
stenosis.
.........................
Hyperviscosity symptomps in polycythemia appears when Hb>20 or HCT> 65%
.........................
Total body iron store is 4 gram but clinical features of hemochromatosis appears
when total body iron store exceeds 20 grams.
Each 500ml of whole blood contain 250mg of iron, so one unit phlebotomy every week
for 50 weeks will deplet 10 grams of iron.
.........................
1- Treatment of IBS-C:
- Polyethylene glycol sachet OD
- Lubiprostone 8mcg cap.  BD (locally acting chloride channel activator)
- Linaclotide 290mcg cap.  OD (gunylate cyclase agonist)

2- Treatment of IBS-D:
- Loperamide 2 mg TDS before meal
- Cholestyramine 4gm sachet OD(Bile acid sequestrants)
- Aloserton 0.5 mg tab BD (5HT3 recep. agonist)
- Eluxadoline 100mg tab BD(mu-opioid recep.  agonist and delta-opioid recep.
antagonist)

3- Treatment of IBS-Pain and Bloating:

- Hyoscyamine 0.125 mg tab TDS
- Dicycloverine 20mg tab QID
- Amitriptyline 10mg tab OD
.........................
Coronary artery disease equivalents (conditions associated with 10-year risk of
myocardial infarction (MI) of at least 20% on Framingham risk score):
1- clinical coronary artery disease
2- symptomatic carotid artery stenosis
3- peripheral arterial disease
4- abdominal aortic aneurysm
5- diabetes milletus
6- chronic kidney disease
.........................
Chest X-ray features:
A:airway
B:bone
C:cardiac
D:diaphragm
E:effusion
F:field
G:gases
H:hila
I:implants
.........................
Suppurative lung disease:
- Bronchectasis
- Lung abscess
- Empyema with bronchopleural fistula
- Infected hydatid cyst (water lilley sign)
.........................
Medbrain Syndromes (WBC):
- W: Weakness=Weber syndrome (basal infarction - lower medial part): ipsilat. III
cranial nerve + contralat. hemiparesis
- B: Both of W&C=Bendict syndrome (medial infarction- upper and lower medial
parts): ipsilat. III cranial nerve + contralat. hemiparesis and ataxia
- C: Cerebellum=Claude syndrome (paramedian infarction - upper medial part):
ipsilat. III cranial nerve + contralat. ataxia
........................
Pontine Syndromes (MV):
- Millard Gubler syndrome (basal infarction): ipsilat. 7th CN LMN palsy and
ipsilat. 6th CN palsy + contralat. hemiparesis
- Foville syndrome (mediolat. infarction): ipsilat. 7th LMN palsy and ipsilat.
conjugate gaze palsy + contralat. hemiparesis
.........................
Medullary syndromes (DW):
- Wallenberg Syndrome (lat. medullary syndrome):ipsilateral facial anesthesia 5th
CN palsy,ipsilateral, 9th & 10th CN palsy, ipsilateral Horner, ipsilateral ataxia +
Contralateral pain & temperature loss.
- Dejerine Syndrome (med. medullary syndrome): ipsilat. tongue atrophy & paralysis
12th CN palsy + contralat. hemiparesis and contralat. fine touch and proprioception
loss.
.........................
Thickened ulnar nerve:
1- leprosy
2- hereditary motor and sensory neuropathies (types 1 and 3); Charcot-Mari-Tooth
disease and Refsum disease
3- chronic inflammatory demyelinating neuropathies
4- Diabetes
5- Amyloidosis
6- Sarcoidosis
.........................
Causes skin tightening and sclerodactyly:
- Systemic sclerosis
- MCTD
- Antisynthetase Antibody Syndrome
- Diabetic Cheiroarthropathy
- Scleromyxedema
- Nephrogenic systemic fibrosis
- GVHD
- Eosinophilic Fascitis
- Amyloidosis
- Leprosy
- Drug induced fibrosis (Bleomycin, Docetaxil)
.........................
Painful myopathy:
1- Polymyositis
2- Diabetic amyotrophy
3- Hypokalemia & Hypocalcemia
4- Trichenella spiralis
5- Statin myopathy
6- Cholchicine myopathy
.........................
Frisen Classification for Grading of Optic Disk Edema:
Stage 0: Normal disk with blurring of nasal and temporal disk; the cup is
maintained, and there is no obscuration of   retinal vessels.
Stage 1: C-shaped blurring of the superior, nasal, and inferior disk borders; the
temporal margin is usually normal.
Stage 2: 360-degree elevation of the disk margin.
Stage 3: Entire disk elevation with partial obscuration of one or more retinal
vessels at the disk margin.
Stage 4: Complete obliteration of the cup and complete obscuration of at least some
vessels on the surface of the   disk. Small, dilated telangiectatic capillaries may
be seen on the disk.
Stage 5: Dome-shaped disk appearance, with all retinal vessels obscured.
.........................
Beevor's sign; shifting of umbilicus on setting up to localize motor level
.........................
Surface anatomy of lung lobes:
- Oblique line from T2 to 6the coastal cartilage.
- Horizontal line from 4th coastal cartilage to the oblique line.
- Another line from 6th coastal cartilage to T12.
.........................
Surface anatomy of Mediastinum:
Lateral chest view is divided into upper middle and lower parts by a horizontal 
line from sternal angle to upper border of T4 and another oblique line from upper
border of T4 to Xephoid process.
.........................
Very severe hypertension is mainly caused by renal shutdown or pheochromocytoma and
treated with aliskiren
.........................
Fever Patterns:
1- Continuous: lobar pneumonia, meningitis, typhoid, UTI, Gm -ve bacteremia.
2- Remittent: Infective Endocarditis, Rickettsiae infections, brucellosis.
3- Intemittent: Malaria, Kala azar, Schistsomiasis, T.B, pyogenic infection,
Septicemia, C.T diseases.
4- Periodic or Relapsing: Malaria, Lymphoma, Borrelia, Cyclic Neutropenia, Rat-bite
fever.
5- Fever associated with night sweats: TB, Nocardia, Brucellosis, liver or lung
abscess, Sub-acute infective endocarditis, Polyarteritis nodosa, Lymphomas.
6- Special types:
a- Undulant: Brucellosis
b- Saddleback: Dengue fever
c- Stepladder: Typhoid fever
d- Spiky, hicktic: abscess
e- Twice-Thrice fever: lieshmania
f- Quotidian (daily spikes): P.falciparam, Still's disease
g- Tritian: P.ovale, P. vivax
h- Quartan: P.malare.
.........................
Fever with relative bradycardia (Faget’s sign):
1- Typhoid fever
2- Salmonelliasis
3- Leishmaniasis
4- Brucellosis
5- Legionellar disease
6- Psittacosis
7- Acute cholangitis
8- Yellow fever
9- Dengue fever+/-
.........................
Causes of indeterminant HIV serologic test:
1- influenza vaccine.
2- auto-Ab.
3- cross-reacting allo -Ab. from pregnancy.
4- experimental HIV vaccine.
.........................
DIC findings:
1- bleeding tendency & thrombosis.
2- prolonged PT, PTT.
3- elevated D-dimer.
4- decreased fibrinogen, factor V&VIII.
5- decreased platelets.
.........................
Thrombophilia work up indications:
1- younger than 50 years.
2- clot in unusual sites.
3- recurrent thrombosis.
4- strong family hx.
5- suspected antiphospholipid syn.
.........................
Mechanism of Coagulopathy in CLD:
1- protein C&S def.
2- antithrombin III def.
3- dec. Plasminogen.
4- inc. Endoth. Cell-derived factor VIII & vWF.
5- blood stasis due to portal HTN.
6- development of HCCarcinoma.
.........................
4T Score of Heparin Induced Thrombocytopenia:
1- Thromocytopenia:
a. Less than to 30%.
b. 30% - 50%.
c. More than 50%.
2- Timing:
a. Less than 4 days e out recent exposure.
b. 5-10 days e out documentation or after 10 days e prior heparin exposure within
last 30-100 days.
c. 5-10 days e documentation & heparin exposure within last 30 days.
3- thrombosis or other sequelae:
a. No thrombosis or sequelae.
b. Progressive or recurrent thrombosis, non-necrotizing (erythematous) skin
lesions, or suspected thrombosis e out evidence.
c. Confirmed new thrombosis, skin necrosis, or acute systemic reaction after
unfractionated heparin bolus.
4- availability of other causes of thrombocytopenia:
a. None apparent.
b. Possible.
c. Definite.
.........................
Chronic Liver diseases & CNS:
1- dementia (Alzheimer type II astrocytosis).
2- delirium: Hepatic Encephalopathy/SONIC (Spectrum of Neurocognitive Impairment in
Cirrhosis)
A- tremor & incoordination.
B- astrexis, ataxic gait & slurred speech.
C- muscular rigidity, clonus, Babinski & hyporeflexia.
D- oculocephalic reflex & pain unresposive.
3- parkinson like syndrome.
4- progressive paraplegia.
.........................
Patients at high risk of Hepato-Renal syndrome:
1- S. Creat. more than 1 mg/dl
2- BUN more than 30 mg/dl
3- T. Bilirubin more than 4 mg/dl
4- Propranolol increases risk of Hepato-Renal syndrome in patients with S.B.P.
These patients should be managed with albumin 1.5 g/kg.
.........................
Criteria of SBP diagnosis:
1- fever is equal or more than 37.8 C (100 F).
2- abd. Pain &/or tenderness.
3- change in mental status.
4- ascitic PNM cells are equal or more than 250 cells/mm3.
.........................
Indications of SBP prophylaxis for pt. With CLD (norfloxacin 400 mg daily):
A. For indefinite duration:
1- previous SBP.
2- ascitic protein is less than 1.5 g/dl plus one of the following:
a- child pugh is equal or more than 9 and S. Bilirubin is equal or more than 3
mg/dl.
b- S. Creatinine is equal or more than 1.2 mg/dl or BUN is equal or more than 25
mg/dl or S. Sodium is equal or less than 130 meq/l.
B. For short duration:
1- pt. Who are post-controlled GIT bleeding (for one week).
2- ascitic protein is less than 1 g/dl (during the period of hospitalization).
.........................
Cushing triad:
1-hypertension (diastolic)
2-bradypnea (irregular)
3-bradycardia
.........................
Insulin therapy for D.M type II:
1- Initial treatment at diagnosis(HbA1c>9.5, FBS>250, RBS>300, ketonuria, unplanned
weight loss with hyperglycemia).
2- Persistent hyperglycemia on oral hypoglycemic drugs (HbA1c>8.5, symptomatic pt.)
3- Difficulty distinguishing type of diabetes(patients who are underweight, are
losing weight, or are ketotic).
.........................
Celiac disease:
anti-tTG, anti-endomysial IgA (EMA). anti-deaminated gliadin peptide IgA (DGP),
decreased total IgA, anti-reticulin (ARA), anti-gliadin (AGA).
Criteria of diagnosis:
*for asymptomatic pt.:
1- +ve anti-tTG
2- +ve anti-EMA
3- +ve duodenal biopsy.
4- +ve skin biopsy for dermatitis herpetiformis.
.........................
ENA profile - extractable nuclear antigen:
anti-Ro, anti-La, anti -Sm, anti-Jo1, anti-RNP, anti -Scl 70.
.........................
Indications of cardiac pleural effusion aspiration:
1- unilat. or markedly disparate size.
2- failure to respond to ttt.
3- fever or pleuritic chest pain.
4- no cardiomegaly.
.........................
pleural effusion in liver cirrhosis is due to movement of ascitic fluid to chest
through diaph. defects and Rt. thoracic duct.
.........................
Indications of chest tube in pleural effusion:
1- PH less than 7.2.
2- LDH more than 1000.
3- glucose less than 40.
4- WBCs more than 10000/mm.
5- bacteria on Gram stain or culture.
6- loculated effusion.
7- massive effusion involving 2/3 of a lung or more.
8- RBCs more than 100000/mm.
9- fluid blood hematocrit ratio more than 0.5%.
10- T.G more than 110 mg/dl.
.........................
false high HbA1c:
1- acromegaly.
2- thyrotoxicosis.
3- phaechromocytoma.
4- cushing syndrome.
5- splenectomy.
6- iron def. Anemia.
7- Vit. B12 def. Anemia.
8- alcoholism.
false low HbA1c:
1- hemolytic anemia (Congenital: SCA, G6PD def. & spherocytosis, Drugs: dapsone,
methyldopa, antiretrovirals, TMP-SMZ, hydroxyurea).
2- chronic renal failure.
3- chronic blood loss.
4- splenomegaly.
.........................
1 g/dl decrease in albumin (below 4 g/dl) is ass. with 0.8 - 1.0 decrease in Ca+2
mg/dl
corrected S. Ca+2= 0.8(4 - albumin g/dl) + S. Ca+2
.........................
Heparin S.E:
heparin induced thrombocytopenia caused by heparin-platelet factor 4 complex IgG
formation which activate platelet to factor 4 release which serve as positive
feedback and dec. platelet formation.
heparin induced osteoprosis - high dose 15-30 T I.U for 3-6 mon.:
1- inc. PTH function
2- depletion of plasma cell in B.M.
3- inc. osteoclastic & dec. osteoblastic activity.
4- partial mucopolysacch. replacement in B.M.
heparin induced hyperkalemia by inhib. aldosterone
heparin resistance due to anti-thrombin deficiency and heparin binding proteins
( high acute phase reactant in acutely ill pt.)
defined as need to more than 35 T I.U/24 hr to inc. APPT into theraputic range (in
VTE) or Activated Clotting Time is less than 400 sec. after heparinization or need
to exogenous anti-thrombin III (in cardiac bypass surgery).
heparin is not effective in NSTEMI as heparin -anti-thrombin complex can not bind
to thrombin within the clot.
.........................
Dementia causes:
1- alzhaimer e memory affection
2- vascular e motor affection
3- dementia e lowey bodies
4- frontotemporal e nightmares
5- normal tension hydroephalus e traid of dementia, urine incontinece & gait
apraxia.
.........................
Multiple sclerosis:
WATSON - Weakness, ataxia, tremor, speech disturbance, optic neuritis & nystagmus.
.........................
Babeneski groups:
Babeneski, Chadwick, Shivers, Jordanian, Obenhim's test, Gunda test.
.........................
Pulmonary pressure: 13 - 28 / 3 - 13 mmHg
.........................
Jaundice is only manifested when total bilirubin is more than 2.5 mg/dl
.........................
Immunological reactions of T. B:
1- Mantoux test
2- IFN-Gamma releasing assay
3- erythema induratum
4- erythema nodosum
5- phenticular conjunctivitis
6- poncent arthritis
7- ductylitis
.........................
T.B diagnosis tests:
- Stained smears: needs 5000 - 10000 organisms/ml (sensitivity 45-80%)
- Culture: needs 10 - 100 organisms/ml and it is the gold standard for diagnosis
confirmation (sensitivity & specificity 80 & 98%)
- NAAT: needs 1 - 10 organisms/ml and can differentiate bt. tuberculous and non-
tuberculous in more than 95% (sensitivity & specificity 95 & 98% in AFB positive
and 75-88% & 95% in AFB negative)
.........................
Terminal tuft resorption (acro-osteolysis):
1- Scleroderma
2- Leprosy
3- Berger's disease
4- Infective Endocarditis
5- D.M
6- Frost bite
.........................
Low platelets and thrombosis:
1- antiphospholipid syn.
2- TTB
3- HIT
4- DIC
5- SLE
.........................
Systemic causes of itching:
1- allergy
2- liver disease
3- uremia
4- hypothyroidism
5- polycythemia
6- infectious;  scabies
7- prurigo annularis & psoriasis
.........................
Causes of pale skin without anemia:
- Racial
- Hypothyroidism
- D.M
- CLD
- Shocked pt.
.........................
Serum Biomarkers:
1- Asthma;  serum periostin 1
2- COPD;  Plasma fibrinogen
3- Interstitial Lung Diseases;  Matrix Metalloproteinase 1 & 7 (MMP1&7)
Krebs von den Lungen 6(KL-6)
.........................
Bronchial breathing types:
1- tubular(high pitch): consolidation.
2- cavernous(low pitch): cyst, cavitatory lesion.
3- amphoric(low pitch metalic): big abscess connecting to bronchus, bronchopleural
fistula.
.........................
Causes of fever in hospital (6C):
1- cannula related infection
2- catheter related infection
3- central line related infection
4- chest infection
5- cutaneous infection (bed sores & fruncles)
6- clostridium difficle colitis (pseudomem. colitis)
.........................
Parentral iron:
1- Ferric pyrophosphate ( blood loss of 5 - 7 mg/L each hemodialysis, 27.2 mg in
2.5 gallon of bicarbonate concentrate for hemodialysate)
2- ferric carboxymaltose (750 mg slow I.V over 8 minutes or in 250 ml N/S infusion
over 15 minutes)
3- Iron oxide (iron deficit= 30 and 27 mg/kg * Hb deficit)
4- Iron sucrose (test dose, 100 mg in 100 ml N/S slow I.V injection over 5 minutes
or infusion over 15 minutes)
5- Iron dextran (test dose, 25 - 100 mg in 250 - 1000 ml N/S, initial slow infusion
of first 25 ml then infusion over 1-6 hours or Z track technique for deep I.M)
.........................
Confirmation of H.I.T:
1- anti-heparin/PF4 antibody by ELIZA
2- HIPA (heparin induced platelet aggregation)
3- SRA (serotonin release assay)
.........................
Elevated MCHC is ass.  with increased spherocytes as in hereditary spherocytosis or
autoimmune hemolytic anemia.
.........................
Thyroid Storm Score (Burch Wartofsky):
1- hyperpyrexia
2- CNS symptoms
3- GIT-Hepatic symptoms
4- tachycardia
5- edema
6- arrhythmia
7- precipitant history
< 25 points = no thyroid storm
25 - 45 points = impending storm
> 45 points = thyroid storm
.........................
Causes of CLD (ABCDE):
A- autoimmune & alcohol
B- Bilharsiasis & hepatitis B
C- hepatitis C,  cryptogenic
D- drugs (AMMIN:Amiodarone, Methotrexate, Methyldopa, Isoniazide, Nitrofurantoin)
E- extra (Wilson,  Hemochromatosis, alpha-1 antitrypsin deficiency)
.........................
Drug induced Hepatitis (AMMIN):
Amiodarone
Methyldopa
Methotrexate
Isoniazide
Nitrofurantoin
.........................
Ortner syndrome: mitral stenosis and dysphagia
.........................
Drug decreasing polycystic kidney disease progression; Tolvaptan (vasopressin
receptor antagonist)
.........................
Drugs for treatment of cystic fibrosis; ivacaftor/lumacavtor (CFTR potentiator) 
.........................
Specific signs of chronic kidney disease:
1- uremic frost
2- band keratopathy
3- perforating dermatosis
4- shrunken kidneys
5- renal osteodystrophy
.........................
Renal osteodystrophy
1-Osteoprosis
2-Osteomalacia
3-Osteosclerosis
4-Ostitis fibrosa cystica
.........................
Centor criteria of strep. pharyngitis:
1- fever
2- tonsillar exudate
3- enlarged ant. cervical L.N
4- absence of cough
.........................
Enlarged kidneys in CKD:
1- D.M
2- amyloidosis
3- HIV
4- multiple myeloma
5- polycystic kidney disease
6- scelroderma.
.........................
Black tarry stool:
1- iron
2- bismuth
3- char coal
4- spenach
5- melena
.........................
Deviation of tongue by genoglossus
.........................
Leipzig criteria for Wilson disease:
1- high 24 urine copper > 40 mcg/ day
2- low ceruloplasmin < 20 mg /dl
3- high copper level in dried liver > 250 mcg/g
4- Kayser Flischer ring
5- Coombs negative hemolytic anemia
Other confirmatory tests include MRI & molecular analysis of ATP7B mutations.
.........................
Ristocetin-induced platelet aggregation (RIPA) is a test for Von Willberand
disease.
.........................
Measurement of insulin dose:
1- Baseline insulin (long acting)=weight (kg)* 0.55 OR weight (pounds)*0.4
2- Preprandial insulin (short acting)=carbohydrate load/15
3- Tetrate the baseline insulin dose according to response: increase the dose 1
unit per 50 mg beyond 200 mg/dl blood sugar.
.........................
Wiskott–Aldrich syndrome (EXIT):
- Eczema,
- X-linked recessive disease,
- Immune deficiency (low IgM and high IgA and IgE) &
- Thrombocytopenia.
.........................
Hughe's syndrome is a another name for antiphospholipid syndrome.
.........................
Hughes Stoven syndrome: pulmonary artery thrombosis & aneurysm and peripheral
thrombophebitis as a subtype of Behcet syndrome.
.........................
Pickwickian syndrome (obesity hypoventilation syndrome) criteria:
1-obesity (body mass index above 30 kg/m2),
2- hypoxemia during sleep, and
3- hypercapnia ( > 45 mmHg) during the day, resulting from hypoventilation.
Cor pulmonale may result from hypoxia due to pulmonary arteries constriction and
strain on Rt. Sided of the heart.
.........................
Eltrombopag is a thrombopiotin receptor agonist And Romiplostim is a thrombopoietin
analogue for ttt of ITP.
.........................
Novel anticoagulants:

A. Direct thrombin inhibitors:

1- Dabigatran - oral - for non-valvular AF and DVT or PE(reveresed with
Idarucizumab).
2- Argatroban - for HIT and PCI.
Direct thrombin inhibitors (Hirudin analogues):
1- Bivalirudin - for HIT,  PTCA and PCI (safe for pt. with renal or hepatic
impairment).
2- Lepirudin - for HIT and stopped by the manufacturer.
B. Oral factor Xa inhibitors:
1- Apixaban - for non-valvular AF and DVT or PE.
2- Rivaroxapan - for non-valvular AF and DVT or PE.
3- Edoxaban - for non-valvular AF and DVT or PE(reversed with andexanet alfa)
C. Indirect factor Xa inhibitors:
1- Fondaparinux - for DVT, PE and HIT in pregnancy??
2- Danaparoid - for HIT in pregnancy??
.........................
Acid Base Balance

The Base Deficit (or Base Excess) is the amount of base (or acid) needed to titrate
a serum pH back to normal when the contribution of respiratory factors is taken out
of the equation. That is, how much acid or base would be required to correct the
patient's pH to 7.4 if the pCO2 were 40.

Base Deficit/Excess = (1 - 0.014 x Hb)[(calculated HCO3 - 24.8) + (1.43 x Hb + 7.7)

(pH - 7.40)]

Base Excess = (Actual pH - Predicted pH) * 67

Normal Range: -2 to +2 meq/L
Positive (Base Excess); metabolic alkalosis
Negative (Base Deficit); metabolic acidosis

Bicarbonate increase of 0.67 meq/L will increase the PH by 0.01

PaCO2 increase of 10 mmHg will decrease the PH by 0.03 in chronic conditions and
0.08 in acute conditions.
.........................
Expected PaCO2 in metabolic disorders:

1- metabolic acidosis;
PaCO2 = 1.5 x HCO3 + 8 (acute)
PaCO2 = HCO3 + 15 (chronic)

2- metabolic alkalosis;
PaCO2 = 0.7 x HCO3 + 20 OR each 1 mEq/L increase in HCO3 results in 0.7 mmHg
increase in PCO2 (acute & chronic)
.........................
Resp. Acidosis:
Each 10 mmHg increase in PCO2 results in 1 mEq/L increase in HCO3 in acute setting
and 3.5 mEq/L increase in chronic setting.

Resp. Alkalosis:
Each 10 mmHg decrease in PCO2 results in 2 mEq/L decrease in HCO3 in acute setting
and 4-5 mEq/L decrease in chronic setting.

In questions, you can consider the refrence PCO2 = 40 mmHg and refrence HCO3 = 25
mEq/L.
.........................
Cardiac procedures:
1- Cardiac resynchronization therapy (CRT)= Severe heart failure with QRS > 150
msec.
2- Implantable cardiac defibrillator (ICD)= risk of vent. tachycardia or
fibrillation.
3- Transcatheter ablation = frequent premature vent. complex (PVCs)
.........................
Indications of subclinical hypothyroidism ttt:
1- critically-ill pt.
2- pt. in ICU
3- pt. with goiter
4- auto-antibodies
5- TSH is more than 10
6- hx. of Graves disease ttt.
7- pregnancy
.........................
Novel ttt of H.F (NYHA II or IV):
- ARBs + Sacubitril (Angiotensin Receptor Neprylisin antagonist; block the enzyme
responsible for BNP & ANP degredation)
- Veruseguit
.........................
Indications of exchange transfusion in SCA:
1- multi-organ failure/hepatomegaly
2- Acute chest syndrome with significant hypoxia
3- Ischemic CVA
.........................
Indications of blood transfusion in SCA:
1- Acute chest syndrome
2- Ischemic CVA
3- priapism
4- symptomatic anemia (Hb < 7 g/dl or HbS > 30%)
5- surgery
6- pulm. H.T.N
.........................
Postpartum cardiomyopathy
Digoxin 0.5 mg in 100 ml N/S infusion over 30 minutes.
.........................
Hepatic encephalopathy precipitants (HEPATICS):
- Hemorrhage
- Electrolytes
- Protein overload
- Alcohol
- TIPS
- Infection
- Constipation
- Sedatives
.........................
M.O.A of lactulose:
lactulose is degraded to lactic acid (converts NH3 to NH4, intestinal acidosis and
inhibits bacterial overgrowth) and disaccharides (laxative effect)
.........................
mesna;(sodium mercaptoethanesulfonate)
.........................
DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms); a
complication of rheumatoid arthritis ttt and consists of fever, morbiliform skin
rash, elevated liver enzymes and eosinophilia
.........................
Finkelstein's test:
flexion of the thumb into the palm, making a fist over the thumb and ulnar
deviation of wrist. This results in dorsoradial wrist pain which indicates De
Quervain's tenosynovitis
Tinel's test:
tabbing in front of wrist results in pain in the palm which indicates capal tunnel
syndrome
Phalen's sign:
bilat. flextion of wrist (anti-prayer) produces pain in capal tunnel syndrome.
.........................
corticosteroids equivalents (1728):
1 dexamethasone = 7 prednisolone = 28 hydrocortisone
.........................
Hepatitis and D.M association:
1- autoimmune + type1
2- HCV + type 2
3- hemochromatosis
4- metabolic
.........................
Causes of hypoglycemia in D.M:
1- Renal failure
2- Adrenal insufficiency
3- Paraneoplastic syndromes
.........................
Causes of fluctuating conscious level :
1- Encephalitis
2- Subdural hematoma
3- Subarachnoid hemorrhage
4- space occupying lesion
5- dementia e lowey bodies
6- Hypoglycemia
.........................
Lawrence Moon Biedi syndrome:
D.M, obesity & mental retardation
.........................
Causes of tinnitus:
1- Aspirin
2- Loop diuretics
3- Aminoglycosides
4- Quinine
.........................
Causes of decreased Thyroxin absorption:
1- Iron, Calcium & Aluminum
2- Cholestyramine & Resins
3- Estrogens
4- Tricyclic antidepressant
5- Phenytoin & Carbamazepine
.........................
Opportunistic infections in HIV pt.:
CD4 < 200(TCCP; milliary T.B, esophygeal Candidiasis, Cervical cancer &
Pneumocystis jiroveci)
CD4 < 100 (TLL; Toxoplasmosis, Lymphoma of CNS & Leukoencephalopathy- JC virus)
CD4 < 50 (MCC; Mycobacterium Avium Complex, CMV retinitis & Cryptocococcal
menengitis)
.........................
Daily salt requirement is 5 - 8 gm/day
Low salt diet is 2 gm/day
.........................
mechanisms of ACE inhibitors in H.F:
1- decrease preload by decreasing Na+ reabsorption.
2- decrease afterload by vasodilation effect.
3- decrease thrist by decreasing Na+ retention.
4- decrease albumine excretion.
5- decrease cardiac remodeling.
.........................
Blood supply of lungs;
1- Pulmonary trunk
2- Aortic branches
3- Tracheobronchial artery
Tow arteries must be occluded to cause pulmonary infarct
.........................
interstitial lung diseases:
1- C.T diseases (SS, SLE, RA)
2- Casating granulomatous lung disease (T.B)
3- Non-casating granulomatous lung diseases (Sarcoidosis, Wegners disease)
4- Occupatinal lung diseases (pneumoconiosis, hypersensitivity alveolitis)
5- drug-induced fibrosis.
6- idiopathic pulmonary fibrosis
.........................
Causes of soft spleen (MESSI):
Malaria
Endocarditis
Salmonella
Sepsis
Infectious mononulceosus
.........................
Types of dysphasia:
1- Motor
2- Sensory
3- Global
4- Conduction
5- Nominal
6- Paraphasia
7- Jargon
.........................
The only pneumonia which causes expansion of lungs and depression of diaphragm is
Klebsilla
.........................
Ominous signs of CLD are pesistent hypotension and hypothermia
.........................
most common  cause of unresolved pneumonia
1-TB (35.5%)
2-malignancy (22%)
3-bronchictasis
4-pneumocystitis
5-antibiotic resistance
.........................
- Max. dose of Propranolol 160 mg in CLD and 240mg in pheochromocytoma
- Max dose of Warfarine is 20 mg
- Max dose of lactulose is 200 ml / day
- Max dose of Furosemide is 400mg in CLD, 600mg in CHF,  800mg in pulm edema,  1 -
3g in renal failure
.........................
Local Examination of muscloskeletal system:
G:gait
A:arms
L:legs
S:spine
.........................
Diffuse rhonchi:
1- High-pitched; Bronchial asthma, heart failure.
2- Low-pitched; COPD, bronchopneumonia, Post-viral bronchospasm.
.........................
Delayed Deep Reflexes:
Delayed Relaxation Phase:
- hypothyroidism
Delayed Contraction and Relaxation Phase:
- Hypothermia
- B-Blockers
- Advanced age
.........................
Watershedding areas:
1- Brain:
- Cortical watershedding areas between the cortical territories of the anterior
cerebral artery, middle cerebral artery, and posterior cerebral artery.
Internal watershedding areas between the deep and the superficial arterial systems
of the middle cerebral artery, or between the superficial systems of the middle
cerebral artery and anterior cerebral artery.
2- Spinal cord:
- Anterior spinal artery between T7 & T9.
- Upper thoracic(T1-T4).
- First lumbar(L1).
3- Colon:
- Splenic flexure of colon (superior mesenteric artery & inferior mesenteric area).
- Distal Sigmoid colon (inferior mesenteric artery & hypogastric arteries).
4- Kidney:
- Proximal tubule and ascending limb of Henle’s loop located in the outer medulla
.........................
macular sparing:
dual arterial supply
.........................
Cause of hepatic bruit:
- hemangioma
- HCC
- alcoholic liver disease
- hepatic artery aneurysm
.........................
G6PD deficiency classes:
1- Class I: chronic nonspherocytic hemolytic anemia (CNSHA) without precipitating
cause and severe G6PD deficiency.
2- Class II: intermittent hemolysis and severe G6PD deficiency.
3- Class III: hemolysis after oxidant stress and mild G6PD deficiency.
4- Class IV & V: asymptomatic.
.........................
International Study Group (ISG) diagnostic criteria of Behcet syndrome:
1- Recurrent oral aphthae (at least three times in one year and not involving outer
part of lips) plus two of the following clinical features:
2- Recurrent genital aphthae (aphthous ulceration or scarring).
3- Eye lesions (including anterior or posterior uveitis, cells in vitreous on slit
lamp examination, or retinal vasculitis observed by an ophthalmologist).
4- Skin lesions (including erythema nodosum, pseudo-vasculitis, papulopustular
lesions, or acneiform nodules consistent with Behçet syndrome).
5- A positive pathergy test. Pathergy is defined by a papule 2 mm or more in size
developing 24 to 48 hours after oblique insertion of a 20-gauge needle 5 mm into
the skin, generally performed on the forearm.
.........................
The International Criteria for Behcet's disease (at least three points for
diagnosis):
- Genital aphthosis – Two points
- Ocular lesions (anterior uveitis, posterior uveitis, or retinal vasculitis) – Two
points
- Oral aphthosis – One point
- Skin lesions (pseudofolliculitis or erythema nodosum) – One point
- Vascular lesions (superficial phlebitis, deep vein thrombosis, large vein
thrombosis, arterial thrombosis, or aneurysm) – One point
- Pathergy – One point
.........................
Autonomic nervous system examination:
1. Standing test for orthostatic hypotension (sympathetic);normally systolic B.P
decreases upto 25 mmHg and diastolic B.P increases by 10mmHg.
2. Standing test for HR (parasympathetic); normally H.R inceases on standing upto
15 beat/min.
3. Deep breath test (parasympathetic); normally H.R increases during inspiration
and decreases during expiration and the difference bt. the fastest and slowest H.R
is usually more than 15 beat/min.
4. Hand grip test (sympathetic); normally systolic B.P increases.
5.Valsalva test(both sympathetic and parasympathetic); 4 phases, 1st pahse
increases B.P slightly then pulse pressure decreases, 2nd phase increases H.R, 3rd
phase decreases B.P and increases H.R, 4th phase increases B.P markedly(overshoot
HTN) and decreases H.R(reflex bradycardia).
.........................