General Medicine (2) Summary

1-What is the definition of GERD?

❖ It is incompetence of the lower esophageal sphincter leading to reflux of

gastric contents into the esophagus, causing burning pain.

2- What are the common symptoms of GERD?

1) Heartburn
2) Regurgitation of gastric contents into the mouth.
3) Vomiting specially in Infants.
4) Chronic aspiration leading to cough, hoarseness, or wheezing.

3- What is the treatment of GERD?

1- Change of life style:
a) Avoiding eating within 2 to 3 h of bedtime.
b) Bed head elevated 15 cm.
c) Coffee, alcohol, fats, and smoking avoided.
2- Proton pump inhibitors.
3- promotility drugs s such as Itopride 50 mg tablets 30 minutes before meals
and at bedtime).
4- Surgery.

4-What is the definition of gastritis?

❑ Gastritis is inflammation of the gastric mucosa caused by :

- Infection ( Helicobacter pylori )

- Drugs (NSAIDs, alcohol)

- Stress
 - Autoimmune phenomena (atrophic gastritis).

5- What is the definition of peptic ulcer?

❖ Peptic ulcer is a breakdown in a segment of the GI mucosa, typically in the

stomach (gastric ulcer) or the duodenum (duodenal ulcer), that penetrates
through the muscularis mucosae.

6-What is the treatment of peptic ulcer?

1) Eradication of H. pylori (when present)

H. pylori eradication requires multidrug therapy, typically antibiotics
(Clarithromycin 500 mg bid, plus Amoxicillin 1 gm bid) plus acid
suppressants.
2) Acid-suppressive drugs
a. Proton pump inhibitors such as omeprazole ( Losec ),
pantoprazole (Controloc ), rabeprazole ( Pariet ), esomeprazole (
Nexium ) and lansoprazole ( Lanzor ).
b. H 2- blockers : ( Tagamet) , ranitidine ( Zantac ), famotidine (
Antodin ), and nizatidine (Nizatect ).
3) Antacids to neutralize gastric acid and reduce pepsin activity.

7-What are the types and modes of transmission of viral

hepatitis?
The 5 most common types of viral hepatitis are :

Hepatitis A : fecal-oral transmission

 Hepatitis B : blood to blood & sexual fluids

Hepatitis C : blood to blood

Hepatitis D : travels with B

Hepatitis E : fecal–oral transmission

8- Give an account on Chronic viral hepatitis?

1) Patients infected with HBV and HCV can develop chronic hepatitis.

2) Chronic hepatitis is hepatitis that lasts longer than 6 months.

3) In chronic hepatitis, the viruses live and multiply in the liver for years or
decades.

4) For unknown reasons, these patients' immune systems are unable to

eradicate the viruses, and the viruses cause chronic inflammation of the
liver.

5) Chronic hepatitis can lead to the development over time of extensive

liver scarring (cirrhosis), liver failure, and liver cancer.

6) Liver failure from chronic hepatitis C infection is the most common

reason for liver transplantation.

7) Patients with chronic viral hepatitis can transmit the infection to others .

9-What is the definition and types of jaundice?

It is yellowish discoloration of the skin &eyes that is caused by hyperbilirubinemia
(an excess of bilirubin in the blood).

Bilirubin :

- Indirect Bilirubin is a waste product that is formed from Porphyrin in the blood
stream after degradation of RBCs.
- In the liver , Indirect bilirubin is conjugated & converted to Direct bilirubin ,
which is secreted in bile and then excreted giving stool its brown color.

Types of jaundice:

1- Hemolytic jaundice :

A type of jaundice that occurs as a result of hemolysis of RBCs leading to

increase in production of Indirect bilirubin.

2- Obstructive jaundice :

Jaundice that occurs as a result of an obstruction in the bile ducts that carries
bile from the liver to the small intestine) leading to increase in production of
Direct bilirubin.

3- Hepatocellular (biphasic) jaundice :

Jaundice that occurs as a result of liver disease leading to increase in both ,

Indirect & Direct bilirubin.

10- What is the definition and types of DM?

► It’s a clinical syndrome in which there is an error of carbohydrate

metabolism due to insulin deficiency, resistance or both, ending in chronic
hyperglycemia.

a) Type 1 : previously called Insulin-Dependant DM (IDDM) or juvenile-

onset DM.
b) Type 2: previously called non insulin-dependant DM (NIDDM) or adult-
onset DM.

11- What are the stages of DM?

I. Pre diabetes.

II. Latent diabetes.

III. Chemical diabetes.

 IV. Clinical diabetes.

12- Give an account on Clinical diabetes?

a. Uncomplicated : Classic triad of symptoms :

▪ polyuria : due to osmotic diuresis induced by sugar.

▪ polydepsia : due to loss of fluid.

▪ polyphagia with weight loss : ↓ insulin → no glucose can enter satiety

center → ↑↑ of satiety center. While loss of weight is caused by fluid
depletion , fat & muscle breakdown.

b. Complicated : May be the 1st presentation.

13- Mention the Investigations for a case DM?

1. Blood sugar tests :

I . Fasting blood glucose (Fasting for at least 8 hours):
70 - 110 mg /dl → normal
110 -125 mg /dl → impaired glucose tolerance
125 mg /dl → DM.
II. 2 h. post-prandial (after ingestion of 75 gm glucose):
< 140 mg /dl → normal
140 - 200 mg /dl → impaired glucose tolerance
> 200 mg /dl → DM.
III. Random ( casual ) glucose level :
glucose level any time of a day regardless to last meal
should NOT exceeds 200 mg /dl
2. Oral glucose tolerance test : ( OGTT )
I. Patient should be fasting overnight.
II. Fasting blood sugar is done.
III. The patient is fed 75 gm glucose orally.
IV. Take blood & urine samples every 1/2 h. for 2 h.
3. Glycosylated hemoglobin ( HBA1c )
I. Normally it's less than 7 % of total HB.
II. To check glycemic control in the past 3 months.
4. Urine:
- Glycosuria: occurs when glucose serum level exceeds
180 mg % (renal threshold).
- Ketonuria: for diagnosis of diabetic ketoacidosis.
5. Investigations for complication :
Fasting Plasma lipids, kidney function tests, ECG , Echo,……..

14- Enumerate the complications of DM?

❑ Acute complications:
o Diabetic Ketoacidosis (DKA).
o The hyperglycemic hyperosmolar state (HHS).
o Hypoglycemia.

❑ Chronic complications:
o Disorders of the microcirculation:

▪ Diabetic Neuropathy

▪ Diabetic Nephropathy (Chronic renal failure).

 ▪ Diabetic Retinopathy.
o Macrovascular complications.

▪ Ischemic heart disease (silent MI may occur).

▪ Cerebrovascular disease

▪ Peripheral vascular disease /diabetic foot (Gangrene , ulcers ,

infection).

15- Give an example and the mechanism of action of each of the following oral
hypoglycemic groups:
a) Biguanide?
b) Thiazolidenedione?
c) Dipeptidyl peptidase-4 (DPP-4) inhibitor?

1- Biguanides
► Biguanides are derivatives of the antimalarial agent Chloroguanide. Which is
found to have hypoglycemic action.

► The most commonly used member of biguanides is Metformin ( Cidophage ).

Mode of action:

▪ Decreases the intestinal absorption of CHO.

▪ Increases glucose uptake and utilization .

▪ Increases glycogenesis.

2- Thiazolidenedione
❖ Rosiglitazone (Avandia) and Pioglitazone (Actos).

► Mode of action:
 ▪ Insulin sensitizer (increase insulin sensitivity in muscle, adipose tissue
& liver)

▪ They are not insulin secretagogues (Not insulin releasers).

4- Dipeptidyl peptidase-4 (DPP-4) inhibitor

They decrease Glucagon secretion leading to decrease blood glucose level.
► Sitagliptin (FDA approved 2006, marketed by Merck & Co. as Januvia),
► Vildagliptin (EU approved 2007, marketed in the EU by Novartis as Galvus),
► Saxagliptin (FDA approved in 2009, marketed as Onglyza).

16-Enumerate Clinical picture and treatment of hyperthyroidism?:

1) Heat intolerance and Diaphoresis.
2) Tachycardia and Palpitations.
3) Exophthalmos.
4) Restless with fatigue and weakness.
5) Highly excitable and agitated.
6) Fine hand tremors.
7) Increased appetite with weight loss and diarrhea.
8) Neck swelling.
Treatment:

1- Antithyroid medications: Propylthiouracil (PTU)

2- Radiation: Radioactive iodine.
3- Surgery: Subtotal or total thyroidectomy.
17- Enumerate Clinical picture and treatment of hypothyroidism?:
1) Decrease metabolic rate, physical and mental activities.
2) Fatigue.
3) Weight gain.
4) Cold intolerance, hypothermia.
5) Decrease pulse.
 6) Mental sluggishness.
7) Masklike (unemotional expression).
8) Non-pitting edema of lower limbs.
9) Constipation.
10) Skin and hair:
- Hair is dry, coarse, sparse, falls out.
- Skin is thick, dry and rough.
Treatment:

- Thyroid replacement therapy.

18- Mention the different types of insulin?

1- Rapid-acting: Lispro S.C.

(onset 15 min, peak 60-90 min and last from 2-4 hours) e.g. Apidra

2- Short-acting: Regular S.C. or IV

(Onset is 30-60’, peak in 2-3h and last for 4-6 hours) e.g. Novorapid , Actarapid.

3- Intermediate-acting: NPH or Lente S.C.

(Onset 3-4h, peak 4-12 hours and last 16-20 hours) e.g. Humulin N

4- Long-acting: Ultralente S.C.

(Onset 6-8h, peak 12-16 h and lasts 20-30h).

5- Basal insulin: S.C.

(Distributed over 24 hours) e.g. Lantus

19- Give a short account on Acne Vulgaris ?

● Etiology
 • Inflammatory disease of the hair follicle and the sebaceous
glands
• Sex hormones may contribute
● Signs and Symptoms
• Present with whiteheads, blackheads, flesh or red colored
papules, pustules or cysts
• If chronic and deep = may scar
• Psychological impact
● Management
• Topical and systemic agents used to treat acne
• Mild soaps are recommended.

20- Mention the different types of fungal infections of the skin?

1- Tinea capitis (of the scalp).

2- Tinea of the Body (tinea corporis).
3- Tinea of the Nail (onchomycosis).
4- Tinea of the Groin (tinea cruris).
5- Tinea of the Foot (tinea pedis)( Athlete’s Foot).
6- Candidiasis (Moniliasis).
7- Tinea Versicolor.
21- Give an account on oral manifestations of Syphyilis?
1- Primary syphilis of the mouth manifests as a solitary ulcer (chancre) usually
of the lip or the tongue. The ulcer is usually painless , deep, with a red,
purple, or brown base and an irregular raised border. There is usually an
accompanying cervical lymphadenopathy.
2- The oral manifestations of secondary syphilis can be more extensive and/or
variable than those of the primary disease. Oral lesions arise in at least 30%
of patients with secondary syphilis in the form of maculopapular rash.
3- Tertiary syphilis : Gummas tend to arise on the hard palate and tongue,
although very rarely they may occur on the soft palate, lower alveolus, and
parotid gland. A gumma manifests initially as 1 or more painless swelling.
When multiple, they tend to fuse, giving rise to large lesions. There may be
eventual bone destruction, palatal perforation, and oro-nasal fistula
formation

Multiple Choice Questions ( MCQ)

1- Peptic ulcers are differentiated from erosions by:
a) Size.
b) Duration.
c) Depth.
d) Symptoms.
e) All of the above.
2- NSAIDs as a cause of peptic ulcers represent:
a) 10% of all causes of peptic ulcers.
b) 20% of all causes of peptic ulcers.
c) 50% of all causes of peptic ulcers.
d) 90% of all causes of peptic ulcers.
3- Heartburn is the most common presenting symptom of:
a) GERD.
 b) Gastritis.
c) Gastric ulcer.
d) Duodenal ulcer.
4- Approximately 90% of blood transfusion-associated hepatitis is caused by:
a) HAV.
b) HBV.
c) HCV.
d) HDV.
e) HEV.
5- All the following is true regarding HAV except:
a) It is transmitted by fecal-oral transmission.
b) It has an incubation period of about 15 to 45 days.
c) Rarely, it may cause acute fulminant hepatitis.
d) It may cause chronic hepatitis after 6 months of infection.
6- Treatment of GERD includes all the following except:
a) Elevation of head of bed 15 cm.
b) Eating a light meal at bedtime.
c) Avoid coffee, alcohol, fats, and smoking.
d) Proton pump inhibitors.
e) Promotility agents.
7- One of the following tests cannot be used to check for successful
eradication of H.pylori infection :
a) H.pylori-Ag in stool.
b) H.pylori -Ab in blood.
c) Endoscopic biopsy.
d) Urea breathe test.
8- Dentists are susceptible to catch viral hepatitis if the patient has:
a) HAV.
b) HBV.
c) HEV.
d) All of the above.
e) None of the above.
9- The pain of gastric ulcer is described as:
a) Burning in character.
 b) Localized in the epigastrium.
c) Increase by eating.
d) Relieved by antacids.
e) All of the above.
10- The mortality rate is 80% in patients with:
a) GERD.
b) Peptic ulcer.
c) Acute viral hepatitis.
d) Chronic viral hepatitis.
e) Acute fulminant hepatitis.
11- Acute gastritis is characterized by:
a) Metaplasia.
b) Atrophy of the mucosa.
c) Decreased gastrin secretion.
d) PMN infiltration of the mucosa.
e) All of the above.
12- As a treatment of peptic ulcers Antodin is considered as:
a) Proton pump inhibitors.
b) An Antibiotic.
c) H 2 blockers.
d) An Antacid.
13- As a treatment of peptic ulcers Esomeprazole is:
e) Proton pump inhibitors.
f) An Antibiotic.
g) H 2 blockers.
h) An Antacid.
14- Treatment of GERD includes all the following except:
a) Change of life style.
b) Antibiotics.
c) Omeprazole.
d) Itopride.
15- Blood borne viral hepatitis include all the following except:
a) HAV.
 b) HBV.
c) HCV.
d) HDV.
16- Which of the following is true regarding HAV:
a) It is transmitted by needle stick.
b) It has an incubation period of about 15 to 45 days.
c) It always causes acute fulminant hepatitis.
d) It may cause chronic hepatitis after 6 months of infection.
17- Treatment of GERD includes all the following except:
a) Avoid eating 2 hours before sleep.
b) Avoid coffee, alcohol, and smoking.
c) Take excess fat in food to coat the mucosa.
d) Proton pump inhibitors.
e) Promotility agents.
18- Dentist may harm his patient by causing all the following except :
a) Viral hepatitis.
b) Rheumatic fever.
c) Infective endocarditis.
d) Peptic ulcer.
e) AIDS.
19- Dentists are susceptible to catch viral hepatitis if the patient has:
a) HAV.
b) HBV.
c) HEV.
d) All of the above.
e) None of the above.
20- The pain of gastric ulcer is described as:
a) Burning in character.
b) Retrosternal in location.
c) Decrease by eating.
d) Relieved by NSAIDs.
e) All of the above.
21- The newborn should receive an immunoglobuline and a vaccine if
his mother is infected by:
a) HAV.
b) HBV.
c) HCV.
d) HDV.
e) HEV.
22- All the following acid-suppressive drugs are H2-blockers except:
a) Pariet.
b) Zantac.
c) Antodin.
d) Nizatect.

23- Hepatitis C (HCV) is characterized by all the following except:

a) It was previously called serum hepatitis.
b) It spreads by shared needles among drug abusers.
c) It represents 90% of transfusion-associated hepatitis.
d) 50% to 70% of patients with acute HCV infection develop chronic
hepatitis.
e) It may be complicated by cirrhosis, liver failure, and liver cancer.

24- Pre diabetes ( impaired glucose tolerance ( is characterized by all

the following except:
a) fasting blood glucose > 110 & < 126 mg%.
b) disappears after removal of stress.
c) It’s an intermediate category between normal & DM.
d) There is risk factor for future diabetes & CVS diseases.
e) Obesity.
25- WHO diagnostic criteria for diagnosis of DM include any 2 of the
following criteria except:
a) Fasting plasma glucose > 126 mg % + Classic triad ( 3p ).
b) 2 h. post-prandial glucose > 140 mg % + Classic triad ( 3p ).
c) Random plasma glucose > 200 mg %+ Classic triad ( 3p ).
 d) Fasting plasma glucose > 126 mg % + Random plasma glucose >
200 mg %.
26- Oral hypoglycemic that regulates post prandial blood glucose is:
a) Biguanides.
b) Sulphonylurea.
c) Glucobay.
d) Thiazolidenedione.
e) Meglitinide.
27- Oral hypoglycemic that decrease Glucagon secretion is:
a) Thiazolidenedione.
b) Meglitinide.
c) DPP-4.
d) Sulphonylurea.
e) Biguanides.
28- Epidermis is characterized by all the following except:
a) It contains cells with no nuclei.
b) Does not contain any blood vessels.
c) Contains sebaceous glands.
d) Contains melanocytes.
e) Subjected to continuous exfoliation.
29- Papule is:
a) A flat lesion less than 1 cm.
b) A raised lesion less than 1 cm.
c) A flat lesion larger than 1 cm.
d) A raised lesion larger than 1 cm.
e) A complete loss of the epidermis.
30- Group A-beta-hemolytic streptococci is the causative organism of:
a) Impetigo .
b) Furunculosis (Boils).
c) Folliculitis.
d) Hidradenitis Suppurativa.
e) Acne Vulgaris.
31- Fungal infections include all the following except:
 a) Athlete’s Foot (tinea pedis).
b) Candidiasis (Moniliasis).
c) Tinea Versicolor.
d) Onchomycosis.
e) Paronychia.
32- sexually transmitted infections (STI) include all the following
except:
a) Gonorrhea.
b) Syphilis.
c) Viral hepatitis C.
d) Herpes Simplex.
e) AIDS.
33- Chancre is characterized by all the following except:
a) It is characteristic of primary syphilis.
b) It appears within 2 -12 weeks of infection.
c) It causes severe pain.
d) It heals within 3- 6 weeks.
e) It passes to the secondary stage if untreated.
34- The most painful lesion of the following diseases is:
a) Gonococcal rash.
b) Syphilis maculopapular rash.
c) Herpes zoster rash.
d) Common warts.
e) Tinea Versicolor.

35- A single intramuscular injection of penicillin results in complete cure of:

a) Gonorrhea.
b) Syphilis.
c) Onchomycosis.
d) Herpes Simplex.
e) Herpes zoster.
36- Gonorrhea is characterized by all the following except:
a) Clear-to-purulent discharge.
 b) Pharyngitis.
c) Painful urination.
d) Gumma.
e) Easy treatment.

Answer the following questions by (true) or (false):

1- Cancer esophagus may be a complication of GERD. ( T )

2- Surgery may be indicated in the treatment of GERD. (T)

3- Duodenal ulcer pain is relieved by eating. (T)

4- Eradication of H.pylori increased the recurrence of peptic ulcer disease from
10% to 70%. (F)
5- A family history exists in 50 to 60% of children with duodenal ulcer. (T)
6- Hepatitis D virus (HDV) requires concomitant infection with HCV to
survive. (F)

7- About 6% to 10% of patients with acute HCV hepatitis develop chronic

HCV. (F)

8- Sexual contact is an important mode of transmission of HBV. (T)

9- Vertical transmission (from mother to her newborn) is an important mode

of transmission of HCV.(F)

10- Many patients infected with HBV, and HCV have no symptoms. (T)
11- Barrett esophagus is a good sign of improvement of GERD. (F)

12- Chronic gastritis is characterized by PMN infiltration of the mucosa of the

antrum and body. (F)
13- Hepatitis D virus (HDV) requires concomitant infection with HBV to
survive. (T)

14- Barrett esophagus is a warning sign of GERD. (T)

15- 24-h pH testing is a good diagnostic test for peptic ulcer. (F)
16- Individuals who already have chronic HCV infection can acquire HDV
infection at the same time. (F)

17- Antibiotics may be one of the lines of treatment of peptic ulcer. (T)

18- Glucagon increases the sensitivity of the cells to Insulin. (F)

19- Diabetic ketoacidosis is much more common in type (1) DM than in type (2)
(T)
20- Glucosuria occurs when serum glucose level exceeds 200 mg %. (F)
21- Actos is an Insulin sensitizer. (T)
22- The advantage of Meglitinide (Novonorm) is that it is taken once daily.(F)
23- Folliculitis is an Inflammation of hair follicles caused by Staphylococcus
aureus. (T)
24- Furunculosis (Boils) is treated by topical and systemic anti-fungal drugs.
(F)
25- In tinea versicolor, re-pigmentation occurs only when microorganism is
eradicated. (T)
26- Herpes zoster and Herpes simplex diseases are self- limited diseases. (T)
27- Sexually transmitted infection (STI) is now a preferred name than sexually
transmitted disease (STD) or venereal disease (VD). (T)
28- Gonorrhea is a STD passes in 3 stages. (F)
29- Dentist can not diagnose syphilis disease as it is a STD diagnosed only by a
dermatologist. (F)
 30- Gonorrhea is treated easily by a single intramuscular Pinicillin injection. (F)

Practical cases
Case (1): (5 Marks)

A male patient, 48 -year-old presented to your clinic for tooth extraction. After
extraction you prescribed him an antibiotic (Amoxicillin) and analgesic
(Cataflam). Three days, later he developed severe epigastric pain and hematemesis
(vomiting of blood) for which he was admitted to the hospital.

a) What is the medical problem this patient has? Peptic ulcer

b) What is the cause of this condition? NSAIDs ( Cataflam)
c) How to confirm the diagnosis? Endoscopy – Serum gastrin level

Case (2): (5 Marks)

A 39 -year-old female presented to dental clinic for endodontic therapy. Three

weeks later, she developed fever, nausea, and vomiting, abdominal pain, loss of
appetite, jaundice and dark urine.

a) What is the diagnosis of this condition? Acute viral hepatitis

( HBV-HCV)
b) What is the expected cause of this condition? Transmission of infection by
infected dental tools
c) What is the action you have to take in your clinic and instruments? Strict
sterilization – NSAIDs should be avoided- Antibiotic prophylaxis- bilirubin
test & CBC test & hepatitis A,B,C are required

Case (3): (5 Marks)

A 48 -year-old male presented to dental clinic complaining of glossitis and

stomatitis, on history taking the patient has heartburn, cough, hoarseness of voice
and chest wheezes.

a) What is your diagnosis? GERD

b) What is the ideal investigation to confirm the diagnosis?
History taking -Endoscopy-24-h ph test
 c) What is the treatment of this patient?
1- Change life style : -Take small frequent meals
-avoid eating within 2or3 hours of bed time
-avoid spicy,acidic and fatty foods and drinks
-Avoid coffe,alchol and smoking
- elvated head of bed 15 cm
2- Poroton pump inhibitor
3- Promotility agents
4- Antireflux Surgery
Case (4): (5 Marks)

A 61 -year-old female presented to dental clinic to take an oral impression. While

in the waiting room she developed dizziness, sweating and then lost her
consciousness. By history taking from her relatives you knew that she is diabetic
on Insulin injection twice daily. On examination, Blood pressure: 100/70 mmHg,
pulse: 90/m (weak) and temperature: 36.8 c.

a) What is the most appropriate cause of coma? Hypoglycemia

b) How to deal with this condition? IV glucose
c) What is the next step if she does not respond? glucagon injection

Case (5): (5 Marks)

A 12 -year-old boy presented to his physician by polyuria, polydipsia and

polyphagia. Random blood sugar was 250 mg%.

a) Which type of DM this boy has? Type I DM

b) What is treatment of this patient? Diet control & regular exercise - Insulin

Case (6): (5 Marks)

A 42 -year-old male patient presented to your dental clinic by perforation of the

hard palate. By history taking, the patient had an illegal sexual history while he
was young and developed some medical problems during the previous 20 years.

a) What is cause of perforation? Tertiary syphilis

b) What are the medical problems this patient suffered during the previous 20
years?
Non itchy skin rash on palms of hands and soles of feet-mucous membrane
lesions-fever-lymhadenopathy-sore throat-wieght loss-flu-like symptoms
c) What is the treatment of this patient? Single intramuscular injection of
penicillin I.M